Improving Sedative-Hypnotic Prescribing in Older Hospitalized Patients: Provider-Perceived Benefits and Barriers of a Computer-Based Reminder

Background: Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium. Objective: To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications. Design: Qualitative study using semi-structured interviews. Participants and setting: Thirty-six house staff physicians at a university hospital. Measurements: Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Responses were analyzed using grounded theory methodology. Results: The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (±0.9 SD), with 10 indicating high satisfaction. Conclusions: Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing

Long-term negative emotional outcomes of warzone TBI

Objective: Many veterans of the Iraq and Afghanistan Wars have experienced traumatic brain injury (TBI). Although prior work has examined associations between TBI and development of psychi- atric syndromes, less is known about associations between TBI and component emotions constituting these syndromes, especially in the long term. The purpose of this study was to examine the long-term emotional consequences of deployment-related TBI. Methods: As part of VA Cooperative Studies Program #566, we assessed a sample of n1⁄4456US Army soldiers prior to an index deployment to Iraq, and again an average of 8.3 years (SD1⁄42.4years) after their deployment for a long-term follow-up assessment. In this report, we used adjusted regression analyses to examine the relationship of deployment TBI to depression, anxiety, and stress symptom severity measured at the long-term follow-up assessment. A structured interview was used to determine TBI history; the Depression, Anxiety, and Stress Scale, 21-item version (DASS-21) was used to determine emotional status at the follow-up evaluation. Results: Warzone TBI events, particularly when greater than mild in severity, were independently associated with depression, anx- iety, and stress severity at long-term follow-up, even after taking into account variance attributable to pre-deployment emotional distress and war-zone stress. Post-hoc analyses did not detect independent associations of either number of events or injury mechanism with outcomes. Conclusions: These findings highlight the potentially enduring and multi-faceted emotional effects of deployment TBI, underscor- ing the need for early assessment of negative affectivity in war- zone veterans reporting TBI

Long-term negative emotional outcomes of warzone TBI

Objective: Many veterans of the Iraq and Afghanistan Wars have experienced traumatic brain injury (TBI). Although prior work has examined associations between TBI and development of psychi- atric syndromes, less is known about associations between TBI and component emotions constituting these syndromes, especially in the long term. The purpose of this study was to examine the long-term emotional consequences of deployment-related TBI. Methods: As part of VA Cooperative Studies Program #566, we assessed a sample of n1⁄4456US Army soldiers prior to an index deployment to Iraq, and again an average of 8.3 years (SD1⁄42.4years) after their deployment for a long-term follow-up assessment. In this report, we used adjusted regression analyses to examine the relationship of deployment TBI to depression, anxiety, and stress symptom severity measured at the long-term follow-up assessment. A structured interview was used to determine TBI history; the Depression, Anxiety, and Stress Scale, 21-item version (DASS-21) was used to determine emotional status at the follow-up evaluation. Results: Warzone TBI events, particularly when greater than mild in severity, were independently associated with depression, anx- iety, and stress severity at long-term follow-up, even after taking into account variance attributable to pre-deployment emotional distress and war-zone stress. Post-hoc analyses did not detect independent associations of either number of events or injury mechanism with outcomes. Conclusions: These findings highlight the potentially enduring and multi-faceted emotional effects of deployment TBI, underscor- ing the need for early assessment of negative affectivity in war- zone veterans reporting TBI

Key Indexing Terms: RISK COMMUNICATION NUMERACY DRUG TOXICITY RHEUMATOID ARTHRITIS Personal, non-commercial use only

Effectively communicating the risk and benefits of available treatment alternatives is an essential component of medical care. This is particularly true regarding the treatment of rheumatoid arthritis (RA), where there are now multiple treatment options available, each with distinct risk profiles. Effective communication of risk is difficult, however, in part because of limitations associated with both the provision and interpretation of probabilistic information 1-8 . At the most basic level, there is little agreement on how to present risk information in clinical practice, with some investigators arguing for the use of verbal phrases such as "rare" or "frequent" and others advocating the use of quantitative estimates (e.g., proportions or percentages). Use of words is limited by the wide range of values that patients and physicians assign to verbal expressions of probability 12 . People with protected values believe that certain objects should be protected from any and all trade-offs with other values no matter how small the risk. For example, people with protected values for forest conservation believe that forests should be protected from loggers no matter how small the threat to the forest. Studies have shown that protected values often result from incorrect assumptions and may therefore lead to poor decision-making. To test our hypothesis, we examined whether using several strategies to facilitate risk-communication, patients alter their willingness to take medications as the risk of toxicity is substantially decreased, and whether increased willingness to accept the risk of toxicity varies depending on the specific AE. MATERIALS AND METHODS Patients. Consecutive patients with RA belonging to a community rheumatology practice serving New Haven, Connnecticut, and surrounding areas were asked to participate in a study examining the importance patients attach Risk Communication in Rheumatoid Arthritis LIANA FRAENKEL, SIDNEY BOGARDUS, JOHN CONCATO, and DAVID FELSON ABSTRACT. Objective. Some people believe that certain issues should be protected from all trade-offs. These issues are referred to as "protected values." We investigated whether some patients with rheumatoid arthritis (RA) treat the risk of adverse effects (AE) as "protected values," i.e., as unacceptable regardless of how small the risk. Methods. Patients with RA rated willingness to risk 17 different AE on a visual analog scale, where 0 = not willing under any circumstances and 100 = definitely willing. Participants then rated willingness to take medication as the risk of each AE was progressively decreased by 2 levels from its actual risk, using a 5 level scale ranging from 10 in 100 to 1 in 100,000. Results. Between 32% and 39% of participants were not more willing to accept a risk of AE causing reversible cosmetic changes (e.g., acne), between 35% and 47% were not more willing to accept a risk of AE causing reversible discomfort (e.g., rash), and between 41% and 45% were not more willing to accept a risk of AE causing potential irreversible damage (e.g., pneumonitis) as the probability of each of these AE was substantially decreased. Unwillingness to accept risk of toxicity was especially evident for cancer, where 66% of patients refused to accept a risk of cancer occurring in 1 in 100,000 persons. Conclusion. Among patients particularly concerned with the risk of drug toxicity, many remain unwilling to accept the risk of AE even when their probability is decreased to levels far below their actual risk. These results suggest that patients may treat particularly worrisome AE as protected values, which may lead to poor decision-making in clinical practice

Association between admission haematocrit and mortality among men with acute ischaemic stroke

Objective: Anaemia is associated with higher mortality among patients with non-stroke cardiovascular conditions; less is known regarding the relationship between anaemia and mortality among patients with acute ischaemic stroke. Methods: Medical records were abstracted for n=3965 veterans from 131 Veterans Health Administration facilities who were admitted with ischaemic stroke in fiscal year 2007. Haematocrit values within 24 hours of admission were classified as ≤27%, 28%-32%, 33%-37%, 38%-42%, 43%-47% or ≥48%. Multivariate logistic regression was used to examine the relationship between anaemia and in-hospital, 30-day, 6-month and 1-year mortality, adjusting for age, medical comorbidities, modified Acute Physiology and Chronic Health Evaluation-III and stroke severity. Impact factors were calculated to standardise comparisons between haematocrit tier and other covariates. Results: Among n=3750 patients included in the analysis, the haematocrit values were ≤27% in 2.1% (n=78), 28%-32% in 6.2% (n=234), 33%-37% in 17.9% (n=670), 38%-42% in 36.4% (n=1366), 43%-47% in 28.2% (n=1059) and ≥48% in 9.1% (n=343). Patients with haematocrit ≤27%, compared with patients in the 38%-42% range, were more likely to have died across all follow-up intervals, with statistically significant adjusted ORs (aORs) ranging from 2.5 to 3.5. Patients with polycythaemia (ie, haematocrit ≥48%) were at increased risk of in-hospital mortality (aOR=2.9; 95% CI 1.4 to 6.0), compared with patients with mid-range admission haematocrits. Pronounced differences between patients receiving and not receiving blood transfusion limited our ability to perform a propensity analysis. Impact factors in the 1-year mortality model were 0.46 (severe anaemia), 0.06 (cancer) and 0.018 (heart disease). Conclusions: Anaemia is independently associated with an increased risk of death throughout the first year post stroke; high haematocrit is associated with early poststroke mortality. Severe anaemia is associated with 1-year mortality to a greater degree than cancer or heart disease. These data cannot address the question of whether interventions targeting anaemia might improve patient outcomes

Reducing cardiovascular risk through treatment of obstructive sleep apnea: 2 methodological approaches

Obstructive sleep apnea (OSA) significantly impacts cardiovascular health, demonstrated by observational investigations showing an independently increased risk of ischemic heart disease, diabetes, hypertension, congestive heart failure, acute coronary syndrome, stroke, cardiovascular mortality, and all-cause mortality. Positive airway pressure (PAP), a medical therapy for sleep apnea, reverses airway obstruction and may help reduce cardiovascular risk. Prior to planning large phase III randomized controlled trials to test the impact of PAP on cardiovascular outcomes, several gaps in knowledge need to be addressed. This article describes 2 independent studies that worked collaboratively to fill these gaps. The populations, design features, and relative benefits/challenges of the 2 studies (SleepTight and BestAIR) are described. Both studies were encouraged to have multidisciplinary teams with expertise in behavioral interventions to improve PAP compliance. Both studies provide key information that will be useful to the research community in future large-scale, event-driven, randomized trials to evaluate the efficacy and/or effectiveness of strategies to identify and treat significant OSA for decreasing risk of major adverse cardiovascular events in high-risk patients

Ethnic differences in respiratory impairment

Objective Spirometric Z scores by lambda-mu-sigma (LMS) rigorously account for age-related changes in lung function. Recently, the Global Lung Function Initiative (GLI) expanded LMS spirometric Z scores to multiple ethnicities. Hence, in aging populations, the GLI provides an opportunity to rigorously evaluate ethnic differences in respiratory impairment, including airflow limitation and restrictive pattern. Methods Using data from the Third National Health and Nutrition Examination Survey, including participants aged 40-80, we evaluated ethnic differences in GLI-defined respiratory impairment, including prevalence and associations with mortality and respiratory symptoms. Results Among 3506 white Americans, 1860 African Americans and 1749 Mexican Americans, the prevalence of airflow limitation was 15.1% (13.9% to 16.4%), 12.4% (10.7% to 14.0%) and 8.2% (6.7% to 9.8%), and restrictive pattern was 5.6% (4.6% to 6.5%), 8.0% 6.9% to 9.0%) and 5.7% (4.5% to 6.9%), respectively. Airflow limitation was associated with mortality in white Americans, African Americans and Mexican Americans - adjusted HR (aHR) 1.66 (1.23 to 2.25), 1.60 (1.09 to 2.36) and 1.80 (1.17 to 2.76), respectively, but associated with respiratory symptoms only in white Americans - adjusted OR (aOR) 2.15 (1.70 to 2.73). Restrictive pattern was associated with mortality but only in white Americans and African Americans - aHR 2.56 (1.84 to 3.55) and 3.23 (2.06 to 5.05), and associated with respiratory symptoms but only in white Americans and Mexican Americans-aOR 2.16 (1.51 to 3.07) and .12 (1.45 to 3.08), respectively. Conclusions In an aging population, we found ethnic differences in GLI-defined respiratory impairment. In particular, African Americans had high rates of respiratory impairment that were associated with mortality but not respiratory symptoms

Chronic obstructive pulmonary disease in older persons: A comparison of two spirometric definitions

SummaryBackgroundAmong older persons, we previously endorsed a two-step spirometric definition of chronic obstructive pulmonary disease (COPD) that requires a ratio of forced expiratory volume in 1sec to forced vital capacity (FEV1/FVC) below .70, and an FEV1 below the 5th or 10th standardized residual percentile (“SR-tile strategy”).ObjectiveTo evaluate the clinical validity of an SR-tile strategy, compared to a current definition of COPD, as published by the Global Initiative for Obstructive Lung Disease (GOLD-COPD), in older persons.MethodsWe assessed national data from 2480 persons aged 65–80 years. In separate analyses, we evaluated the association of an SR-tile strategy with mortality and respiratory symptoms, relative to GOLD-COPD. As per convention, GOLD-COPD was defined solely by an FEV1/FVC<.70, with severity staged according to FEV1 cut-points at 80 and 50 percent predicted (%Pred).ResultsAmong 831 participants with GOLD-COPD, the risk of death was elevated only in 179 (21.5%) of those who also had an FEV1<5th SR-tile; and the odds of having respiratory symptoms were elevated only in 310 (37.4%) of those who also had an FEV1<10th SR-tile. In contrast, GOLD-COPD staged at an FEV1 50–79%Pred led to misclassification (overestimation) in terms of 209 (66.4%) and 77 (24.6%) participants, respectively, not having an increased risk of death or likelihood of respiratory symptoms.ConclusionRelative to an SR-tile strategy, the majority of older persons with GOLD-COPD had neither an increased risk of death nor an increased likelihood of respiratory symptoms. These results raise concerns about the clinical validity of GOLD guidelines in older persons

Using Radiological Data to Estimate Ischemic Stroke Severity

Background Risk-adjusted poststroke mortality has been proposed for use as a measure of stroke care quality. Although valid measures of stroke severity (e.g., the National Institutes of Health Stroke Scale [NIHSS]) are not typically available in administrative datasets, radiology reports are often available within electronic health records. We sought to examine whether admission head computed tomography data could be used to estimate stroke severity. Materials and Methods Using chart review data from a cohort of acute ischemic stroke patients (1998-2003), we developed a radiographic measure ([BIS]) of stroke severity in a two-third development set and assessed in a one-third validation set. The retrospective NIHSS was dichotomized as mild/moderate (<10) and severe (≥10). We compared the association of this radiographic score with NIHSS and in-hospital mortality at the patient level. Results Among 1348 stroke patients, 86.5% had abnormal findings on initial head computed tomography. The c-statistic for the BIS for modeling severe stroke (development, .581; validation, .579) and in-hospital mortality (development, .623; validation, .678) were generated. Conclusions Although the c-statistics were only moderate, the BIS provided significant risk stratification information with a 2-variable score. Until administrative data routinely includes a valid measure of stroke severity, radiographic data may provide information for use in risk adjustment