Using Telehealth to Program Generalization of Caregiver Behavior.

Stokes and Baer, Journal of Applied Behavior Analysis, 10(2), 349-367 (1977) provided guidelines to assist practitioners with programming for the generalization of behavior change. Despite the suggestions provided in their seminal paper, generalization remains an often overlooked area within behavior analytic research and practice. In addition, few studies have described explicit strategies to program for the generalization of caregiver behaviors that are consistent with interventions to reduce child challenging behavior. In the current discussion, we describe how telehealth provides a potential avenue for practitioners to focus on generalization. Telehealth helps practitioners access behavior-change agents, materials, and contexts that they may not directly contact in educational and clinical environments. Using telehealth to target these areas early on, and throughout treatment for child challenging behavior, may facilitate more rapid treatment success and maintenance. We provide a case example to demonstrate the use of telehealth to program the generalization of a mother's treatment plan implementation to reduce the severe challenging behavior of an adolescent. We report clinically and socially significant outcomes related to caregiver fidelity and challenging behavior reduction.

Three complementary definitions of polypharmacy: methods, application and comparison of findings in a large prescription database.

PURPOSE: To develop and compare three operational definitions of polypharmacy using a large prescription database. METHODS: We defined Cumulative polypharmacy as all prescriptions filled during a 178 day window--which captured 95% of eventual refills as calculated from Kaplan-Meier and cumulative incidence curves. Continuous polypharmacy was all prescriptions filled in two such windows 6 months apart. Simultaneous polypharmacy was the number of prescriptions active on a particular day, as determined by fill dates and amount of medication given. We applied these definitions to the outpatient prescription files of New England veterans and compared the resulting estimates of polypharmacy using descriptive statistics. RESULTS: 118,013 patients received at least one prescription between January 1998 and July 1999. Cumulative polypharmacy averaged 3.54 (SD = 4.95) medications and continuous polypharmacy averaged 1.96 (SD = 3.23). Examination of simultaneous polypharmacy over 40 2-week intervals revealed an average of 2.63 (CI 2.61-2.65), a minimum of 1.09 (CI 1.08-1.10) and maximum of 4.94 (CI 4.92-4.96). One arbitrarily selected observation point had an average of 3.87 (SD = 3.17). CONCLUSIONS: Our definitions of cumulative and continuous polypharmacy serve to set upper and lower bounds for the estimate of polypharmacy. Our method for simultaneous polypharmacy gives numbers that diverge in some respects, but it is better at showing transient changes in medications. The methods are complementary and allow exploration of various aspects of medication use, such as cumulative medication exposure over time, the influence of chronic medical problems, and the causes of rapid changes in medications.

Anticoagulant use for atrial fibrillation in the elderly.

OBJECTIVES: To determine the influence of advanced age on anticoagulant use in subjects with atrial fibrillation and to explore the extent to which risk factors for stroke and contraindications to anticoagulant therapy predict subsequent use. DESIGN: Retrospective cohort study. SETTING: The Veterans Affairs Boston Healthcare System. PARTICIPANTS: A total of 2,217 subjects with nonvalvular atrial fibrillation. MEASUREMENTS: Administrative databases were use to identify subject's age, anticoagulant use, and the presence of a diagnosis of atrial fibrillation, cerebrovascular accident, hypertension, diabetes mellitus, congestive heart failure, or gastrointestinal or cerebral hemorrhage. RESULTS: Unadjusted analysis showed no difference in warfarin use between those aged 75 and older and younger subjects regardless of the presence (33.9% vs 35.7%, P=.37) or absence (33.4% vs 34.7%, P=.58) of contraindications to anticoagulant therapy. Multivariate modeling demonstrated a 14% reduction (95% confidence interval (CI)=4-22%) in anticoagulant use with each advancing decade of life. Intracranial hemorrhage was a significant deterrent (odds ratio (OR)=0.27 95% CI=0.06-0.85). History of hypertension (OR=2.90, 95% CI=2.15-3.89), congestive heart failure (OR=1.70, 95% CI=1.41-2.04), and cerebrovascular accident (OR=1.54, 95% CI=1.25-1.89) were significant independent predictors for anticoagulant use. CONCLUSION: Despite consensus guidelines to treat all atrial fibrillation patients aged 75 and older with anticoagulants, advancing age was found to be a deterrent to warfarin use. Better estimates of the risk:benefit ratio for oral anticoagulant therapy in older patients with atrial fibrillation are needed to optimize decision-making.