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Biomedical subjects

J Avorn

Publications and source records attributed to J Avorn.

At least 73 records · Page 4Linked to original sources
PubMed1997

Physician attitudes concerning warfarin for stroke prevention in atrial fibrillation: results of a survey of long-term care practitioners.

BACKGROUND: The prevalence of atrial fibrillation (AF) increases dramatically with advancing patient age, and, as a result, this condition is common in persons residing in the long-term care setting. OBJECTIVES: To assess the knowledge and attitudes of physicians regarding the use of warfarin for stroke prevention in patients with atrial fibrillation in long-term care facilities. METHODS: We surveyed physicians actively providing primary care to older patients in 30 long-term care facilities located in New England, Quebec, and Ontario. Physicians were requested to complete a structured questionnaire about use of warfarin therapy for stroke prevention in patients with AF residing in long-term care facilities. The questionnaire included two clinical scenarios designed to provide substantial contrasts in patient characteristics including underlying comorbidity, functional status, bleeding risk, and stroke risk. RESULTS: A total of 269 physicians were asked to participate in the survey, and 182 (67.7%) completed the questionnaire between February 1, 1995, and July 31, 1995. Only 47% of respondents indicated that the benefits of warfarin therapy "greatly outweigh the risks" in this setting; the remainder of physicians indicated that benefits only "slightly outweigh the risks" (34%) or that risks "outweigh benefits" (19%). The most frequently cited contraindications to warfarin use were: excessive risk of falls (71%), history of gastrointestinal bleeding (71%), history of other non-central nervous system bleeding (36%), and history of cerebrovascular hemorrhage (25%). Among the 164 physicians who reported using the international normalized ratio to monitor warfarin therapy, 27% indicated a target range with a lower limit less than 2, 71% indicated a target range between 2 and 3, and 2% indicated an upper limit greater than 3. Among respondents who answered questions about the two clinical scenarios, estimates of the risk of a stroke without warfarin therapy and the risk of an intracranial hemorrhage with therapy varied widely. CONCLUSIONS: Our findings suggest that many uncertainties surround the decision to prescribe warfarin to patients with AF in the long-term care setting, as well as questions about the appropriate intensity of this treatment when it is prescribed. Concerns about the risks of bleeding appear to prevail over stroke prevention when physicians make such prescribing decisions.

Aged↗
PubMed1996

Bowel habit in relation to age and gender. Findings from the National Health Interview Survey and clinical implications.

BACKGROUND: Constipation is widely considered to be a common problem among the elderly, as evidenced by the high rate of laxative use in this population. Yet, age-related prevalence studies of constipation generally do not distinguish between actual alteration in bowel movement frequency and subjective self-report of constipation. OBJECTIVE: To determine the relationship between advancing age and bowel habit. METHODS: We employed data collected on 42,375 subjects who participated in the National Health Interview Survey on Digestive Disorders based on interviews with a random nationwide sample of US households. We examined the following characteristics reported by this population according to selected age groupings by decade: constipation, levels of laxative use, and two bowel movements per week or less. RESULTS: Contrary to conventional wisdom, there was no age-related increase in the proportion of subjects reporting infrequent bowel movements. Nonetheless, the prevalence of self-report of constipation increased with advancing age, with a greater proportion of women reporting this symptom than men across all age groups. Laxative use also increased substantially with aging; while women were more likely to use laxatives than men, this effect attenuated with advancing age. A U-shaped relationship was observed between advancing age and bowel habit in men and women; 5.9% of individuals younger than 40 years reported two bowel movements per week or less compared with 3.8% of those aged 60 to 69 years and 6.3% of those aged 80 years or older. This relationship persisted after adjusting for laxative use. CONCLUSION: These findings suggest that a decline in bowel movement frequency is not an invariable concomitant of aging. In elderly patients who report being constipated, it is essential to take a careful physical, psychological, and bowel history rather than to automatically assume the need for laxative use.

Adult↗
PubMed1996

Variability in length of hospitalization for stroke. The role of managed care in an elderly population.

OBJECTIVES: To measure hospital stay for acute stroke care and to describe health services and demographic factors associated with longer length of stay (LOS). DESIGN: Observational, retrospective consecutive case series. SETTING: Large tertiary-care teaching hospital in Massachusetts. PATIENTS: The patient population comprised 745 patients aged 65 years and older admitted with ischemic stroke from 1982 through 1995. MAIN OUTCOME MEASURES: Hospital LOS (1-5, 6-10, and >10 days) as well as total charges and discharge location. RESULTS: Median LOS was 7 days (range, 1-289 days), and median total charges were $8740 (range, $522-$135172); LOS explained 62% of the variance in total charges. Insurance status was a major factor in determining LOS: after possible confounders were controlled for, patients enrolled in a health maintenance organization were significantly less likely to have long hospital stays (odds ratio [OR], 0.45; 95% confidence interval, 0.31-0.66) than were conventional Medicare enrollees, while the LOS of patients with other insurance coverage was no different from that of Medicare patients. Longer LOS was significantly associated with greater comorbidity (OR, 1.52 for a Charlson comorbidity index >2), institutionalization prior to hospital admission (OR, 1.83), and unmarried status (OR, 1.37) and was inversely associated with year of admission (OR, 0.30 in years 1991-1995 vs 1982-1986). Age, sex, and race were not associated with LOS. Discharge to a nursing home or inpatient rehabilitation site was not associated with type of insurance coverage (OR, 1.10; 95% confidence interval, 0.72-1.69 for patients in a health maintenance organization vs conventional Medicare patients). CONCLUSIONS: There is marked variability in length of hospital stay for ischemic stroke among the elderly, even after underlying patient differences are controlled for. Managed care may result in increased efficiency of in-hospital care and improved discharge planning for these patients; further study of the ultimate clinical outcomes of such care is needed.

Aged↗
PubMed1996

The impact of sedative-hypnotic use on sleep symptoms in elderly nursing home residents.

OBJECTIVE: To determine the frequency of sleep-related complaints among institutionalized elderly subjects and to assess the relationship between perceived sleep quality and the use of sedative-hypnotic agents and other psychoactive medications. METHODS: In 12 nursing homes in Massachusetts, we conducted observational, cross-sectional, and longitudinal studies of 145 institutionalized elderly subjects (average age, 83.0 years; age range, 65 to 105 years). We recorded the patients' demographic characteristics and all medication use (both scheduled and as needed) during a 1-month baseline period. A research assistant who was blinded to diagnoses and medication use performed detailed neuropsychologic testing and administered a series of standardized questions concerning difficulty sleeping, early morning awakening, and time spent awake in bed. Medication use and patient assessments were repeated after a 6-month interval. RESULTS: One or more sleep-related complaints were present at baseline in 94 (65%) of the residents studied. Using logistic regression to adjust for potential confounding, we found no relationship in the baseline month between use of sedative-hypnotic agents and the presence or absence of sleep complaints. After 6 months of follow-up, 27 (19%) of the residents had decreased their use of sedative-hypnotic agents and 23 (16%) had increased their use. However, there was no relationship between decreased use of sedative-hypnotic agents and worsened sleep (p > 0.20) or between their increased use and improved sleep reports (p > 0.10). Improvement in functional status was significantly associated with improved sleep at follow-up (p < 0.005). CONCLUSIONS: Sleep complaints occur in the majority of institutionalized elderly persons. Neither cross-sectional nor longitudinal analyses showed a relationship between patterns of sedative-hypnotic use and the presence, absence, or change in sleep complaints.

Aged↗
PubMed1996

The impact of ibuprofen on the efficacy of antihypertensive treatment with hydrochlorothiazide in elderly persons.

BACKGROUND: Nonsteroidal antiinflammatory drugs (NSAIDs) may alter blood pressure through their inhibitory effects on prostaglandin biosynthesis. Such potential hypertensive effects of NSAIDs have not been adequately examined in the elderly, who are the largest group of NSAID users. METHODS: We performed a randomized, double-blind, two-period crossover trial of ibuprofen (1800 mg per day) vs placebo treatment in patients older than 60 years of age with hypertension controlled with hydrochlorothiazide. While continuing their usual thiazide dosage, subjects were randomized to a 4-week treatment period (ibuprofen or placebo) followed by a 2-week placebo wash-out period and a second 4-week treatment period with the alternative therapy. Supine and standing systolic and diastolic blood pressures were measured weekly. RESULTS: Of 25 randomized subjects, 22 completed the study protocol (mean age = 73 +/- 6.7 years). Supine systolic blood pressure and standing systolic blood pressure were increased significantly with ibuprofen treatment, compared with placebo. Mean supine systolic blood pressures were 143.8 +/- 21.0 and 139.6 +/- 15.9 mmHg on ibuprofen and placebo, respectively (p = .004). Mean standing systolic blood pressures were 148.1 +/- 19.9 and 143.4 +/- 17.9 mmHg on ibuprofen and placebo, respectively (p = .002). CONCLUSION: We conclude that 1800 mg per day of ibuprofen does induce a significant increase in systolic blood pressure in older hypertensive patients treated with hydrochlorothiazide. NSAID therapy may negatively impact the control of hypertension in elderly patients.

Aged↗
PubMed1996

Compliance with antihypertensive therapy among elderly Medicaid enrollees: the roles of age, gender, and race.

OBJECTIVES: This study measured compliance and related demographic factors in a retrospective cohort of 4068 elderly outpatients newly starting antihypertensive therapy from 1982 through 1988. METHODS: Logistic regression modeling of data from the New Jersey Medicaid program was used. RESULTS: These patients filled antihypertensive prescriptions covering an average of only 179 days in the 365-day follow-up period (49%) Good compliance (> or = 80%) was associated with advanced age (odds ratio [OR] = 2.12, for patients 85 or older) and White race (OR = 0.55 for Blacks). There was no relationship between compliance and gender. CONCLUSIONS: Despite the efficacy of antihypertensive therapy in preventing cardiovascular morbidity, such high rates of noncompliance may contribute to suboptimal patient outcomes.

Age Factors↗
PubMed1996

Drug use in academic medical centres in an era of ferment.

The causes and implications of streamlining and consolidation in academic medical centres in the US have a number of parallels in the research-intensive pharmaceutical industry. In both cases there is increasing competition between institutions (centres or companies), and the costs of research and innovation are rising sharply. However, with increasing emphasis on cost reduction in healthcare, fewer and fewer payers are willing to help underwrite the costs of research and innovation within academic health centres or for new drug development. At the Brigham and Women's Hospital, an ongoing study is investigating the effects of 'reminding' doctors, through an interactive hospital computer system, that the drug they are about to prescribe may not be the most clinically appropriate or cost-effective in a given situation. While physicians are not deprived of the right to prescribe a 'deviant' drug, it is hoped that, unless exceptional circumstances prevail, they will improve their prescribing choice if provided with the correct information at the time of decision-making. This approach reflects a new understanding that teaching institutions are required to educate trainees about the fact that resources are not infinite, and that critical selection among competing products must be a prominent concern for the rest of their professional lives. Attention to such concerns is vital to quality assurance and cost management. However, it is also true that the most cost-effective drug may not necessarily be the one with the lowest acquisition cost, provided that one conducts a thorough interdisciplinary analysis of clinical outcomes and expenditures. As academic medical centres redefine their priorities while attempting to preserve their leadership in innovation, research-oriented drug manufacturers are also developing more creative and efficient goals for their constrained research budgets. Liaisons between academic medical centres and research-driven pharmaceutical companies can help ensure that both types of innovation-based organisations are able to continue their respective missions of discovery into the next century.

Academic Medical Centers↗
PubMed1996

Medications and falls. Causation, correlation, and prevention.

Both medication use and fall rates increase with advancing age. The increased risk of falls conferred by drugs is clearest for psychoactive agents such as long-acting benzodiazepines. The most frail patients (those likeliest to fall) also are receiving the largest drug burden, imposing considerable confounding by indication. Nonetheless, improving the drug regimen is probably one of the most effective means of reducing fall risk, especially in the frail elderly.

Accidental Falls↗
PubMed1995

Increased incidence of levodopa therapy following metoclopramide use.

OBJECTIVE: To determine whether there is an increase in use of antiparkinsonian therapy in older persons taking metoclopramide hydrochloride. DESIGN: Case-control study. SETTING: New jersey Medicaid program. PATIENTS: Medicaid enrollees aged 65 years and older. Cases were patients newly prescribed a levodopa-containing medication (n = 1253); a secondary case group were patients newly prescribed an anticholinergic antiparkinsonian drug (n = 2377). The control group consisted of 16435 Medicaid enrollees older than 65 years who were not users of any antiparkinsonian therapy. MAIN OUTCOME MEASURES: We used logistic regression to determine the odds ratio (OR) for the initiation of antiparkinsonian therapy in patients using metoclopramide relative to nonusers, after adjusting for age, sex, race, nursing home residence, exposure to antipsychotic medication, and days hospitalized. RESULTS: Metoclopramide users were three times more likely to begin use of a levodopa-containing medication compared with nonusers (OR = 3.09; 95% confidence interval [Cl], 2.25 to 4.26). Risk increased with increasing daily metoclopramide dose: the OR was 1.19 (95% Cl, 0.50 to 2.81) for more than 0 to 10 mg per day, 3.33 (95% Cl, 1.98 to 5.58) for more than 10 to 20 mg per day, and 5.25 (95% Cl, 1.16 to 8.50) for more than 20mg per day. The effect persisted after adjustment for demographic, health service utilization, and medication use variables. The OR for initiation of anticholinergic antiparkinsonian drugs was also elevated in metoclopramide users. CONCLUSION: Metoclopramide use confers an increased risk for the initiation of treatment generally reserved for the management of idiopathic Parkinson's disease in patients with drug-induced parkinsonian symptoms, which should be ruled out before starting dopaminergic therapy for this condition.

Aged↗
PubMed1995

Drug use in the nursing home.

Some of the most intensive pharmacotherapy today occurs in nursing homes in very complex and vulnerable patients. The nursing home provides an opportunity for highly effective drug use, but it also presents risks for polypharmacy and adverse events. Nursing homes are complex social institutions, in which physicians, nurses, consultant pharmacists, other health care professionals, aides, and administrators must interact to make decisions about drug use for patients who generally are frail and have numerous comorbid conditions. Federal regulations have recently been implemented to direct the ways in which specific drugs are to be used in this setting. The nursing home environment can present an ideal opportunity for comprehensive drug regimen review, an exercise too often neglected in the care of elderly patients in all clinical settings. Psychoactive medications, analgesics, and laxatives are examples of drugs that should receive such review. The possible underuse of drug therapies that may be beneficial to nursing home residents, including antidepressant, antihypertensive, and antithrombotic agents; calcium supplements; and vaccines, must be further quantified and must receive increased attention. Morbidity and functional incapacity can be substantially reduced by applying currently established principles of geriatric pharmacology in the nursing home setting, but enormous gaps still exist in the knowledge base necessary to guide this aspect of geriatric medical practice. Data on the efficacy, toxicity, and cost-effectiveness of pharmacotherapeutic choices in nursing home patients are in short supply; considerably more clinical and epidemiologic research is needed to define the relations between the benefits and risks of drugs for this unique population.

Drug Utilization↗
PubMed1995

A cost-effectiveness model of thrombolytic therapy for acute myocardial infarction.

OBJECTIVE: To assess the short- and long-term costs and clinical and quality of life outcomes with the use of streptokinase (SK) vs tissue plasminogen activator (tPA) for acute myocardial infarction (MI). DESIGN: A decision analysis model. PATIENTS: Patients with acute MI who were candidates for thrombolytic therapy and who presented within six hours of symptom onset. MEASUREMENTS: 30-day and one-year mortality, impacts of disabling and nondisabling stroke, reinfarction, hemorrhage, hypotension, anaphylaxis, and long-term medical costs. RESULTS: Using 30-day mortality data from the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial, the baseline analysis yielded an incremental cost-effectiveness for tPA of $30,300 per additional quality-adjusted life year (QALY) gained, compared with SK. Using one-year mortality data from the GUSTO trial, the analysis yielded an incremental cost-effectiveness for tPA of $27,400 per additional QALY, compared with SK. The incremental cost-effectiveness of tPA over SK was sensitive to the difference in mortality seen with the two agents, exceeding $100,000 per QALY, for a relative survival advantage of approximately one-third that seen in the GUSTO trial. The incremental cost per QALY of tPA remained under $60,000 if the survival benefit was half that seen in the GUSTO trial. The cost-effectiveness of tPA declined with a shorter projected life expectancy following MI and for inferior (vs anterior) wall infarction. The analysis was modestly sensitive to the costs of the thrombolytic agents. CONCLUSIONS: In spite of its higher cost relative to SK, tPA is a cost-effective therapy for MI under a wide range of assumptions regarding clinical outcomes and costs.

Aged↗
PubMed1995

Neuroleptic drug exposure and treatment of parkinsonism in the elderly: a case-control study.

PURPOSE: Despite the widespread use of neuroleptic medications for the elderly, little is known about the frequency of treatment for drug-induced parkinsonian syndromes in this age group, particularly with L-dopa-type drugs, which are more appropriate for the treatment of true idiopathic Parkinson's disease. PATIENTS AND METHODS: We identified 3,512 patients aged 65 to 99 enrolled in a large state Medicaid program who were newly prescribed a drug to treat parkinsonian symptoms. Controls were comparable program enrollees of similar age who had not been prescribed an antiparkinsonian drug. In a case-control study, we evaluated the use of neuroleptic drugs in the 90 days before initiation of antiparkinsonian therapy. RESULTS: Patients taking neuroleptics were 5.4 times more likely to begin antiparkinsonian medication than were nonusers (95% confidence interval [CI] 4.8 to 6.1). They also had a greater than two-fold increase in risk of beginning therapy with a dopaminergic drug specific for idiopathic Parkinson's disease, not generally indicated for treatment of drug-induced parkinsonism (adjusted odds ratio 2.2, 95% CI 1.9 to 2.7). Clear dose-response relationships were demonstrated, as were differences among neuroleptics. Among all patients started on dopaminergic drugs in this population, 37% of such therapy was attributable to prior neuroleptic use. Continuation of the neuroleptic persisted in 71% of patients so treated. CONCLUSION: Neuroleptic use is a common cause of extrapyramidal dysfunction in the elderly, and the side effect is frequently treated by adding an anticholinergic or dopaminergic drug to the regimen. The use of anticholinergic drugs presents risks of additional drug side effects; the use of dopaminergic drugs, generally not appropriate for drug-induced parkinsonian syndrome, suggests that extrapyramidal neuroleptic side effects may often be mistaken for idiopathic Parkinson's disease in older patients.

Age Distribution↗
PubMed1995

Correlates of regular laxative use by frail elderly persons.

PURPOSE: To examine the demographic, clinical, and pharmacological correlates of regular laxative use in elderly persons residing in a long-term care setting. METHODS: This was a cross-sectional study using retrospective record review undertaken in an academically affiliated long-term care facility in the United States. All individuals residing in the institution for at least 1 month (n = 694) were characterized regarding use of laxatives. Regular laxative use was defined as more than 30 doses of laxatives, stool softeners, or enemas taken over the most recent 1-month period. RESULTS: Residents with regular laxative use (n = 349) were compared with those who received no laxatives (n = 227). Factors significantly associated with regular laxative use at the P < 0.05 significance level were simultaneously included in a multiple logistic regression model. Factors associated with regular laxative use were immobility, Parkinson's disease, diabetes mellitus, and use of iron supplements, calcium channel blockers, and antidepressants with moderate to strong anticholinergic properties. CONCLUSION: Regular laxative use is often associated with neurologic dysfunction that directly or indirectly affects the gut, or medications known to depress colonic motility. Identification of potentially modifiable correlates of regular laxative use in older individuals may suggest management strategies to avoid or reduce laxative, stool softener, and enema requirements, improve constipation symptoms, and enhance quality of life for the frail elderly population.

Aged↗
PubMed1995

Hemophilia home treatment. Economic analysis and implications for health policy.

This analysis describes the development of technology for home self-infusion of factor VII in the treatment of hemophilia and its clinical, economic, and social consequences, and uses the case study of such home care treatment to illustrate the potentials and pitfalls of formal economic analyses of programs to treat chronically ill children. A comprehensive review of all original data on hemophilia programs, their related costs, and outcomes, conducted from 1966 through 1993, examined the economic outcomes for two hypothetical cohorts, one aged 0-4 years and the other aged 30-34 years. Including the measurement of treatment effects on the productivity of parental caregivers substantially increases the benefit-cost relationship of an intervention directed at chronically ill children. Increased economic productivity and societal return resulting from such a program for young adults exceeds those for a cohort of children, primarily due to assumptions related to discounting. However, estimation of quality-adjusted life years favors the younger age cohort, since children survive for a longer period of time and with each year survived comes a higher quality of life. Unlike simpler instances in which economic benefits can be shown to outweigh resource costs, policy decisions concerning services for chronically ill children raise an additional set of complex analytic issues. Inclusion of the benefits in productivity experienced by family caregivers provides an important added dimension to such analyses. The development of cost-benefit or cost-effectiveness analyses of these programs illustrates the importance of careful measurement of outcomes and explicit statements of underlying assumptions. Such an analysis of home care for children with hemophilia therefore demonstrates both the strengths and the limitations of this approach.

Adult↗