Implementation and Assessment of an Ambulatory Prescribing Guidance Tool to Improve Patient Safety in the Geriatric Population.

OBJECTIVE: The purpose of this study was to assess the effects of a clinical decision support (CDS) tool aimed at decreasing the prescribing of glyburide, a potentially inappropriate medication (PIM), in patients 65 years of age and older. DESIGN: Quasi-experimental, pre-post intervention study. SETTING: Ambulatory care clinics of an academic medical center. INTERVENTION: The tool appeared to providers when entering new prescriptions or refills for glyburide. Glimepiride, which is a more appropriate sulfonylurea, was suggested as an alternative at order entry. MAIN OUTCOME MEASURE(S): The primary outcome was the prescribing of glyburide orders, measured as a percentage of the total oral diabetic medications ordered in patients 65 years of age and older, during the study period. The secondary outcome measured was the response to the CDS tool (accept versus reject). RESULTS: The CDS tool alerted providers 101 times during the 90-day postimplementation period. When the tool appeared, patients were transitioned off of glyburide 17.8% of the time. Subanalysis found that when physicians viewed the alert, patients were transitioned off of glyburide 46.2% of the time. As a percentage of the total number of oral diabetic medications, glyburide prescribing was significantly decreased from pre- to postimplementation study period (3.3% vs. 1.2%; P < 0.001). CONCLUSIONS: A CDS tool can be used in the ambulatory care setting to influence prescribing and provide a safer alternative medication. Additional information is needed to test the use of a CDS tool in conjunction with education to ensure providers are comfortable with and understand implications of a CDS tool.

Acquired Thrombophilia.

Acquired thrombophilia is associated with an increased risk of venous thromboembolism (VTE). Antiphospholipid syndrome (APS) is the most prevalent acquired thrombophilia and is associated with both venous and arterial thromboses. Human immunodeficiency virus (HIV) is another form of acquired thrombophilia. Risk factors associated with VTE in this population include those related to the disease itself, host factors, and the pharmacotherapy for HIV. A significant proportion of VTE events occur in patients with malignancies. There is an increase in mortality associated with patients having cancer who experience VTE when compared to patients having cancer without VTE. Combination oral contraceptive (COC) use infers risk of thromboembolic events. The risk is dependent upon the presence of an underlying inherited thrombophilia, the estrogen dose, and generation of progestin. Patients at highest risk of VTE include those receiving high-dose estrogen and fourth-generation, progesterone-containing contraceptives. With the exception of APS, thrombophilia status does not alter the acute treatment of an initial VTE in nonpregnant patients.

Pregnancy-Related Venous Thromboembolism.

Pregnancy is associated with an increased risk of venous thromboembolism (VTE), with a reported incidence ranging from 0.49 to 2 events per 1000 deliveries. Risk factors include advanced maternal age, obesity, smoking, and cesarian section. Women with a history of previous VTE are at a 4-fold higher risk of recurrent thromboembolic events during subsequent pregnancies. Additionally, the presence of concomitant thrombophilia, particularly factor V Leiden (homozygosity), prothrombin gene mutation (homozygosity), or antiphospholipid syndrome (APS), increases the risk of pregnancy-related VTE. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are the drugs of choice for anticoagulation during pregnancy. LMWH is preferred due to ease of use and lower rates of adverse events. Women with high thromboembolic risk particularly those with a family history of VTE should receive antepartum thromboprophylaxis. Women with low thromboembolic risk or previous VTE caused by a transient risk factor (ie, provoked), who have no family history of VTE, may undergo antepartum surveillance. Postpartum anticoagulation can be considered in women with both high and low thromboembolic risk.

Inherited Thrombophilia.

Thrombophilia alters normal hemostasis, shifting the balance in favor of thrombus formation. Inherited conditions include factor V Leiden (FVL), prothrombin G20210A mutation, deficiencies in natural anticoagulants (antithrombin [AT], protein C, and protein S), hyperhomocysteinemia, and elevations in clotting factors (factors VIII and XI). Although FVL and prothrombin mutation are common disorders, deficiencies in the natural anticoagulants are rare. The risk of initial thrombosis conferred by inherited thrombophilia varies with the highest risk in those homozygous for either FVL or prothrombin mutation, or with AT deficiency. In the nonpregnant patient, the presence of a thrombophilia does not affect treatment of an acute event. Although vitamin B supplementation has been shown to decrease the levels of homocysteine, the treatment has failed to show a benefit in thrombus prevention and is therefore not recommended.

Thrombophilia Screening.

Although controversial, screening for thrombophilia has become common. Testing for antiphospholipid antibodies is indicated in order to guide treatment decisions if there is clinical suspicion for antiphospholipid syndrome. The utility of identifying other thrombophilias in symptomatic venous thromboembolism (VTE) is questionable, as the risk of recurrence does not appear to be increased by an appreciable degree with the most common disorders (heterozygosity for factor V Leiden or prothrombin mutation). Although recurrence appears to be increased in those with homozygous or multiple abnormalities and potentially deficiencies in natural anticoagulants, screening to detect these conditions is difficult to justify based on their rarity. The American College of Chest Physicians' current guidelines note the increased risk of recurrence with idiopathic, proximal events regardless of thrombophilia status. They suggest duration of anticoagulation therapy be based on location and provoking factors rather than whether or not the individual has a thrombophilia. Because routine prophylaxis in asymptomatic individuals with thrombophilia is not recommended, screening of asymptomatic family members is difficult to justify. Screening prior to prescribing combination oral contraceptives is not cost effective, may result in unwanted pregnancies, and may have little effect on the overall rate of VTE.

Postdischarge interventions by pharmacists and impact on hospital readmission rates.

OBJECTIVES: To determine whether a difference exists in hospital readmission rates at 60 days postdischarge between patients who saw (intervention group) or did not see (control group) a pharmacist within 60 days of discharge and to describe the number and type of pharmacist interventions. DESIGN: Retrospective electronic record review. SETTING: Austin, TX, from January 2006 to January 2010. PATIENTS: 131 adult patients aged 18 to 65 years who were on at least three prescription medications. INTERVENTION: Pharmacist visit within 60 days post-hospital discharge. MAIN OUTCOME MEASURE: Hospital readmission rates at 60 days postdischarge. RESULTS: The intervention and control groups did not differ regarding age or gender, but the control group had a higher percentage of whites, fewer medications, and fewer diseases. Chi-square analyses revealed that of 65 patients in the control group, 28 (43.1%) were readmitted to the hospital within 60 days of discharge compared with 12 of 66 (18.2%) intervention group patients (P = 0.0020). Pharmacists provided approximately two interventions per patient. The most frequently provided pharmacist interventions were medication counseling (88.1%) and drug dosage adjustment (52.2%). CONCLUSION: Patients on multiple prescription medications and with chronic diseases may benefit from a pharmacist visit within 60 days of hospital discharge. However, future studies are needed to further determine the effectiveness of pharmacists' interventions post-hospital discharge.

Evaluation and pharmacologic approach to patients with resistant hypertension.

Patients are diagnosed as having resistant hypertension when they have blood pressure readings that remain above goal despite the concomitant use of 3 optimally dosed antihypertensive agents from different classes, with 1 of the agents being a diuretic. Prior to diagnosing a patient as having resistant hypertension, it is important to document adherence and exclude white-coat hypertension, inaccurate measurement of blood pressure, and secondary causes of hypertension (eg, aldosterone excess). After determining resistance, optimization of the medication regimen is essential. Combination strategies, which might include dual renin-angiotensin-aldosterone blockade with spironolactone as 1 agent, have been proven successful. This article focuses on the safety and efficacy of spironolactone when added to an optimized 3-drug regimen. Additionally, the use of spironolactone in chronic kidney disease and obstructive sleep apnea complicated by resistant hypertension is discussed. These 2 clinical entities are frequently accompanied by resistant hypertension and are indications for the use of spironolactone as well.

A review of insulin pen devices and use in the elderly diabetic population.

The prevalence of diabetes mellitus (DM) in the elderly population currently represents almost one-half of the overall diabetic population. Treatment of DM often requires a multidrug regimen that includes insulin therapy; however, due to concomitant comorbidities such as dementia, vision loss, neuropathies, poor mobility, and poor manual dexterity, elderly patients may be at increase risk for hypoglycemia and other dosing errors that are associated with insulin administration. Insulin pen devices have been shown to provide more reliable, accurate, and simplified dosing, and therefore may be a safer, easier, and more acceptable method of insulin delivery in the elderly population. This review will describe the various insulin pen devices available today, as well as discuss the potential advantages of these devices in the elderly population.