- 121 South Main Street, Box G-S121-8, Providence, RI 02912
Andrew R Zullo
Brown University, Health Services, Policy & Practice, Faculty Member
- Rhode Island Hospital, Pharmacy, Department Memberadd
- Pharmacy, Clinical Pharmacy, Public Health, Health Policy, Health Services Research, Comparative Effectiveness Research, and 22 morePatient-Centered Care, Nursing Homes, Geriatrics, Geriatric medicine, Quality Use of Medications, Pharmacoepidemiology, Pharmacoepidemiology and drug safety, Type 2 Diabetes Mellitus, Pharmacotherapy, Elderly Falls (Geriatrics), Cardiovascular disease, Healthcare, Food and Drug Administration, Long Term Care, Drug Regulatory Affairs, Epidemiology, Variance Estimation for Complex Surveys, Analysis of Complex Surveys, Causal Inference, Causality, Causation, and Evidence Based Medicineedit
- Andrew R. Zullo, PharmD, ScM, PhD is a pharmacoepidemiologist and health services researcher. He joined Brown Univers... moreAndrew R. Zullo, PharmD, ScM, PhD is a pharmacoepidemiologist and health services researcher. He joined Brown University in 2012 as a joint PhD student in Health Services Research and ScM student in Epidemiology. In 2015, he then transitioned to become an AHRQ K12 Scholar in Patient Centered Outcomes Research and an Investigator in the Department of Health Services, Policy, and Practice.
Andrew's main research interest is in the study of prescription drug effects, particularly in geriatric patients and nursing home settings. He applies comparative effectiveness and safety methodologies to patient-centered outcomes research topics in diabetes, cardiovascular disease, fractures/osteoporosis, nephrology, and more. His other interests include 1) the quality and determinants of medication use, 2) personal prescription drug importation, and 3) new models of pharmaceutical care delivery and medication management.
Andrew continues to practice as an inpatient clinical pharmacist at Rhode Island Hospital, where he trains residents and students.edit - Vincent Mor, David D. Dore, Ira Wilson, Omar Galarraga, Chanelle Howe, Christine Berard-Collins, Issa Dahabreh, Sarah Berry, Michael A. Steinmanedit
OBJECTIVE: Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a... more
OBJECTIVE:
Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.
DESIGN AND SETTING:
Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.
PARTICIPANTS:
A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.
MEASUREMENTS:
Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.
RESULTS:
We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).
CONCLUSIONS:
Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.
Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.
DESIGN AND SETTING:
Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.
PARTICIPANTS:
A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.
MEASUREMENTS:
Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.
RESULTS:
We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).
CONCLUSIONS:
Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.
Research Interests:
Introduction: Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic... more
Introduction: Despite high rates of hip fracture among United States (US) nursing home (NH) residents, little is known about geographic variation in hip fracture incidence. We used nationally representative data to identify geographic variation in hip fracture among US NH residents. Design and setting: Retrospective cohort study using Part A claims for a 100% of Medicare enrollees in 15,289 NHs linked to NH minimum data set and Online Survey, Certification, and Reporting databases. Participants: A total of 891,085 long-stay (continuous residence of 100 days) NH residents 65 years old. Measurements: Medicare Part A claims documenting a hip fracture. Mean incidence rates of hip fracture for long-stay NH residents were calculated for each state and US Census Division from 2007 to 2010. Results: The age-, sex-, and race-adjusted incidence rate of hip fracture ranged from 1.49 hip fractures/ 100 person-years (Hawaii) to 3.60 hip fractures/100 person-years (New Mexico), with a mean of 2.38 (standard deviation 0.43) hip fractures/100 person-years. The mean incidence of hip fracture was 1.7-fold greater in the highest quintile than the lowest. Conclusions: We observed modest US state and regional variation in hip fracture incidence among long-stay NH residents. Future studies should assess whether state policies or NH characteristics explain the variation.
Research Interests:
Background: Hip fractures are associated with significant morbidity and mortality in the nursing home. Our objective was to describe the incidence rate (IR) of hip fracture according to age, sex, and race in a nationwide sample of... more
Background: Hip fractures are associated with significant morbidity and mortality in the nursing home. Our objective was to describe the incidence rate (IR) of hip fracture according to age, sex, and race in a nationwide sample of long-stay nursing home residents. Methods: Using 2007–2010 Medicare claims data linked with the Minimum Data Set, we identified 892,837 long-stay residents (≥100 days in the same nursing facility) between May 1, 2007 and April 30, 2008. Hip fractures were defined using Part A diagnostic codes (ICD-9). Residents were followed from the date they became a long-stay resident until the first event of death, discharge, hip fracture, or 2 years of follow-up. Results: Mean age was 84 years (range 65–113 years), and 74.5% were women. 83.9% were white and 12.0% were black. The overall IR of hip fracture was 2.3/100 person years. The IR was similar in men and women across age groups. The IR of hip fracture was highest in Native Americans aged 85 years or older (3.7/100 person years), in whites (2.6/100 person years), and during the first 100 days of institutionalization (2.7/100 person years). IRs of hip fracture were lowest in blacks (1.3/100 person years). Conclusions: In nursing home residents surviving 100 days or more in a facility, the incidence of hip fracture is high, particularly among older white, Native American, and newly admitted residents. This is the first nationwide study to provide sex-and age-specific estimates among U.S. nursing home residents, and it underscores the magnitude of the problem.
Research Interests: Geriatrics, Sex and Gender, Epidemiology, Elderly Falls (Geriatrics), Race and Ethnicity, and 11 moreClinical Epidemiology, Native American, Nursing Homes, Fractures, Native Americans, Hip Fractures, Medicare, International Classification of Diseases, Falls in the Elderly, Minimum Data Set, and Geriatrics and Gerontology
The purpose of this study was to evaluate whether home-delivered meals, and the frequency of delivery, reduces self-reported falls among homebound older adults. Data come from a randomized parallel three-arm study of 371 older adults on... more
The purpose of this study was to evaluate whether home-delivered meals, and the frequency of delivery, reduces self-reported falls among homebound older adults. Data come from a randomized parallel three-arm study of 371 older adults on seven Meals on Wheels programs' waiting lists. Participants were randomly assigned to receive (a) daily meal delivery (n = 139); (b) once weekly, frozen meal delivery (n = 106); or (c) control, remain on the waiting list for meals (n = 126). Participants were surveyed at baseline and 15 weeks post randomization. At follow-up, 36 (28.6%) in the control group, 29 (27.4%) receiving once weekly delivered meals, and 33 (23.7%) receiving daily delivered meals reported a fall (compared with control, daily meal risk ratio [RR] = 0.83, 95% confidence limits [CL] = [0.55, 1.25]; frozen meal RR = 0.96, 95%CL = [0.63, 1.45]). Our study suggests that daily delivered meals may reduce the risk of falls. Additional work is needed to understand the effect of meals on falls, particularly among previous fallers, a high-risk subgroup.
Research Interests:
To the Editor: The recent American Diabetes Association position statement on the management of type 2 diabetes mellitus in long-term care settings highlights the need for different pharmacological treatment approaches to... more
To the Editor: The recent American Diabetes Association position statement on the management of type 2 diabetes mellitus in long-term care settings highlights the need for different pharmacological treatment approaches to community-dwelling adults and long-stay nursing home (NH) residents.[1] The position statement recommends simplified medication regimens with a lower risk of adverse effects for NH residents,[1] but there is little information on how glucose-lowering treatment use in NHs compares with that in the community.[2] Identifying and quantifying common glucose-lowering medication patterns would help inform future efforts to improve glucose-lowering medication management and prioritization of pharmaceutical comparative effectiveness research (CER) questions for NH residents.[1, 3]
This letter describes and juxtaposes common glucose-lowering medication usage patterns for a national cross-section of U.S. adults aged 65 and older residing in NH and community settings between January 1, 2007, and December 31, 2010. A random 20% national sample of Medicare fee-for-service beneficiaries with Parts A, B, and D claims linked to the Minimum Data Set (MDS), a federally mandated NH health assessment tool, was used. Individuals could have Medicare insurance coverage for any duration. All beneficiaries had at least one dispensing of a glucose-lowering treatment during the study period.
Prevalent glucose-lowering medication use was assessed using Part D data. Medication use patterns were mutually exclusive and defined without regard to the time sequence of the dispensings. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes from Part B claims during the study period were used to ascertain the prevalence of comorbidities and geriatric conditions. Hospitalizations during the study period were identified through Part A claims. MDS version 2.0 and the Residential History File algorithm were used to identify Medicare beneficiaries who resided in a NH for the long term (≥90 consecutive days).[4, 5] The study cohort was then divided into two mutually exclusive subpopulations: community-dwelling adults and long-stay NH residents.
Two-sample t-tests and chi-squared tests were used to compare the characteristics of those who resided in the community with the characteristics of those who resided in a NH. The period prevalences of glucose-lowering medication usage patterns were then calculated in each subpopulation. Exact (Clopper-Pearson) binomial 95% confidence intervals were calculated to facilitate comparisons of the pattern prevalences between and within the subpopulations.[6] The institutional review board of Brown University reviewed and approved this study.
Of 1,215,715 individuals, 1,119,874 (92.1%) were identified as community dwelling and 95,841 (7.9%) as long-stay NH residents. Mean age of the community-dwelling subpopulation was 75.4, 56.9% were female, and 36.8% had been hospitalized during the study period. Mean age of the NH subpopulation was 82.3, 68.8% were female, and 76.6% had been hospitalized (P < .001 for all). All examined comorbidities were more prevalent in the NH than the community subpopulation, including coronary artery disease (53.6% vs 34.9%), heart failure (57.5% vs 21.8%), hypertension (87.6% vs 67.4%), depression (47.4% vs 12.0%), and dementia (68.8% vs 9.9%) (P < .001 for all comparisons).
In the community-dwelling population, 42.7% (95% confidence interval (CI) = 42.6–42.8%) were dispensed a single class of glucose-lowering medication during the study period. The prevalence of single class use was lower in the NH (28.2%, 95% CI = 27.9–28.5). Most NH residents (71.8%) were dispensed medications from two or more classes, 41.6% were dispensed three or more, and 19.9% four or more. Of community-dwelling adults, 57.3% were dispensed two or more medication classes, 25.6% three or more, and 9.6% four or more (P < .001 vs NH subpopulation). The 20 most-prevalent glucose-lowering medication use patterns (Table 1) accounted for a large proportion of all observed patterns. In the community, the five most-common patterns of medication class use were oral therapies. In the NH, three of the five most-common patterns involved parenterally administered drug classes. Biguanides (metformin) and sulfonylureas were commonly used in the community and NH, but use was greater in the community (P < .001).
The complexity of glucose-lowering medications is greater in NH than community-dwelling populations, with substantial differences in the prevalence of various drug combinations between the two cohorts. In combination with existing evidence, these results suggest that continued efforts are warranted to improve glucose-lowering medication management and simplify treatment regimens in the NH.[7] They also suggest that the relative importance of CER questions regarding specific glucose-lowering treatments may differ according to care setting.[8] The data further indicate that CER studies of glucose-lowering treatments in older adults must address the combination use of medications, especially in NH residents.[9, 10]
This letter describes and juxtaposes common glucose-lowering medication usage patterns for a national cross-section of U.S. adults aged 65 and older residing in NH and community settings between January 1, 2007, and December 31, 2010. A random 20% national sample of Medicare fee-for-service beneficiaries with Parts A, B, and D claims linked to the Minimum Data Set (MDS), a federally mandated NH health assessment tool, was used. Individuals could have Medicare insurance coverage for any duration. All beneficiaries had at least one dispensing of a glucose-lowering treatment during the study period.
Prevalent glucose-lowering medication use was assessed using Part D data. Medication use patterns were mutually exclusive and defined without regard to the time sequence of the dispensings. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes from Part B claims during the study period were used to ascertain the prevalence of comorbidities and geriatric conditions. Hospitalizations during the study period were identified through Part A claims. MDS version 2.0 and the Residential History File algorithm were used to identify Medicare beneficiaries who resided in a NH for the long term (≥90 consecutive days).[4, 5] The study cohort was then divided into two mutually exclusive subpopulations: community-dwelling adults and long-stay NH residents.
Two-sample t-tests and chi-squared tests were used to compare the characteristics of those who resided in the community with the characteristics of those who resided in a NH. The period prevalences of glucose-lowering medication usage patterns were then calculated in each subpopulation. Exact (Clopper-Pearson) binomial 95% confidence intervals were calculated to facilitate comparisons of the pattern prevalences between and within the subpopulations.[6] The institutional review board of Brown University reviewed and approved this study.
Of 1,215,715 individuals, 1,119,874 (92.1%) were identified as community dwelling and 95,841 (7.9%) as long-stay NH residents. Mean age of the community-dwelling subpopulation was 75.4, 56.9% were female, and 36.8% had been hospitalized during the study period. Mean age of the NH subpopulation was 82.3, 68.8% were female, and 76.6% had been hospitalized (P < .001 for all). All examined comorbidities were more prevalent in the NH than the community subpopulation, including coronary artery disease (53.6% vs 34.9%), heart failure (57.5% vs 21.8%), hypertension (87.6% vs 67.4%), depression (47.4% vs 12.0%), and dementia (68.8% vs 9.9%) (P < .001 for all comparisons).
In the community-dwelling population, 42.7% (95% confidence interval (CI) = 42.6–42.8%) were dispensed a single class of glucose-lowering medication during the study period. The prevalence of single class use was lower in the NH (28.2%, 95% CI = 27.9–28.5). Most NH residents (71.8%) were dispensed medications from two or more classes, 41.6% were dispensed three or more, and 19.9% four or more. Of community-dwelling adults, 57.3% were dispensed two or more medication classes, 25.6% three or more, and 9.6% four or more (P < .001 vs NH subpopulation). The 20 most-prevalent glucose-lowering medication use patterns (Table 1) accounted for a large proportion of all observed patterns. In the community, the five most-common patterns of medication class use were oral therapies. In the NH, three of the five most-common patterns involved parenterally administered drug classes. Biguanides (metformin) and sulfonylureas were commonly used in the community and NH, but use was greater in the community (P < .001).
The complexity of glucose-lowering medications is greater in NH than community-dwelling populations, with substantial differences in the prevalence of various drug combinations between the two cohorts. In combination with existing evidence, these results suggest that continued efforts are warranted to improve glucose-lowering medication management and simplify treatment regimens in the NH.[7] They also suggest that the relative importance of CER questions regarding specific glucose-lowering treatments may differ according to care setting.[8] The data further indicate that CER studies of glucose-lowering treatments in older adults must address the combination use of medications, especially in NH residents.[9, 10]
Research Interests:
OBJECTIVES: To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of... more
OBJECTIVES: To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers., had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission. MEASUREMENTS: The outcome was beta-blocker initiation within 30 days of NH readmission. RESULTS: Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment , use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79–1.00 for aged 75–84 to OR = 0.65, 95% CI = 0.54–0.79 for ≥95 vs 65–74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75–0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80–0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership. CONCLUSION: Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards. J Am Geriatr Soc 2016.
Research Interests:
The Centers for Disease Control and Prevention has previously recommended that all adolescents undergo HIV testing in the United States (US). Despite these recommendations, national HIV testing among US adolescents has remained low. This... more
The Centers for Disease Control and Prevention has previously recommended that all adolescents undergo HIV testing in the United States (US). Despite these recommendations, national HIV testing among US adolescents has remained low. This study estimated the prevalence of and identified risk factors for not receiving an HIV test among adolescents with a history of sexual intercourse in New York City (NYC), an urban area that has been greatly impacted by the HIV epidemic. Cross-sectional data on 1199 NYC high school students who completed the 2013 NYC Youth Risk Behavior Survey were used. Modified Poisson regression models were used to assess whether demographic factors, alcohol/drug use and sexual behaviors were associated with self-report of lack of HIV testing. In the weighted study population, about 72% were ≥16 years old, approximately 35% were African-American and nearly half were male. Sixty percent reported no history of HIV testing. In adjusted analyses, younger age, male gender, White race/ethnicity, heroin use, as well as reporting one prior sexual partner, were significantly and positively associated with no prior history of HIV testing. Our findings suggest that among NYC adolescents with a history of sexual intercourse, the prevalence of HIV testing is low. HIV testing may have been low in part because of limited experience with current screening guidelines among clinicians. Furthermore, many of the adolescents identified as being more likely to not be tested may have not been screened because of inadequate knowledge about HIV, a low perceived HIV risk or an unstable lifestyle. Therefore, to increase HIV testing among NYC adolescents, interventions that enhance HIV knowledge among adolescents as well as interventions that promote review and application of current screening guidelines among clinicians should be implemented in NYC. Educational interventions should especially be targeted at the adolescents identified in this study.
Research Interests:
OBJECTIVES: To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment. DESIGN: Cross-sectional study.... more
OBJECTIVES:
To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment.
MEASUREMENTS:
Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses.
RESULTS:
Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic.
CONCLUSION:
Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.
To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment.
MEASUREMENTS:
Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses.
RESULTS:
Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic.
CONCLUSION:
Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.
Research Interests:
IMPORTANCE: Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential... more
IMPORTANCE:
Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.
OBJECTIVE:
To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.
DESIGN, SETTING, AND PARTICIPANTS:
This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.
MAIN OUTCOMES AND MEASURES:
Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.
RESULTS:
The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new β-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of β-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of β-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, β-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from β-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to β-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of β-blockers were similar across all subgroups.
CONCLUSIONS AND RELEVANCE:
Use of β-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of β-blockers yielded a considerable mortality benefit in all groups.
Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.
OBJECTIVE:
To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.
DESIGN, SETTING, AND PARTICIPANTS:
This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.
MAIN OUTCOMES AND MEASURES:
Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.
RESULTS:
The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new β-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of β-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of β-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, β-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from β-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to β-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of β-blockers were similar across all subgroups.
CONCLUSIONS AND RELEVANCE:
Use of β-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of β-blockers yielded a considerable mortality benefit in all groups.
Research Interests: Geriatrics, Pharmacoepidemiology, Aging, Mild Cognitive Impairment, Mortality, and 16 moreCognitive Aging, Nursing Homes, Healthy Aging, Hospitalization, Propensity Scores, Acute Myocardial Infarction, Propensity Score Matching, Medicare, Myocardial Infarction, Comparative Effectiveness Research, Antihypertensive Drugs, Beta Blockers, Minimum Data Set, Geriatrics and Gerontology, Pharmacoepidemiology and drug safety, and Functional Decline
Background: The timing and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia in trauma patients are not well characterized. This information is critical for the selection of appropriate empiric antibiotics. The... more
Background: The timing and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia in trauma patients are not well characterized. This information is critical for the selection of appropriate empiric antibiotics. The objective of this study was to determine the incidence of MRSA pneumonia in early-onset and late-onset pneumonia and to identify risk factors for MRSA in the trauma-burn intensive care unit (ICU). Patients and Methods: We conducted a retrospective cohort study from January 2012 to March 2015 of patients in the trauma and burn ICU with clinical and microbiologic evidence of pneumonia. Demographics, injury type and severity, co-morbidities, antimicrobial agents, and MRSA nasal colonization at ICU admission were extracted from the medical record. A multi-variable exact logistic regression was performed to assess predictors of MRSA pneumonia. Results: Eighty patients with 88 episodes of pneumonia were included in the cohort. Ten patients had MRSA pneumonia, an overall incidence of 11.4% of pneumonia episodes with a median onset of seven days. The proportion of MRSA pneumonia episodes was not significantly different in early-onset (<5 days) or late-onset pneumonia, and there were no statistically significant risk factors for developing MRSA pneumonia. The majority of patients with MRSA had at least one known risk factor including homelessness, substance abuse, and receipt of broad-spectrum antibiotic agents. Conclusions: The 11.4% overall incidence of MRSA pneumonia in this trauma-burn cohort was similar to what has been reported in other trauma populations, although MRSA was equally likely to be identified in early-and late-onset pneumonia. Our results suggest that risk factors other than duration of hospitalization may be important considerations in the decision to initiate MRSA-active empiric therapy for pneumonia in the trauma-burn ICU.
Research Interests: Homelessness, Critical Care, Hospital Acquired infection, Trauma, Hospitals, and 10 moreCritical Care Medicine, Substance Abuse, INTENSIVE CARE, Pneumonia, Antibiotics, Intensive Care Unit, Burns, Intensive Care Medicine, Ventilator Associated Pneumonia, and Methicillin Resistant Staphylococcus Aureus (MRSA)
OBJECTIVE: We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing. DESIGN:... more
OBJECTIVE:
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
MEASUREMENTS:
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
RESULTS:
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
CONCLUSION:
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
MEASUREMENTS:
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
RESULTS:
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
CONCLUSION:
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
Research Interests:
BACKGROUND: Activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) monitoring methods for unfractionated heparin (UFH) often disagree. The extent of discordance for those with elevated bilirubin remains unclear. Our... more
BACKGROUND: Activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) monitoring methods for unfractionated heparin (UFH) often disagree. The extent of discordance for those with elevated bilirubin remains unclear. Our objective was to evaluate concordance between activated aPTT and anti-Xa methods for hyperbilirubinemic patients on UFH.
Research Interests: Pharmacy, Hemostasis and Thrombosis, Pharmacy Practice, Clinical Pharmacy, Therapeutic drug monitoring, and 15 moreHeparin, Hospital Management, Adverse Drug Reactions, Drug Safety, Medicine, Pharmacovigilance, Anticoagulation, Adverse Events, Hospital, Thromboembolism, Anticoagulant, Academic Medical Center, Rhode Island, Medication Errors - Medication Safety, Pharmacoepidemiology and drug safety, Activated partial thromboplastin time, and Hyperbilirubinemia
Personal prescription drug importation occurs in the United States because of the high cost of U.S. medicines and lower cost of foreign equivalents. Importation carries a risk of exposure to counterfeit (i.e., falsified, fraudulent),... more
Personal prescription drug importation occurs in the United States because of the high cost of U.S. medicines and lower cost of foreign equivalents. Importation carries a risk of exposure to counterfeit (i.e., falsified, fraudulent), adulterated, and substandard drugs. Inadequate health insurance may increase the risk of importation. We use inverse probability weighted marginal structural models and data on 87,494 individuals from the 2011-2013 National Health Interview Survey to estimate the marginal association between no health insurance and importation within U.S. subpopulations. The marginal prevalence difference [95% confidence limits] for those without (prevalence = 0.031) versus those with health insurance was 0.016 [0.011, 0.021]. The prevalence difference was higher among persons who were Hispanic, born in Latin America, Russia, or Europe, traveled to developing countries, and did not use the Internet to fill prescriptions or to find health information. Health insurance coverage may effectively reduce importation, especially among particular subpopulations.
Research Interests:
Research Interests:
BACKGROUND: Healthcare-associated infections (HAIs) are seen in 17% of critically ill patients. Probiotics, live nonpathogenic microorganisms, may aid in reducing the incidence of infection in critically ill patients. We hypothesized that... more
BACKGROUND: Healthcare-associated infections (HAIs) are seen in 17% of critically ill patients. Probiotics, live nonpathogenic microorganisms, may aid in reducing the incidence of infection in critically ill patients. We hypothesized that administration of probiotics would be safe and reduce the incidence of HAIs among mechanically ventilated neurocritical care patients.
METHODS: We assembled 2 retrospective cohorts of mechanically ventilated neurocritical care patients. In the preintervention cohort from July 1, 2011, to December 31, 2011, probiotics were not used. In the postintervention group from July 1, 2012, to December 31, 2012, 1 g of a combination of Lactobacillus acidophilus and Lactobacillus helveticus was administered twice daily to all patients who were mechanically ventilated for more than 24 hours.
RESULTS: There were a total of 167 patients included, 80 patients in the preintervention group and 87 patients in the postintervention group. No patients in the preintervention group received probiotics. Eighty-five (98%) patients in the postintervention group received probiotics for a median of 10 days (interquartile range, 4-20 days). There were 14 (18%) HAIs in the preintervention group and 8 (9%) HAIs in the postintervention group (P = .17). Ventilator days, lengths of stay, in-hospital mortality, and discharge disposition were similar between the pre- and postintervention groups. There were no cases of Lactobacillus bacteremia or other adverse events associated with probiotics use.
CONCLUSION: Probiotics are safe to administer in neurocritical care patients; however, this study failed to demonstrate a significant decrease in HAIs or secondary outcomes associated with probiotics.
METHODS: We assembled 2 retrospective cohorts of mechanically ventilated neurocritical care patients. In the preintervention cohort from July 1, 2011, to December 31, 2011, probiotics were not used. In the postintervention group from July 1, 2012, to December 31, 2012, 1 g of a combination of Lactobacillus acidophilus and Lactobacillus helveticus was administered twice daily to all patients who were mechanically ventilated for more than 24 hours.
RESULTS: There were a total of 167 patients included, 80 patients in the preintervention group and 87 patients in the postintervention group. No patients in the preintervention group received probiotics. Eighty-five (98%) patients in the postintervention group received probiotics for a median of 10 days (interquartile range, 4-20 days). There were 14 (18%) HAIs in the preintervention group and 8 (9%) HAIs in the postintervention group (P = .17). Ventilator days, lengths of stay, in-hospital mortality, and discharge disposition were similar between the pre- and postintervention groups. There were no cases of Lactobacillus bacteremia or other adverse events associated with probiotics use.
CONCLUSION: Probiotics are safe to administer in neurocritical care patients; however, this study failed to demonstrate a significant decrease in HAIs or secondary outcomes associated with probiotics.
Research Interests: Traumatic Brain Injury, Probiotics, Critical Care, INTENSIVE CARE, Adult neuro intensive care, and 12 moreBloodstream Infections, Mechanical Ventilation, Clabsi, Intensive Care Medicine, Antibiotic stewardship, control of Health care associated infections, Ventilator Associated Pneumonia, Ventilator Associated Pneumonia in the Neuro ICU, Central Line Infections, Critically Ill Patient Nutrition, Interrupted time series, Neurocritical Care, and Critically Ill Patients
Objective Personal prescription drug importation (PPDI) is prevalent in the USA because of the high cost of US medicines and lower cost of foreign equivalents. The practice carries the risk of exposure to counterfeit, adulterated and... more
Objective Personal prescription drug importation (PPDI) is prevalent in the USA because of the high cost of US medicines and lower cost of foreign equivalents. The practice carries the risk of exposure to counterfeit, adulterated and substandard medicines. No known tools are available for predicting person-level PPDI risk. The objective of this study was to develop and validate a predictive PPDI index for policymakers, researchers and clinicians. Methods Using 2011 and 2012 National Health Interview Survey data as the development and validation cohorts respectively, we identified predictors, built multivariable logistic regression models and validated the index by comparing predicted risk of PPDI in the development cohort with the observed risk in the validation cohort. We assessed calibration using the Hosmer–Lemeshow goodness-of-fit test and discrimination with C-statistics. The outcome measure was survey-reported PPDI (1 = yes; 0 = no). Key findings In the development cohort, prevalence of PPDI in respondents with 0–2, 3, 4, 5–6 or ≥7 risk factors were 0.32%, 0.57%, 1.09%, 2.95% and 13.67% (C-statistic = 0.78), and in the validation cohort, were 0.32%, 0.54%, 0.95%, 2.89% and 10.80% (C-statistic = 0.76). The Hosmer–Lemeshow test indicated the absence of a gross lack of fit (P = 0.58) in the validation cohort. Conclusion This predictive index accurately stratifies US adults into groups at differential risk of PPDI and may provide value to those who are responsible for health policy and regulation of pharmaceutical importation.
Research Interests:
PURPOSE: The implementation and outcomes of a program combining electronic home blood pressure monitoring (HBPM) and pharmacist-provided medication therapy management (MTM) services in a renal transplantation clinic are described.... more
PURPOSE: The implementation and outcomes of a program combining electronic home blood pressure monitoring (HBPM) and pharmacist-provided medication therapy management (MTM) services in a renal transplantation clinic are described.
SUMMARY: Patients enrolled in the program were provided with a computer-enabled blood pressure monitor. A dedicated renal transplantation pharmacist was integrated into the renal transplantation team under a collaborative care practice agreement. The collaborative care agreement allowed the pharmacist to authorize medication additions, deletions, and dosage changes. Comprehensive disease and blood pressure education was provided by a clinical pharmacist. In the pretransplantation setting, the pharmacist interviewed the renal transplant candidate and documents allergies, verified the patient's medication profile, and identified and assessed barriers to medication adherence. A total of 50 renal transplant recipients with at least one recorded home blood pressure reading and at least one year of follow-up were included in our analysis. A significant reduction in mean systolic and diastolic blood pressure values were observed at 30, 90, 180, and 360 days after enrollment in the program (p < 0.05). Pharmacist interventions were documented for 37 patients. Medication-related problems accounted for 46% of these interventions and included dosage modifications, regimen changes, and mitigation of barriers to medication access and adherence.
CONCLUSION: Implementation of electronic HBPM and pharmacist-provided MTM services implemented in a renal transplant clinic was associated with sustained improvements in blood pressure control. Incorporation of a pharmacist in the renal transplant clinic resulted in the detection and resolution of medication-related problems.
SUMMARY: Patients enrolled in the program were provided with a computer-enabled blood pressure monitor. A dedicated renal transplantation pharmacist was integrated into the renal transplantation team under a collaborative care practice agreement. The collaborative care agreement allowed the pharmacist to authorize medication additions, deletions, and dosage changes. Comprehensive disease and blood pressure education was provided by a clinical pharmacist. In the pretransplantation setting, the pharmacist interviewed the renal transplant candidate and documents allergies, verified the patient's medication profile, and identified and assessed barriers to medication adherence. A total of 50 renal transplant recipients with at least one recorded home blood pressure reading and at least one year of follow-up were included in our analysis. A significant reduction in mean systolic and diastolic blood pressure values were observed at 30, 90, 180, and 360 days after enrollment in the program (p < 0.05). Pharmacist interventions were documented for 37 patients. Medication-related problems accounted for 46% of these interventions and included dosage modifications, regimen changes, and mitigation of barriers to medication access and adherence.
CONCLUSION: Implementation of electronic HBPM and pharmacist-provided MTM services implemented in a renal transplant clinic was associated with sustained improvements in blood pressure control. Incorporation of a pharmacist in the renal transplant clinic resulted in the detection and resolution of medication-related problems.