Michael A. Steinman

Age Affects Outcomes in Chronic Kidney Disease

Chronic kidney disease (CKD) is common among the elderly. However, little is known about how the clinical implications of CKD vary with age. We examined the age-specific incidence of death, treated end-stage renal disease (ESRD), and change in estimated glomerular filtration rate (eGFR) among 209,622 US veterans with CKD stages 3 to 5 followed for a mean of 3.2 years. Patients aged 75 years or older at baseline comprised 47% of the overall cohort and accounted for 28% of the 9227 cases of ESRD that occurred during follow-up. Among patients of all ages, rates of both death and ESRD were inversely related to eGFR at baseline. However, among those with comparable levels of eGFR, older patients had higher rates of death and lower rates of ESRD than younger patients. Consequently, the level of eGFR below which the risk of ESRD exceeded the risk of death varied by age, ranging from 45 ml/min per 1.73 m(2) for 18 to 44 year old patients to 15 ml/min per 1.73 m(2) for 65 to 84 year old patients. Among those 85 years or older, the risk of death always exceeded the risk of ESRD in this cohort. Among patients with eGFR levels <45 ml/min per 1.73 m(2) at baseline, older patients were less likely than their younger counterparts to experience an annual decline in eGFR of >3 ml/min per 1.73 m(2). In conclusion, age is a major effect modifier among patients with an eGFR of <60 ml/min per 1.73 m(2), challenging us to move beyond a uniform stage-based approach to managing CKD.

Polypharmacy and Prescribing Quality in Older People

OBJECTIVES: To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients.

Of principles and pens: attitudes and practices of medicine housestaff toward pharmaceutical industry promotions

PURPOSE Little is known about the factors that influence housestaff attitudes toward pharmaceutical industry promotions or, how such attitudes correlate with physician behaviors. We studied these attitudes and practices among internal medicine housestaff. SUBJECTS AND METHODS Confidential surveys about attitudes and behaviors toward industry gifts were distributed to 1st- and 2nd-year residents at a university-based internal medicine residency program. RESULTS Ninety percent of the residents (105 of 117) completed the survey. A majority of respondents considered seven of nine types of promotions appropriate. Residents judged the appropriateness of promotions on the basis of their cost (median percentage of items considered appropriate 100% for inexpensive items vs. 60% for expensive ones) more than on the basis of their educational value (80% for educational items vs.75% for noneducational ones; P < .001 for comparison of appropriateness based on cost vs. educational value). Behaviors were often inconsistent with attitudes; every resident who considered conference lunches (n = 13) and pens (n = 18) inappropriate had accepted these gifts. Most respondents (61%)stated that industry promotions and contacts did not influence their own prescribing, but only 16% believed other physicians were similarly unaffected (P< .0001). Nonetheless, more than two thirds of residents agreed that it is appropriate for a medical institution to have rules on industry interactions with residents and faculty. CONCLUSIONS Residents hold generally positive attitudes toward gifts from industry, believe they are not influenced by them, and report behaviors that are often inconsistent with their attitudes. Thoughtful education and policy programs may help residents learn to critically appraise these gifts.

Changing Use of Antibiotics in Community-Based Outpatient Practice, 1991-1999

Context Indiscriminate use of antibiotics promotes the development of antibiotic-resistant strains of bacteria. Contribution This survey of patient visits to community-based clinics shows that antibiotic use for ambulatory infections, especially upper respiratory tract infections, decreased from 19911992 to 19981999. However, the use of broad-spectrum antibiotics rose over this period. Implications Efforts to encourage rational use of antibiotics should focus on which antibiotic to use as well as whether or not to use antibiotics. The Editors Over the past decade, antibiotic resistance has increased substantially in the United States (1-3). In response, many experts have advocated a judicious approach to antibiotic use in both inpatient and outpatient settings (4-6). Such an approach may decrease community rates of antibiotic resistance, even to older drugs with long-standing histories of resistance (7, 8). Similarly, judicious use of potent newer agents may preserve their utility in the treatment of severe or complicated infections, forestalling the emergence of widespread resistance (9, 10). In a landmark study, McCaig and Hughes (11) documented increasing outpatient use of amoxicillin and the cephalosporins between 1980 and 1992 in the United States. Over the past decade, several studies and interventions have focused on the excess use of antibiotics. However, only recently has increasing attention been paid to the type of agents being prescribed (12-14). As a result, relatively little is known about the impact of antibiotic prescribing choices on quality of care, health care costs, and antibiotic resistance. In this study, we used a large, nationally representative sample of community-based physicians to evaluate outpatient antibiotic prescribing during the 1990s. First, we examined the ways in which patterns of antibiotic use have changed over the past decade, particularly among broad-spectrum agents such as azithromycin and clarithromycin, quinolones, amoxicillinclavulanate, and second- and third-generation cephalosporins. Next, we determined the association between these patterns of use and clinical factors related to the need for broad-spectrum therapy. Methods National Ambulatory Medical Care Survey We used the National Ambulatory Medical Care Survey (NAMCS) to collect data on outpatient antibiotic use. We collapsed 6 survey years into three study periods (19911992, 19941995, and 19981999), combining data from consecutive years to add power to our analyses. The NAMCS is an annual sample of outpatient visits to office-based community physicians who are principally engaged in patient care. Patient care encounters in emergency departments or hospital-based clinics and visits outside the office (for example, house calls or nursing home visits) were not recorded. Visits were sampled by using a multistage clustered probability sample design based on geographic location, provider specialty, and visits within individual physician practices. When patient weights are used, these data can be extrapolated to the approximately 650 million community-based outpatient visits that occur in the United States each year (15). Participation in the survey ranged from 63% to 73% of invited practices, with different physicians and patients being surveyed each year (15, 16). The NAMCS collected information on up to five (19911994) or six (19951999) medications prescribed for each patient at the conclusion of his or her visit, including both new and ongoing prescriptions. The NAMCS also collected data on up to three physician diagnoses related to the visit, including new diagnoses and ongoing medical conditions. All data, including demographic char acteristics, were recorded by the physician or by office staff completing the visit encounter form. Design and Classification We were interested in the use of oral and intramuscular antibiotics, but the NAMCS does not provide information on the route of drug administration. We therefore excluded patient visits to dermatologists and ophthalmologists because these specialists frequently prescribe topical antibiotics, which we could not distinguish from systemic forms of the same drugs. Visits to these specialists made up approximately 10% of patient encounters in each study period. Among the remaining sample, 60 252 visits were recorded in 19911992, 62 169 visits were recorded in 19941995, and 37 467 visits were recorded in 19981999. The smaller sample size in the last study period reflects a smaller number of visits surveyed by the NAMCS in those years. We divided the remaining sample into patient visits that did and did not involve an antibiotic. Antimicrobial medications used by outpatients almost exclusively in topical or intravenous form, such as polymyxins and aminoglycosides, were not counted as antibiotics. We also did not count antimycobacterial medications as antibiotics because they are infrequently used for typical bacterial infections. Antibiotic use, according to these criteria, was recorded in 8208 sampled visits in 19911992, 7944 visits in 19941995, and 4200 visits in 19981999. In each study period, 3% to 4% of these visits involved the use of more than one antibiotic. In total, there were 8514 antibiotic prescriptions in 19911992, 8308 antibiotic prescriptions in 19941995, and 4406 antibiotic prescriptions in 19981999. For the purposes of this study, we defined broad-spectrum agents as azithromycin and clarithromycin, quinolones, amoxicillinclavulanate, and second- and third-generation cephalosporins (17). Many of the broad-spectrum agents we studied were introduced more recently than narrow-spectrum ones. All nine narrow-spectrum agents that made up at least 2% of total antibiotic prescriptions in any study period received U.S. Food and Drug Administration approval before 1979. Among broad-spectrum agents that made up at least 2% of total antibiotic prescriptions, Food and Drug Administration approval was granted between 1979 and 1984 for amoxicillinclavulanate, cefaclor, and cefuroxime; in 1987 for ciprofloxacin; in 1991 for azithromycin, cefprozil, and clarithromycin; and in 1996 for levofloxacin (Bergman E. Personal communication. Publically available data from the Tufts Center for the Study of Drug Developments approved products database). Patients were considered to have a common infectious condition if the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code appeared as the first, second, or third diagnosis for that visit (18). Diagnoses included nasopharyngitis (the common cold) or upper respiratory tract infection not otherwise specified (ICD-9-CM codes 460, 465); acute or chronic sinusitis (ICD-9-CM codes 461, 473); pharyngitis and streptococcal sore throat (ICD-9-CM codes 462, 34.0); suppurative or nonsuppurative otitis media (ICD-9-CM codes 381.0381.4, 382); acute or acute-on-chronic bronchitis and bronchiolitis (ICD-9-CM codes 466, 490, 491.21); acute tonsillitis, laryngitis, and tracheitis (ICD-9-CM codes 463464); bacterial or unspecified pneumonia (ICD-9-CM codes 481483, 485486); urinary tract infection or acute or unspecified cystitis (ICD-9-CM codes 599.0, 595.0, 595.9); cellulitis, carbuncle, or furuncle (ICD-9-CM codes 680682); prostatitis or pelvic inflammatory disease (ICD-9-CM codes 601, 614); and sexually transmitted diseases, including syphilis, gonococcal infections, and other venereal infections (ICD-9-CM codes 9099, 647.0647.2). In each study period, 11% to 13% of patients who were prescribed antibiotics received a diagnosis of more than one of these infectious conditions. To prevent confusion over which disease was treated by the listed antibiotics, we excluded these patients from the diagnosis-specific analyses. Among adults with a single diagnosis of an infectious disease, there were 1657 visits for the common cold and unspecified upper respiratory tract infections, 2652 visits for sinusitis, 963 visits for pharyngitis, 908 visits for otitis media, 1674 visits for acute bronchitis, and 1636 visits for urinary tract infection over the entire study period. Among children, there were 1976 visits for the common cold and unspecified upper respiratory tract infections, 651 visits for sinusitis, 1120 visits for pharyngitis, 3107 visits for otitis media, and 625 visits for acute bronchitis. Statistical Analysis We analyzed overall antibiotic use for a given patient at the level of the patient visit. Individual prescriptions were analyzed at the level of the antibiotic prescription. For example, a patient visit involving amoxicillin and ciprofloxacin would be counted twice, once for each medication. We did not account for clustering of more than one antibiotic in a single visit because only 3% to 4% of visits at which an antibiotic was prescribed in each period involved more than one antibiotic. To make our point estimates nationally representative, we used patient weights, which weight each visits contribution in inverse proportion to the likelihood of that visit being sampled from all community-based visits (15, 19). Patient weight can be interpreted as the number of visits in the population that the sampled visit represents. To adjust for the effects of survey design on standard errors, we clustered our analyses at the level of the physician. This accounts for correlation among outcomes sampled from the same physician and increases the standard errors to account for weighting and clustering within physicians. Identifiers of the true primary sampling unit (county or county equivalent) were not available to the public at the time this study was performed and therefore could not be used in our analyses. As a result, the calculated variances and point estimates in our analyses may differ slightly from those in analyses that incorporate both the primary and secondary sampling units. We conducted all analyses using the design-based F test, comparing the first study period (19911992) with the

Self-restriction of medications due to cost in seniors without prescription coverage

OBJECTIVE: Little is known about patients who skip doses or otherwise avoid using their medications because of cost. We sought to identify which elderly patients are at highest risk of restricting their medications because of cost, and how prescription coverage modifies this risk.DESIGN AND PARTICIPANTS: Cross-sectional study from the 1995–1996 wave of the Survey of Asset and Health Dynamics Among the Oldest Old, a population-based survey of Americans age 70 years and older.MEASUREMENTS: Subjects were asked the extent of their prescription coverage, and whether they had taken less medicine than prescribed for them because of cost over the prior 2 years. We used bivariate and multivariate analyses to identify risk factors for medication restriction in subjects who lacked prescription coverage. Among these high-risk groups, we then examined the effect of prescription coverage on rates of medication restriction.MAIN RESULTS: Of 4,896 seniors who regularly used prescription medications, medication restriction because of cost was reported by 8% of subjects with no prescription coverage, 3% with partial coverage, and 2% with full coverage (P<.01 for trend). Among subjects with no prescription coverage, the strongest independent predictors of medication restriction were minority ethnicity (odds ratio [OR], 2.9 compared with white ethnicity; 95% confidence interval [95% CI], 2.0 to 4.2), annual income <

Managing Medications in Clinically Complex Elders: “There's Got to Be a Happy Medium”

10,000 (OR, 3.8 compared with income ≥

Interventions to reduce unnecessary antibiotic prescribing: a systematic review and quantitative analysis.

20,000; 95% CI, 2.4 to 6.1), and out-of-pocket prescription drug costs >

Interactions between pharmaceutical representatives and doctors in training : A thematic review

100 per month (OR, 3.3 compared to costs ≤

Potential Overtreatment of Diabetes Mellitus in Older Adults With Tight Glycemic Control

20; 95% CI, 1.5 to 7.2). The prevalence of medication restriction in members of these 3 risk groups was 21%, 16%, and 13%, respectively. Almost half (43%) of subjects with all 3 risk factors and no prescription coverage reported restricting their use of medications. After multivariable adjustment, high-risk subjects with no coverage had 3 to 15 times higher odds of medication restriction than subjects with partial or full coverage (P<.01).CONCLUSIONS: Medication restriction is common in seniors who lack prescription coverage, particularly among certain vulnerable groups. Seniors in these high-risk groups who have prescription coverage are much less likely to restrict their use of medications.

Beyond the Prescription: Medication Monitoring and Adverse Drug Events in Older Adults

Multiple medication use is common in older adults and may ameliorate symptoms, improve and extend quality of life, and occasionally cure disease. Unfortunately, multiple medication use is also a major risk factor for prescribing and adherence problems, adverse drug events, and other adverse health outcomes. Using the case of an older patient taking multiple medications, this article summarizes the evidence-based literature about improving medication use and withdrawing specific drugs and drug classes. It also describes a systematic approach for how health professionals can assess and improve medication regimens to benefit patients and their caregivers and families.