Risk of volume depletion events with concomitant use of sodium glucose co-transporter 2 inhibitors and loop diuretics: A self-controlled case series study.

BACKGROUND: Sodium glucose co-transporter 2 inhibitors (SGLT2is) are used to prevent cardiovascular complications in type 2 diabetes mellitus (T2DM) and newly indicated to treat heart failure (HF). Loop diuretics are commonly prescribed to manage volume overload in HF and may increase the risk of volume depletion in real-world practice. This study evaluated the risk of volume depletion following concomitant use of SGLT2is and loop diuretics in veterans. METHODS: Veterans with T2DM were included if they received concomitant loop diuretics and SGLT2is and experienced at least one volume depletion event between December 2012 and December 2019, utilizing a self-controlled case series design. Concomitant prescribing periods were divided into focal windows of 1 to 14 days, 14 to 28 days, and greater than 28 days. Incidence rate ratios (IRR) were estimated using multivariable Poisson regressions adjusted for age and renal function. RESULTS: 3352 patients experienced at least one volume depletion event and were concomitantly prescribed SGLT2is and loop diuretics at least once. The risk of volume depletion increased in the treatment versus control windows during the 1 to 14-day window (IRR = 1.82, 95% CI 1.63-2.02) the 15-to-28-day window (IRR = 1.46, 95% CI 1.28-1.67), and the greater than 28-day window (IRR = 1.22, 95% CI 1.21-1.34). CONCLUSIONS: Concomitant prescribing of SGLT2is and loop diuretics is associated with an increased risk of volume depletion, an effect that attenuates with longer therapy durations. Prescribers need to closely monitor fluid status in patients receiving concomitant therapy, especially those with advancing age or with eGFR below 60.

The Effect of Saccharomyces boulardii Primary Prevention on Risk of Hospital-onset Clostridioides difficile Infection in Hospitalized Patients Administered Antibiotics Frequently Associated With C. difficile Infection.

BACKGROUND: Hospital-onset Clostridioides difficile infection (HO-CDI) is a costly problem leading to readmissions, morbidity, and mortality. We evaluated the effect of a single probiotic strain, Saccharomyces boulardii, at a standardized dose on the risk of HO-CDI within hospitalized patients administered antibiotics frequently associated with HO-CDI. METHODS: This retrospective cohort study merged hospital prescribing data with HO-CDI case data. The study assessed patients hospitalized from January 2016 through March 2017 who were administered at least 1 dose of an antibiotic frequently associated with HO-CDI during hospitalization. Associations between S. boulardii administration, including timing, and HO-CDI incidence were evaluated by multivariable logistic regression. RESULTS: The study included 8763 patients. HO-CDI incidence was 0.66% in the overall cohort. HO-CDI incidence was 0.56% and 0.82% among patients coadministered S. boulardii with antibiotics and not coadministered S. boulardii, respectively. In adjusted analysis, patients coadministered S. boulardii had a reduced risk of HO-CDI (odds ratio [OR], 0.57 [95% confidence interval {CI}, .33-.96]; P = .04) compared to patients not coadministered S. boulardii. Patients coadministered S. boulardii within 24 hours of antibiotic start demonstrated a reduced risk of HO-CDI (OR, 0.47 [95% CI, .23-.97]; P = .04) compared to those coadministered S. boulardii after 24 hours of antibiotic start. CONCLUSIONS: Saccharomyces boulardii administered to hospitalized patients prescribed antibiotics frequently linked with HO-CDI was associated with a reduced risk of HO-CDI.

Working smarter, not harder: evaluating a population health approach to anticoagulation therapy management.

Inappropriate direct acting oral anti-coagulants (DOAC) prescribing increases the risk of adverse events. Population health management tools (PMTs) could help reduce adverse events through the early, efficient identification of questionable prescribing practices, but the impact of such a tool remains unknown. We evaluated the effect of PMT use on questionable DOAC dosing rates within 40 VHA medical centers and whether this effect differed by DOAC indication or agent. Medical centers were divided into PMT user or standard of care (SOC) groups based upon high or low tool access in the prior year. Questionable DOAC dosing rate was defined as the proportion of patients prescribed DOACs who were also flagged by the tool. Chi-square tests were used to determine if PMT user versus SOC groups differed with high (above 15.3%) versus low (below 15.3%) questionable dosing rates. T-tests were used to determine if mean questionable dosing rates significantly differed between the PMT user and SOC groups. DOAC PMT users were classified less frequently as being 'High" questionable dosage rate compared to SOCs (25% PMT vs. 75% SOC, respectively, p = 0.002). DOAC PMT utilization within the overall cohort was associated with a 4.3% absolute reduction in questionable DOAC dosing rates (13.2% PMT vs 17.5% SOC; p = 0.01). Tool use within the atrial fibrillation (AF) subgroup was associated with a 5.1% absolute reduction in questionable dosing rates (10.4% SOC vs. 5.3% PMT, p < 0.001). Tool use was also associated with lower questionable dosing rates in the apixaban (p < 0.001), dabigatran (p = 0.03) and AF plus venous thromboembolism (p < 0.001) subgroups. In our study, PMT use was associated with reduced questionable DOAC dosing, a difference most pronounced within AF patients. A population health approach has the potential to reduce adverse events among patients prescribed DOACs.

Estimated GFR Decline Following Sodium Phosphate Enemas Versus Polyethylene Glycol for Screening Colonoscopy: A Retrospective Cohort Study.

BACKGROUND: Associations between sodium phosphate enemas and nephropathy have raised concerns about the safety of use as part of a bowel-cleansing regimen administered prior to colonoscopies. The objectives of this analysis are to evaluate the impact of sodium phosphate enema versus polyethylene glycol powder for oral solution (PEG) use prior to colonoscopy screening on estimated glomerular filtration rate (eGFR) decline in Veterans Affairs (VA) patients and identify other risk factors contributing to eGFR decline. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 70,499 VA patients receiving sodium phosphate enemas (with or without PEG) or PEG alone prior to colonoscopy screenings. PREDICTOR: Use of either sodium phosphate or PEG. OUTCOMES: A 50% increase in serum creatinine level over a 15-month, over a 6-week, and between a 9- and 15-month period was used to define any, acute, or long-term eGFR decline, respectively. MEASUREMENTS: Multivariable logistic regressions estimated the likelihood of eGFR decline conditional on the use of sodium phosphate enemas versus PEG alone, controlling for potential confounders. RESULTS: A greater proportion of patients using sodium phosphate enemas versus PEG had any (P<0.001) or long-term (P=0.003) eGFR declines, whereas similar proportions had acute eGFR declines (P=0.9). In the adjusted analyses, use of sodium phosphate enemas (± PEG was associated with an increased likelihood of having any (OR, 1.3; 95% CI, 1.2-1.5) or long-term (OR, 1.4; 95% CI, 1.1-1.8) eGFR decline, but not acute eGFR decline (OR, 1.0; 95% CI, 0.6-1.7). Other risk factors for eGFR decline included diabetes and non-iron deficient anemia. LIMITATIONS: Unobserved heterogeneity due to volume depletion and potential selection bias due to higher-risk patients preferentially prescribed sodium phosphate enemas. CONCLUSIONS: Use of sodium phosphate enemas versus PEG alone prior to colonoscopy screening increases the risk for VA patients having long-term eGFR decline. Patients with non-iron deficient anemia are at particularly high risk for eGFR decline. These findings motivate the need to re-examine prescribing practices for sodium phosphate enemas as part of a bowel-cleansing regimen.

Report of the 2023-2024 AACP Research and Graduate Affairs Committee.

The 2023-2024 American Association of Colleges of Pharmacy Research and Graduate Affairs Committee ("the Committee") was charged with developing programs focused on career and professional development for researchers, new faculty, and graduate students in colleges and schools of pharmacy. After reviewing exiting resources available to pharmacy faculty for grant writing, the Committee recognized a need for more comprehensive, diverse, and tailored resources for pharmacy faculty. The Committee, therefore, focused its effort on creating an intensive grant writing course intended for independent pharmacy researchers without previous major grant awards that would support writing for career development and research grant applications and cater to faculty in translational, clinical sciences, and pharmacy practice, along with fellows and residents. To implement this grant writing course and other programs to advance research progress by pharmacy faculty, the Committee proposes 3 recommendations for consideration by the American Association of Colleges of Pharmacy and 1 suggestion for consideration by colleges and schools of pharmacy.

Inpatient prescribing patterns of long-acting injectables and their oral or short-acting injectable equivalent formulations.

Background: Long-acting injectable (LAI) antipsychotics (APs) each have an oral equivalent formulation, while aripiprazole, olanzapine, and ziprasidone each also have a short-acting injectable (SAI) equivalent formulation. Inpatient prescribing patterns of LAIs and their oral/SAI equivalents are less characterized in populations other than Medicaid, Medicare, and Veterans Affairs populations. Mapping out inpatient prescribing patterns remains an important first step to ensure appropriate use of antipsychotics during this critical juncture of patient care prior to discharge. This study determined inpatient prescribing patterns of first- (FGA) and second-generation antipsychotic (SGA) LAIs and their oral/SAI formulations. Methods: This was a large retrospective study using the Cerner Health Facts® database. Hospital admissions due to schizophrenia, schizoaffective disorder, or bipolar disorder from 2010 to 2016 were identified. AP utilization was defined as the proportion of inpatient stays during which at least 1 AP was administered to the total number of inpatient visits over the observed period. Descriptive analyses were used to determine prescribing patterns for APs. Chi-square tests were used to determine utilization differences across years. Results: 94,989 encounters were identified. Encounters during which oral/SAI of SGA LAIs were administered were most common (n = 38,621, 41%). Encounters during which FGA LAIs or SGA LAIs were administered were the least common (n = 1,047, 1.1%). Prescribing patterns differed across years (p < 0.05) within the SGA LAI subgroup analysis (N = 6,014). Paliperidone palmitate (63%, N = 3,799) and risperidone (31%, N = 1,859) were the most frequently administered. Paliperidone palmitate utilization increased from 30% to 72% (p < 0.001), while risperidone utilization decreased from 70% to 18% (p < 0.001). Conclusions: Compared with their oral or SAI formulations, LAIs were underutilized from 2010 to 2016. Among SGA LAIs, the prescribing patterns of paliperidone palmitate and risperidone changed significantly.

Medication discrepancy rates and sources upon nursing home intake: A prospective study.

BACKGROUND: Medication discrepancies at nursing home intake increase the risk of drug-related adverse events. Measuring discrepancy incidence rates and locating the origins of discrepancies can assist in identifying information exchange deficits for high-risk medications. OBJECTIVE: To determine class-specific discrepancy rates, to determine discordance between medication lists, and to explore patient and system-level factors associated with medication discrepancies discovered between the first and second medication reconciliations conducted at nursing home intake. METHODS: Medication discrepancy data were prospectively collected from four long-term care facilities over a 9-month period. Medication discrepancies were defined as mismatched prescribing orders between at least two medication history lists. Discrepancy locations were defined as the pairs or triads of facilities between which medication history lists were discordant. Unadjusted logistic regressions were used to identify medication classes with the highest discrepancy rates and patient factors significantly associated with any medication discrepancy. RESULTS: 40.8% of newly admitted or re-admitted residents and 6.3% of medications reviewed had at least one medication discrepancy discovered during the second medication reconciliation conducted at nursing home intake. Residents prescribed fewer than 14 medications were at less risk of discrepancies. Residents with Charlson Comorbidity Index of 5, COPD, HF, anemia or HTN were at greater risk of discrepancies. Respiratory and analgesic medications were twice as likely as other medication classes to be discrepant (OR = 2.2, 95% CI 1.2-4.4; OR = 2.2, 95% CI 1.3-3.5). Most discrepancies occurred between hospital and nursing home lists (44.9%), or between the hospital, nursing home, and community pharmacy lists (39.3%) CONCLUSIONS: Given the higher risk of discrepancies within respiratory or analgesics, transitions of care teams need to prioritize residents with respiratory conditions or pain. Although re-admitted residents' increased discrepancy risk is likely due to poorer health status, miscommunications across the nursing home, hospital and community pharmacy require further research to clarify system failures.

Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission.

BACKGROUND: Children with epilepsy are at increased risk of medication errors due to disease complexity and administration of time-sensitive medication. Errors frequently occur during transitions of care between home and hospital, a time when accuracy of medication history lists is difficult to ascertain. Adverse events likely from medication discrepancies underscore the importance of improving medication reconciliation upon inpatient intake. This quality improvement project was designed to evaluate and optimize the current medication history process in epileptic patients upon hospital admission at a pediatric academic hospital. METHODS: A retrospective chart review was conducted on 30 patients with epilepsy admitted in during April, July, and October 2018 to identify unintentional medication discrepancies among 6 sources: documented medication history, inpatient orders from the electronic medical record, outpatient clinic notes, inpatient history and admission document, phone message records, and external insurance claims. RESULTS: A total of 63% percent of patients had at least 1 unintentional medication discrepancy. Most discrepancies occurred with daily maintenance anticonvulsants (63%). The most common types were omission of medication history (31%) and inpatient order omissions (27%). The number of medication histories completed with at least 1 discrepancy varied across pharmacists, nurses, and physicians, yet differences were not statistically significant. CONCLUSIONS: Our study found a higher incidence of anticonvulsant discrepancies compared with previous studies. This quality improvement initiative identified the absence of a standardized process as the root cause for the high incidence of anticonvulsant discrepancies in pediatric patients with epilepsy at hospital admission.

Process of care performance measures and long-term outcomes in patients hospitalized with heart failure.

BACKGROUND: Recent efforts to improve care for patients hospitalized with heart failure have focused on process-based performance measures. Data supporting the link between current process measures and patient outcomes are sparse. OBJECTIVE: To examine the relationship between adherence to hospital-level process measures and long-term patient-level mortality and readmission. RESEARCH DESIGN: Analysis of data from a national clinical registry linked to outcome data from the Centers for Medicare and Medicaid Services (CMS). SUBJECTS: A total of 22,750 Medicare fee-for-service beneficiaries enrolled in the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure between March 2003 and December 2004. MEASURES: Mortality at 1 year; cardiovascular readmission at 1 year; and adherence to hospital-level process measures, including discharge instructions, assessment of left ventricular function, prescription of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker at discharge, prescription of beta-blockers at discharge, and smoking cessation counseling for eligible patients. RESULTS: Hospital conformity rates ranged from 52% to 86% across the 5 process measures. Unadjusted overall 1-year mortality and cardiovascular readmission rates were 33% and 40%, respectively. In covariate-adjusted analyses, the CMS composite score was not associated with 1-year mortality (hazard ratio, 1.00; 95% confidence interval, 0.98-1.03; P = 0.91) or readmission (hazard ratio, 1.01; 95% confidence interval, 0.99-1.04; P = 0.37). Current CMS process measures were not independently associated with mortality, though prescription of beta-blockers at discharge was independently associated with lower mortality (hazard ratio, 0.94; 95% confidence interval, 0.90-098; P = 0.004). CONCLUSION: Hospital process performance for heart failure as judged by current CMS measures is not associated with patient outcomes within 1 year of discharge, calling into question whether existing CMS metrics can accurately discriminate hospital quality of care for heart failure.

Resource use and costs of treatment with anticoagulation and antiplatelet agents: results of the WATCH trial economic evaluation.

BACKGROUND: The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial revealed no significant differences among 1587 symptomatic heart failure patients randomized to warfarin, clopidogrel, or aspirin in time to all-cause death, nonfatal myocardial infarction, or nonfatal stroke. We compared within-trial medical resource use and costs between treatments. METHODS AND RESULTS: We assigned country-specific costs to medical resources incurred during follow-up. Annualized rates of hospitalizations, inpatient and outpatient procedures, and emergency department visits did not differ significantly between groups. Annualized total costs averaged $5901 (95% confidence interval [CI], $4776-$7520) for the aspirin group, $5646 (95% CI, $4903-$6584) for the clopidogrel group, and $5830 (95% CI, $4838-$7400) for the warfarin group. CONCLUSIONS: Consistent with clinical findings, our analyses did not identify significant cost differences between treatments.

Inter-facility communication barriers delay resolving medication discrepancies during transitions of care.

BACKGROUND: Medication discrepancies occurring during transitions of care between hospitals and nursing homes increase the risk of adverse events for patients. Resolving mismatched information between hospitals and nursing homes adds additional burden to nursing home staff. OBJECTIVE: The aim of this study was to characterize challenges facing nursing home staff in receiving and resolving medication discrepancies during resident intake. METHODS: This study used one focus group comprised of five nurses, one pharmacist and two administrators from four nursing homes to explore the staffs' experiences resolving medication discrepancies at resident intake. Thematic analysis was used to determine primary themes and categories arising from focus group transcripts. RESULTS: Three common challenges included 1) Nursing homes relying upon external providers for accurate information that is frequently delayed; 2) Prescribing data shared between hospitals and nursing facilities on incompatible formats with inconsistent content; 3) Following a specific communication workflow between facilities to resolve errors as efficiently as possible. CONCLUSIONS: Improving access to formularies and medical histories for providers across the continuum of care and improving information sharing across transitions would improve communication, decrease discrepancies and increase patient safety during post-acute care transitions.

A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists.

OBJECTIVE: Underreporting near-miss errors undermines hospitals' ability to improve patient safety. The objective of this analysis was to determine the extent to which punitive work climate, inadequate error feedback to staff, or insufficient preventative procedures are associated with decreased frequency of near-miss error reporting among hospital pharmacists. METHODS: Survey data were obtained from the Agency of Healthcare Research and Quality 2010 Hospital Survey on Patient Safety Culture. Near-miss error reporting was defined using a Likert scale response to the question, "When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported?" Work climate, error feedback to staff, and preventative procedures were defined similarly using responses to survey questions. Multivariate ordinal regressions estimated the likelihood of agreeing that near-miss errors were rarely reported, conditional upon perceived levels of punitive work climate, error feedback, or preventative procedures. RESULTS: Pharmacists disagreeing that procedures were sufficient and that feedback on errors was adequate were more likely to report that near-miss errors were rarely reported (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.7-3.8; OR, 3.5; 95% CI, 2.5-5.1). Those agreeing that mistakes were held against them were equally likely as those disagreeing to report that errors were rarely reported (OR, 0.84; 95% CI, 0.61-1.1). CONCLUSIONS: Inadequate error feedback to staff and insufficient preventative procedures increase the likelihood that near-miss errors will be underreported. Hospitals seeking to improve near-miss error reporting should improve error-reporting infrastructures to enable feedback, which, in turn, would create a more preventative system that improves patient safety.

A Focus Group Exploration of Automated Case-Finders to Identify High-Risk Heart Failure Patients Within an Urban Safety Net Hospital.

BACKGROUND: Leveraging "big data" as a means of informing cost-effective care holds potential in triaging high-risk heart failure (HF) patients for interventions within hospitals seeking to reduce 30-day readmissions. OBJECTIVE: Explore provider's beliefs and perceptions about using an electronic health record (EHR)-based tool that uses unstructured clinical notes to risk-stratify high-risk heart failure patients. METHODS: Six providers from an inpatient HF clinic within an urban safety net hospital were recruited to participate in a semistructured focus group. A facilitator led a discussion on the feasibility and value of using an EHR tool driven by unstructured clinical notes to help identify high-risk patients. Data collected from transcripts were analyzed using a thematic analysis that facilitated drawing conclusions clustered around categories and themes. RESULTS: From six categories emerged two themes: (1) challenges of finding valid and accurate results, and (2) strategies used to overcome these challenges. Although employing a tool that uses electronic medical record (EMR) unstructured text as the benchmark by which to identify high-risk patients is efficient, choosing appropriate benchmark groups could be challenging given the multiple causes of readmission. Strategies to mitigate these challenges include establishing clear selection criteria to guide benchmark group composition, and quality outcome goals for the hospital. CONCLUSION: Prior to implementing into practice an innovative EMR-based case-finder driven by unstructured clinical notes, providers are advised to do the following: (1) define patient quality outcome goals, (2) establish criteria by which to guide benchmark selection, and (3) verify the tool's validity and reliability. Achieving consensus on these issues would be necessary for this innovative EHR-based tool to effectively improve clinical decision-making and in turn, decrease readmissions for high-risk patients.

Associations between perceived crisis mode work climate and poor information exchange within hospitals.

BACKGROUND: Because hospital units operating in crisis mode could create unsafe transitions of care due to miscommunication, our objective was to estimate associations between perceived crisis mode work climate and patient information exchange problems within hospitals. METHODS: Self-reported data from 247,140 hospital staff members across 884 hospitals were obtained from the 2010 Hospital Survey on Patient Safety Culture. Presence of a crisis mode work climate was defined as respondents agreeing that the hospital unit in which they work tries to do too much too quickly. Presence of patient information exchange problems was defined as respondents agreeing that problems often occur in exchanging patient information across hospital units. Multivariable ordinal regressions estimated the likelihood of perceived problems in exchanging patient information across hospital units, controlling for perceived levels of crisis mode work climate, skill levels, work climate, and hospital infrastructure. RESULTS: Compared to those disagreeing, hospital staff members agreeing that the hospital unit in which they work tries to do too much too quickly were 1.6 times more likely to perceive problems in exchanging patient information across hospital units (odds ratio: 1.6, 95% confidence interval: 1.58-1.65). CONCLUSIONS: Hospital staff members perceiving crisis mode work climates within their hospital unit are more likely to perceive problems in exchanging patient information across units, underscoring the need to improve communication during transitions of care.

Associations between communication climate and the frequency of medical error reporting among pharmacists within an inpatient setting.

OBJECTIVE: Although error-reporting systems enable hospitals to accurately track safety climate through the identification of adverse events, these systems may be underused within a work climate of poor communication. The objective of this analysis is to identify the extent to which perceived communication climate among hospital pharmacists impacts medical error reporting rates. METHODS: This cross-sectional study used survey responses from more than 5000 pharmacists responding to the 2010 Hospital Survey on Patient Safety Culture (HSOPSC). Two composite scores were constructed for "communication openness" and "feedback and about error," respectively. Error reporting frequency was defined from the survey question, "In the past 12 months, how many event reports have you filled out and submitted?" Multivariable logistic regressions were used to estimate the likelihood of medical error reporting conditional upon communication openness or feedback levels, controlling for pharmacist years of experience, hospital geographic region, and ownership status. RESULTS: Pharmacists with higher communication openness scores compared with lower scores were 40% more likely to have filed or submitted a medical error report in the past 12 months (OR, 1.4; 95% CI, 1.1-1.7; P = 0.004). In contrast, pharmacists with higher communication feedback scores were not any more likely than those with lower scores to have filed or submitted a medical report in the past 12 months (OR, 1.0; 95% CI, 0.8-1.3; P = 0.97). CONCLUSIONS: Hospital work climates that encourage pharmacists to freely communicate about problems related to patient safety is conducive to medical error reporting. The presence of feedback infrastructures about error may not be sufficient to induce error-reporting behavior.

Associations between prescription copayment levels and ß-blocker medication adherence in commercially insured heart failure patients 50 years and older.

BACKGROUND: High prescription copayments may create barriers to care, resulting in medication nonadherence. Although many studies have examined these associations in commercially insured patients with chronic disease, few have examined ß-blocker effects in heart failure patients. OBJECTIVE: Associations between ß-blocker prescription copayment levels and medication nonadherence were examined within commercially insured beneficiaries with a diagnosis of heart failure. METHODS: Heart failure patients were identified as those with at least 1 inpatient claim or 2 outpatient claims with an associated International Classification of Diagnosis, 9th Edition (ICD-9) code of 428.x, in addition to those with at least 2 ß-blocker claims. Copayment levels were defined in using $5.00 (USD) interval categories, and adherence was defined using the medication possession ratio (MPR). Ordinary least squares (OLS), fixed effects (FE), and random effect (RE) models were used to estimate associations between copayment level and MPR. Logistic regression was used to estimate the probability of nonadherence (MPR < 0.80) conditional upon copayment level. Regressions controlled for patient demographics, health status, prior hospitalizations, and concomitant medication use. RESULTS: The highest ß-blocker copayment level ($26+) had an average MPR that was 0.07 (95% CI, -0.11 to -0.03), 0.08 (95% CI, -0.12 to -0.04), and 0.09 (95% CI, -0.17 to -0.02) units lower than ß-blocker copayment level ($0 to $1) in the OLS, RE, and FE models, respectively. Copayment levels $21-$25 and $26+ were significantly associated with an increased risk of medication nonadherence (OR = 1.64; 95% CI, 1.1-2.4; and OR = 2.5; 95%, CI 1.6-4, respectively). CONCLUSIONS: Commercially insured heart failure patients aged ≥50 years who are prescribed higher costing ß-blockers may have up to an average 9% decrease in annual ß-blocker medication supply as well as an increased risk of nonadherence (MPR <0.80). Results need to be interpreted with caution given the potential of selection bias due to selective prescribing. Associations between copayment levels and nonadherence need to be further explored given the adverse health consequences of nonadherence to ß-blockers.

Psychological distress as a barrier to preventive care in community-dwelling elderly in the United States.

OBJECTIVE: The presence of psychologic distress in older adults may be associated with decreased adherence to recommended preventive-care services. This analysis aimed to measure the association between psychologic distress and adherence to United States Preventive Services Task Force (USPSTF)-recommended preventive-care services among older adults in the United States. DESIGN: We undertook a cross-sectional analysis of 3655 U.S. community-dwelling elderly from the 2001 Medical Expenditure Panel (MEPS) survey. MEASUREMENTS: The presence of psychologic distress was captured by the Mental Component Survey (MCS) of the SF-12. The receipt of 9 preventive care services were captured using MEPS: hypertension screening, influenza vaccination, fecal occult blood testing or sigmoidoscopy, mammography, clinical breast examination, cholesterol screening, prostate-specific antigen test, routine check-up, and dental checkup. RESULTS: Elderly reporting psychologic distress were 30% less likely than nondistressed elderly to receive influenza vaccination (OR = 0.70, 95% CI = 0.55-0.88) and 23% less likely to receive annual dental check-ups (OR= 0.77, 95% CI = 0.61-0.97). Women with psychologic distress were 27% less likely to receive a clinical breast examination (OR = 0.73, 95% CI = 0.57-0.94). Psychologic distress was not significantly associated with screening for hypertension, colon cancer, high cholesterol, or prostrate cancer, mammography, or routine check-ups. CONCLUSIONS: Elderly reporting psychologic distress were less likely to adhere to some, but not all, recommended preventive care guidelines. These results suggest that adherence to recommended preventive care guidelines may be improved, indirectly, by improving recognition and treatment of emotional health problems in the elderly.