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1.
J Geriatr Oncol ; 2020 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-32354675

RESUMO

OBJECTIVES: Our objective was to assess the incidence of Alzheimer's Disease and related dementia diagnosis following treatment for muscle-invasive bladder cancer and impact on survival outcomes. MATERIALS AND METHODS: A total of 4814 patients diagnosed with clinical stage T2-T4a, N0, M0 bladder cancer between January 1, 2002 to December 31, 2011 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database were identified. Alzheimer's disease and related dementia diagnosis was identified using International Statistical Classification of Disease-Ninth Edition outpatient and inpatient codes. Incidence of dementia following treatment were calculated and reported as dementia cases per 10,000 person-years. Cox proportional hazards models were used to assess the impact of dementia on survival outcomes. RESULTS: Of the 4814 patients, 2403 (49.9%) underwent radical cystectomy (RC) and 2411 (50.1%) underwent radiotherapy (RTX) and/or chemotherapy (CTX). Overall, 837 (17.4%) patients developed Alzheimer's disease and related dementia following bladder cancer treatment. There was no significant difference in the incidence of Alzheimer's disease and related dementia following either treatment. Patients diagnosed with Alzheimer's disease and related dementia had worse overall (Hazard Ratio (HR), 2.64; 95% Confidence Interval (CI), 2.41-2.89) and cancer-specific (HR, 2.45; 95% CI, 2.18-2.76) survival than those without a dementia diagnosis following treatment. CONCLUSION: While we observed no difference in new-onset Alzheimer's disease and related dementia diagnosis following RC or RTX and/or CTX, patients with a Alzheimer's and related dementia diagnosis was associated with worse overall and cancer-specific survival. These findings have important implications for screening and the development of targeted interventions for improving outcomes in older adults following complex cancer treatments, as observed in this bladder cancer population.

2.
J Gen Intern Med ; 2020 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-32333312

RESUMO

BACKGROUND: Prescription opioid overprescribing is a focal point for legislators, but little is known about opioid prescribing patterns of primary care nurse practitioners (NPs) and physician assistants (PAs). OBJECTIVE: To identify prescription opioid overprescribers by comparing prescribing patterns of primary care physicians (MDs), nurse practitioners (NPs), and physician assistants (PAs). DESIGN: Retrospective, cross-sectional analysis of Medicare Part D enrollee prescription data. PARTICIPANTS: Twenty percent national sample of 2015 Medicare Part D enrollees. MAIN MEASURES: We identified potential opioid overprescribing as providers who met at least one of the following: (1) prescribed any opioid to > 50% of patients, (2) prescribed ≥ 100 morphine milligram equivalents (MME)/day to > 10% of patients, or (3) prescribed an opioid > 90 days to > 20% of patients. KEY RESULTS: Among 222,689 primary care providers, 3.8% of MDs, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of MDs, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription-restricted states. CONCLUSIONS: Most NPs/PAs prescribed opioids in a pattern similar to MDs, but NPs/PAs had more outliers who prescribed high-frequency, high-dose opioids than did MDs. Efforts to reduce opioid overprescribing should include targeted provider education, risk stratification, and state legislation.

3.
Oncologist ; 25(4): 281-289, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32297437

RESUMO

BACKGROUND: Given concerns about suboptimal pain management for actively treated cancer patients following the 2014 federal reclassification of hydrocodone, we examined changes in patterns of opioid prescribing among surgical breast cancer patients. MATERIALS AND METHODS: Data from a large nationally representative commercial health insurance program from 2009 to 2017 were used to identify women aged 18 years and older who were diagnosed with carcinoma in-situ or malignant breast cancer and received breast-conserving surgery or mastectomy from 2010 to 2016. Generalized linear mixed models were used to estimate the adjusted odds ratio (aOR) for receipt of ≥1-day, >30-day, or ≥ 90-day supply of opioids in the 12 months following surgery adjusting for demographics, cancer treatment-related characteristics, and preoperative opioid use. RESULTS: A total of 60,080 patients were included in the study. Surgically treated breast cancer patients in 2015 (aOR = 0.90, 0.84-0.97) and 2016 (aOR = 0.80, 0.74-0.86) were less likely to receive ≥1-day supply of opioid prescriptions when compared with patients in 2013. Patients who had surgery in 2015 (aOR = 0.89, 0.81-0.98) and 2016 (aOR = 0.80, 0.73-0.87) were also less likely to receive >30-day supply of prescription opioids in the 12 months following surgery. However, only surgical breast cancer patients in 2016 were less likely to receive ≥90-day supply (aOR = 0.86, 0.76-0.98). CONCLUSION: Surgically treated breast cancer patients are less likely to receive short- and long-term opioid prescriptions following the implementation of hydrocodone rescheduling. Further studies on the potential impact of federal policy on cancer patient pain management are needed. IMPLICATIONS FOR PRACTICE: Clinicians and researchers with diverse perspectives should be included as stakeholders during policy development for restricting opioid prescriptions. Stakeholders can identify potential unintended consequences early and help identify methods to mitigate concerns, specifically as it relates to policy that influences how providers manage pain for actively treated cancer patients. This work shows how federal policy may have led to declines in opioid prescribing for breast cancer patients who underwent mastectomy or breast-conserving surgery.

4.
Public Health Rep ; 135(1): 114-123, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31835012

RESUMO

OBJECTIVES: Deaths from prescription opioid overdoses have reached an epidemic level in the United States, particularly among persons with disabilities. The 2014 federal rescheduling regulation is associated with reduced opioid prescribing in the general US population; however, to date, no data have been published on this regulation's effect on persons with disabilities. We examined whether the 2014 hydrocodone rescheduling change was associated with reduced opioid prescribing among adult Medicare beneficiaries with disabilities. METHODS: We identified 680 876 Medicare beneficiaries with disabilities aged 21-64 in 2013 and 657 687 in 2015 from a 20% national sample. We examined changes in the monthly opioid-prescribing rates from January 1, 2013, through December 31, 2015. We also compared opioid-prescribing rates in 2013 with rates in 2015. RESULTS: In 2014, the percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased by 0.154% per month (95% confidence interval [CI], -0.186 to -0.121, P < .001). The percentage of Medicare beneficiaries with disabilities who received hydrocodone prescriptions decreased from 32.2% in 2013 to 27.7% in 2015, whereas rates of any opioid prescribing, prolonged prescribing (≥90-day supply), and high-dose prescribing (≥100 morphine milligram equivalents per day for >30 days) decreased only modestly, from 50.2% to 49.0%, from 27.4% to 26.5%, and from 7.5% to 7.0%, respectively. CONCLUSIONS: The 2014 federal rescheduling of hydrocodone was associated with only minor changes in overall and potentially high-risk opioid-prescribing rates. Neither state variation in long-term prescribing nor beneficiary characteristics explained the changes in persistently high opioid-prescribing rates among adults with disabilities after the 2014 regulation. Future studies should examine patient and provider characteristics underlying the persistent high-risk prescribing patterns in this population.


Assuntos
Analgésicos Opioides/administração & dosagem , Pessoas com Deficiência/estatística & dados numéricos , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Hidrocodona/administração & dosagem , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Comorbidade , Grupos de Populações Continentais , Uso de Medicamentos , Feminino , Humanos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Prescrições/estatística & dados numéricos , Características de Residência , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
5.
Oncologist ; 2019 Dec 04.
Artigo em Inglês | MEDLINE | ID: mdl-31801903

RESUMO

BACKGROUND: Given concerns about suboptimal pain management for actively treated cancer patients following the 2014 federal reclassification of hydrocodone, we examined changes in patterns of opioid prescribing among surgical breast cancer patients. MATERIALS AND METHODS: Data from a large nationally representative commercial health insurance program from 2009 to 2017 were used to identify women aged 18 years and older who were diagnosed with carcinoma in-situ or malignant breast cancer and received breast-conserving surgery or mastectomy from 2010 to 2016. Generalized linear mixed models were used to estimate the adjusted odds ratio (aOR) for receipt of ≥1-day, >30-day, or ≥ 90-day supply of opioids in the 12 months following surgery adjusting for demographics, cancer treatment-related characteristics, and preoperative opioid use. RESULTS: A total of 60,080 patients were included in the study. Surgically treated breast cancer patients in 2015 (aOR = 0.90, 0.84-0.97) and 2016 (aOR = 0.80, 0.74-0.86) were less likely to receive ≥1-day supply of opioid prescriptions when compared with patients in 2013. Patients who had surgery in 2015 (aOR = 0.89, 0.81-0.98) and 2016 (aOR = 0.80, 0.73-0.87) were also less likely to receive >30-day supply of prescription opioids in the 12 months following surgery. However, only surgical breast cancer patients in 2016 were less likely to receive ≥90-day supply (aOR = 0.86, 0.76-0.98). CONCLUSION: Surgically treated breast cancer patients are less likely to receive short- and long-term opioid prescriptions following the implementation of hydrocodone rescheduling. Further studies on the potential impact of federal policy on cancer patient pain management are needed. IMPLICATIONS FOR PRACTICE: Clinicians and researchers with diverse perspectives should be included as stakeholders during policy development for restricting opioid prescriptions. Stakeholders can identify potential unintended consequences early and help identify methods to mitigate concerns, specifically as it relates to policy that influences how providers manage pain for actively treated cancer patients. This work shows how federal policy may have led to declines in opioid prescribing for breast cancer patients who underwent mastectomy or breast-conserving surgery.

6.
JAMA Netw Open ; 2(11): e1915638, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31730188

RESUMO

Importance: Patients qualifying for Medicare disability have the highest rates of opioid use compared with older Medicare beneficiaries and commercial insurance beneficiaries. Research on opioid overdose deaths in this population can help identify appropriate interventions. Objective: To assess the rate of opioid overdose death and to identify its associated risk factors. Design, Setting, and Participants: This cohort study included a 20% national sample of Medicare enrollees aged 21 to 64 years whose initial Medicare entitlement was based on disability and who resided in 50 US states and Washington, DC, in 2012 to 2016. Data analyses were performed from March 15, 2019, through September 23, 2019. Exposures: Fifty-five chronic or potentially disabling conditions were selected from the Centers for Medicare & Medicaid Services Chronic Disease Data Warehouse. Main Outcomes and Measures: Opioid overdose death rate estimated from Medicare National Death Index linkage data. Results: Among 1 766 790 Medicare enrollees younger than 65 years who qualified for Medicare because of disability, the mean (SD) age was 52.2 (10.2) years, and 866 914 (49.1%) were women. These enrollees represent 14.9% (95% CI, 14.9%-15.0%) of the entire Medicare population and accounted for 80.8% (95% CI, 78.9%-82.7%) of opioid overdose deaths among all Medicare enrollees. Opioid overdose mortality in this population increased from 57.4 per 100 000 (95% CI, 53.9-61.0 per 100 000) in 2012 to 77.6 per 100 000 (95% CI, 73.5-81.8 per 100 000) in 2016. Results from the stepwise logistic regression model revealed that 3 categories of conditions are associated with opioid overdose death: substance abuse, psychiatric diseases, and chronic pain. Among the 11.1% (95% CI, 11.0%-11.2%) of adults with disability who had all 3 conditions, the rate of opioid overdose death was 363.7 per 100 000 (95% CI, 326.7-402.6 per 100 000), which is 23.4 times higher than the rate for individuals with none of the conditions (15.5 per 100 000; 95% CI, 11.6-20.1 per 100 000). Conclusions and Relevance: This study identifies differences in opioid overdose mortality among subgroups of Medicare enrollees younger than 65 years who qualify for Medicare because of disability. Understanding the heterogeneity of medical and psychiatric conditions associated with opioid use and misuse is key to developing specific, data-driven interventions targeted to each subgroup of high-risk populations.

7.
Med Care ; 57(11): 905-912, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31568165

RESUMO

BACKGROUND: It is unclear whether Medicare data can be used to identify type and degree of collaboration between primary care providers (PCPs) [medical doctors (MDs), nurse practitioners, and physician assistants] in a team care model. METHODS: We surveyed 63 primary care practices in Texas and linked the survey results to 2015 100% Medicare data. We identified PCP dyads of 2 providers in Medicare data and compared the results to those from our survey. Sensitivity, specificity, and positive predictive value (PPV) of dyads in Medicare data at different threshold numbers of shared patients were reported. We also identified PCPs who work in the same practice by Social Network Analysis (SNA) of Medicare data and compared the results to the surveys. RESULTS: With a cutoff of sharing at least 30 patients, the sensitivity of identifying dyads was 27.8%, specificity was 91.7%, and PPV 72.2%. The PPV was higher for MD-nurse practitioner/physician assistant pairs (84.4%) than for MD-MD pairs (61.5%). At the same cutoff, 90% of PCPs identified in a practice from the survey were also identified by SNA in the corresponding practice. In 5 of 8 surveyed practices with at least 3 PCPs, about ≤20% PCPs identified in the practices by SNA of Medicare data were not identified in the survey. CONCLUSIONS: Medicare data can be used to identify shared care with low sensitivity and high PPV. Community discovery from Medicare data provided good agreement in identifying members of practices. Adapting network analyses in different contexts needs more validation studies.


Assuntos
Assistência à Saúde/estatística & dados numéricos , Medicare/estatística & dados numéricos , Equipe de Assistência ao Paciente/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Interpretação Estatística de Dados , Assistência à Saúde/métodos , Humanos , Colaboração Intersetorial , Profissionais de Enfermagem/estatística & dados numéricos , Assistentes Médicos/estatística & dados numéricos , Médicos de Atenção Primária/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Texas , Estados Unidos
9.
Mayo Clin Proc Innov Qual Outcomes ; 3(3): 276-284, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31485565

RESUMO

Objective: To examine the incidence of screening, diagnosis, and treatment of hypogonadism among men treated with opioids in the United States. Patients and Methods: Using one of the nation's largest commercial insurance databases, we identified 53,888 men aged 20 years or older who had 90 or more days of opioid prescriptions in a single 12-month period between January 1, 2010, and December 31, 2017, with no history of hypogonadism or testosterone therapy in the preceding 12 months. We matched this cohort to 53,888 men with 14 or fewer days of opioid prescriptions based on age, opioid initiation date, opioid indication, and comparable exclusion criteria. We assessed whether men, 14 or fewer days after initiation of opioid treatment, received a serum testosterone test, a diagnosis of hypogonadism, or a prescription for testosterone therapy. All men were followed up until they lost coverage from the commercial insurance plan, experienced one of the study outcomes, or the end of study (December 31, 2017). Results: In the multivariable analyses-adjusting for age, year of opioid initiation, region, comorbid disease, glucocorticoid use, and health care utilization-the 53,888 prolonged opioid users, in comparison with 53,888 short-term users, had an increased incidence of serum testosterone screening (5991 [17.15%; 95% CI, 16.70%-17.61%] vs 3514 [11.55%; 95% CI, 11.11%-12.01%] at 5 years; hazard ratio [HR], 1.46; 95% CI, 1.38-1.55), hypogonadism diagnosis (3125 [9.44%; 95% CI, 9.09%-9.80%] vs 1421 [4.85%; 95% CI, 4.55%-5.16%; HR, 1.74; 95% CI, 1.60-1.90]), and receipt of testosterone therapy (1919 [5.76%; 95% CI, 5.49%-6.05%] vs 631 [2.21%; 95% CI, 2.04%-2.43%; HR, 2.41; 95% CI, 2.13-2.74]). Each of these findings persisted across multiple sensitivity analyses. Conclusion: Prolonged opioid exposure was associated with increased rates of screening, diagnosis, and treatment for opioid-induced hypogonadism, but these rates were much lower than expected based on previous serum-based studies.

10.
Ther Adv Chronic Dis ; 10: 2040622319862691, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31321014

RESUMO

Elderly patients with diabetes are at high risk of polypharmacy because of multiple coexisting diseases and syndromes. Polypharmacy increases the risk of drug-drug and drug-disease interactions in these patients, who may already have age-related sensory and cognitive deficits; such deficits may delay timely communication of early symptoms of adverse drug events. Several glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have been approved for diabetes: liraglutide, exenatide, lixisenatide, dulagluatide, semaglutide, and albiglutide. Some are also approved for treatment of obesity. The current review of literature along with clinical case discussion provides evidence supporting GLP-1 RAs as diabetes medications for polypharmacy reduction in older diabetes patients because of their multiple pleiotropic effects on comorbidities (e.g. hyperlipidemia, hypertension, and fatty liver) and syndromes (e.g. osteoporosis and sleep apnea) that commonly co-occur with diabetes. Using one medication (in this case, GLP-1 RAs) to address multiple conditions may help reduce costs, medication burden, adverse drug events, and medication nonadherence.

11.
J Am Board Fam Med ; 32(4): 531-538, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31300573

RESUMO

PURPOSE: We examined the relationship between retail clinic use and primary care physician (PCP) continuity among Medicare enrollees in the Houston metropolitan area. METHODS: We identified retail clinic providers in the study area using a 2015 health care provider database. Medicare claims data from enrollees who received care from retail clinics in 2015 were compared with propensity score-matched sample of enrollees who received no care from retail clinics. RESULTS: There were 2.32 retail clinic visits per 1000 beneficiaries in a month. Approximately 1.3% of Medicare beneficiaries used retail clinics. Retail clinic users were more likely to be aged 65 to 74 years, female, White, and Medicaid ineligible. In multivariable analyses with adjustments for covariates, significant predictors of retail clinic use included having ≥3 chronic conditions (Odds Ratio [OR], 1.53 vs no condition), living within 1 mile of a retail clinic (OR, 2.44 vs living ≥5 miles), and having no PCP (OR, 1.11 vs having PCP). Compared with propensity-matched controls, among enrollees with an identified PCP, likelihood of seeing their PCP (OR, 0.82; 95% CI, 0.73 to 0.93) and continuity of care was lower (0.75 ± 0.33 vs 0.80 ± 0.31) if they had retail clinic visits. CONCLUSIONS: Retail clinic use was lower in the elderly population compared with the previously published rate in the younger populations. The lower rate of continuity of care observed among retail clinic users is concerning, especially for those with chronic medical conditions.

12.
Ann Am Thorac Soc ; 16(10): 1245-1251, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31104504

RESUMO

Rationale: Older adults with chronic obstructive pulmonary disease (COPD) are at substantially increased risk for medication-related adverse events. Two frequently prescribed classes of drugs that pose a particular risk to this patient group are opioids and benzodiazepines. Research on this topic has yielded conflicting findings.Objectives: The purpose of this study was to examine, among older adults with COPD, whether: 1) independent or concurrent use of opioid and benzodiazepine medications was associated with hospitalizations for respiratory events, and 2) this association was exacerbated by the presence of obstructive sleep apnea (OSA).Methods: We conducted a case-control study of Medicare beneficiaries aged ≥66 years, who were diagnosed with COPD in 2013, using the 5% national Medicare database. Cases (n = 3,232) were defined as patients hospitalized for a primary COPD-related respiratory diagnosis in 2014 and were matched with up to two control subjects (n = 6,247) on index date, age, sex, socioeconomic status, comorbidity, presence of OSA, COPD medication, and COPD complexity.Results: In comparison to the referent (no opioid or benzodiazepine use), opioid use alone (adjusted odds ratio [aOR], 1.73; 95% confidence interval [CI], 1.52-1.97), benzodiazepine use alone (aOR, 1.42; 95% CI, 1.21-1.66), and concurrent opioid/ benzodiazepine use (aOR, 2.32; 95% CI, 1.94-2.77) in the 30 days before the event/index date were all associated with an increased risk of hospitalization for a respiratory condition. Risk of hospitalization was higher with concurrent opioid and benzodiazepine use when compared with use of either medication alone. There was no statistically significant interaction between OSA and either of the drugs, alone or in combination. However, the adverse respiratory effects of concurrent opioid and benzodiazepine use were increased in patients with a high degree of COPD complexity. All of the above findings persisted using exposure windows that extended to 60 and 90 days before the event/index date.Conclusions: Among older adults with COPD, use of opioid and benzodiazepine medications alone or in combination were associated with increased adverse respiratory events. The adverse effects of these medications were not exacerbated in patients with COPD-OSA overlap syndrome. However, the adverse impact of dual opioid and benzodiazepine was greater in patients with high-complexity COPD.

13.
Prev Med ; 125: 62-68, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31125629

RESUMO

We examine the association between opioid prescription patterns in privately insured adults and changes in state cannabis laws among five age groups (18-25, 26-35 36-45, 46-55 and 56-64 years). Using the 2016 Clinformatics Data Mart, a nationwide commercial health insurance database, we performed a cross-sectional analysis of two types of opioid prescribing (>30-day and >90-day prescriptions) among all adults aged 18-64 based on the stringency of cannabis laws. We found a significant interaction between age and cannabis law on opioid prescriptions. Age-stratified multilevel multivariable analyses showed lower opioid prescription rates in the four younger age groups only in states with medical cannabis laws, when considering both >30 day and >90 day opioid use [>30 day adjusted odds ratio (aOR) = 0.56, in 18-25, aOR = 0.67 in 26-35, aOR = 0.67 in 36-45, and aOR = 0.76 in 46-54 years; >90 day aOR = 0.56, in 18-25, aOR = 0.68 in 26-35, aOR = 0.69 in 36-45, and aOR = 0.77 in 46-54 years, P < 0.0001 for all]. This association was not significant in the oldest age group of 55-64 years. There was no significant association between opioid prescriptions and other categories of cannabis laws (recreational use and decriminalization) in any of the age groups studied.

14.
J Am Geriatr Soc ; 67(5): 945-952, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31026356

RESUMO

OBJECTIVES: To examine the rates and predictors of long-term opioid therapy in older cancer survivors. DESIGN: Retrospective cohort study. SETTING: Texas, United States. PARTICIPANTS: Cancer survivors (5 years or more postcancer diagnosis) diagnosed from 1995 to 2008 and who were also Medicare Parts A, B, and D beneficiaries. MEASUREMENTS: We used Medicare Part D event data to calculate the proportion of cancer survivors with a prolonged opioid prescription (90-day or more supply of opioids/year). Adjusted odds ratios were calculated to identify predictors of prolonged opioid prescribing. All analyses were repeated with a subcohort of opioid-naïve cancer survivors. RESULTS: The rate of prolonged opioid therapy for cancer patients diagnosed in 2008 was 7.1% prior to cancer diagnosis; it rose to 9.8% within a year of cancer treatments, and to 13.3% at 5 years postdiagnosis. The rate at the sixth year varied by cancer sites: 19.4% in lung cancer and 9.6% in prostate cancer. Among opioid-naïve survivors, the rate increased from 1.4% to 7.1%, from 5 to 18 years postcancer diagnosis. Cancer survivors diagnosed in 2004 to 2008 had higher rates of opioid prescribing compared to those diagnosed in 1995 to 1998 and 1999 to 2003. Years since diagnosis, a later year of diagnosis, female sex, urban location, lung cancer diagnosis, disability as reason for Medicare entitlement, Medicaid eligibility, one or more comorbidity, and history of depression or drug abuse were predictors of prolonged opioid therapy. Among opioid-naïve cancer survivors, diagnosis in 2004 to 2008 was the strongest predictor, while a history of drug abuse was the strongest predictor for all the survivors. CONCLUSION: The rates of prolonged opioid prescribing for older cancer survivors remained high at 5 or more years after cancer diagnosis. Our findings have potential to inform the development of clinical guidelines and public policy to ensure safer and more effective pain treatment in older cancer survivors. J Am Geriatr Soc 67:945-952, 2019.

15.
Aging Ment Health ; 23(10): 1405-1412, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30472880

RESUMO

Objectives: Impaired cognition and pre-frailty are associated with poor health outcomes. However, research has not examined the combined impact of cognitive impairment and pre-frailty on future frailty and mortality among older Mexican Americans. Methods: Data for this analysis came from the 2006-2007 and 2010-2011 waves of the Hispanic EPESE. The final sample included 639 Mexican Americans aged ≥77 years who were non-frail or pre-frail in 2006-2007. Frailty measure included weight loss, exhaustion, weakness, and slow walking speed. Participants were classified as non-frail (0 criteria) and pre-frail (1 criterion) at baseline. Cognitive impairment was defined as <21 points on the MMSE. At baseline, participants were grouped as: cognitively intact non-frail, cognitively intact pre-frail, cognitively impaired non-frail, and cognitively impaired pre-frail. Logistic and hazard regression models were used to evaluate the odds of being frail in 2010-2011 and risk for 10-year mortality. Results: Cognitively impaired pre-frail participants were more likely to become frail (OR = 4.82, 95% CI = 2.02-11.42) and deceased (HR = 1.99, 95% CI = 1.42-2.78). Cognitively impaired non-frail participants had significantly higher risk for mortality (HR = 1.55, 95% CI = 1.12-2.19) but not frailty (OR = 1.29, 95% CI = 0.50-3.11). Being cognitively intact and pre-frail at baseline was not significantly associated with being frail at follow-up (OR = 1.62, 95% CI = 0.83-3.19) or mortality (HR = 1.29, 95% CI = 0.97-1.71). Conclusions: Comorbid cognitive impairment and pre-frailty is associated with future frailty and mortality in older Mexican Americans. Screening for cognitive impairment may be effective for identifying pre-frail Mexican Americans who are at the highest risk of frailty and mortality.

16.
J Am Geriatr Soc ; 66(5): 945-953, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29656382

RESUMO

OBJECTIVES: To examine how an October 2014 Drug Enforcement Administration policy reclassified hydrocodone product from schedule III to II has affected older adults, who are among the largest consumers of prescription opioids in the United States. DESIGN: Retrospective cohort study. SETTING: United States. PARTICIPANTS: A 20% sample of Medicare Part D beneficiaries aged 65 and older from 2013 through 2015 (> 2,500,000 beneficiaries each year) MEASUREMENTS: From January 2013 to December 2015, we calculated the monthly prevalence of opioid prescriptions and the prevalence of individuals who received prescriptions for a 90-day supply or longer (prolonged), as well as hospitalizations related to opioid toxicity in 2013 and 2015. RESULTS: From 2013 to 2015, the proportion of Medicare Part D enrollees who received a hydrocodone prescription in a year decreased from 21.9% to 18.3%. Monthly rates for hydrocodone prescriptions declined significantly in 2014. The risk of receiving prolonged opioid prescriptions decreased by approximately 7% in the multivariable analyses comparing 2015 to 2013 (prevalence ratio=0.93, 95% confidence interval (CI)=0.93-0.94). Medicare enrollees with an original entitlement because of disability or with Medicaid eligibility had smaller decreases in prolonged prescriptions and, unexpectedly, small increases in high-dose prescriptions. Opioid-related hospitalizations did not change significantly, but opioid-related hospitalizations without a documented opioid prescription increased (odds ratio=1.24, 95% CI=1.03-1.50). CONCLUSION: The 2014 change in hydrocodone from schedule III to schedule II was associated with modest decreases in rates of opioid use in the elderly. The unexpected increase in opioid-related hospitalizations without documented opioid prescriptions may represent an increase in illegal use.


Assuntos
Analgésicos Opioides/provisão & distribução , Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Hidrocodona/provisão & distribução , Hidrocodona/uso terapêutico , Padrões de Prática Médica , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Medicare Part D , Transtornos Relacionados ao Uso de Opioides , Estudos Retrospectivos , Estados Unidos
17.
Pharmacoepidemiol Drug Saf ; 27(5): 513-519, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29271049

RESUMO

PURPOSE: To examine differences in opioid prescribing by patient characteristics and variation in hydrocodone combination product (HCP) prescribing attributed to states, before and after the 2014 Drug Enforcement Administration's reclassification of HCP from schedule III to the more restrictive schedule II. METHODS: We used 2013 to 2015 data for 9 202 958 patients aged 18 to 64 from a large nationally representative commercial health insurance program to assess the temporal trends in the monthly rate of opioid prescribing. RESULTS: HCP prescribing decreased by 26% from June 2013 to June 2015; the rate of prescriptions for any opioid decreased by 11%. Prescribing of non-hydrocodone schedule III opioids increased slightly while prescribing of non-hydrocodone schedule II opioids and tramadol was stable. Absolute decreases in HCP prescribing rates were larger in patients being treated for cancer (-2.26% vs -0.7% for non-cancer patients, P < 0.0001) and in those with high comorbidities (-2.13% vs -0.55% for those with no comorbidity, P < 0.0001). Differences in the absolute and relative changes in HCP prescribing rates among states were large; for example, a relative decrease of 46.7% in Texas and a 12.7% increase in South Dakota. The variation in HCP prescribing attributable to the state of residence increased from 6.6% in 2013 to 8.7% in 2015. CONCLUSIONS: The 2014 federal policy was associated with a decrease in rates of HCP and total opioid prescribing. The large decrease in the rates of HCP prescribing for patients with actively treated cancer may represent an unintended consequence.


Assuntos
Analgésicos Opioides/administração & dosagem , Substâncias Controladas , Controle de Medicamentos e Entorpecentes/legislação & jurisprudência , Hidrocodona/administração & dosagem , Padrões de Prática Médica/tendências , Adulto , Analgésicos Opioides/efeitos adversos , Combinação de Medicamentos , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Hidrocodona/efeitos adversos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/etiologia , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Dor/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto Jovem
18.
Am J Alzheimers Dis Other Demen ; 33(2): 73-85, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28974110

RESUMO

Elderly patients with Alzheimer's disease (AD) and other dementias are at high risk of polypharmacy and excessive polypharmacy for common coexisting medical conditions. Polypharmacy increases the risk of drug-drug and drug-disease interactions in these patients who may not be able to communicate early symptoms of adverse drug events. Three acetylcholinesterase inhibitors (ACHEIs) have been approved for AD: donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). They are also used off-label for other causes of dementia such as Lewy body and vascular dementia. We here report evidence from the literature that ACHEI treatment, prescribed for cognitive impairment, can reduce the load of medications in patients with AD by also addressing cardiovascular, gastrointestinal, and other comorbidities. Using one drug to address multiple symptoms can reduce costs and improve medication compliance.


Assuntos
Doença de Alzheimer/tratamento farmacológico , Inibidores da Colinesterase/uso terapêutico , Comorbidade , Doenças Cardiovasculares , Donepezila/uso terapêutico , Galantamina/uso terapêutico , Polimedicação , Rivastigmina/uso terapêutico
19.
J Card Fail ; 24(1): 9-18, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28870732

RESUMO

BACKGROUND: Having nurse practitioners (NPs) as primary care providers for patients with congestive heart failure (CHF) is 1 way to address the growing shortage of primary care physicians (PCPs). METHODS AND RESULTS: We used inverse probability of treatment weighted with propensity score to examine the processes and outcomes of care for patients under 3 care models. Approximately 72.9%, 0.8%, and 26.3% of CHF patients received care under the PCP model, the NP model, and the shared care model, respectively. Patients under the NP or shared care models were more likely than those under the PCP model to be referred to cardiologists (odds ratio 1.35, 95% confidence interval 1.32-1.37; odds ratio 1.32, 95% confidence interval 1.30-1.35) and to get guideline-recommended medications. NPs and PCPs had similar rates of emergency room (ER) visits and Medicare spending after adjusting for processes of care. Patients under the shared care model had a higher burden of comorbidity and experienced a higher rate of ER visits and hospitalizations than those under the PCP model. CONCLUSION: The delivery of CHF care mirrors the severity of comorbidity in these patients. The high rate of hospitalization and ER visits in the shared care model underscores the need to design and implement more effective chronic disease management and integrated care programs.


Assuntos
Gerenciamento Clínico , Insuficiência Cardíaca/terapia , Modelos Organizacionais , Atenção Primária à Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Prognóstico , Pontuação de Propensão , Estados Unidos
20.
J Prim Care Community Health ; 8(4): 256-263, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29047322

RESUMO

OBJECTIVES: To document the temporal trends in alternative primary care models in which physicians, nurse practitioners (NPs), or physician assistants (PAs) engaged in care provision to the elderly, and examine the role of these models in serving elders with multiple chronic conditions and those residing in rural and health professional shortage areas (HPSAs). DESIGN: Serial cross-sectional analysis of Medicare claims data for years 2008, 2011, and 2014. SETTING: Primary care outpatient setting. PARTICIPANTS: Medicare fee-for-service beneficiaries who had at least 1 primary care office visit in each study year. The sample size is 2 471 498. MEASUREMENTS: Physician model-Medicare beneficiary's primary care office visits in a year were conducted exclusively by physicians; shared care model-conducted by a group of professionals that included physicians and either NPs or PAs or both; NP/PA model: conducted either by NPs or PAs or both. RESULTS: There was a decrease in the physician model (85.5% to 70.9%) and an increase in the shared care model (11.9% to 23.3%) and NP/PA model (2.7% to 5.9%) from 2008 to 2014. Compared with the physician model, the adjusted odds ratio (AOR) of receiving NP/PA care was 3.97 (95% CI 3.80-4.14) in rural and 1.26 (95% CI 1.23-1.29) in HPSAs; and the AOR of receiving shared care was 1.66 (95% CI 1.61-1.72) and 1.14 (95% CI 1.13-1.15), respectively. Beneficiaries with 3 or more chronic conditions were most likely to received shared care (AOR = 1.67, 95% CI 1.65-1.70). CONCLUSION: The increase in shared care practice signifies a shift toward bolstering capacity of the primary care delivery system to serve elderly populations with growing chronic disease burden and to improve access to care in rural and HPSAs.


Assuntos
Medicare , Múltiplas Afecções Crônicas/terapia , Profissionais de Enfermagem/tendências , Assistentes Médicos/tendências , Médicos de Atenção Primária/tendências , Atenção Primária à Saúde/tendências , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , População Rural , Estados Unidos
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