Vancomycin-associated nephrotoxicity in adult medicine patients: incidence, outcomes, and risk factors.

OBJECTIVE: The prevalence of vancomycin-associated nephrotoxicity (VAN) is reported to vary from 1.0-42.6%, with most data from critically ill patients. Evaluation of VAN among internal medicine patients is lacking. Our objectives were to determine the incidence, time-course, outcomes, and risk factors of VAN in adult internal medicine patients. DESIGN: Retrospective cohort. SETTING: Tertiary care academic medical center. PATIENTS: A total of 125 adult internal medicine patients receiving vancomycin treatment with mean baseline creatinine clearance of 84.6 ± 27.6 ml/min. INTERVENTION: Vancomycin treatment for a minimum of 72 hours. MEASUREMENTS AND MAIN RESULTS: Nephrotoxicity, defined as an increase in serum creatinine of 0.5 mg/dl or 50% above baseline (whichever was larger), occurred in 17 (13.6%) of 125 patients. No patients with VAN progressed to Loss or End stage as defined by the RIFLE criteria. The incidence rate of VAN was 0.02 cases/day of vancomycin treatment. Nephrotoxicity developed at a median of 4.5 days (interquartile range [IQR] 2.2-4.9) peaked at 5.7 days (IQR: 3.8-9.6), and resolved in 70.6% of the cases within 16.5 days (IQR: 6.0-17.8) after onset. On multivariable logistic regression analysis, after controlling for hypotensive episodes, Charlson Comorbidity Index, and baseline creatinine clearance, concomitant use of piperacillin-tazobactam was associated with increased VAN (adjusted odds ratio 5.36, 95% confidence interval 1.41-20.5). CONCLUSIONS: Vancomycin-associated nephrotoxicity is prevalent among internal medicine patients, with 5.36-fold higher odds if piperacillin-tazobactam is concomitantly administered.

Prescription fill patterns in underserved children with asthma receiving subspecialty care.

BACKGROUND: Children with asthma receiving specialty care have been found to have improved asthma outcomes. However, these outcomes can be adversely affected by poor adherence with controller medications. OBJECTIVE: To analyze pharmacy fill patterns as a measure of primary adherence in a group of underserved minority children receiving allergy subspecialty care. METHODS: As part of a larger 18-month nebulizer use study in underserved children (ages 2-8 years) with persistent asthma, 53 children were recruited from an urban allergy practice. Pharmacy records were compared with prescribing records for all asthma medications. RESULTS: Allergist controller prescriptions were written in 30-day quantities with refills and short-acting ß-agonists (SABAs) with no refills. Only 49.1% of inhaled corticosteroid (ICS), 49.5% of combination ICS and long-acting ß-agonist, and 64.5% of leukotriene modifier (LTM) initial and refill prescriptions were ever filled during the 18-month period. A mean of 5.1 refills (range, 0-14) for SABAs were obtained during 18 months, although only 1.28 SABA prescriptions were prescribed by the allergist. Mean times between first asthma prescription and actual filling were 30 days (range, 0-177 days) for ICSs, 26.6 days (range, 0-156 days) for LTMs, and 16.8 days (range, 0-139 days) for SABAs. CONCLUSION: Underserved children with asthma receiving allergy subspecialty care suboptimally filled controller prescriptions, yet filled abundant rescue medications from other prescribers. Limiting albuterol prescriptions to one canister without additional refills may provide an opportunity to monitor fill rates of both rescue and controller medications and provide education to patients about appropriate use of medications to improve adherence.

Seasonal patterns of controller and rescue medication dispensed in underserved children with asthma.

OBJECTIVE: To determine whether temporal trends exist for short-acting beta agonist (SABA), oral corticosteroid (OCS), and anti-inflammatory prescription fills in children with persistent asthma. METHOD: This was a longitudinal analysis of pharmacy record data and health information data obtained by parent report over 12 months for children with persistent asthma 2 to 9 years of age. Eligible children had to report current nebulizer use and one or more emergency department visits or hospitalizations within the past 12 months. RESULTS: Children were primarily African-American (89%), male (64%), received Medicaid health insurance (82%), and were a mean age of 4.5 years (SD 2.1). Few families (11%) reported any problems paying for their child's asthma medications at baseline or at the 12-month follow-up. There was a high degree of association between filling a rescue (SABA or OCS) and controller (leukotriene modifier, inhaled corticosteroid, cromolyn) medication during the same month for all months with Pearson's correlation coefficients ranging from a low of 0.28 for October to a high of 0.53 in September. Short-acting beta agonist fills were significantly more likely to be filled concurrently with inhaled corticosteroid fills. However, significantly fewer prescription fills were obtained in the summer months with an acceleration of medication fills in September through December and an increase in early spring. CONCLUSIONS: There was a summer decline in both inhaled corticosteroid and SABA fills. Timing of asthma monitoring visits to occur before peak prescription fill months, i.e., August and December for an asthma "tune-up," theoretically could improve asthma control. During these primary care visits children could benefit from more intensive monitoring of medication use including monitoring lung function, frequency of prescription refills, and assessment of medication device technique to ensure that an effective dose of medication is adequately delivered to the respiratory tract. Additionally, scheduling non-urgent asthma care visits at pre-peak prescription fill months can take advantage of "step down" during decreased symptom periods and when appropriate restart daily controller medications to "step up" prior to peak asthma periods.

Concordance of Medicaid and pharmacy record data in inner-city children with asthma.

BACKGROUND: Management of asthma involves adherence to medication regimens. Assessing adherence is difficult for health care providers and researchers. Self-reported medication use is subjective, so objective methods of data collection for medication use are frequently used in asthma research. The aim of this project is to examine the concordance between asthma medication pharmacy data culled from Medicaid claims data ("Medicaid pharmacy data") and patient pharmacy record data obtained from individual pharmacies ("pharmacy record data"). METHODS: Medicaid pharmacy data and pharmacy record data were obtained from inner-city children enrolled in a prospective study of children with persistent asthma. A subject level comparison of pharmacy records and Medicaid pharmacy data pharmacy records was done to determine concordance between the 2 data collection methods. RESULTS: Of 513 children recruited for inclusion, 221 were consented and randomized. Medicaid claims data were collected on 72.8% (n=161) of the 221 enrolled subjects. Pharmacy record data were available on 96.8% (n=214) of the 221 subjects. Data presented represent the 159 subjects who had both Medicaid claims data and pharmacy records data available throughout the study period. There was complete agreement between Medicaid pharmacy data and pharmacy record for 26% (n=42) of subjects. A total of 1858 asthma medication claims were captured by the Medicaid pharmacy data. Medicaid pharmacy data missed 149 claims that were capture by the pharmacy record data. Medicaid pharmacy data failed to capture a single claim on 4.4% (n=7) of subjects. The pharmacy record data captured a total of 1627 asthma medication claims and missed 371 claims that were captured by the Medicaid pharmacy data. Pharmacy record data failed to capture a single claim in 1.9% (n=3) of subjects. CONCLUSIONS: There was overlap between the pharmacy data captured by the Medicaid pharmacy dataset and pharmacy record dataset, but the overall concordance between the two data collection methods was low. Pharmacy records collected directly from the pharmacy included data on more subjects and pharmacy data culled from Medicaid claims captured more total number of claims. In spite of the differences in the methods used to collect data, pharmacy fill records are a rich source of data with both clinical and research applications. Clinicians and researchers must weigh the benefits and limitations of each method used to collect pharmacy data.

Factors affecting pharmacists' pediatric asthma counseling.

OBJECTIVE: To explore various factors that may influence community pharmacists' pediatric asthma counseling. DESIGN: Cross-sectional. SETTING: Maryland from September 2002 through March 2003. PARTICIPANTS: Random sample of 400 community pharmacists. INTERVENTION: Mail survey. MAIN OUTCOME MEASURES: Pharmacists' attitude, subjective norm, perceived behavioral control, intention to provide pediatric asthma counseling, and reported counseling using the theory of planned behavior as a framework; demographic and pharmacy characteristics. RESULTS: 98 of 389 (25%) eligible pharmacists responded. Most acknowledged the importance of providing asthma counseling to children (54%) or caregivers (68%). However, only a small number reported demonstrating to children or caregivers or asking them to demonstrate how to use antiasthmatic medications. Multivariate logistic regressions revealed that intention to counsel was a significant predictor of providing counseling for children or caregivers (odds ratio [OR], 3.95 and 3.09, respectively). Intention to counsel children was significantly associated with subjective norm (OR, 1.88) and perceived ease of counseling (OR, 1.48); intention to counsel caregivers was significantly associated with perceived ease (OR, 1.45). Pharmacists also reported the following barriers that made counseling difficult: lack of time, lack of parent's interest, and lack of placebo devices useful for demonstration of inhalation technique. CONCLUSION: Despite a positive attitude toward providing asthma counseling, the majority of pharmacists reported not fully engaging in counseling. A number of barriers to counseling were reported that, if targeted, could improve the management of pediatric asthma through pharmacist-initiated counseling.

Assessment of hospice nurses' technique in the use of inhalers and nebulizers.

Dyspnea, a common distressing end-of-life symptom, is treated with oral (i.e., opioids and anxiolytics) and inhaled medications (anti-inflammatory and bronchodilator agents). Health care providers and patients have demonstrated an inability to use inhaler devices correctly, which can lead to suboptimal drug delivery and poor symptom relief. Hospice nurses are the primary health care providers educating patients, making it critical that they convey accurate device technique. This study assessed hospice nurses' ability to demonstrate proper inhaler device technique and their knowledge of agents used to treat dyspnea. Forty-seven nurses participated. Participants completed a written questionnaire, which gathered demographic data, as well as information regarding previous training with an inhaler device, administration, pharmacokinetics, mechanism of action, patient assessment, and nursing technique. Additionally, each nurse demonstrated the use of a metered dose inhaler, spacer, dry powder inhaler, and a nebulizer, while being observed by a pharmacist trained in the use of inhalers. A standardized evaluation form was used to ensure consistency between evaluators and subjects. Percentage of steps completed correctly by the study participants ranged from 34.9% with the dry powder inhaler to 67.6% with the metered dose inhaler. Years of experience, presence of hospice certification, personal use of inhaler, and nursing comfort level significantly impacted ability to use inhalation devices. This study demonstrated the existence of knowledge gaps regarding patient assessment, pharmacology and pharmacokinetics of inhaled medications, and inhalation device technique among hospice nurses. Formal education of hospice practitioners regarding inhaled medications and inhalation delivery devices is needed.

Effectiveness of nebulizer use-targeted asthma education on underserved children with asthma.

OBJECTIVE: To determine the effectiveness of a home-based asthma education intervention in increasing appropriate nebulizer use and reducing symptom frequency, emergency department (ED) visits, and hospitalizations over 12 months. DESIGN: A randomized clinical trial. Settings Pediatric primary care, pulmonary/allergy, and ED practices associated with the University of Maryland Medical System and The Johns Hopkins Hospital, Baltimore. PARTICIPANTS: Children with persistent asthma, aged 2 to 9 years, with regular nebulizer use and an ED visit or hospitalization within the past 12 months. Children were randomized into the intervention (n = 110) or control (n = 111) group. Follow-up data were available for 95 intervention and 86 control children. INTERVENTION: Home-based asthma education, including symptom recognition, home treatment of acute symptoms, appropriate asthma medication, and nebulizer practice. MAIN OUTCOME MEASURES: Estimates of mean differences in asthma symptom frequency, number of ED visits and hospitalizations and appropriate quick relief, controller medication, and nebulizer practice over 12 months. RESULTS: Of the 221 children, 181 (81.9%) completed the study. There were no significant differences in home nebulizer practice, asthma morbidity, ED visits, or hospitalizations between groups (P range, .11-.79). Although most children received appropriate nonurgent asthma care (mean, 2 visits per 6 months), more than one third of all children received at least 6 quick-relief medication prescriptions during 12 months, with no difference by group. CONCLUSIONS: A nebulizer education intervention had no effect on asthma severity or health care use. Of concern is the high quick-relief and low controller medication use in young children with asthma seen nearly every 3 months for nonurgent care.