Reamer L. Bushardt

Polypharmacy: Misleading, but manageable

The percentage of the population described as elderly is growing, and a higher prevalence of multiple, chronic disease states must be managed concurrently. Healthcare practitioners must appropriately use medication for multiple diseases and avoid risks often associated with multiple medication use such as adverse effects, drug/drug interactions, drug/disease interactions, and inappropriate dosing. The purpose of this study is to identify a consensus definition for polypharmacy and evaluate its prevalence among elderly outpatients. The authors also sought to identify or develop a clinical tool which would assist healthcare practitioners guard against inappropriate drug therapy in elderly patients. The most commonly cited definition was a medication not matching a diagnosis. Inappropriate was part of definitions used frequently. Some definitions placed a numeric value on concurrent medications. Two common definitions (ie, 6 or more medications or a potentially inappropriate medication) were used to evaluate polypharmacy in elderly South Carolinians (n = 1027). Data analysis demonstrates that a significant percentage of this population is prescribed six or more concomitant drugs and/or uses a potentially inappropriate medication. The findings are 29.4% are prescribed 6 or more concurrent drugs, 15.7% are prescribed one or more potentially inappropriate drugs, and 9.3% meet both definitions of polypharmacy used in this study. The authors recommend use of less ambiguous terminology such as hyperpharmacotherapy or multiple medication use. A structured approach to identify and manage inappropriate polypharmacy is suggested and a clinical tool is provided.

Non-estrogen treatments for osteoporosis: an evidence-based review.

Supporting bone health is fundamental to patient care and must continue throughout life to prevent the fractures that are so often the devastating consequences of osteoporosis.

Insurance Barriers for Childhood Survivors of Pediatric Brain Tumors: The Case for Neurocognitive Evaluations

Objective: The purpose of the present study was to provide empirical evidence of system-based barriers to psychological services for pediatric brain tumor patients when they are medically indicated. Method: Insurance claims data covering 263,866 insured lives during the 1996 fiscal year were pooled from a cross-sectional national sample of adults and their families insured byprivate insurance companies or self-insured firms. Based on inclusion criteria, records for 209 pediatric brain tumor patients aged 18 and under were extracted and analyzed. Claims data including total amount of payments made on behalf of a member, total length of hospital stays, and total number of unique admissions were recorded for all patients, and current procedural terminology (CPT) codes were analyzed to determine frequency of payment for routinely billed psychological procedures. Results were then compared to the frequency of payment for routinely billed psychological procedures for children with other medical conditions. Results: Results indicate that two of the CPT codes commonly associated with neurocognitive evaluations were reimbursed by these third-party payers for pediatric brain tumor patients during the 1996 fiscal year. Additionally, seven of the CPT codes commonly associated with psychological therapy were also reimbursed. Conclusions: The present findings provide empirical evidence of system-based obstacles (i.e., lack of third-party reimbursement) for medically indicated psychological services in pediatric brain tumor patients.

A Preliminary Investigation of Cognitive Late Effects and the Impact of Disease Versus Treatment Among Pediatric Brain Tumor Patients

The purpose of this study was to examine the impact of treatment modality on the cognitive functioning of pediatric brain tumor survivors. Cognitive and behavioral testing batteries were administered to 20 brain tumor survivors (12 receiving surgical intervention only and 8 receiving chemotherapy, radiation therapy, or both). Findings revealed significant declines in intellectual functioning and moderately elevated levels of behavioral problems among patients in both treatment groups. These results have important clinical implications including the need for adjunctive treatments for all brain tumor survivors, regardless of treatment type.

Are immunizations safe and effective for patients being treated with immunosuppressive agents

Most immunizations have not been well studied in patients with drug-induced immune suppression. This article reviews strategies for administering vaccines to patients with rheumatoid arthritis who are taking disease-modifying antirheumatic drugs.

Is dronedarone more effective than amiodarone

Reamer Bushardt is professor and chair of the Department of Physician assistant Studies, Wake forest university School of Medicine, Winston-Salem, North Carolina. Kelly Jones is an associate professor of the McLeod family residency Program at McLeod regional Medical Center in florence, South Carolina. The authors have indicated no relationships to disclose relating to the content of this article. reaMer L. buSHarDT, PharmD, Pa-C; KeLLy W. JONeS, PharmD, bCPS

Rethinking osteoporosis: balancing risk and benefit in diagnosis, prevention, and treatment.

ABSTRACTThe standard of care for osteoporosis is changing amid questions about the long-term safety and efficacy of current drugs for preventing and treating osteoporosis. This article provides a guide for evidence-based treatment, but not overtreatment, as well as the selection and duration of available drug therapies.

A call for physician assistants to make a ruckus--and a difference.

This is who we are; who we have always been. More im-portantly, America’s health care system needs us to be a guiding force. Godin describes how the business world is now em-bracing and rewarding leaders that challenge the status quo. And these leaders are folks who make a ruckus. He points out that people are not really afraid of failure but rather of blame or criticism. This struck a chord with me. My parents did not raise me to be fearless but instead to live my life with integrity, abiding by a set of core values. I will admit that I am not unfamiliar with criticism. My mentors and friends keep it constructive. To those who are critical simply to be critical or quick to denounce in-novation or creativity, I would recommend you share with them a long-standing Southern tradition: offer them a “bless your heart,” then forget about them.

Dermatology diagnoses among rural and urban physician assistants.

Objectives: Dermatology is not heavily covered in the curricula of physician assistant (PA) programs or on the certification examination, even though patient visits to PAs for skin complaints are very common. If significant on‐the‐job training is thus required for dermatology care, then practice setting differences likely impact the quality of that informal training. This study sought to identify differences in the ability of rural and urban PAs to diagnose skin disorders. Methods: An Internet‐based survey of rural and urban primary care PAs (n = 295) was conducted. The survey collected demographic information and provided case scenarios with questions related to diagnosis of a skin disease or complication. Results: Average quiz score was higher for rural PAs than for urban PAs (61.6% versus 55.4%, P = .024). Rural PAs more commonly treated the majority of their patients seen for skin complaints. Rural PAs reported a greater comfort level in diagnosing and treating skin disease than did urban PAs (91% versus 80%, P < .05). Both groups referred a comparable percentage of patients to skin specialists. Regression analysis identified several factors that accounted for the ability to predict success scores for both the rural (P < .05) and urban (P < .05) groups. Conclusions: The stronger overall ability of rural PAs to diagnose a variety of skin diseases is likely impacted by the higher number of dermatologic cases they see. PA educators should re‐evaluate the curricula devoted to skin conditions and consider elective opportunities for students with an interest in a dermatology career.

A guide for primary care PAs

Pediatric clinicians should know how to distinguish juvenile‐onset bipolar disorder from ADHD, since arriving at the right diagnosis is essential to providing the most effective treatment.