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Daniel H Solomon

Publications and source records attributed to Daniel H Solomon.

At least 55 records · Page 3Linked to original sources
PubMed2005

Older adults' knowledge and beliefs about osteoporosis: results of semistructured interviews used for the development of educational materials.

OBJECTIVE: Although osteoporosis and associated fractures have been recognized as a significant public health problem, underdiagnosis and undertreatment are common. We investigated older adults' knowledge and beliefs regarding osteoporosis and its prevention, in order to develop effective osteoporosis health education messages and materials. These messages will be used as part of a trial that will test the efficacy of both public and doctor education to improve osteoporosis management. METHODS: We conducted semistructured one-on-one interviews with 15 older adult volunteers. A standard interview guide was developed and used for all interviews, which were audiotaped and transcribed. Key themes were extrapolated by 3 study staff using data abstraction forms. The data forms were then compared for consistency. RESULTS: We found that the term "osteoporosis" was well recognized, but many participants had only a fragmented understanding of its meaning. All participants identified osteoporosis as a serious condition, but many did not perceive themselves to be at personal risk for developing the condition. Many participants were confused about the difference between osteoporosis and osteoarthritis. Participants expressed reservations about taking prescription medications because of concerns over cost, side effects, and interactions with their current medications. CONCLUSION: Osteoporosis awareness is high, but the older adults interviewed had an incomplete understanding of the condition. This could hinder efforts to improve prevention and treatment of osteoporosis.

Aged↗
PubMed2005

Performance of a rheumatoid arthritis records-based index of severity.

OBJECTIVE: To assess the performance of a rheumatoid arthritis (RA) records-based index of severity (RARBIS) developed by a Delphi panel process in a cohort of patients with RA. METHODS: We reviewed the medical records of 120 RA patients from the New England Veteran's Administration (VA) Healthcare System and collected data on markers of RA disease severity. Markers were refined through a Delphi panel process before developing the RARBIS based on chart review. The RARBIS includes 5 subscales on surgery, radiography, extraarticular manifestations, clinical status, and laboratory values. Factors that were regarded by the Delphi panel as highly related to severity of RA were assigned higher points on the index. We assessed the validity of the RARBIS by comparing it to the intensity of the actual RA treatment that these patients received: low, neither biologic nor disease modifying antirheumatic drug (DMARD) use; moderate, therapy with DMARD such as hydroxychloroquine, gold, or sulfasalazine; high, treatment with stronger DMARD such as methotrexate, azathioprine, leflunomide, and cyclosporine; and very high, use of any biologics. RESULTS: The RARBIS had a range of 0 to 8. All subscales except extraarticular manifestations were statistically significantly related to intensity of RA treatment (chi-square test p <or= 0.015); the overall index was linearly correlated with intensity of RA treatment (r = 0.35, 95% CI 0.18-0.55). After adjusting for age and sex in a linear regression, the RARBIS was found to be an independent predictor of intensity of treatment (beta for 1-point increase in score = 0.16, p = 0.002). CONCLUSION: A medical records-based index of RA severity was developed with attention to face and criterion validity that correlated moderately with RA treatment intensity (construct validity) in a VA population. Further tests of the RARBIS are recommended before it can be used as a tool to adjust for RA disease severity in performing epidemiologic studies on the safety of drugs.

Activities of Daily Living↗
PubMed2004

Adherence with osteoporosis practice guidelines: a multilevel analysis of patient, physician, and practice setting characteristics.

PURPOSE: The diagnosis and treatment of patients at risk of fragility fractures is uncommon. We examined the patient, physician, and practice characteristics associated with adherence to local osteoporosis guidelines. METHODS: Data were obtained from electronic medical records from one academic medical center. Local guidelines suggest screening and consideration of treatment for at-risk patients, including women aged > or =65 years, women aged 50 to 64 years who smoke cigarettes, persons who used more than 5 mg of oral prednisone for >3 months, and those with a history of a fracture after age 45 years. Clinical notes, medication lists, and radiology records were reviewed to determine whether patients had undergone bone mineral density testing or received any medications for osteoporosis. Possible correlates of guideline adherence, including patient, physician, and practice site characteristics, were assessed in mixed multivariable models. RESULTS: We identified 6311 at-risk patients seen by 160 doctors at 10 primary care sites during 2001 to 2002. Of these patients, 45% (n = 2820) had a prior bone mineral density test and 30% (n = 1922) had received a medication for osteoporosis; 54% (n = 3401) had one or the other. After adjusting for patient case mix, 17% to 71% of patients had been managed according to local guidelines and had undergone at least bone mineral density testing or received a medication. Patient variables that significantly lowered the probability of guideline adherence included age >74 years (odds ratio [OR] = 0.49; 95% confidence interval [CI]: 0.43 to 0.55), age <55 years (OR = 0.34; 95% CI: 0.28 to 0.42), male sex (OR = 0.17; 95% CI: 0.12 to 0.23), black race (OR = 0.40; 95% CI: 0.34 to 0.47), and having more than one comorbid condition (OR = 0.79; 95% CI: 0.69 to 0.89). Patients seen by male physicians were less likely to have care that was adherent with guidelines (OR = 0.70; 95% CI: 0.55 to 0.89). CONCLUSION: Rates of adherence with local osteoporosis guidelines for patients at risk of fragility fractures vary by patient, physician, and practice site characteristic.

Aged↗
PubMed2004

Medicaid prior-authorization programs and the use of cyclooxygenase-2 inhibitors.

BACKGROUND: Over the past five years, selective cyclooxygenase-2 inhibitors (coxibs) have accounted for a growing proportion of prescriptions for nonsteroidal antiinflammatory drugs (NSAIDs). To control these expenses, many state Medicaid programs have implemented prior-authorization requirements before coxibs can be prescribed. We evaluated the effect of such programs on the use of coxibs by Medicaid beneficiaries. METHODS: We surveyed state Medicaid agencies to determine whether prescription of coxibs required prior authorization and, if so, the criteria for authorization. For each program, we compared these criteria with evidence-based recommendations for prescribing of coxibs. Using data for all filled prescriptions in 50 state Medicaid programs from 1999 through the end of 2003, we calculated the proportion of defined daily doses of NSAIDs accounted for by coxibs. Time-series analyses were used to measure the changes in prescription patterns after the implementation of each prior-authorization program. RESULTS: By 2001, coxibs accounted for half of all NSAID doses covered by Medicaid. This proportion varied widely according to the state in 2003, from a low of 11 percent to a high of 70 percent of all NSAID doses. Twenty-two states implemented prior-authorization programs for coxibs during the study period. Overall, the implementation of such programs reduced the proportion of NSAID doses made up by coxibs by 15.0 percent (95 percent confidence interval, 10.9 to 19.2 percent), corresponding to a decrease of 10.28 dollars (95 percent confidence interval, 7.56 dollars to 13.00 dollars) in spending per NSAID prescription. The effect of such programs was not influenced by the degree to which a prior-authorization program incorporated evidence-based prescribing recommendations. CONCLUSIONS: The use of coxibs and spending on NSAIDs varies widely by state and declined substantially after the implementation of prior-authorization programs. Determining whether these reductions are clinically appropriate will have important implications for the development of rational drug-reimbursement policies.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

Relationship between COX-2 specific inhibitors and hypertension.

There is controversy whether cyclooxygenase-2 (COX-2) specific inhibitors are associated with elevations in blood pressure requiring treatment in typical clinical practice. We examined the risk of new onset hypertension in a retrospective case-control study involving 17 844 subjects aged > or =65 years from 2 US states. Multivariable logistic models were examined to assess the relative risk of new onset hypertension requiring treatment in patients who used celecoxib or rofecoxib compared with patients taking either the other COX-2 specific inhibitor, a nonspecific NSAID, or no NSAID. During the 1999 to 2000 study period, 3915 patients were diagnosed and began treatment for hypertension; 4 controls were selected for every case. In no model was celecoxib significantly associated with the development of hypertension. Rofecoxib users were at a significantly increased relative risk of new onset hypertension compared with patients taking celecoxib (odds ratio [OR] 1.6; 95% confidence interval [CI], 1.2 to 2.1), taking a nonspecific NSAID (OR 1.4; 95% CI, 1.1 to 1.9), or taking no NSAID (OR 1.6; 95% CI, 1.3 to 2.0). There were no clear dosage or duration effects. In patients with a history of chronic renal disease, liver disease, or congestive heart failure, the relative risk of new onset hypertension was twice as high in those taking rofecoxib compared with celecoxib (OR 2.1; 95% CI, 1.0 to 4.3). In this retrospective case-control study of patients aged > or =65 years, rofecoxib use was associated with an increased relative risk of new onset hypertension; this was not seen in patients taking celecoxib.

Aged↗
PubMed2004

Multifaceted intervention to improve rheumatologists' management of glucocorticoid-induced osteoporosis: a randomized controlled trial.

OBJECTIVE: To assess the effectiveness of a multifaceted intervention to improve the management of glucocorticoid-induced osteoporosis (GIOP). METHODS: Of 21 rheumatologists, 11 were randomly assigned to a 3-part intervention consisting of a lecture and discussion regarding optimal management of GIOP, a confidential doctor-specific audit regarding management of GIOP, and a reminder mailing including concise pharmacologic recommendations. The remaining 10 rheumatologists received no special education. Patients with rheumatoid arthritis (RA) taking oral glucocorticoids seen in the 2 months after the intervention were followed for 6 months. Medical records were assessed to determine the proportion undergoing bone mineral density testing or receiving pharmacologic interventions for GIOP during the 6 months before and 6 months after the intervention. RESULTS: There were 373 patients with RA taking oral glucocorticoids whose records were assessed. Patients in both arms of the trial were similar with respect to age, sex, menopausal status, glucocorticoid dosage and duration, duration of RA, disease-modifying antirheumatic drug use, and the proportion with comorbid conditions. At baseline, there was no significant difference between the patients with respect to osteoporosis medication use (intervention 32% versus control 34%) or bone densitometry use (intervention 9% versus control 5%). After the intervention and a 6-month followup period, there were no differences in treatment (intervention 33% versus control 38%) or bone densitometry use (intervention 8% versus control 8%). Adjusting for patient and physician characteristics did not significantly change these results. CONCLUSION: A multifaceted intervention for GIOP, including doctor education, practice audit, and treatment suggestions, had no significant benefit on testing or treatment by rheumatologists over a 6-month followup period. Other intervention approaches need to be tested.

Education, Medical, Continuing↗
PubMed2004

Cardiovascular care and cancer screening in female nurses with and without rheumatoid arthritis.

OBJECTIVE: To compare frequencies of cancer screening and cardiovascular treatments aimed at reducing acute myocardial infarction in women with and without rheumatoid arthritis (RA). METHODS: Data from the prospective Nurses' Health Study were analyzed for the 491 women diagnosed with RA prior to 1998 and the 82,884 women without RA. Cardiovascular treatments included aspirin use, treatment with a cholesterol-lowering agent, cardiac catheterization, and coronary artery revascularization; cancer screening consisted of mammography and bimanual pelvic examinations. Adjustments were made for potential confounders using multivariate logistic regression. RESULTS: After adjusting for cardiovascular risk factors, use of nonsteroidal antiinflammatory drugs, and a history of gastric or duodenal ulcer, women with RA and no history of cardiac disease were 35% less likely to report taking aspirin regularly (odds ratio [OR] 0.65, 95% confidence interval [95% CI] 0.51-0.84). The use of cholesterol-lowering treatment, angiography, and revascularization was not statistically different in women with and without RA. After adjusting for cancer risk factors, there appeared to be an increased likelihood of mammography in women with RA compared with those without RA (OR 1.41, 95% CI 0.97-2.04), although this result was not statistically significant. Bimanual pelvic examination was reported with similar frequency between the 2 groups. CONCLUSION: Other than aspirin use, care to prevent acute myocardial infarction and cancer screening practices were similar among women with RA compared with women without RA.

Adult↗
PubMed2004

Relationship between selective cyclooxygenase-2 inhibitors and acute myocardial infarction in older adults.

BACKGROUND: Although cyclooxygenase-2 inhibitors (coxibs) were developed to cause less gastrointestinal hemorrhage than nonselective nonsteroidal antiinflammatory drugs (NSAIDs), there has been concern about their cardiovascular safety. We studied the relative risk of acute myocardial infarction (AMI) among users of celecoxib, rofecoxib, and NSAIDs in Medicare beneficiaries with a comprehensive drug benefit. METHODS AND RESULTS: We conducted a matched case-control study of 54 475 patients 65 years of age or older who received their medications through 2 state-sponsored pharmaceutical benefits programs in the United States. All healthcare use encounters were examined to identify hospitalizations for AMI. Each of the 10 895 cases of AMI was matched to 4 controls on the basis of age, gender, and the month of index date. We constructed matched logistic regression models including indicators for patient demographics, healthcare use, medication use, and cardiovascular risk factors to assess the relative risk of AMI in patients who used rofecoxib compared with persons taking no NSAID, taking celecoxib, or taking NSAIDs. Current use of rofecoxib was associated with an elevated relative risk of AMI compared with celecoxib (odds ratio [OR], 1.24; 95% CI, 1.05 to 1.46; P=0.011) and with no NSAID (OR, 1.14; 95% CI, 1.00 to 1.31; P=0.054). The adjusted relative risk of AMI was also elevated in dose-specific comparisons: rofecoxib < or =25 mg versus celecoxib < or =200 mg (OR, 1.21; 95% CI, 1.01 to 1.44; P=0.036) and rofecoxib >25 mg versus celecoxib >200 mg (OR, 1.70; 95% CI, 1.07 to 2.71; P=0.026). The adjusted relative risks of AMI associated with rofecoxib use of 1 to 30 days (OR, 1.40; 95% CI, 1.12 to 1.75; P=0.005) and 31 to 90 days (OR, 1.38; 95% CI, 1.11 to 1.72; P=0.003) were higher than >90 days (OR, 0.96; 95% CI, 0.72 to 1.25; P=0.8) compared with celecoxib use of similar duration. Celecoxib was not associated with an increased relative risk of AMI in these comparisons. CONCLUSIONS: In this study, current rofecoxib use was associated with an elevated relative risk of AMI compared with celecoxib use and no NSAID use. Dosages of rofecoxib >25 mg were associated with a higher risk than dosages < or =25 mg. The risk was elevated in the first 90 days of use but not thereafter.

Aged↗
PubMed2004

Measuring quality in arthritis care: methods for developing the Arthritis Foundation's quality indicator set.

OBJECTIVE: To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis, rheumatoid arthritis, and analgesics use. METHODS: Potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes were developed through a comprehensive literature review. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. Using a modification of the RAND/UCLA Appropriateness Method, the panel rated each proposed measure for its validity as a measure of health care quality. RESULTS: Among 66 proposed indicators, the expert panel rated 51 as valid measures of health care including 14 for osteoarthritis, 27 for rheumatoid arthritis, and 10 for analgesics use. CONCLUSIONS: Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis, rheumatoid arthritis, and analgesics use. These measures can be used to gain an understanding of the quality of care for patients with arthritis.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

Which patients with knee problems are likely to benefit from nonarthroplasty surgery? Development of a clinical prediction rule.

BACKGROUND: We examined factors associated with the clinical presentation of patients judged likely by orthopedic surgeons to benefit from nonarthroplasty knee surgery. METHODS: Consecutive patients presenting to orthopedic surgeons were eligible for the study and 103 were recruited. A trained research assistant took histories, performed physical examinations, and administered a standardized questionnaire. Surgeons provided diagnoses and, in each case, rated their confidence that nonarthroplasty knee surgery would help the patient. We assessed the relationship between patient characteristics and the orthopedic surgeon's level of confidence that the patient was likely to benefit from knee surgery. RESULTS: In multivariable logistic regression models, the following characteristics were associated with a surgeon's judgment that a patient would likely benefit from knee surgery: a history of sports-related trauma, low functional status, limited knee flexion or extension, medial or lateral knee joint line tenderness, a click or pain noted with the McMurray test, and a positive Lachmann or anterior drawer test (c statistic from model, 0.83). These items were combined into a clinical prediction score, and low-, medium-, and high-risk categories were identified. Independent evaluation by surgeons indicated that only 8% of patients in the low-risk category but 84% of patients in the high-risk category were judged likely to benefit from surgery (P for trend <.001). CONCLUSION: Using a small group of easily accessible patient characteristics, we developed a clinical prediction score that clearly differentiated patients who were viewed by experienced orthopedic knee surgeons as likely or not likely to benefit from nonarthroplasty knee surgery.

Adult↗
PubMed2004

Cardiovascular risk factors in women with and without rheumatoid arthritis.

OBJECTIVE: The risk of cardiovascular disease (CVD) is increased in patients with rheumatoid arthritis (RA). The objective of this study was to examine the distribution of known CVD risk factors and biomarkers of CVD in women with and without RA. METHODS: This study included two components: an examination of clinical CVD risk factors among women participating in the Nurses' Health Study, a prospective longitudinal cohort, and an analysis of CVD biomarkers among a subgroup of women from this cohort who provided a blood specimen in 1989 (biospecimen cohort). Data regarding clinical risk factors for CVD were collected in 1990 by mailed questionnaire. The diagnosis of RA was confirmed through a structured medical record abstraction. We compared clinical risk factors for CVD and biomarkers of CVD between women with and without RA, adjusting for age, body mass index (BMI), smoking status, and menopause status. RESULTS: Women with RA (n = 287) were significantly more likely than women without RA (n = 87,019) to report no alcohol use (48.2% versus 39.4%) and past cigarette smoking (47.8% versus 38.0%). No significant differences between these groups were observed for current smoker status, BMI, regular aspirin use, diabetes, hypertension, physical activity, and family history of early myocardial infarction. In the biospecimen cohort (69 RA cases and 491 controls), the levels of several inflammatory biomarkers linked to CVD were significantly elevated in women with RA, including CRP, fibrinogen, sICAM-1, sTNFRI, sTNFRII, and osteoprotegerin. Levels of total cholesterol, low-density lipoprotein, triglycerides, apolipoprotein B, and Lp(a) were similar between groups. Levels of homocysteine were similar, but vitamin B(12) was significantly higher among women with RA than among the controls. CONCLUSION: In women participating in the Nurses' Health Study, most traditional CVD risk factors were similar between those who had RA and those who did not. However, as expected, biomarkers of inflammation associated with CVD were generally elevated in women with RA.

Adult↗
PubMed2004

Accuracy of Medicare claims-based diagnosis of acute myocardial infarction: estimating positive predictive value on the basis of review of hospital records.

BACKGROUND: Many cardiovascular epidemiologic studies rely on diagnosis codes in health care claims databases. Despite important changes in the care and diagnosis of acute myocardial infarction (AMI), the validity of hospital discharge diagnosis codes for AMI in the US Medicare system has not been recently examined. Our objective was to examine the accuracy of International Classification of Diseases--ninth revision--Clinical Modifications (ICD-9-CM) discharge diagnosis codes and diagnosis-related groups (DRG) codes for AMI in a Medicare claims database. METHODS: We sampled hospitalization episodes from Medicare beneficiaries in Pennsylvania during 1999, 2000, or both. We used Medicare data to identify patients with hospitalizations containing indicators of AMI (ICD-9-CM diagnosis codes 410.X0 and 410.X1 or DRG codes 121, 122, and 123). Hospital records for these episodes were reviewed by trained abstractors using World Health Organization criteria for diagnosing AMI. We then calculated the positive predictive value of Medicare claims-based definitions of AMI. RESULTS: Of 2200 hospitalization episodes with Medicare diagnosis codes suggestive of AMI, 2022 hospital records (91.9%) were obtained. The positive predictive value for a primary Medicare claims-based definition was 94.1% (95% CI, 93.0%-95.2%). Positive predictive values for alternative claims-based definitions ranged slightly, with the definition including DRG codes and length-of-stay restrictions yielding the highest positive predictive value, 95.4% (95% CI, 94.3%-96.4%). Subjects with a history of myocardial infarction had a significantly lower positive predictive value than subjects without a history of myocardial infarction (88.1% vs 94.6%, P <.001). CONCLUSIONS: In this study, we observed high positive predictive values for a Medicare claims-based diagnosis of AMI and a diagnosis based on structured hospital record review.

Aged↗
PubMed2004

Patterns of bone mineral density testing: current guidelines, testing rates, and interventions.

OBJECTIVES: To identify potential obstacles to bone mineral density (BMD) testing, we performed a structured review of current osteoporosis screening guidelines, studies of BMD testing patterns, and interventions to increase BMD testing. DESIGN: We searched medline and HealthSTAR from 1992 through 2002 using appropriate search terms. Two authors examined all retrieved articles, and relevant studies were reviewed with a structured data abstraction form. MEASUREMENTS AND MAIN RESULTS: A total of 235 articles were identified, and 51 met criteria for review: 24 practice guidelines, 22 studies of screening patterns, and 5 interventions designed to increase BMD rates. Of the practice guidelines, almost one half (47%) lacked a formal description of how they were developed, and recommendations for populations to screen varied widely. Screening frequencies among at-risk patients were low, ranging from 1% to 47%. Only eight studies assessed factors associated with BMD testing. Female patient gender, glucocorticoid dose, and rheumatologist care were positively associated with BMD testing; female physicians, rheumatologists, and physicians caring for more postmenopausal patients were more likely to test patients. Five articles described interventions to increase BMD testing rates, but only two tested for statistical significance and no firm conclusions can be drawn. CONCLUSIONS: This systematic review identified several possible contributors to suboptimal BMD testing rates. Osteoporosis screening guidelines lack uniformity in their development and content. While some patient and physician characteristics were found to be associated with BMD testing, few articles carefully assessed correlates of testing. Almost no interventions to improve BMD testing to screen for osteoporosis have been rigorously evaluated.

Bone Density↗
PubMed2003

Determinants of selective cyclooxygenase-2 inhibitor prescribing: are patient or physician characteristics more important?

BACKGROUND: Little is known about which factors influence the widespread use of selective cyclooxygenase (COX)-2 inhibitors. We examined the relative effects of patient risk factors for gastrointestinal toxicity, other patient characteristics, and physician prescribing preferences on the decision to prescribe a selective COX-2 inhibitor. METHODS: We retrospectively studied a cohort of 28,190 Medicare beneficiaries who were continuously enrolled in a large, state-run pharmacy benefits program that reimbursed for selective COX-2 inhibitors and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) without restrictions. Half of the study sample filled a prescription for a selective COX-2 inhibitor and the other half for a nonselective NSAID. Multivariable logistic regression models were developed to predict COX-2 inhibitor use. RESULTS: Seventeen percent of patients using a COX-2 inhibitor had no identifiable risk factor for NSAID-associated gastrointestinal toxicity, compared with 23% of those using a nonselective NSAID. Established risk factors (age > or =75 years, history of gastrointestinal hemorrhage or peptic ulcer disease, or concomitant warfarin or oral glucocorticoid use) were all significant predictors of COX-2 inhibitor use, but a multivariable model including only these risk factors discriminated poorly between the two patient groups (C statistic = 0.55). Adding other patient clinical and demographic characteristics to the model somewhat improved this association (C statistic = 0.66); however, when physician prescribing preference was included, the model had excellent ability to discriminate between the two treatment groups (C statistic = 0.83). CONCLUSION: Established risk factors for NSAID-associated gastrointestinal toxicity were poor predictors of who was prescribed a selective COX-2 inhibitor; in contrast, physician prescribing preference was an important determinant.

Aged↗
PubMed2003

Conversion from intravenous to oral medications: assessment of a computerized intervention for hospitalized patients.

BACKGROUND: Many hospitalized patients continue to receive intravenous medications longer than necessary. Earlier conversion from the intravenous to the oral route could increase patient safety and comfort, reduce costs, and facilitate earlier discharge from the hospital without compromising clinical care. We examined the effect of a computer-based intervention to prompt physicians to switch appropriate patients from intravenous to oral medications. METHODS: This study was performed at Brigham and Women's Hospital, an academic tertiary care hospital at which all medications are ordered online. We targeted 5 medications with equal oral and intravenous bioavailability: fluconazole, levofloxacin, metronidazole, ranitidine, and amiodarone. We used the hospital's computerized order entry system to prompt physicians to convert appropriate intravenous medications to the oral route. We measured the total use of the targeted medications via each route in the 4 months before and after the implementation of the intervention. We also measured the rate at which physicians responded to the intervention when prompted. RESULTS: The average intravenous defined daily dose declined by 11.1% (P =.002) from the preintervention to the postintervention period, while the average oral defined daily dose increased by 3.7% (P =.002). Length of stay, case-mix index, and total drug use at the hospital increased during the study period. The average total monthly use of the intravenous preparation of all of the targeted medications declined in the 4 months after the intervention began, compared with the 4 months before. In 35.6% of 1045 orders for which a prompt was generated, the physician either made a conversion from the intravenous to the oral version or canceled the order altogether. CONCLUSIONS: Computer-generated reminders can produce a substantial reduction in excessive use of targeted intravenous medications. As online prescribing becomes more common, this approach can be used to reduce excess use of intravenous medications, with potential benefits in patient comfort, safety, and cost.

Administration, Oral↗
PubMed2003

Economic consequences of routine coronary angiography in low- and intermediate-risk patients with unstable angina pectoris.

In low- and intermediate-risk patients with unstable angina pectoris (UAP) and non-ST-elevation acute myocardial infarction (NSTEAMI), routine early invasive management with coronary angiography does not decrease the risk of death or AMI. The economic consequences of this strategy in low- and intermediate-risk patients are unknown. We applied a risk prediction rule to a multihospital practice database and to the population of the Thrombolysis In Myocardial Ischemia trial, phase IIIB (TIMI 3B), which compared early invasive with conservative therapy for UAP and NSTEAMI. We then analyzed the effect of an early invasive strategy with regard to the composite end point of death, AMI, or rehospitalization for ischemia at rest. A logistic regression model was used to compare outcomes in patients with high versus low or intermediate risk scores. The costs and benefits of early invasive management in low- or intermediate-risk patients were assessed. In the practice database, 56% of patients with UAP and NSTEAMI who had low or intermediate risk scores underwent early cardiac catheterization, although early invasive management of these lower risk patients has not been associated with a reduction in the rate of death or MI. In TIMI 3B, when rehospitalization for ischemia at rest was added to the composite end point, invasive management was superior to conservative management at 42 days (p = 0.005) and at 1 year (p = 0.03). If all low- or intermediate-risk patients randomized to conservative therapy in that trial had been treated instead with an early invasive strategy, an estimated 5.4% of rehospitalizations would have been avoided. Within TIMI 3B, such a routine invasive strategy would have resulted in an additional cost of 2,695,700 US dollars with no effect on death or AMI, but it would have led to 34 fewer rehospitalizations. This expenditure of 79,285 US dollars per hospitalization prevented far exceeds the monetary cost of rehospitalization (14,000 US dollars). Although common in clinical practice, routine early invasive management of low- or intermediate-risk patients with UAP generates substantial health-care costs without a mortality benefit or decrease in the risk of AMI. Unless the incremental benefit in quality of life from prevented rehospitalizations for UAP is judged to be worth the large incremental cost (79,285 US dollars per hospitalization prevented), such a strategy is unlikely to be cost effective.

Aged↗