General practitioner management plans delaying time to next potentially preventable hospitalisation for patients with heart failure

BACKGROUND

Several studies have shown that the Australian Medicare-funded chronic disease management programme can lead to improvements in care processes. No study has examined the impact on long-term health outcomes.

AIMS

This retrospective cohort study assessed the association between provision of a general practitioner management plan and time to next potentially preventable hospitalisation for older patients with heart failure.

METHODS

We used the Australian Government Department of Veterans' Affairs (DVA) claims database and compared patients exposed to a general practitioner management plan with those who did not receive the service. Kaplan-Meier analysis and Cox proportional hazards models were used to compare time until next potentially preventable hospitalisation for heart failure between the exposed and unexposed groups.

RESULTS

There were 1993 patients exposed to a general practitioner management plan and 3986 unexposed patients. Adjusted results showed a 23% reduction in the rate of potentially preventable hospitalisation for heart failure at any time (adjusted hazard ratio, 0.77; 95% confidence interval, 0.64 to 0.92; P = 0.0051) among those with a general practitioner management plan compared with the unexposed patients. Within one year, 8.6% of the exposed group compared with 10.7% of the unexposed group had a potentially preventable hospitalisation for heart failure.

CONCLUSIONS

A general practitioner management plan is associated with delayed time to next potentially preventable hospitalisation for heart failure.

Antithrombotic use following transient ischaemic attack or ischaemic stroke among older Australians with atrial fibrillation

Hospital audits may underestimate anticoagulant use among acute ischaemic stroke patients with atrial fibrillation (AF), as treatment may commence after discharge. To account for this, antithrombotic use in the 4 months after hospitalisation for transient ischaemic attack or ischaemic stroke among AF patients was assessed using claims data. Results suggest that treatment may be commenced soon after discharge and should be considered when assessing prevalence of use.

Comorbidity of chronic disease and potential treatment conflicts in older people dispensed antidepressants

OBJECTIVES

the study aimed to examine the prevalence of comorbidity, the prescribing of potentially inappropriate medications and treatment conflicts in a large sample of older people who have been dispensed an antidepressant medicine.

METHODS

a cross-sectional study of administrative claims data from the Department of Veterans' Affairs, Australia, 1 April-31 July 2007, of veterans aged > or =65 years was conducted. Comorbidities determined using the pharmaceutical-based comorbidity index, Rx-Risk-V. Concomitant medicines that may be potentially inappropriate for patients with depression and areas of treatment conflicts were determined from Australian clinical guidelines or reference compendia.

RESULTS

a total of 39,695 subjects were included, with a median of 5 comorbid conditions (inter-quartile range 3-6). Ninety percent of medicine use was attributed to the treatment of comorbid conditions. Eighty-seven percent of the study cohort was identified as having at least one comorbid condition that may cause a potential treatment conflict when an antidepressant is used. Those conditions of most concern included cardiovascular diseases, anxiety disorders, arthritis or pain management and osteoporosis.

CONCLUSION

we observed a high level of potentially inappropriate prescribing and treatment conflicts that may arise when caring for older patients dispensed an antidepressant with comorbidity. These have the potential to place a large number of older people with depression at increased risk for adverse events.

Comorbid chronic diseases, discordant impact on mortality in older people: a 14-year longitudinal population study

OBJECTIVES

To determine the impact of comorbid chronic diseases on mortality in older people.

DESIGN

Prospective cohort study (1992-2006). Associations between numbers of chronic diseases or mutually exclusive comorbid chronic diseases on mortality over 14 years, by Cox proportional hazards model adjusting for sociodemographic variables or Kaplan-Meier analyses, respectively.

SETTING

Population based, Australia.

PARTICIPANTS

2087 randomly selected participants aged ≥65 years old, living in the community or institutions.

MAIN RESULTS

Participants with 3-4 or ≥5 diseases had a 25% (95% CI 1.05 to 1.5, p=0.01) and 80% (95% CI 1.5 to 2.2, p<0.0001) increased risk of mortality, respectively, by comparison with no chronic disease, after adjusting for age, sex and residential status. When cardiovascular disease (CVD), mental health problem or diabetes were comorbid with arthritis, there was a trend towards increased survival (range 8.2-9.5 years) by comparison with CVD, mental health problem or diabetes alone (survival 5.8-6.9 years). This increase in survival with arthritis as a comorbidity was negated when CVD and mental health problems or CVD and diabetes were present in disease combinations together.

CONCLUSION

Older people with ≥3 chronic diseases have increased risk of mortality, but discordant effects on survival depend on specific disease combinations. These results raise the hypothesis that patients who have an increased likelihood of opportunity for care from their physician are more likely to have comorbid diseases detected and managed.

Potentially inappropriate prescribing among Australian veterans and war widows/widowers

This study examined the extent of potentially inappropriate medicine, as defined by explicit criteria, dispensed to Australian veterans using the Repatriation Pharmaceutical Benefits Scheme Pharmacy Claims database. Twenty-one per cent of the 192,363 veterans aged 70 years, with an eligible gold card, were dispensed at least one potentially inappropriate medicine in the first 6 months of 2005. Long-acting benzodiazepines, amitriptyline, amiodarone, oxybutynin and doxepin were the medicines most commonly implicated. Strategies to support quality prescribing of medicines to the elderly must include a focus on these medicines.

Further evidence that Whorfian effects are stronger in the right visual field than the left

The Whorf hypothesis holds that differences between languages induce differences in perception and/or cognition in their speakers. Much of the experimental work pursuing this idea has focused on the domain of color and has centered on the issue of whether linguistically coded color categories influence color discrimination. A new perspective has been cast on the debate by recent results that suggest that language influences color discrimination strongly in the right visual field but not in the left visual field (LVF). This asymmetry is likely related to the contralateral projection of visual fields to cerebral hemispheres and the specialization of the left hemisphere for language. The current study presents three independent experiments that replicate and extend these earlier results by using different tasks and testing across different color category boundaries. Our results differ in one respect: although we find that Whorfian effects on color are stronger for stimuli in the right visual field than in the LVF, we find that there are significant category effects in the LVF as well. The origin of the significant category effect in the LVF is considered, and two factors that might account for the pattern of results are proposed.

Achieving a sustained reduction in benzodiazepine use through implementation of an area-wide multi-strategic approach

OBJECTIVE

This study aimed to evaluate the impact, in a regional setting, of a multi-strategic partnership approach for reducing benzodiazepine use in the management of insomnia, as recommended in Australia's National Policy on Quality Use of Medicines.

METHOD

The setting was a rural region of South Australia, covering approximately 2000 km2, with a population of over 20 000. The study involved participatory action research, with qualitative and quantitative evaluations. The intervention involved a multi-strategic approach, including provision of treatment guidelines, provision of consumer information, a local media campaign and education and training of health professionals. The quantitative evaluation involved a single region before/after study with 2 years of follow-up using pharmacy-based dispensing data for benzodiazepines and antidepressants, gathered for the months of November to April in 1998/99 ('before' period) through to 2000/01 ('after' period). The data were analysed using non-parametric statistics.

RESULTS

There was a 19% reduction in benzodiazepine dispensing 2 years after the intervention compared with a 6% reduction nationally. Dispensing of antidepressants increased by 33%, compared with a 28% increase nationally.

CONCLUSION

It was concluded that the multi-strategic approach to the management of sleep disorders proved successful in promoting the use of non-drug alternatives, achieving sustained reduction in benzodiazepine consumption in a rural community, without therapeutic substitution of antidepressants.

IMPLICATIONS

The study demonstrated that a sustainable reduction in prescribing of benzodiazepines can be achieved through the implementation of a multi-strategic approach involving local consumers, health professionals, a Division of General Practice, a government department, aged-care facilities and the local media.

Medication-related problems commonly occurring in an Australian community setting

PURPOSE

This study characterised medication-related problems in 1000 Australian patients living in the community, and who were considered at risk of medication misadventure.

METHODS

A review was undertaken of 1000 clinical case notes, developed during the delivery of medication management reviews. Patient demographics, medications used, medical conditions and medication-related problems were categorised according to established classification systems. Descriptive analyses were undertaken.

RESULTS

Overall, 2222 problems were identified. Ninety per cent of patients had at least one medication-related problem. One in three people were found to require additional monitoring, one in four required additional medication, one in four were using the wrong or inappropriate medication and one in five were using insufficient medication. Cardiovascular, nervous system, alimentary and respiratory medicines were most commonly implicated, accounting for 69% of the medication-related problems.

CONCLUSION

This analysis reveals the need for ongoing vigilance of, and support for, people at high risk of medication misadventure. This information is also useful for informing the design of public health or health promotion strategies aiming to reduce the prevalence of these problems.

Enzyme replacement therapy in the mouse model of Pompe disease

Deficiency of acid alpha-glucosidase (GAA) results in widespread cellular deposition of lysosomal glycogen manifesting as myopathy and cardiomyopathy. When GAA-/- mice were treated with rhGAA (20 mg/kg/week for up to 5 months), skeletal muscle cells took up little enzyme compared to liver and heart. Glycogen reduction was less than 50%, and some fibers showed little or no glycogen clearance. A dose of 100 mg/kg/week resulted in approximately 75% glycogen clearance in skeletal muscle. The enzyme reduced cardiac glycogen to undetectable levels at either dose. Skeletal muscle fibers with residual glycogen showed immunoreactivity for LAMP-1/LAMP-2, indicating that undigested glycogen remained in proliferating lysosomes. Glycogen clearance was more pronounced in type 1 fibers, and histochemical analysis suggested an increased mannose-6-phosphate receptor immunoreactivity in these fibers. Differential transport of enzyme into lysosomes may explain the strikingly uneven pattern of glycogen removal. Autophagic vacuoles, a feature of both the mouse model and the human disease, persisted despite glycogen clearance. In some groups a modest glycogen reduction was accompanied by improved muscle strength. These studies suggest that enzyme replacement therapy, although at much higher doses than in other lysosomal diseases, has the potential to reverse cardiac pathology and to reduce the glycogen level in skeletal muscle.

Possible interaction of zopiclone and nefazodone

OBJECTIVE

To describe a case in which concurrent treatment with nefazodone was associated with an elevation in the plasma concentration of zopiclone, possibly resulting in enhanced hypnosedative efficacy.

CASE REPORT

An 86-year-old white woman was treated with nefazodone for depression. Zopiclone was also introduced for the management of insomnia, but she subsequently experienced morning drowsiness. The concentration of zopiclone in plasma was subsequently measured eight hours after administration on two occasions, during nefazodone therapy and after its withdrawal. After discontnuation of nefazodone, the plasma concentration of the S-enantiomer of zopiclone decreased from 107 to 16.9 ng/mL, while the R-enantiomer plasma concentration decreased from 20.6 to 1.45 ng/mL.

DISCUSSION

Nefazodone is a relatively potent inhibitor of CYP3A4, a hepatic isoenzyme thought to play a major role in the metabolic elimination of zopiclone. The substantial decrease in the plasma zopiclone concentrations observed after withdrawal of nefazodone likely reflects a drug interaction. Despite the normally short elimination half-life of zopiclone, the residual sedation initially observed in this case suggests that the interaction may have clinical significance.

CONCLUSIONS

The features observed in this case suggest the possibility of a drug-drug interaction between nefazodone and zopiclone. Further prospective investigation is required to elucidate the nature and magnitude of this effect.

Bioindication potential of carbonic anhydrase activity in anemones and corals

Activity levels of carbonic anhydrase (CA) were assessed in anemones Condylactis gigantea and Stichodactyla helianthus with laboratory exposures to copper, nickel, lead, and vanadium, and also in animals collected from polluted vs pristine field sites. CA activity was found to be decreased with increase in metal concentration and also in animals collected from the polluted field site. Preliminary assessments to adapt the CA assay for use in the widespread coral Montastraea cavernosa show decreased CA activity in specimens from the polluted field site and provide an avenue for future research aimed at more thoroughly describing coral CA activity for potential application in bioindication.

Characteristics of tranquilizer use among Australian Vietnam War veterans

OBJECTIVE

To examine characteristics of tranquilizer use in a cohort of Australian Vietnam War veterans.

DESIGN

Prospective analysis of medication use and assessment of social and clinical variables, including tranquilizer dependence.

PATIENTS

Fifty-one Australian Vietnam War veterans were recruited from the department of psychiatry of an Australian teaching hospital. All subjects were men, with a mean +/- SD age of 52.2 +/- 3.3 years.

MAIN OUTCOME MEASURES

A structured interview was used to obtain details of medical and psychiatric history, medication use, substance use, forensic history, and health service utilization data. Anxiety was assessed using the Hamilton Anxiety Rating Scale (Ham-A). A validated tranquilizer dependence rating scale was administered for each patient.

RESULTS

Commonly used tranquilizers included diazepam (n = 19 patients) and zopiclone (26). Most patients (44) reported the use of one or more drugs for the purpose of nighttime sedation, while exclusive daytime use of tranquilizers for anxiolytic effect was uncommon. The median time spent in the hospital during the preceding year was 21.0 +/- 56.8 days. Symptoms of anxiety were prevalent, with a mean Ham-A score of 35.5 +/- 7.8. Screening criteria suggestive of tranquilizer dependence were met in 34 subjects. Health service utilization was correlated with tranquilizer intake and overall medication use. Tranquilizer dependence was independently associated with cigarette smoking (p = 0.039; odds ratio = 5.13, 95% CI 1.08 to 24.33).

CONCLUSIONS

This study provides insight into the nature of tranquilizer use in an Australian population of Vietnam War veterans. The extensive use of these drugs suggests that further research and possibly intervention in this area is needed.

Hospitalization rates as outcome indicators of national medicinal drug policies: the example of gastrointestinal ulcer

National medicinal drug policies are employed around the world as a means of maximizing the benefits of medication use. An essential component to the implementation of these policies is their concurrent evaluation, which informs future policy implementation and strategic directions. The overall effect of the policy can be measured by monitoring changes in health outcomes and hospitalization rates for conditions that can be managed with appropriate medication use have been proposed as a potential outcome indicator of national medicinal drug policies. In this paper, a method for establishing the validity of this indicator is described. The method enables suitable conditions to be identified and takes into account potential confounding factors. To demonstrate this a case study of hospitalization rates for gastrointestinal ulcer is presented. The analysis shows that hospitalization rates are suitable as outcome indicators of quality medication use where the hospitalization rate is not confounded by changes in the population profile, disease prevalence and severity, diagnosis, hospital based policies, coding practices, environmental factors or hospital based treatments, but is responsive to changes in the utilization of medication. This method could be used in many countries for determining relevant and valid indicators for monitoring health outcomes.

Outcomes of an educational-outreach service for community medical practitioners: non-steroidal anti-inflammatory drugs

OBJECTIVE

Exploration of longer-term outcomes of an ongoing educational-outreach service for community doctors.

DESIGN

Quasi-experimental, with parallel and historical comparisons.

SETTING

Since 1992, a teaching-hospital-based service has been providing advice and information on drugs and therapeutic strategies to community medical practitioners.

PARTICIPANTS

210 doctors practising in a particular area of metropolitan Adelaide (79% general practitioners; 21% specialists).

INTERVENTIONS

Two surgery visits during 1992 focused on better use of prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Subsequent visits on other topical therapeutic issues have occurred regularly.

MAIN OUTCOME MEASURES

Doctor participation in the service; supply of prescription NSAIDs; hospital admissions for gastrointestinal (GI) effects of NSAID use.

RESULTS

89% of doctors practising within the service area received the first visit on NSAIDs and 86% received the second visit. More than 85% continue to receive the service. Relative to a comparison area, aggregate reductions of 9% and 28%, respectively, were observed in two different measures of NSAID use. During an 11-year observation period, a single change point in the number of hospital admissions for GI disorders occurred in the service area, coinciding with delivery of the NSAID program. In the five years since the visits commenced, a 70% reduction in admissions was observed. No notable changes in hospital admission rates occurred in the comparison area.

CONCLUSIONS

A continuing education and support service for community medical practitioners which uses principally academic detailing methods in its contact with doctors has contributed to sustained changes in prescribed NSAID use over a five-year period. A focus on risk-minimisation in prescribing of NSAIDs appears to have contributed to reductions in hospitalisations for GI adverse events.

Improving drug use: a case study of events which led to changes in use of flucloxacillin in Australia

Policy makers and health professionals charged with implementing policies to improve medication use require knowledge as to how to integrate and co-ordinate strategies and interventions which have been shown to be effective. Experimental methodologies are commonly used to assess the effectiveness of interventions to improve medication use and while valuable for determining the effectiveness of particular interventions, they do not add to our understanding of how to co-ordinate and integrate multiple initiatives to improve medication use. We argue that analyses of the overall system of events which are implemented to improve medication use are also needed. In this paper, we demonstrate how the case study analysed within the framework of the Transtheoretical Model of behaviour change can be used to provide an understanding of the relationship of events which result in changes in medication use. A case study of the sequence of events which led to changes in the utilisation of flucloxacillin in Australia is assessed. The analysis demonstrated that the effectiveness of individual interventions was dependent upon the initiatives which were implemented concurrently and those that had been implemented previously. Changes in the utilisation of flucloxacillin resulted from regulatory interventions and the promotion of appropriate alternative therapies. The effectiveness of this change was enhanced by previous interventions which had raised awareness amongst health professionals of the adverse hepatic reaction associated with the use of flucloxacillin. This methodology adds to those currently employed to study methods of improving use of medications. It provides an understanding of the role of each initiative in the overall system. This is valuable for policy makers, providing them with information on how to co-ordinate and orchestrate the myriad of activities which support quality use of medicines.

Commercial detailing techniques used by pharmaceutical representatives to influence prescribing

AIM

To determine the use of influence techniques by pharmaceutical representatives in their encounters with medical practitioners.

METHOD

We identified six influence techniques from the marketing literature which are thought to be commonly used by sales people. These have been termed the principles of reciprocity, friendship/liking, commitment/consistency, social validation, authority, and scarcity. We examined the use of these techniques by analysing audio-recordings of pharmaceutical representatives' presentations to medical practitioners.

RESULTS

Sixteen recordings, detailing 64 medicines, were obtained from seven medical practitioners. Reciprocation was the most commonly observed method of influence. Samples, gifts, printed material, patient information leaflets or invitations were offered in all encounters. Appeals to authority figures, where promotional claims were supported by reference to professors or specialists, specialist groups and specialist hospitals, were recorded. Social validation acts, where reference was made to the peer group were also common. Commitment acts were observed to occur in two ways; the first was as a direct request to use the product detailed and the second was as a series of questions or statements which gradually moved from pre-agreed areas to solicitation of a commitment to prescribe the drug.

CONCLUSION

Influence techniques were found to be commonly used by pharmaceutical representatives when they detailed products to medical practitioners. Medical practitioners may not be aware of the potential effect these techniques can have on their prescribing practices. Knowledge of these techniques must be incorporated into educational programmes designed to provide health professionals with critical appraisal skills.

Self-regulatory codes of conduct: are they effective in controlling pharmaceutical representatives' presentations to general medical practitioners?

Self-regulatory codes of conduct are used to control the promotional practices of the pharmaceutical industry, but the effectiveness of these codes in controlling pharmaceutical representatives' presentations has not been examined. This is a matter of concern because pharmaceutical representatives have more influence than any other promotional media on prescribing practices. The authors developed a method for monitoring the oral presentations of pharmaceutical representatives when promoting products to medical practitioners. Sixteen audio-recordings, detailing 64 medicines, were obtained; 38 of the 64 products were prescription-only medicines. Information on indications and on dosage and administration was commonly provided, but information on other areas of drug knowledge, particularly product risk, was minimal. Thirteen presentations contained at least one inaccuracy when compared with Australian Approved Product Information. Presentations did not always comply with current guidelines in the Code of Conduct. The Code provides only limited standards for pharmaceutical representatives' presentations, and no active monitoring system is in place to ensure adherence to the code. There is an urgent need for policy development on the role of pharmaceutical representatives, their standards of practice, and regulation of their activities to ensure they contribute to the appropriate use of medicines.

Drug-related hospital admissions: a review of Australian studies published 1988-1996

OBJECTIVE

To examine the extent of drug-related hospital admissions in Australia by reviewing Australian studies published between 1988 and 1996.

DATA SOURCES AND STUDY SELECTION

The terms "drug-related", "admissions", "readmissions", "hospitalisation", "hospitalization" and "iatrogenic" were used to search MEDLINE and Australian Public Affairs Information Service databases. The Australian Journal of Hospital Pharmacy and conference proceedings of the Society of Hospital Pharmacists and the Australasian Pharmaceutical Science Association were searched manually. Studies were included if they were Australian, had the primary aim of identifying drug-related admissions, and had at least one clinical pharmacist or medical practitioner review the admissions.

DATA EXTRACTION

Total number of admissions assessed; proportion considered drug-related; drug groups implicated; and proportion considered avoidable.

DATA SYNTHESIS

14 studies were identified; 2.4%-3.6% of all hospital admissions were reported to be drug-related. 6%-7% of emergency admissions, 12% of all admissions to medical wards and 15%-22% of all emergency admissions among the elderly were drug related. Between 32% and 69% of drug-related admissions were reported as definitely or possibly preventable. Drug groups most commonly implicated were cytotoxics, cardiovascular agents, antihypertensives, anticoagulants and non-steroidal anti-inflammatory drugs.

CONCLUSION

Drug-related hospital admissions are a significant and expensive public health problem in Australia, and approximately half were considered possibly or probably preventable.

Finding edges in noisy scenes

Edge detection in the presence of noise is a well-known problem. This paper examines an applications-motivated approach for solving the problem using novel techniques and presents a method developed by the authors that performs well on a large class of targets. ROC curves are used to compare this method with other well-known edge detection operators, with favorable results. A theoretical argument is presented that favors LMMSE filtering over median filtering in extremely noisy scenes. Simulated results of the research are presented.

A real-time video tracking system

Object identification and tracking applications of pattern recognition at video rates is a problem of wide interest, with previous attempts limited to very simple threshold or correlation (restricted window) methods. New high-speed algorithms together with fast digital hardware have produced a system for missile and aircraft identification and tracking that possesses a degree of ``intelligence'' not previously implemented in a real-time tracking system. Adaptive statistical clustering and projection-based classification algorithms are applied in real time to identify and track objects that change in appearance through complex and nonstationary background/foreground situations. Fast estimation and prediction algorithms combine linear and quadratic estimators to provide speed and sensitivity. Weights are determined to provide a measure of confidence in the data and resulting decisions. Strategies based on maximizing the probability of maintaining track are developed. This paper emphasizes the theoretical aspects of the system and discusses the techniques used to achieve real-time implementation.