Effectiveness of a community program for older adults with type 2 diabetes and multimorbidity: a pragmatic randomized controlled trial.

BACKGROUND: Type II diabetes mellitus (T2DM) affects upwards of 25% of Canadian older adults and is associated with high comorbidity and burden. Studies show that lifestyle factors and self-management are associated with improved health outcomes, but many studies lack rigour or exclude older adults, particularly those with multimorbidity. More evidence is needed on the effectiveness of community-based self-management programs in older adults with T2DM and multimorbidity. The study purpose is to evaluate the effect of a community-based intervention versus usual care on physical functioning, mental health, depressive symptoms, anxiety, self-efficacy, self-management, and healthcare costs in older adults with T2DM and 2 or more comorbidities. METHODS: Community-living older adults with T2DM and two or more chronic conditions were recruited from three Primary Care Networks (PCNs) in Alberta, Canada. Participants were randomly allocated to the intervention or control group in this pragmatic randomized controlled trial comparing the intervention to usual care. The intervention involved up to three in-home visits, a monthly group wellness program, monthly case conferencing, and care coordination. The primary outcome was physical functioning. Secondary outcomes included mental functioning, anxiety, depressive symptoms, self-efficacy, self-management, and the cost of healthcare service use. Intention-to-treat analysis was performed using ANCOVA modeling. RESULTS: Of 132 enrolled participants (70-Intervention, 62-Control), 42% were 75 years or older, 55% were female, and over 75% had at least six chronic conditions (in addition to T2DM). No significant group differences were seen for the baseline to six-month change in physical functioning (mean difference: -0.74; 95% CI: - 3.22, 1.74; p-value: 0.56), mental functioning (mean difference: 1.24; 95% CI: - 1.12, 3.60; p-value: 0.30), or other secondary outcomes.. CONCLUSION: No significant group differences were seen for the primary outcome, physical functioning (PCS). Program implementation, baseline differences between study arms and chronic disease management services that are part of usual care may have contributed to the modest study results. Fruitful areas for future research include capturing clinical outcome measures and exploring the impact of varying the type and intensity of key intervention components such as exercise and diet. TRIAL REGISTRATION: NCT02158741 Date of registration: June 9, 2014.

Healthcare providers' experiences in supporting community-living older adults to manage multiple chronic conditions: a qualitative study.

BACKGROUND: Living with multiple chronic conditions (MCC), the coexistence of two or more chronic conditions, is becoming more prevalent as the population ages. Primary care and home care providers play key roles in caring for older adults with MCC such as facilitating complex care decisions, shared decision-making, and access to community health and support services. While there is some research on the perceptions and experiences of these providers in caring for this population, much of this literature is focused specifically on family physicians. Little is known about the experiences of other primary care and home care providers from multiple disciplines who care for this vulnerable group. The purpose of this study was to explore the experiences of primary and home care healthcare providers in supporting the care of older adults with MCC living in the community, and identify ways of improving care delivery and outcomes for this group. METHODS: The study used an interpretive descriptive design. A total of 42 healthcare providers from two provinces in Canada (Ontario and Alberta) participated in individual semi-structured, face-to-face 60-min interviews. Participants represented diverse disciplines from primary care and home care settings. Inductive thematic analysis was used for data analysis. RESULTS: The experiences and recommendations of healthcare providers managing care for older adults with MCC were organized into six major themes: (1) managing complexity associated with MCC, (2) implementing person-centred care, (3), supporting caregivers, (4) using a team approach for holistic care delivery, (5) encountering challenges and rewards, and (6) recommending ways to address the challenges of the healthcare system. Healthcare providers identified the need for a more comprehensive, integrated system of care to improve the delivery of care and outcomes for older adults with MCC and their family caregivers. CONCLUSIONS: Study findings suggest that community-based healthcare providers are using many relevant and appropriate strategies to support older adults living with the complexity of MCC, such as implementing person-centred care, supporting caregivers, working collaboratively with other providers, and addressing social determinants of health. However, they also identified the need for a more comprehensive, integrated system of care.

Managing multiple chronic conditions in the community: a Canadian qualitative study of the experiences of older adults, family caregivers and healthcare providers.

BACKGROUND: The prevalence of multiple chronic conditions (MCC) among older persons is increasing worldwide and is associated with poor health status and high rates of healthcare utilization and costs. Current health and social services are not addressing the complex needs of this group or their family caregivers. A better understanding of the experience of MCC from multiple perspectives is needed to improve the approach to care for this vulnerable group. However, the experience of MCC has not been explored with a broad sample of community-living older adults, family caregivers and healthcare providers. The purpose of this study was to explore the experience of managing MCC in the community from the perspectives of older adults with MCC, family caregivers and healthcare providers working in a variety of settings. METHODS: Using Thorne's interpretive description approach, semi-structured interviews (n = 130) were conducted in two Canadian provinces with 41 community-living older adults (aged 65 years and older) with three or more chronic conditions, 47 family caregivers (aged 18 years and older), and 42 healthcare providers working in various community settings. Healthcare providers represented various disciplines and settings. Interview transcripts were analyzed using Thorne's interpretive description approach. RESULTS: Participants described the experience of managing MCC as: (a) overwhelming, draining and complicated, (b) organizing pills and appointments, (c) being split into pieces, (d) doing what the doctor says, (e) relying on family and friends, and (f) having difficulty getting outside help. These themes resonated with the emotional impact of MCC for all three groups of participants and the heavy reliance on family caregivers to support care in the home. CONCLUSIONS: The experience of managing MCC in the community was one of high complexity, where there was a large gap between the needs of older adults and caregivers and the ability of health and social care systems to meet those needs. Healthcare for MCC was experienced as piecemeal and fragmented with little focus on the person and family as a whole. These findings provide a foundation for the design of care processes to more optimally address the needs-service gap that is integral to the experience of managing MCC.

Embedding the perceptions of people with dementia into quantitative research design.

PURPOSE: Patient perspectives about quality of life are often found in the results of qualitative research and could be applied to steer the direction of future research. The purpose of this paper was to describe how findings from a body of qualitative research on patient perspectives about quality of life were linked to a clinical administrative dataset and then used to design a subsequent quantitative study. METHODS: Themes from two systematic reviews of qualitative evidence (i.e., metasyntheses) identified what affects quality of life according to people with dementia. Selected themes and their sub-concepts were then mapped to an administrative dataset (the Resident Assessment Instrument 2.0) to determine the study focus, formulate nine hypotheses, and select a patient-reported outcome. A literature review followed to confirm existence of a knowledge gap, identify adjustment variables, and support design decisions. RESULTS: A quantitative study to test the association between conflict and sadness for people with dementia in long-term care was derived from metasynthesis themes. Challenges included (1) mapping broad themes to the administrative dataset; (2) decisions associated with inclusion of variables not identified by people with dementia from the qualitative research; and (3) selecting a patient-reported outcome, when the dataset lacked a valid subjective quality-of-life measure. CONCLUSIONS: Themes derived from a body of qualitative research capturing a target populations' perspective can be linked to administrative data and used to design a quantitative study. Using this approach, the quantitative findings will be meaningful with respect to the quality of life of the target population.

Seniors managing multiple medications: using mixed methods to view the home care safety lens.

BACKGROUND: Patient safety is a national and international priority with medication safety earmarked as both a prevalent and high-risk area of concern. To date, medication safety research has focused overwhelmingly on institutional based care provided by paid healthcare professionals, which often has little applicability to the home care setting. This critical gap in our current understanding of medication safety in the home care sector is particularly evident with the elderly who often manage more than one chronic illness and a complex palette of medications, along with other care needs. This study addresses the medication management issues faced by seniors with chronic illnesses, their family, caregivers, and paid providers within Canadian publicly funded home care programs in Alberta (AB), Ontario (ON), Quebec (QC) and Nova Scotia (NS). METHODS: Informed by a socio-ecological perspective, this study utilized Interpretive Description (ID) methodology and participatory photographic methods to capture and analyze a range of visual and textual data. Three successive phases of data collection and analysis were conducted in a concurrent, iterative fashion in eight urban and/or rural households in each province. A total of 94 participants (i.e., seniors receiving home care services, their family/caregivers, and paid providers) were interviewed individually. In addition, 69 providers took part in focus groups. Analysis was iterative and concurrent with data collection in that each interview was compared with subsequent interviews for converging as well as diverging patterns. RESULTS: Six patterns were identified that provide a rich portrayal of the complexity of medication management safety in home care: vulnerabilities that impact the safe management and storage of medication, sustaining adequate supports, degrees of shared accountability for care, systems of variable effectiveness, poly-literacy required to navigate the system, and systemic challenges to maintaining medication safety in the home. CONCLUSIONS: There is a need for policy makers, health system leaders, care providers, researchers, and educators to work with home care clients and caregivers on three key messages for improvement: adapt care delivery models to the home care landscape; develop a palette of user-centered tools to support medication safety in the home; and strengthen health systems integration.

Does the quality of life construct as illustrated in quantitative measurement tools reflect the perspective of people with dementia?

AIMS: A discussion of the extent to which people with dementia's perspectives on quality of life have been included in quantitative research. BACKGROUND: Capturing the perspective of people with dementia may improve understanding of their quality of life. Quantitative tools to assess quality of life exist, but the extent to which these reflect the perspective of people with dementia has not been evaluated. DESIGN: A discussion paper. DATA SOURCES: Ten tools (designed between 1992-2012) to measure quality of life from the perspective of people with dementia were located from existing reviews. DISCUSSION: Each tool was rated according to the extent to which the developers included the perspectives of people with dementia at three different points of quality of life conceptualization: during quality of life assessment, to identify quality of life domains and to define an overall conceptual framework. This analysis demonstrates that tool developers were inconsistent in their approach to including the perspectives of people with dementia to understand quality of life. The perspective of people with dementia was included primarily to assess, but not to select domains or define overall quality of life. IMPLICATIONS FOR NURSING: Nurses should consider not only who assesses quality of life, but also whose understanding of quality of life is being assessed. CONCLUSION: It is unclear whether the quantitative quality of life literature reflects the perspective of people with dementia. Debate is needed regarding the impact of this issue on the lives of people with dementia.

Factors influencing nurse managers' intent to stay or leave: a quantitative analysis.

AIM: To identify and report on the relative importance of factors influencing nurse managers' intentions to stay in or leave their current position. BACKGROUND: Effective nurse managers play an important role in staff nurse retention and in the quality of patient care. The advancing age of nurse managers, multiple job opportunities within nursing and the generally negative perceptions of the manager role can contribute to difficulties in retaining nurse managers. METHODS: Ninety-five Canadian nurse managers participated in a web survey. Respondents rated the importance of factors related to their intent to leave or stay in their current position for another 2 years. Descriptive, t-test and mancova statistics were used to assess differences between managers intending to stay or leave. RESULTS: For managers intending to leave (n = 28), the most important factors were work overload, inability to ensure quality patient care, insufficient resources, and lack of empowerment and recognition. Managers intending to leave reported significantly lower job satisfaction, perceptions of their supervisor's resonant leadership and higher burnout levels. IMPLICATIONS FOR NURSING MANAGEMENT: Organisations wishing to retain existing nurse managers and to attract front-line staff into leadership positions must create and foster an environment that supports nurse managers.

A Scoping Literature Review: The State of Knowledge on Home Care Equipment and Supplies.

We explored the state of knowledge on home care supplies and equipment because not much is known about this topic. We used a scoping review for the literature review because it was the most appropriate approach considering the state of the literature. We searched for articles published in both the gray and peer-reviewed literature. We established five overarching themes based on the findings. These were supply management, durable medical equipment, wound care, best practices, and costs. This review demonstrates that although knowledge about home care supplies and equipment is growing, it is still an understudied area.

A systematic process for creating and appraising clinical vignettes to illustrate interprofessional shared decision making.

Vignettes and written case simulations have been widely used by educators and health services researchers to illustrate plausible situations and measure processes in a wide range of practice settings. We devised a systematic process to create and appraise theory-based vignettes for illustrating an interprofessional approach to shared decision making (IP-SDM) for health professionals. A vignette was developed in six stages: (1) determine IP-SDM content elements; (2) choose true-to-life clinical scenario; (3) draft script; (4) appraise IP-SDM concepts illustrated using two evaluation instruments and an interprofessional concept grid; (5) peer review script for content validity; and (6) retrospective pre-/post-test evaluation of video vignette by health professionals. The vignette contained six scenes demonstrating the asynchronous involvement of five health professionals with an elderly woman and her daughter facing a decision about location of care. The script scored highly on both evaluation scales. Twenty-nine health professionals working in home care watched the vignette during IP-SDM workshops in English or French and rated it as excellent (n = 6), good (n = 20), fair (n = 0) or weak (n = 3). Participants reported higher knowledge of IP-SDM after the workshops compared to before (p < 0.0001). Our video vignette development process resulted in a product that was true-to-life and as part of a multifaceted workshop it appears to improve knowledge among health professionals. This could be used to create and appraise vignettes targeting IP-SDM in other contexts.

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention.

BACKGROUND: Audit with feedback is a moderately effective approach for improving professional practice in other health care settings. Although unregulated caregivers give the majority of direct care in long-term care settings, little is known about how they understand and perceive feedback reports because unregulated providers have not been directly targeted to receive audit with feedback in quality improvement interventions in long-term care. The purpose of this paper is to describe unregulated care providers' perceptions of usefulness of a feedback report in four Canadian long-term care facilities. METHODS: We delivered monthly feedback reports to unregulated care providers for 13 months in 2009-2010. The feedback reports described a unit's performance in relation to falls, depression, and pain as compared to eight other units in the study. Follow-up surveys captured participant perceptions of the feedback report. We conducted descriptive analyses of the variables related to participant perceptions and multivariable logistic regression to assess the association between perceived usefulness of the feedback report and a set of independent variables. RESULTS: The vast majority (80%) of unregulated care providers (n = 171) who responded said they understood the reports. Those who discussed the report with others and were interested in other forms of data were more likely to find the feedback report useful for making changes in resident care. CONCLUSIONS: This work suggests that unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care. Further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings.

Impact of care management processes and integration of care on blood pressure control in diabetes.

BACKGROUND: Fragmentation within health care systems may negatively impact the quality of chronic disease patient care. We sought to evaluate the relationship between care management processes (CMP), integration of services, and blood pressure (BP) control among diabetic patients. METHODS: Retrospective chart reviews were performed for a random sample of adult diabetic hypertensive patients (n = 2,162) from 28 physician organizations in the United States (US). A modified version of the Physician Practice Connection Readiness Survey (PPC-RS) was completed by the chief medical officer at each site. The PPC-RS measured health system organization, delivery system redesign, decision support, clinical information systems, and self-management support, and an integration scale measured structure, functions, and financial risk. Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients. RESULTS: Approximately 39.9% of diabetic patients had controlled BP. Mean total PPC score across sites was 55, with highest mean scores for health system organization (81), followed by design support (60), clinical information systems (57), self-management support (39), and delivery system redesign (39). Mean integration score was 46 (SD 27, range 4-93), and means of subscores were 64 for structure, 33 for financial risk, and 42 for function. Clinical information systems subscore was correlated with uncontrolled BP (r = -0.38, p < 0.05), while association with total PPC score was strong but not significant at p < 0.05 (r = -0.32). Total integration score and the structure subscore were significantly correlated with BP control (r = 0.38, p < 0.05, and r = 0.49, p < 0.01). CONCLUSIONS: This study suggests that CMP and service integration may be associated with better outcomes in diabetes, though results were mixed and limited by a small number of participating sites. Primary care implementation of integrated electronic medical records may have a beneficial effect on patient outcomes for diabetes and other chronic diseases.

Factors influencing intentions to stay and retention of nurse managers: a systematic review.

AIMS: This systematic review aimed to explore factors known to influence intentions to stay and retention of nurse managers in their current position. BACKGROUND: Retaining staff nurses and recruiting nurses to management positions are well documented; however, there is sparse research examining factors that influence retention of nurse managers. EVALUATIONS: Thirteen studies were identified through a systematic search of the literature. Eligibility criteria included both qualitative and quantitative studies that examined factors related to nurse manager intentions to stay and retention. Quality assessments, data extraction and analysis were completed on all studies included. Twenty-one factors were categorized into three major categories: organizational, role and personal. KEY ISSUES: Job satisfaction, organizational commitment, organizational culture and values, feelings of being valued and lack of time to complete tasks leading to work/life imbalance, were prominent across all categories. CONCLUSION: These findings suggest that intentions to stay and retention of nurse managers are multifactoral. However, lack of robust literature highlights the need for further research to develop strategies to retain nurse managers. ImplICATIONS FOR NURSE MANAGEMENT: Health-care organizations and senior decision-makers should feel a responsibility to support front-line managers in relation to workload and span of control, and in understanding work/life balance issues faced by managers.

Regulated provider perceptions of feedback reports.

AIM: This paper reports on regulated (or licensed) care providers' understanding and perceptions of feedback reports in a sample of Canadian long-term care settings using a cross-sectional survey design. BACKGROUND: Audit with feedback quality improvement studies have seldom targeted front-line providers in long-term care to receive feedback information. METHODS: Feedback reports were delivered to front-line regulated care providers in four long-term care facilities for 13 months in 2009-10. Providers completed a postfeedback survey. RESULTS: Most (78%) regulated care providers (n = 126) understood the reports and felt they provided useful information for making changes to resident care (64%). Perceptions of the report differed, depending on the role of the regulated care provider. In multivariable logistic regression, the regulated nurses' understanding of more than half the report was negatively associated with 'usefulness of information for changing resident care', and perceiving the report as generally useful had a positive association. CONCLUSIONS: Front-line regulated providers are an appropriate target for feedback reports in long-term care. IMPLICATIONS FOR NURSING MANAGEMENT: Long-term care administrators should share unit-level information on care quality with unit-level managers and other professional front-line direct care providers.

Outcomes of erythropoiesis-stimulating agents in cancer patients with chemotherapy-induced anemia.

PURPOSE: To assess the clinical and economic outcomes among patients with chemotherapy-induced anemia (CIA) treated with United States Food and Drug Administration-approved fixed dosing regimens of erythropoiesis-stimulating agents (ESA). METHODS: Data were employed from the Dosing and Outcomes Study of Erythropoiesis-Stimulating Therapies (DOSE) registry to evaluate CIA patients who were initiated on either epoetin alfa (EPO) 40,000 Units (U) or darbepoetin alfa (DARB) 500 micrograms (mcg) between January 1, 2006 and May 8, 2009. Study measurements included ESA treatment dose and dose ratio, changes in hemoglobin (Hb) levels from baseline, and cumulative ESA costs. RESULTS: Five hundred forty patients treated in 44 clinical centers were evaluated, of which 420 were initiated on EPO 40,000 U and 120 were initiated on DARB 500 mcg. Both cohorts had similar baseline characteristics, although EPO patients were less likely than DARB patients to have received iron supplementation before ESA initiation (11.4% EPO vs. 20.0% DARB, p = 0.015). The EPO-to-DARB dose ratio based on cumulative ESA dose was 169:1 (U EPO: mcg DARB). EPO patients showed statistically greater Hb improvement compared to DARB patients, and compared to EPO patients, a greater proportion of DARB patients required a blood transfusion (13.9% EPO vs. 22.5% DARB, p = 0.026). Mean cumulative ESA cost was significantly lower for EPO patients than DARB patients ($4,261 EPO vs. $8,643 DARB, p < 0.0001). CONCLUSIONS: These findings reported that patients with CIA achieved more favorable clinical and economic outcomes if initiated with EPO 40,000 U vs. DARB 500 mcg.

Predictors of pain medication selection among patients diagnosed with fibromyalgia.

OBJECTIVES: Several pharmacologic therapies have been recommended for managing fibromyalgia. However, the factors associated with each treatment initiation have not been well established. This study assessed factors that were associated with the use of duloxetine vs. other pain medications among patients with fibromyalgia. RESEARCH DESIGN AND METHODS: Administrative claims from a large, U.S. commercially insured population were analyzed using a retrospective cohort design. Patients with fibromyalgia who were 18 to 64 years old and initiated duloxetine vs. selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), venlafaxine, gabapentin, pregabalin, tramadol, or nontramadol opioids between January 1, 2007 and December 12, 2008 were selected. Treatment initiation was defined as no access to the same medication over the previous 90 days, with the most recent initiation date as the index date. All patients selected had at least one fibromyalgia diagnosis (ICD-9-CM: 729.1) in the 12 months prior to initiation of each study medication. Multiple logistic regression models were estimated to assess the predictors of initiating duloxetine vs. each of the other medications. RESULTS: The study included 117,305 patients with fibromyalgia (48 years of age on average; 76% women) who initiated duloxetine (n = 5,827), SSRIs (n = 8,620), TCAs (n = 5,424), venlafaxine (n = 2,038), gabapentin (n = 5,733), pregabalin (n = 11,152), tramadol (n = 7,312), or nontramadol opioids (n = 71,199). Common fibromyalgia-related comorbidities were low back pain (31% to 49%), osteoarthritis (14% to 21%), and sleep disturbance (10% to 15%). Controlling for demographic and clinical characteristics, patients who received pregabalin in the prior 12-month period were more likely to initiate duloxetine. Patients from other treatment cohorts, except for those in the pregabalin and nontramadol opioid cohorts, were more likely to re-initiate the same prior medication than to begin treatment with duloxetine. Other predictors of duloxetine initiation included history of rheumatoid and sleep disturbance. CONCLUSIONS: The presence of select comorbidities and prior use of certain medications were associated with the duloxetine initiation among working-age, commercially insured patients with fibromyalgia.

Oxygen use for preterm infants: factors that may influence clinical decisions surrounding oxygen titration.

Preterm infants in neonatal intensive care units frequently require oxygen therapy. Clinicians are responsible for titrating oxygen to maximize the benefits and minimize the risks of this therapy. Studies have identified various toxic effects of oxygen on the developing tissues of the preterm infant; however, optimal target SpO(2) ranges have not been identified. Current trends in neonatology are focusing on defining optimal oxygen saturation ranges to improve infant outcomes and to decrease complications associated with the oxygen use. Consequently, research-based guidelines are being developed in neonatal intensive care units to guide oxygen administration. As target oxygen saturation ranges are developed, issues regarding health care professional compliance with these ranges have been identified. The specific reasons for this noncompliance have not been widely explored. However, factors such as nursing shortages, staffing issues, and a de-emphasis on staff education surrounding oxygen use have been offered as possible reasons. Understanding factors shaping clinical decision-making about oxygen titration is critical when designing policies and educational programs to change oxygen titration practice and ultimately improve patient outcomes. In this article, the literature outlining the importance of oxygen titration for preterm infants is reviewed. Discussion then focuses on factors that influence clinical decision-making and how these factors may influence decisions surrounding the use of oxygen for preterm infants.

Medication adherence and healthcare costs among fibromyalgia patients treated with duloxetine.

OBJECTIVE: The study aims to examine predictors associated with duloxetine adherence and its association with healthcare costs among fibromyalgia patients. METHODS: Administrative claims from both commercially and Medicare supplemental-insured fibromyalgia patents aged 18+ who initiated duloxetine in 2006 were analyzed. Initiation was defined as a 90-day clean period without duloxetine. The dispense date of the first duloxetine prescription was denoted as the index date. Two cohorts were constructed based on duloxetine adherence over the 12-month postindex period (high adherence as medication possession ratio ≥0.8). Predictors of high adherence were examined via logistic regression. Generalized linear regressions were performed to estimate the association between duloxetine adherence and healthcare costs. RESULTS: A total of 4,869 commercially and 566 Medicare supplemental-insured fibromyalgia patients were identified. Two-thirds of patients had low adherence. Higher duloxetine average daily dose (ADD) was associated with increased adherence (reference group=30mg; Commercial: Odds ratio [OR]=3.03, 2.40, and 3.73 for 31 to 59mg, 60mg, and >60mg, respectively, all P<0.05; Medicare supplemental: OR=3.11, 2.33, and 4.76 for 31 to 59mg, 60mg, and >60mg, respectively, all P<0.05). Commercially insured patients with high adherence had significantly lower total healthcare costs than low-adherence patients (-$1,164, P<0.05), primarily because of lower inpatient (-$2,222, P<0.05) and outpatient (-$1,075, P<0.05) costs. Medicare supplemental-insured patients with high adherence had similar overall and inpatient costs, but significantly lower outpatient costs (-$2,025, P<0.05). CONCLUSION: Fibromyalgia patients with higher duloxetine ADD were more likely to adhere to the therapy. High duloxetine adherence was associated with lower (Commercial) or similar (Medicare supplemental) healthcare costs.

Opioid utilization and health-care costs among patients with diabetic peripheral neuropathic pain treated with duloxetine vs. other therapies.

OBJECTIVE: This retrospective cohort study assessed subsequent opioid utilization and health-care costs among patients with diabetic peripheral neuropathic pain (DPNP) who initiated duloxetine vs. other standard of care (SOC) treatments. METHODS: Medical and pharmacy claims were analyzed for commercially-insured individuals aged 18-64. Two study cohorts were constructed from DPNP patients who initiated duloxetine or SOC medications (tricyclic antidepressants, venlafaxine, gabapentin, pregabalin) between March 1, 2005 and December 31, 2005. Initiation was defined as a prior 90-day period without access of the medication. The dispense date of the first initiation was denoted as the index date. Patients with opioids dispensed in the prior 90 days were excluded. Opioid utilization including total days, number of prescriptions filled, and morphine equivalent dosage was assessed for overall, long-acting, and short-acting opioids. Health-care costs and opioid use in the 12-month post-index period were examined via multivariate regression analyses. RESULTS: Four hundred and ninety-nine DPNP patients (272 duloxetine, 227 SOC) were identified. SOC patients had higher prevalence of comorbidities and pre-index health-care costs than duloxetine patients. Controlling for cross-cohort differences, duloxetine patients were significantly less likely to use any opioids than SOC patients. Also, duloxetine patients had 20 fewer adjusted opioid supply days (largely due to the use of short-acting opioids, P < 0.05) and significantly lower adjusted total costs ($8,088, P < 0.05) and diabetes-related costs ($3,092, P < 0.05) in the 12-month post-index period, with most of the cost differences from lower outpatient costs. CONCLUSIONS: DPNP patients who initiated duloxetine therapy were less likely to have subsequent opioid use and had lower health-care costs than SOC patients.

The relationship between average daily dose, medication adherence, and health-care costs among diabetic peripheral neuropathic pain patients initiated on duloxetine therapy.

OBJECTIVE: To examine the relationship between average daily dose (ADD) of duloxetine, adherence to therapy, and health-care costs among patients with diabetic peripheral neuropathic pain (DPNP). METHODS: A retrospective analysis of commercially insured DPNP patients was conducted among those aged 18 to 64 years who initiated duloxetine therapy between Ocotober 1, 2004 and December 31, 2006. The dispense date of the first duloxetine prescription was defined as the index date. All duloxetine prescriptions over the 12-month post-index period were used to assess ADD and adherence. Four study cohorts were constructed based on ADD: 30 mg, 31 to 59 mg, 60 mg; and >60 mg. High adherence was defined as having a medication possession ratio for duloxetine of ≥0.8. Health-care costs over 12-month post-index period were estimated. Multiple regression models were used to examine the association between ADD, adherence, and health-care costs. RESULTS: The study sample included 1,351 DPNP patients (mean age: 55 years; male: 41%). Twelve percent of patients had a duloxetine ADD of 30 mg, 17% of 31 to 59 mg, 56% of 60 mg, and 15% of >60 mg. Patients with ADD of 30 mg (>60 mg) were significantly less (more) likely to adhere to duloxetine therapy compared with those in the 60 mg cohort. Controlling for cross-cohort demographic and clinical differences, patients with ADD of 30 mg, 31 to 59 mg, or >60 mg had significantly higher total health-care costs than those with ADD of 60 mg (adjusted differences: $6,090, $6,320, $6,466 for 30 mg, 31 to 59 mg, >60 mg, respectively, all P < 0.05). CONCLUSION: The findings suggest that having an ADD of 60 mg for duloxetine among commercially insured DPNP patients is associated with improved medication adherence and lower health-care costs.

The relational nature of case manager resource allocation decision making: an illustrated case.

We used ethnographic methods in the tradition of Spradley (1979) and constant comparative analysis to explore case manager resource allocation decision making. We interviewed; observed and shadowed 11 case managers within a children's home care program in a regional health authority in western Canada as they went about their daily work over a 5-month period. Our findings provide knowledge about the little-understood set of processes at the micro level of resource allocation. Although the case manager considers many factors, reported elsewhere (Fraser, Estabrooks, Allen, & Strang, 2009), they balance and weigh these factors within a relational context. The purpose of this article is to use Jenna's story as a case example to illustrate how the case manager balances and weighs the factors that influence their resource allocation decisions within this context. Jenna's story demonstrates the complex and multidimensional processes that are embedded in the relational nature of resource allocation decisions. We discuss home care case manager resource allocation decisions as viewed through the lens of relational ethics.