Autonomous ambulatory care by nurse practitioners and physician assistants in office-based settings.

Data from the 1997 National Ambulatory Medical Care Survey were used to examine the autonomous provision of ambulatory medical care by nurse practitioners (NPs) and physician assistants (PAs) in physician-managed office-based settings. An estimated 6.81 million office visits involved autonomous care by NPs and PAs, for an overall rate of 2.55 visits per 100 persons. The visit rates were greatest for patients over 64 years of age, females, blacks, and patients from the Northeast. The visits encompassed a broad range of acute and chronic problems, with a greater proportion of non-illness care visits when compared with visits to physicians. While NPs and PAs provided diagnostic services and pharmacotherapy, there was more emphasis on therapeutic or preventive services in their practices than among physicians' practices. Predisposing, enabling, and need factors were differentially associated with visits to NPs and PAs. Utilization of NPs and PAs as autonomous providers in office-based settings appears limited. Public policy and educational initiatives can focus on predisposing, enabling, and need factors to increase access to autonomous practice of NPs and PAs in ambulatory care.

Utilization of ambulatory care services caused by adverse effects of medications in the United States.

Using the 1996 national ambulatory care surveys for the United States, this study examined the utilization of ambulatory care services because of the adverse effects of medications. Of the visits to ambulatory settings, 0.31% were because of adverse effects of medications, representing an estimated 2.73 million visits annually or 1.03 visits per 100 persons. Most (88%) of the visits were to office-based physicians, and the remainder were to hospitals. From both cost and quality perspectives, implementing strategies to prevent and/or effectively manage the adverse effects of medications could prove beneficial for payers and patients.

Prescribing potentially inappropriate psychotropic medications to the ambulatory elderly.

BACKGROUND: Psychotropic agents account for 23% to 51% of all inappropriate medications prescribed based on 1991 inappropriate medication criteria for nursing home residents. The criteria were revised to apply to all people older than 65 years. This study used the revised criteria in ambulatory settings to quantify potentially inappropriate prescription of psychotropic agents and identify associated characteristics. METHODS: The 1996 public use data files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey were analyzed for inappropriate prescription of psychotropic medications for the elderly in office-based settings and outpatient departments. Disease-independent and disease-dependent criteria were analyzed. RESULTS: Elderly patients were prescribed a psychotropic agent in 8. 7% of all visits, antidepressant and antianxiety agents being the most frequently prescribed medications. Commonly, elderly patients receiving psychotropic agents were female, white, aged between 65 and 74 years, and received health care in a metropolitan area. Potentially inappropriate psychotropic agents were prescribed in 27. 2% of all visits involving a psychotropic agent for the elderly. Disease-independent criteria (eg, antidepressant agents and long-acting benzodiazepines) accounted for most of the potentially inappropriate prescriptions. Factors positively associated with potentially inappropriate prescriptions included older age, "seen before" status, and antidepressant drug class, while enrollment in Medicaid, antipsychotic drug class, living in the Northeast region, and receiving health care in a metropolitan area were negatively associated. CONCLUSIONS: Potentially inappropriate prescription of psychotropic agents is very common for the elderly patient in the ambulatory setting. By focusing on the agents most frequently involved (eg, amitriptyline and long-acting benzodiazepines), provider characteristics (eg, location), and patient characteristics (eg, age), the greatest impact on potentially inappropriate prescribing can be achieved.

Inappropriate prescribing for the elderly: beers criteria-based review.

OBJECTIVE: To review currently available literature applying the Beers criteria for inappropriate medication use in the elderly to prescribing practices in various settings. DATA SOURCE: Key words including inappropriate, Beers, medication, prescribing, elderly, geriatric, and criteria were used to search MEDLINE records from January 1992 to June 1999. DATA EXTRACTION: Eight relevant studies were found that applied the Beers criteria in various healthcare settings. DATA SYNTHESIS: Each study was examined for methodologic issues, criteria used, prevalence, nature and extent of inappropriate medication use, and factors associated with their use. Despite the methodologic differences, the review revealed some consistent patterns across healthcare settings. This review has shown that: (1) most of the researchers modified the Beers criteria to examine inappropriate medication use in the elderly; (2) studies using patient-based prevalence showed that between nearly one in four (23.5%) and one in seven (14.0%) elderly patients received an inappropriate medication as defined by either the Beers list of 20 inappropriate medications or the Modified Beers list; (3) the majority of these patients received one inappropriate agent; and (4) long-acting benzodiazepines, dipyridamole, propoxyphene, and amitriptyline were among the most frequently prescribed inappropriate medications. Univariate analyses indicated that women, patients >80 years old, and Medicaid patients appeared to receive more inappropriate medications than others; however, multivariate analyses found that only a higher number of medications was consistently associated with inappropriate medication use. CONCLUSIONS: Inappropriate prescribing or use trends are noteworthy because they were observed despite methodologic differences. The findings can be instrumental in developing targeted interventions to influence future prescribing practices. More research is needed to address the national trends and healthcare impact of inappropriate drug use in the elderly.

Opioid-induced emesis among hospitalized nonsurgical patients: effect on pain and quality of life.

There is very little information in the medical literature regarding opioid-induced emesis and its relationship to patient outcomes. Two-hundred and six nonsurgical patients in a 400-bed teaching hospital with minimal known risks of disease-associated emesis were interviewed to examine emesis and associated outcomes following the administration of opioids for acute pain management. The mean age, weight, and height of the study group were 54.4 (+/- 19.6) years, 175.8 (+/- 45.7) pounds, and 67.1 (+/- 4.4) inches, respectively. Seventy-three (35.4%) patients experienced nausea; 28 (13.6%) patients vomited; and 15 (7.3%) patients retched following the opioid therapy. These symptoms were mild and discomforting for relatively short periods of time. The patients' ability to concentrate and eat was affected by the incidence of nausea/vomiting. The intensity, duration, and severity of nausea were positively associated with the magnitude of the functional limitations. The symptoms also influenced patients' ratings of various hospital satisfaction measures. In conclusion, emesis due to opioids represents a notable burden on nonsurgical patients. Successful therapies that prevent opioid-induced emesis are likely to positively influence patient outcomes by reducing adverse effects, improving functional outcomes, and enhancing quality of life.

Visits to office-based physicians in the United States for medication-related morbidity.

OBJECTIVE: To examine the prevalence, nature, demographics, and resource use associated with visits to office-based physicians in the United States during 1995 for medication-related morbidity. DESIGN: A nationwide cross-sectional survey of ambulatory care visits to physician offices, based on data from the National Center for Health Statistics' 1995 National Ambulatory Medical Care Survey. SETTING: Physician office-based settings in the United States. PATIENTS: Patients visiting office-based physicians for principal diagnoses of adverse effect of medications (ICD-9-CM E-code 930.00-947.9). MAIN OUTCOME MEASURES: Weighted measures of prevalence, nature, demographics, and resource use associated with visits related to adverse effects of medications. RESULTS: An estimated 2.01 million (95% confidence interval, 1.69 to 2.34 million) visits for medication-related morbidity were made to office-based physicians in the United States during 1995, representing an annual rate of 7.70 visits per 1,000 persons. Medication-related visit rates were greater in women, in patients between 65 and 74 years of age, and in the Midwest. The most frequently cited reasons for medication-related visits were skin rash, nausea, and shortness of breath. The therapeutic agents responsible for medication-related visits were most often hormone and synthetic substitutes (13.32%), antibiotics (11.55%), and cardiovascular drugs (9.30%). Medication-related visits most often involved diagnostic services and medication therapy. The majority included instructions for a scheduled follow-up, and fewer than 1% resulted in hospital admission. CONCLUSION: Medication-related ambulatory care utilization can pose a significant burden on health care resources unless specific strategies are initiated to control medication-related problems. The provision of pharmaceutical care can play an important role in reducing medication-related problems and associated health care costs.

Inappropriate prescribing for elderly outpatients.

The frequency of potentially inappropriate prescribing for elderly outpatients and factors predicting inappropriate prescribing for these patients were studied. A panel of experts in geriatric medicine and geriatric pharmacology developed a list of 20 drugs generally considered to be inappropriate for elderly patients. Data on outpatient visits by patients aged 65 years or older were extracted from the 1994 National Hospital Ambulatory Medical Care Survey and analyzed with respect to the 20 potentially inappropriate medications. Potentially inappropriate medications were prescribed at 4.45% of elderly outpatient visits involving medications. An estimated 319,302 (95% confidence interval, 256,269 to 382,334) visits involved potentially inappropriate medications. The most frequently prescribed potentially inappropriate medications were diazepam, propoxyphene, dipyridamole, amitriptyline, and chlordiazepoxide; these drugs accounted for 85% of the outpatient visits involving potentially inappropriate medications. Patients were more likely to be prescribed potentially inappropriate medications if they had been referred; had a number of medications prescribed; had a prescription for an antianxiety agent, a sedative, an antidepressant, an analgesic, a platelet inhibitor, or an antispasmodic agent; or had a medication prescribed by a provider from a nonmetropolitan area. Ambulatory care providers prescribed at least one potentially inappropriate medication at 4.45% of visits by elderly patients at which a medication was prescribed; patient characteristics, provider characteristics, and drug-use profiles can be used to predict inappropriate prescribing.

Psychotropic prescribing for the elderly in office-based practice.

This study employed data from the National Ambulatory Medical Care Survey (NAMCS) 1995 to (1) determine the prevalence of the prescribing of psychotropic drugs for elderly patients by office-based physicians in the United States; (2) estimate the prevalence of the prescribing of potentially inappropriate psychotropic drugs in this patient population; and (3) identify any factors that predict such prescribing. For the purposes of this study, previously developed consensus criteria were adopted defining inappropriate psychotropic drugs as those that should be avoided in the elderly. According to the NAMCS data, psychotropic medications were prescribed in an estimated 12.02 million visits by elderly patients (95% confidence interval [CI], 11.07-12.97 million). The psychotropic medications most frequently prescribed for elderly patients by office-based physicians were antidepressants and antianxiety agents. The occurrence of visits at which psychotropic medications were prescribed was greater in patients who were over 84 years of age, female, white, or from the western United States. Primary care physicians prescribed the majority of these psychotropic drugs, and most visits to psychiatrists by elderly patients resulted in the prescribing of psychotropic drugs. Office-based physicians prescribed at least one potentially inappropriate psychotropic medication in 2.03 million visits by the elderly (95% CI, 1.70-2.36 million), or 16.87% of visits by the elderly involving prescriptions for psychotropic drugs. The most frequently prescribed potentially inappropriate psychotropic drugs were amitriptyline and long-acting benzodiazepines such as diazepam, chlordiazepoxide, and flurazepam. Logistic regression analyses revealed that inappropriate prescribing of psychotropic drugs for elderly patients was associated with particular patient characteristics (visit due to an injury), drug characteristics (number of medications prescribed and the drug being an antidepressant or antianxiety agent), and physician characteristics (psychiatric specialty and location in the South or Northeast). The patterns of psychotropic prescribing found in the ambulatory setting raise concerns about the quality of care being received by elderly patients with psychiatric illnesses.

Factors predicting survival, changes in activity limitations, and disability in a geriatric post-stroke population.

This study is based on data for individuals with a history of stroke taken from the NIA-sponsored Longitudinal Study of Aging (LSOA), 1984-1990. It provides information on the factors predicting survival and changes in disability and activity limitations in this cohort with stroke or cerebrovascular accident over the period of two years, 1984 to 1986. The results indicate that individuals who were less than 80 years old had higher chances of survival and were likely to show reduced activity limitations and disabilities. It was also observed that the individuals who were in excellent health were more likely to survive despite a history of stroke. Individuals with severe activity limitations had a very low incidence of survival over the two-year period. Further, the results of this study support the contention that the increased use of health care resources in the form of visits to physicians, hospitals, and nursing homes results in improved survival and lower disability and activity limitations among the elderly.

Inappropriate medication prescribing for the elderly by office-based physicians.

OBJECTIVE: To estimate the prevalence of inappropriate medications prescribed by office-based physicians for patients 65 years or older. DESIGN: A nationwide cross-sectional survey of office visits by the elderly. SETTING: The National Ambulatory Medical Care Survey (NAMCS) 1992, a national probability sample survey of office visits by ambulatory patients within the continental US. SUBJECTS: A national probability sample of patients 65 years or older visiting office-based physicians. National estimates are based on the National Center for Health Statistics weighting procedure for the NAMCS sample. MAIN OUTCOME MEASURES: Prevalence of 20 inappropriate medications that should be entirely avoided in the elderly, using criteria developed by a panel of national experts in geriatric medicine and geriatric pharmacology. RESULTS: In the US during 1992, an estimated 8.47 million (95% CI 7.66 million to 9.28 million) office visits by the elderly indicated prescribing of at least 1 of the 20 inappropriate medications. Approximately 7.75 million (95% CI 6.98 million to 8.52 million) visits by the elderly involved 1 inappropriate medication and 0.72 million (95% CI 0.51 million to 0.93 million) visits included 2 inappropriate medications. According to the NAMCS, office-based physicians prescribed at least 1 inappropriate medication to 7.58% of the elderly who received prescriptions. The most frequently prescribed inappropriate medications were propoxyphene, amitriptyline, dipyridamole, diazepam, and chlorpropamide. Elderly patients rarely received prescriptions from office-based physicians for drugs such as secobarbital, isoxsuprine, trimethobenzamide, and carisoprodol. Furthermore, office-based physicians did not prescribe cyclandelate, pentobarbital, or phenylbutazone for the elderly. CONCLUSIONS: The prescribing of inappropriate medications by office-based physicians raises concerns regarding the quality of care for the elderly in ambulatory settings. The crux of improving patient care in ambulatory settings rests with collaborative efforts between physicians and pharmacists.