Physical health monitoring in dementia and associations with ethnicity: a descriptive study using electronic health records.

BACKGROUND: Good physical health monitoring can increase quality of life for people with dementia, but the monitoring may vary and ethnic inequalities may exist. AIM: To investigate UK primary care routine physical health monitoring for people with dementia by: (a) ethnic groups, and (b) comorbidity status. DESIGN & SETTING: A retrospective cohort study was undertaken using electronic primary care records in the UK. METHOD: Physical health monitoring was compared in people with dementia from white, black, and Asian ethnic groups and compared those with ≥1 comorbidity versus no comorbidity, from 1 April 2015 to 31 March 2016. Using the Dementia : Good Care Planning framework and expert consensus, good care was defined as receiving, within 1 year: a dementia review; a blood pressure (BP) check (at least one); a GP consultation (at least one); a weight and/or body mass index (BMI) recording (at least one); and an influenza vaccination. RESULTS: Of 20 821 people with dementia, 68% received a dementia review, 80% at least one BP recording, 97% at least one GP contact, 48% a weight and/or BMI recording, and 81% an influenza vaccination in 1 year. Compared with white people, black people were 23% less likely and Asian people 16% less likely to have weight recorded (adjusted incidence rate ratio [IRR] = 0.77, 95% confidence interval [CI] = 0.60 to 0.98/0.84, 0.71 to 1.00). People without comorbidities were less likely to have weight recorded (adjusted IRR = 0.74, 95% CI = 0.69 to 0.79) and BP monitored (adjusted IRR = 0.71, 95% CI = 0.68 to 0.75). CONCLUSION: Ethnic group was not associated with differences in physical health monitoring, other than weight monitoring. Comorbidity status was associated with weight and BP monitoring. Physical health monitoring in dementia, in particular nutrition, requires improvement.

Combined hormonal contraceptive use in Europe before and after the European Commission mandated changes in product information.

OBJECTIVES: We investigated combined hormonal contraceptives (CHC) prescribing patterns (focusing on combined oral contraceptives; COC) in three countries (Netherlands, Denmark, United Kingdom) in a time period preceding and in a time period following the European Commission's decision to update product information, and we estimated changes in incidence of venous thromboembolism (VTE) between the two periods. STUDY DESIGN: We conducted a drug utilization analysis and a cohort study using routinely collected data. We calculated number, proportion and incidence rate of new users, switchers, and stoppers of COC in both time periods. VTE incidence was calculated in new users of COC and in all women aged 18-49 years. RESULTS: In all countries, the largest proportion (> 75%) of new users used COC containing levonorgestrel, norethisterone, or norgestimate, (i.e., indicated by European Medicines Agency (EMA) as the safest preparations) in both time periods. Switching did not demonstrate a clear pattern towards these types of COC and distribution of stoppers was similar in both time periods. While the proportion of new users initiating COC containing levonorgestrel, norethisterone, or norgestimate increased slightly, this did not translate to a decrease in the overall VTE incidence. CONCLUSION: All three countries had the greatest proportion of women initiating a COC containing levonorgestrel, norethisterone, or norgestimate, and this proportion increased in the period after the European Commission decision albeit the increase was small due to the high percentage of use before the decision. This did not translate into a measureable change in the incidence of VTE. IMPLICATIONS: Both before and after the European Commission's decision, the largest proportion of new users started with combined oral contraceptives containing levonorgestrel, norethisterone, or norgestimate. Earlier studies had already indicated an increased risk of VTE associated with COC containing other progestogens compared with these preparations, so it is possible that physicians were already preferentially prescribing COC containing levonorgestrel, norethisterone, or norgestimate to new users.

Differences in Psychotropic Drug Prescribing Between Ethnic Groups of People with Dementia in the United Kingdom.

PURPOSE: To test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms. PATIENTS AND METHODS: We analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014-2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia. RESULTS: We included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76-0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6-199.1) and 200.7 (191.1-206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44-0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19-1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups. CONCLUSION: Among people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.

Increased Risk of Musculoskeletal Disorders and Mental Health Problems in Retired Professional Jockeys: A Cross-Sectional Study.

To examine the prevalence of chronic disease and mental health problems in retired professional, male jockeys compared to an age-matched reference population. A cross-sectional study comparing data from a cohort of retired professional jockeys with an age-matched general population sample. Male participants (age range: 50-89 years old) were used to compare health outcomes of self-reported physician-diagnosed conditions: heart disease, stroke, diabetes, hypertension, osteoporosis, osteoarthritis, depression and anxiety between study populations. Conditional logistic regression models were used to estimate associations between study groups and health outcome. In total, 810 participants (135 retired professional male jockeys and 675 participants from the reference population) were included, with an average age of 64.7±9.9 years old. Increased odds of having osteoporosis (OR=6.5, 95%CI 2.1-20.5), osteoarthritis (OR=7.5, 95%CI 4.6-12.2), anxiety (OR=2.8, 95%CI 1.3-5.9) and depression (OR=2.6, 95%CI 1.3-5.7) were seen in the retired professional jockeys. No differences were found for the remaining health outcomes. Retired professional jockeys had increased odds of musculoskeletal disease and mental health problems compared to the general population. Understanding the prevalence of chronic disease and mental health problems in retired professional jockeys will help inform screening and intervention strategies for jockeys.

Antipsychotic polypharmacy prescribing patterns and costs in the Florida adult and child Medicaid populations.

The rapid growth in the use of antipsychotic medications and their related costs have resulted in states developing programs to measure, monitor, and insure their beneficial relevance to public program populations. One such program developed in the state of Florida has adopted an evidence-based approach to identify prescribers with unusual psychotherapeutic prescription patterns and track their utilization and costs among Florida Medicaid patients. This study reports on the prescriber prescription and cost patterns for adults and children using three measures of unusual antipsychotic prescribing patterns: (1) two antipsychotics for 60 days (2AP60), (2) three antipsychotics for 60 days (3AP60), and (2) two antipsychotics for 90 or more days (2AP90). We find that over the four-year study period there were substantial increases in several aspects of the Florida Medicaid behavioral drug program. Overall, for adults and children, patient participation increased by 29 percent, the number of prescriptions grew by 30 percent, and the number of prescribers that wrote at least one prescription grew 48.5 percent, while Medicaid costs for behavioral drugs increased by 32 percent. But the results are highly skewed. We find that a relatively small number of prescribers account for a disproportionately large share of prescriptions and costs of the unusual antipsychotic prescriptions. In general, the top 350 Medicaid prescribers accounted for more than 70 percent of the unusual antipsychotic prescriptions, and we find that this disparity in unusual prescribing patterns appears to be substantially more pronounced in adults than in children prescribers. For just the top 13 adult and children prescribers, their practice patterns accounted for 11 percent to 21 percent of the unusual prescribing activity and, overall, these 13 top prescribers accounted for 13 percent of the total spent on antipsychotics by the Florida Medicaid program and 9.3 percent of the total expenditure by the state for all drugs. Our findings suggest that a strategy to monitor and ensure patient safety and prescribing patterns that targets a relatively small number of Medicaid providers could have a substantial benefit and prove to be cost effective.

Improving psychotherapeutic medication prescribing in Florida: implementation of the Florida Medicaid Drug Therapy Management Program (MDTMP).

This paper describes a program that was established by Florida Medicaid to improve the quality of prescribing of psychotherapeutic medications. It relates the process used for defining quality medication treatment including the definitions of unusual psychotherapeutic medication indicators (UPMI). It details the results of analysis of FY 2007-2008 pharmacy claims data using these indicators that enabled the Program to identify practices and prescribers that required targeted interventions. The most frequently triggered UPMI for adults involved the use of 2 or more antipsychotics for greater than 60 days; high doses of psychotherapeutic medications was the indicator most frequently triggered for children closely followed by the use of 2 or more antipsychotics for more than 45 days. Prescriptions that triggered UPMI were concentrated in a small number of prescribers. These results led to the Program focusing on these high frequency practices and on the prescribers most associated with them. They also led to the implementation of new quality improvement initiatives like the implementation of a psychiatric telephone consultation line for pediatricians who are treating children with serious emotional disturbances who do not have access to child psychiatrists.

Impact of the Florida Medicaid prior-authorization program on use of antipsychotics by children under age six.

OBJECTIVE: This study assessed the impact of a prior-authorization process on the use of antipsychotic medications by children under six years old in Florida's fee-for-service Medicaid program. METHODS: Child psychiatrists reviewed requests for antipsychotic treatment (N=1,424) using forms and criteria created by a panel of Florida-based experts. Data on the characteristics of the children and clinicians involved were organized into 11 consecutive quarters beginning in July 2008. Multivariate generalized estimating equations were used to examine the association between each study variable and changes in the odds of submission of a new request over time. RESULTS: Prior-authorization requests declined from 124 in the first quarter to 81 in the last quarter. Compared with applications from child psychiatrists, the odds of applications being submitted by adult psychiatrists, neurologists, and pediatricians increased over time. CONCLUSIONS: Although applications declined, the diminished role of child psychiatry specialists raises questions about the impact of the program on the quality of care provided.

Stage-specific functions of E-proteins at the ß-selection and T-cell receptor checkpoints during thymocyte development.

The E-protein transcription factors E2A and HEB function in a lineage- and stage-specific manner to orchestrate many critical events throughout lymphocyte development. The function of E-proteins in both B- and T-lymphocyte development has been extensively studied through the use of single-gene knockout animals. Unlike B cells, which rely primarily on E2A alone, T cells are regulated by the combinatorial expression of both E2A and HEB. Therefore, many of the roles of E-proteins during T-cell development may be masked in single-gene knockout studies due to the compensatory function of E2A and HEB. More recently, our laboratory has established double-conditional knockout models to eliminate both E2A and HEB in a stage-specific manner throughout T-cell development. These models, in combination with other complimentary genetic approaches, have identified new E-protein functions at each of the two major T-cell developmental checkpoints. Here, we will discuss how E-proteins function to regulate the expression of T-cell receptor components and cell cycle at the ß-selection checkpoint, and how they control positive selection, survival, and lineage-specific gene expression at the subsequent T-cell receptor checkpoint.

Regulation of V(D)J recombination by E-protein transcription factors.

Extensive study of the E-proteins E2A and HEB duringlymphocyte development has revealed various functions for these bHLH transcription factors in regulating V(D)J recombination in both B- and T-cells. The study of E-proteins in mammals began with the identification of E2A by its ability to bind immunoglobulin heavy and light chain enhancers. Subsequent analysis has identified numerous roles for E2A and HEB at the immunoglobulin and T-cell receptor loci. E-protein targets also include the rag genes and other factors critical for recombination and for regulation of the developmental windows when cells undergo recombination. E-proteins appear to be master regulators that coordinate antigen receptor gene rearrangement and expression. This chapter focuses on how E-proteins regulate V(D)J recombination by activating transcription, initiating rearrangement and driving differentiation during B- and T-cell development.

Acquisition of a functional T cell receptor during T lymphocyte development is enforced by HEB and E2A transcription factors.

The T cell receptor (TCR) is required for positive selection and the subsequent transition from the CD4(+)CD8(+) double-positive (DP) to the CD4(+) or CD8(+) single-positive (SP) stage of alphabeta T cell development. The molecular mechanism that maintains DP fate prior to the acquisition of a functional TCR is not clear. We have shown here that the structurally and functionally related transcription factors HEB and E2A work together to maintain DP fate and to control the DP to SP transition. Simultaneous deletion of HEB and E2A in DP thymocytes was sufficient for DP to SP transition independent of TCR. Loss of HEB and E2A allowed DP cells to bypass the requirement for TCR-mediated positive selection, downregulate DP-associated genes, and upregulate SP-specific genes. These results identify HEB and E2A as the gatekeepers that maintain cells at the DP stage of development until a functional alphabetaTCR is produced.

New insights into E-protein function in lymphocyte development.

Lymphocyte development has long served as an experimental paradigm, revealing fundamental mechanisms of gene regulation and cellular differentiation in mammals. The study of E-protein-mediated transcriptional regulation in lymphocyte development provides a means to address these mechanistic issues. Both genetic and biochemical studies have defined many important regulatory events during lymphocyte development that are mediated by E-proteins. The E2A gene, one of the three known E-protein genes in mammals, has a particularly important role in B-lymphocyte development. Major progress has been made in recent years towards understanding the physiological targets of E2A during B-lymphocyte development. Most notably, new insights have been gained regarding the role of E2A in controlling lineage commitment and V(D)J recombination. This Review focuses primarily on E2A-mediated gene regulation during B-lymphocyte development.