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April 27, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases. THIS WEEK'S CONTENTS
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, April 27, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 27, 2009
High Co-Payments Associated With Delay in Starting Drug Therapy in Patients with Chronic Diseases
CHICAGO—High co-payments are associated with delayed initiation of medication in patients with newly diagnosed hypertension, diabetes and elevated cholesterol levels, according to a report in the April 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Rising prescription drug costs in the past decade have caused more restrictive insurance benefits, including an increase in cost sharing (i.e., 'co-payments'), multi-tier formularies and mandatory generic substitution, according to background information in the article. "Several studies have demonstrated that these new arrangements reduce overall drug utilization and expenditures and that the chronically ill are sensitive to out-of-pocket costs. However, detailed mechanisms outlining how these reductions occur are lacking," the authors write. "The interruption of drug therapy can have negative health consequences for the chronically ill, particularly for elderly patients who have the highest rates of chronic disease and prescription drug use." Matthew D. Solomon, M.D., Ph.D., of Stanford University School of Medicine, Stanford, Calif., and colleagues analyzed data from 17,183 older adults with employer-provided drug coverage from 1997 to 2002 from 31 different health plans. The researchers examined the time it took patients to start drug therapy after being diagnosed with hypertension (high blood pressure), diabetes or hypercholesterolemia (elevated cholesterol levels). Five years after diagnosis, 21.5 percent of patients with hypertension, 36 percent of patients with hypercholesterolemia and 32.5 percent of patients with diabetes remained untreated with medications. Higher co-payments were associated with delayed initiation of therapy. In statistical models, "doubling co-payments resulted in large reductions in the predicted proportion of patients initiating pharmacotherapy at one and five years after diagnosis: for hypertension, 54.8 percent vs. 39.9 percent at one year and 81.6 percent vs. 66.2 percent at five years; for hypercholesterolemia, 40.2 percent vs. 31.1 percent at one year and 64.3 percent vs. 53.8 percent at five years; and for diabetes, 45.8 percent vs. 40 percent at one year and 69.3 percent vs. 62.9 percent at five years," the authors write. Those with no previous use of drug therapy (26.1 percent of hypertension patients, 10.4 percent of hypercholesterolemia patients and 12.9 percent of diabetes patients) had a median (midpoint) initiation of drug use at 833 days, more than 1,170 days and more than 1,402 days after diagnosis, respectively. This group was also more price sensitive than those with a history of medication use.
"These results raise concerns about high cost-sharing levels for elderly, insured patients without experience using prescription drugs. Based on our findings, high cost-sharing levels could be a barrier to treatment for this population and possibly result in poor health outcomes," the authors conclude. "Policy makers and physicians should consider the effects of benefits design on patient behavior to encourage the adoption of necessary care."
Editor's Note:This research was supported by a grant from the Agency for Healthcare Research and Quality, Rockville, Md., with additional funding from the California HealthCare Foundation, Oakland. Data were provided by Ingenix Inc., Eden Prairie, Minn. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 27, 2009
Lifestyle Factors Related to Risk of Diabetes Among Older Adults
CHICAGO—Even for older adults, lifestyle factors such as physical activity, dietary habits, tobacco and alcohol use and the amount of body fat are associated with risk of new-onset diabetes, according to a study published in the April 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "Given medical challenges, health care costs, long-term complications and growing incidence and prevalence of type 2 diabetes mellitus, preventing the onset of clinical diabetes is of paramount importance," the authors write. While previous studies have found lifestyle factors such as level of physical activity, diet, smoking habits, alcohol use and body fat levels as risk factors linked to onset of diabetes in younger populations, the combined impact of these factors on risk of diabetes in older adults is largely unknown. Dariush Mozaffarian, M.D., Dr.P.H., of Harvard School of Public Health, Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues with the Cardiovascular Health Study examined the relationships of lifestyle risk factors with incidence of diabetes during a 10-year period (1989 to 1998) among 4,883 men and women age 65 years or older. At the beginning of the study, the average participant age was 73 years, 58.6 percent were women and 11.4 percent were nonwhite; 95 percent of nonwhite participants were black. Approximately half of the participants had never smoked. Low-risk lifestyle groups were defined by physical activity level (leisure time activity and walking pace) above the median (midpoint); dietary score (higher fiber intake and polyunsaturated to saturated fat ratio, lower trans-fat intake and lower average glycemic index); amount of smoking, if any; alcohol use (predominantly light or moderate); body mass index less than 25; and waist circumference of 34.6 inches or less for women or 36 inches or less for men. After adjustment for age, sex, race, educational level, annual income and other lifestyle factors simultaneously, each lifestyle risk factor was independently associated with incidence of diabetes. Overall, each additional lifestyle factor an individual had in the lower-risk group was associated with a 35 percent lower risk of diabetes. Individuals in the low-risk category for only physical activity level and dietary habits (nearly one in four adults) had a 46 percent lower incidence of diabetes. Combining low-risk groups for physical activity level, dietary habits, smoking habits and alcohol use (6 percent of participants), an 82 percent lower risk of diabetes was present, and four in five new cases of diabetes appeared to be attributable to not having these low-risk lifestyle factors. Adding either not being overweight or not having large waist circumference was associated with an 89 percent lower risk of diabetes.
"These findings provide an estimate of the public health burden of combined nonoptimal lifestyle risk factors for incidence of diabetes in older adults, the fastest growing segment of the U.S. population," the authors write. "Our findings suggest that, even later in life, the great majority of cases of diabetes are related to lifestyle factors."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, April 27, 2009
Interventions Appear Related to Reduced Risk of Adverse Drug Events
CHICAGO—Interventions that included enhanced communication between a pharmacist and patients and physicians and computerized organization of a patient's medications appear to be associated with a decreased risk of adverse drug events, according to two articles appearing in the April 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Adverse drug events (ADEs) and medication errors (MEs) are common and costly threats to the quality of care. Such drug-related problems are common in outpatients in the United States and added together with other drug-related problems cost $77 billion to $177 billion annually, according to background information in the first article. While the incidence of these events among inpatients is well recognized, such events often go unnoticed in the outpatient setting and are more difficult to measure. Inpatient studies suggest that a pharmacist may help reduce these events, but little is known regarding the effect on outpatients. Michael D. Murray, Pharm.D., M.P.H., of the University of North Carolina at Chapel Hill, and colleagues examined the effect of a pharmacist intervention on ADEs and MEs in outpatients with heart failure or hypertension by combining data from two randomized controlled trials. The pooled analysis included 800 outpatient cases of hypertension divided into complicated (n = 535; patients had heart failure or other cardiovascular complications) and uncomplicated (n = 265). Computer programs examined one-year electronic record data to identify events classified as ADEs and preventable or potential ADEs. Study participants were an average of 59 years old; 71 percent were women. The intervention was provided by specifically trained pharmacists, who spent more of their time instructing patients on the appropriate use of their medications, drug monitoring, and communication with patients' primary care physicians, with the goal of improving adherence and medication use. There were a total of 210 ADE or ME events, with fewer of these events occurring in the intervention group. The five most common events, occurring in a total of 68 participants, included receipt of a prescription for a drug that should be avoided in elderly patients; vaginal candidiasis (yeast infection) resulting from an orally administered antibiotic; an increase in serum creatinine level associated with a medication; inadequate monitoring after prescribing; and prescription of multiple acetaminophen products. Compared with the control group, the intervention group had a 34 percent lower risk of any event, including a 35 percent lower risk of ADEs and a 37 percent lower risk of MEs.
"In conclusion, this post hoc analysis of a pharmacist intervention to improve medication use in adult outpatients suggests a lower risk of adverse drug events and medication errors. Further studies are needed to confirm this finding," the authors write.
Editor's Note: This study was funded by the National Institutes of Health. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Computerized Organization of Patient's Medications Associated With a Lower Risk of Adverse Drug Events
An intervention that included computerized identification of medications a patient is taking to help create a more accurate medication list for patients checking in or out of a hospital was associated with a lower rate of potential adverse drug events, according to an article in the April 27 issue of Archives of Internal Medicine. Efforts to improve the quality and safety of health care include attention to unintentional medical discrepancies, defined as unexplained differences among documented regimens across different sites of care (e.g., prior to admission compared with hospital admitting orders). "Discrepancies are highly prevalent; up to 67 percent of inpatients have at least one unexplained discrepancy in their prescription medication history at admission," the authors write. Because medication discrepancies are an important contributor to ADEs among hospitalized and recently discharged patients, The Joint Commission on Accreditation of Healthcare Organizations has designated medication reconciliation as a priority. Medication reconciliation is a process of identifying the most accurate list of all medications a patient is taking, and using this list to provide correct medications for patients anywhere within the health care system, according to background information in the article. Few studies have shown that medication reconciliation efforts improve important patient outcomes. Jeffrey L. Schnipper, M.D., M.P.H., of Brigham and Women's Hospital and Harvard Medical School, Boston, and colleagues conducted a study to determine the effects of a redesigned process for medication reconciliation, supported by information technology (IT), on potential ADEs (PADEs). The trial, at general medical inpatient units in two academic hospitals, included 322 patients, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool (that included a Web-based application that promotes the creation of a preadmission medication list from several electronic sources) and process redesign, which involved changes in the roles and workflows involving physicians, nurses, and pharmacists. The researchers found that among 162 patients assigned to the intervention, there were 170 unintentional medication discrepancies with potential for patient harm (1.05 PADEs per patient) vs. 230 (1.44 PADEs per patient) among the 160 patients assigned to usual care, a 28 percent risk reduction. Ninety-eight PADEs were considered serious, i.e., to have potential to cause serious harm such as rehospitalization or a change in health function, including 43 PADEs in the intervention group (0.27 per patient) and 55 PADEs in those assigned to the usual care group (0.34 per patient).
"We believe our intervention was successful because it combined effective process redesign with IT. The new reconciliation process encouraged interdisciplinary communication and cross-checks. The Preadmission Medication List (PAML) Builder application facilitated accurate medication histories by presenting several sources of available medication information, and it displayed the PAML with current inpatient medications during the discharge ordering process," the researchers write.
Editor's Note: This study was funded in part by an investigator-initiated grant from the Harvard Risk Management Foundation as well as internal funding from Brigham and Women's Hospital, Massachusetts General Hospital and Partners HealthCare. Dr. Schnipper was supported by a mentored clinical scientist award from the National Heart, Lung and Blood Institute. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: The Change We Need in Health Care
In an accompanying editorial, David C. Goff Jr., M.D., Ph.D., and Philip Greenland, M.D., of the Feinberg School of Medicine, Northwestern University, Chicago, write that significant changes are needed in the U.S. health care system. "As we look back at the results of over a decade of attention to health care quality, we also look forward to the prospects of stimulating real change in the health care system and breakthroughs in health care quality. We believe that the time has come to quit nibbling around the edges of a dysfunctional system. Implementation of proven strategies to enhance quality will require structural changes in our health care system to align incentives so that (1) patients are protected from exposure to medications of dubious cost-effectiveness; (2) providers are reimbursed appropriately for efforts to implement quality initiatives; and (3) payers are armed with information regarding quality and cost-effectiveness during contract negotiations."
"Rising health care costs threaten our economic future, yet many indicators of the quality of care in the United States lag behind those reported from countries spending for less. In this time of change, the status quo in health care is not acceptable."
Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. |
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