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Biomedical subjects

D B Christensen

Publications and source records attributed to D B Christensen.

At least 19 recordsLinked to original sources
PubMed1998

A randomized controlled trial of CQI teams and academic detailing: can they alter compliance with guidelines?

BACKGROUND: The availability of clinical guidelines in isolation has generally failed to promote voluntary change in practice patterns. Accordingly, a randomized controlled trial was conducted to determine the effectiveness of academic detailing (AD) techniques and continuous quality improvement (CQI) teams in increasing compliance with national guidelines for the primary care of hypertension and depression. METHODS: Fifteen small group practices at four Seattle primary care clinics were assigned to one of three study arms--AD alone, AD plus CQI teams, or usual care. The activity of 95 providers and 4,995 patients was monitored from August 1, 1993, through January 31, 1996. Twelve-month baseline and study periods were separated by a six-month "wash-in" period during which training sessions were held. Changes in hypertension prescribing, blood pressure control, depression recognition, use of older tricyclics, and scores on the Hopkins Symptom Checklist depression scale were examined. RESULTS: Clinics varied considerably in their implementation of both the AD and the CQI team interventions. Across all sites, AD was associated with change in a single process measure, a decline in the percentage of depressives prescribed first-generation tricyclics (-4.7 percentage points versus control, p = 0.04). No intervention effects were demonstrated for CQI teams across all sites for either disease condition. Within the clinic independently judged most successful at implementing both change strategies, the use of CQI teams and AD in combination did increase the percentage of hypertensives adequately controlled (17.3 percentage points versus control, p = 0.03). SUMMARY AND CONCLUSIONS: The AD techniques and the CQI teams evaluated were generally ineffective in improving guideline compliance and clinical outcomes regarding the primary care of hypertension and depression.

Adult↗
PubMed1998

A randomized controlled trial of a drug use review intervention for sedative hypnotic medications.

OBJECTIVES: Drug use review is used by both the public and private sector to influence prescribing behavior and patient drug use. Past interventions mailed to prescribers have had mixed results. The objective was to evaluate the effect of a one-time, mailed intervention on subsequent use of sedative hypnotic medication. METHODS: An experimental design was used. The intervention contained guidelines for the use of sedative hypnotics, a prescriber profile detailing sedative hypnotic prescribing, and a patient profile. Clustering of patients and their shared prescribers was done to avoid contamination bias and statistical problems associated with a lack of independence of observations. Subjects were 189 Washington State Medicaid recipients who had received at least one tablet per day of a sedative hypnotic medication for 1 year and their prescribing physicians or (when information about the physician was lacking) the dispensing pharmacy. RESULTS: A significant reduction in the use of targeted sedative hypnotic medications was measured in the intervention group (-27.6%) versus the control group (-8.5%). In the intervention group, 9.4% of patients began a new prescription for a benzodiazepine not targeted by the drug use review, whereas no control patients had new use of nontarget benzodiazepines. CONCLUSIONS: The intervention achieved a statistically significant decrease in targeted drug use, and the amount of reduction is likely to have decreased the risk of fractures associated with benzodiazepine use. This study adds to the recent evidence that mailed drug use review interventions can have a desirable impact on patient drug use.

Adult↗
PubMed1998

Alprazolam as an alternative to low-dose haloperidol in older, cognitively impaired nursing facility patients.

OBJECTIVES: To determine if alprazolam is equally as effective as low dose haloperidol in managing disruptive behavioral episodes associated with delirium, dementia, and amnesic and other cognitive disorders (formerly called organic mental syndromes). SETTING: Twenty-five community nursing homes in western Washington. PARTICIPANTS: Older nursing home residents (N = 48) receiving a low-dose neuroleptic for the treatment of agitation and behavioral disturbances. INTERVENTION: Randomized, double-blind, crossover trial of alprazolam and low dose haloperidol. Data were gathered at baseline and at the end of 6 and 12 weeks from direct observation and from clinical forms completed routinely by trained nurses. MEASUREMENTS: Number of behavioral episodes, activities of daily living as measured by the Blessed Dementia Scale, extrapyramidal symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS), and psychopathology as measured by the Clinical Global Impressions (CGI) and the Sandoz Clinical Assessment - Geriatric (SCAG) scales. RESULTS AND CONCLUSIONS: No significant differences were observed between patients using haloperidol or alprazolam in terms of behavioral episodes per week. Further, with few exceptions, no significant differences were found in other outcome scales. Essentially the same findings were found when analyses were repeated for subgroups of patients with high levels of cognitive impairment and for patients with low and high levels of recorded problematic behavioral episodes. Alprazolam was as effective as low dose haloperidol in this population.

Aged↗
PubMed1998

Principal findings from the Washington State cognitive services demonstration project.

In addition to dispensing, pharmacists are ideally positioned to provide cognitive services that are targeted at optimizing drug therapy through identification and resolution of drug therapy problems. The Washington Cognitive Activities and Reimbursement Effectiveness project sought to determine: (1) if pharmacists would respond to a financial incentive by performing more cognitive services, and (2) the effect on drug cost of cognitive services they performed.

Attitude of Health Personnel↗
PubMed1997

Assessing compliance to antihypertensive medications using computer-based pharmacy records.

Systematic approaches for compliance problem detection and intervention are needed if the benefits of prescribed drug therapy in chronic disease management are to be optimized. As with all measures of compliance, computer algorithms based on refill patterns have advantages and disadvantages. They are unobtrusive and easily determined, but they measure the timeliness of prescription refills, not actual drug-taking. Computer-generated algorithms for assessing compliance based on refill patterns should be used by practitioners with caution, because they are not only markers for potential drug taking compliance problems, but also for discrepancies between the medical chart, pharmacy records and verbal advice given to the patient. Because patients may obtain refills before depleting their supply, compliance rates using this methodology are best determined across several refills. In particular, we urge caution in applying them over time periods of less than 60 days. Longer minimum time periods further decrease the likelihood of "false positives" but limit the number of patients for whom a compliance measure can be computed. For the health professional (eg, the pharmacist) responsible for monitoring drug-taking compliance of patients, the message seems clear: when reviewing computer-generated noncompliance "flags," the first task is to fully explore the possibility of discrepancies in drug records before initiating compliance-related interventions.

Algorithms↗
PubMed1996

Conducting a randomized controlled trial of CQI and academic detailing to implement clinical guidelines.

BACKGROUND: A multisite, randomized controlled trial was conducted from August 1994 through January 1996 to compare the impact of two strategies-academic detailing (AD) and continuous quality improvement (CQI) teams-on the implementation of national guidelines for the primary care of hypertension and depression. STUDY: Twelve small groups of providers at four clinics-two at Group Health Cooperative of Puget Sound (Seattle) and two at academic medical centers-were randomized in blocks along with their primary care patients to receive AD alone, AD plus CQI, or usual care. A detailing session conducted by a physician and two follow-up sessions conducted by a pharmacist lasted an average of 8-9 minutes. Each CQI team, which met, on average, 14 times in nine months, devised at least one intervention (for example, weight loss counseling for hypertensives by nurse practitioners). RESULTS: The detailing endeavors differed greatly across organizations. Although all teams generally worked well together, organizational factors such as staff layoffs and reorganizations competed for the teams' attention. Team leaders differed in their ability to inspire members to "run with" ideas and to motivate personnel outside the team to implement interventions. SUMMARY AND CONCLUSIONS: Surveys and semi-structured interviews suggest that both the AD and CQI interventions involved complex social interactions that resulted in varied implementation across the different organizations. Final analyses will need to focus on identifying factors associated with the relative success or failure of both clinical change techniques.

Academic Medical Centers↗
PubMed1996

Understanding capitation and pharmaceutical care.

Although capitation has not yet emerged as the predominant mode of payment for health care, many experts believe that this will happen within a few years, and that capitation will predominate among methods to pay for pharmaceutical care services as well. Capitation is confusing because it exists in many forms. This article: Explains alternative forms of capitation for pharmaceutical care services. Offers some thoughts on what might be acceptable and not-so-acceptable forms from the perspective of the pharmacy manager.

Capitation Fee↗
PubMed1996

Satisfaction with prescriptive authority protocols.

OBJECTIVES: The use of prescriptive authority protocols by pharmacists and physicians in Washington was described as to: (1) types of decisions made, frequency of use, and nature of working arrangements among participants; (2) their perceived impact on professional practice and care rendered to patients; and (3) their satisfaction with the protocol arrangements. DESIGN: A mail survey of participants currently engaged in prescriptive authority was conducted. RESULTS: Responses were received from participants in 44 of 57 protocols. A total of 135 prescribers and 84 pharmacists responded. On average, 7 pharmacists and 27 prescribers were involved in each protocol, and had been involved for 6 years or more. It was estimated that approximately 10% of all active practitioners participated in protocols. Most protocols involved continuation of drug therapy or authorizing renewals. Modification of therapy (usually involving dosage or dose from changes) was practiced in two-thirds of the protocols, and initiation of therapy in about half of them. Most existed within managed care and group practice settings. Most prescribers (98%) and pharmacists (95%) were satisfied with protocol arrangements. Additionally, they generally agreed that the protocols increase patient convenience and increase the quality of patient care, and they encouraged their colleagues to use prescribing protocols. CONCLUSIONS: Protocol arrangements appear to be working well from the perspective of participants. Based on this experience, the authors encourage the development of similar protocol arrangements in other states.

Clinical Protocols↗
PubMed1996

Identification and clarification of drug therapy problems by Indian health service pharmacists.

OBJECTIVE: To describe drug therapy problem intervention activities of Indian Health Service (IHS) pharmacists and to characterize the types of drug therapy problems encountered. DESIGN: Longitudinal descriptive study of documented potential drug therapy problems detected by pharmacists during the conduct of routine dispensing activities during a 6-month period. SETTING: All 18 IHS hospitals and ambulatory care facilities in one geographic area. MAIN OUTCOME MEASURES: Potential drug therapy problem detection rates by pharmacists and problem detection rates per 100 dispensed prescriptions are reported. Problems are characterized as to type, nature of intervention activities undertaken, and results of interventions. Changes in problem detection rate across clinics and over time are reported. RESULTS: Pharmacists detected and reported problems at a rate of slightly less than one per 100 prescriptions dispensed; however, drug therapy changes occurred 78% of the time as a result of the interventions. The types of drug therapy problems occurring most frequently were incorrect information (40.7%), prescription clarification (39.6%), clinical problems (10.4%), and inappropriate drug (9.3%). Physician acceptance of pharmacist interventions varied by type of drug therapy problem. Drug therapy changes occurred 77.7% of the time as a result of the interventions. Pharmacists at several sites used records of the drug therapy problems to make changes in policy or procedures as a part of continuous quality improvement activities. As a result, the problem detection rate declined over time in several settings. CONCLUSIONS: In comparison with other settings where cognitive services have been reported, IHS pharmacists detected fewer problems, but their interventions resulted in a higher percentage of drug therapy changes.

Drug Prescriptions↗
PubMed1996

Pharmaceutical counseling and medication adherence monitoring: an essential component of any drug benefit program.

Prescription drugs are an essential component of any health benefit. This is hardly a controversial statement, yet it is only relatively recently that prescription drugs have been included as part of the benefits package available to most Americans. The United States has lagged behind most other industrialized countries in providing a drug benefit, and such a benefit is still lacking for one of the most needy segment of our society--the elderly.

Aged↗
PubMed1994

Comparison of prescription and medical records in reflecting patient antihypertensive drug therapy.

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n = 982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5-8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.

Antihypertensive Agents↗
PubMed1991

The Health of the Public Program at the University of Washington: a new role for academic medical centers.

The University of Washington Health of the Public Program has convened a consortium composed of the region's academic medical center, the two largest managed care plans in Washington, and representatives of the state's major private and public purchasers of health care. The consortium's purpose is to test the feasibility of collaboratively collecting cross-system data, assessing variations in practice, and implementing site-specific interventions to improve the management of common illnesses and encourage preventive care. Changes under way in the ambulatory training environment and in the undergraduate curriculum as a result of the consortium's initial efforts are described. In today's climate of cost consciousness and concerns about quality, academic medical centers can play an important role in helping to improve community-wide outcomes of care.

Academic Medical Centers↗
PubMed1990

Medical and psychosocial factors predictive of psychotropic drug use in elderly patients.

The purpose of this study was to investigate medical and psychosocial factors that may be used to identify patients at risk of psychotropic drug use. Population-based surveys were completed by 278 elderly health maintenance organization (HMO) patients in August 1984. Physical and mental health status and social support were measured in the survey. Automated prescription records from the year prior to and the year after the survey were linked to data from the survey. Patients received 737 prescriptions for psychotropic drugs during the two-year period under study. Doxepin (20.2 percent), flurazepam (15.2 percent), and diazepam (14.8 percent) were dispensed most frequently. Nearly 30 percent of the patients received a prescription for at least one psychotropic drug during the two-year period, and 14 percent received at least one prescription during both years. Three significant predictors of subsequent psychotropic drug use were: prior use (odds ratio = 17.2, 95% CI = 6.25, 47.33), the number of physical impairments (OR = 1.73, 95% CI = 1.05, 2.84), and the respondent's rating on the Alameda Health Scale (OR = 1.65, 95% CI = 0.99, 2.75). Patients' self-reported mental health status and sociodemographic characteristics were not significant predictors of subsequent use.

Age Factors↗
PubMed1990

Prospective comparison of patient tolerance to enteric-coated vs nonenteric-coated erythromycin.

Erythromycin base and its salts are frequently used in clinical practice. The most frequent side effects of oral erythromycin preparations are gastrointestinal. Various salts and enteric coatings have been developed without adequate comparison in regard to gastrointestinal side effects. The overall incidence of gastrointestinal side effects (abdominal pain and cramps, nausea, vomiting, diarrhea, and gas) of two common erythromycin base formulations, Erythromycin Base Filmtab (Abbott), a nonenteric-coated base tablet, and Eryc (Parke-Davis), a pelletized, encapsulated, enteric-coated base capsule, were compared in 368 adults at two dosage levels (1 g/d and 2 g/d). Minimal differences were found when target symptoms were compared by preparation coating. In contrast, subjects receiving erythromycin at the 2-g/d dosage level reported higher incidence rates for each of the target symptoms, regardless of product coating, than did those patients treated at the 1-g/d dosage level. Enteric coating of erythromycin base offers little protection from the common dose-related gastrointestinal adverse effects of oral erythromycin.

Administration, Oral↗
PubMed1989

Use and misuse of metered-dose inhalers by patients with chronic lung disease. A controlled, randomized trial of two instruction methods.

Metered-dose inhalers are often used incorrectly by patients with chronic airflow obstruction, and there is a lack of controlled studies designed to evaluate methods to teach the correct use of these devices. Therefore, we screened 100 consecutive stable outpatients for correct or incorrect inhaler use and then conducted a randomized trial of two methods to teach correct use. Patients were classified as correct or incorrect users with a modified metered-dose inhaler containing a thermistor that detected inspiration, inhaler activation, and the duration of breath-holding. Patients were classified as incorrect users if they failed to: (1) activate the inhaler once during inspiration, and/or (2) hold their breath at the end of inspiration. There were 38 correct users and 62 incorrect users. Incorrect users were randomized to one of two teaching protocols: (1) standardized verbal instruction alone, or (2) standardized verbal instruction plus an automatic visual signal during inspiration. Incorrect users were restudied 6 to 10 wk later to reassess technique. Both treatment protocols were equally effective in converting incorrect user. However, the verbal instruction alone required significantly less time than the instruction with the mechanical aid. For all subjects, the proportion using correct technique declined over time, particularly for incorrect users. We also examined a series of patient characteristics, obtained by questionnaire and spirometry, to determine whether they could be used in the clinical setting to identify incorrect users. By discriminant analysis, a group of four variables predicted correct metered-dose inhaler use: bronchodilator responsiveness, a history of additional about proper technique, verbal knowledge of the correct inhaler maneuvers, and the patient's perception of whether it is important to use an inhaler.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

A psychosocial perspective in the explanation of patients' drug-taking behavior.

The goal of this study was to examine the applicability of the Health Belief (HBM) and Theory of Reasoned Action (TRA) models in predicting drug-taking compliance behavior among female patients with uncomplicated urinary tract infections. Thirty-eight percent of the respondents were compliant, 25% finished all of their medication, but missed one or more doses during the course of therapy, and 37% did not finish all of their medication as directed. Two HBM and three TRA variables had a statistically significant relationship with compliance: barriers and benefits (HBM) and belief strength, outcome evaluation, and behavioral intention (TRA). HBM variables explained 10% of the variance in the compliance variable. Adding the TRA variables to the model explained an additional 19% of the variance. Social influence variables (normative expectations, motivation to comply, and subjective norms) had a significant influence in the prediction of behavioral intention, but not in the prediction of compliance behavior. Suggestions for improving compliance based on these findings include: simplification of drug therapy by customizing and simplifying the regimen, continued patient reminders of the therapy's value, and benchmarks for patients to evaluate the success or failure of therapy. A frank and open discussion from the start of therapy about its complexity, the medication's side effects, time and fiscal constraints, and other factors which may modify patients' perception of the likelihood of compliance is an important key to improving patients' compliance behavior.

Adolescent↗