Adherence to treatment guidelines: the association between stroke risk stratified comparing CHADS2 and CHA2DS2-VASc score levels and warfarin prescription for adult patients with atrial fibrillation.

BACKGROUND: Ischemic stroke is a risk associated with atrial fibrillation (AF) and is estimated to occur five times more often in afflicted patients than in those without AF. Anti-thrombotic therapy is recommended for the prevention of ischemic stroke. Risk stratification tools, such as the CHADS2, and more recently the CHA2DS2-VASc, for predicting stroke in patients with AF have been developed to determine the level of stroke risk and assist clinicians in the selection of antithrombotic therapy. Warfarin, for stroke prevention in AF, is the most commonly prescribed anticoagulant in North America. The purpose of this study was to examine the utility of using the CHADS2 score levels (low and high) in contrast to the CHA2DS2-VASc when examining the outcome of warfarin prescriptions for adult patients with AF. The CHA2DS2-VASc tool was not widely used in 2010, when the data analyzed were collected. It has only been since 2014 that CHA2DS2-VASc criteria has been recommended to guide anticoagulant treatment in updated AF treatment guidelines. METHODS: Bivariate and multivariate data analysis strategies were used to analyze 2010 National Ambulatory Care Survey (NAMCS) data. NAMCS is designed to collect data on the use and provision of ambulatory care services nationwide. The study population for this research was US adults with a diagnosis of AF. Warfarin prescription was the dependent variable for this study. The study population was 7,669,844 AF patients. RESULTS: Bivariate analysis revealed that of those AF patients with a high CHADS2 score, 25.1% had received a warfarin prescription and 18.8 for those with a high CHA2DS2-VASc score. Logistic regression analysis yielded that patients with AF had higher odds of having a warfarin prescription if they had a high CHADS2 score, were Caucasian, lived in a zip code where < 20% of the population had a university education, and lived in a zip code where < 10% of the population were living in households with incomes below the federal poverty level. Further, the analysis yielded that patients with AF had lesser odds of having a warfarin prescription if they were ≥ 65 years of age, female, or had health insurance. CONCLUSIONS: Overall, warfarin appears to be under-prescribed for patients with AF regardless of the risk stratification system used. Based on the key findings of our study opportunities for interventions are present to improve guideline adherence in alignment with risk stratification for stroke prevention. Interprofessional health care teams can provide improved medical management of stroke prevention for patients with AF. These interprofessional health care teams should be constituted of primary care providers (physicians, physician assistants, and nurse practitioners), nurses (RN, LPN), and pharmacists (PharmD, RPh).

Potentially Inappropriate Medication Prescribing in U.S. Older Adults with Selected Chronic Conditions.

OBJECTIVE: Developing one or more chronic diseases increases with age. Appropriate treatment for chronic conditions often requires multiple medications. The purpose of this study was to examine potentially inappropriate prescriptions in patients 65 years of age or older, seen in a primary care office, with at least one of three chronic conditions (diabetes, arthritis, depression), who were prescribed at least two medications, one of which was inappropriate for the patient's condition. DESIGN: 2012 National Ambulatory Medical Care Survey data were examined using multivariate techniques. SETTING: U.S. primary care office visits. MAIN OUTCOME MEASURES: Drug appropriateness was ascertained from practice guidelines. Potentially inappropriate medications were ascertained from the 2012 Beers criteria. The 2012 Beers criteria were used since the data analyzed were from 2012. RESULTS: Logistic regression analysis yielded that older adults with diabetes had greater odds of having a potentially inappropriate prescription if they saw a provider in a rural setting, were non-white, had health insurance, and had two or more office visits in the last 12 months. CONCLUSION: There is a need to address prescribing of potentially inappropriate medications to older, non-white patients who have diabetes. Living in rural areas is also an important factor in prescribing patterns for older adults with diabetes. Our findings suggest that interventions are warranted to address this health problem. One solution is the establishment of interprofessional and multidisciplinary teams of health care providers constituted of prescribers and nonprescribers to comprehensively evaluate prescribing practices.

Injuries in Adults 65 Years of Age and Older Prescribed Muscle Relaxants.

OBJECTIVE: The Beers criteria list skeletal muscle relaxants (SMR) as inappropriate for individuals 65 years of age and older because of anticholinergic effects, sedation, and risk of falls/fractures. Patients 65 years of age and older presenting to U.S. primary care clinics for injury, prescribed an SMR, are at risk for these events. SMR prescribing patterns in older adults with injury have not been well studied at the population level. Using nationally representative data, the prevalence of older adults prescribed an SMR presenting to U.S. primary care clinics with injury was examined. DESIGN: A cross-sectional study analyzing 2012 National Ambulatory Medical Care Survey (NAMCS) data using bivariate and multivariate techniques. NAMCS, a nationally representative database of the U.S. population, collects data from primary care office visits and uses a multi-stage sampling strategy. SETTING: Primary care offices throughout the United States. PATIENTS, PARTICIPANTS: Adults 65 years of age and older, presenting to rural primary care clinics with injury. MAIN OUTCOME MEASURE(S): Prescription for SMR. RESULTS: Multivariate analysis yielded that the study population presenting to rural clinics for injury had 28% greater odds, non-Caucasian adults had 11% greater odds, and those who had been seen at least twice in the past 12 months had 34% greater odds of being prescribed an SMR. Logistic regression analysis also yielded that females 65 to 74 years of age had greater odds of having a prescription for an SMR. CONCLUSION: The results of this study identified disparities among adults 65 years of age and older presenting to U.S. rural primary care clinics with injury and prescribed an SMR. Adults 65 years of age and older, Collaborative.

Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data.

BACKGROUND: Non-malignant chronic pain (NMCP) is one of the most common reasons for primary care visits. Pain management health care disparities have been documented in relation to patient gender, race, and socioeconomic status. Although not studied in relation to chronic pain management, studies have found that living in a rural community in the US is associated with health care disparities. Rurality as a social determinant of health may influence opioid prescribing. We examined rural and non-rural differences in opioid prescribing patterns for NMCP management, hypothesizing that distinct from education, income, racial or gender differences, rural residency is a significant and independent factor in opioid prescribing patterns. METHODS: 2010 National Ambulatory Medical Care Survey (NAMCS) data were examined using bivariate and multivariate techniques. NAMCS data were collected using a multi-stage sampling strategy. For the multivariate analysis performed the SPSS complex samples algorithm for logistic regression was used. RESULTS: In 2010 an estimated 9,325,603 US adults (weighted from a sample of 2745) seen in primary care clinics had a diagnosis of NMCP; 36.4% were prescribed an opioid. For US adults with a NMCP diagnosis bivariate analysis revealed rural residents had higher odds of having an opioid prescription than similar non-rural adults (OR = 1.515, 95% CI 1.513-1.518). Complex samples logistic regression analysis confirmed the importance of rurality and yielded that US adults with NMCP who were prescribed an opioid had higher odds of: being non-Caucasian (AOR =2.459, 95% CI 1.194-5.066), and living in a rural area (AOR =2.935, 95% CI 1.416-6.083). CONCLUSIONS: Our results clearly indicated that rurality is an important factor in opioid prescribing patterns that cannot be ignored and bears further investigation. Further research on the growing concern about the over-prescribing of opioids in the US should now include rurality as a variable in data generation and analysis. Future research should also attempt to document the ecological, sociological and political factors impacting opioid prescribing and care in rural communities. Prescribers and health care policy makers need to critically evaluate the implications of our findings and their relationship to patient needs, best practices in a rural setting, and the overall consequences of increased opioid prescribing on rural communities.

A population-based cross-sectional study of health service deficits among U.S. adults with depressive symptoms.

BACKGROUND: Depression is a psychiatric condition that affects approximately one in five U.S. adults in their lifetime. No study that we know of has examined depressive symptoms and health service deficits in rural compared with non-rural populations. Four factors constitute the variable health service deficits: did not have health insurance, did not have a healthcare provider, deferred medical care because of cost and did not have a routine medical exam, all within the last 12 months. The aim of this study was to ascertain the prevalence of health service deficits in rural versus non-rural adults with depressive symptoms. Examining depressive symptoms by health service deficits is important because it allows us to approximate those with the condition who might not be receiving care for it. By analyzing national, population-based data, this study sought to fill in some important epidemiological gaps regarding depressive symptoms and health service deficits. METHODS: For this analysis the population of interest was U.S. adults identified as currently having depressive symptoms using the PHQ-8 criteria. Behavior Risk Factor Surveillance Survey 2006 data were used in this analysis. Health service deficits was the primary dependent variable. Multivariate logistic regression analysis was performed to examine health service deficits experienced by adults with depression controlling for socioeconomic status, race and ethnicity and geographic locale (rural or non-rural). RESULTS: Logistic regression analysis yielded that U.S. adults currently having depressive symptoms who were of low socioeconomic status, Hispanic ethnicity, or living in a rural locale were more likely to have at least one health service deficit. CONCLUSION: Analyzing data collected by a large surveillance system such as BRFSS, allows for an analysis incorporating an array of covariates not available from clinically-based data such as electronic health records. By identifying clinically depressed U.S. adults who also have at least one health service deficit, we were able to ascertain those most likely not receiving care for this debilitating condition. We believe community pharmacists are well suited to assist in connecting depressed, vulnerable populations with appropriate and needed care. This care would be best provided by an inter-professional team led by a primary care provider.

Knowledge of heart attack and stroke symptomology: a cross-sectional comparison of rural and non-rural US adults.

BACKGROUND: Understanding the signs and symptoms of heart attacks and strokes are important not only in saving lives, but also in preserving quality of life. Findings from recent research have yielded that the prevalence of cardiovascular disease risk factors are higher in rural populations, suggesting that adults living in rural locales may be at higher risk for heart attack and/or stroke. Knowledge of heart attack and stroke symptomology as well as calling 911 for a suspected heart attack or stroke are essential first steps in seeking care. This study sought to examine the knowledge of heart attack and stroke symptoms among rural adults in comparison to non-rural adults living in the U.S. METHODS: Using multivariate techniques, a cross-sectional analysis of an amalgamated multi-year Behavioral Risk Factor Surveillance Survey (BRFSS) database was performed. The dependent variable for this analysis was low heart attack and stroke knowledge score. The covariates for the analysis were: age, sex, race/ethnicity, annual household income, attained education, health insurance status, having a health care provider (HCP), timing of last routine medical check-up, medical care deferment because of cost, self-defined health status and geographic locale. RESULTS: The weighted n for this study overall was 103,262,115 U.S. adults > =18 years of age. Approximately 22.0% of these respondents were U.S. adults living in rural locales. Logistic regression analysis revealed that those U.S. adults who had low composite heart attack and stroke knowledge scores were more likely to be rural (OR=1.218 95%CI 1.216-1.219) rather than non-rural residents. Furthermore, those with low scores were more likely to be: male (OR=1.353 95%CI 1.352-1.354), >65 years of age (OR=1.369 95%CI 1.368-1.371), African American (OR=1.892 95%CI 1.889-1.894), not educated beyond high school (OR=1.400 955CI 1.399-1.402), uninsured (OR=1.308 95%CI 1.3-6-1.310), without a HCP (OR=1.216 95%CI 1.215-1.218), and living in a household with an annual income of < $50,000 (OR=1.429 95%CI 1.428-1.431). CONCLUSIONS: Analysis identified clear disparities between the knowledge levels U.S. adults have regarding heart attack and stroke symptoms. These disparities should guide educational endeavors focusing on improving knowledge of heart attack and stroke symptoms.

A scoping review of opioid misuse in the rural United States.

INTRODUCTION: This study is a scoping review of the original research literature onthe misuse of opioids in the rural United States (US) and maps theliterature of interest to address the question: What does theoriginal research evidence reveal about the misuse of opioids inrural US communities? METHODS: This study used a modified preferred reporting items for systematicreviews and meta-analyses (PRISMA) approach which is organized byfive distinct elements or steps: beginning with a clearly formulatedquestion, using the question to develop clear inclusion criteria toidentify relevant studies, using an approach to appraise the studiesor a subset of the studies, summarizing the evidence using anexplicit methodology, and interpreting the findings of the review. RESULTS: The initial search yielded 119 peer reviewed articles and aftercoding, 41 papers met the inclusion criteria. Researcher generatedsurveys constituted the most frequent source of data. Most studieshad a significant quantitative dimension to them. All the studieswere observational or cross-sectional by design. CONCLUSIONS: This analysis found an emerging research literature that hasgenerated evidence supporting the claim that rural US residents andcommunities suffer a disproportionate burden from the misuseof opioidscompared to their urban or metropolitan counterparts.

A Population-Based, Cross-Sectional Study Examining Health Services Deficits of US Veterans Using 2014 Behavioral Risk Factor Surveillance System Data: Is Rural Residency an Independent Risk Factor after Controlling for Multiple Covariates?

Introduction: In 2014, it was reported that there was a backlog of an estimated 1.2 million claims nationwide at the United States Veterans Administration (VA). This ecological occurrence opened up a space for asking and answering some important questions about health service deficits (HSD) of US veterans, which is the focus of the research reported on in this paper. The purpose of this study was to ascertain if rural veterans were more likely to experience HSDs than urban military veterans after controlling for a number of covariates. Methods: Bivariate and multivariate data analysis strategies were used to examine 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey data. HSD was the dependent variable. Results: Two multivariate models were tested. The first logistic regression analysis yielded that rural veterans had higher odds of having at least one HSD. The second yielded that rural US veterans in 2014 who had higher odds of having at least one HSD were: 18-64 years of age, unemployed seeking employment, living in households with annual incomes lower than $75,000, without a university degree, not part of a married or unmarried couple, a current smoker, and/or a binge drinker within the last 30 days. Conclusions: The study described here fills identified epidemiological gaps in our knowledge regarding rural US military veterans and HSDs. The findings are not only interesting but important, and should be used to inform interventions to reduce HSDs for rural veterans.

Team science as interprofessional collaborative research practice: a systematic review of the science of team science literature.

The National Institute of Health's concept of team science is a means of addressing complex clinical problems by applying conceptual and methodological approaches from multiple disciplines and health professions. The ultimate goal is the improved quality of care of patients with an emphasis on better population health outcomes. Collaborative research practice occurs when researchers from >1 health-related profession engage in scientific inquiry to jointly create and disseminate new knowledge to clinical and research health professionals in order to provide the highest quality of patient care to improve population health outcomes. Training of clinicians and researchers is necessary to produce clinically relevant evidence upon which to base patient care for disease management and empirically guided team-based patient care. In this study, we hypothesized that team science is an example of effective and impactful interprofessional collaborative research practice. To assess this hypothesis, we examined the contemporary literature on the science of team science (SciTS) produced in the past 10 years (2005-2015) and related the SciTS to the overall field of interprofessional collaborative practice, of which collaborative research practice is a subset. A modified preferred reporting items for systematic reviews and meta-analyses (PRISMA) approach was employed to analyze the SciTS literature in light of the general question: Is team science an example of interprofessional collaborative research practice? After completing a systematic review of the SciTS literature, the posed hypothesis was accepted, concluding that team science is a dimension of interprofessional collaborative practice.

Evaluation of the impact of comprehensive medication management services delivered posthospitalization on readmissions and emergency department visits.

BACKGROUND: The impact of providing cognitive pharmacy services following hospital discharge has been studied with various results. This study is specifically focused on comprehensive medication management services delivered postdischarge in an interprofessional team environment to patients aged >65 years. OBJECTIVE: To determine if delivery of comprehensive medication management services postdischarge will prevent hospital readmissions or emergency department visits within 6 months following discharge in patients aged >65 years. Secondary endpoints included 30-day and 60-day postdischarge events. METHODS: This was a prospective group matched-controlled study of patients aged >65 years with selected diagnoses identified as high risk for readmission. The intervention group received comprehensive medication management that was provided face-to-face in the patient's primary care clinic within 2 weeks of discharge. RESULTS: No statistically significant difference was found between intervention and control groups in hospital readmissions or emergency department visits at 30 days, 60 days, or 6 months after discharge. No statistically significant difference was seen in mortality between groups. CONCLUSIONS: Provision of comprehensive medication management services did not reduce emergency department visits or readmissions in this study. This study was limited by multiple other changes occurring in the health system during the time of this study that potentially confounded results. In addition, the study may have been too small to detect a difference.

Maximizing medication therapy management services through a referral initiative.

PURPOSE: The implementation and effects of an initiative to refer patients to receive medication therapy management (MTM) services after hospital discharge are described. METHODS: A check box to order an MTM appointment was added to the discharge medication order form printed for hospitalized patients in an integrated health system. Hospitalists were informed about MTM services and encouraged to refer hospitalized patients to the service who were at risk for adverse drug events or medication nonadherence. A retrospective case series review was conducted to evaluate documented MTM encounters, comparing the number of patients seen at the MTM practice for hospital follow-up during the four months before and after the initiative's implementation. Secondary endpoints included revenue generated by MTM encounters and the percentage of patients with documented drug therapy problems due to medication nonadherence. RESULTS: A total of 313 encounters were included in the analysis (142 preimplementation and 171 postimplementation). The percentage of MTM hospital follow-up encounters significantly increased from the preimplementation period to the post-implementation period, from 30.28% (n = 43) to 63.74% (n = 109) (p < 0.001). After the referral initiative was implemented, MTM hospital follow-up encounters were more likely to reveal medication nonadherence, compared with regular office visits (odds ratio, 2.1; 95% confidence interval, 1.01-4.34; p = 0.039). CONCLUSION: The implementation of an initiative to refer hospitalized patients to an MTM service in an integrated health system increased the percentage of recently discharged patients seen in an MTM practice; patients seen postimplementation were more likely to be nonadherent to their medication regimen.

Examination of pneumococcal vaccination rates among U.S. adult smokers.

PURPOSE: Pneumococcal vaccination rates among U.S. adult smokers in rural and nonrural areas were compared to determine the effect of federal vaccination recommendations. METHODS: Using bivariate and multivariate techniques, 2005 and 2010 Behavioral Risk Factor Surveillance Survey data were analyzed for comparative purposes. The dependent variable for this analysis was receipt of pneumococcal vaccine. The population of interest was U.S. adults age 19-64 years who reported that they currently smoked. Covariates included sex, race and ethnicity, household income, educational attainment, geographic area (rural or nonrural location of last routine medical checkup), having a personal health care provider, having health insurance, deferring medical care because of cost, self-defined health status, and receipt of seasonal influenza vaccination in the past 12 months. Results In 2005, 15.5% of smokers reported that they had ever received a pneumonia vaccine; by 2010, this percentage increased to 20.8%. In 2005, rural adult smokers were more likely to receive a pneumococcal vaccine (odds ratio [OR], 1.357; 95% confidence interval [CI], 1.338-1.377) than their nonrural counterparts. In 2010, rural adult smokers were less likely to receive the vaccine (OR, 0.952; 95% CI, 0.938-0.966). In both years, men were more likely to receive pneumococcal vaccine, as were those with health insurance and a health care provider. Overall, receipt of a seasonal influenza vaccine was the strongest predictor of smokers receiving pneumococcal vaccine. CONCLUSION: U.S. adult smokers were most likely to receive pneumococcal vaccine if they were men, had health insurance, had a health care provider, and received a seasonal influenza vaccination within the past year.

Incorporating research into a postgraduate year 1 pharmacy residency.

OBJECTIVE: To implement a longitudinal research experience in the form of an embedded mini-fellowship in a first-postgraduate year (PGY1) residency program. DESIGN: In September 2011, a research module was initiated and research meetings were established on a recurrent basis throughout the residency so that residents would have protected time for academic work. The research module was structured around lecture seminars, statistical analysis workshops, and works-in-progress sessions. ASSESSMENT: Two residents completed the initial module and worked on multiple research projects. The projects were assessed by the lead faculty member on the research module based on established learning objectives for the module. The 3 completed research projects were presented at national meeting poster sessions. Five papers were submitted to scholarly journals for peer review. Residents were able to submit their final required project manuscripts just 4 months after beginning the research module. CONCLUSION: Formalizing the research efforts of PGY1 residents by establishing a research module with protected time ensured residents worked steadily toward established deadlines and met the objectives of the module.

Myoclonus associated with long-term use of diltiazem.

PURPOSE: A case of possible diltiazem-induced myoclonus in a patient receiving long-term therapy, with residual symptoms after discontinuation, is reported. SUMMARY: A 61-year-old Caucasian man who had received diltiazem therapy for 5 years for the treatment of premature ventricular contractions (PVCs) was seen at a clinic for complaints of abnormal sensations and body movements that had worsened over 2 years and were sometimes triggered by an exaggerated startle response to light and startling scenes on television and in movies. After a sleep study, electroencephalography, and other evaluations to rule out neurologic and other causes of the patient's myoclonus, diltiazem therapy was discontinued; two weeks later, the man reported a 50% reduction in symptoms. At 1- and 3-year follow-up visits, the patient reported further diminution but not complete resolution of the myoclonic symptoms. In contrast to other published cases of calcium-channel-blocker-induced myoclonus, the onset of movement symptoms in this case was delayed, occurring years rather than days after the initiation of diltiazem use; the residual symptoms persisted far longer than in other reported cases. It is possible that the concomitant use of citalopram and a change in the patient's lipid-lowering medication may have contributed to or prolonged the abnormal movement symptoms in this case. Using the adverse drug reaction probability algorithm of Naranjo et al., the case was classified as possible diltiazem-induced myoclonus. CONCLUSION: A 61-year-old man developed myoclonus three years after starting diltiazem therapy for PVCs. The symptoms gradually resolved after the discontinuation of diltiazem but did not stop completely.