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Age at first intercourse and subsequent sexual partnering among adult women in the United States, a cross-sectional study

Wed, 05/13/2015 - 2:53pm

BACKGROUND: Concurrency and serial monogamy may increase risk for STIs when gaps fall within the infectious period. This study examined the association between early sexual debut and concurrent or serial sexual partnering among heterosexual adult women.

METHODS: We identified 6,791 heterosexually active women, ages 21-44, from the 2006-2010 National Survey of Family Growth, a multi-stage probability sample of women in the United States. Self-reported age at first intercourse was categorized as < 15, 15-17 and > /=18 years (referent). Sexual partnering was defined as concurrency (within the same month), serial monogamy with either a 1-3 month, or > /=4 month gap between partners, or monogamy (referent) in the year prior to interview. Polytomous logistic models provided adjusted odds ratios (aOR) and 95% confidence intervals (CI).

RESULTS: Concurrent partnerships in the year prior to interview were reported by 5.2% of women. Serial monogamy with a 1-3 month gap was reported by 2.5% of women. Compared with women whose sexual debut was > /=18 years, those < 15 years at sexual initiation had 3.7 times the odds of reporting concurrent partnerships (aOR: 3.72; 95% CI: 2.46-5.62). Women < 15 years of age at sexual debut had twice the odds of serial monogamy with gap lengths of 1-3 months between partners (aOR1-3 months: 2.13; 95% CI 1.15-3.94) as compared to women > /=18 years at sexual debut.

CONCLUSIONS: Sexual debut at < 15 years is associated with both concurrency and serial monogamy with 1-3 month gaps between partners in U.S. women aged 21-44.

Association of objectively measured physical activity and metabolic syndrome among U.S. adults with osteoarthritis

Wed, 05/13/2015 - 2:53pm

OBJECTIVE: To investigate the association between objectively-measured physical activity and metabolic syndrome among adults with osteoarthritis (OA).

METHODS: Using cross-sectional data from 2003-2006 NHANES, we identified 566 adults with OA with available accelerometer data assessed using Actigraph AM-7164 and measurements necessary to determine metabolic syndrome by Adult Treatment Panel III. Analysis of variance was conducted to examine the association between continuous variables in each activity level and metabolic syndrome components. Logistic models estimated the relationship of quartile of daily minutes of different physical activity levels to odds of metabolic syndrome adjusted for socioeconomic and health factors.

RESULTS: Among persons with OA, most were female with average age 62.1 years and average duration of disease of 12.9 years. Half of adults with OA had metabolic syndrome (51.0%; 95% Confidence Interval (CI): 44.2% to 57.8%), and only 9.6% engaged in the recommended 150 minutes per week of moderate/vigorous physical activity. Total sedentary time was associated with higher rates of metabolic syndrome and its components while light and moderate/vigorous objectively-measured physical activity were inversely associated with metabolic syndrome and its components. Higher levels of light activity was associated with lower prevalence of metabolic syndrome (quartile 4 versus quartile 1: adjusted odds ratio: 0.45; 95% CI: 0.24 to 0.84; p-value for linear trend < 0.005).

CONCLUSION: Most U.S. adults with OA are sedentary. Increased daily minutes in physical activity, especially in light intensity, is more likely to be associated with decreasing prevalence of metabolic syndrome among persons with OA. This article is protected by copyright. All rights reserved.

Performance of the Present-on-Admission Indicator for Clostridium difficile Infection

Wed, 05/13/2015 - 2:53pm

The performance of a hospital- and community-onset Clostridium difficile infection definition using administrative data with a present-on-admission indicator was compared with definitions using clinical surveillance. For hospital-onset C. difficile infection, there was moderate sensitivity (68%) and high specificity (93%); for community-onset, sensitivity and specificity were high (both 85%). Infect Control Hosp Epidemiol 2015;00(0): 1-3.

Pain management in nursing home residents with cancer

Wed, 05/13/2015 - 2:53pm

OBJECTIVES: To assess improvements in pain management of nursing home (NH) residents with cancer since the implementation of pain management quality indicators.

DESIGN: Cross-sectional.

SETTING: One thousand three hundred eighty-two U.S. NHs (N = 1,382).

PARTICIPANTS: Newly admitted, Medicare-eligible NH residents with cancer (N = 8,094).

MEASUREMENTS: Nationwide data on NH resident health from Minimum Data Set 2.0 linked to all-payer pharmacy dispensing records (February 2006-June 2007) were used to determine prevalence of pain, including frequency and intensity, and receipt of nonopioid and opioid analgesics. Multinomial logistic regression was used to evaluate resident-level correlates of pain and binomial logistic regression to identify correlates of untreated pain. RESULTS: More than 65% of NH residents with cancer had any pain (28.3% daily, 37.3% < daily), 13.5% of whom had severe and 61.3% had moderate pain. Women; residents admitted from acute care or who were bedfast; and those with compromised activities of daily living, depressed mood, an indwelling catheter, or a terminal prognosis were more likely to have pain. More than 17% of residents in daily pain (95% confidence interval (CI) = 16.0-19.1%) received no analgesics, including 11.7% with daily severe pain (95% CI = 8.9-14.5%) and 16.9% with daily moderate pain (95% CI = 15.1-18.8%). Treatment was negatively associated with age of 85 and older (adjusted OR (aOR) = 0.67, 95% CI = 0.55-0.81 vs aged 65-74), cognitive impairment (aOR = 0.71, 95% CI = 0.61-0.82), presence of feeding tube (aOR = 0.77, 95% CI = 0.60-0.99), and restraints (aOR = 0.50, 95% CI = 0.31-0.82).

CONCLUSION: Untreated pain is still common in NH residents with cancer and persists despite pain management quality indicators. Geriatrics Society.

Adherence to guidelines for glucose assessment in starting second-generation antipsychotics

Wed, 05/13/2015 - 2:16pm

OBJECTIVES: In 2003, the US Food and Drug Administration issued warnings about hyperglycemia and diabetes with second-generation antipsychotics (SGAs); guidelines have recommended metabolic screening since 2004. However, little is known of contemporary practices of glucose screening among youth initiating SGAs. Our objective was to evaluate baseline glucose assessment among youth in the Mini-Sentinel Distributed Database starting an SGA.

METHODS: The cohort included youth ages 2 through 18 newly initiating SGAs January 1, 2006, through December 31, 2011, across 10 sites. Baseline glucose was defined as fasting/random glucose or hemoglobin A1c (GLU) measurement occurring relative to first SGA dispensing. Differences in GLU assessment were evaluated with chi(2) tests and logistic regression.

RESULTS: The cohort included 16,304 youth; 60% boys; mean age 12.8 years. Risperidone was most commonly started (43%). Eleven percent (n = 1858) had GLU assessed between 90 days before and 3 days after first dispensing. Assessment varied across SGAs (olanzapine highest), sites (integrated health care systems higher), ages (16-18 highest), years (2007 highest), and gender (female higher; all P < .001). GLU assessment among those starting olanzapine was more likely than among those starting quetiapine (odds ratio [OR]: 1.72 [95% confidence interval (CI): 1.37-2.18]), aripiprazole (OR: 1.49 [95% CI: 1.18-1.87]), or risperidone (OR: 1.61 [95% CI: 1.28-2.03]).

CONCLUSIONS: Few children and adolescents starting SGA have baseline glucose assessed. This is concerning because those at high diabetes risk may not be identified. Further, lack of screening impedes determining the contribution of SGAs to hyperglycemia development.

Trends in elective labor induction for six United States health plans, 2001-2007

Wed, 05/13/2015 - 2:16pm

BACKGROUND: To describe trends in labor induction, including elective induction, from 2001 to 2007 for six U.S. health plans and to examine the validity of induction measures derived from birth certificate and health plan data.

METHODS: This retrospective cohort study included 339,123 deliveries at 35 weeks' gestation or greater. Linked health plan and birth certificate data provided information about induction, maternal medical conditions, and pregnancy complications. Induction was defined from diagnosis and procedure codes and birth certificate data and considered elective if no accepted indication was coded. We calculated induction prevalence across health plans and years. At four health plans, we reviewed medical records to validate induction measures.

RESULTS: Based on electronic data, induction prevalence rose from 28% in 2001 to 32% in 2005, then declined to 29% in 2007. The trend was driven by changes in the prevalence of apparent elective induction, which rose from 11% in 2001 to 14% in 2005 and then declined to 11% in 2007. The trend was similar for subgroups by parity and gestational age. Elective induction prevalence varied considerably across plans. On review of 86 records, 36% of apparent elective inductions identified from electronic data were confirmed as valid.

CONCLUSIONS: Elective induction appeared to peak in 2005 and then decline. The decrease may reflect quality improvement initiatives or changes in policies, patient or provider attitudes, or coding practices. The low validation rate for measures of elective induction defined from electronic data has important implications for existing quality measures and for research studies examining induction's outcomes.

Home medication support for childhood cancer: family-centered design and testing

Wed, 05/13/2015 - 2:16pm

PURPOSE: Errors in the use of medications at home by children with cancer are common, and interventions to support correct use are needed. We sought to (1) engage stakeholders in the design and development of an intervention to prevent errors in home medication use, and (2) evaluate the acceptability and usefulness of the intervention.

METHODS: We convened a multidisciplinary team of parents, clinicians, technology experts, and researchers to develop an intervention using a two-step user-centered design process. First, parents and oncologists provided input on the design. Second, a parent panel and two oncology nurses refined draft materials. In a feasibility study, we used questionnaires to assess usefulness and acceptability. Medication error rates were assessed via monthly telephone interviews with parents.

RESULTS: We successfully partnered with parents, clinicians, and IT experts to develop Home Medication Support (HoMeS), a family-centered Web-based intervention. HoMeS includes a medication calendar with decision support, a communication tool, adverse effect information, a metric conversion chart, and other information. The 15 families in the feasibility study gave HoMeS high ratings for acceptability and usefulness. Half recorded information on the calendar to indicate to other caregivers that doses were given; 34% brought it to the clinic to communicate with their clinician about home medication use. There was no change in the rate of medication errors in this feasibility study.

CONCLUSION: We created and tested a stakeholder-designed, Web-based intervention to support home chemotherapy use, which parents rated highly. This tool may prevent serious medication errors in a larger study.

Statin discontinuation in nursing home residents with advanced dementia

Wed, 05/13/2015 - 2:16pm

OBJECTIVES: To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days.

DESIGN: Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files.

SETTING: All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida).

PARTICIPANTS: NH residents with dementia.

MEASUREMENTS: Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation.

RESULTS: Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication.

CONCLUSION: Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up. Geriatrics Society.

Medication adherence among pediatric patients with sickle cell disease: a systematic review

Wed, 05/13/2015 - 2:16pm

OBJECTIVES: Describe rates of adherence for sickle cell disease (SCD) medications, identify patient and medication characteristics associated with nonadherence, and determine the effect of nonadherence and moderate adherence (defined as taking 60%-80% of doses) on clinical outcomes.

METHODS: In February 2012 we systematically searched 6 databases for peer-reviewed articles published after 1940. We identified articles evaluating medication adherence among patients < 25 years old with SCD. Two authors reviewed each article to determine whether it should be included. Two authors extracted data, including medication studied, adherence measures used, rates of adherence, and barriers to adherence.

RESULTS: Of 24 articles in the final review, 23 focused on 1 medication type: antibiotic prophylaxis (13 articles), iron chelation (5 articles), or hydroxyurea (5 articles). Adherence rates ranged from 16% to 89%; most reported moderate adherence. Medication factors contributed to adherence. For example, prophylactic antibiotic adherence was better with intramuscular than oral administration. Barriers included fear of side effects, incorrect dosing, and forgetting. Nonadherence was associated with more vaso-occlusive crises and hospitalizations. The limited data available on moderate adherence to iron chelation and hydroxyurea indicates some clinical benefit.

CONCLUSIONS: Moderate adherence is typical among pediatric patients with SCD. Multicomponent interventions are needed to optimally deliver life-changing medications to these children and should include routine monitoring of adherence, support to prevent mistakes, and education to improve understanding of medication risks and benefits.

Association of Early Post-Discharge Follow-Up by a Primary Care Physician and 30-Day Rehospitalization Among Older Adults

Wed, 05/13/2015 - 2:16pm

BACKGROUND: Rehospitalizations within 30 days of discharge are responsible for a large portion of healthcare spending. One approach to preventing rehospitalizations is early follow-up, usually defined as an office visit with a primary care physician within 7 days of discharge-an approach that is being incentivized by health plans. However, evidence regarding its effectiveness is limited.

OBJECTIVE: We aimed to determine whether an office visit with a primary care physician within 7 days after discharge is associated with 30-day rehospitalization.

DESIGN: This was an observational study set within a randomized trial.

PARTICIPANTS: The study included patients age 65 and older receiving care from a multi-specialty group practice and discharged from hospital to home between 26 August 2010 and 25 August 2011. To control for confounding, we identified characteristics of patients and hospital stays that are predictive of rehospitalization, and also developed high-dimensional propensity scores. Analyses used Cox proportional hazards models and took into account varying amounts of opportunity time for office visits.

MAIN MEASURES: We looked at 30-day rehospitalizations at any hospital.

KEY RESULTS: Of 3,661 patients discharged to home during the study year, 707 (19.3 %) were rehospitalized within 30 days. Patients receiving an office visit within 7 days numbered 1,808 (49.4 %), and of these, 1,000 (27.3 %) were with a primary care physician. In models predicting rehospitalization, stratified on deciles of propensity score and controlling for additional confounders, the hazard ratios associated with office visits with a primary care physician within 7 days were 0.98 (95 % CI 0.80, 1.21); for visits with any physician, the hazard ratio was HR 1.04, (95 % CI 0.87, 1.25).

CONCLUSIONS: We found no protective effect for office visits within 7 days. Such visits may need to be specifically focused on a range of issues related to the specific reasons why patients are rehospitalized. It is likely that outpatient visits will need to be set within comprehensive transition programs.

The Complex Relationship of Race to Outcomes in Heart Failure with Preserved Ejection Fraction

Wed, 05/13/2015 - 2:16pm

BACKGROUND: An improved understanding of racial differences in the natural history, clinical characteristics, and outcomes of heart failure will have important clinical and public health implications. We assessed how clinical characteristics and outcomes vary across racial groups (whites, blacks, and Asians) in adults with heart failure with preserved ejection fraction.

METHODS: We identified all adults with heart failure with preserved ejection fraction between 2005 and 2008 from 4 health systems in the Cardiovascular Research Network using hospital principal discharge and ambulatory visit diagnoses.

RESULTS: Among 13,437 adults with confirmed heart failure with preserved ejection fraction, 85.9% were white, 7.6% were black, and 6.5% were Asian. After adjustment for potential confounders and use of cardiovascular therapies, compared with whites, blacks (adjusted hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.62-0.85) and Asians (HR, 0.75; 95% CI, 0.64-0.87) had a lower risk of death from any cause. Compared with whites, blacks had a higher risk of hospitalization for heart failure (HR, 1.48; 95% CI, 1.29-1.68); no difference was observed for Asians compared with whites (HR, 1.01; 95% CI, 0.86-1.18). Compared with whites, no significant differences were detected in risk of hospitalization for any cause for blacks (HR, 1.03; 95% CI, 0.95-1.12) and Asians (HR, 0.93; 95% CI, 0.85-1.02).

CONCLUSIONS: In a diverse population with heart failure with preserved ejection fraction, we observed complex relationships between race and important clinical outcomes. More detailed studies of large populations are needed to fully characterize the epidemiologic picture and to elucidate potential pathophysiologic and treatment-response differences that may relate to race.

Beginning and duration of pregnancy in automated health care databases: review of estimation methods and validation results

Wed, 05/13/2015 - 2:16pm

PURPOSE: To describe methods reported in the literature to estimate the beginning or duration of pregnancy in automated health care data, and to present results of validation exercises where available.

METHODS: Papers reporting methods for determining the beginning or duration of pregnancy were identified based on Pubmed searches, by consulting investigators with expertise in the field and by reviewing conference abstracts and reference lists of relevant papers. From each paper or abstract, we extracted information to characterize the study population, data sources, and estimation algorithm. We then grouped these studies into categories reflecting their general methodological approach.

RESULTS: Methods were classified into 5 categories: (i) methods that assign a uniform duration for all pregnancies, (ii) methods that assign pregnancy duration based on preterm-delivery or health care related codes, or codes for other pregnancy outcomes, (iii) methods based on the timing of prenatal care, (iv) methods based on birth weight, and (v) methods that combine elements from 2 and 3. Validation studies evaluating these methods used varied approaches, with results generally reporting on the mistiming of the start of pregnancy, incorrect estimation of the duration of pregnancy, or misclassification of drug exposure during pregnancy or early pregnancy.

CONCLUSIONS: In the absence of accurate information on the beginning or duration of pregnancy, several methods of varying complexity are available to estimate them. Validation studies have been performed for many of them and can serve as a guide for method selection for a particular study.

Copyright (c) 2015 John Wiley and Sons, Ltd.

Effect of Preoperative Pain and Depressive Symptoms on the Development of Postoperative Delirium

Wed, 05/13/2015 - 2:16pm

BACKGROUND: Preoperative pain and depression predispose patients to delirium. Our goal was to determine whether pain and depressive symptoms interact to increase delirium risk.

METHODS: We enrolled 459 persons without dementia aged > /=70 years scheduled for elective orthopedic surgery. At baseline, participants reported their worst and average pain within seven days and current pain on a 0-10 scale. Depressive symptoms were assessed using the 15-item Geriatric Depression Scale and chart. Delirium was assessed with the Confusion Assessment Method and chart. We examined the relationship between preoperative pain, depressive symptoms and delirium using multivariable analysis of pain and delirium stratified by presence of depressive symptoms.

FINDINGS: Delirium, occurring in 23% of the sample, was significantly higher in those with depressive symptoms at baseline than those without (relative risk, RR, 1.6, 95% confidence interval, CI, 1.2-2.3). Preoperative pain was associated with an increased adjusted risk for delirium across all pain measures (RR from 1.07-1.08 per point of pain). In stratified analyses, patients with depressive symptoms had a 21% increased risk for delirium for each one-point increase in worst pain score, demonstrating a significant interaction (P=0.049). Similarly, a significant 13% increased risk for delirium was demonstrated for a one-point increase in average pain score, but the interaction did not achieve statistical significance.

INTERPRETATION: Preoperative pain and depressive symptoms demonstrated increased risk for delirium independently and with substantial interaction, suggesting a cumulative impact. Thus, pain and depression are vulnerability factors for delirium that should be assessed before surgery.

FUNDING: U.S. National Institute on Aging.

Cognitive and Brain Reserve and the Risk of Postoperative Delirium in Older Patients

Wed, 05/13/2015 - 2:16pm

BACKGROUND: Cognitive and brain reserve theories suggest that aspects of neural architecture or cognitive processes modify the impact of neuropathological processes on cognitive outcomes. While frequently studied in the context of dementia, reserve in delirium is relatively understudied.

METHODS: We examined the association of three markers of brain reserve (head circumference, MRI-derived brain volume, and leisure time physical activity) and five markers of cognitive reserve (education, vocabulary, cognitive activities, cognitive demand of lifetime occupation, and interpersonal demand of lifetime occupation) and the risk of postoperative delirium in a prospective observational study of 566 older adults free of dementia undergoing scheduled surgery.

FINDINGS: Twenty four percent of patients (135/566) developed delirium during the postoperative hospitalization period. Of the reserve markers examined, only the Wechsler Test of Adult Reading (WTAR) was significantly associated with the risk of delirium. A one-half standard deviation better performance on the WTAR was associated with a 38% reduction in delirium risk (P = 0.01); adjusted relative risk of 0.62, 95% confidence interval 0.45-0.85.

INTERPRETATION: In this relatively large and well-designed study, most markers of reserve fail to predict delirium risk. The exception to this is the WTAR. Our findings suggest that the reserve markers that are important for delirium may be different from those considered to be important for dementia.

Rationales that providers and family members cited for the use of antipsychotic medications in nursing home residents with dementia

Wed, 05/13/2015 - 2:16pm

OBJECTIVES: To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs).

DESIGN: Qualitative, descriptive study.

SETTING: Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions.

PARTICIPANTS: Individuals diagnosed with dementia who received an antipsychotic medication.

MEASUREMENTS: Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded reasons for antipsychotic prescribing were summarized across all sources.

RESULTS: Major categories of reasons for use of antipsychotic medications in the 204 NH residents in the study sample were behavioral (n = 171), psychiatric (n = 159), emotional states (n = 105), and cognitive diagnoses or symptoms (n = 114). The most common behavioral reasons identified were verbal (n = 91) and physical (n = 85) aggression. For the psychiatric category, psychosis (n = 95) was most frequently described. Anger (n = 93) and sadness (n = 20) were the most common emotional states cited.

CONCLUSION: The rationale for use of antipsychotic drug therapy frequently relates to a wide variety of indications for which these drugs are not approved and for which evidence of efficacy is lacking. These findings have implications for clinical practice and policy. Geriatrics Society.

Antidepressant Use and Cognitive Decline: The Health and Retirement Study

Wed, 05/13/2015 - 2:16pm

BACKGROUND: Depression is associated with cognitive impairment and dementia, but whether treatment for depression with antidepressants reduces the risk for cognitive decline is unclear. We assessed the association between antidepressant use and cognitive decline over 6 years.

METHODS: Participants were 3,714 adults aged 50 or older enrolled in the nationally-representative Health and Retirement Study (HRS) and with self-reported antidepressant use. Depressive symptoms were assessed using the 8-item Center for Epidemiologic Studies Depression Scale. Cognitive function was assessed at four time-points (2004, 2006, 2008, 2010) through using a validated 27-point scale. Change in cognitive function over the 6-year follow-up period was examined using linear growth models, adjusted for demographics, depressive symptoms, comorbidities, functional limitations and antidepressant anticholinergic activity load.

RESULTS: At baseline, cognitive function did not differ significantly between the 445 (12.1%) participants taking antidepressants and those not taking antidepressants (mean 14.9%, 95% CI: 14.3-15.4 vs. mean 15.1%, 95% CI: 14.9-15.3). During the 6-year follow up period, cognition declined in both users and nonusers of antidepressants, ranging from -1.4 change in mean score in those with high depressive symptoms and taking antidepressants to -.5 change in mean score in those with high depressive symptoms and not taking antidepressants. In adjusted models, people taking antidepressants declined at the same rate as those not taking antidepressants. Results remained consistent across different levels of baseline cognitive function, age, and duration of antidepressant use (prolonged versus short-term).

CONCLUSIONS: Antidepressant use did not modify the course of 6-year cognitive change in this nationally- representative sample.

Cognitive and Physical Demands of Activities of Daily Living in Older Adults: Validation of Expert Panel Ratings

Wed, 05/13/2015 - 2:16pm

BACKGROUND: Difficulties with performance of functional activities may result from cognitive and/or physical impairments. To date, there has not been a clear delineation of the physical and cognitive demands of activities of daily living.

OBJECTIVES: To quantify the relative physical and cognitive demands required to complete typical functional activities in older adults.

DESIGN: Expert panel survey.

SETTING: Web-based platform.

PARTICIPANTS: Eleven experts from 8 academic medical centers and 300 community-dwelling elderly adults age 70 and older scheduled for elective noncardiac surgery from 2 academic medical centers.

METHODS: Sum scores of expert ratings were calculated and then validated against objective data collected from a prospective longitudinal study.

MAIN OUTCOME MEASUREMENTS: Correlation between expert ratings and objective neuropsychologic tests (memory, language, complex attention) and physical measures (gait speed and grip strength) for performance-based tasks.

RESULTS: Managing money, self-administering medications, using the telephone, and preparing meals were rated as requiring significantly more cognitive demand, whereas walking and transferring, moderately strenuous activities, and climbing stairs were assessed as more physically demanding. Largely cognitive activities correlated with objective neuropsychologic performance (r = 0.13-0.23, P < .05) and largely physical activities correlated with physical performance (r = 0.15-0.46, P < .05).

CONCLUSIONS: Quantifying the degree of cognitive and/or physical demand for completing a specific task adds an additional dimension to standard measures of functional assessment. This additional information may significantly influence decisions about rehabilitation, postacute care needs, treatment plans, and caregiver education. Published by Elsevier Inc. All rights reserved.

Use of atypical antipsychotics in nursing homes and pharmaceutical marketing

Wed, 05/13/2015 - 2:16pm

OBJECTIVES: To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN: Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING: Forty-one NHs in Connecticut.

PARTICIPANTS: NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS: Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level characteristics, NH staffing, and NH quality. Qualitative data, including semistructured interviews and surveys of NH leaders conducted in the first quarter of 2011, were used to determine encounters with pharmaceutical marketing.

RESULTS: Leadership at 46.3% of NHs (n = 19) reported pharmaceutical marketing encounters, consisting of educational training, written and Internet-based materials, and sponsored training. No association was detected between level of atypical antipsychotic prescribing and reports of any pharmaceutical marketing by at least one NH leader.

CONCLUSION: NH leaders frequently encounter pharmaceutical marketing through a variety of ways, although the impact on atypical antipsychotic prescribing is unclear. Geriatrics Society.

Incidence, in-hospital case-fatality rates, and management practices in Puerto Ricans hospitalized with acute myocardial infarction

Tue, 05/12/2015 - 10:32pm

OBJECTIVE: There are extremely limited data on minority populations, especially Hispanics, describing the clinical epidemiology of acute coronary disease. The aim of this study is to examine the incidence rate of acute myocardial infarction (AMI), in-hospital case-fatality rate (CFR), and management practices among residents of greater San Juan (Puerto Rico) who were hospitalized with an initial AMI.

METHODS: Our trained study staff reviewed and independently validated the medical records of patients who had been hospitalized with possible AMI at any of the twelve hospitals located in greater San Juan during calendar year 2007.

RESULTS: The incidence rate (# per 100,000 population) of 1,415 patients hospitalized with AMI increased with advancing age and were significantly higher for older patients for men (198) than they were for women (134). The average age of the study population was 64 years, and women comprised 45% of the study sample. Evidence-based cardiac therapies, e.g., aspirin, beta blockers, ACE inhibitors/angiotensin receptor blockers, and statins, were used with 60% of the hospitalized patients, and women were less likely than men to have received these therapies (59% vs. 65%) or to have undergone interventional cardiac procedures (47% vs. 59%) (p < 0.05). The in-hospital CFR increased with advancing age and were higher for women (8.6%) than they were for men (6.0%) (p < 0.05).

CONCLUSION: Efforts are needed to reduce the magnitude of AMI, enhance the use of evidence-based cardiac therapies, reduce possible gender disparities, and improve the short-term prognoses of Puerto Rican patients hospitalized with an initial AMI.