Pamela C. Heaton

Relationship between Asthma Drug Therapy Patterns and Healthcare Utilization

BACKGROUND AND OBJECTIVE: Asthma drug therapy problems contribute significantly to preventable hospitalizations and increased healthcare use in asthmatics. Since asthma patients often require >1 medication for control of symptoms, concurrent asthma drug therapies may be important in predicting excessive healthcare utilization. The purpose of this study was to link inappropriate asthma drug therapy patterns and selected patient demographics to healthcare utilization. METHODS: This study was a retrospective, cross-sectional analysis of Ohio Medicaid medical, institutional, and prescription claims. We included ambulatory patients aged 15–65 years who had ≥2 claims for asthma (493.x) and who were continuously enrolled in the Medicaid fee-for-service program for the 12-month period from April 1998 through March 1999. We examined age, race, gender, metropolitan residence, presence of gastroesophageal reflux disease, and the usage patterns of inhaled corticosteroids, short-acting β2-agonists, long-acting β2-agonists, theophylline, and leukotriene receptor modifiers to identify asthma drug therapy problems based on national guidelines. The primary outcomes included the number of asthma-related hospitalizations, asthma-related emergency department visits, and oral steroid bursts. RESULTS: Among 10 959 asthma patients, only 46.8% of the study patients received >1 puff of inhaled corticosteroid per day. Forty-four percent of the patients received >3 puffs of short-acting β2-agonists per day. The most common outcome was an oral steroid burst (46.5%). Patients on high doses of short-acting β2-agonists had the greatest odds of receiving an oral steroid burst and were most likely to be hospitalized. African Americans were more likely to incur a hospitalization or emergency department visit. Women had greater odds of any undesirable asthma outcome. Higher use of short-acting β2-agonists led to higher odds of receiving a steroid burst or being hospitalized. Leukotriene receptor modifier use was related to higher levels of all outcomes. CONCLUSIONS: A large percentage of Ohio Medicaid patients were not receiving asthma medications in compliance with the National Heart, Lung, and Blood Institute guidelines. Despite nearly a decade of national efforts, asthma drug therapy patterns still have substantial room for improvement and continue to be associated with excess healthcare utilization.

Patients’ Need for More Counseling on Diet, Exercise, and Smoking Cessation: Results from the National Ambulatory Medical Care Survey

OBJECTIVE To determine the percentage of physicians who reported counseling patients on diet/nutrition, exercise, weight reduction, or smoking cessation during their office visits when responding to the 2002 National Ambulatory Medical Care Survey (NAMCS). We sought to establish whether patients are receiving adequate counseling from physicians on the basis of this nationwide survey. DESIGN Retrospective database analysis. SETTING United States. PARTICIPANTS Data included 184,668,007 physician visits for patients diagnosed with type 2 diabetes, hyperlipidemia, hypertension, or obesity; 140,362,102 physician visits for patients in which insulin/oral antidiabetics, antihyperlipidemia drugs, angiotensin-converting enzyme inhibitors, thiazide diuretics, or weight loss drugs were prescribed; and 82,317,640 physician visits for patients who smoked or used tobacco. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURES Frequency of responses for counseling/education/therapy about diet/nutrition, exercise, weight reduction, and tobacco use/exposure. RESULTS For patients with type 2 diabetes, hyperlipidemia, or hypertension, or patients receiving a drug in one of the drug classes that may indicate the presence of these diseases, patients did not receive any type of diet or exercise counseling during more than one half of all visits. Visits by patients who were diagnosed as obese were most likely to receive any type of counseling (80.2%). Of visits for patients who used tobacco, 78.6% did not include any counseling about smoking cessation. CONCLUSION Patients are insufficiently counseled and educated about the need for lifestyle changes that can affect their risks for common chronic diseases. As accessible and ideally positioned health care providers, pharmacists could potentially affect the rising epidemic of obesity and other lifestyle-related diseases by filling this void.

β-Blocker Underuse in Secondary Prevention of Myocardial Infarction

OBJECTIVE To review the clinical benefits of β-blockers as secondary prevention following a myocardial infarction (MI) and to address the reasons that clinicians are reluctant to use β-blockers in specific patient populations. DATA SOURCES MEDLINE was searched for articles published from January 1966 to October 2002. Relevant studies were identified by systematic searches of the literature for all reported studies of associations between β-blocker underuse and secondary prevention of MI. Additional studies were identified by a hand search of references of original or review articles. STUDY SELECTION AND DATA EXTRACTION English-language human studies were selected and analyzed. DATA SYNTHESIS Associations were observed in studies of β-blocker use as secondary prevention of MI. A lower rate of β-blocker treatment occurred in older patients and in patients with comorbid conditions such as diabetes, heart failure, chronic obstructive pulmonary disease, asthma, and peripheral arterial disease. In addition, underuse was attributed to the perception of high rates of adverse events associated with β-blockers. β-Blocker use as secondary prevention of an MI can lead to a 19–48% decrease in mortality and up to a 28% decrease in reinfarction rates. Nonetheless, β-blockers are significantly underused in many patient populations due to concomitant disease states. Due to their normal physiologic deterioration, the elderly are at an increased risk of low cardiac output and bradycardia when given a β-blocker; therefore, they should be started on a low dose that is then slowly titrated. In diabetic patients, β-blockers can impair glucose control leading to hypoglycemia; therefore, post-MI diabetic patients must routinely monitor their blood glucose levels. In patients with decompensated heart failure, β-blocker use can lead to further cardiac depression, but lower oral starting doses with slow titration can reduce this risk. β-Blockers can induce bronchospasm in patients with chronic obstructive pulmonary disease or asthma, but cardioselective β-blockers and appropriate use of medications such as albuterol can minimize these effects. Finally, in patients with peripheral arterial disease, with the exception of hypertensive patients with Reynauds phenomenon, β-blockers can be used safely. The only absolute contraindications to β-blockers are severe bradycardia, preexisting sick sinus syndrome, second- and third-degree atrioventricular block, severe left ventricular dysfunction, active peripheral vascular disease with rest ischemia, or reactive airway disease so severe that airway support is required. CONCLUSIONS Overall, the cardiovascular benefits of β-blockers as secondary prevention of MI significantly outweigh the risks associated with their use.

Association between tetracycline or doxycycline and hepatotoxicity: a population based case–control study

Background and objective:  An FDA Working Group, along with representatives of PhRMA and the American Association for the Study of Liver Diseases, as well as the Institute of Medicine Report ‘To Err is Human: Building a Safer Health Care System’ have suggested that post‐marketing drug surveillance is a important method to decrease adverse drug events. While tetracyclines are known to cause hepatotoxicity, no post‐marketing drug surveillance studies have examined the risk of developing hepatotoxicity with tetracyclines. Therefore, the objective of this study is to determine the difference in risk of hepatotoxicity in patients receiving doxycycline or tetracycline using California Medicaid claims.

Postoperative heart block in children with common forms of congenital heart disease: results from the KID Database.

Postoperative Heart Block in Congenital Heart Disease.

National burden of pediatric hospitalizations for inflammatory bowel disease: results from the 2006 Kids' Inpatient Database.

Objectives: The objective of the present study was to quantify the national pediatric inpatient inflammatory bowel disease (IBD) burden in terms of the number of IBD-related hospitalizations, the number of days spent in the hospital, and hospitalization costs. Methods: Hospitalizations for children and adolescents 20 years and younger with a primary diagnosis of either Crohn disease (CD) or ulcerative colitis (UC) were selected from the 2006 Kids’ Inpatient Database (KID). Length of the hospital stay in days (LOS) and charges for the hospitalization were found directly in the Kids’ Inpatient Database, and cost was calculated using the hospitals cost-to-charge ratio. Predictor variables included patient characteristics, such as age and severity of illness, and hospital characteristics. Ordinary-least-squares regressions were developed and estimated to explain hospitalization costs. Results: In 2006, there were 10,777 IBD-related hospitalizations. The total and mean costs for CD were

Impact of the Food and Drug Administration's antipsychotic black box warning on psychotropic drug prescribing in elderly patients with dementia in outpatient and office-based settings.

66.3 million and

Pediatric Syncope: National Hospital Ambulatory Medical Care Survey Results

10,176 (95% confidence interval [CI]

Treatment of obesity: Pharmacotherapy trends in the United States from 1999 to 2010

9647–

Use of Modafinil for the Treatment of Attention Deficit/Hyperactivity Disorder:

10,705), and for UC were