Objectives To determine the role of information sources in the treatment decision-making process of men diagnosed with local stage prostate cancer. Diagnosed men have access to a large number of ...information sources about therapy, including print and broadcast media, the Internet, books, and friends with the disease. Methods Prospective survey of men with local stage prostate cancer in 3 geographically separate regions was carried out. Most men were surveyed after diagnosis but before starting therapy. Results On average, men with local prostate cancer consulted nearly 5 separate sources of information before treatment. The most common source of information was the patient's physician (97%), followed by lay-literature (pamphlets, videos) (76%), other health professionals (71%), friends with prostate cancer (67%), and the Internet (58%). Most men rated the sources they consulted as helpful. Consulting the Internet was associated with considering more treatment options. Several information sources were significantly associated with considering particular treatments, but the magnitude of association was small in relation to patient age, comorbidity, and Gleason score. More than 70% of men stated that they were considering or planning only one type of therapy. Conclusions Men with local stage prostate cancer consult a wide range of information sources. Nonphysician information sources appear to influence their treatment considerations, but to a smaller degree than clinical factors.
Objectives
This study describes urologist recommendations for treatment among local-stage prostate cancer patients presenting for initial management consultations versus second opinions. We ...hypothesized that urologists present a wider range of management recommendations and are less likely to consider the patient preference during the initial consultation.
Methods
Newly diagnosed local-stage prostate cancer patients and their urologists participated in a survey at urology practices in three states. The urologist’s survey included questions about the patient’s clinical status, treatments discussed and recommended, and factors that influenced the urologist’s recommendations.
Results
Of the 238 eligible patients, 95 men presented for an initial consultation, and 143 men presented for a second opinion. In multivariate analysis, urologists recommended 0.52 more treatments (standard error 0.19,
P
< 0.001) during an initial consultation as opposed to a second opinion. The proportion recommending surgery increased from 71–91% (initial consultation versus second opinion setting). Among initial consultations, 59% had low-risk disease, and urologists’ recommendations included surgery (80%), external radiation (38%), brachytherapy (seeds) (52%), and active surveillance (25%). Of the 54% with low-risk disease in a second opinion consultation, urologists’ recommendations included surgery (90%), external radiation (16%), brachytherapy (14%), and active surveillance (16%).
Conclusions
In second opinion settings urologists discussed fewer treatment options and recommended surgery more often. These findings also applied to men with low-risk prostate cancer.
The impact of pharmacist interventions on the care and outcomes of patients with depression in a primary care setting was evaluated.
Patients diagnosed with a new episode of depression and started on ...anti-depressant medications were randomized to enhanced care (EC) or usual care (UC) for one year. EC consisted of a pharmacist collaborating with primary care providers to facilitate patient education, the initiation and adjustment of antidepressant dosages, the monitoring of patient adherence to the regimen, the management of adverse reactions, and the prevention of relapse. The patients in the UC group served as controls. Outcomes were measured by the Hopkins Symptom Checklist, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for major depression, health-related quality of life, medication adherence, patient satisfaction, and use of depression-related health care services. An intent-to-treat analysis was used.
Seventy-four patients were randomized to EC or UC. At baseline, the EC group included more patients diagnosed with major depression than did the UC group (p = 0.04). All analyses were adjusted for this difference. In both groups, mean scores significantly improved from baseline for symptoms of depression and quality of life at three months and were maintained for one year. There were no statistically significant differences between treatment groups in depression symptoms, quality of life, medication adherence, provider visits, or patient satisfaction.
Frequent telephone contacts and interventions by pharmacists and UC in a primary care setting resulted in similar rates of adherence to antidepressant regimens and improvements in the outcomes of depression at one year.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Objectives: To determine whether benzodiazepine use in older women increased the risk of decline in physical function.
Design: A four‐year prospective cohort study.
Setting: The communities of Iowa ...and Washington counties, Iowa.
Participants: Eight hundred eighty‐five women aged 70 and older who had completed physical performance tests in 1988 and 1992.
Measurements: Benzodiazepine use was determined during in‐home interviews and classified by dose, duration, indication for use, and half‐life. Physical performance tests included an assessment of standing balance, walking speed (8‐foot distance), and repeated chair raises.
Results: Ninety (10.2%) reported benzodiazepine use at baseline. After adjustment for baseline physical performance score and potential confounders, benzodiazepine use was associated with a greater decline in physical performance over 4 years than nonuse (β=–1.16; standard error (SE)=0.25; P<.001). The use of higher‐than‐recommended dose was related to decline (β=–2.26; SE=0.47; P<.001), and use of lower doses was not (β=–0.53; SE=0.46; P=.246). Long‐term use (≥3 years) was related to decline (β=–1.65; SE=0.34; P<.001), whereas recent and past use were not. Similar results were obtained when restricting the sample to those without disability at baseline.
Conclusion: This study provides evidence that older women who used benzodiazepines were at risk for decline in physical performance. Subgroup analyses indicated that risk was greater with use of higher‐than‐recommended doses or for long duration (≥3 years). These findings highlight the importance of using benzodiazepines at the lowest effective dose for a limited duration in older women.
Study Objective. To investigate the occurrence of tramadol‐associated seizures.
Design. Retrospective cohort and case‐control studies.
Setting. UnitedHealth Group‐affiliated independent practice ...model health plans, from different regions of the United States, contracting with large networks of physicians.
Intervention. Analysis of administrative data from a large U.S. managed care population.
Patients. A cohort of 9218 adult tramadol users and 37,232 concurrent nonusers.
Measurements and Main Results. Fewer than 1% of users (80) had a presumed incident seizure claim after the first tramadol prescription. Risk of seizure claim was increased 2‐ to 6‐fold among users adjusted for selected comorbidities and concomitant drugs. Risk was highest among those aged 25–54 years, those with more than four tramadol prescriptions, and those with history of alcohol abuse, stroke, or head injury. A case‐control study among users was conducted to validate incident seizure outcomes from medical records. Only eight cases were confirmed, and all had cofactors associated with increased seizure risk.
Conclusion. In a general population, risk of seizure may be associated with long‐term therapy with tramadol or the presence of cofactors, or confined to a small sensitive population subset.
Background. The impact of secondary hyperparathyroidism on morbidity and mortality among patients with chronic kidney disease (CKD) is unclear. Methods. We conducted a retrospective cohort study to ...investigate the relationship between CKD and serum phosphorous. Through clinical databases at a large health maintenance organization, we identified a dynamic CKD inception cohort between 1997 and 2004, with stage 3–5 kidney disease with subsequent phosphorous measurement; the patients were followed up for up to 5 years for outcomes of mortality, cardiovascular mortality, cardiovascular hospitalizations and renal replacement therapy (RRT; dialysis or transplant). Survival analysis with time-varying covariables for phosphorous and renal function estimated the relationship between phosphorous level and outcomes, adjusting for potential confounding variables. Results. A total of 930 patients with complete data were included in our analysis; they had a higher disease burden than excluded patients. Phosphorous did not predict overall or cardiovascular mortality, or cardiovascular hospitalizations. The rate of RRT increased significantly with the level of phosphorous, even when controlling for renal function. Conclusions. Contrary to some previous reports, we did not find evidence of increased mortality with phosphorous, but did find that increased levels of phosphorous are related to excess rates of RRT. Our work does not suggest that controlling phosphorous will lower the risk of RRT; our work motivates randomized controlled trials to investigate the clinical value of such interventions.
Pain in persons who receive hospice care is not fully understood. The purpose of this study was to describe the demographics, clinical characteristics, and pain intensity of persons who received ...hospice care in the United States from 2000–2004. Data for this study were obtained from a provider of hospice pharmacy services and included information about the hospice organization, demographics and clinical characteristics, pain intensity, and opioid analgesic prescribing. Worst pain intensity during the previous 24 hours was assessed using a 0–10 numeric rating scale (0
=
none, 10
=
worst) periodically during hospice care. During the study period, 347,555 persons received hospice services; 55.2% of these persons were female, 87.4% were Caucasian, and mean age was 75.3 years. At least one pain score was available for 156,887 (45.1%) individuals. Among persons with at least one pain score, pain was reported a mean of 2.9 times per person. Overall, mean pain intensity was mild, but severe pain was reported at least once by 20.3% of persons. Of individuals who reported severe pain at least once, mean age was 68.9 years, 53.7% were female, 78.0% were Caucasian, 7.4% were cared for in long-term care hospices, and 73.9% had a primary diagnosis of cancer. Severe pain was reported at least once by a substantial percentage of persons in this study. These data provide insight into pain reported by persons who received hospice care, and may be useful as process indicators of the quality of care.
Abstract Objectives We examined health care use in conjunction with primary prophylaxis use of colony stimulating factors (CSF) during patients' initial course of chemotherapy. Methods This ...retrospective cohort study identified adults aged 25 years and older with a diagnosis of breast, colorectal, or nonsmall cell lung cancer between 2002 and 2005 from the Western Washington Surveillance Epidemiology and End Results Puget Sound registry. We linked these records to health insurance claims from four payers representing 75% of those insured in the state. Claims records were used to determine chemotherapy regimen type, CSF use, febrile neutropenia occurrences, and supportive care. Chemotherapy regimens were categorized as conferring high, intermediate, or low risk of myelosuppression according to the National Comprehensive Cancer Network guidelines. CSF use was described as primary prophylaxis, other, or none. Antibiotics and antifungal and antiviral agents per National Comprehensive Cancer Network guidelines for supportive care for cancer infection were categorized using Healthcare Common Procedure Coding System and National Drug Code assignments. Results Use of CSF as primary prophylaxis is not significantly associated with a reduction in antibiotic use or inpatient or outpatient visits. Primary prophylactic CSF use was associated with less use of antiviral drugs. Conclusions CSF use is not associated with a reduction in health care use, with the exception of antiviral drug use. Given the expense associated with CSF use, pragmatic trials and additional research are needed to further assess the affects of CSF on health care use.
Objectives: We examine the frequency with which newly diagnosed cancer patients are covered by Medicaid in Washington State and the duration of coverage. Methods: Medicaid enrollment and claims files ...were linked to the Washington State Cancer Registry to identify all Medicaid enrollees with breast, cervical, lung, colorectal, and prostate cancer between 1997 and 2002. Results: We identified 5009 newly diagnosed cancer patients covered by Medicaid, approximately 13% of the total cases diagnosed in subjects less than 65 years of age in Washington State. The majority, 2866 (57%), enrolled in Medicaid around the time of diagnosis; the remainder had been enrolled at least 3 months before diagnosis. Persons enrolled at diagnosis had later-stage cancer; those enrolled before diagnosis had more noncancer comorbidities. Overall, 18% had disenrolled by 6 months after diagnosis; 34% by 1 year; and 54% by 2 years. Conclusions: Medicaid patients with cancer in Washington State experience a high rate of disenrollment within 1 year after diagnosis. Further research is needed to determine whether disenrollment compromises initial therapy or follow-up care.
A pilot study was conducted to characterize the epidemiology of prescribing errors, comparing those that occurred pre- to postimplementation of an electronic prescribing system; this article ...describes the results of the study during the preimplementation phase, when a handwritten prescription process was still in place.
A retrospective review of 1411 prescriptions that were handwritten during a five-month time frame was used to identify and characterize medication errors and potential medication errors. The review was conducted in an internal medicine clinic in a large health system that was preparing to implement an electronic prescribing system. The first phase was the implementation of a basic system-one that facilitated the writing of a more complete and legible prescription. The second phase consisted of adding more sophisticated clinical decision support (CDS) capabilities. Three data sources were reviewed: the handwritten prescription, the electronic health record and the prescription as it had been entered into the pharmacy computer system. Almost 28% of the prescriptions evaluated contained one or more errors or potential errors. Over 90% of the errors were potential errors. Only 0.2% of the errors caused patient harm. Non-clinical errors (illegibility, missing information, wrong dose) may be affected by a basic electronic prescribing system, and clinical errors (drug-disease interaction, contraindication of a drug) may be affected only when more sophisticated levels of CDS programming are added.
Potential prescribing errors occurred frequently but few reached the patient or caused harm. The most severe errors were those that may be reduced by the implementation of an electronic prescribing system with CDS capabilities.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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