Primary non-adherence to bisphosphonates in an integrated healthcare setting

We estimated primary non-adherence to oral bisphosphonate medication and examined the factors associated with primary non-adherence. Nearly 30% of women did not pick up their new bisphosphonate within 60 days. Identifying barriers and developing interventions that address patients' needs and concerns at the time a new medication is prescribed are warranted.

INTRODUCTION

To estimate primary non-adherence to oral bisphosphonate medications using electronic medical record data in a large, integrated healthcare delivery system and to describe patient and prescribing provider factors associated with primary non-adherence.

METHODS

Women aged 55 years and older enrolled in Kaiser Permanente Southern California (KPSC) with a new prescription for oral bisphosphonates between December 1, 2009 and March 31, 2011 were identified. Primary non-adherence was defined as failure to pick up the new prescription within 60 days of the order date. Multivariable logistic regression models were used to investigate patient factors (demographics, healthcare utilization, and health conditions) and prescribing provider characteristics (demographics, years in practice, and specialty) associated with primary non-adherence.

RESULTS

We identified 8,454 eligible women with a new bisphosphonate order. Among these women, 2,497 (29.5%) did not pick up their bisphosphonate prescription within 60 days of the order date. In multivariable analyses, older age and emergency department utilization were associated with increased odds of primary non-adherence while prescription medication use and hospitalizations were associated with lower odds of primary non-adherence. Prescribing providers practicing 10 or more years had lower odds of primary non-adherent patients compared with providers practicing less than 10 years. Internal medicine and rheumatology providers had lower odds of primary non-adherent patients than primary care providers.

CONCLUSION

This study found that nearly one in three women failed to pick up their new bisphosphonate prescription within 60 days. Identifying barriers and developing interventions aimed at reducing the number of primary non-adherent patients to bisphosphonate prescriptions are warranted.

Surveillance of autoimmune conditions following routine use of quadrivalent human papillomavirus vaccine

OBJECTIVE

An observational safety study of the quadrivalent human papillomavirus vaccine (HPV4) in women was conducted. This report presents findings from autoimmune surveillance. Design.  Subjects were followed for 180days after each HPV4 dose for new diagnoses of 16 prespecified autoimmune conditions.

SETTING

Two managed care organizations in California. Subjects.  Number of 189,629 women who received ≥1 dose of HPV4 between 08/2006 and 03/2008.

OUTCOME

Potential new-onset autoimmune condition cases amongst HPV4 recipients were identified by electronic medical records. Medical records of those with ≥12-month health plan membership prior to vaccination were reviewed by clinicians to confirm the diagnosis and determine the date of disease onset. The incidence of each autoimmune condition was estimated for unvaccinated women at one study site using multiple imputations and compared with that observed in vaccinated women. Incidence rate ratios (IRR) were calculated. Findings were reviewed by an independent Safety Review Committee (SRC).

RESULTS

Overall, 1014 potential new-onset cases were electronically identified; 719 were eligible for case review; 31-40% were confirmed as new onset. Of these, no cluster of disease onset in relation to vaccination timing, dose sequence or age was found for any autoimmune condition. None of the estimated IRR was significantly elevated except Hashimoto's disease [IRR=1.29, 95% confidence interval: 1.08-1.56]. Further investigation of temporal relationship and biological plausibility revealed no consistent evidence for a safety signal for autoimmune thyroid conditions. The SRC and the investigators identified no autoimmune safety concerns in this study.

CONCLUSIONS

No autoimmune safety signal was found in women vaccinated with HPV4.

Matched case-control study of adjusted versus nonadjusted gentamicin dosing in perforated and gangrenous appendicitis

A matched case-control study of the efficacy of gentamicin dosage adjustment through the use of pharmacokinetic analysis of serum drug concentrations in patients treated by appendectomy for perforated or gangrenous appendicitis was performed. Two groups of patients were compared. In one group gentamicin was initiated preoperatively at 1.5 mg/kg Intravenous Piggy Back (IVPB) every 8 h. Postoperatively, serum levels were obtained to maintain peak concentrations within a range of 6-8 micrograms/ml. The comparison group was given gentamicin without measurement of drug levels. Both groups received clindamycin 600 mg IVPB every six h. Matched cases and control subjects were compared, controlling for pathologic state of the appendicitis, age, and sex. The patients were predominantly young men with normal renal function. More patients in the nonadjusted group had infectious complications than in the dose-adjusted group. There were seven failures (11.3%) in the nonadjusted group compared with only one failure (1.6%) in the dose-adjusted group, a significant difference (p = 0.03). Among the nonadjusted group, the complications were four abdominal abscesses, two wound infections, and one persistent high fever. There was no evidence of nephrotoxicity in either group. Our recommendations are that patients who are to undergo appendectomy for perforated/gangrenous appendicitis should be treated with clindamycin and gentamicin at a dose of 1.5 mg/kg. With normal renal function, an interval of 8 h is appropriate. Serum gentamicin levels should be obtained and the dose adjusted to maintain peak concentrations of 6-8 micrograms/ml.

Comparison of physician and pharmacist management of anticoagulant therapy of inpatients

The management of anticoagulant therapy for hospitalized patients by seven certified pharmacist prescribers and one physician was compared. Eighty-one consecutive patients referred to the anticoagulation service were randomly assigned to two groups. For patients in the pharmacist-prescriber group, the physician independently monitored laboratory results and simulated heparin and warfarin doses. The roles of pharmacist and physician were reversed for patients in the physician-prescriber group. According to an established protocol, adjustments in heparin sodium infusion rate were based on activated partial thromboplastin time (PTT); warfarin sodium dosage was adjusted using a proconvertin and prothrombin (P&P) method. Heparin doses, warfarin doses, and clotting-test results were compared for patients in the two prescriber groups; simulated and actual doses also were compared. Patients were observed for complications of anticoagulant therapy. There were no significant differences in the mean heparin and warfarin doses administered to patients in the two prescribed groups. Similarly, PTT and number of days to reach therapeutic P&P were not significantly different. Within each group, the mean prescribed and simulated heparin doses were not significantly different. There were no episodes of major bleeding, but four patients in the pharmacist-prescriber group had minor bleeding. While the results are not applicable to all pharmacists or all settings, the certified pharmacist prescribers in this study adjusted anticoagulant therapy as well as an experienced physician.