Persistent polypharmacy and fall injury risk: the Health, Aging and Body Composition Study.

BACKGROUND: Older adults receive treatment for fall injuries in both inpatient and outpatient settings. The effect of persistent polypharmacy (i.e. using multiple medications over a long period) on fall injuries is understudied, particularly for outpatient injuries. We examined the association between persistent polypharmacy and treated fall injury risk from inpatient and outpatient settings in community-dwelling older adults. METHODS: The Health, Aging and Body Composition Study included 1764 community-dwelling adults (age 73.6 ± 2.9 years; 52% women; 38% black) with Medicare Fee-For-Service (FFS) claims at or within 6 months after 1998/99 clinic visit. Incident fall injuries (N = 545 in 4.6 ± 2.9 years) were defined as the initial claim with an ICD-9 fall E-code and non-fracture injury, or fracture code with/without a fall code from 1998/99 clinic visit to 12/31/08. Those without fall injury (N = 1219) were followed for 8.1 ± 2.6 years. Stepwise Cox models of fall injury risk with a time-varying variable for persistent polypharmacy (defined as ≥6 prescription medications at the two most recent consecutive clinic visits) were adjusted for demographics, lifestyle characteristics, chronic conditions, and functional ability. Sensitivity analyses explored if persistent polypharmacy both with and without fall risk increasing drugs (FRID) use were similarly associated with fall injury risk. RESULTS: Among 1764 participants, 636 (36%) had persistent polypharmacy over the follow-up period, and 1128 (64%) did not. Fall injury incidence was 38 per 1000 person-years. Persistent polypharmacy increased fall injury risk (hazard ratio [HR]: 1.31 [1.06, 1.63]) after adjusting for covariates. Persistent polypharmacy with FRID use was associated with a 48% increase in fall injury risk (95%CI: 1.10, 2.00) vs. those who had non-persistent polypharmacy without FRID use. Risks for persistent polypharmacy without FRID use (HR: 1.22 [0.93, 1.60]) and non-persistent polypharmacy with FRID use (HR: 1.08 [0.77, 1.51]) did not significantly increase compared to non-persistent polypharmacy without FRID use. CONCLUSIONS: Persistent polypharmacy, particularly combined with FRID use, was associated with increased risk for treated fall injuries from inpatient and outpatient settings. Clinicians may need to consider medication management for FRID and other fall prevention strategies in community-dwelling older adults with persistent polypharmacy to reduce fall injury risk.

Economic Burden Associated with Receiving Inhaled Corticosteroids with Leukotriene Receptor Antagonists or Long-Acting Beta Agonists as Combination Therapy in Older Adults.

BACKGROUND: There is a paucity of literature on the health care expenditures associated with different pharmacologic treatments in older adults with asthma that is not well controlled on inhaled corticosteroids (ICS). OBJECTIVE: To compare asthma-related and all-cause health care expenditures associated with leukotriene receptor antagonists (LTRA) versus long-acting beta agonists (LABA) when added to ICS in older adults with asthma. METHODS: A retrospective cohort was constructed using 2009-2010 Medicare fee-for-service medical and pharmacy claims from a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009. The sample comprised patients who were aged 65 years and older, diagnosed with asthma, and treated exclusively with ICS + LABA or ICS + LTRA. Outcomes assessed were asthma-related expenditures (medical, pharmacy, and total) and all-cause health care expenditures (medical, pharmacy, and total). Outcomes were measured from the date of the first prescription for the add-on treatment (LABA or LTRA in combination with ICS) after having at least a 4-month "wash-in" period in which patients were receiving no controller, ICS alone, or ICS plus the add-on treatment of the follow-up period. Patients were followed until death, switching to or adding the other add-on treatment, or the end of the study (December 31, 2010). Multivariable regression models with nonparametric bootstrapped standard errors were used to compare all-cause and asthma-related expenditures per patient per month (PPPM) between ICS + LABA and ICS + LTRA users. All models were adjusted for demographics, comorbidities, and county-level health care access variables. RESULTS: The primary analysis included 14,702 patients, of whom 12,940 were treated with ICS + LABA and 1,762 were treated with ICS + LTRA. The mean (SD) follow-up periods were 12.3 (± 5.7) months for the ICS + LABA group and 15.3 (± 5.1) months for the ICS + LTRA group. Adjusted asthma-related expenditures PPPM were $400 for the ICS + LTRA group compared with $286 for the ICS + LABA group (P < 0.001). However, adjusted total all-cause expenditure PPPM was significantly lower for patients treated with ICS + LTRA ($6,087 for ICS + LTRA compared with $6,975 for ICS + LABA, P = 0.029). CONCLUSIONS: Older adults with asthma often experience economic burden from asthma and other chronic illnesses. Compared with ICS + LTRA, ICS + LABA was associated with lower asthma-related expenditures but with higher all-cause expenditures in older adults. DISCLOSURES: Support for this study was provided by the University of Pittsburgh School of Pharmacy and the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AGAG024827). C. Thorpe reports grants from the National Institute of Aging during the conduct of this study. The other authors have nothing to disclose.

Cost effectiveness of an internet-delivered lifestyle intervention in primary care patients with high cardiovascular risk.

OBJECTIVE: To assess the cost-effectiveness of an online adaptation of the diabetes prevention program (ODPP) lifestyle intervention. METHODS: ODPP was a before-after evaluation of a weight loss intervention comprising 16 weekly and 8 monthly lessons, incorporating behavioral tools and regular, brief, web-based individualized counseling in an overweight/obese cohort (mean age 52, 76% female, 92% white, 28% with diabetes). A Markov model was developed to estimate ODPP cost effectiveness compared with usual care (UC) to reduce metabolic risk over 10years. Intervention costs and weight change outcomes were obtained from the study; other model parameters were based on published reports. In the model, diabetes risk was a function of weight change with and without the intervention. RESULTS: Compared to UC, the ODPP in our cohort cost $14,351 and $29,331 per quality-adjusted life-year (QALY) gained from the health care system and societal perspectives, respectively. In a hypothetical cohort without diabetes, the ODPP cost $7777 and $18,263 per QALY gained, respectively. Results were robust in sensitivity analyses, but enrolling cohorts with lower annual risk of developing diabetes (≤1.8%), enrolling fewer participants (≤15), or increasing the hourly cost (≥$91.20) or annual per-participant time (≥1.45h) required for technical support could increase ODPP cost to >$20,000 per QALY gained. In probabilistic sensitivity analyses, ODPP was cost-effective in 20-58% of model iterations using an acceptability threshold of $20,000, 73-92% at $50,000, and 95-99% at $100,000 per QALY gained. CONCLUSIONS: The ODPP may offer an economical approach to combating overweight and obesity.

Rationale, design, and implementation of a cluster randomized trial using certified diabetes educators to intensify treatment for glycemia, blood pressure and lipid control: REMEDIES 4D.

BACKGROUND: Evidence supports that adequate treatment of hyperglycemia, hypercholesterolemia, and hypertension can reduce morbidity and mortality in people with diabetes, however achieving treatment goals remains elusive. The majority of diabetes care occurs in the primary care setting; however there are often missed opportunities for timely intervention during office visits. This paper describes a systematic redesign of current diabetes treatment in primary care by implementing evidence-based protocols. MATERIALS/METHODS: This is a cluster randomized controlled trial using certified diabetes educators (CDEs) to intensify therapeutic management. Fifteen primary care practices from the University of Pittsburgh Medical Center were recruited. Practices were randomized to intervention (implementation of diabetes management protocols) or usual care. Eligibility criteria included diagnosis of type 2 diabetes at least one year prior to baseline and an A1C ≥ 7%, LDLc ≥ 100 mg/dl or blood pressure ≥ 130/80 mmHg which were the goal levels established by the American Diabetes Association at study inception. Treatment was intensified according to preapproved protocols. Participants also received diabetes education during their visits. Research assessments were done at baseline, three, six and twelve months. Clinical visits were scheduled between research visits, as needed, to adjust medications. Primary outcomes were achievement of glycemic, blood pressure, or lipid control goals. Secondary outcomes included quality of life, medication and diabetes care satisfaction, medication adherence, and cost-effectiveness. CONCLUSIONS: Results from this study will provide the evidence to support expanded roles for CDEs in primary care. Using this model to deliver diabetes care may offer a more cost-effective approach for diabetes management.

Cost-effectiveness of implementing the chronic care model for diabetes care in a military population.

BACKGROUND: Applying the chronic care model (CCM) for diabetes management helps improve health outcomes and patient care. The CCM was implemented at U.S. Air Force Wilford Hall Medical Center through the Diabetes Outreach Clinic (DOC) in 2006, but its cost-effectiveness in this setting is unknown. METHODS: We constructed a Markov decision model to estimate DOC cost-effectiveness compared with usual care (UC) over a 20-year period. Based on empirical, post-intervention demographic and clinical data, we applied United Kingdom Prospective Diabetes Study risk equations to predict long-term probabilities of developing microvascular or macrovascular complications. Health care system and societal perspectives were considered, discounting costs and benefits at 3% annually. Intervention costs and outcomes were obtained from military data, while other costs, disease progression data, and utilities were drawn from published literature. RESULTS: From a health care system perspective, the DOC cost $45,495 per quality-adjusted life-year (QALY) compared with UC; from a societal perspective, the DOC compared with UC cost $42,051/QALY (when the model started with the uncomplicated diabetes cohort), $61,243/QALY (when starting with the DOC cohort), or $61,813/QALY (when starting with the UC cohort). In one-way sensitivity analyses, results were most sensitive to yearly costs for specialty care visits. In probabilistic sensitivity analysis, the DOC was favored in 51% of model iterations using an acceptability threshold of $50,000/QALY and in 72% at a threshold of $100,000/QALY. CONCLUSIONS: The DOC strategy for diabetes care, performed with the CCM methodology in a military population, appears to be economically reasonable compared with UC.

Cost-effectiveness analysis of efforts to reduce risk of type 2 diabetes and cardiovascular disease in southwestern Pennsylvania, 2005-2007.

INTRODUCTION: We assessed the cost-effectiveness of a community-based, modified Diabetes Prevention Program (DPP) designed to reduce risk factors for type 2 diabetes and cardiovascular disease. METHODS: We developed a Markov decision model to compare costs and effectiveness of a modified DPP intervention with usual care during a 3-year period. Input parameters included costs and outcomes from 2 projects that implemented a community-based modified DPP for participants with metabolic syndrome, and from other sources. The model discounted future costs and benefits by 3% annually. RESULTS: At 12 months, usual care reduced relative risk of metabolic syndrome by 12.1%. A modified DPP intervention reduced relative risk by 16.2% and yielded life expectancy gains of 0.01 quality-adjusted life-years (3.67 days) at an incremental cost of $34.50 ($3,420 per quality-adjusted life-year gained). In 1-way sensitivity analyses, results were sensitive to probabilities that risk factors would be reduced with or without a modified DPP and that patients would enroll in an intervention, undergo testing, and acquire diabetes with or without an intervention if they were risk-factor-positive. Results were also sensitive to utilities for risk-factor-positive patients. In probabilistic sensitivity analysis, the intervention cost less than $20,000 per quality-adjusted life-year gained in approximately 78% of model iterations. CONCLUSION: We consider the modified DPP delivered in community and primary care settings a sound investment.

The Diabetes Self-management Assessment Report Tool (D-SMART): process evaluation and patient satisfaction.

PURPOSE: The purpose of this article is to present the results of the process evaluation and patient experience in completing the Diabetes Self-management Assessment Report Tool (D-SMART), an instrument within the AADE Outcome System to assist diabetes educators to assess, facilitate, and track behavior change in the provision of diabetes self-management education (DSME). METHODS: The D-SMART was integrated into computer and telephonic systems at 5 sites within the Pittsburgh Regional Initiative for Diabetes Education (PRIDE) network. Data were obtained from 290 patients with diabetes using the system at these programs via paper-and-pencil questionnaires following baseline D-SMART assessments and electronic system measurement of system performance. Process evaluation included time of completion, understanding content, usability of technology, and satisfaction with the system. Patients were 58% female and 85% Caucasian and had a mean age of 58 years. Fifty-six percent of patients had no more than a high school education, and 78% had Internet access at home. RESULTS: Most patients reported completing the D-SMART at home (78%), in 1 attempt (86%) via the Internet (55%), and in less than 30 minutes. Seventy-six percent believed the questions were easy to understand, and 80% did not need assistance. Age was negatively associated with ease of use. Moreover, 76% of patients believed the D-SMART helped them think about their diabetes, with 67% indicating that it gave the diabetes educator good information about themselves and their diabetes. Most (94%) were satisfied with the D-SMART. Level of satisfaction was independent of the system being used. CONCLUSIONS: The D-SMART was easily completed at home in 1 attempt, content was understandable, and patients were generally satisfied with the wording of questions and selection of answers. The D-SMART is easy to use and enhanced communication between the patient and clinician; however, elderly patients may need more assistance. Computer-based and telephonic D-SMARTs appear to be feasible and useful assessment methods for diabetes educators.

Deploying the chronic care model to implement and sustain diabetes self-management training programs.

PURPOSE: The purpose of this project was to evaluate the utility of using the 6 elements of the chronic care model (CCM; health system, community, decision support, self-management support, clinical information systems, and delivery system design) to implement and financially sustain an effective diabetes self-management training (DSMT) program. METHODS: The University of Pittsburgh Medical Center (UPMC) uses all elements of the CCM. Partnerships were formed between UPMC and western Pennsylvanian community hospitals and practices; the American Diabetes Association DSMT recognition program provided decision support. A clinical data repository and reorganization of primary care practices aided in supporting DSMT. The following process and patient outcomes were measured: number of recognized programs, reimbursement, patient hemoglobin A1C levels, and the proportion of patients who received DSMT in primary care practices versus hospital-based programs. RESULTS: Using elements of the CCM, the researchers were able to gain administrative support; expand the number of recognized programs from 3 to 21; cover costs through increased reimbursement; reduce hemoglobin A1C levels (P < .0001), and increase the proportion of patients receiving DSMT through delivery in primary care (26.4% suburban; 19.8% urban) versus hospital-based practices (8.3%; P < .0001). CONCLUSIONS: The CCM serves as an effective model for implementing and sustaining DSMT programs.

Tracking and improving influenza immunization rates in a high-risk medicare beneficiary population.

Immunization rates for end stage renal disease (ESRD) patients were well below the 80% target set by Healthy People 2000 and Centers for Medicare and Medicaid Services. The authors sought to increase documentation of immunization status, and influenza immunization rates of these patients. A survey was distributed to dialysis facilities to determine immunization practices. Facilities were provided with an immunization toolbox and spreadsheets to document the immunization status of patients. A total of 102 facilities (53%) provided data for three collection periods (1999, 2000, and 2001). Immunization rates for each influenza season increased significantly from 62.1% and 61.4% in 1998-1999 to 80.3% and 80.0% in 2000-2001 (Pennsylvania and Delaware respectively).

Diabetes: a growing epidemic of all ages.

BACKGROUND: The incidence and prevalence of diabetes mellitus are increasing, with more than 135 million people affected worldwide. Despite greater knowledge of the disease, one-third of people with the disease are undiagnosed. Recent estimates indicate that one in three U.S. children born in 2000 will develop diabetes. OVERVIEW: Diabetes is not equally distributed within the U.S. population. Type 1 diabetes occurs most frequently in white non-Hispanic children. A higher prevalence of type 2 diabetes is seen among those who are older, female and overweight. Non-Hispanic African-American and Hispanic populations in the United States also have been found to be at greater risk of developing type 2 disease. Among certain older patient populations, the prevalence of type 2 diabetes may be as high as 20 to 25 percent. As the percentage of older Americans increases and as the prevalence of obesity increases, a greater number of patients with diabetes will be seen and treated by dental practitioners. CONCLUSIONS AND PRACTICE IMPLICATIONS: Oral health complications, including extensive periodontal disease, tooth loss, soft-tissue pathologies, xerostomia and burning mouth syndrome have been reported among patients with long-standing and poorly controlled diabetes. Dentists have an opportunity and responsibility to educate patients with diabetes about the oral complications of the disease, and to promote proper oral health behaviors that limit the risks of tooth loss, periodontal disease and soft-tissue pathologies.