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.

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.

Reporting of studies on new medicines in major medical journals: a case study in breast cancer

A comparison of the results of pivotal trials on three new medicines for advanced breast cancer published in medical journals with those presented in the US Food and Drug Administration (FDA) reviews showed that analyses reported in journals were of lower quality and were given a favorable interpretation by minimizing toxicity and ignoring methodological shortcomings. Several proposals to strengthen the quality of reporting of clinical trials in medical journals and to support reliable assessment of the therapeutic value of new medicines are discussed.

Pharmaceutical care services: a systematic review of published studies, 1990 to 2003, examining effectiveness in improving patient outcomes

Objective

To systematically review the evidence for the effect of pharmaceutical care practice on patient outcomes.

Setting

Community and outpatient setting.

Method

Randomised controlled trials (RCTs) published in English between 1990 and 2003 were identified through a systematic literature search. To be included, studies had to assess the effect of a pharmaceutical care intervention, defined as a one-to-one consultation between each patient and a pharmacist with a focus on managing health or resolving drug-related problems, development of a care plan and follow-up.

Key findings

Twenty-two RCTs met the review criteria. Studies targeted general patient populations at risk of drug-related problems, disease-specific target groups or patients with risk factors including hypertension and raised cholesterol. While a number of trials have been undertaken, the variability in the application of endpoints utilised means the evidence for effectiveness of single endpoints apart from quality of life is generally limited to one or two controlled trial results. Collectively, the studies provide evidence that the service improves signs and symptoms for people with asthma, surrogate endpoints such as blood pressure, cholesterol levels and glycosylated haemoglobin and medication use, but do not provide evidence supporting improved health-related quality of life. One study showed an improvement in combined all-cause mortality and non-fatal heart failure-related events in patients with heart failure.

Conclusion

Pharmaceutical care services are effective in improving medication use and surrogate endpoints, but improvement in other outcomes is less conclusive. Given that the focus of the service is to resolve medication-related problems, consideration should be given to the use of adverse drug events and resolution of medication-related problems as an outcome measure in future studies.

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.