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Biomedical subjects

J Avorn

Publications and source records attributed to J Avorn.

At least 127 records · Page 7Linked to original sources
PubMed1991

The ambiguous relation between aging and adverse drug reactions.

PURPOSE: To examine the evidence for a relation between advancing patient age and the risk for adverse drug reactions. DATA SOURCE: A computer-assisted search of the English-language literature (MEDLINE, 1966 to 1990) followed by selective review of all pertinent articles. STUDY SELECTION: Studies that stratified data on adverse drug reactions by patient age were screened for review. Article selection was not limited by study design; the relation between age and the occurrence of adverse drug reactions did not have to be a primary focus of the study. DATA EXTRACTION: Pertinent data were abstracted from the results of case-control and cohort studies and from clinical trials. The methodologic strengths and weaknesses of these studies are discussed with particular reference to gerontologic issues. RESULTS OF DATA SYNTHESIS: Most studies have neglected the issue of whether the increased frequency of adverse drug reactions in the elderly is attributable to age alone or to the fact that older patients are more likely to have coexisting illnesses and to be taking several medications. Studies that combine all drug exposures for each patient and report the risk for any adverse effect provide little useful information about the risks associated with specific drug therapies in the elderly. The association between age and the risk for adverse drug reactions is best examined for individual pharmacologic agents. However, the exclusion of elderly subjects from clinical trials makes the determination of age effects impossible in many studies. Where subjects do represent an adequate age range, most studies fail to control for important clinical differences among subjects of different ages to distinguish the independent effects of chronologic age. CONCLUSION: Conventional clinical wisdom suggests that the risk for adverse drug reactions increases with advancing age, but available data do not confirm this "truism" of geriatric medicine. The inter-individual variability of the aging process, including the non-uniform nature of the pharmacokinetic and pharmacodynamic changes that occur with aging, indicates that clinical reality is far more complex. Patient-specific physiologic and functional characteristics are probably more important than any chronologic measure in predicting both adverse and beneficial outcomes associated with specific drug therapies.

Aged↗
PubMed1991

Resident behavior and staff distress in the nursing home.

Newly enacted Federal regulations have focused increasing attention on the use of psychoactive drugs and on the treatment of disruptive behavior in the nursing home. To study the interaction between resident behavior and staff distress in nursing homes, we measured the frequency of seven types of behavior problems among 346 residents of intermediate care facilities who were receiving some form of psychoactive medication. Nurses were interviewed on two shifts to determine their perception of the frequency and severity of each behavior in each patient as well as the level of distress it caused among caregivers. The most common behavior problems noted were agitation (42%), withdrawal (33%), and noisiness (27%). Only half of the reported instances of behavior disorders were considered distressful by nursing home staff. While physical abuse caused distress 92% of the time and verbal abuse 90% of the time, wandering was seen as distressful to staff only 50% of the time. Nearly a third of "wandering" patients were restrained; they produced less distress than non-restrained wanderers. There was substantial disagreement, ranging from 6% to 22% for individual residents, over the presence of distress-causing behavior, although day and evening nursing shifts rated the frequencies of behavior and the degrees of distress equally on average. Residents with higher cognitive function were less likely to cause distress for all behaviors, except for verbal abuse where the reverse was true. Age and dependency in activities of daily living were not associated with problematic behavior or staff distress. These findings indicate that the existence of "problematic" behaviors in a given resident is often perceived differently by different staff, and its impact on staff also differs widely.

Aged↗
PubMed1991

Behavior changes after notification of HIV infection.

BACKGROUND: To learn more about how people who did not volunteer for testing react to information about HIV infection, we assessed short-term behavior changes in HIV-positive blood donors. METHODS: Blood donors who were notified at the New York Blood Center that they were HIV positive were asked to participate in a study. A nurse elicited a medical history, performed a limited medical examination, and asked participants to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. Participants were asked to return in 2 weeks to complete another questionnaire. RESULTS: Many fewer men and women reported engaging in unsafe sexual behaviors in the 2 weeks preceding the follow-up visit than had reported such behaviors prior to notification. These changes were greater than those other investigators have reported, but about 40% of the participants still reported unsafe sexual activity at the follow-up interview. CONCLUSIONS: To make nonvolunteer screening programs for HIV infection more effective in reducing the spread of HIV infection, we need to learn more about how to help people change their high-risk behaviors.

Adolescent↗
PubMed1991

The neglected medical history and therapeutic choices for abdominal pain. A nationwide study of 799 physicians and nurses.

A random national sample of 501 physicians and 298 nurse practitioners was presented a case vignette describing a patient with epigastric pain and endoscopy showing diffuse gastritis. Respondents were encouraged to request further information and then were asked for recommendations. History available if requested included substantial use of aspirin, coffee, cigarettes, and alcohol, and severe psychosocial stress. More than one third of the physicians chose to initiate therapy without seeking a relevant history. Nearly half of all physicians indicated that a prescription would be the single most effective therapy; 65% recommended a histamine antagonist. By contrast, only 19% of nurse practitioners opted to treat without taking further history; the nurse sample asked an average of 2.6 questions vs 1.6 for physicians; only 20% of the nurses recommended a prescription medication. These findings raise concerns about the adequacy of basic history taking in this setting and the underuse of nonpharmacologic approaches in favor of excessive reliance on prescription drugs, even when not indicated by clinical circumstances.

Abdominal Pain↗
PubMed1991

Trends in sociodemographic and behavioral characteristics of HIV antibody-positive blood donors.

This paper describes the sociodemographic characteristics of people who donated blood to the New York Blood Center between April 1985 and February 1988 and tested positive for antibodies to HIV. Information on HIV-related risk factors and knowledge of blood screening is presented for seropositive donors who participated in an evaluation study. The most commonly reported risk factor among men was sexual contact with another man, and many of the male seropositive donors reported sex with an intravenous (IV) drug user or use of IV drugs. The proportion of men reporting sexual contact with another man decreased over the period of the study, and the proportion reporting use of IV drugs or sex with an IV drug user increased. Awareness of blood screening for HIV antibodies increased over the study period. The greatest increase was among those donating for transfusion, but only about a quarter of seropositive donors used the confidential unit exclusion (CUE) process.

Adolescent↗
PubMed1990

Nonsteroidal anti-inflammatory drug-associated azotemia in the very old.

We conducted a prospective study in 114 elderly patients to determine the renal effects of short-term therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) in the very old. Study subjects were patients in a long-term care facility (mean age, 87 years) newly begun on a regimen of NSAID therapy. For the study group as a whole, the serum urea nitrogen level rose 1.7 mmol/L 5 to 7 days after initiation of therapy, with no significant changes in serum creatinine or potassium levels. In a comparison group of 45 patients not receiving NSAID therapy, no significant change in the serum urea nitrogen level was noted during a similar period. A subgroup of 15 patients (13%) experienced a greater than 50% increase in the serum urea nitrogen level during NSAID therapy, with a mean increase of 89% (8.6 mmol/L). A return to the baseline level occurred within 14 days after discontinuation of NSAID therapy. Two factors were significantly predictors of a greater than 50% increase in the serum urea nitrogen level: concurrent loop diuretic therapy (odds ratio, 2.2) and high NSAID dose (odds ratio, 2.0). These findings suggest that reversible azotemia develops in a sizable proportion of the very old who are treated with short-term NSAID therapy.

Aged↗
PubMed1990

Influence of clinical knowledge, organizational context, and practice style on transfusion decision making. Implications for practice change strategies.

Evidence shows that blood products, like other health care resources, are often used inappropriately, but the reasons for this have not been well studied. We conducted a face-to-face survey of 122 general surgeons, orthopedic surgeons, and anesthesiologists in three hospitals to evaluate the influence of several clinical and nonclinical factors on transfusion decision making. We found widespread deficiencies in physicians' knowledge of transfusion risks and indications. Each transfusion risk was estimated correctly by fewer than half of the physicians surveyed, and only 31% responded correctly to a set of four questions regarding transfusion indications. Attending physicians routinely had lower knowledge scores than did residents, yet they exhibited more confidence in their knowledge. Residents' transfusion decisions, however, were strongly influenced by the desires of their attending physicians, resulting in their ordering potentially inappropriate transfusions. Of the residents surveyed, 61% indicated that they ordered transfusions that they judged unnecessary at least once a month because a more senior physician suggested that they do so. These findings provide insights for the development of strategies to improve transfusion practices, which would address the dual concerns of quality of care and cost containment.

Analysis of Variance↗
PubMed1990

Withdrawing payment for nonscientific drug therapy. Intended and unexpected effects of a large-scale natural experiment.

Little is known about the effect on clinical decision making of nonreimbursement for ineffective medical technologies. Using a time-series design, we studied the effects of cessation of government payment for 12 categories of drugs of questionable efficacy (Drug Efficacy Study Implementation drugs) in a random sample of the New Jersey Medicaid population (N=390 465) and in four cohorts of regular users of these products. We measured changes in the overall levels of prescriptions, expenditures, and physicians' use of substitute drugs. Although withdrawn drugs accounted for 7% of prescriptions in the base year, there was no measurable reduction in overall drug use or expenditures after the regulation; prescription rates actually rose from 0.86 to 1.00 monthly prescriptions per enrollee throughout the 42-month study. Controlling for preexisting trends, an estimated drop in the use of study drugs of 21.7 prescriptions per 1000 enrollees per month was offset by an increase in the use of substitute drugs of 33.7 prescriptions. Both desirable and unimproved therapeutic substitutions were observed. Used alone, curtailment of reimbursement for marginally effective therapies results in both desirable and unintended clinical substitutions and may not reduce costs. Supplementing such restrictions with education may be necessary to promote practices that are more therapeutically and economically appropriate.

Adult↗
PubMed1990

Principles of educational outreach ('academic detailing') to improve clinical decision making.

With the efficacy and costs of medications rising rapidly, it is increasingly important to ensure that drugs be prescribed as rationally as possible. Yet, physicians' choices of drugs frequently fall short of the ideal of precise and cost-effective decision making. Evidence indicates that such decisions can be improved in a variety of ways. A number of theories and principles of communication and behavior changes can be found that underlie the success of pharmaceutical manufacturers in influencing prescribing practices. Based on this behavioral science and several field trials, it is possible to define the theory and practice of methods to improve physicians' clinical decision making to enhance the quality and cost-effectiveness of care. Some of the most important techniques of such "academic detailing" include (1) conducting interviews to investigate baseline knowledge and motivations for current prescribing patterns, (2) focusing programs on specific categories of physicians as well as on their opinion leaders, (3) defining clear educational and behavioral objectives, (4) establishing credibility through a respected organizational identity, referencing authoritative and unbiased sources of information, and presenting both sides of controversial issues, (5) stimulating active physician participation in educational interactions, (6) using concise graphic educational materials, (7) highlighting and repeating the essential messages, and (8) providing positive reinforcement of improved practices in follow-up visits. Used by the nonprofit sector, the above techniques have been shown to reduce inappropriate prescribing as well as unnecessary health care expenditures.

Cost-Benefit Analysis↗
PubMed1990

Systemic effects of medications used to treat glaucoma.

Medications used to treat glaucoma can have clinically important systemic effects in some patients; these effects may not be recognized in elderly patients who have chronic medical problems and who are taking several systemic medications. Beta-blocking ophthalmic agents are generally safe, but can be absorbed systemically to induce bronchospasm, worsen heart block, decompensate congestive heart failure, or create central nervous system effects in some patients. Reports of adverse systemic effects from miotics, such as pilocarpine, are rare, although cardiovascular decompensation has been seen in patients with acute angle closure who were given excessive doses before surgery. Topical sympathomimetic agents such as epinephrine may increase ventricular extrasystoles and have, on occasion, caused severe hypertensive reactions. Nearly 50% of patients taking carbonic anhydrase inhibitors must discontinue their use because of various adverse constitutional and central nervous system symptoms. Although these drugs are not usually part of internal medicine regimens, they can produce adverse effects that mimic primary disease in nonocular organ systems.

Adrenergic beta-Antagonists↗
PubMed1990

Old age--is it a risk for adverse drug reactions?

Pharmacotherapy is often the single most important medical intervention in the care of the elderly. However, there are obvious concerns about the vulnerability of this group to adverse drug reactions (ADRs). A rapidly accumulating literature regarding changes in pharmacokinetics and pharmacodynamics with advancing age suggests a strong pharmacologic basis for such concerns. Yet, the results of epidemiologic studies exploring the relationship between age and ADRs are ambiguous. Interpretation of the results of these studies is limited by inconsistent definitions of outcomes of interest and failure to control for important age-related covariates including the clinical status of the patient and the number of medications that a patient is receiving. Some recent studies have investigated age-related aspects of specific adverse consequences of drug therapy. For example, age, in and of itself, does not appear to be a risk factor for bleeding complications of warfarin therapy. Older patients may actually be at less risk than younger patients to experience depression associated with beta-blocker therapy. Although examination of data from premarketing studies might be considered a promising strategy to explore the relationship between age and ADR risk, the small number of truly elderly subjects included in these studies greatly limits their usefulness. Postmarketing studies utilizing databases containing clinical data for large numbers of older patients may provide the optimal approach for investigating whether old age is an independent risk factor for ADRs.

Aging↗
PubMed1990

Clinical decision-making in the evaluation and treatment of insomnia.

We interviewed a representative random sample of 501 office-based general physicians and 298 nurse practitioners to evaluate their approach to the symptoms of insomnia. Clinicians were presented with a standard case of a patient complaining of difficulty sleeping, with the age of the patient depicted as either 37 years or 77 years. Historical information was provided in response to practitioners' questions. In evaluating the history, physicians asked an average of 2.5 questions and were most likely to ask about psychologic problems. Only 47% of the physicians who were presented with the elderly case vignette elicited a sleep history. By contrast, nurse practitioners asked an average of 3.2 questions, and 60% of them took a sleep history. Despite many possible non-pharmacologic therapies for the patients presented, 46% of physicians identified a prescription medication as the single most effective therapy for the older patient, compared with 17% of nurse practitioners. These findings suggest that physicians place inadequate emphasis on history-taking in the evaluation of insomnia and resort to the use of psychoactive drugs even when non-pharmacologic approaches might be more effective.

Adult↗
PubMed1990

Changing surgical antimicrobial prophylaxis practices through education targeted at senior department leaders.

Prescribing antibiotics for perioperative prophylaxis in common surgical procedures presents an ideal target for educational intervention. In this situation, antibiotics are often used inappropriately, with consequent excess expense and risk of morbidity. We developed an educational intervention aimed at the choice and appropriate dosing of antibiotics for the prophylaxis of cesarean sections. Person-to-person educational messages targeted at authoritative senior department members were supplemented by brief reminders on a structured antibiotic order form. Time-series analyses were conducted on 34 months of antibiotic use data for 2,783 cesarean sections to estimate the trend of magnitude and significance of discontinuities associated with the start of the program. Prior to the intervention, 95% of sections receiving prophylaxis were given cefoxitin and 3% were given cefazolin. After the intervention, these proportions were reversed, with the shift in use occurring immediately after the intervention (p less than .001). Two years after the intervention, virtually all patients undergoing cesarean sections who receive antibiotic prophylaxis are given cefazolin. Savings from this change alone accounted for over $26,000 each year, or $47.36 per patient-day of prophylaxis. Substantial changes in prescribing practices for routine procedures can be accomplished through the implementation of a coordinated educational program that enlists influential senior staff members in a department in which policy-making is highly centralized, coupled with a structured educational ordering system. Lasting improvements in clinical practices may be brought about by means that are noncoercive, inexpensive and well-accepted by medical staff.

Anti-Bacterial Agents↗
PubMed1990

Quality assurance for drug prescribing.

This article reports the results of a critical analysis of English-language studies describing programs designed to improve physician prescribing behavior in primary care settings. Only 64% of studies met minimum research design standards, and are the basis for the results reported. The overall findings of the review confirm the conclusions of a previous evaluation of hospital-based studies. (1) The simple dissemination of printed educational materials had no detectable effect on prescribing practice when used alone in well-controlled studies. However, such educational materials do lay a necessary foundation for more personalized educational efforts. (2) Merely distributing computerized listings of patient-specific medication profiles, without specific recommendations for change, is ineffective in reducing overall drug costs or use of inappropriate drugs. Their lack of effect may be due to the large quantity and clinical irrelevance of such data. (3) Continuous computerized reminder systems have been shown to prevent omission of essential care, although such systems are effective only as long as reminders continue. This strategy has not been evaluated for its potential to reduce excessive or inappropriate drug prescribing. (4) Repeated feedback to physicians with specific suggestions for alternative agents has been shown to increase use of generic drugs in academic group practice settings. No adequate studies have tested whether this approach might reduce other types of misprescribing. Also in academic primary care settings, small group tutorials have been shown to improve use of antibiotics and hypertension treatment control. (5) A substantial literature in the U.S. and Canada supports the conclusion that brief, face-to-face educational outreach visits, conducted by either specially trained clinical pharmacists or physician "counsellors" and "opinion leaders", are effective in reducing prescribing of inefficient or contraindicated drugs in pediatric and adult primary care settings. These face-to-face approaches emphasize a tactful, supportive and facilitative role; in some cases, emphasis is put on helping physicians overcome barriers to appropriate prescribing (e.g. patient demand or addiction to minor tranquilizers). Most effective programs also utilize professionally credible sponsors and high-quality educational materials. In addition to improving quality, some programs have been found to produce savings in drug use which exceed the operational costs of the program.

Drug Information Services↗
PubMed1990

Pygmalion in the nursing home. The effects of caregiver expectations on patient outcomes.

Several characteristics of nursing home care can diminish rather than enhance the clinical status of older residents. In view of evidence from other settings that "interpersonal expectancy effects" can influence outcomes in a variety of relations, we conducted a randomized controlled trial to test the effects of caregiver expectations on the clinical status of nursing home residents. Within 2 weeks of admission, 63 older residents at six nursing homes were given a comprehensive assessment of cognitive, functional, and emotional status. Residents were then randomly assigned to a "high-expectancy" or "average-expectancy" condition. Nurses and aides were told that, in comparison with other residents having similar problems, residents in the high-expectancy group were predicted to perform above average in their rehabilitation. The assessment was repeated 3 months later; information on the health and psychosocial status of residents was drawn from their medical records covering the same period. Aides reported having higher expectations for treatment group residents. When assessed by a blinded research assistant, residents in the high-expectancy group experienced greater relief of depressive symptoms but showed greater decrements in functional independence in comparison with control residents. Treatment group residents were admitted significantly less frequently to hospitals despite a comparable number of emergency ward visits, suggesting a lower incidence of severe illness despite comparable medical surveillance. There was also a trend toward improved performance in mental status testing among the high-expectancy residents compared with controls (P = .08). Additional research is needed to define further the magnitude and mechanisms of expectancy effects in relations between nursing home caregivers and residents.

Activities of Daily Living↗
PubMed1990

Improving medication prescribing and utilization in the nursing home.

There is ample and compelling evidence to suggest that medications are frequently used inappropriately in the nursing home. The occurrence of avoidable adverse drug reactions is the most serious consequence of inappropriate prescribing; economic implications are also of interest. With increasing concern over the quality of care in nursing homes, and with the revision of regulations governing such care by the Health Care Financing Administration, it is important to consider the experience thus far in monitoring and improving drug use in nursing homes. A number of studies have investigated approaches designed to reduce inappropriate prescribing and drug utilization in this setting. In contrast to the wide range of approaches that have been evaluated and implemented in the hospital setting, interventions in the nursing home have centered primarily around consultant-pharmacist activities. Although these activities are now federally mandated in all nursing homes, there is little evidence from adequately controlled studies to document their impact or cost-effectiveness. By contrast, face-to-face educational interventions directed at physicians ("academic detailing") have been shown to be effective in improving prescribing for some medications. The prominent role played by the nursing staff in the utilization of many medications in the nursing home implies that an educational intervention excluding nursing staff would be insufficient to influence drug utilization positively in many situations (eg, psychoactive medications and laxatives). Future research efforts must pay greater attention to adequate study design considerations as well as to the clinical outcomes of such interventions and their cost-effectiveness.

Aged↗