Andrew R Zullo
Andrew R. Zullo, PharmD, ScM, PhD is a pharmacoepidemiologist and health services researcher. He joined Brown University in 2012 as a joint PhD student in Health Services Research and ScM student in Epidemiology. In 2015, he then transitioned to become an AHRQ K12 Scholar in Patient Centered Outcomes Research and an Investigator in the Department of Health Services, Policy, and Practice.
Andrew's main research interest is in the study of prescription drug effects, particularly in geriatric patients and nursing home settings. He applies comparative effectiveness and safety methodologies to patient-centered outcomes research topics in diabetes, cardiovascular disease, fractures/osteoporosis, nephrology, and more. His other interests include 1) the quality and determinants of medication use, 2) personal prescription drug importation, and 3) new models of pharmaceutical care delivery and medication management.
Andrew continues to practice as an inpatient clinical pharmacist at Rhode Island Hospital, where he trains residents and students.
Supervisors: Vincent Mor, David D. Dore, Ira Wilson, Omar Galarraga, Chanelle Howe, Christine Berard-Collins, Issa Dahabreh, Sarah Berry, and Michael A. Steinman
Address: 121 South Main Street, Box G-S121-8, Providence, RI 02912
Andrew's main research interest is in the study of prescription drug effects, particularly in geriatric patients and nursing home settings. He applies comparative effectiveness and safety methodologies to patient-centered outcomes research topics in diabetes, cardiovascular disease, fractures/osteoporosis, nephrology, and more. His other interests include 1) the quality and determinants of medication use, 2) personal prescription drug importation, and 3) new models of pharmaceutical care delivery and medication management.
Andrew continues to practice as an inpatient clinical pharmacist at Rhode Island Hospital, where he trains residents and students.
Supervisors: Vincent Mor, David D. Dore, Ira Wilson, Omar Galarraga, Chanelle Howe, Christine Berard-Collins, Issa Dahabreh, Sarah Berry, and Michael A. Steinman
Address: 121 South Main Street, Box G-S121-8, Providence, RI 02912
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Papers by Andrew R Zullo
Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.
DESIGN AND SETTING:
Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.
PARTICIPANTS:
A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.
MEASUREMENTS:
Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.
RESULTS:
We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).
CONCLUSIONS:
Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.
This letter describes and juxtaposes common glucose-lowering medication usage patterns for a national cross-section of U.S. adults aged 65 and older residing in NH and community settings between January 1, 2007, and December 31, 2010. A random 20% national sample of Medicare fee-for-service beneficiaries with Parts A, B, and D claims linked to the Minimum Data Set (MDS), a federally mandated NH health assessment tool, was used. Individuals could have Medicare insurance coverage for any duration. All beneficiaries had at least one dispensing of a glucose-lowering treatment during the study period.
Prevalent glucose-lowering medication use was assessed using Part D data. Medication use patterns were mutually exclusive and defined without regard to the time sequence of the dispensings. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes from Part B claims during the study period were used to ascertain the prevalence of comorbidities and geriatric conditions. Hospitalizations during the study period were identified through Part A claims. MDS version 2.0 and the Residential History File algorithm were used to identify Medicare beneficiaries who resided in a NH for the long term (≥90 consecutive days).[4, 5] The study cohort was then divided into two mutually exclusive subpopulations: community-dwelling adults and long-stay NH residents.
Two-sample t-tests and chi-squared tests were used to compare the characteristics of those who resided in the community with the characteristics of those who resided in a NH. The period prevalences of glucose-lowering medication usage patterns were then calculated in each subpopulation. Exact (Clopper-Pearson) binomial 95% confidence intervals were calculated to facilitate comparisons of the pattern prevalences between and within the subpopulations.[6] The institutional review board of Brown University reviewed and approved this study.
Of 1,215,715 individuals, 1,119,874 (92.1%) were identified as community dwelling and 95,841 (7.9%) as long-stay NH residents. Mean age of the community-dwelling subpopulation was 75.4, 56.9% were female, and 36.8% had been hospitalized during the study period. Mean age of the NH subpopulation was 82.3, 68.8% were female, and 76.6% had been hospitalized (P < .001 for all). All examined comorbidities were more prevalent in the NH than the community subpopulation, including coronary artery disease (53.6% vs 34.9%), heart failure (57.5% vs 21.8%), hypertension (87.6% vs 67.4%), depression (47.4% vs 12.0%), and dementia (68.8% vs 9.9%) (P < .001 for all comparisons).
In the community-dwelling population, 42.7% (95% confidence interval (CI) = 42.6–42.8%) were dispensed a single class of glucose-lowering medication during the study period. The prevalence of single class use was lower in the NH (28.2%, 95% CI = 27.9–28.5). Most NH residents (71.8%) were dispensed medications from two or more classes, 41.6% were dispensed three or more, and 19.9% four or more. Of community-dwelling adults, 57.3% were dispensed two or more medication classes, 25.6% three or more, and 9.6% four or more (P < .001 vs NH subpopulation). The 20 most-prevalent glucose-lowering medication use patterns (Table 1) accounted for a large proportion of all observed patterns. In the community, the five most-common patterns of medication class use were oral therapies. In the NH, three of the five most-common patterns involved parenterally administered drug classes. Biguanides (metformin) and sulfonylureas were commonly used in the community and NH, but use was greater in the community (P < .001).
The complexity of glucose-lowering medications is greater in NH than community-dwelling populations, with substantial differences in the prevalence of various drug combinations between the two cohorts. In combination with existing evidence, these results suggest that continued efforts are warranted to improve glucose-lowering medication management and simplify treatment regimens in the NH.[7] They also suggest that the relative importance of CER questions regarding specific glucose-lowering treatments may differ according to care setting.[8] The data further indicate that CER studies of glucose-lowering treatments in older adults must address the combination use of medications, especially in NH residents.[9, 10]
To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment.
MEASUREMENTS:
Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses.
RESULTS:
Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic.
CONCLUSION:
Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.
Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.
OBJECTIVE:
To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.
DESIGN, SETTING, AND PARTICIPANTS:
This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.
MAIN OUTCOMES AND MEASURES:
Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.
RESULTS:
The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new β-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of β-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of β-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, β-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from β-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to β-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of β-blockers were similar across all subgroups.
CONCLUSIONS AND RELEVANCE:
Use of β-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of β-blockers yielded a considerable mortality benefit in all groups.
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
MEASUREMENTS:
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
RESULTS:
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
CONCLUSION:
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
METHODS: We assembled 2 retrospective cohorts of mechanically ventilated neurocritical care patients. In the preintervention cohort from July 1, 2011, to December 31, 2011, probiotics were not used. In the postintervention group from July 1, 2012, to December 31, 2012, 1 g of a combination of Lactobacillus acidophilus and Lactobacillus helveticus was administered twice daily to all patients who were mechanically ventilated for more than 24 hours.
RESULTS: There were a total of 167 patients included, 80 patients in the preintervention group and 87 patients in the postintervention group. No patients in the preintervention group received probiotics. Eighty-five (98%) patients in the postintervention group received probiotics for a median of 10 days (interquartile range, 4-20 days). There were 14 (18%) HAIs in the preintervention group and 8 (9%) HAIs in the postintervention group (P = .17). Ventilator days, lengths of stay, in-hospital mortality, and discharge disposition were similar between the pre- and postintervention groups. There were no cases of Lactobacillus bacteremia or other adverse events associated with probiotics use.
CONCLUSION: Probiotics are safe to administer in neurocritical care patients; however, this study failed to demonstrate a significant decrease in HAIs or secondary outcomes associated with probiotics.
SUMMARY: Patients enrolled in the program were provided with a computer-enabled blood pressure monitor. A dedicated renal transplantation pharmacist was integrated into the renal transplantation team under a collaborative care practice agreement. The collaborative care agreement allowed the pharmacist to authorize medication additions, deletions, and dosage changes. Comprehensive disease and blood pressure education was provided by a clinical pharmacist. In the pretransplantation setting, the pharmacist interviewed the renal transplant candidate and documents allergies, verified the patient's medication profile, and identified and assessed barriers to medication adherence. A total of 50 renal transplant recipients with at least one recorded home blood pressure reading and at least one year of follow-up were included in our analysis. A significant reduction in mean systolic and diastolic blood pressure values were observed at 30, 90, 180, and 360 days after enrollment in the program (p < 0.05). Pharmacist interventions were documented for 37 patients. Medication-related problems accounted for 46% of these interventions and included dosage modifications, regimen changes, and mitigation of barriers to medication access and adherence.
CONCLUSION: Implementation of electronic HBPM and pharmacist-provided MTM services implemented in a renal transplant clinic was associated with sustained improvements in blood pressure control. Incorporation of a pharmacist in the renal transplant clinic resulted in the detection and resolution of medication-related problems.
Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents.
DESIGN AND SETTING:
Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs.
PARTICIPANTS:
A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse.
MEASUREMENTS:
Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation.
RESULTS:
We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3).
CONCLUSIONS:
Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.
This letter describes and juxtaposes common glucose-lowering medication usage patterns for a national cross-section of U.S. adults aged 65 and older residing in NH and community settings between January 1, 2007, and December 31, 2010. A random 20% national sample of Medicare fee-for-service beneficiaries with Parts A, B, and D claims linked to the Minimum Data Set (MDS), a federally mandated NH health assessment tool, was used. Individuals could have Medicare insurance coverage for any duration. All beneficiaries had at least one dispensing of a glucose-lowering treatment during the study period.
Prevalent glucose-lowering medication use was assessed using Part D data. Medication use patterns were mutually exclusive and defined without regard to the time sequence of the dispensings. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes from Part B claims during the study period were used to ascertain the prevalence of comorbidities and geriatric conditions. Hospitalizations during the study period were identified through Part A claims. MDS version 2.0 and the Residential History File algorithm were used to identify Medicare beneficiaries who resided in a NH for the long term (≥90 consecutive days).[4, 5] The study cohort was then divided into two mutually exclusive subpopulations: community-dwelling adults and long-stay NH residents.
Two-sample t-tests and chi-squared tests were used to compare the characteristics of those who resided in the community with the characteristics of those who resided in a NH. The period prevalences of glucose-lowering medication usage patterns were then calculated in each subpopulation. Exact (Clopper-Pearson) binomial 95% confidence intervals were calculated to facilitate comparisons of the pattern prevalences between and within the subpopulations.[6] The institutional review board of Brown University reviewed and approved this study.
Of 1,215,715 individuals, 1,119,874 (92.1%) were identified as community dwelling and 95,841 (7.9%) as long-stay NH residents. Mean age of the community-dwelling subpopulation was 75.4, 56.9% were female, and 36.8% had been hospitalized during the study period. Mean age of the NH subpopulation was 82.3, 68.8% were female, and 76.6% had been hospitalized (P < .001 for all). All examined comorbidities were more prevalent in the NH than the community subpopulation, including coronary artery disease (53.6% vs 34.9%), heart failure (57.5% vs 21.8%), hypertension (87.6% vs 67.4%), depression (47.4% vs 12.0%), and dementia (68.8% vs 9.9%) (P < .001 for all comparisons).
In the community-dwelling population, 42.7% (95% confidence interval (CI) = 42.6–42.8%) were dispensed a single class of glucose-lowering medication during the study period. The prevalence of single class use was lower in the NH (28.2%, 95% CI = 27.9–28.5). Most NH residents (71.8%) were dispensed medications from two or more classes, 41.6% were dispensed three or more, and 19.9% four or more. Of community-dwelling adults, 57.3% were dispensed two or more medication classes, 25.6% three or more, and 9.6% four or more (P < .001 vs NH subpopulation). The 20 most-prevalent glucose-lowering medication use patterns (Table 1) accounted for a large proportion of all observed patterns. In the community, the five most-common patterns of medication class use were oral therapies. In the NH, three of the five most-common patterns involved parenterally administered drug classes. Biguanides (metformin) and sulfonylureas were commonly used in the community and NH, but use was greater in the community (P < .001).
The complexity of glucose-lowering medications is greater in NH than community-dwelling populations, with substantial differences in the prevalence of various drug combinations between the two cohorts. In combination with existing evidence, these results suggest that continued efforts are warranted to improve glucose-lowering medication management and simplify treatment regimens in the NH.[7] They also suggest that the relative importance of CER questions regarding specific glucose-lowering treatments may differ according to care setting.[8] The data further indicate that CER studies of glucose-lowering treatments in older adults must address the combination use of medications, especially in NH residents.[9, 10]
To quantify prescription analgesic use of elderly nursing home (NH) residents with persistent noncancer pain and to identify individual and facility traits associated with no treatment.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
Individuals aged 65 and older with persistent noncancer pain were identified from a cross-section of all long-stay U.S. NH residents with an MDS assessment and Medicare Part D enrollment in 2008, excluding those who were terminally ill, those with Alzheimer's disease, and those with the most-severe cognitive impairment.
MEASUREMENTS:
Residents with moderate to severe daily pain on consecutive assessments at least 90 days apart constituted the cohort with persistent pain. Part D dispensing for an opioid or nonsteroidal anti-inflammatory drug (NSAID) within 30 days of persistent pain onset was identified. Information on resident and facility characteristics was obtained from MDS and OSCAR records. Associations between resident and facility attributes and pain treatment were estimated using multilevel mixed-effects logistic regression analyses.
RESULTS:
Of the study sample of 18,526 residents with persistent pain, 3,094 (16.7%) did not receive prescription analgesics, 12,815 (69.2%) received a prescription opioid, 485 (2.6%) received a prescription NSAID, and 2,132 (11.5%) received a prescription opioid and NSAID. After adjusting for potentially confounding covariates, residents who were older (≥95, odds ratio (OR) = 2.06, 95% confidence interval (CI) = 1.70-2.49), more cognitively impaired (moderately severe cognitive impairment, OR = 2.12, 95% CI = 1.71-2.62), or black (OR = 1.20, 95% CI = 1.03-1.39) or Asian (OR = 1.97, 95% CI = 1.22-3.20) were less likely to receive a prescription analgesic.
CONCLUSION:
Through 2008, pain remained undertreated in NHs, especially in certain subpopulations, including cognitively impaired and older residents. Changes in pain management practice and policies may be necessary to target these vulnerable residents.
Although β-blockers are a mainstay of treatment after acute myocardial infarction (AMI), these medications are commonly not prescribed for older nursing home residents after AMI, in part owing to concerns about potential functional harms and uncertainty of benefit.
OBJECTIVE:
To study the association of β-blockers after AMI with functional decline, mortality, and rehospitalization among long-stay nursing home residents 65 years or older.
DESIGN, SETTING, AND PARTICIPANTS:
This cohort study of nursing home residents with AMI from May 1, 2007, to March 31, 2010, used national data from the Minimum Data Set, version 2.0, and Medicare Parts A and D. Individuals with β-blocker use before AMI were excluded. Propensity score-based methods were used to compare outcomes in people who did vs did not initiate β-blocker therapy after AMI hospitalization.
MAIN OUTCOMES AND MEASURES:
Functional decline, death, and rehospitalization in the first 90 days after AMI. Functional status was measured using the Morris scale of independence in activities of daily living.
RESULTS:
The initial cohort of 15 720 patients (11 140 women [70.9%] and 4580 men [29.1%]; mean [SD] age, 83 [8] years) included 8953 new β-blocker users and 6767 nonusers. The propensity-matched cohort included 5496 new users of β-blockers and an equal number of nonusers for a total cohort of 10 992 participants (7788 women [70.9%]; 3204 men [29.1%]; mean [SD] age, 84 [8] years). Users of β-blockers were more likely than nonusers to experience functional decline (odds ratio [OR], 1.14; 95% CI, 1.02-1.28), with a number needed to harm of 52 (95% CI, 32-141). Conversely, β-blocker users were less likely than nonusers to die (hazard ratio [HR], 0.74; 95% CI, 0.67-0.83) and had similar rates of rehospitalization (HR, 1.06; 95% CI, 0.98-1.14). Nursing home residents with moderate or severe cognitive impairment or severe functional dependency were particularly likely to experience functional decline from β-blockers (OR, 1.34; 95% CI, 1.11-1.61 and OR, 1.32; 95% CI, 1.10-1.59, respectively). In contrast, little evidence of functional decline due to β-blockers was found in participants with intact cognition or mild dementia (OR, 1.03; 95% CI, 0.89-1.20; P = .03 for effect modification) or in those in the best (OR, 0.99; 95% CI, 0.77-1.26) and intermediate (OR, 1.05; 95% CI, 0.86-1.27) tertiles of functional independence (P = .06 for effect modification). Mortality benefits of β-blockers were similar across all subgroups.
CONCLUSIONS AND RELEVANCE:
Use of β-blockers after AMI is associated with functional decline in older nursing home residents with substantial cognitive or functional impairment, but not in those with relatively preserved mental and functional abilities. Use of β-blockers yielded a considerable mortality benefit in all groups.
We quantified transdermal fentanyl prescribing in elderly nursing home residents without prior opioid use or persistent pain, and the association of individual and facility traits with opioid-naïve prescribing.
DESIGN:
Cross-sectional study.
SETTING:
Linked Minimum Data Set (MDS) assessments; Online Survey, Certification and Reporting (OSCAR) records; and Medicare Part D claims.
PARTICIPANTS:
From a cross-section of all long-stay US nursing home residents in 2008 with an MDS assessment and Medicare Part D enrollment, we identified individuals (≥65 years old) who initiated transdermal fentanyl, excluding those with Alzheimer disease, severe cognitive impairment, cancer, or receipt of hospice care.
MEASUREMENTS:
We used Medicare Part D to select beneficiaries initiating transdermal fentanyl in 2008 and determined whether they were "opioid-naïve," defined as no opioid dispensing during the previous 60 days. We obtained resident and facility characteristics from MDS and OSCAR records and defined persistent pain as moderate-to-severe, daily pain on consecutive MDS assessments at least 90 days apart. We estimated associations of patient and facility attributes and opioid-naïve fentanyl initiation using multilevel mixed effects logistic regression modeling.
RESULTS:
Among 17,052 residents initiating transdermal fentanyl, 6190 (36.3%) were opioid-naïve and 15,659 (91.8%) did not have persistent pain. In the regression analysis with adjustments, residents who were older (ages ≥95 odds ratio [OR] 1.69, 95% confidence interval [CI] 1.46-1.95) or more cognitively impaired (moderate-to-severe cognitive impairment, OR 1.99, 95% CI 1.73-2.29) were more likely to initiate transdermal fentanyl without prior opioid use.
CONCLUSION:
Most nursing home residents initiating transdermal fentanyl did not have persistent pain and many were opioid-naïve. Changes in prescribing practices may be necessary to ensure Food and Drug Administration warnings are followed, particularly for vulnerable subgroups, such as the cognitively impaired.
METHODS: We assembled 2 retrospective cohorts of mechanically ventilated neurocritical care patients. In the preintervention cohort from July 1, 2011, to December 31, 2011, probiotics were not used. In the postintervention group from July 1, 2012, to December 31, 2012, 1 g of a combination of Lactobacillus acidophilus and Lactobacillus helveticus was administered twice daily to all patients who were mechanically ventilated for more than 24 hours.
RESULTS: There were a total of 167 patients included, 80 patients in the preintervention group and 87 patients in the postintervention group. No patients in the preintervention group received probiotics. Eighty-five (98%) patients in the postintervention group received probiotics for a median of 10 days (interquartile range, 4-20 days). There were 14 (18%) HAIs in the preintervention group and 8 (9%) HAIs in the postintervention group (P = .17). Ventilator days, lengths of stay, in-hospital mortality, and discharge disposition were similar between the pre- and postintervention groups. There were no cases of Lactobacillus bacteremia or other adverse events associated with probiotics use.
CONCLUSION: Probiotics are safe to administer in neurocritical care patients; however, this study failed to demonstrate a significant decrease in HAIs or secondary outcomes associated with probiotics.
SUMMARY: Patients enrolled in the program were provided with a computer-enabled blood pressure monitor. A dedicated renal transplantation pharmacist was integrated into the renal transplantation team under a collaborative care practice agreement. The collaborative care agreement allowed the pharmacist to authorize medication additions, deletions, and dosage changes. Comprehensive disease and blood pressure education was provided by a clinical pharmacist. In the pretransplantation setting, the pharmacist interviewed the renal transplant candidate and documents allergies, verified the patient's medication profile, and identified and assessed barriers to medication adherence. A total of 50 renal transplant recipients with at least one recorded home blood pressure reading and at least one year of follow-up were included in our analysis. A significant reduction in mean systolic and diastolic blood pressure values were observed at 30, 90, 180, and 360 days after enrollment in the program (p < 0.05). Pharmacist interventions were documented for 37 patients. Medication-related problems accounted for 46% of these interventions and included dosage modifications, regimen changes, and mitigation of barriers to medication access and adherence.
CONCLUSION: Implementation of electronic HBPM and pharmacist-provided MTM services implemented in a renal transplant clinic was associated with sustained improvements in blood pressure control. Incorporation of a pharmacist in the renal transplant clinic resulted in the detection and resolution of medication-related problems.