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1.  Using Machine Learning to Examine Medication Adherence Thresholds and Risk of Hospitalization 
Medical care  2015;53(8):720-728.
Quality improvement efforts are frequently tied to patients achieving ≥80% medication adherence. However, there is little empirical evidence that this threshold optimally predicts important health outcomes.
To apply machine learning to examine how adherence to oral hypoglycemic medications is associated with avoidance of hospitalizations, and to identify adherence thresholds for optimal discrimination of hospitalization risk.
Retrospective cohort study of 33,130 non-dual-eligible Medicaid enrollees with type 2 diabetes. We randomly selected 90% of the cohort (training sample) to develop the prediction algorithm and used the remaining (testing sample) for validation. We applied random survival forests to identify predictors for hospitalization and fit survival trees to empirically derive adherence thresholds that best discriminate hospitalization risk, using the proportion of days covered (PDC).
Time to first all-cause and diabetes-related hospitalization.
The training and testing samples had similar characteristics (mean age, 48 years; 67% female; mean PDC 0.65). We identified eight important predictors of all-cause hospitalizations (rank in order): prior hospitalizations/emergency department visit, number of prescriptions, diabetes complications, insulin use, PDC, number of prescribers, Elixhauser index, and eligibility category. The adherence thresholds most discriminating for risk of all-cause hospitalization varied from 46% to 94% according to patient health and medication complexity. PDC was not predictive of hospitalizations in the healthiest or most complex patient subgroups.
Adherence thresholds most discriminating of hospitalization risk were not uniformly 80%. Machine-learning approaches may be valuable to identify appropriate patient-specific adherence thresholds for measuring quality of care and targeting non-adherent patients for intervention.
PMCID: PMC4503478  PMID: 26147866
medication adherence; diabetes; machine learning; survival tree; classification and regression tree
2.  Antihypertensive Use and Recurrent Falls in Community-Dwelling Older Adults: Findings From the Health ABC Study 
Despite wide-spread use of antihypertensives in older adults, the literature is unclear about their association with incident recurrent falls over time.
Health, Aging and Body Composition study participants (n = 2,948) who were well functioning at baseline (1997) were followed to Year 7 (2004). The main outcome was recurrent falls (≥2) in the ensuing 12 months. Antihypertensive use was examined as: (a) any versus none, (b) long- versus short-term (≥2 vs <2 years), and by (c) summated standardized daily dose (SDD; 1 = maximum recommended daily dose for one antihypertensive), and (d) subclass.
Controlling for potential demographic, health status/behavior and access to care confounders, we found no increase in risk of recurrent falls in antihypertensive users compared to nonusers (adjusted odds ratio [AOR] = 1.13; 95% CI = 0.88–1.46), or those taking higher SDDs or for longer durations. Only those using a loop diuretic were found to have a modest increased risk of recurrent falls (AOR = 1.50; 95% CI = 1.11–2.03).
Antihypertensive use overall was not statistically significantly associated with recurrent falls after adjusting for important confounders. Loop diuretic use may be associated with recurrent falls and needs further study.
PMCID: PMC4643613  PMID: 26265732
Falls; Medication; Epidemiology; Drug related
3.  Antidepressant Use and Recurrent Falls in Community-Dwelling Older Adults: Findings From the Health ABC Study 
The Annals of pharmacotherapy  2016;50(7):525-533.
Few studies have compared the risk of recurrent falls across various antidepressant agents—using detailed dosage and duration data—among community-dwelling older adults, including those who have a history of a fall/fracture.
To examine the association of antidepressant use with recurrent falls, including among those with a history of falls/fractures, in community-dwelling elders.
This was a longitudinal analysis of 2948 participants with data collected via interview at year 1 from the Health, Aging and Body Composition study and followed through year 7 (1997-2004). Any antidepressant medication use was self-reported at years 1, 2, 3, 5, and 6 and further categorized as (1) selective serotonin reuptake inhibitors (SSRIs), (2) tricyclic antidepressants, and (3) others. Dosage and duration were examined. The outcome was recurrent falls (≥2) in the ensuing 12-month period following each medication data collection.
Using multivariable generalized estimating equations models, we observed a 48% greater likelihood of recurrent falls in antidepressant users compared with nonusers (adjusted odds ratio [AOR] = 1.48; 95% CI = 1.12-1.96). Increased likelihood was also found among those taking SSRIs (AOR = 1.62; 95% CI = 1.15-2.28), with short duration of use (AOR = 1.47; 95% CI = 1.04-2.00), and taking moderate dosages (AOR = 1.59; 95% CI = 1.15-2.18), all compared with no antidepressant use. Stratified analysis revealed an increased likelihood among users with a baseline history of falls/fractures compared with nonusers (AOR = 1.83; 95% CI = 1.28-2.63).
Antidepressant use overall, SSRI use, short duration of use, and moderate dosage were associated with recurrent falls. Those with a history of falls/fractures also had an increased likelihood of recurrent falls.
PMCID: PMC4892949  PMID: 27066988
antidepressants; aging; drug-related problems; epidemiology; geriatrics; outcomes research/analysis; pharmacoepidemiology
4.  Medication Oversupply in Patients with Diabetes 
Studies in integrated health systems suggest that patients often accumulate oversupplies of prescribed medications, which is associated with higher costs and hospitalization risk. However, predictors of oversupply are poorly understood, with no studies in Medicare Part D.
The aim of this study was to describe prevalence and predictors of oversupply of antidiabetic, antihypertensive, and antihyperlipidemic medications in adults with diabetes managed by a large, multidisciplinary, academic physician group and enrolled in Medicare Part D or a local private health plan.
This was a retrospective cohort study. Electronic health record data were linked to medical and pharmacy claims and enrollment data from Medicare and a local private payer for 2006-2008 to construct a patient-quarter dataset for patients managed by the physician group. Patients’ quarterly refill adherence was calculated using ReComp, a continuous, multiple-interval measure of medication acquisition (CMA), and categorized as <0.80 = Undersupply, 0.80-1.20 = Appropriate Supply, >1.20 = Oversupply. We examined associations of baseline and time-varying predisposing, enabling, and medical need factors to quarterly supply using multinomial logistic regression.
The sample included 2,519 adults with diabetes. Relative to patients with private insurance, higher odds of oversupply were observed in patients aged <65 in Medicare (OR=3.36, 95% CI=1.61-6.99), patients 65+ in Medicare (OR=2.51, 95% CI=1.37-4.60), patients <65 in Medicare/Medicaid (OR=4.55, 95% CI=2.33-8.92), and patients 65+ in Medicare/Medicaid (OR=5.73, 95% CI=2.89-11.33). Other factors associated with higher odds of oversupply included any 90-day refills during the quarter, psychotic disorder diagnosis, and moderate versus tight glycemic control.
Oversupply was less prevalent than in previous studies of integrated systems, but Medicare Part D enrollees had greater odds of oversupply than privately insured individuals. Future research should examine utilization management practices of Part D versus private health plans that may affect oversupply.
PMCID: PMC4362914  PMID: 25288448
Refill adherence; oversupply; medication surplus; diabetes
5.  Safeguarding Older Adults From Inappropriate Over-the-Counter Medications: The Role of Community Pharmacists 
The Gerontologist  2013;54(6):989-1000.
Purpose of the Study: To elicit the thought process or mental model that community pharmacists use when making recommendations on over-the-counter (OTC) medications to older adults and to elicit the current practices of community pharmacists in providing information, advice, and counseling to older adults about potentially inappropriate OTC medications. Design and Methods: Three separate focus groups with pharmacists were conducted with 5 to 8 pharmacists per group. A vignette about an elderly woman seeking an OTC sleep aid was used to elicit information that pharmacists seek to establish when making a recommendation. Focus groups were recorded, transcribed verbatim, and analyzed for themes using the initial and focused coding methods of grounded theory. Results: Community pharmacists’ mental models were characterized by 2 similarities: a similarity in what community pharmacists seek to establish about patients and a similarity in when community pharmacists seek to establish it—the sequence in which they try to learn key details about patients. It was identified that pharmacists gather specific information about the patient’s medication profile, health conditions, characteristics of the problem, and past treatments in order to make a recommendation. Community pharmacists recommended behavioral modifications and seeing their physician prior to recommending an OTC sleep aid, primarily due to medication safety concerns. Implications: Pharmacists can play a key role in assisting older adults to select and use OTC medications.
PMCID: PMC4271106  PMID: 24197014
Over the counter medication; Community pharmacy; Older adult; Medication counseling; Medication safety
6.  The Impact of Family Caregivers on Potentially Inappropriate Medication Use in Non-institutionalized Older Adults with Dementia 
The risk of potentially inappropriate prescription and over-the-counter medication (PIM) use in dementia patients is high. Informal caregivers often facilitate patients’ use of medications, but the effect of caregiver factors on PIM use has not been a focus of prior research.
To examine PIM use in dementia patients and caregivers, and identify caregiver risk factors for PIM use in dementia patients.
We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample was comprised of 566 persons with dementia aged 65 and older and their co-residing family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of socio-demographic and health variables.
In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use; spouse caregivers; Hispanic caregivers; and greater number of years the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients.
PIM use may be higher in dementia patients and their informal caregivers compared to the general older adult population. Further, patterns of medication use in one member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.
PMCID: PMC3413778  PMID: 22683399
Dementia; informal caregivers; inappropriate medications; care quality
7.  Rural-Urban Differences in Preventable Hospitalizations Among Community-Dwelling Veterans with Dementia 
Alzheimer’s patients living in rural communities may face significant barriers to effective outpatient medical care.
We sought to examine rural-urban differences in risk for ambulatory care sensitive hospitalizations (ACSH), an indicator of access to outpatient care, in community-dwelling veterans with dementia.
Medicare and VA inpatient claims for 1,186 United States veterans with dementia were linked to survey data from the 1998 National Longitudinal Caregiver Survey. ACSH were identified in inpatient claims over a one-year period following collection of independent variables. Urban Influence Codes were used to classify care-recipients into four categories of increasing county-level rurality: large metropolitan; small metropolitan; micropolitan; and non-core rural counties. We used the Andersen Behavioral Model of Health Services Use to identify veteran, caregiver, and community factors that may explain urban-rural differences in ACSH.
Thirteen percent of care-recipients had at least one ACSH. Likelihood of ACSH was greater for patients in non-core rural counties versus large metropolitan areas (22.6% versus 12.8%, unadjusted odds ratio [OR] = 1.99; p < .05). The addition of other Andersen behavioral model variables did not eliminate the disparity (adjusted OR = 1.97; p < .05).
We found that dementia patients living in the most rural counties were more likely to have an ACSH; this disparity was not explained by differences in caregiver, care-recipient, or community factors. Furthermore, the annual rate of ACSH was higher in community-dwelling dementia patients compared to previous reports on the general older adult population. Dementia patients in rural areas may face particular challenges in receiving timely, effective ambulatory care.
PMCID: PMC3691102  PMID: 20447001
Preventable hospitalizations; rural; dementia; caregivers; access
8.  Anticholinergic Use and Recurrent Falls in Community-Dwelling Older Adults: Findings From the Health ABC Study 
The Annals of pharmacotherapy  2015;49(11):1214-1221.
Although it is generally accepted that anticholinergic use may lead to a fall, results from studies assessing the association between anticholinergic use and falls are mixed. In addition, direct evidence of an association between use of anticholinergic medications and recurrent falls among community-dwelling elders is not available.
To assess the association between anticholinergic use across multiple anticholinergic subclasses, including over-the-counter medications, and recurrent falls.
This was a longitudinal analysis of 2948 participants, with data collected via interview at year 1 from the Health, Aging and Body Composition study and followed through year 7 (1997–2004). Self-reported use of anticholinergic medication was identified at years 1, 2, 3, 5, and 6 as defined by the list from the 2015 American Geriatrics Society Beers Criteria. Dosage and duration were also examined. The main outcome was recurrent falls (≥2) in an ensuing 12-month period from each medication data collection.
Using multivariable generalized estimating equation models, controlling for demographic, health status/behaviors, and access-to-care factors, a 34% increase in likelihood of recurrent falls in anticholinergic users (adjusted odds ratio = 1.34; 95% CI = 0.93–1.93) was observed, but the results were not statistically significant; similar results were found with higher doses and longer duration of use.
Increased point estimates suggest an association of anticholinergic use with recurrent falls, but the associations did not reach statistical significance. Future studies are needed for more definitive evidence and to examine other measures of anticholinergic burden and associations with more intermediate adverse effects such as cognitive function.
PMCID: PMC4609603  PMID: 26228936
cholinergic antagonist; accidental falls; older adults; pharmacoepidemiology
9.  Prescription of Opioid and Non-opioid Analgesics for Dental Care in Emergency Departments: Findings from the National Hospital Ambulatory Medical Care Survey 
The aim of this study was to examine trends and associated factors in the prescription of opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics by emergency physicians for nontraumatic dental condition (NTDC)-related visits. Our secondary aim was to investigate whether race/ethnicity is a possible predictor of receiving a prescription for either type of medication for NTDC visits in emergency departments (EDs) after adjustment for potential covariates.
We analyzed data from the National Hospital Ambulatory Medical Care Survey for 1997–2000 and 2003–2007, and used multinomial multivariate logistic regression to estimate the probability of receiving a prescription for opioid analgesics, non-opioid analgesics, or a combination of both compared to receiving no analgesics for NTDC-related visits.
During 1997–2000 and 2003–2007, prescription of opioid analgesics and combinations of opioid and non-opioid analgesics increased and that of no analgesics decreased over time. The prescription rates for opioid analgesics, non-opioid analgesics, opioid and non-opioid analgesic combinations and no analgesics for NTDC-related visits in EDs were 43%, 20%, 12% and 25% respectively. Majority of patients categorized as having severe pain received prescriptions for opioids for NTDC-related visits in EDs. After adjusting for covariates, patients with self-reported dental reasons for visit and severe pain had a significantly higher probability of receiving prescriptions for opioid analgesics and opioid and non-opioid analgesic combinations.
Prescription of opioid analgesics increased over time. ED physicians were more likely to prescribe opioid analgesics and opioid and non-opioid analgesic combinations for NTDC-related visits with reported severe pain.
PMCID: PMC4245386  PMID: 24863407
Nontraumatic dental conditions; dental health services; dental care; emergency physicians; opioid analgesics; non-opioid analgesics; toothache
10.  Racial Differences in Anticholinergic Use among Community-Dwelling Elders 
Few studies have examined racial differences in potentially inappropriate medication use. The objective of this study was to examine racial disparities in using prescription and/or non-prescription anticholinergics, a type of potentially inappropriate medication, over time.
Health, Aging, and Body Composition Study (years 1, 5, and 10)
Three thousand fifty-five black and white community-dwelling older adults at year one
Main Outcome Measure
Highly anticholinergic medication use as per the 2012 American Geriatrics Society Beers Criteria.
Blacks represented 41.4% of the participants at year 1. At year 1, 13.4% of blacks used an anticholinergic medication compared to 17.8% of whites, and this difference persisted over the ensuing ten-year period. Diphenhydramine was the most common anticholinergic medication reported at baseline and year 5 and meclizine at year 10 for both races. Controlling for demographics, health status and access to care factors, blacks were 24-45% less likely to use any anticholinergics compared to whites over the years considered (all p<0.05).
The use of prescription and/or non-prescription anticholinergic medications was less common in older blacks than whites over a ten-year period, and the difference was unexplained by demographics, health status and access-to-care.
PMCID: PMC4405895  PMID: 25893702
aged; cholinergic antagonists; drug utilization; African -American
11.  The Active Patient Role and Asthma Outcomes in an Underserved Rural Community 
Patient activation, an individual’s knowledge, skills, and confidence for managing their own health and health care, can play an important role in the management of chronic conditions. However, few studies have examined patient activation in underserved rural communities. The purpose of this study was to describe patient activation and examine how patient activation is associated with adherence to asthma maintenance medication and disease control in a low-income rural population with asthma.
We conducted a cross-sectional telephone survey with 98 adults. Patient activation was assessed with the Patient Activation Measure. Adherence to long-term controller (LTC) medications and asthma control were examined using the Morisky Medication Adherence Scale (MMAS) and Asthma Control Test (ACT). Multivariate regression analyses were used to assess the associations between patient activation and 1) adherence to LTC medications and 2) asthma control.
The majority of participants (50%) were classified in the highest level of patient activation. The least activated participants had lower mean MMAS and ACT scores in comparison to participants who were classified in higher patient activation levels. Multivariate analyses found significant positive associations between patient activation and adherence and asthma control.
Patient activation may be instrumental in low-income rural patients’ use of asthma medication and disease control. Study results inform interventions to help patients use asthma medications appropriately and achieve better asthma control. In addition to increasing access to health care services in rural communities, health care professionals also may develop and implement strategies to positively impact rural patients’ involvement in care.
PMCID: PMC4327938  PMID: 24689537
asthma; patient activation; rural; self-management; underserved
12.  RN jurisdiction over nursing care systems in nursing homes: application of latent class analysis 
Nursing research  2012;61(1):28-38.
In the context of declining registered nurse (RN) staffing levels in nursing homes, professional nursing jurisdiction over nursing care systems may erode.
The purpose of this study is to develop a typology of professional nursing jurisdiction in nursing homes in relation to characteristics of RN staffing, drawing upon Abbott's (1988) tasks and jurisdictions framework.
The study was a cross-sectional, observational study using the 2004 National Nursing Home Survey (N=1,120 nursing homes). Latent class analysis tested whether RN staffing indicators differentiated facilities in a typology of RN jurisdiction, and compared classes on key organizational environment characteristics. Multiple logistic regression analysis related the emergent classes to presence or absence of specialty care programs in 8 clinical areas.
Three classes of capacity for jurisdiction were identified, including ‘low capacity’ (41% of homes) with low probabilities of having any indicators of RN jurisdiction, ‘mixed capacity’ (26% of homes) with moderate to high probabilities of having higher RN education and staffing levels, and ‘high capacity’ (32% of homes) with moderate to high probabilities of having almost all indicators of RN jurisdiction. ‘High capacity’ homes were more likely to have specialty care programs relative to ‘low capacity’ homes; such homes were less likely to be chain-owned, and more likely to be larger, provide higher technical levels of patient care, have unionized nursing assistants, have a lower ratio of LPNs to RNs, and a higher education level of the administrator.
Findings provide preliminary support for the theoretical framework as a starting point to move beyond extensive reliance on staffing levels and mix as indicators of quality. Further, findings indicate the importance of RN specialty certification.
PMCID: PMC4360952  PMID: 22166907
nurse staffing; staff mix; organizational performance; authority; autonomy
13.  Effects of Medicare Part D on Drug Affordability and Utilization: Are Seniors with Prior High Out-of-Pocket Drug Spending Affected More? 
Medicare Part D was expected to have differential impacts on patient drug expenditures and utilization based on beneficiaries’ levels of pre-Part D patient drug spending, but it is unknown whether these projections have borne out
We sought to evaluate whether and how the policy effect of Medicare Part D on drug expenditures and utilization was modified by levels of pre-Part D drug spending.
A quasi-experimental, pretest-posttest, nonequivalent control group design was used. Data were obtained from a regional supermarket chain for all prescriptions dispensed between January 1, 2005 and December 31, 2007 (n =1,230,612) to patients age 60 and older as of January 1, 2005 (n = 51,305) to construct 12-month pre-Part D and post-Part D periods. The treatment group was defined as individuals who were eligible via age, for Part D coverage on January 1, 2006 (ages 65+). The control group included individuals aged 60 through 62 on January 1, 2006. Annual medication utilization was measured as the total number of pill-days acquired. Annual drug expenditures were measured as total expenditures, patient out-of-pocket expenditures, and the proportion of total expenditures paid out of pocket by the patient.
Part D resulted in significantly greater reductions in absolute and relative out-of-pocket spending for individuals in the highest pre-Part D drug spending group relative to the moderate and low pre-Part D drug spending groups.
Our findings suggest that, as expected, Part D facilitated access to medications for patients who previously experienced the greatest costs without adversely increasing use and costs among those with the lowest prior cost.
PMCID: PMC4087326  PMID: 20511108
Medicare Part D; Utilization; Out-of-pocket Spending; Access
14.  Do Nurse-Led Skill Training Interventions Affect Informal Caregivers’ Out-of-Pocket Expenditures? 
The Gerontologist  2012;53(1):60-70.
Purpose of the Study:
This paper is a report of a study of the Assistance, Support, and Self-health Initiated through Skill Training (ASSIST) randomized control trial. The aim of this paper is to understand whether participating in ASSIST significantly changed the out-of-pocket (OOP) costs for family caregivers of Alzheimer’s disease (AD) or Parkinson's disease (PD) patients.
Design and Methods:
Secondary analysis of randomized control trial data, calculating average treatment effects of the intervention on OOP costs. Enrollment in the ASSIST trial occurred between 2002 and 2007 at 2 sites: Durham, North Carolina, and Birmingham, Alabama. We profile OOP costs for caregivers who participated in the ASSIST study and use 2-part expenditure models to examine the average treatment effect of the intervention on caregiver OOP expenditures.
ASSIST-trained AD and PD caregivers reported monthly OOP expenditures that averaged $500–$600. The intervention increased the likelihood of caregivers spending any money OOP by 26 percentage points over usual care, but the intervention did not significantly increase overall OOP costs.
The ASSIST intervention was effective and inexpensive to the caregiver in direct monetary outlays; thus, there are minimal unintended consequences of the trial on caregiver financial well-being.
PMCID: PMC3551205  PMID: 22459694
Cost analysis; Intervention study; Nurses/midwives/nursing; Alzheimer’s disease; Parkinson's disease; Average treatment effect
15.  Facilitating Healthy Coping in Patients with Diabetes: A Systematic Review 
The Diabetes educator  2012;39(1):33-52.
The purpose of this study is to summarize recent literature on approaches to supporting healthy coping in diabetes, in two specific areas: 1) impact of different approaches to diabetes treatment on healthy coping; and 2) effectiveness of interventions specifically designed to support healthy coping.
A PubMed search identified 129 articles published August 1, 2006 – April 30, 2011, addressing diabetes in relation to emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem-solving, couples therapy, or marital therapy.
Evidence suggests that treatment choice may significantly influence quality of life, with treatment intensification in response to poor metabolic control often improving quality of life. The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes, Cognitive Behavior Therapy and collaborative care for treating depression, and family therapy for improving coping in youths.
Healthy coping in diabetes has received substantial attention in the past five years. A variety of approaches show positive results. Research is needed to compare effectiveness of different approaches in different populations and determine how to overcome barriers to intervention dissemination and implementation.
PMCID: PMC3549032  PMID: 23073967
16.  Use of pharmacists or pharmacies as Medicare Part D information sources 
To characterize beneficiaries who used a pharmacy or pharmacist as a Medicare Part D information source.
This cross-sectional descriptive study involved 4,724 Medicare Part D beneficiaries who graduated from Wisconsin high schools in 1957. The main outcome measure was beneficiary self-reported use of a pharmacy or pharmacist as a Medicare Part D information source.
Only 13% of the total sample and 15% of those with three or more medications used a pharmacy or pharmacist for Medicare Part D information. Adjusted logistic regression revealed that beneficiaries living in rural communities, compared with metropolitan areas, and with higher out-of-pocket prescription costs were more likely to use a pharmacy or pharmacist for Medicare Part D information. Beneficiaries with lower educational attainment were less likely to use a pharmacy or pharmacist for Medicare Part D information.
Pharmacists have the knowledge and are in the position in the community to effectively educate beneficiaries about the Medicare Part D program. However, this study suggests that few beneficiaries are using pharmacists or pharmacies for Medicare Part D information.
PMCID: PMC3774520  PMID: 23229982
Medicare Part D; community pharmacies; pharmacists; information sources; rural setting; prescription costs
17.  Patient And phaRmacist Telephonic Encounters (PARTE) in an Underserved Rural Patient Population with Asthma: Results of a Pilot Study 
Telemedicine Journal and e-Health  2012;18(6):427-433.
Objective: To assess the feasibility, acceptability, and preliminary impact of a telepharmacy intervention in an underserved, rural asthma patient population. Subjects and Methods: Patients with asthma were randomized to receive either standard care or telephone consultations from pharmacists regarding asthma self-management over a 3-month period. Qualitative interviews were conducted to identify participants' attitudes/opinions regarding the intervention. Baseline and follow-up surveys assessed asthma control, patient activation, and medication utilization. Results: Ninety-eight adults were recruited (78% accrual); 83 completed the study (15% dropout). Participants reported positive opinions and believed the intervention improved their asthma self-management. The intervention group had significantly higher patient activation compared with the control (p<0.05). There were no significant between-group differences regarding asthma control. However, within-group analyses of the intervention group showed an improvement in asthma control (p<0.01) and medication adherence (p<0.01). No within-group differences were found for the control group. Conclusions: This telepharmacy intervention is feasible and showed indicators of effectiveness, suggesting the design is well suited for a robust study to evaluate its impact in uncontrolled asthma patients. Pharmacists helping patients manage asthma through telecommunications may resolve access barriers and improve care.
PMCID: PMC3399112  PMID: 22656403
patient–pharmacist communication; asthma; telepharmacy; intervention; rural; underserved
Medical Care  2012;50(6):508-512.
Prior research has documented factors associated with non-traumatic dental condition (NTDC) visits to emergency departments (EDs), but little is known about the care received by patients in EDs for NTDC visits.
We examined national trends in prescription of analgesics and antibiotics in EDs for NTDC visits in the United States.
Research Design
We analyzed data from the National Hospital Ambulatory Medical Care survey for 1997 to 2007. We used a multivariable logistic regression model to examine factors associated with receiving analgesics and antibiotics for NTDC visit in EDs.
Overall 74% received at least one analgesic, 56% at least one antibiotic and 13% received no medication at all during an NTDC visit to the ED. The prescription of medications at EDs for NTDC visits steadily increased over time for analgesics (OR=1.11/year, p=<.0001) and antibiotics (OR=1.06/year, p<0.0001). In the multivariable analysis, self-pay patients had significantly higher adjusted odds of receiving antibiotics, while those with non-dental reason for visit and children (0–4 years) had significantly lower adjusted odds of receiving a prescription for antibiotics in EDs for NTDC visits. Children 0–4 years, adults 53–72 years and older adults (73 years and older) had lower adjusted odds (p<0.001) of receiving analgesics.
Nationally, analgesic and antibiotic prescriptions for NTDC visits to EDs have increased substantially over time. Self-pay patients had significantly higher odds of being prescribed antibiotics. Adults over 53 years and especially those 73 years and older had significantly lower odds of receiving analgesics in EDs for NTDC visits.
PMCID: PMC3353147  PMID: 22584886
Nontraumatic dental conditions; Emergency Department; Medications
19.  Number of First-Contact Access Components Required to Improve Preventive Service Receipt in Primary Care Homes 
A fundamental aim of primary care redesign and the patient-centered medical home is improving access to care. Patients who report having a usual site of care and usual provider are more likely to receive preventive services, but less is known about the influence of specific components of first-contact access (e.g., availability of appointments, advice by telephone) on preventive services receipt.
To examine the relationship between number of first-contact access components and receipt of recommended preventive services.
Secondary survey data analysis.
Five thousand five hundred and seven insured adults who had continuity with a usual primary care physician and participated in the 2003–2006 round of the Wisconsin Longitudinal Survey.
Using multivariable logistic regression, we calculated adjusted risk ratios, adjusted predicted probabilities and 95% confidence intervals for each preventive service.
Experiencing more first-contact access components was significantly associated with a higher rate of receiving cholesterol tests, flu shots and prostate exams but not mammography. There was variation in the number of components needed (between two and seven) to achieve a significant difference.
Having an increasing number of first-access components in a primary care office may improve preventive services receipt, and more components may be required for those services requiring greater provider contact (e.g., prostate exam) versus those that require less (e.g., mammography). In primary care redesign, the largest gains in preventive services receipt likely will come with redesign of multiple components simultaneously. While our study is a necessary step towards broadly understanding the relationship between first-contact access and preventive service receipt, other important questions remain. Certain components may drive greater improvements in the receipt of different services, and the effect of some of these components may depend on individual patient characteristics. Further research is critical for understanding redesign strategies that may optimize preventive service delivery.
PMCID: PMC3358386  PMID: 22215269
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; health care utilization; aging
20.  Depressive Symptoms and Reduced Preventive Care Use in Older Adults: The Mediating Role of Perceived Access 
Medical Care  2012;50(4):302-310.
Depressive symptomatology is common in older adults and is associated with reduced adherence to recommended preventive care, but little is known as to why. Understanding how depressive symptoms may interfere with adherence can help identify leverage points for interventions to increase preventive service use.
This study examined perceived access to medical care as a possible mediator linking depressive symptomatology to reduced preventive service use in older adults.
We analyzed data from 5,465 respondents completing the 1993 and 2003/2004 waves of the Wisconsin Longitudinal Study. Depressive symptomatology was assessed using the Center for Epidemiologic Studies Depression Scale. Perceived access survey items were organized via factor analysis to represent key dimensions of access: availability/accessibility, affordability, acceptability, and accommodation. The primary outcome was the total number of seven recommended preventive services that respondents received. Multivariate path analysis was used to estimate direct and indirect effects between depressive symptomatology, perceived access, and preventive service use.
Older adults with depressive symptomatology received fewer recommended services. Depressive symptomatology reduced preventive service use by adversely affecting two dimensions of perceived access: (1) acceptability, pertaining to poor patient-provider trust and communication, and (2) accommodation, pertaining to inconveniently organized services.
Depressive symptomatology may negatively alter older adults’ perceptions of access and, in turn, negatively impact their preventive service use. In addition to treating depression, interventions designed to mitigate the impact of depression on the patient-provider relationship, and organizational changes to practice that better accommodate the needs of depressed patients, may increase adherence to preventive care guidelines in depressed older adults.
PMCID: PMC3240709  PMID: 21577167
preventive care; depression; access; elderly
21.  Receipt of Diabetes Monitoring in Older Adults with Co-Morbid Dementia 
In diabetes patients with co-morbid dementia, continued monitoring of HbA1c, cardiovascular risk, and diabetes complications can inform treatment decisions and minimize further declines in cognition, function, and quality of life. However, a clinically dominant, symptomatic, and discordant condition such as dementia may inhibit efforts to monitor diabetes in accordance with guidelines for older, complex patients. We examined the extent to which receipt of recommended diabetes monitoring differed for patients with and without co-morbid dementia, as well as the effect of other co-morbidities on diabetes monitoring in patients with co-morbid dementia.
Retrospective cohort study.
Secondary analysis of 2005–2006 claims and enrollment data for a 5% national random sample of Medicare beneficiaries.
288,805 Medicare fee-for-service beneficiaries with a diabetes diagnosis prior to 2006; 44,717 (16%) of whom had evidence of co-morbid dementia in claims.
We used established algorithms to determine whether patients received at least one HbA1c test, one LDL cholesterol test, and one annual eye exam in 2006, and construct variables representing co-morbidities common in diabetes, socio-demographics, and patterns of health care utilization.
In unadjusted and fully adjusted models, the presence of dementia reduced patients’ likelihood of receiving HbA1c tests, LDL tests, and eye exams, with effects being smallest for HbA1c tests. The effects of other co-morbidities on diabetes monitoring in patients with dementia varied by the nature of the co-morbidity and the specific test.
Dementia reduces the likelihood that diabetes patients received recommended annual monitoring for diabetes. More research is needed to understand reasons for reduced monitoring in this patient subgroup and how this impacts patient functioning, adverse events, and quality of life.
PMCID: PMC3325373  PMID: 22428535
diabetes; dementia; guideline adherence; care quality; Medicare
22.  An Online Virtual-Patient Program to Teach Pharmacists and Pharmacy Students How to Provide Diabetes-Specific Medication Therapy Management 
Objective. To develop, implement, and assess the effectiveness of an online medication therapy management (MTM) program to train pharmacists and pharmacy students in providing MTM services for patients with diabetes and to increase their intent to perform these services.
Design. An online program was created using an Internet-based learning platform to simulate 4 MTM meetings between a pharmacist and a virtual patient diagnosed with diabetes.
Assessment. Eighty students and 42 pharmacists completed the program. After completing the program, scores on post-intervention assessments showed significant improvement in 2 areas: control over performing MTM, and knowledge of how to perform MTM. Students had a significantly less-positive attitude about MTM and a decline in their perception of the social expectation that MTM is part of the practice of pharmacy, while pharmacists’ attitudes did not change significantly in these areas.
Conclusion. This online program using a virtual patient improved both participants’ belief that they have control over performing MTM, and their knowledge of how to perform MTM for diabetic patients, which may increase the likelihood that pharmacists and pharmacy students will perform MTM in the future.
PMCID: PMC3448469  PMID: 23049103
medication therapy management; diabetes; pharmacist; virtual patient; simulation; pharmacy student
23.  Preventive Service Gains from First Contact Access in the Primary Care Home 
The patient-centered medical home (PCMH) concept has recently garnered national attention as a means of improving the quality of primary care. Preventive services are one area where the PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign.
To examine whether first-contact access characteristics of a medical home (e.g., availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals already in a longitudinal relationship with a usual primary care physician at a site of care.
Secondary analysis examining data from 5,507 insured adults with a usual physician who participated in the 2003–2006 round of the Wisconsin Longitudinal Survey. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access to those without first-contact access.
Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate exam (OR 1.62; 95% CI 1.20–2.18), a flu shot (OR 1.36; 95% CI 1.01–1.82) and a cholesterol test (OR 1.36; 95% CI 1.01–1.82) in the past year. There was no significant difference in receipt of mammograms (OR 1.23; 95% CI 0.94–1.61).
In the primary care home, first-contact accessibility adds benefit beyond continuity of care with a physician in improving receipt of preventive services. Amid increasing primary care demands and finite resources to translate the PCMH into clinic settings there is need for further studies of the interplay between specific PCMH principles and how they perform in practice.
PMCID: PMC3137250  PMID: 21737759
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; quality improvement
25.  Patient characteristics and trends in nontraumatic dental condition visits to emergency departments in the United States 
We examined trends and patient characteristics for non-traumatic dental condition (NTDC) visits to emergency departments (EDs), and compared them to other ED visit types, specifically non-dental ambulatory care sensitive conditions (non-dental ACSCs) and non-ambulatory care sensitive conditions (non-ACSCs) in the United States.
We analyzed data from the National Hospital Ambulatory Medical Care survey (NHAMCS) for 1997 to 2007. We performed descriptive statistics and used a multivariate multinomial logistic regression to examine the odds of one of the three visit types occurring at an ED. All analyses were adjusted for the survey design.
NTDC visits accounted for 1.4% of all ED visits with a 4% annual rate of increase (from 1.0% in 1997 to 1.7% in 2007). Self-pay patients (32%) and Medicaid enrollees (27%) were over-represented among NTDC visits compared to non-dental ACSC and non-ACSC visits (P < 0.0001). Females consistently accounted for over 50% of all types of ED visits examined. Compared to whites, Hispanics had significantly lower odds of an NDTC visit versus other visit types (P < 0.0001). Blacks had significantly lower odds of making NDTC visits when compared to non-dental ACSC visits only (P < 0.0001). Compared to private insurance enrollees, Medicaid and self-pay patients had 2–3 times the odds of making NTDC visits compared to other visit types.
Nationally, NTDC visits to emergency departments increased over time. Medicaid and self-pay patients had significantly higher odds of making NDTC visits.
PMCID: PMC3652363  PMID: 23674919
emergency service; dental disease; adults; dental utilization

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