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Biomedical subjects

J Avorn

Publications and source records attributed to J Avorn.

At least 91 records · Page 5Linked to original sources
PubMed1995

The prescription as final common pathway.

There is an informational void about pharmaceuticals in the training of most doctors, despite the importance of the prescription in medical care. The writing of the prescription is the final common pathway in therapeutic decision making, which involves such diverse forces and disciplines as anthropology, decision science, health economics, ethics, and politics, as well as pharmacology and clinical medicine. Programs to improve the precision and cost-effectiveness of doctors' prescribing must consider all of these factors if pharmacotherapeutics are to be used optimally.

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PubMed1995

A randomized trial of an education and support program for HIV-infected individuals.

OBJECTIVES: To assess the effectiveness of an intervention for providing information and support to HIV-positive donors on changes in their sexual behavior, and to assess which donor characteristics are predictive of behavior change. DESIGN: Subjects were randomly assigned to a structured intervention or community referral group. Follow-up assessments were conducted every 6 months. SETTING: New York City, New York, USA. PARTICIPANTS: A cohort of 271 HIV-infected persons who donated blood to the New York Blood Center. INTERVENTION: Donors randomized to the structured intervention program met individually with a nurse for counseling and were offered a six-session support group. The program was designed to provide information, encourage safer sexual behavior and provide support. MAIN OUTCOME MEASURES: Sexual behavior, psychological distress and psychological help seeking, and immune function. RESULTS: In both groups there was a large decrease over time in reports of unsafe sexual activity. However, more than 30% of participants in both groups reported unsafe sexual activity at the 1-year follow-up visit. Donors randomized to the structured intervention program did not report significantly more behavior change at the 1-year follow-up. CONCLUSIONS: Better programs to promote behavior change in seropositive individuals are needed.

Adult↗
PubMed1995

Antipsychotic prescribing patterns and the treatment of extrapyramidal symptoms in older people.

OBJECTIVES: We have previously identified antipsychotic use as a risk factor for the use of both dopaminergic and anticholinergic antiparkinsonian drugs in older people. This study examines whether and how such antipsychotic regimens were adjusted before the addition of an antiparkinsonian drug. DESIGN: Retrospective comparison study PARTICIPANTS: There were 1307 antipsychotic users begun on anticholinergic antiparkinsonian drugs and 345 antipsychotic users begun on dopaminergic drugs; 1864 antipsychotic users not prescribed antiparkinsonian drugs served as comparison subjects. Data were drawn from health care claims of patients aged 65-99 in the New Jersey Medicaid Program from 1981 to 1990. MEASUREMENTS: We determined if antipsychotic regimens were discontinued, reduced in dosage, or modified to reduce extrapyramidal toxicity before the institution of antiparkinsonian therapy. RESULTS: Thirty-five percent of the patients begun on dopaminergic drugs had their antipsychotic medication discontinued before beginning antiparkinsonian therapy; the antipsychotic was discontinued in only 12% of patients who started anticholinergic medications (P < .001). Among the smaller subset of patients with sufficient duration of antipsychotic exposure to examine changes in dose, 54% of patients begun on dopaminergic agents had their antipsychotic regimen reduced or discontinued before antiparkinsonian therapy, whereas 33% of patients begun on anticholinergic agents had one of these regimen changes (P < .001). Controlling for potential clinical and demographic confounders using multivariate logistic regression did not substantively alter these results. CONCLUSIONS: These data indicate that physicians frequently fail to discontinue or modify an antipsychotic regimen before adding a new drug to treat probable drug-induced extrapyramidal symptoms. Such prescribing patterns preceding use of dopaminergic antiparkinsonian drugs suggest that addition of such drugs may represent an inappropriate attempt to treat presumed idiopathic Parkinson's disease in many cases.

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PubMed1995

Epidemiologic and diagnostic aspects of bacteriuria: a longitudinal study in older women.

OBJECTIVE: To examine month-by-month variability of bacteriuria in a cohort of older women and to evaluate the performance of rapid diagnostic tests commonly used to indicate the presence of significant bacteriuria. DESIGN: Prospective, observational study. SETTING: Community housing sites and a long-term care institution. PARTICIPANTS: Sixty-one women, mean age 77.6, took part in the study. MEASUREMENTS: Midstream clean-catch urine samples and medical information on subjects were collected at baseline, and then monthly for 6 months. RESULTS: Bacteriuria alone (> or = 10(5) organisms per mL) occurred in 17% of all urine samples (28% of patients), bacteriuria with pyuria in 15% (26% of patients), and bacteriuria with symptoms in 3% (10% of patients). Spontaneous clearance of bacteriuria with pyuria was common (P = .30), as were new occurrences (P = .12) over 6 months of follow-up. For the outcome of bacteriuria with symptoms, sensitivity of urinary diagnostic tests such as bacteria and pyuria on microscopic analysis, and leukocyte esterase on dipstick testing, ranged from 79 to 93%. Negative predictive values of these tests approached 100%. CONCLUSIONS: Bacteriuria was a very common event, occurring in almost one-fifth of all urine samples and one-third of all subjects during 6 months of follow-up. Month-by-month follow-up indicates that the natural history of bacteriuria is marked by frequent spontaneous alternation between positive and negative events. The high negative predictive value of many simple diagnostic tests commonly used for urinary tract disease suggests that they can quickly and cost-effectively rule out bacteriuria in the older female patient.

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PubMed1995

Trends in medication choices for hypertension in the elderly. The decline of the thiazides.

We studied the evolution in choice of antihypertensive therapy in the elderly over a seven-year period and defined factors associated with such prescribing. To accomplish this, we performed a retrospective analysis of 8428 enrollees older than 65 years of age in the New Jersey Medicaid and Medicare programs newly begun on antihypertensive therapy between 1982 and 1988. Diuretics were the most common agents prescribed (51%), followed by calcium channel blockers (14%), beta-blockers (13%), central adrenergic antagonists (11%), and angiotensin-converting enzyme inhibitors (5%). However, the use of diuretics declined sharply during the latter part of the time interval studied. Using logistic regression modeling, we determined that the odds of a subject being started on a diuretic compared with any other antihypertensive drug decreased from 1.0 during the referent years 1982 to 1984 to 0.75 in 1985 to 1986 and to 0.41 in 1987 to 1988, after controlling for demographics, comorbidity, and hospital and physician visits (P < .001). The relative odds of diuretic use were significantly increased (P < .05) for the oldest subjects (odds ratio, 1.28 for age 85 and older versus ages 65 to 74 odds), women (odds ratio, 1.15), and blacks (odds ratio, 1.14). Despite the growing evidence during the study interval of the efficacy of diuretics in treating hypertension in the elderly, diuretic use diminished throughout this period in relation to other antihypertensive drugs. Subject characteristics (oldest subjects, women, and blacks) were important determinants of physicians' choice of antihypertensive therapy.

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PubMed1995

Epidemiology of adverse drug events in the nursing home setting.

There is widespread concern about the level of use, particularly the inappropriate use, of drugs among elderly residents of nursing homes. Medication consumption by these individuals is among the highest of any patient population; residents of nursing homes are prescribed an average of 5 to 8 regularly scheduled medications in addition to those drugs prescribed on an as needed ('prn') basis. Ideally, drug therapy should result in beneficial effects and improved quality of life for patients. However, the development of adverse drug events (ADEs) can compromise the expected benefits of pharmacotherapy for the individual nursing-home resident and may represent a public health problem of considerable magnitude.

Adverse Drug Reaction Reporting Systems↗
PubMed1994

Initiation of antihypertensive treatment during nonsteroidal anti-inflammatory drug therapy.

OBJECTIVE: To determine whether there is an increased risk for the initiation of antihypertensive therapy in older persons prescribed nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Case-control study. SETTING: New Jersey Medicaid program. PATIENTS: Medicaid enrollees aged 65 years and older. The 9411 case patients were newly started on an antihypertensive medication between November 1981 and February 1990. A similar number of controls were randomly selected among other enrollees. MAIN OUTCOME MEASURES: We used logistic regression to determine the odds ratio for the initiation of antihypertensive therapy in patients using NSAIDs relative to nonusers, after adjusting for age, sex, race, nursing home residence, number of prescriptions filled, intensity of physician utilization, and days hospitalized. RESULTS: The adjusted odds ratio for the initiation of antihypertensive therapy for recent NSAID users compared with nonusers was 1.66 (95% confidence interval, 1.54 to 1.80). The odds ratio increased with increasing daily NSAID dose: the adjusted odds ratio for users of low average daily doses relative to nonusers was 1.55 (95% CI, 1.38 to 1.74), that for medium-dose users was 1.64 (95% CI, 1.44 to 1.87), and that for high-dose users was 1.82 (95% CI, 1.62 to 2.05). CONCLUSIONS: Use of NSAIDs may increase the risk for initiation of antihypertensive therapy in older persons. Given the high prevalence of NSAID use by elderly persons, this association may have important public health implications for the management of hypertension in the older population.

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PubMed1994

Clinical assessment of extrapyramidal signs in nursing home patients given antipsychotic medication.

BACKGROUND: We sought to quantify the relationship between antipsychotic drug use and clinical evidence of extrapyramidal dysfunction in a large population of elderly nursing home patients. METHODS: Subjects were 251 residents (mean age, 84.1 years; range, 65 to 105 years) who were taking psychoactive drugs in 12 long-term care facilities. Patient characteristics and all medication use (both scheduled and as needed) were measured during a 1-month observation period. We then performed neuropsychological and functional testing on residents who received any psychoactive medications during the study month. The presence of rigidity, bradykinesia, or masklike facies was assessed in each patient by a research assistant who was unaware of diagnoses and medication use. RESULTS: The parkinsonian signs studied were found in 127 (50.6%) of these residents. Using logistic regression modeling to adjust for potential confounding, we found this outcome to be increased more than threefold in patients who took low-potency neuroleptics (odds ratio [OR], 3.49 for > or = 50 mg/d of chlorpromazine-type drugs; 95% confidence interval [CI], 1.28 to 9.57) and more than sixfold for use of 1 mg/d or more of haloperidol (OR, 6.42; 95% CI, 2.16 to 19.04). Age, gender, and use of nonneuroleptic psychoactive drugs were not associated with an increase in parkinsonian signs. CONCLUSIONS: Clinical evidence of extrapyramidal dysfunction is three to six times more common in institutionalized elderly patients given antipsychotic medication than in comparable patients not using such drugs. Its risk is substantially increased even in patients given low-potency chlorpromazine-type drugs, as well as those taking haloperidol. The effect is not explained by age or mental status and is not seen with other psychoactive medications. The expected frequency of parkinsonian symptoms can help to inform the balancing of risks vs therapeutic effect when the use of all drugs in this class is considered.

Aged↗
PubMed1994

Reduction of bacteriuria and pyuria after ingestion of cranberry juice.

OBJECTIVE: To determine the effect of regular intake of cranberry juice beverage on bacteriuria and pyuria in elderly women. DESIGN: Randomized, double-blind, placebo-controlled trial. SUBJECTS: Volunteer sample of 153 elderly women (mean age, 78.5 years). INTERVENTION: Subjects were randomly assigned to consume 300 mL per day of a commercially available standard cranberry beverage or a specially prepared synthetic placebo drink that was indistinguishable in taste, appearance, and vitamin C content but lacked cranberry content. OUTCOME MEASURES: A baseline urine sample and six clean-voided study urine samples were collected at approximately 1-month intervals and tested quantitatively for bacteriuria and the presence of white blood cells. RESULTS: Subjects randomized to the cranberry beverage had odds of bacteriuria (defined as organisms numbering > or = 10(5)/mL) with pyuria that were only 42% of the odds in the control group (P = .004). Their odds of remaining bacteriuric-pyuric, given that they were bacteriuric-pyuric in the previous month, were only 27% of the odds in the control group (P = .006). CONCLUSIONS: These findings suggest that use of a cranberry beverage reduces the frequency of bacteriuria with pyuria in older women. Prevalent beliefs about the effects of cranberry juice on the urinary tract may have microbiologic justification.

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PubMed1994

Noncompliance with congestive heart failure therapy in the elderly.

BACKGROUND: Noncompliance with long-term medication regimens, such as those employed in the treatment of congestive heart failure (CHF), has been found to be approximately 50%. However, no evaluation has been performed on a population-based cohort of elderly patients beginning the use of digoxin and followed up longitudinally for an extended observation period. METHODS: To study patterns of medication compliance, we conducted a retrospective follow-up of 7247 outpatients aged 65 to 99 years newly prescribed digoxin between 1981 and 1991, with the use of the complete prescription claims file of the New Jersey Medicaid program. Noncompliance was measured in terms of the number of days during the 12-month period after an initial digoxin prescription in which no CHF medication was available to the patient. RESULTS: Patients started on a regimen of digoxin were without digoxin or any other common alternative CHF drug for an average of 111 of the 365 days of follow-up. Only 10% of the population filled enough prescriptions to have daily CHF medication available for the entire year of follow-up. Compliance rates were higher in patients over 85 years of age, women, those taking multiple medications, and those with hospital or nursing home stays before the initiation of therapy. CONCLUSIONS: A large proportion of patients who begin digoxin therapy end CHF therapy or consume substantially less medication than expected in the first year of therapy. Such high rates of cessation could represent an important impediment to effective CHF therapy.

Aged↗
PubMed1994

Glucocorticoids and the risk for initiation of hypoglycemic therapy.

PURPOSE: To quantify risk for the occurrence of hyperglycemia requiring initiation of hypoglycemic therapy in patients treated with oral glucocorticoids. PATIENTS AND METHODS: A case-control study of enrollees in the New Jersey Medicaid program 35 years of age or older. The 11,855 case patients had newly initiated treatment with a hypoglycemic agent (oral or insulin) between 1981 and 1990. The 11,855 controls represented a random sample of other Medicaid enrollees. RESULTS: In patients using oral glucocorticoids, the estimated relative risk for development of hyperglycemia requiring treatment was 2.23 (95% confidence interval, 1.92 to 2.59) as compared with nonusers. Risk increased with increasing average daily steroid dose, in hydrocortisone-equivalent milligrams; the odds ratio was 1.77 for 1 to 39 mg/d, 3.02 for 40 to 79 mg/d, 5.82 for 80 to 119 mg/d, and 10.34 for 120 mg/d or more. The estimated effects persisted after adjustment for a variety of potentially confounding demographic, health service utilization, and medication use variables. CONCLUSION: The findings of this population-based study quantify the risk of developing hyperglycemia requiring hypoglycemic therapy after oral glucocorticoid use. The magnitude of risk increases substantially with increasing glucocorticoid dose. These findings demonstrate the utility of large-scale health claims databases in defining the risk of important adverse drug effects.

Administration, Oral↗
PubMed1994

Topical glaucoma medications and cardiovascular risk in the elderly.

OBJECTIVE: To determine the frequency of congestive heart failure and cardiac conduction disturbances in elderly patients treated with topical glaucoma medications. METHODS: These case-control studies were conducted among participants in the New Jersey Medicaid and Medicare program from 1986 to 1990. A total of 35,445 subjects (ages 65 to 99 years) were included in the congestive heart failure analysis, and 4278 subjects were included in the conduction disorder analysis. RESULTS: The frequency of initiation of congestive heart failure therapy, defined as the new use of digoxin or furosemide, was not increased for users of topical glaucoma medications. The frequency of pacemaker placement was also not increased for topical glaucoma medication users. Analyses were adjusted for age, race, gender, nursing home or hospital status, number of prescription medications, and selected medication exposures. Advanced age and heavy use of other prescription medications were associated with an increased likelihood of both cardiovascular outcomes. CONCLUSION: Major cardiovascular side effects did not occur at an increased rate among patients using topical beta-blockers or other glaucoma medications compared with control subjects. This population-based study places findings from case reports and small clinical trials in a broader context to help with clinical assessment of the risks and benefits of glaucoma therapy in the elderly.

Administration, Topical↗
PubMed1994

The appropriateness of oral fluoroquinolone-prescribing in the long-term care setting.

OBJECTIVE: To evaluate the appropriateness of ciprofloxacin-prescribing in the long-term care setting. DESIGN: Retrospective chart review. SETTING: A large academically oriented long-term care facility. PATIENTS: Institutionalized elderly patients with a mean age of 88 years. METHODS: One hundred orders were randomly selected for review from all ciprofloxacin orders initiated over a 3-year period. Criteria for appropriateness of ciprofloxacin-prescribing were developed based on a comprehensive review of the medical literature. Evaluation of appropriateness of prescribing was based on the indication for therapy and the availability of more effective and/or less expensive alternative antibiotic regimens. Only information available to the physician at the time of the order was used to judge appropriateness. Abstracted medical records were evaluated independently by a geriatrician and an infectious diseases specialist. RESULTS: With respect to site of infection, the urinary tract accounted for 43% of all ciprofloxacin orders; the lower respiratory tract, 28%; and skin and soft-tissue infections, 17%. Only 25% of orders were judged appropriate. Twenty-three percent of orders were judged less than appropriate based on indication, and 49% due to the availability of a more effective and/or less expensive alternative antibiotic choice. There was insufficient information in the medical record to judge 3% of the orders. CONCLUSION: These results indicate less than optimal prescribing of oral fluoroquinolones in the long-term care setting, with potential consequences including the development of resistant bacterial strains and increased health care costs.

Administration, Oral↗
PubMed1994

Risk factors for non-insulin-dependent diabetes mellitus requiring treatment in the elderly.

OBJECTIVE: To examine the relationship of possible modifiable risk factors, including obesity, physical activity level, alcohol consumption, blood pressure, and thiazide diuretic use with the development of non-insulin-dependent diabetes mellitus (NIDDM) requiring treatment among a large cohort of community-dwelling elderly. SETTING: The East Boston Senior Health Project, one of four components of the National Institute on Aging-sponsored Established Populations for the Epidemiologic Study of the Elderly (EPESE). PARTICIPANTS: Residents of East Boston who were 65 years of age or older. MEASUREMENTS: We performed a prospective cohort study with follow-up over two consecutive 3-year time periods beginning in 1982-1983. The main outcome measure was the occurrence of NIDDM, defined as new treatment with a hypoglycemic agent. A total of 2737 study participants contributed 4682 3-year intervals for analysis. MAIN RESULTS: NIDDM requiring hypoglycemic therapy occurred in 185 participants over the duration of the study. High body mass index (> 26 kg/m2) (adjusted odds ratio 2.4, 95% confidence interval 1.3-4.4) and low physical activity level (adjusted odds ratio 1.5, 95% confidence interval 1.0-2.1) were significant predictors of NIDDM in a multiple logistic regression model adjusting for age, sex, blood pressure, and self-report of "high blood sugar" moderate alcohol consumption (0.5-<1 ounce per day) had an inverse relation to NIDDM of borderline significance (adjusted odds ratio 0.4, 95% confidence interval 0.2-1.0). Those receiving one or more non-thiazide antihypertensive agents had a higher risk of developing NIDDM in a model including age, sex, body mass index, various antihypertensive regimens, physical activity level, alcohol consumption, blood pressure, and self-report of "high blood sugar." Thiazide diuretic therapy alone or in combination with another antihypertensive was not associated with NIDDM. CONCLUSIONS: Our findings suggest a positive relationship of obesity and low physical activity level with the development of NIDDM requiring treatment in elderly persons. The inverse association of borderline significance between moderate alcohol use and NIDDM deserves further study. Thiazide diuretic therapy conferred no excess risk for developing NIDDM in this older population although selection factors in the choice of antihypertensive therapy may partially explain the absence of a thiazide effect.

Age Factors↗
PubMed1994

Constipation: assessment and management in an institutionalized elderly population.

OBJECTIVES: To examine prescribing and utilization patterns of laxatives, stool softeners, and enemas in a large, long-term care facility, to compare self-reports of constipation with specific, bowel-related symptoms in residents of this facility, and to examine concordance between bowel symptoms reported by residents and the assessments of the nursing staff. DESIGN: Cross-sectional study. SETTING AND SUBJECTS: All individuals residing in an academically oriented long-term care facility in the United States for at least 1 month (n = 694). MEASUREMENTS: Clinical, functional, and medication data were abstracted from the medical and nursing records. Individual interviews regarding bowel-related symptoms were conducted with all able participants (n = 456 (66%)) and their respective primary nurses, and concordance was determined. The study definition of symptom-specific constipation was no more than 2 bowel movements per week and/or straining on more than 1 in 4 bowel movements. RESULTS: Fifty percent (n = 367) of all residents used at least 1 daily laxative, stool softener or enema during a 1-month study period. Over half of all laxative users (n = 200) took more than 60 doses per month. Stool softeners were most commonly prescribed, followed by saline laxatives, stimulant laxatives, hyperosmolar laxatives, and bulk laxatives. Forty-seven percent (n = 213) of the 456 interview responders reported constipation ("self-reporters"), but only 62% of self-reporters met the study criteria for symptom-specific constipation. Concordance between resident's and nurse's report regarding specific bowel symptoms was only fair to slight (kappa 0.12-0.38). Self-reporters of constipation took almost twice as many laxatives, stool softeners, and enemas as residents who did not report constipation.

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PubMed1994

Physicians' knowledge of drug costs for the elderly.

OBJECTIVE: To measure physicians' knowledge of the costs of commonly used medications in geriatric practice and how such awareness influences their prescribing decisions. DESIGN: A survey of pharmacies to determine the prices of 14 commonly used brand name and generic drugs and an in-person survey of physicians asking them to price these drugs. SETTING: Eastern Massachusetts. PARTICIPANTS: One hundred thirty-two primary care practitioners were surveyed during hospital rounds and medical society meetings. MEASUREMENT: The study examined physician awareness of patients' ability to afford drugs, the use of generic drugs, clinical decision-making practices, and the physicians' level of knowledge of drug costs. Actual drug prices were measured by surveying 22 pharmacies. RESULTS: Of the 132 respondents, 85% reported that inability to afford medications was a problem for some of their patients. One in five indicated that they did not believe generic drugs to be as safe or effective as brand name drugs, and 30% reported that they rarely or never had access to information about drug costs. Of the 99 physicians who estimated drug prices, there was a marked trend toward underestimation of the prices of more expensive drugs as well as overestimation of the prices of less costly drugs. Physician estimates of prices were highly variable; their estimates were much more variable than pharmacy prices. Younger physicians were more likely than older physicians to make correct estimates, and specialists in internal medicine were less likely to make correct estimates than physicians in other specialties. CONCLUSIONS: These data indicate that substantial knowledge deficits exist in physicians' understanding of the economic implications of the prescriptions they write. Considerable educational activity will be necessary in this area if clinicians are to function as cost-effective prescribers under health care reform.

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