Impact of patient-centered prescription medication labels on adherence in community pharmacy.

BACKGROUND: Prescription medication labels are often constructed in a manner which hinders safe and appropriate use of medicines. The United States Pharmacopeia released voluntary standards to revise medication labels in an effort to support patients' understanding and improve medication use. OBJECTIVE: To examine the impact of label changes on medication adherence before and after pharmacy implementation of the United States Pharmacopeia patient-centered prescription medication label standards. METHODS: This study used a retrospective pre-post cohort design. Prescription fill claims data were obtained from a community health plan serving Medicaid patients for 1 independent community pharmacy organization across 8 retail pharmacy sites. We calculated medication possession ratios (MPR) and proportion of days covered (PDC) for medications used for contraception, asthma, hypertension, and depression from 15 months before to 13 months after implementation of the label changes. RESULTS: Findings showed significant increases in mean MPR for asthma controller (increased by 0.111 [t = 0.290, P<0.0001]), antihypertensives (increased by 0.062 [t = 0.146, P < 0.0002]), and contraceptives medications (increased 0.133 [t = 0.209, P < 0.0001]) from preintervention to postintervention periods. Results also revealed increases in mean PDC for asthma controllers (increased by 0.193 [t = 0.267, P < 0.0001]), antihypertensives (increased by 0.067 [t = 0.175, P = 0.049]), and contraceptives (increased by 0.111 [t = 0.208, P < 0.0119]) from preintervention to postintervention periods. CONCLUSION: We report an association between a change to more patient-centered prescription medication labels and increased medication adherence based on MPR and PDC among Medicaid recipients.

Immunizations at Wisconsin Pharmacies: Results of a statewide vaccine registry analysis and pharmacist survey.

BACKGROUND: There is currently limited data in the United States on the proportion of immunization doses given at pharmacies outside the influenza vaccine. This study aims to obtain baseline information on the percentage of vaccine doses administered at pharmacies in Wisconsin and to understand the immunization barriers for Wisconsin pharmacists, to inform interventions to increase immunization access at pharmacies. METHODS: Aggregated data from the Wisconsin Immunization Registry (WIR) was obtained for all vaccines administered at pharmacies to patients over the age of six from July 2017 through June 2018. In addition, a survey on attitudes towards and barriers to vaccination was sent to 2000 Wisconsin pharmacists with 236 respondents yielding a 12% response rate. RESULTS: WIR data demonstrates that zoster and influenza vaccines have the highest proportion of doses administered at pharmacies (39% and 20%, respectively). Human papillomavirus (HPV) vaccines have the lowest proportion of doses at 0.2%. Pharmacy survey shows that 86% provide immunizations. Most stock influenza vaccines (84%), whereas much fewer stock HPV vaccines (21%). The greatest immunization barriers for the pharmacy respondents include billing and reimbursement challenges and competing demands for staff. CONCLUSIONS: Despite the barriers, community pharmacies have significant potential to address vaccination gaps. Physicians, patients, and legislative bodies are generally well-accepting of pharmacists as immunizers. Pharmacists, in order to be fully utilized as immunizers, must engage in active communication with patients and be willing to collaborate with physicians. Legislative policy and health insurance reimbursement reforms are also necessary to facilitate further pharmacist participation in immunization.

Clinical practice guideline: tympanostomy tubes in children--executive summary.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Tympanostomy Tubes in Children. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 12 recommendations developed address patient selection, surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes.

Clinical practice guideline: Tympanostomy tubes in children.

OBJECTIVE: Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. PURPOSE: The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. ACTION STATEMENTS: The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months' duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Blood center practice and education for blood donors with anemia.

BACKGROUND: Anemia is an early indicator of many diseases, yet blood donors with low hematocrit (Hct) often receive inadequate information about its medical importance. We sought to understand the types of information that are and should be provided to these donors. STUDY DESIGN AND METHODS: Two companion studies were performed. The first investigated blood center practices for care of donors with low Hct including deferral length, information provided, and cutoff values used when referring donors for medical attention. The second was a randomized prospective pilot study comparing behavior of deferred donors receiving an "older" pamphlet providing a list of iron-rich foods or a "newer" pamphlet providing descriptions of common causes of anemia and advice for seeking medical attention. RESULTS: More than 70% of centers defer donors for 1 day. Only 6% defer donors for more than 2 weeks. Most centers provide written and/or verbal information about low Hct. Only 35% have a cutoff value defining significant anemia that requires additional medical attention. In the study of donors with low Hct, significant disease was identified within 3 months after deferral in 2 of 104 subjects: metastatic lung cancer and acute lymphocytic leukemia. Only donors receiving the newer pamphlet reported that it "definitely improved" their ability to speak with their doctor about anemia. CONCLUSIONS: The diagnosis of anemia in blood donors may be an indicator of significant undiagnosed disease. There are wide variations in how centers care for and educate donors with anemia. Donors with anemia should be provided improved and consistent educational information.

Community blood donors' knowledge of anemia and design of a literacy-appropriate educational intervention.

BACKGROUND: The purpose of this project is to improve the health of blood donors by educating and motivating them to seek medical attention for anemia. The National Anemia Action Council, BloodCenter of Wisconsin, and the Medical College of Wisconsin formed a partnership to engage volunteer blood donors and develop an educational intervention to motivate donors with anemia to seek appropriate medical care. STUDY DESIGN AND METHODS: Partners developed an educational pamphlet and conducted two focus groups with volunteer blood donors for feedback. Participants were recruited from volunteer donors at BloodCenter of Wisconsin found to have anemia (men age, 18 years and older with a hematocrit [Hct] level of <38%; women age 50 years and older with a Hct level of <36%) at blood screening before donation. RESULTS: Participants (n = 25) addressed their understanding of anemia, information they received after being deferred, their reactions about the deferral, and comments on the educational material. The educational pamphlet was revised based on focus group comments. CONCLUSION: Volunteer donors are extremely dedicated and interested in increasing their understanding of anemia and the ability to continue donation. Community members' feedback on educational material is a valuable resource to improve the literacy level of information.

Implementing an electronic medical record at a residency site: physicians' perceived effects on quality of care, documentation, and productivity.

BACKGROUND: Electronic Medical Records (EMRs) are quickly becoming a standard component of medical practices. OBJECTIVES: We longitudinally studied the impact of EMR implementation on physician perceptions of quality of care, documentation, and work hours, as well as on measured physician productivity. METHODS: Physicians were surveyed at 3-month intervals regarding perceived impact of the EMR on quality of care, documentation, and productivity. Relative Value Units (RVUs) per clinic hours were used to measure productivity. Paired t-tests were used to compare the mean RVUs per clinic hour in the pre-EMR with the immediate post-EMR time period and the long-term post-EMR time period. RESULTS: RVUs per hour increased significantly from the pre-EMR time period to the immediate post-EMR time period (means 1.49 and 1.82, respectively, P = 0.0007). The long-term post-EMR time period also showed a significant increase over the pre-EMR period (mean 1.79, P = 0.007). Sixty-six percent of physicians perceived that EMR implementation increased their work amount a little or much more. CONCLUSION: Not only did physician production rise immediately, it stayed at the increased level for the duration of our study period. This may be due to improved documentation supporting more appropriate billing. However, physicians also perceived the EMR as taking up more of their time.

Disparities in colon cancer screening in the Medicare population.

BACKGROUND: Colorectal cancer is the third most common cancer in the United States, but the rate of screening remains low. Since 2001, Medicare has provided coverage of colonoscopy for colorectal cancer screening in individuals at average risk, but little is known about the effect of this coverage on screening or disparities in screening practices. METHODS: We examined the Medicare physician/supplier billing claims file for New York, Florida, and Illinois for the years 2002 and 2003. Using a previously employed algorithm, we identified the rates of colorectal screening tests in individuals at average risk. We performed multivariate logistic regression analysis to calculate the effects of sex, racial/ethnic, and socioeconomic characteristics on screening. We also looked for interactions between socioeconomic and demographic variables. RESULTS: A total of 596 470 Medicare beneficiaries were included in the study. Approximately 18.3% of the population had undergone a screening colon test during the study period. Nonwhite persons were less likely to be screened for colorectal cancer than were white persons (relative risk [RR], 0.52; 95% confidence interval [CI], 0.50-0.53). The lowest RR of screening colonoscopy in women compared with men was in the oldest age group and the highest income tertile (RR for whites, 0.64; 95% CI, 0.59-0.70). Higher income level was associated with screening colonoscopy in white patients (men: RR, 1.19; 95% CI, 1.14-1.25; women: RR, 1.09; 95% CI, 1.05-1.15) but not in nonwhite patients (men: RR, 0.97; 95% CI, 0.78-1.22; women: RR, 0.94; 95% CI, 0.78-1.14). CONCLUSION: Despite the expansion of Medicare coverage for colorectal cancer screening, there still remain significant disparities between sex and racial/ethnic groups in screening practices.

Effect of model of care delivery on mammography use among elderly breast cancer survivors.

BACKGROUND: Despite gaps in the quality of follow-up care for breast cancer survivors, the most effective model for such care remains unclear. We evaluated receipt of mammography among survivors followed by generalist physicians, specialists, or both (referred to as 'shared care'). METHODS: We used Surveillance, Epidemiology, and End Results tumor registry data and Medicare claims to study 3828 older women, diagnosed with breast cancer in 1995. RESULTS: During the first 3 years after treatment, about two-thirds of patients underwent shared care. Use of mammography in such patients was 84.0, 81.0 and 78.6% in follow-up years 1-3 respectively. For patients not using shared care, use of mammography was 76.3, 70.5, 66.0% in years 1-3 respectively. In a multivariate logistic regression model, women receiving shared care had substantially greater mammography use than others, with an odds ratio of 2.13 (95% CI: 1.74, 2.58) in the first follow-up year and similar odds ratios in subsequent follow-up years. CONCLUSIONS: Most older breast cancer survivors undergo shared care. These patients receive better quality of care as measured by follow-up mammography.

Glycemic control and the risk of multiple microvascular diabetic complications.

BACKGROUND AND OBJECTIVES: Tight glycemic control in type 2 diabetes reduces risk of certain end-organ complications. However, among patients with one complication already, it is unknown whether tight glycemic control reduces the risk of subsequent complications in another organ. We sought to determine if glycemic control is associated with the risk of a second, distinct, end-organ diabetic complication. METHODS: Subjects were a retrospective cohort of 250 patients with type 2 diabetes, at least one microvascular diabetic complication, and at least one hemoglobin A1c (HbA1c) measurement after that complication. Proportional hazard models estimated the relative hazard of developing another diabetic complication in a second organ system, as predicted by either (1) mean HbA1c level over the study period or (2) first HbA1c after the initial complication. RESULTS: Thirty-eight patients had a second complication; the average follow-up duration was 3.7 years. The mean HbA1c model showed an adjusted relative hazard of 1.25 (95% confidence interval [CI]=1.04, 1.51) per percentage-point elevation in mean HbA1c. The first HbA1c model showed an adjusted relative hazard of 1.23 (95% CI=1.08, 1.40) per percentage-point elevation in first HbA1c. CONCLUSIONS: Among these type 2 diabetes patients with an initial complication, tight glycemic control was associated with reduced risk of additional complications in other organs.

Colposcopic proficiency-disease spectrum in a single family practice colposcopists' clinic.

PURPOSE: We sought to assess colposcopic proficiency in a family practice teaching clinic. METHODS: Subjects were a prospective cohort of women age 13 to 68 who were colposcopy clinic attendees from 1991 to 2002. Data recorded on each subject included demographic variables, sexual history, history of sexually transmitted diseases, reason for referral to colposcopy, Pap smear results, colposcopic impression, colposcopic biopsy results, and diagnoses. The Kappa statistic was used to measure agreement between clinical colposcopic assessment and biopsy results. RESULTS: Eight hundred twenty-six patients were enrolled. Compared to biopsy, colposcopic impression overall correctly predicted normal cervical biopsy in 55.8% (95% CI: 45.8%, 65.8%) of cases, and predicted abnormal biopsy 84.9% (95% CI: 81.6%, 88.1%) of the time. Colposcopic impression of low-grade squamous intraepithelial lesion (LSIL) correctly predicted LSIL on biopsy in 64.6% of cases, and correctly predicted the absence of LSIL 74.2% of the time. Colposcopic impression of high-grade squamous intraepithelial lesion (HSIL) correctly predicted biopsy results of HSIL in 70.05% of cases (Kappa = 0.544, P<.0001). There was a 12.7% error rate in discriminating normal from LSIL (Kappa -.258, with P<.0001). CONCLUSION: Family physicians perform colposcopy with good correlation between colposcopic impression and subsequent histology.

Providers' reactions to an automated health maintenance reminder system incorporated into the patient's electronic medical record.

BACKGROUND: Automated health maintenance reminder (HMR) systems embedded in electronic medical records systems have been found to improve utilization of preventive services, but underuse persists. Our goal was to learn how to make HMRs more effective by measuring clinicians' self-reported use of HMRs and attitudes toward an HMR system embedded in an electronic medical record. METHODS: We surveyed 43 clinicians using an electronic medical record with an automated HMR system that prompted the provision of preventive or screening interventions. We measured general attitudes toward computers and the HMR, attitudes toward health maintenance, reactions to key features of the HMR system, and use of information provided by the HMR system; and we asked open-ended responses on how to improve the system. RESULTS: Seventy-five percent of clinicians reported not observing or paying attention to the HMR flashing reminder icon when reviewing a chart, and 62.8% reported they either ignored or forgot to address an alert when it appeared. Only 20% reported regularly reviewing health maintenance needs of the patient before the clinical encounter, and 56% reported seldom or never acting on HMR information during an encounter that was not health maintenance. CONCLUSIONS: This HMR system embedded in an electronic medical record was underused by clinicians, causing lost opportunities for provision of preventive care. As electronic medical records become more common, we need to find practical ways that are acceptable to clinicians to use the new capabilities the systems provide.

Glucose screening and the risk of complications in Type 2 diabetes mellitus.

It is unknown whether glucose screening for Type 2 diabetes mellitus (DM2) reduces the risk of diabetic complications. We conducted a case-control study using 303 cases with DM2 and at least one symptomatic microvascular diabetic complication, matched 1:1 to control subjects. All subjects' blood glucose tests for the decade before the first clinical suspicion of DM2 were categorized as screening or not based on the presence of symptoms suggestive of DM2. Approximately 90% of case subjects and control subjects had been screened for diabetes. After adjusting for multiple covariates in a logistic regression model, the odds ratio of developing a complication associated with screening was 0.87 (95% confidence interval 0.38-1.98), suggesting that screening may be associated with a modest reduction in the risk of certain diabetic complications. However, the confidence limits were wide and consistent with no true benefit. Further studies are needed to establish whether the small reduction we observed is genuine.