Inappropriate Prescribing to Older Patients by Nurse Practitioners and Primary Care Physicians.

BACKGROUND: Many U.S. states have legislated to allow nurse practitioners (NPs) to independently prescribe drugs. Critics contend that these moves will adversely affect quality of care. OBJECTIVE: To compare rates of inappropriate prescribing among NPs and primary care physicians. DESIGN: Rates of inappropriate prescribing were calculated and compared for 23 669 NPs and 50 060 primary care physicians who wrote prescriptions for 100 or more patients per year, with adjustment for practice experience, patient volume and risk, clinical setting, year, and state. SETTING: 29 states that had granted NPs prescriptive authority by 2019. PATIENTS: Medicare Part D beneficiaries aged 65 years or older in 2013 to 2019. MEASUREMENTS: Inappropriate prescriptions, defined as drugs that typically should not be prescribed for adults aged 65 years or older, according to the American Geriatrics Society's Beers Criteria. RESULTS: Mean rates of inappropriate prescribing by NPs and primary care physicians were virtually identical (adjusted odds ratio, 0.99 [95% CI, 0.97 to 1.01]; crude rates, 1.63 vs. 1.69 per 100 prescriptions; adjusted rates, 1.66 vs. 1.68). However, NPs were overrepresented among clinicians with the highest and lowest rates of inappropriate prescribing. For both types of practitioners, discrepancies in inappropriate prescribing rates across states tended to be larger than discrepancies between these practitioners within states. LIMITATION: The Beers Criteria addresses the appropriateness of a selected subset of drugs and may not be valid in some clinical settings. CONCLUSION: Nurse practitioners were no more likely than physicians to prescribe inappropriately to older patients. Broad efforts to improve the performance of all clinicians who prescribe may be more effective than limiting independent prescriptive authority to physicians. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation and National Science Foundation.

Accuracy of Valuations of Surgical Procedures in the Medicare Fee Schedule.

BACKGROUND: The Relative Value Scale Update Committee (RUC) of the American Medical Association plays a central role in determining physician reimbursement. The RUC's role and performance have been criticized but subjected to little empirical evaluation. METHODS: We analyzed the accuracy of valuations of 293 common surgical procedures from 2005 through 2015. We compared the RUC's estimates of procedure time with "benchmark" times for the same procedures derived from the clinical registry maintained by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We characterized inaccuracies, quantified their effect on physician revenue, and examined whether re-review corrected them. RESULTS: At the time of 108 RUC reviews, the mean absolute discrepancy between RUC time estimates and benchmark times was 18.5 minutes, or 19.8% of the RUC time. However, RUC time estimates were neither systematically shorter nor longer than benchmark times overall (ß, 0.97; 95% confidence interval, 0.94 to 1.01; P = 0.10). Our analyses suggest that whereas orthopedic surgeons and urologists received higher payments than they would have if benchmark times had been used ($160 million and $40 million more, respectively, in Medicare reimbursement in 2011 through 2015), cardiothoracic surgeons, neurosurgeons, and vascular surgeons received lower payments ($130 million, $60 million, and $30 million less, respectively). The accuracy of RUC time estimates improved in 47% of RUC revaluations, worsened in 27%, and was unchanged in 25%. (Percentages do not sum to 100 because of rounding.). CONCLUSIONS: In this analysis of frequently conducted operations, we found substantial absolute discrepancies between intraoperative times as estimated by the RUC and the times recorded for the same procedures in a surgical registry, but the RUC did not systematically overestimate or underestimate times. (Funded by the National Institutes of Health.).

Satisfaction of Search in Periapical Radiograph Interpretation.

INTRODUCTION: Several studies in radiology and medicine have evaluated the satisfaction of search (SOS) error effect in chest radiography, abdominal radiography, osteoradiology, and patients with multiple trauma. No research to date has been published evaluating the possible existence of the SOS error phenomenon made during dental periapical radiograph interpretations. The purpose of the present pilot study was to determine if an SOS error effect exists when dental clinicians interpret periapical radiographs. The null hypothesis was that the detection accuracy will be the same or will improve for the detection of native lesions in the presence of an added abnormality. The alternative hypothesis is that there will be a decrease in detection accuracy for native lesions in the presence of an added abnormality. METHODS: Six images were selected to be part of the present experiment. One of the 6 images served as the positive control, and another image served as the negative control. Four images, each including a single subtle carious lesion, were selected to represent the experimental images. The single subtle carious lesion present within the 4 experimental radiographs served as the native pathology, and an abnormality such as a periapical radiolucency, resorption, inadequate nonideal root canal obturation material, or recurrent carious lesion was artificially inserted into the image as the added pathology. Thus, the second set of images consisted of the same 4 images containing the native pathology including an added pathology that was inserted into the image using Adobe Photoshop CS6 (Adobe, Inc, San Jose, CA). Purposive sampling was obtained from 16 examiners including residents from endodontics and periodontics as well as alumni and faculty from the Saint Louis University Center for Advanced Dental Education, St Louis, MO. Each observer participated as a subject during 2 time-separated sessions. Each session was separated by a minimum period of 3 months' duration in order to prevent memory bias. Before starting each interpretation session, the participants were given verbal instructions. Subjects were instructed to provide a location (by tooth number), identify, and rate the presence of all suspected pathology using a Likert scale of 1-5 (1: definitely normal, 2: probably normal, 3: possibly abnormal, 4: probably abnormal, and 5: definitely abnormal). In the second session, the radiographs that were initially presented containing only the native lesion were presented again with the added abnormality, and vice versa. The observers' reports and confidence ratings were recorded and analyzed. Ratings of 3-5 were considered as being positive for the presence of pathology. RESULTS: A true SOS error occurs when the presence of the native lesion is reported correctly without an added abnormality but is not reported (missed) in the presence of an added abnormality. In our study, a true SOS error occurred in 13 of the 64 interpretation sets (20.31%). There was a total of 64 expected native lesions present within the 4 native images viewed by 16 observers. In the 4 added images, there was a total of 64 expected added findings. In the images containing only native lesions, the observers reported 30 of the 64 expected native lesions. In the images containing an artificially added abnormality, the observers reported 58 of the 64 expected added abnormalities and 25 of the 64 expected native lesions. Observers reported fewer native lesions in the presence of an added abnormality. CONCLUSIONS: The current investigation demonstrated the existence of the SOS effect during periapical radiographic interpretations. In 20.31% of interpretations, a true SOS error occurred. This study is clinically relevant because it can help clinicians in reducing false-negative errors made during radiographic interpretation, thus preventing misdiagnosis.

Development and Validation of a Stability-indicating High-performance Liquid Chromatographic Method for Quantification of Progesterone in Compounded Glycerinated Gelatin Troches.

The objective of this study was to develop a validated stability-indicating high-performance liquid chromatographic method that quantifies progesterone in compounded glycerinated gelatin troches. The mobile phase was composed of methanol and water (75:25 v/v), while the stationary phase was a Waters Nova-Pak C18 column (3.9 mm Å~ 15 cm Å~ 4.0 µm) with the column's temperature set to 40°C. The injection volume was 20 µL, while the gradient flow rate was maintained at 0.75 mL/min for a run time of 15 minutes. The detection wavelength for progesterone was set to 245 nm. In the forced degradation study, there was significant hydrolytic, oxidative, ultraviolet, and thermal degradation but insignificant photodegradation. However, no degradants co-eluted with progesterone. All method validation parameters met the respective acceptance criteria established by the International Conference on Harmonisation guidelines. This developed and validated method is suitable for both routine potency/strength testing as well as stability testing of progesterone in compounded glycerinated gelatin troche dosage forms. The method was utilized to successfully quantify progesterone in multiple compounded preparations from two different compounding pharmacies.

Achievement of Glycated Hemoglobin Goals in the US Remains Unchanged Through 2014.

INTRODUCTION: Previous research has found that the percentage of US adults with diabetes achieving a glycated hemoglobin (HbA1c) target of <7.0% with currently available treatments has been fairly constant from 2003 to 2010, remaining at just over 50% [1]. The objective of this study was to compare the most recent data (2011-2014) with earlier data to track progress on HbA1c target achievement, for both the general target of <7.0% and inferred individualized targets based on age and the presence of complications. METHODS: Data from 2677 adults with self-reported diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2014 were examined to determine the percentage of adults who achieved HbA1c targets of <7% and an individualized target based on age and comorbidities. National estimates are reported by using weights that account for the complex sampling design of the NHANES. RESULTS: The percentage of people with diabetes and HbA1c <7.0% slightly declined from 52.2% (95% CI 48.7-55.7%) to 50.9% (95% CI 47.2-54.7%) between the two most recent waves of data. Achievement of individualized targets declined from 69.8% (95% CI 66.5-73.0%) to 63.8% (95% CI 60.1-67.5%). The percentage with HbA1c >9.0% increased from 12.6% (95% CI 10.5-14.8%) to 15.5% (95% CI 12.9-18.2%). Achievement of individualized targets varied by age group and presence of comorbidities, but exhibited similar trends as general target achievement. CONCLUSIONS: Despite the development of many new medications to treat diabetes during the past decade, the proportion of patients achieving glycemic control targets has not improved. FUNDING: Intarcia Therapeutics.

Understanding the Gap Between Efficacy in Randomized Controlled Trials and Effectiveness in Real-World Use of GLP-1 RA and DPP-4 Therapies in Patients With Type 2 Diabetes.

OBJECTIVE: The objective of this study was to estimate and explain the gap between clinical efficacy and real-world (RW) effectiveness of type 2 diabetes medications. RESEARCH DESIGN AND METHODS: This mixed-methods quasi-experimental study used retrospective claims (Optum/Humedica) to compare the change in HbA1c of RW patients with type 2 diabetes 12 months after starting a glucagon-like peptide 1 receptor agonist (GLP-1 RA) or dipeptidyl peptidase 4 (DPP-4) inhibitor with published findings from randomized controlled trials (RCTs) evaluating these drugs. Selected RW patients were similar to RCT patients, and regression analysis was used in the RW data to adjust for differences between poorly adherent and adherent patients to explain why RCT and RW findings may differ. RESULTS: RW patients initiating a GLP-1 RA (n = 221) or a DPP-4 (n = 652) experienced smaller reductions in HbA1c (GLP-1 RA: -0.52% [-6 mmol/mol], DPP-4: -0.51% [-6 mmol/mol])than reported in RCTs (-1.30% [-14 mmol/mol] from seven GLP-1 RA RCTs, n = 2,600; -0.68% [-8 mmol/mol] from four DPP-4 RCTs, n = 1,889). Baseline HbA1c, additional medications, and adherence were significant explanatory factors in the RW HbA1c change. Modeled estimates of RCT efficacy (-1.04% GLP-1 RA [-12 mmol/mol], -0.69% DPP-4 [-8 mmol/mol]) were within the RCTs' reported range (GLP-1 RA: -0.84% to -1.60% [-9 to -18 mmol/mol], DPP-4: -0.47% to -0.90% [-5 to -10 mmol/mol]). Poor medication adherence accounted for approximately three-fourths of the gap between RW and expected RCT results (gap = 0.51% [6 mmol/mol] GLP-1 RA; 0.18% [3 mmol/mol] DPP-4). CONCLUSIONS: Poor medication adherence is primarily why RW effectiveness is significantly less than RCT efficacy, suggesting an urgent need to effectively address adherence among patients with type 2 diabetes.