A system-wide analysis using a senior-friendly hospital framework identifies current practices and opportunities for improvement in the care of hospitalized older adults.

Older adults are vulnerable to hospital-associated complications such as falls, pressure ulcers, functional decline, and delirium, which can contribute to prolonged hospital stay, readmission, and nursing home placement. These vulnerabilities are exacerbated when the hospital's practices, services, and physical environment are not sufficiently mindful of the complex, multidimensional needs of frail individuals. Several frameworks have emerged to help hospitals examine how organization-wide processes can be customized to avoid these complications. This article describes the application of one such framework-the Senior-Friendly Hospital (SFH) framework adopted in Ontario, Canada-which comprises five interrelated domains: organizational support, processes of care, emotional and behavioral environment, ethics in clinical care and research, and physical environment. This framework provided the blueprint for a self-assessment of all 155 adult hospitals across the province of Ontario. The system-wide analysis identified practice gaps and promising practices within each domain of the SFH framework. Taken together, these results informed 12 recommendations to support hospitals at all stages of development in becoming friendly to older adults. Priorities for system-wide action were identified, encouraging hospitals to implement or further develop their processes to better address hospital-acquired delirium and functional decline. These recommendations led to collaborative action across the province, including the development of an online toolkit and the identification of accountability indicators to support hospitals in quality improvement focusing on senior-friendly care.

Inhaled corticosteroids and the risk of pneumonia in Medicare patients with COPD.

OBJECTIVE: To determine the association between inhaled corticosteroid (ICS) use and the risk of pneumonia among Medicare patients with chronic obstructive pulmonary disease (COPD). METHODS: A nested case control analysis was performed to study the relationship between ICS use and pneumonia risk in a cohort of Medicare Advantage members with COPD. Patients were identified through a medical and pharmacy claims database. A case was designated as patient's first inpatient or outpatient pneumonia episode. Cases were matched to controls who entered the COPD cohort at the same time, but had not yet developed pneumonia by the case's index date. The association between ICS use and pneumonia was estimated using logistic regression. Adjusted models controlled for age, sex, race, use of other COPD medications, markers of COPD severity, receipt of the pneumococcal vaccine, and comorbidities. Analyses were also stratified by current or past ICS use, as well as dosage (low, medium, or high). RESULTS: Out of a COPD cohort of 83,455 members, 13,778 pneumonia episodes were identified; these cases were matched to 36,767 controls. Adjusting for covariates, having used any ICS during the past year was associated with increased risk of a pneumonia episode (OR 1.11, 95% CI: 1.05-1.18). Pneumonia risk was highest for current ICS users (OR 1.26, 95% CI: 1.16-1.36) and current high-dose users (OR 1.55, 95% CI: 1.25-1.92), compared to non-users. CONCLUSION: As a retrospective claims analysis, this study had inherent limitations. The pneumonia diagnosis could not be confirmed, smoking history and other health confounders were not included. However, given the large study sample size and extensive number of available controls, the results remain persuasive and confirm previous studies' findings that ICS use, particularly current use and high-dose use, is associated with increased pneumonia risk.

The Disability burden of COPD.

Affecting an estimated 12.6 million people and causing over 100,000 deaths per year, chronic obstructive pulmonary disease (COPD) exacts a heavy burden on American society. Despite knowledge of the impact of COPD on morbidity, mortality, and health care costs, little is known about the association of the disease with economic outcomes such as employment and the collection of disability. We quantify the impact of COPD on Americans aged 51 and older-in particular, their employment prospects and their likelihood of collecting federal disability benefits-by conducting longitudinal regression analysis using the Health and Retirement Study. Controlling for initial health status and a variety of sociodemographic factors, we find that COPD is associated with a decrease in the likelihood of employment of 8.6 percentage points (OR = 0.58, 95% CI 0.50-0.67), from 44% to 35%. This association rivals that of stroke and is larger than those of heart disease, cancer, hypertension, and diabetes. Furthermore, COPD is associated with a 3.9 percentage point (OR 2.52, 95% CI 2.00-3.17) increase in the likelihood of collecting Social Security Disability Insurance (SSDI), from 3.2% to 7.1%, as well as a 1.7 percentage point (OR 2.87, 95% CI 2.02-4.08) increase in the likelihood of collecting Supplemental Security Income (SSI), from 1.0% to 2.7%. The associations of COPD with SSDI and SSI are the largest of any of the conditions studied. Our results are consistent with the hypothesis that COPD imposes a substantial burden on American society by inhibiting employment and creating disability.

Disparities in adherence to and persistence with antihypertensive regimens: an exploratory analysis from a community-based provider network.

Despite the availability of effective antihypertensive therapies, adherence to and persistence with treatment is suboptimal. As such, there is a need to better understand factors associated with adherence and persistence, such as race/ethnicity. In a retrospective, exploratory analysis of 51,772 hypertensive adult subjects identified in the electronic medical record, we examined medication possession ratio and proportion of days covered as proxies for adherence and persistence, respectively. Logistic regression analyses were performed to assess the role of race/ethnicity in adherence to and persistence with antihypertensive treatments. Relative to white subjects, Asian American/Pacific Islander, black, Hispanic, and "other" subjects were significantly less likely to be adherent to and persistent with their antihypertensive regimens. Black and Hispanic subjects had the lowest odds of adherence (0.46, 95% CI: 0.43-0.49 and 0.58, 95% CI: 0.54-0.62, respectively) and persistence (0.70, 95% CI: 0.65-0.75 and 0.70, 95% CI: 0.66-0.74, respectively) relative to white subjects. Other factors significantly associated with both lower adherence and persistence included younger age and lower chronic disease score. Disparities were found with regard to adherence to and persistence with antihypertensive regimens. Future studies should address these disparities by designing interventions to improve medication-taking behavior in high-risk populations.

Global cardiovascular risk associated with hypertension and extent of treatment and control according to risk group.

BACKGROUND: Hypertension (HTN) confers increased cardiovascular disease (CVD) risk; however, the variation in risk and how treatment and control rates may differ according to extent of risk needs clarification. We examined CVD risk distribution and treatment and control patterns according to risk group. METHODS: We estimated 10-year Framingham global risk in 1,509 U.S. persons aged ≥30 years from the National Health and Nutrition Examination Survey (NHANES) 2005-2006 with HTN and the proportion of subjects in low (<10%), intermediate (10-20%), and high (>20%) risk groups, or with pre-existing CVD, or who otherwise had high cardiometabolic risk according to European Society of Hypertension (ESH) criteria (diabetes (DM), metabolic syndrome (MetS), stage 3 HTN, or 3 additional CVD risk factors). We also examined HTN treatment and control rates by risk group. RESULTS: From Framingham risk assessment, 24% of subjects were low risk, 21% intermediate risk, 23% high risk, and 32% had CVD. An additional 39% of low and 51% of intermediate risk subjects were at high or very high risk based on European criteria, for a total of 80% classified high risk or with CVD by either criterion. Treatment rates across Framingham risk groups ranged from 58 to 75%. HTN control rates were over 80% for lower risk persons, but under 50% for higher risk subjects. CONCLUSIONS: There is a wide variation in CVD risk in persons with HTN with control rates still suboptimal in higher risk subjects. Future guidelines should consider risk stratification combining shorter and longer-term risk assessment to best identify those who have the greatest CVD risk.

Disparities in blood pressure control within a community-based provider network: an exploratory analysis.

BACKGROUND: Despite treatment for hypertension, blood pressure (BP) remains uncontrolled in many individuals. Identification of patterns in BP control may inform strategies to improve treatment and optimize health outcomes. OBJECTIVE: To examine patterns in BP control among individuals receiving antihypertensive treatment in a diverse, community-based provider network. METHODS: In this retrospective exploratory analysis, a total of 51,772 hypertensive subjects were identified in the electronic medical record between January 1, 2007, and June 30, 2010, who were aged 18 years or older, with 2 or more claims for antihypertensive medication, documented race/ethnicity, and 1 or more documented BP readings. RESULTS: On the basis of Joint National Committee VII guidelines, 76.4% of nondiabetic patients had their BP controlled with treatment (<140/90 mm Hg) and 52.3% of those with diabetes had their BP controlled with treatment (<130/80 mm Hg). The overall rate of BP control was 71.4%. Factors associated with controlled BP included younger age, lower disease burden, better medication adherence, fewer concurrent prescriptions, lower prescription copayments, and living in a region with a higher median household income. Furthermore, when adjusting for age, sex, and disease burden, black (OR 0.68; 95% CI 0.62 to 0.75; p < 0.001), Hispanic (OR 0.80; 95% CI 0.74 to 0.86; p < 0.001), and other race/ethnic group (OR 0.81; 95% CI 0.70 to 0.94; p = 0.005) individuals were less likely than white individuals to have their treated BP controlled. Among nondiabetic hypertensive subjects with controlled BP, the most frequently prescribed therapy was a ß-blocker or an angiotensin-converting enzyme (ACE) inhibitor across race/ethnicities; however, those who were black were most frequently prescribed a diuretic or calcium channel blocker. Among diabetic patients with controlled BP, the most frequently prescribed therapy was an ACE inhibitor, regardless of race/ethnicity. CONCLUSIONS: Potential disparities, particularly among diabetic individuals and those of minority race/ethnicity, were found with regard to BP control and the agents used to treat hypertension. Future studies should address these disparities by designing interventions to improve the treatment of hypertension in high-risk populations.

Adoption and use of health information technology in physician practice organisations: systematic review.

BACKGROUND: Health information technology (HIT) has the potential to improve clinical outcomes, increase health provider productivity and reduce healthcare costs. Over half of all patient care is delivered in physician practice organisations, yet adoption and utilisation of HIT in these groups lags behind inpatient facilities. OBJECTIVE: To better understand current utilisation rates along with benefits and barriers to HIT adoption in physician practice organisations. METHODS: Published literature on the adoption and use of HIT in physician practice organisations within the USA between 12 January 2004 and 12 January 2009 and indexed in MEDLINE and EMBASE was included in the systematic review. Grey literature was also searched. Studies related to the adoption and use of HIT in hospitals and community health centres were excluded. RESULTS: A total of 119 articles were eligible for inclusion in the review. Adoption rates across physician groups remain low, with between 9% and 29% of practices having implemented electronic medical records. HIT improves clinical outcomes, increases the use of vaccinations and improves medication adherence. Furthermore, HIT adoption leads to cost savings for physician groups, improves staff productivity and enriches patient-provider interactions. The largest barrier to HIT adoption in physician groups is the high initial and ongoing costs of electronic systems. Lack of sufficient training, a disorganised or non-receptive practice culture and technological problems such as inadequate connectivity appear to impede effective HIT use. CONCLUSIONS: HIT has the potential to positively impact on physician practice organisations, although significant and diverse barriers block adoption. Research into these obstacles should be coupled with efforts to understand barriers to effective implementation after HIT adoption.

Blood pressure control and pharmacotherapy patterns in the United States before and after the release of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines.

OBJECTIVES: Despite recommendations from the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), only 36.8% of patients were at target blood pressure (BP) in 2003 and 2004. The objective of this study was to assess improvements in BP control and treatment patterns before and after the publication of JNC 7. METHODS: This was a retrospective, time series analysis of 27 provider groups and managed care organizations from 1998 through 2006. Patients with hypertension were identified from more than 4000 physicians. Medical charts were collected and clinical data were evaluated using prevailing JNC criteria during the time period before and after JNC 7. RESULTS: A total of 19,258 patients were identified with hypertension: 15,258 included in the before-JNC 7 cohort and 4,000 in the after-JNC 7 cohort. BP control in the before-JNC 7 cohort was 40.8% compared with 49.3% in the after-JNC 7 cohort (P < .0001). After controlling for demographic and clinical covariates, patients in the before-JNC 7 cohort were 45% less likely to achieve BP control compared with the after-JNC 7 cohort (odds ratio, 0.551; P < .0001). CONCLUSION: Although findings indicate BP control is improving, a significant need for further improvement remains.

Oral antidiabetic medication adherence and glycemic control in managed care.

OBJECTIVE: To evaluate adherence to oral diabetes medications (ODMs) in patients with type 2 diabetes and the impact of ODM adherence on glycemic control. STUDY DESIGN: Retrospective observational study. METHODS: Medical and pharmacy claims from a managed care plan in Oregon were used to identify adults with diabetes who newly initiated ODM therapy (n = 2741); a subset of this cohort linked to electronic health records was used to evaluate the relationship between adherence and glycemic control (n = 249). Glycemic control was assessed based on most recent glycosylated hemoglobin (A1C) measurement within the study period. RESULTS: Mean cohort age was 54 years; 46% initiated therapy with metformin, 39% with a sulfonylurea, and 12% with a thiazolidinedione. Mean adherence overall was 81%, and 65% of subjects had good adherence (>80%). Increasing age and comorbidity burden were associated with higher medication adherence. In the patient subset with A1C measurements, mean baseline A1C was 8%. An inverse relationship existed between ODM adherence and A1C; controlling for baseline A1C and therapy regimen, each 10% increase in ODM adherence was associated with a 0.1% A1C decrease (P = .0004). CONCLUSION: Although most patients were adherent to ODM therapy, adherent patients were more likely to achieve glycemic control than nonadherent patients. Greater efforts are needed to facilitate diabetes self-management behaviors to improve patient outcomes.

High-risk patients with hypertension: Are we doing enough?

Despite the increasing risk of cardiovascular disease, especially in patients with multiple risk factors, blood pressure (BP) control remains suboptimal. This study investigated real-world BP goal attainment and prescribing patterns for high-risk patients. A retrospective chart review study was conducted in patients treated by eight large primary care physician group practices between December 2003 and May 2006. A total of 1,917 hypertensive patients were identified with >/=1 risk factors: African-American ethnicity (634); diabetes (851); advanced age (1,123); body mass index (BMI) 25 kg/m(2) (1,614). BP control rate was 46% overall, and similar in the advanced age and overweight/obese subpopulations, but substantially lower (28%) in the diabetic subpopulation. Systolic blood pressure >/=20 mm Hg above the Joint National Committee on Prevention, Detection, Evaluation, and Treatment Report recommendation was found in 13% of the overall, advanced age and overweight/obese subpopulations, and in 20% of diabetics and 18% of African-Americans. Overall, 62% of patients received >/=2 antihypertensive while 36% of diabetics, 31% of African-Americans, 28% of advanced age, and 26% of overweight/obese patients received >/=3 antihypertensive classes. Despite availability of multiple antihypertensive classes, BP control rates were still suboptimal in this study's high-risk patients. There is a need for awareness and more aggressive treatment in high-risk patients given their increased risk of poor outcomes.

Assessment of outcomes and parental effect on Quality-of-Life endpoints in the management of atopic dermatitis.

The objective of this study was to assess the consequences of atopic dermatitis/ eczema on two areas: (1) the quality of life of parents/caregivers and (2) resource utilization from two large group practices. Data from 414 patients with atopic dermatitis, aged two to 12 years, were collected between January 2001 and December 2003. Parents/caregivers completed the Parent's Index of Quality of Life-Atopic Dermatitis (PIQoL-AD). One-way analysis of variance and analysis of covariance models determined statistical significance. Pairwise significance testing was performed to determine statistical differences (P < .05). Mean patient age was 6.7 years and 55% of patients were males; mild and moderate atopic dermatitis was present in 82% and 13% of patients, respectively. Mean PIQoL-AD scores worsened (5.9 +/- 5.4 vs. 3.0 +/- 3.6, P < .001) for caregivers whose child had disease flares versus those without disease flares. Patients with atopic dermatitis incurred an additional 1.8 unscheduled visits annually at a cost of $93.54 per patient. It was determined that atopic dermatitis may have considerable quality-of-life and financial consequences to both family and community.

Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care.

OBJECTIVE: To measure the impact of medication copayment level and other predictors on compliance with antihypertensive medications, as measured by the medication possession ratio. STUDY DESIGN: Retrospective observational analysis. METHODS: We used claims data from a large managed care organization. The identification of subjects was based on a diagnosis of hypertension and a filled prescription for antihypertensive medication between January 1999 and June 2004. Multivariate logistic regression models were used to evaluate copayment level and patient characteristics as predictors of medication compliance. RESULTS: Analysis of data for 114,232 patients filling prescriptions for antihypertensive medications revealed that compliance was lower for drugs in less preferred tiers. Relative to medications with a 5 dollars copayment, the odds ratio (95% confidence interval) for compliance with drugs having a 20 dollars copayment was 0.76 (0.75, 0.78); for drugs requiring a 20 dollars to 165 dollars copayment, the odds ratio for compliance was 0.48 (0.47, 0.49). Medication compliance also differed by patient age, morbidity level, and ethnicity, as well as by medication therapeutic class--with the best compliance observed for angiotensin receptor blockers, followed by calcium channel blockers, beta-adrenergic receptor antagonists (beta-blockers), angiotensin-converting enzyme inhibitors, and last, thiazide diuretics. CONCLUSIONS: Copayment level, independent of other determinants, was found to be a strong predictor of compliance with antihypertensive medications, with greater compliance seen among patients filing pharmacy claims for drugs that required lower copayments. This finding suggests that patient use is sensitive to price. The potential impact on compliance should be considered when making pricing and policy decisions.