Differing patterns of antiresorptive pharmacotherapy in nursing facility residents and community dwellers.

OBJECTIVES: Little is known about differences between current patterns of antiresorptive therapy (ART) use in nursing facility (NF) residents and by community-dwelling older adults (CDs). ART use was compared in older NF residents and CDs. DESIGN: Cross-sectional analysis. SETTING: Kansas Medicaid files from May 2000 through April 2001. PARTICIPANTS: Women aged 65 and older having at least 9 months of data as a CD or NF resident. MEASUREMENTS: Pharmacy claims were used to identify any ART prescription, including hormone replacement therapy (HRT), a bisphosphonate, raloxifene, or calcitonin. Demographic and clinical variables were identified from the claims files. Factors associated with ART use in bivariate analyses were entered into logistic regression models. Similar analyses were performed for bisphosphonate use among non-estrogen replacement therapy (non-ERT) ARTs (excluding HRT). RESULTS: The final study sample (N=2,289) included 898 NF (mean age 85.2) residents and 1,391 CDs (mean age 76.6). CDs were more likely to receive any ART (24.5%) than NF residents (19.6%). After adjustment for potential confounders, NF residents aged 65 to 84 were less likely (odds ratio (OR)=0.61, 95% confidence interval (CI)=0.44-0.85) to receive ART than CDs of the same age. Conversely, of those aged 85 and older, NF residents were more likely than CDs to receive ART (OR=1.96, 95% CI=1.18-3.25). Calcitonin was the most common non-ERT ART prescribed for NF residents, whereas bisphosphonates were more often prescribed for CDs. CONCLUSION: Underusage of ART is common in NF and CD cohorts. NF residents are less likely to receive bisphosphonates and more likely to receive calcitonin, for which efficacy is less clear. Further research is needed to identify factors influencing ART prescribing and selection of specific ARTs in different settings.

The cost effect of newer medication adoption in an older Medicaid cohort.

OBJECTIVES: State Medicaid programs struggle with rapidly increasing expenditures for pharmaceuticals, and Medicare will likely face the same challenge. This article demonstrates how the adoption of newer drugs across diverse therapeutic classes contributed to one state's Medicaid expenditures over a 3-year period. DESIGN: Retrospective analysis of administrative claims data. SETTING: Older Kansas Medicaid community dwellers and institutionalized beneficiaries. PARTICIPANTS: A 15% random sample (N = 6,256) of recipients aged 60 and older. MEASUREMENTS: Prescription medication use was tracked for three sequential 1-year periods for eight therapeutic classes accounting for the greatest Medicaid drug expenditures, categorizing individual medications as newer or older agents based on generic availability and other clinical distinctions. Outcome measures were utilization per person-year, price per prescription, market share as percentage of prescriptions, and market share as percentage of expenditures for prescriptions within each class. RESULTS: Use increased for all classes, driven by the adoption of newer agents. Mean prescription prices rose in nearly all classes primarily because of the higher prices of the newer agents. Newer drugs accounted for more than 50% of prescriptions in four of eight classes and constituted a disproportionately greater share of expenditures than their prescription share among several classes: antidepressants (>95%), antipsychotics (>92%), antiulcer agents (>63%), antiinflammatory drugs (>60%), and opiates (>45%). CONCLUSION: Newer drug products for a variety of treatment indications consume a majority of pharmaceutical expenditures through widespread adoption and higher prices. Although these agents may offer some therapeutic advantages, further research is needed to determine in what circumstances, and for which patients, the advantages of new pharmaceuticals outweigh their higher costs.

Osteoporosis: Health beliefs and barriers to treatment in an assisted living facility.

The purpose of this study was to describe residents' perceptions of osteoporosis and barriers to treatment in an assisted living setting. An exploratory, qualitative design was used. Five residents and the Director of Nursing participated in semi-structured interviews. Common health behaviors themes related to osteoporosis emerged that provide insight for nursing education and practice. The themes are discussed in light of the Health Belief Model, providing a framework for understanding osteoporosis-related health beliefs. This model lays a foundation upon which future interventions can be tested for effectiveness in improving osteoporosis-related care in assisted living.

Patterns of potentially inappropriate medication use across three cohorts of older Medicaid recipients.

BACKGROUND: Potentially inappropriate medication use is a serious quality concern, especially when it occurs in more vulnerable older adults or for extended durations. OBJECTIVE: To characterize patterns of inappropriate medication use and duration among 3 cohorts with differing health status. METHODS: We identified unconditionally inappropriate drug use, using Beers 1997 criteria, among 3185 older Kansas Medicaid beneficiaries. Claims from May 2000 to April 2001 provided data for 3 cohorts: nursing facility (NF) residents, recipients of home- and community-based services through the Frail Elderly (FE) program, and persons with neither NF/FE care (Ambulatory). Duration, categorized as short-term (< or = 1 month's supply), extended (> 1-9 mo), or chronic (> 9-12 mo), was determined for each drug and cohort. Drug-disease associations were explored. RESULTS: Any inappropriate medication use occurred in 21%, 48%, and 38% of Ambulatory, FE, and NF cohorts, respectively. Inappropriate analgesics, antihistamines, antidepressants, muscle relaxants, and oxybutynin were most common, but prevalence and duration varied by cohort. Short-term analgesic and antihistamine use was common. FE cohort members had the highest use rates for all drugs. The NF cohort had less antidepressant and muscle relaxant use. Drug-disease associations were noted for amitriptyline use in diabetes mellitus, propoxyphene use in musculoskeletal and upper gastrointestinal conditions, and muscle relaxant use in musculoskeletal conditions. CONCLUSIONS: Cross-sectional, one-year prevalence figures are comprised of both short- and long-term use that varies by drug and cohort. NF residence is associated with reduced use of drugs scrutinized during mandated medication review. Relevant diseases are associated with specific inappropriate prescribing. Future efforts should target extended and chronic duration of use and persons at highest risk for adverse effects, including recipients of home- and community-based care.

Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients.

The objective of this study was to determine if hospitalist consultation during admission for hip fracture results in improved treatment for osteoporosis. This was a retrospective chart review, carried out in a university-based academic hospital. Administrative discharge data was used to identify patients discharged between 1 September 1999 and 1 September 2001, discharged with the diagnosis of hip fracture. Eighty-two patient charts were reviewed after exclusion for traumatic and pathologic fractures. Treatment for osteoporosis consisted of medications recommended by the National Osteoporosis Foundation (NOF), including calcium (+/-vitamin D), estrogen, raloxifene, calcitonin, alendronate and risedronate. Osteoporosis treatment improvement was defined as the addition of a medication for osteoporosis that strengthened treatment. Twenty-nine percent of patients in our study received treatment for osteoporosis at the time of discharge from the hospitalization for hip fracture. While 20% received calcium, only 7% received a bisphosphonate. Twelve percent received improvement in osteoporosis treatment from admission to discharge. Those that received hospitalist consultation did not have a significant improvement in osteoporosis treatment (P=0.314), but had significantly more co-morbid illnesses and were significantly older than those receiving no consultation (P<0.05). Identification of osteoporosis as a medical problem was significantly associated with osteoporosis treatment (P<0.05). Potential barriers to hospitalist consultation's effect on osteoporosis treatment included patient age and co-morbidities. Further research is needed to identify and overcome barriers to effective osteoporosis treatment in patients with fractures.