Prediction Score for Anticoagulation Control Quality Among Older Adults.

BACKGROUND: Time in the therapeutic range (TTR) is associated with the effectiveness and safety of vitamin K antagonist (VKA) therapy. To optimize prescribing of VKA, we aimed to develop and validate a prediction model for TTR in older adults taking VKA for nonvalvular atrial fibrillation and venous thromboembolism. METHODS AND RESULTS: The study cohort comprised patients aged ≥65 years who were taking VKA for atrial fibrillation or venous thromboembolism and who were identified in the 2 US electronic health record databases linked with Medicare claims data from 2007 through 2014. With the predictors identified from a systematic review and clinical knowledge, we built a prediction model for TTR, using one electronic health record system as the training set and the other as the validation set. We compared the performance of the new models to that of a published prediction score for TTR, SAMe-TT2R2. Based on 1663 patients in the training set and 1181 in the validation set, our optimized score included 42 variables and the simplified model included 7 variables, abbreviated as PROSPER (Pneumonia, Renal dysfunction, Oozing blood [prior bleeding], Staying in hospital ≥7 days, Pain medication use, no Enhanced [structured] anticoagulation services, Rx for antibiotics). The PROSPER score outperformed SAMe-TT2R2 when predicting both TTR ≥70% (area under the receiver operating characteristic curve 0.67 versus 0.55) and the thromboembolic and bleeding outcomes (area under the receiver operating characteristic curve 0.62 versus 0.52). CONCLUSIONS: Our geriatric TTR score can be used as a clinical decision aid to select appropriate candidates to receive VKA therapy and as a research tool to address confounding and treatment effect heterogeneity by anticoagulation quality.

Relationship between attitudes toward mental illness and provision of pharmacy services.

OBJECTIVES: To compare how community pharmacists felt they and other health professionals perceived individuals with depression and schizophrenia and whether pharmacists' attitudes and other factors affected willingness to provide services to patients with mental illness. SETTING: Northeastern United States in summer 2006. PARTICIPANTS: Pharmacists at 750 community pharmacies. INTERVENTION: A survey was mailed to the community pharmacies, which were randomly selected from a list obtained from a state board of pharmacy in the northeastern United States. MAIN OUTCOME MEASURES: Pharmacist attitudes toward individuals with schizophrenia and depression and willingness to provide pharmacy services to patients with mental illness. RESULTS: 292 surveys were completed (response rate 38.9%). The pharmacists surveyed felt that they had more positive attitudes toward individuals with depression and schizophrenia compared with other pharmacists (P =≤0.01). Compared with physicians, pharmacists perceived themselves as having less negative attitudes toward those with depression (P =≤0.001) but greater negative attitudes toward individuals with schizophrenia (P =≤.05). More pharmacists were willing to provide services to those with asthma than those with mental illness (P =≤0.001). Pharmacists were more likely to provide services to patients with mental illness if they had fewer negative attitudes for those with depression or schizophrenia and placed a greater value on counseling patients (P =≤0.001). Minority pharmacists were more willing to provide services to patients with mental illness. CONCLUSION: Community pharmacists have more negative views of schizophrenia than depression and felt that they perceived those with schizophrenia more negatively than physicians. Our findings suggest two ways to improve community pharmacist willingness to provide services to patients with mental illness: reduce negative attitudes toward patients with mental illness and increase pharmacists' perceived value of counseling patients.