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Prescriber and pharmacist attitudes toward inclusion of diagnosis or clinical indication on prescription orders
No full textBackground: Pharmacy and medication safety organizations have long recommended that diagnosis or clinical indication be required on medication orders to improve the safety and effectiveness of care. Objective: To assess attitudes of Arizona prescribers and pharmacists toward the inclusion of the clinical indication or the diagnosis on prescription orders and perceived barriers to its implementation in Arizona. Methods: Data were obtained by questionnaires from pharmacists and primary care prescribers after a continuing pharmacy education presentation on the value of including a clinical indication or a diagnosis on prescription orders. The survey was distributed to licensed pharmacists who attended the Arizona Pharmacy Association\u27s Southwest Clinical Pharmacy Seminar. The survey was distributed to primary care providers with active Arizona licenses who attended the Arizona Osteopathic Medical Association Annual Convention and to nurse practitioners after an Arizona Nurse Practitioner Council educational webinar. Prescriber and pharmacist responses were compared using the Mann-Whitney U test. An a priori alpha of 0.05 was used, and in the cases of multiple comparisons, a Bonferroni correction was employed. Results: A total of 74 complete questionnaires were submitted by prescribers and 54 by pharmacists. Approximately 71% of the prescribers and 66% of the pharmacists agreed that they would support voluntary inclusion of a diagnosis or a clinical indication on prescription orders (P = 0.81). However, the 2 groups disagreed on whether the inclusion of the diagnosis or clinical indication should be a requirement (44% of prescribers agreed vs. 96% of pharmacists, P \u3c 0.001). Two perceived barriers revealed statistically significant differences, with the prescribers being more concerned about possible insurance rejections than pharmacists (P = 0.005, whereas the pharmacists were more concerned about potential software transmission accuracy than prescribers (P \u3c 0.001). Conclusion: Arizona prescribers and pharmacists in our convenience sample supported the voluntary inclusion of a diagnosis or a clinical indication on prescriptions orders but disagreed as to whether it should be required. Prescribers especially indicated they have a variety of concerns that need to be overcome before they could support a statewide mandate
Mediation of Coping Strategies among Patients with Advanced Cancer
No full textThe purpose of this study was to test the mediating effects of coping on relationships of psychological distress and stress with anxiety, depression, and quality of life. A cross-sectional and correlational research study was used to recruit a sample of 440 patients with advanced cancer in Indonesia. A bootstrap resampling procedure was used to test the significance of the total and specific indirect effects of coping. Data analysis showed that problem-focused coping (PFC) mediated relationships of psychological distress and stress on depression, anxiety and functional well-being. PFC also mediated the relationship between stress and social well-being. Emotional-focused coping (EFC) mediated the relationship of stress with physical and emotional well-being. EFC also mediated the relationships between psychological distress and physical well-being. Thus, proper assessments and interventions should be tailored and implemented for patients in order to facilitate their use of coping strategies when needed in stressful situations
Persistent opioid use and opioid-related harm after hospital admissions for surgery and trauma in New Zealand: A population-based cohort study
No full textIntroduction Opioid use has increased globally for the management of chronic non-cancer-related pain. There are concerns regarding the misuse of opioids leading to persistent opioid use and subsequent hospitalisation and deaths in developed countries. Hospital admissions related to surgery or trauma have been identified as contributing to the increasing opioid use internationally. There are minimal data on persistent opioid use and opioid-related harm in New Zealand (NZ), and how hospital admission for surgery or trauma contributes to this. We aim to describe rates and identify predictors of persistent opioid use among opioid-naïve individuals following hospital discharge for surgery or trauma. Methods and analysis This is a population-based, retrospective cohort study using linked data from national health administrative databases for opioid-naïve patients who have had surgery or trauma in NZ between January 2006 and December 2019. Linked data will be used to identify variables of interest including all types of hospital surgeries in NZ, all trauma hospital admissions, opioid dispensing, comorbidities and sociodemographic variables. The primary outcome of this study will be the prevalence of persistent opioid use. Secondary outcomes will include mortality, opioid-related harms and hospitalisation. We will compare the secondary outcomes between persistent and non-persistent opioid user groups. To compute rates, we will divide the total number of outcome events by total follow-up time. Multivariable logistic regression will be used to identify predictors of persistent opioid use. Multivariable Cox regression models will be used to estimate the risk of opioid-related harms and hospitalisation as well as all-cause mortality among the study cohort in a year following hospital discharge for surgery or trauma. Ethics and dissemination This study has been approved by the Auckland Health Research Ethics Committee (AHREC- AH1159). Results will be reported in accordance with the Reporting of studies Conducted using Observational Routinely collected health data statement (RECORD)
Adrenocorticotropic Hormone Stimulation Test
No full textThe adrenocorticotropic hormone (ACTH) stimulation test is a relatively noninvasive laboratory assessment that involves administration of a medication followed by the collection of blood samples. ACTH is a naturally occurring hormone released from the pituitary gland that stimulates the secretion of cortisol from the adrenal glands. Cortisol is a glucocorticoid that is responsible for the regulation of fat, carbohydrate, and protein metabolism. The test is extremely valuable, as it is safe and reliable in the diagnosis and assessment of adrenal insufficiency. Other names for this test include corticotropin or cosyntropin stimulation test, or short Synacthen test
HIV-Associated Neurocognitive Disorder (HAND): Relative Risk Factors
No full textThis chapter will address the issue of risk for HIV-associated neurocognitive disorder (HAND), focusing on HIV-associated dementia (HAD), among persons living with HIV in relationship to the risk for other dementias. Advances in effective antiretroviral therapy (ART) have led to an increase in the prevalence of older persons surviving with HIV – in addition to older persons who become infected by HIV later in life. Hence, HIV is no longer a disease of younger persons, and additional attention has been brought to bear against the plight of older persons living with HIV – not only as it pertains to treatment but also to prevention. The additional risk caused by aging among older persons living with HIV is complex to asses, and HIV infection is a research area that requires a robust approach to multiple other factors causing neurocognitive impairment with older age. The long-term and potentially neurotoxic exposure to ART and the deleterious consequences of chronic infection with HIV and its associated neuro-inflammation have been described for health. This aids in the understanding of dementia risk factors in this patient population, but the comorbidities (HIV- and non-HIV-associated) occurring among older persons living with HIV must also be addressed to properly assess the overall impact on dementia risk in this group. This need also warrants our examination of the risk factors for other dementias (and comorbid dementias) in persons living with HIV versus the general population through the assessment and quantification of modifiable and non-modifiable risk factors identified as major contributors toward dementia
A Mixed-Methods Exploration of the Developmental Trajectory of Autonomous Motivation in Graduate Medical Learners
No full textIntroduction: Self-determination theory (SDT), when applied to curricular construction, emphasizes curiosity, self-awareness, and resilience. Physicians need these qualities to face the challenges of clinical practice. SDT offers a lens for medical educators to track learner development toward sustainable, rewarding careers. This study describes the changes observed in learner communications about feelings of competence, relatedness, and autonomy across a 3-year family medicine training program designed to develop activated, lifelong learners. Methods: This retrospective, mixed-methods case study uses a phenomenological approach to explore how 51 learners described their experiences at various intervals in residency training. Data collected from 2009 to 2015 from resident focus groups, competency assessment meetings, and faculty assessment reports inform a 3-stage analysis process to determine learner motivation levels along the SDT continuum. Results: Aggregated qualitative and quantitative data show residents’ progression from introjection (controlled motivation) in PGY1, to identification (autonomous motivation) in PGY2, and integration (autonomous) by the end of PGY3. The examination of a single learner’s data set reveals an advanced motivation level in PGY1 (identification), followed by a period of retrograde in PGY2 (introjection), then rebounding in PGY3 (identification), which illustrates how motivation level can be affected by external competency requirements and challenges related to career transitions. Discussion: The examination of self-motivation in medical learners has implications for curriculum development, assessment, teaching and self-directed learning, and resilience training. Learner awareness of intrinsic motivation, and the curriculum designed around it, can better prepare residents for challenges during residency and help them flourish in twenty-first-century medicine
Patient-related factors associated with oral anticoagulation control: A population-based cohort study
No full textObjectives: Time in therapeutic range (TTR) of ≥70% is a commonly used indicator of optimal anticoagulation control. This study aimed to determine the patterns and predictors of anticoagulation control in a population-based cohort of new users of warfarin. Methods: This was a retrospective cohort study. All adults (age ≥18 years) who had been newly initiated on warfarin therapy between January 2006 and March 2011were selected from administrative health databases. TTR was calculated using the Rosendaal method. Multivariable logistic regression models were used to identify patient-related factors associated with optimal TTR. Predictors of patients spending \u3e30% of time above and below the therapeutic international normalised ratio (INR) range were also examined. Key findings: A total of 6032 patients were included in this study. The mean TTR was 54.1 ± 18.8%, and 82.3% of patients had subthreshold TTR (\u3c70%). Compared with New Zealand Europeans, MCrossed D signori and Pacific people had decreased odds of achieving optimal TTR and increased odds of spending \u3e30% of time below the therapeutic INR range. Patients aged 65-74 years and 75 years or older had increased odds of achieving optimal TTR but decreased odds of spending \u3e30% of time below the therapeutic INR range than those \u3c65 years. Compared with those living in the least socioeconomically deprived areas, those living in the most deprived areas had decreased odds of achieving optimal TTR. Conclusions: Anticoagulation control with warfarin is suboptimal in routine care in New Zealand. Age, ethnicity and deprivation index were significant predictors of TTR. It is important to ensure equitable access to appropriate, high-quality care for those living in deprived areas and those from ethnic minority groups
Order of discontinuation of glucose-lowering medications following bariatric surgery
No full textAims: To assess the order of glucose-lowering medication (GLM) discontinuation following bariatric surgery among patients taking ≥2 GLMs. Methods: Patients with diabetes mellitus taking ≥2 GLM classes who underwent bariatric surgery were identified using health claims data from the United States. The order of discontinuation was assessed in patients taking ≥2 GLM classes by comparing each GLM class to the other classes in aggregate. Descriptive statistics and Poisson regression were used to assess the order of discontinuation and changes in trends in the order of discontinuation. Results: Overall, 12,244 of 26,651 patients with type 2 diabetes who underwent bariatric surgery were taking ≥2 GLM classes. When each GLM class was assessed separately, fewer than 50% of patients had metformin, sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, glucosidase inhibitor, or insulin discontinued first when compared to the other classes in aggregate. Between 2008 and 2014, thiazolidinediones were increasingly more likely to be the first GLM discontinued (p = 0.0432). Slightly more than 50% of patients whose GLM regimen included a sulfonylurea discontinued the sulfonylurea first despite clinical recommendations. Conclusions: From a population level, there was no consistent approach in the order of discontinuation of GLM classes in patients following bariatric surgery
Evaluation of total body weight versus adjusted body weight liposomal amphotericin B dosing in obese patients
No full textLiposomal amphotericin B (LAmB) is used for various fungal infections, but it is unclear which dosing weight to use in obese patients. The purpose of this study was to compare clinical outcomes of adjusted body weight (adjBW) versus total body weight (TBW) dosing of LAmB. This single-center, retrospective cohort study included patients who received LAmB for definitive therapy and whose TBW exceeded 120% of their ideal body weight (IBW). Analyses were conducted for 3 mg/ kg for adjBW versus TBW and 5 mg/kg for adjBW versus TBW. A total of 238 patients were included. For the 68 patients who received LAmB at 3 mg/kg, there were no differences in safety or efficacy outcomes. For the 170 patients who received LAmB at 5 mg/kg, significantly more patients in the TBW group experienced the primary outcome of nephrotoxicity (57% versus 35% [P value of 0.016]) and had significantly higher rates of early discontinuation of LAmB due to toxicity (33% versus 17% [P = 0.030]). There was a trend toward increased 90-day mortality in the adjBW group (60% versus 45% [P = 0.079]); however, adjBW dosing was not associated with increased mortality in an adjusted model. Given the lower rates of nephrotoxicity but a possible trend toward increased mortality in patients whose TBW exceeds 120% of their IBW, dosing LAmB by adjBW may be reasonable in patients who are not critically ill and who have lower-risk infections. In critically ill patients or those with fungal pathogens or sites of infection associated with higher mortality risk, dosing by TBW can be considered
Racial Disparities in Readmissions Following Initial Hospitalization for Sepsis
No full textOBJECTIVES: To assess whether Black race is associated with a higher rate of all-cause readmission compared with White race following community-onset sepsis. DESIGN: Retrospective cohort study. SETTING: One-thousand three-hundred bed urban academic medical centers. PATIENTS: Three-thousand three-hundred ninety patients hospitalized with community-onset sepsis between January 1, 2010, and December 31, 2017. INTERVENTIONS: Community-onset sepsis was defined as patients admitted through the emergency department with an International Classification of Disease, ninth revision, Clinical Modification code for either severe sepsis (995.92) or septic shock (785.52). Beginning in 2015, we used International Classification of Disease, Tenth Revision, Clinical Modification codes R65.20 (severe sepsis) and R65.21 (septic shock). We excluded those individuals hospitalized at another acute care facility that were transferred to our facility. Race was abstracted electronically, and patients who expired or self-identified as a race other than Black or White race were excluded. Patients who experienced a subsequent hospitalization at our facility were considered to be readmitted. MEASUREMENTS AND MAIN RESULTS: Compared with White race, Black race demonstrated a significantly higher rate of all-cause readmission (60.8% vs 71.1%; p \u3c 0.001), including a higher rate of readmission for sepsis (14.0% vs 19.8%; p \u3c 0.001). Black patients also resided in zip codes with a lower median household income and were more likely to use public insurance compared with White race. Similar rates of comorbid diseases and disease burden were observed between the two groups, but vasopressors were less likely to be administered to Black patients. Multivariable analysis showed that Black race was associated with a 50% increased odds (odds ratio, 1.52, 99% CI, 1.25-1.84) in all-cause readmission risk compared with White race. CONCLUSIONS: Black race was associated with a higher rate of all-cause and sepsis readmission, possibly as a result of unaddressed health disparities, compared with White race. Programs addressing healthcare disparities should use readmission as another marker of equity