Atrial fibrillation and stroke prevention with warfarin in the long-term care setting.

BACKGROUND: While the benefits of warfarin sodium therapy for stroke prevention in patients with atrial fibrillation (AF) have been extensively documented, generalizing clinical trial results to the majority of elderly persons with AF, especially to those who reside in the long-term care setting, remains challenging. OBJECTIVES: To determine the prevalence of AF in the institutionalized elderly population and the proportion receiving anticoagulation therapy with warfarin: to identify the clinical and functional characteristics of institutionalized elderly persons with AF that are associated with the use of warfarin; and to assess the quality of prescribing and monitoring of warfarin therapy in institutionalized elderly persons with AF. METHODS: This study involved 30 long-term care facilities (total No. of beds, 6437) located in New England, Quebec, and Ontario. The proportion of patients with AF who were receiving treatment with warfarin was determined. The association between clinical and functional characteristics and the use of warfarin was examined with crude and multivariable-adjusted analyses. For study subjects with at least 2 weeks of warfarin therapy during the 12-month period preceding the date of medical record abstraction, we assessed the quality of warfarin prescribing based on all international normalized ratio or prothrombin time ratio values during this period. RESULTS: An electrocardiogram indicating AF was present in the records of 413 of 5500 long-term care residents (7.5%); 32% of such patients were being treated with warfarin. Only a history of stroke was found to be positively associated with the use of warfarin in this setting. Patients with a diagnosis of dementia and those in the oldest age group (> or = 85 years) were less likely to receive warfarin therapy. Warfarin was commonly prescribed to patients with a history of bleeding, substantial comorbidity and functional impairment, a history of falls, or concomitant potentiating drug therapy. Patients were maintained above or below the recommended therapeutic range 60% of the time. CONCLUSIONS: Atrial fibrillation is common in patients residing in long-term care facilities, but its management with warfarin is highly variable. A more systematic approach to decision making regarding the use of warfarin for stroke prevention in these patients is required. Among patients receiving warfarin, the quality of anticoagulation care warrants improvement.

Risk factors for adverse drug events among nursing home residents.

BACKGROUND: In a prospective study of nursing home residents, we found adverse drug events (ADEs) to be common, serious, and often preventable. To direct prevention efforts at high-risk residents, information is needed on resident-level risk factors. METHODS: Case-control study nested within a prospective study of ADEs among residents in 18 nursing homes. For each ADE, we randomly selected a control from the same home. Data were abstracted from medical records on functional status, medical conditions, and medication use. RESULTS: Adverse drug events were identified in 410 nursing home residents. Independent risk factors included being a new resident (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.5-5.2) and taking anti-infective medications (OR, 4.0; CI, 2.5-6.2), antipsychotics (OR, 3.2; CI, 2.1-4.9), or antidepressants (OR, 1.5; CI, 1.1-2.3). The number of regularly scheduled medications was associated with increased risk of ADEs; the OR associated with taking 5 to 6 medications was 2.0 (CI, 1.2-3.2); 7 to 8 medications, 2.8 (CI, 1.7-4.7); and 9 or more, 3.3 (CI, 1.9-5.6). Taking supplements or nutrients was associated with lower risk (OR, 0.42; CI, 0.27-0.63). Preventable ADEs occurred in 226 residents. Independent risk factors included taking opioid medications (OR, 6.6; CI, 2.3-19.3), antipsychotics (OR, 4.0; CI, 2.2-7.3), anti-infectives (OR, 3.0; CI, 1.6-5.8), antiepileptics (OR, 2.2; CI, 1.1-4.5), or antidepressants (OR, 2.0; CI, 1.1-3.5). Scores of 5 or higher on the Charlson Comorbidity Index were associated with increased risk of ADEs (OR, 2.6; CI, 1.1-6.0). The number of regularly scheduled medications was also a risk factor: the OR for 7 to 8 medications was 3.2 (CI, 1.4-6.9) and for 9 or more, 2.9 (CI, 1.3-6.8). Residents taking nutrients or supplements were at lower risk (OR, 0.27; CI, 0.14-0.50). CONCLUSIONS: It is possible to identify nursing home residents at high risk of having an ADE. Particular attention should be directed at new residents, those with multiple medical conditions, those taking multiple medications, and those taking psychoactive medications, opioids, or anti-infective drugs.

Incidence and preventability of adverse drug events in nursing homes.

PURPOSE: Adverse drug events, especially those that may have been preventable, are among the most serious concerns about medication use in nursing homes. We studied the incidence and preventability of adverse drug events and potential adverse drug events in nursing homes. METHODS: We performed a cohort study of all long-term care residents of 18 community-based nursing homes in Massachusetts during a 12-month observation period. Potential drug-related incidents were detected by stimulated self-report by nursing home staff and by periodic review of the records of nursing home residents by trained nurse and pharmacist investigators. Each incident was classified by 2 independent physician-reviewers, using a structured implicit review process, by whether or not it constituted an adverse drug event or potential adverse drug event (those that may have caused harm, but did not because of chance or because they were detected), by the severity of the event (significant, serious, life-threatening, or fatal), and by whether it was preventable. Examples of significant events included nonurticarial rashes, falls without associated fracture, hemorrhage not requiring transfusion or hospitalization, and oversedation; examples of serious events included urticaria, falls with fracture, hemorrhage requiring transfusion or hospitalization, and delirium. RESULTS: During 28,839 nursing home resident-months of observation in the 18 participating nursing homes, 546 adverse drug events (1.89 per 100 resident-months) and 188 potential adverse drug events (0.65 per 100 resident-months) were identified. Of the adverse drug events, 1 was fatal, 31 (6%) were life-threatening, 206 (38%) were serious, and 308 (56%) were significant. Overall, 51% of the adverse drug events were judged to be preventable, including 171 (72%) of the 238 fatal, life-threatening, or serious events and 105 (34%) of the 308 significant events (P < 0.001). Errors resulting in preventable adverse drug events occurred most often at the stages of ordering and monitoring; errors in transcription, dispensing, and administration were less commonly identified. Psychoactive medications (antipsychotics, antidepressants, and sedatives/hypnotics) and anticoagulants were the most common medications associated with preventable adverse drug events. Neuropsychiatric events were the most common types of preventable adverse drug events. CONCLUSIONS: Adverse drug events are common and often preventable in nursing homes. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the ordering and monitoring stages of pharmaceutical care.

The epidemiology of adverse and unexpected events in the long-term care setting.

OBJECTIVE: To describe the adverse and unexpected events reported by staff over a 1-year period in a large, long-term care institution. DESIGN: A retrospective review of resident incident reports. SETTING: A 703-bed, academically oriented, long-term care facility. PATIENTS: Residents of the facility have a mean age of 88.5 years, are 76% female, and have an average length of stay of 4.3 years. MEASUREMENTS AND MAIN RESULTS: Of the 3,390 adverse and unexpected events reports over the 1-year study period, falls (with and without associated injury) were the most frequently reported incidents, followed by non-fall-related injuries, medication-related events, and wandering episodes. While a large proportion of falls occurred in ambulating residents (47%), the majority occurred under different circumstances including falls from bed, wheelchair, and commode/toilet. Bruises and skin tears were the most frequently reported fall- and non-fall-related injuries. The annual incidence rates for falls, fall-related injuries, and non-fall-related injuries varied according to resident care unit level, with semi-dependent residents experiencing the highest rates of falls and dependent residents experiencing the highest rates of non-fall-related injuries. Circadian patterns in the incidence of these events varied according to resident care level. CONCLUSIONS: Information regarding adverse and unexpected events in the long-term care setting can be organized into databases that allow analysis of patterns and trends. The results of these analyses may be helpful in targeting limited resources to areas of greatest need within an individual institution and for comparing quality of care across different long-term care facilities.

Racial bias in using USMLE step 1 scores to grant internal medicine residency interviews.

PURPOSE: To determine whether the United States Medical Licensing Examination (USMLE) Step 1 score, commonly used in screening residency applicants for interviews, eliminates a greater proportion of African-American applicants from the interview process at an internal medicine residency program. METHOD: A survey of internal medicine residency programs was performed to determine the prevalence of using USMLE Step 1 scores to grant interviews. A cohort of applicants was analyzed by constructing a database of USMLE Step 1 scores from the Electronic Residency Application Service (ERAS) database of applications from U.S., Canadian, and osteopathic medical schools to one residency program in 2000. Each applicant was classified as African American or non-African American. Rejection rates were then calculated for each five-point increment from a hypothetical threshold rejection score of <180 to <215. RESULTS: Responses were received from 259 residency programs (69%), and 92% used the USMLE Step 1 score in deciding which applicants to interview. A cohort of 626 non-African-American and 47 African-American applicants was analyzed. The proportion of applicants below each incremental threshold score was significantly higher for African-American applicants (p <.05 at each level). Depending on the threshold score used, an African-American applicant was three to six times less likely to be offered an interview. CONCLUSIONS: When USMLE Step 1 scores are used to screen applicants for a residency interview, a significantly greater proportion of African-American students will be refused an interview.

Nifedipine-induced gingival hyperplasia. A comprehensive review and analysis.

A comprehensive review of the literature and analysis of the clinical history, mechanisms, pathogenesis, histology, and management of nifedipine-induced gingival hyperplasia is reported. A correlation to age, gender, drug, dosage, duration of drug therapy, location, and mode of treatment is discussed. The case report presented provides a model for management of nifedipine-induced gingival hyperplasia and other drug-induced gingival hyperplasia.

Fourth molars: a clinical study.

Supernumerary teeth may be found in both the primary and permanent dentition, although they are more common in the permanent dentition. Presence of a fourth molar is rare, and such a tooth is almost invariably impacted. Dental practitioners should be aware of the possibility of encountering this rare supernumerary, its diagnosis and treatment. The authors of this article conducted a survey of patients in Montreal, looking specifically at the prevalence, aetiology, diagnosis, pathology and treatment of fourth molars. Their findings are reported here, and compared with data from the literature over the past 15 years.