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1.
Am J Cardiol ; 124(7): 1038-1043, 2019 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-31375243

RESUMEN

Guideline-recommended anticoagulation is frequently omitted in high-risk patients with atrial fibrillation (AF) for reasons not fully understood, which may result in suboptimal care. A nationally representative, expert group of physicians (cardiology, neurology, and general medicine), and clinical pharmacists participated in a consensus-seeking, modified Delphi method to identify key clinical decision-making factors driving anticoagulant prescribing in real-world AF patients. Representing >2,500 anticoagulation-related patient encounters per month, 27 of 30 participants completed the study (90% overall response rate). In Round-1, experts rated their level of agreement with factors and suggested modifications or additional factors. Of 66 factors entering Round-1, 21 met and 4 partially met consensus, 41 did not meet consensus, and 7 were newly suggested. Of 32 factors advanced for scoring in Round-2, 16 met consensus criteria. In Round-3, experts were given the option to rescue up to 2 of the 16 nonconsensus factors from Round-2. Including a concomitant need for dual antiplatelet therapy, no factor was successfully rescued into consensus. The most important factors related to risk of infarction rather than bleeding risk or other patient-specific considerations. Among factors not independently addressed in current guidelines, these included baseline hematologic indicators of potential bleeding risk, previous bleeding episodes by specific type, other risk factors for bleeding, and adherence. In conclusion, when determining anticoagulation strategies in AF, there is a need for further research on the clinical implications of these emerging factors as well as the reasons behind divergent opinions toward nonconsensus factors.

2.
J Clin Psychiatry ; 80(4)2019 May 21.
Artículo en Inglés | MEDLINE | ID: mdl-31120203

RESUMEN

OBJECTIVE: Depression guidelines discourage benzodiazepine monotherapy and limit use to short-term adjunctive therapy with antidepressants; however, patients with depression continue to receive benzodiazepine monotherapy. The prevalence and predictors of this prescribing pattern have not been described previously and are warranted to assist clinicians in identifying patients at highest risk of receiving benzodiazepine monotherapy. METHODS: A national, cross-sectional analysis of the National Ambulatory Medical Care Survey from 2012 to 2015 was performed for adults treated for depression. Depression was identified using a survey item specifically assessing the presence of depression. Office visits involving patients with bipolar disorder, schizoaffective disorder, or pregnancy were identified by ICD-9 code or specific survey item and were excluded. The primary endpoint was benzodiazepine monotherapy prescribing rate defined as initiation or continuation of a benzodiazepine in the absence of any antidepressant agent. A multivariate logistic regression model was created to identify variables associated with benzodiazepine monotherapy. RESULTS: In total, 9,426 unweighted visits were eligible for inclusion. Benzodiazepine monotherapy was identified in 9.3% of patients treated for depression (95% CI, 8.2%-10.6%). Predictors of benzodiazepine monotherapy included age of 45-64 years (OR = 1.39; 95% CI, 1.01-1.91), epilepsy-related office visit (OR = 5.34; 95% CI, 1.39-20.44), anxiety-related office visit (OR = 1.67; 95% CI, 1.23-2.27), underlying pulmonary disease (OR = 1.43; 95% CI, 1.09-1.87), and concomitant opiate prescribing (OR = 2.86; 95% CI, 2.01-4.06). Psychiatrists were less likely to prescribe benzodiazepine monotherapy than were other providers (OR = 0.42; 95% CI, 0.29-0.61). CONCLUSIONS: Benzodiazepine monotherapy is utilized in nearly 1 in 10 patients treated for depression. Adults aged 45 to 65 years, patients prescribed opioids, patients seen by primary care providers, and those with underlying anxiety, epilepsy, or pulmonary disorders are at highest risk.

3.
Consult Pharm ; 33(1): 24-32, 2018 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-29336275

RESUMEN

Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.


Asunto(s)
Farmacéuticos , Rol Profesional , Proyectos de Investigación , Anciano , Humanos , Metaanálisis como Asunto , Literatura de Revisión como Asunto
4.
Popul Health Manag ; 17(2): 106-11, 2014 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-24156664

RESUMEN

The specific aim of the PEACE pilot study was to determine the feasibility of a fully powered study to test the effectiveness of an in-home geriatrics/palliative care interdisciplinary care management intervention for improving measures of utilization, quality of care, and quality of life in enrollees of Ohio's community-based long-term care Medicaid waiver program, PASSPORT. This was a randomized pilot study (n=40 intervention [IG], n=40 usual care) involving new enrollees into PASSPORT who were >60 years old. This was an in-home interdisciplinary chronic illness care management intervention by PASSPORT care managers collaborating with a hospital-based geriatrics/palliative care specialist team and the consumer's primary care physician. This pilot was not powered to test hypotheses; instead, it was hypothesis generating. Primary outcomes measured symptom control, mood, decision making, spirituality, and quality of life. Little difference was seen in primary outcomes; however, utilization favored the IG. At 12 months, the IG had fewer hospital visits (50% vs. 55%, P=0.65) and fewer nursing facility admissions (22.5% vs. 32.5%, P=0.32). Using hospital-based specialists interfacing with a community agency to provide a team-based approach to care of consumers with chronic illnesses was found to be feasible. Lack of change in symptom control or quality of life outcome measures may be related to the tools used, as these were validated in populations closer to the end of life. Data from this pilot study will be used to calculate the sample size needed for a fully powered trial.


Asunto(s)
Planificación Anticipada de Atención/organización & administración , Servicios de Atención de Salud a Domicilio/organización & administración , Cuidados a Largo Plazo/organización & administración , Calidad de Vida , Anciano , Anciano de 80 o más Años , Femenino , Anciano Frágil , Evaluación Geriátrica/métodos , Promoción de la Salud , Servicios de Salud para Ancianos/organización & administración , Humanos , Comunicación Interdisciplinaria , Masculino , Ohio , Cuidados Paliativos/organización & administración , Proyectos Piloto , Evaluación de Programas y Proyectos de Salud , Valores de Referencia , Resultado del Tratamiento
5.
Popul Health Manag ; 15(2): 71-7, 2012 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-22088165

RESUMEN

Practice guidelines are available for hospice and palliative medicine specialists and geriatricians. However, these guidelines do not adequately address the needs of patients who straddle the 2 specialties: homebound chronically ill patients. The purpose of this article is to describe the theoretical basis for the Promoting Effective Advance Care for Elders (PEACE) randomized pilot study. PEACE is an ongoing 2-group randomized pilot study (n=80) to test an in-home interdisciplinary care management intervention that combines palliative care approaches to symptom management, psychosocial and emotional support, and advance care planning with geriatric medicine approaches to optimizing function and addressing polypharmacy. The population comprises new enrollees into PASSPORT, Ohio's community-based, long-term care Medicaid waiver program. All PASSPORT enrollees have geriatric/palliative care crossover needs because they are nursing home eligible. The intervention is based on Wagner's Chronic Care Model and includes comprehensive interdisciplinary care management for these low-income frail elders with chronic illnesses, uses evidence-based protocols, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. Our model, with its standardized, evidence-based medical and psychosocial intervention protocols, will transport easily to other sites that are interested in optimizing outcomes for community-based, chronically ill older adults.


Asunto(s)
Enfermedad Crónica , Anciano Frágil , Promoción de la Salud/organización & administración , Servicios de Atención de Salud a Domicilio/organización & administración , Personas Imposibilitadas , Planificación de Atención al Paciente/organización & administración , Anciano , Anciano de 80 o más Años , Determinación de la Elegibilidad , Medicina Basada en la Evidencia , Femenino , Evaluación Geriátrica , Humanos , Masculino , Medicaid , Ohio , Cuidados Paliativos , Proyectos Piloto , Pobreza , Proyectos de Investigación , Apoyo Social , Estados Unidos
6.
Popul Health Manag ; 14(3): 137-42, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-21323461

RESUMEN

Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.


Asunto(s)
Continuidad de la Atención al Paciente , Anciano Frágil , Alta del Paciente , Proyectos de Investigación , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Técnicas de Apoyo para la Decisión , Medicina Basada en la Evidencia , Promoción de la Salud , Humanos , Masculino , Modelos Teóricos , Médicos de Atención Primaria , Pobreza/economía , Pobreza/estadística & datos numéricos , Guías de Práctica Clínica como Asunto , Autocuidado/métodos , Estados Unidos
7.
Pharmacotherapy ; 28(2): 225-34, 2008 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-18225968

RESUMEN

Pharmacists in both ambulatory and institutional settings are often in a position to help optimize the drug regimens of patients who are experiencing falls. Supplementation with vitamin D is an important emerging therapy for the prevention of falls. Numerous investigators have recently studied or reviewed the association between vitamin D supplementation and decreased risk of falls in elderly patients, yet little of this information is available in the pharmacy literature. A MEDLINE search was conducted to collect relevant articles about the role of vitamin D in preventing falls among elderly patients; recently published meta-analyses and randomized controlled trials were identified and reviewed. The studies indicated a statistically significant positive relationship between vitamin D supplementation with either cholecalciferol 700 IU/day or greater or ergocalciferol 800 IU/day or greater and decreased risk of falls. Other practical issues, including who should receive vitamin D replacement, what form of vitamin D should be used, and what dosage is required to prevent falls, are discussed.


Asunto(s)
Accidentes por Caídas/prevención & control , Vitamina D/uso terapéutico , Vitaminas/uso terapéutico , Accidentes por Caídas/estadística & datos numéricos , Anciano , Anciano de 80 o más Años , Calcio/administración & dosificación , Calcio/uso terapéutico , Colecalciferol/administración & dosificación , Colecalciferol/uso terapéutico , Ergocalciferoles/administración & dosificación , Ergocalciferoles/uso terapéutico , Humanos , Educación del Paciente como Asunto , Servicios Farmacéuticos , Vitamina D/administración & dosificación , Vitaminas/administración & dosificación
8.
Cleve Clin J Med ; 71(7): 561-8, 2004 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-15320365

RESUMEN

Many medications that are safe in most patients pose serious risks in older patients, including functional decline, delirium, falls, and poorer outcomes. We describe our institution's program of "academic detailing," designed to reduce the use of three high-risk drugs in elderly patients.


Asunto(s)
Amitriptilina/efectos adversos , Sistemas de Información en Farmacia Clínica , Difenhidramina/efectos adversos , Geriatría/normas , Unidades Hospitalarias/normas , Sistemas de Medicación en Hospital/normas , Meperidina/efectos adversos , Gestión de Riesgos/métodos , Gestión de la Calidad Total/métodos , Anciano , Contraindicaciones , Interacciones de Drogas , Humanos , Ohio
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