• Pharmacotherapeutic Management and Care Transitions among Nursing Home Residents with Atrial Fibrillation

      Dutcher, Sarah Kathryn; Zuckerman, Ilene H. (2014)
      Nursing home (NH) residents are a vulnerable population who experience a high rate of transitions across care settings. This population is also at risk for adverse drug events, given their multimorbidity and polypharmacy. However, the relationship between the quality of medication use and transitions in this population is unknown. This study investigates this relationship in the context of atrial fibrillation (AFIB), as pharmacotherapeutic management of AFIB, especially the use of warfarin, can be problematic, and poor management of AFIB can result in hospitalization. This study has three specific aims, all conducted among long-stay NH residents with AFIB: 1) To describe and identify factors associated with pharmacotherapeutic management of AFIB in the NH; 2) To quantify changes in pharmacotherapeutic management for AFIB across a hospital transition; 3) To determine the bidirectional relationship between quality of AFIB management and hospital transitions. This study used 2006-2009 Medicare administrative data, the NH Minimum Dataset, and NH facility data. The first and third aims used a nonconcurrent prospective cohort design with monthly measures of medication use and hospitalizations. The second aim used a pre-post design to compare medication use before and after a hospitalization. The cohort comprised 16,174 older, long-stay NH residents with AFIB, contributing 219,571 person-months of observation. Forty-eight percent were receiving any antithrombotic, of which warfarin was a majority (78.0%). Among person-months with warfarin use, 84.3% had regular INR monitoring. Approximately 12% of hospitalized individuals experienced a change in their antithrombotic regimen. A hospitalization was associated with 28% higher odds of warfarin use but 29% lower odds of INR monitoring. Conversely, warfarin use was associated with 10% lower odds of any hospitalization, but not with an AFIB-related hospitalization. INR monitoring was not significantly associated with hospitalization. Results from this study suggest that targeting clinicians to increase adherence to management guidelines for chronic conditions such as AFIB and expanding medication reconciliation interventions can improve the quality of care for NH residents and avoid unnecessary care transitions.
    • Prevalence of prescribing evidence-based pharmacotherapy by dementia status among elderly residents of long-term care facilities in the United States

      Hernandez, Jose Josue; Zuckerman, Ilene H. (2007)
      Background. Risk factors associated with underprescribing, such as increasing age and dementia diagnosis, are highly prevalent among LTC residents. Despite being recognized as a highly prevalent problem among elderly persons, underprescribing of EBP has not been studied adequately among elderly persons residing in LTC facilities. The objective of this dissertation was to measure the prevalence of EBP prescribing among LTC elderly residents, as well as to determine if disparities in prescribing EBP exist by dementia and cognitive level.;Methods. A longitudinal cohort at the resident-month level was assembled from a nationally representative sample of Medicare LTC residents. Resident-months with a LTC facility stay of two or more consecutive days from January 1st 2000 to December 31 st 2002 were included in the study. Selected resident-months were retrospectively tested for the presence of each one of seven specific conditions needed to be treated with EBP, and subsequently evaluated for the prevalence of EBP prescribing. A generalized estimating equations procedure was used to study the association between dementia diagnosis, level of cognitive impairment, and prescribing EBP.;Results. 1,938 LTC residents were eligible for inclusion. Mean age was 85 years; 72% were female. The highest EBP prevalence was found for the use of a bowel regimen if receiving opioids (73%) and the lowest EBP was found for the use of beta-blockers among residents with CHF (17%). Resident-months with dementia and/or moderate to severe level of cognitive impairment were not statistically significantly associated with EBP. Increasing age (OR=0.78; 95% CI=0.62, 0.98) and higher comorbidity level (OR=0.71; 95% CI=0.52, 0.98) were statistically significantly associated with lower odds of receiving all of the indicated EBP. Conclusion. The prevalence of EBP among US LTC residents is below what is considered to be optimal among those with and without dementia. The EBP therapies tested in this study have been shown to increase quality of life and to decrease hospitalizations and mortality among elderly patients. However, the low prevalence of EBP in this LTC population suggests that complex care issues associated with age give rise to challenges in defining and implementing "best" care approaches.
    • Stress Ulcer Prophylaxis in Intensive Care Units: Use, Benefit and Risk

      ALJAWADI, MOHAMMAD; Zuckerman, Ilene H. (2014)
      Background: Stress ulcer prophylaxis (SUP) is a standard of care for intensive care unit (ICU) patients with known stress ulcer risk factors (SURFs). Proton pump inhibitors (PPIs) and histamine-2 receptor blockers (H2Bs) are the most common SUP medications. The higher potency of PPIs suggests more reduction in clinically important gastrointestinal bleeding (CIGIB) compared to H2Bs but higher risk of nosocomial pneumonia (NP) and clostridium-difficile associated diseases (CDAD). The goals of this study are to describe factors associated with SUP use and determine whether PPIs are associated with lower risk of CIGIB and higher risk of NP and CDAD compared to H2Bs in the ICU. Methods: Using Philips eICU Research Institute ICU database, a cohort of 572,519 adults admitted to 293 ICUs between 1/1/2008 and 6/30/2012 was created to study SUP use and outcomes. SUP use was defined as the administration PPIs, H2Bs, sucralfate or antacids during the ICU stay. Multivariable logistic regression was used to identify factors associated with use and with overuse; SUP overuse was defined as the receipt of SUP medications in patients without SURFs. Discrete-time Cox proportional hazard multivariable regression models were used to compare PPIs to H2Bs with regard to CIGIB, NP and CDAD. Results: The cohort comprised 76% Caucasians and 54% males; mean age was 62.4 years. SUP use was high (86.4%). While most of SURFs predicted SUP receipt, mechanical ventilation for more than 24 hours (odds ratio (OR) =10.6, 99% CI: 9.8-11.5) and organ transplantation (OR=13.3, 99% CI: 6.9-25.7) were the strongest predictors. PPIs were the most widely used (50 %) followed by H2Bs (18 %). Overuse of SUP medications was observed in 80% of ICU patients. Hazard of CIGIB was two times greater for PPI users compared to H2B users (adjusted hazard ratio (HR) 1.97 (95% CI: 1.48-2.63). Hazard of CDAD was not significantly different between the PPIs and H2B users (HR: 1.12, 95% CI: 0.89-1.41), while the risk of NP was lower among PPI compared to H2B users (HR: 0.87, 95%CI: 0.77-0.97). Conclusions: Knowledge generated from this study on factors associated with SUP use in the ICU, and comparative risks and benefits, can be used to identify and design interventions to improve guideline adherence and improve appropriateness of use and outcomes.