7,007 research outputs found
Quality of Health Care for Medicare Beneficiaries: A Chartbook
Provides the results of a review of recently published studies and reports about the quality of health care for elderly Medicare beneficiaries. Includes examples of deficiencies and disparities in care, and some promising quality improvement initiatives
Persistent nonmalignant pain management using nonsteroidal anti-inflammatory drugs in older patients and use of inappropriate adjuvant medications.
Objective
Due to the high risk of life-threatening side effects, nonsteroidal anti-inflammatory drugs (NSAIDs) are not favored for treating persistent nonmalignant pain in the elderly. We report national prescription trends with determinants of NSAIDs prescription for persistent nonmalignant pain among older patients (age 65 and over) in the US outpatient setting.
Methods
A cross-sectional analysis was performed using National Ambulatory Medical Care Survey data. Prescriptions for NSAIDs, opioids, and adjuvant agents were identified using five-digit National Ambulatory Medical Care Survey drug codes.
Results
About 89% of the 206,879,848 weighted visits in the US from 2000 to 2007 recorded NSAIDs prescriptions in patients (mean age =75.4 years). Most NSAIDs users had Medicare (75%), and about 25% were prescribed with adjuvant medications considered inappropriate for their age. Compared to men, women were 1.79 times more likely to be prescribed NSAIDs.
Conclusion
The high percentage of NSAIDs prescription in older patients is alarming. We recommend investigating the appropriateness of the high prevalence of NSAIDs use among older patients reported in our study.Disclosure
Part of the findings were presented as a poster at the American Geriatric Society (AGS) Annual Meeting in Seattle, WA held in May 2012. The authors report no conflicts of interest in this work
Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations
Describes a system of hospitals and community- and school-based clinics tailored to low-income patients through systemwide strategies, high-quality specialty and hospital care, and integrated care delivery via care management and information technology
L'usage secondaire des donnĂ©es mĂ©dico-administratives afin dâoptimiser lâusage des mĂ©dicaments chez les patients atteints de maladies respiratoires chroniques : adhĂ©sion aux mĂ©dicaments, identification de cas et intensification du traitement
Medication adherence in patients with asthma and chronic obstructive pulmonary disease (COPD) is notoriously low and is associated with suboptimal therapeutic outcomes. To intervene effectively, family physicians need to assess medication adherence efficiently and accurately. Otherwise, failure to detect nonadherence may further reduce patient disease control and result in unnecessary treatment escalation that can increase the risk of adverse events and lead to more complex and costly drug regimens. The overarching goal of this thesis was to investigate how the use of secondary healthcare data can be leveraged to optimize medication adherence in clinical practice. Methodological considerations to facilitate our understanding of treatment escalation in asthma using secondary healthcare data were also examined.
In the first part of my doctoral research program, I led a project which aimed at developing e-MEDRESP, a novel web-based tool built from pharmacy claims data that provides to family physicians with objective and easily interpretable information on patient adherence to asthma/COPD medications. This tool was developed in collaboration with family physicians and patients using a framework inspired by user-centered design principles. As part of a feasibility study, e-MEDRESP was subsequently implemented in electronic medical records across several family medicine clinics in Quebec (346 patients, 19 physicians). Findings showed that its integration within physician workflow was feasible. Physicians reported that the tool helped to: 1) better evaluate their patientsâ medication adherence; and 2) adjust prescribed therapies, with mean ± sd ratings (5-point Likert scale) of 4.8±0.7 and 4.3±0.9, respectively. A pre-post analysis did not reveal improvement in adherence among patients whose physician consulted e-MEDRESP during a medical visit. However, significant improvements in adherence for inhaled corticosteroids (Proportion of days covered (PDC): 26.4% (95% CI: 14.3-39.3%)) and long-acting muscarinic agents (PDC: 26.4% (95% CI: 12.4-40.2%)) were observed among patients whose adherence level was less than 80% in the 6-month period prior to the medical visit.
The second part of this research program consisted of two studies which laid the groundwork to estimate the association between medication adherence and treatment escalation in asthma using Canadian healthcare administrative data, a phenomenon that is currently under-explored in the literature. Prior to embarking in this study, it is important to ensure that healthcare administrative databases can be used to identify asthma patients and treatment escalations in an adequate manner. First, a systematic review was conducted to obtain an overview of the available evidence supporting the validity of algorithms to identify asthma patients in healthcare administrative databases. The algorithm developed by Gershon et al. (Canadian Respiratory Journal, 2009;16(6):183-188) comprising â„2 ambulatory medical visits or â„1 hospitalization for asthma over two years had the best trade-off between sensitivity (84 %) and specificity (77%). Second, an operational definition of treatment escalation was developed through a Delphi study that incorporated an expert consensus process. This definition includes 7 steps and was inspired by the 2020 Global for Initiative for Asthma treatment guidelines. I plan to integrate the definitions obtained from these two studies in a future cohort study which aims to examine the association between medication adherence and treatment escalation in asthma.
My research provides compelling evidence on the importance of developing and evaluating the feasibility of implementing tools which can aid physicians in assessing medication adherence in clinical practice and extends the literature on treatment escalation in asthma.LâadhĂ©sion aux mĂ©dicaments chez les patients prĂ©sentant un asthme ou une maladie pulmonaire obstructive chronique (MPOC) est reconnue pour ĂȘtre faible. Pour intervenir efficacement, les mĂ©decins de famille doivent Ă©valuer de maniĂšre prĂ©cise lâadhĂ©sion aux mĂ©dicaments. Ne pas dĂ©tecter la non-adhĂ©sion peut rĂ©duire davantage la maĂźtrise de la maladie, entraĂźner une intensification non-nĂ©cessaire du traitement, mener Ă des schĂ©mas pharmacologiques plus complexes et coĂ»teux et par consĂ©quent, augmenter le risque dâĂ©vĂ©nements indĂ©sirables. La prĂ©sente thĂšse vise Ă approfondir les connaissances sur l'usage secondaire des donnĂ©es mĂ©dico-administratives afin dâoptimiser lâadhĂ©sion et lâusage des mĂ©dicaments chez les patients atteints de maladies respiratoires chronique, au moyen dâune approche mĂ©thodologique mixte de recherche. Plusieurs questions mĂ©thodologiques cruciales concernant lâĂ©tude de lâintensification du traitement en asthme ont Ă©galement Ă©tĂ© abordĂ©es.
Le premier axe porte sur le dĂ©veloppement de lâoutil e-MEDRESP, qui sâappuie sur les renouvellements dâordonnances et qui est conçu pour donner rapidement accĂšs aux mĂ©decins de famille Ă une mesure objective et facilement interprĂ©table de lâadhĂ©sion aux mĂ©dicaments utilisĂ©s dans le traitement de lâasthme et de la MPOC. Lâoutil a Ă©tĂ© dĂ©veloppĂ© en collaboration avec des mĂ©decins de famille et des patients Ă lâaide de groupes de discussion et dâentrevues individuelles. Dans le cadre dâune Ă©tude de faisabilitĂ©, lâoutil e-MEDRESP a Ă©tĂ© par la suite implantĂ© dans les dossiers mĂ©dicaux Ă©lectroniques de plusieurs cliniques de mĂ©decine familiale au QuĂ©bec (346 patients, 19 mĂ©decins). Les rĂ©sultats ont montrĂ© que lâintĂ©gration de dâe-MEDRESP dans le flux de travail des mĂ©decins Ă©tait faisable. Les mĂ©decins ont indiquĂ© que lâoutil leur a permis de : 1) mieux Ă©valuer lâadhĂ©sion aux mĂ©dicaments de leurs patients (cote moyenne et Ă©cart-type sur une Ă©chelle de Likert Ă 5 points [perception dâaccord] de 4,8±0,7); et 2) ajuster les traitements prescrits (4,8±0,7 et 4.3±0,9). Une analyse prĂ©-post nâa pas rĂ©vĂ©lĂ© dâamĂ©lioration au niveau de lâadhĂ©sion aux mĂ©dicaments chez les patients dont le mĂ©decin a consultĂ© e-MEDRESP lors dâune visite mĂ©dicale. Toutefois, une amĂ©lioration statistiquement significative a Ă©tĂ© observĂ©e chez les patients dont le niveau dâadhĂ©sion Ă©tait infĂ©rieur Ă 80 % au cours de la pĂ©riode de six mois prĂ©cĂ©dant la visite et qui Ă©taient traitĂ©s par des corticostĂ©roĂŻdes inhalĂ©s (Proportion of days covered (PDC) = 26,4 % (IC Ă 95 % : 14,3-39,3 %) ou des antagonistes muscariniques Ă action prolongĂ©e (PDC = 26,9 % (IC Ă 95 % : 12,4-40,2 %)).
Le deuxiĂšme axe prĂ©sente des travaux prĂ©paratoires Ă la conduite dâune cohorte qui sera rĂ©alisĂ©e Ă partir de bases de donnĂ©es mĂ©dico-administratives et qui aura comme objectif dâestimer lâassociation entre lâadhĂ©sion aux mĂ©dicaments et lâintensification du traitement de lâasthme, une question peu explorĂ©e Ă ce jour. Avant de dĂ©buter une telle Ă©tude, il est important de sâassurer que les bases de donnĂ©es mĂ©dico-administratives peuvent ĂȘtre utilisĂ©es pour identifier de maniĂšre adĂ©quate les patients asthmatiques et lâintensification du traitement. Dans un premier temps, une revue systĂ©matique a Ă©tĂ© effectuĂ©e pour identifier les donnĂ©es probantes disponibles concernant la validitĂ© des algorithmes permettant dâidentifier les patients asthmatiques dans les bases de donnĂ©es mĂ©dico-administratives. Lâalgorithme qui a Ă©tĂ© dĂ©veloppĂ© par Gershon et coll. (Revue canadienne de pneumologie, 2009; vol. 16, no 6, p. 183-188), qui comprenait deux visites mĂ©dicales ambulatoires ou une hospitalisation pour asthme sur deux ans, prĂ©sentait le meilleur compromis entre la sensibilitĂ© (84 %) et la spĂ©cificitĂ© (77 %). Dans un second temps, une dĂ©finition opĂ©rationnelle de lâintensification du traitement a Ă©tĂ© Ă©laborĂ©e dans le cadre dâune Ă©tude Delphi qui incorporait un processus consensuel dâexperts. Cette dĂ©finition comprend sept Ă©tapes et sâinspire des lignes directrices 2020 de l'initiative mondiale de lutte contre l'asthme. Les dĂ©finitions obtenues Ă partir de ces deux Ă©tudes seront intĂ©grĂ©es dans lâĂ©tude de cohorte.
Les Ă©tudes constituant cette thĂšse dĂ©montrent lâimportance de dĂ©velopper des outils qui permettent aux mĂ©decins dâĂ©valuer lâadhĂ©sion aux mĂ©dicaments dans leur pratique clinique, en plus dâenrichir la littĂ©rature scientifique mĂ©dicale sur lâintensification du traitement chez les patients asthmatiques
Sustainable reduction of antibiotic-induced antimicrobial resistance (ARena) in German ambulatory care: study protocol of a cluster randomised trial
Background: Despite many initiatives to enhance the rational use of antibiotics, there remains substantial room for improvement. The overall aim of this study is to optimise the appropriate use of antibiotics in German ambulatory care in patients with acute non-complicated infections (respiratory tract infections, such as bronchitis, sinusitis, tonsillitis and otitis media), community-acquired pneumonia and non-complicated cystitis, in order to counter the advancing antimicrobial resistance development.
Methods: A three-armed cluster randomised trial will be conducted in 14 practice networks in two German federal states (Bavaria and North Rhine-Westphalia) and an added cohort that reflects standard care. The trial is accompanied by a process evaluation.
Each arm will receive a different set of implementation strategies. Arm A receives a standard set, comprising of e-learning on communication with patients and quality circles with data-based feedback for physicians, information campaigns for the public, patient information material and performance-based additional reimbursement. Arm B receives this standard set plus e-learning on communication with patients and quality circles with data-based feedback tailored for non-physician health professionals of the practice team and information material for tablet computers (culture sensitive). Arm C receives the standard set as well as a computerised decision support system and quality circles in local multidisciplinary groups.
The study aims to recruit 193 practices which will provide data on 23,934 patients each year (47,867 patients in total). The outcome evaluation is based on claims data and refers to established indicators of the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). Primary and secondary outcomes relate to prescribing of antibiotics, which will be analysed in multivariate regression models. The process evaluation is based on interviews with surveys among physicians, non-physician health professionals of the practice team and stakeholders. A patient survey is conducted in one of the study arms. Interview data will be qualitatively analysed using thematic framework analysis. Survey data of physicians, non-physician health professionals of the practice team and patients will use descriptive and exploratory statistics for analysis.
Discussion: The ARena trial will examine the effectiveness of large scale implementation strategies and explore their delivery in routine practice.
Trial registration: ISRCTN, ISRCTN58150046 . Registered 24 August 2017
"Who receives statins? Variations in physiciansâ prescribing patterns for patients with coronary heart disease, dyslipidemia, and diabetes"
Our objective is to estimate the extent to which clinical and non-clinical factors are associated with physiciansâ prescribing patterns for statins. The data are from the National Ambulatory Medical Care Survey for the period 1992 through 2004. The three samples examined included more than 14,000 patients who were diagnosed with coronary heart disease, high cholesterol, or diabetes, individuals who are most likely to benefit from being prescribed a statin drug. Using a multinomial logit framework, we find disparities in prescribing patterns based on non-clinical factors. Namely, whites and patients who have private insurance are more likely to be prescribed a statin than nonwhites and those with public insurance. Also, even though a large increase occurred in the uptake of statins over the period 1992 to 2004, our results for 2004 show that only about 50 percent of patients diagnosed with coronary heart disease were prescribed a statin. Because coronary heart disease is the leading cause of death in the U.S. and currently is estimated to cost over $150 billion annually in the U.S. in direct and indirect costs, observed differences in prescribing patterns along these dimensions is troubling and should be part of discussions dealing with health care reform.Pharmaceuticals; Statins; Equity in Physician Prescribing Patterns; Insurance
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Patient-reported financial barriers to adherence to treatment in neurology
OBJECTIVE: Many effective medical therapies are available for treating neurological diseases, but these therapies tend to be expensive and adherence is critical to their effectiveness. We used patient-reported data to examine the frequency and determinants of financial barriers to medication adherence among individuals treated for neurological disorders.
PATIENTS AND METHODS: Patients completed cross-sectional surveys on iPads as part of routine outpatient care in a neurology clinic. Survey responses from a 3-month period were collected and merged with administrative sources of demographic and clinical information (eg, insurance type). We explored the association between patient characteristics and patient-reported failure to refill prescription medication due to cost in the previous 12 months, termed here as "nonadherence".
RESULTS: The population studied comprised 6075 adults who were presented between July and September 2015 for outpatient neurology appointments. The mean age of participants was 56 (standard deviation: 18) years, and 1613 (54%) were females. The patients who participated in the surveys (2992, 49%) were comparable to nonparticipants with respect to gender and ethnicity but more often identified English as their preferred language (94% vs 6%, p<0.01). Among respondents, 9.8% (n=265) reported nonadherence that varied by condition. These patients were more frequently Hispanic (16.7% vs 9.8% white, p=0.01), living alone (13.9% vs 8.9% cohabitating, p<0.01), and preferred a language other than English (15.3% vs 9.4%, p=0.02).
CONCLUSION: Overall, the magnitude of financial barriers to medication adherence appears to vary across neurological conditions and demographic characteristics
The Slovakian Long-term Care System. ENEPRI Research Report No. 86, 15 June 2010
Launched in January 2009, ANCIEN is a research project that runs for a 44-month period and involves 20 partners from EU member states. The project principally concerns the future of long-term care (LTC) for the elderly in Europe and addresses two questions in particular: 1) How will need, demand, supply and use of LTC develop? 2) How do different systems of LTC perform? This case study on Slovakia is part of the first stage in the project aimed at collecting the basic data and necessary information to portray long-term care in each country of the EU. It will be followed by analysis and projections of future scenarios on long-term care needs, use, quality assurance and system performance. State-of-the-art demographic, epidemiologic and econometric modelling will be used to interpret and project needs, supply and use of long-term care over future time periods for different LTC systems
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