Impact of Prescription Patterns on Compliance With Follow-Up Visits at an Urban Teaching Primary Care Continuity Clinic.

BACKGROUND: Although limiting prescription refills is considered as a strategy to increase compliance with the treatment regimen and follow-up, no literature exists to support its effectiveness. We sought to investigate whether decreasing the number of prescription refills affects no-show rate at an urban teaching primary care continuity clinic in New York. METHODS: Eight teaching attending physicians and 19 residents implemented a "new prescribing strategy" from February 9 to 22, 2012, which limited the number of refills only to cover until the next intended clinic visit. All adult patient visits were included if follow-up visits were requested to be scheduled within 3 months and prescriptions were given through an electronic prescription system. No-show rates for the first follow-up visits up to 120 days from the initial visits during the interventional period were compared with those during the baseline period (December 15-28, 2011). RESULTS: Two hundred twenty-one patients in the baseline period and 278 in the interventional period were included in the analysis. Median total supply of prescription was 6 and 3 months, respectively (P < .001). The no-show rates were not significantly different between the 2 periods (19.0% [42/221] vs 16.6% [46/278], P = .5). In multivariate regression analysis, the no-show rate did not change significantly during the interventional period compared with the baseline period (odds ratio [OR] 1.0; 95% confidence interval, 0.6-1.5; P = .8). Younger age (OR 1.03 per year, P = .008), male gender (OR 2.0, P = .003), Medicaid or Medicare insurance (OR 3.7, P = .01; OR 4.2, P = .02), and diagnosis of diabetes (OR 1.8, P = .04) or asthma (OR 2.0, P = .03) were associated with higher no-show rates. CONCLUSIONS: Reducing the number of refills did not significantly affect no-show rates in the immediate follow-up. Alternative strategies should be considered to minimize no-shows.

Identification of residual risk factors for the development of venous thromboembolism in medical inpatients receiving subcutaneous heparin therapy for prophylaxis.

OBJECTIVES: Venous thromboembolism (VTE) such as pulmonary embolism and deep venous thrombosis is the most common cause of preventable morbidity and mortality in hospitalized patients. Prophylaxis is recommended for medical patients older than 40 years with at least one risk factor. However, the currently recommended regimen prevents only about half of in-hospital VTE. The aim of this study was to identify the risk factors for development of VTE in medical inpatients who were already on recommended pharmacological prophylaxis. METHODS: We performed a retrospective cohort study of 10,633 patients who were admitted to the medicine service and received prophylaxis with subcutaneous unfractionated heparin. The diagnoses of pulmonary embolism and deep venous thrombosis were confirmed with computed tomography angiography and Doppler ultrasound, respectively. Univariate analysis with the χ(2)-test, followed by log-linear Poisson regression analysis was performed to determine the relative risk associated with each factor. RESULTS: Sixty cases of in-hospital VTE [raw incidence, 0.6%; 95% confidence interval (0.43-0.72)] were observed. On univariate analysis, a previous history of VTE or an active malignancy were found to be significant residual risk factors for the development of in-hospital VTE. On multivariate analysis, only a previous history of VTE remained a significant independent risk factor [relative risk=30.1; 95% confidence interval (17.1-53.0); P<0.0001]. CONCLUSION: Among hospitalized patients admitted to the medicine service and receiving VTE prophylaxis with subcutaneous unfractionated heparin, those with a previous history of VTE were at a significant risk of developing in-hospital VTE. This at-risk population should be considered for more aggressive therapy to prevent recurrent VTE.