Derivation of adherence metrics from electronic dosing records.

Numerous adherence variables have been created from electronic dosing records hindering synthesis of the vast body of adherence research. To elucidate the mathematical foundation for electronic adherence monitoring and to understand how diverse electronic adherence metrics are related to each other and the underlying construct of adherence behavior. Several representative adherence metrics are derived mathematically and their relationship to the underlying consumption (or dosing event) rate analyzed. Data from a 3-month study of 286 individuals on single-drug antihypertensive therapy are then used to empirically study the statistical properties of several of these electronic adherence metrics. As suggested by their common link to the consumption (or dosing event) rate, the analyzed electronic adherence metrics were generally strongly correlated (r <- .6 and > .4). The lowest correlation (r = .15) involved the ratio of the observed number of doses to the recommended number (called average adherence), which tended to emphasize quantity consumed, and the ratio of the observed to maximum mean squared rate deviation (MSRD ratio), which focused more on dose timing. Despite their different formulations, electronic adherence variables are generally closely correlated. Adherence metrics that average the consumption rate over multiple doses (by summing up the number of doses and dividing by the monitored time) may be less sensitive to short-term fluctuations in medication intake. Metrics that are more sensitive to timing variability may thus be preferable when timing as well as quantity of dosing are of interest.

Accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) in determining the risk of aspiration in acute stroke patients.

This prospective study was undertaken to determine the accuracy of bedside clinical methods compared with fiberoptic endoscopic examination of swallowing (FEES) for detecting aspiration in acute stroke patients. Fifty patients underwent an examination of their ability to swallow 50 ml of water in 10-ml aliquots. Later their oxygen saturation levels before and after swallowing 10 ml of water were measured using a pulse oximeter. Oxygen desaturation of more than 2%, was considered to be clinically significant. All patients then underwent a FEES assessment by a speech therapist and were followed up during their inpatient stay for evidence of aspiration pneumonia. The oxygen desaturation test had a sensitivity of 76.9% and specificity of 83.3% (chi2 = 18.154, p = 0.00002), while the 50-ml water swallow test had a sensitivity of 84.6% and specificity of 75.0% (chi2 = 18.001, p = 0.00002). However, when these two tests were combined into one test called "bedside aspiration," the sensitivity rose to 100% with a specificity of 70.8% (chi2 = 27.9, p = 0.000001). Five (10%) patients developed pneumonia during their inpatient stay. The relative risk (RR) of developing pneumonia, if there was evidence of aspiration on FEES, was 1.24 (1.03 < RR < 1.49). We conclude that the oxygen desaturation test combined with the 50-ml water swallow test is suitable as a screening test to identify all acute stroke patients at risk of aspiration for further evaluation and management.

Paronychia in association with indinavir treatment.

To assess a possible association between antiretroviral treatment and paronychia, we conducted a retrospective cohort study of 288 human immunodeficiency virus-positive protease inhibitor recipients. Indinavir treatment-adjusted for age, sex, CD4 count, diabetes status and other antiretroviral drug exposures-was significantly associated with paronychia of the great toe (hazard ratio 4.7; 95% confidence interval 1.6-13.9).

A cohort study of possible risk factors for over-reporting of antihypertensive adherence.

BACKGROUND: The identification of poor medicinal adherence is difficult because direct observation of medication use is usually impractical. Up to 50% of individuals on chronic therapies may not be taking their medication as prescribed. This study is one of the first to explore possible risk factors for over-reporting of antihypertensive adherence using electronic medication monitoring. METHODS: The adherence of 286 individuals on single-drug antihypertensive therapy in a large managed care organization was electronically monitored for approximately three months. Questionnaires on socioeconomic background, adherence to therapy, health beliefs, and social support before and after adherence monitoring were completed. Over-reporting of antihypertensive adherence was assessed by comparing the self-reported frequency of noncompliance with that determined from electronic dosing records. Risk factors for over-reporting were identified by contingency table analysis and step-wise logistic regression. RESULTS: Although only 21% of participants acknowledged missing doses on one or more days per week, electronic monitoring documented nonadherence at this or a higher level in 42% of participants. The following variables were associated with over-reporting: >1 versus 1 daily dose (OR = 2.58; 95% CI = 1.50-4.41; p =.0006), lower perceived health risk from nonadherence (OR = 1.35; 95% CI = 1.10-1.64; p =.0035), and annual household income of <15,000 dollars versus >30,000 dollars (OR = 2.64; 95% CI = 1.13-6.18; p =.025). CONCLUSIONS: Over-reporting of adherence may be affected by factors related to dosing frequency, health beliefs and socioeconomic status. This topic deserves further investigation in other patient populations to elucidate possible underlying behavioral explanations.

Critical role of functional decline in delayed discharge from an acute geriatric unit.

INTRODUCTION: Delayed hospital discharge of elderly patients after an acute illness poses significant problems, including bed-blockade, iatrogenesis, and increase in morbidity, dependency and social isolation. The aim of this study was to determine the factors associated with delayed discharge from an acute geriatric unit. MATERIALS AND METHODS: This was a prospective cohort study involving 172 consecutive non-institutionalised patients, 65 years and older, admitted to an acute geriatric unit. The medical, functional, psychological and social variables of each subject were documented and any decline in functional status recorded. Based on the discharge status, patients were dichotomised into the "delayed" and "non-delayed" groups. Initial bivariate analyses of the variables were performed to select those associated with the "delayed discharge" group at the P < 0.05 levels. These variables were in turn entered into a multivariate logistic regression model to identify factors significantly associated with delayed discharge. RESULTS: Forty-eight patients (27.9%) had their discharge from the acute geriatric care unit delayed despite clinically fit to be so. Variables significantly associated with delayed discharge in the multivariate model were: 1) decline in basic activities of daily living (ADL) status [P < 0.001; adjusted odds ratio (AOR), 3.63; 95% confidence interval (CI), 1.33 to 9.86] and 2) need for skilled nursing [P = 0.012; AOR, 4.57; 95% CI, 1.88 to 11.14]. CONCLUSIONS: The study demonstrates the central importance of effectively identifying elderly patients who are at risk of delayed discharge after acute hospitalisation through a multidisciplinary focus on illness-induced functional decline. It is likely therefore that proactive approaches to rehabilitation and caregiver training, and adequate community-based services, may facilitate early and effective return of these patients to their homes, thereby reducing inappropriate use of acute beds.

A pharmacodynamic assessment of the impact of antihypertensive non-adherence on blood pressure control.

OBJECTIVES: To evaluate if antihypertensive regimens that conform to present FDA guidelines by maintaining > or = 50% of their peak effect at the end of the dosing interval protect patients during sporadic lapses in adherence. METHODS: 169 patients on monotherapy for high blood pressure underwent electronic adherence monitoring for 3 months. Blood pressures were measured during non-study office visits and were retrieved from automated medical records. Questionnaires were used to obtain other covariate information. The ratio of the dosing interval to the half-life of drug activity (I') was used to capture conformity with FDA guidelines. Data analysis focused on the interaction between I' and the impact on blood pressure of delayed dosing. RESULTS: The average (+/- standard deviation) blood pressure during the study was 139.0(+/- 12.0)/85.0(+/- 6.9) mm Hg. Lisinopril followed by sustained-release verapamil, atenolol, and hydrochlorothiazide were the most frequently prescribed agents. The majority of regimens (99%) conformed to FDA dosing guidelines. Of the patients 23% missed a dose before their blood pressure check. Non-adherence, however, did not have a direct impact on blood pressure, and no interaction with I' of was detected. CONCLUSIONS: Among patients with relatively mild hypertension on single-drug therapy, regimens that conform to current FDA dosing guidelines may prevent losses of blood pressure control during episodic lapses of adherence. These findings should be replicated in other patient populations with standardized blood pressure measurement to confirm their validity.

Validation of patient reports, automated pharmacy records, and pill counts with electronic monitoring of adherence to antihypertensive therapy.

OBJECTIVES: To evaluate the validity of patient report, pharmacy dispensing records, and pill counts as measures of antihypertensive adherence using electronic monitoring as the validation standard. METHODS: The study was conducted among 286 members of Harvard Pilgrim Health Care, a managed care organization, who were at least 18 years of age, on monotherapy for hypertension, and had prescription drug coverage. Prescription refill adherence during the 12 months before enrollment was determined from their automated pharmacy dispensing records. Participants were interviewed about their medication adherence before and after a 3-month electronic monitoring period during which pill counts were also performed. Adherence to both recommended number and timing of doses was estimated from electronic monitoring data. Data analysis was based on statistical correlation and analysis of variance. RESULTS: Electronic adherence monitoring revealed that the proportion of prescribed doses consumed was higher (0.92) than the proportion of doses taken on time (0.63). The correlation between adherence to quantity and timing of doses was 0.32. Concurrent pill counts and earlier refilling patterns were moderately correlated with electronic monitoring (pill count: r = .52 with quantity and r = .17 with timing; refill adherence r = .32 with quantity and r = .22 with timing). There was considerable misclassification of adherence reported by patients, although nonadherence was generally accurately reported. CONCLUSIONS: Deviation from recommended timing of doses appears to be greater than from prescribed number of doses. Pharmacy dispensing records demonstrate predictive validity as measures of cumulative exposure and gaps in medication supply. Adherence levels determined from pill counts and pharmacy dispensing records correlate more closely with quantity than with timing of doses. Nonadherence reported by patients can serve as a qualitative indicator and predictor of reduced adherence.

Dementia in the hospitalized elderly--a study of 100 consecutive cases in Singapore.

AIM: This survey aims to study the medical, functional and social aspects of hospitalized elderly patients with dementia. METHODS: The case records of 100 patients with dementia admitted consecutively to our department were systematically reviewed to extract the patients' demographic data, presenting features, underlying cause(s) of dementia, functional disabilities and carers' difficulties. RESULTS: Eighty per cent of the patients were 75 years of age and above and 44% were males. In this cohort 55% had vascular dementia, with Alzheimer's disease being the next most common (40%). The overwhelming majority had marked cognitive impairment as assessed by the Abbreviated Mental Test and worsening degrees of dementia were significantly associated with increasing disabilities in both mobility and activities of daily living (ADL). Fifty-seven families reported coping difficulties and this group had significant correlations with the respective patients' bladder and bowel incontinence as well as worsening states of ambulatory and ADL function. CONCLUSION: Patients with dementia present with complex problems and management requires attention not only to patients' medical problems and rehabilitation strategies but also to education, emotional support and help for their frequently stressed out carers.

Use of the uroflow study in the diagnosis of bladder outlet obstruction in elderly men.

The uroflow and pressure-flow data of 67 men aged 65 years or more were compared. At best, the uroflow study applying the Liverpool nomogram (25th percentile) and Bristol nomogram (OSD) diagnosed bladder outlet obstruction with sensitivity of 62.5% and 62.5% and specificity of 48.8% and 74.4% respectively. Using the 50th percentile of the Liverpool nomogram as the cut-off resulted in a negative predictive value of 100.0% allowing about 10% of men to have this diagnosis ruled out. We conclude that the uroflow study is inaccurate in diagnosing bladder outlet obstruction in elderly men. However, it can be used to rule out this condition in the small subset of men with maximum flow rates above the 50th percentile of the Liverpool nomogram.

Ibuprofen and skin and soft tissue superinfections in children with varicella.

PURPOSE: To investigate the possible association between ibuprofen use and dermatologic superinfections among children with recent varicella infection. METHODS: A retrospective cohort study of children in Harvard Pilgrim Health Care, a health maintenance organization in New England, was conducted. Outcomes and exposures of interest were identified from automated medical and pharmacy records. Exposure was defined by dispensing of ibuprofen before varicella to avoid potential confounding by indication. RESULTS: Between July 1, 1990 and September 30, 1994, 89 superinfections developed among 7,013 cases of varicella. The 30-day risk of superinfection was 7.2/10(3) cases (95% CI = 5.8-8.8/10(3) cases). Four of 169 children dispensed ibuprofen within 180 days of varicella developed superinfection. Relative to children without prior use, children with ibuprofen dispensed in the month prior to varicella were 3.1 times more likely to be diagnosed with a superinfection (95% CI = 0.1-19.7; P-value: 0.31). Restriction of outcomes to superinfections treated with systemic antibiotics increased the odds ratio to 5.1 (95% CI = 0.1-32.5; P-value: 0.22). CONCLUSIONS: The results of this study are consistent with a broad range of effects including no association and suggest that further study is needed.

The sequelae of herpes zoster.

BACKGROUND: The last 40 years was a period during which the incidence of herpes zoster appears to have increased substantially. OBJECTIVE: To determine whether the risk of complications of herpes zoster has changed during the last 40 years. METHODS: The automated medical records of a health maintenance organization were screened for diagnosis codes suggesting herpes zoster and potentially complicated cases of zoster. The predictive value of a herpes zoster diagnosis was calculated from sampling full-text records. Records of all patients with codes suggesting complications were reviewed in full. RESULTS: Of 859 individuals with herpes zoster who met the eligibility criteria, 101 were identified who experienced at least 1 complication, corresponding to a 60-day risk of 12%. Corrected for the sensitivity of the complication-finding strategy, the risk estimate was 14%. Risk increased markedly with age, with those older than 64 years having more than 6 times the risk of complications of those younger than 25 years (odds ratio, 8.3; 95% confidence interval, 2.5-29.3). Trigeminal distribution of rash and the presence of certain conditions associated with immune compromise appeared to increase risk. CONCLUSIONS: The apparent increase in the incidence of herpes zoster was not accompanied by a change in the risk of specific or overall complications in a population-based sample. Advanced age and other conditions associated with waning cellular immunity may confer an increased risk of experiencing a complicated course of herpes zoster.

Risk factors for postherpetic neuralgia.

BACKGROUND: The risk factors for postherpetic neuralgia (PHN), the most common complication of herpes zoster, have not been well established. OBJECTIVE: To elucidate the risk factors for PHN. METHODS: Automated medical, claims, and pharmacy records of a health maintenance organization were used to identify cases of PHN and obtain data on risk factors. A case-base design was used to assess the impact of various patient, disease, and treatment factors on the prevalence of PHN 1 and 2 months after developing zoster. RESULTS: There were 821 cases of herpes zoster that met all eligibility criteria. The prevalence of PHN more than 30 days after onset of zoster was 8.0% (95% confidence interval [CI], 6.3%-10.1%) and 4.5% (95% CI, 3.2%-6.2%) after 60 days. Compared with patients younger than 50 years, individuals aged 50 years or older had a 14.7-fold higher prevalence (95% CI, 6.8-32.0) 30 days and a 27.4-fold higher prevalence (95% CI, 8.8-85.4) 60 days after developing zoster. Prodromal sensory symptoms and certain conditions associated with compromised immunity were also associated with PHN. Systemic corticosteroids before zoster and treatment of zoster with acyclovir or corticosteroids did not significantly affect the prevalence of PHN. CONCLUSIONS: Increased age and prodromal symptoms are associated with higher prevalence of PHN 1 and 2 months after onset of zoster. Overall, systemic acyclovir appears not to confer any protection against PHN, although benefit among elderly patients cannot be excluded.

Prevention of falls in a geriatric ward.

Falls occurring in the hospital are significant events because of the injuries sustained, extended hospital stay and potential medicolegal implications. We conducted a 3-year study to determine the characteristics of fallers in a geriatric ward and assess the effectiveness of lectures and nursing assessments in the prevention of falls. In the first year of the study we found that the rate of falls was 9% of all patients admitted. About 85.7% of falls occurred at the bedside and 41.4% happened while getting in and out of bed. Most falls occurred between 4 pm and 8 pm and half of the fallers had no preceding symptoms. In the second year, a series of lectures and educational material were given to the same nursing staff and the prevalence of falls was reduced to 7% (P > 0.05). However, the implementation of a nursing assessment protocol in the third year of the study achieved a marked reduction in prevalence of falls to 5.9% from the initial 9% (Chi-square chi 2 = 4.19, P = 0.04). Thus, the vigorous administration of a nursing assessment protocol can reduce falls in a geriatric ward.

Bilateral lower limb oedema due to a distended urinary bladder.

A 91-year-old Chinese man developed bilateral lower limb oedema due to venous obstruction resulting from a distended urinary bladder. After the bladder was decompressed by urethral catheterisation, the bilateral lower limb oedema promptly subsided. Although a distended urinary bladder is a rare cause of bilateral lower limb oedema, it can be easily recognised by palpation of the lower abdomen and the relief of symptoms by urethral catheterisation is most rewarding.

Ticlopidine induced cholestatic jaundice.

Ticlopidine hydrochloride (Ticlid) has been increasingly used as an antiplatelet agent. Some studies showed that it has higher efficacy in reducing stroke recurrence when compared to conventional aspirin. Side effects like gastrointestinal disturbances and blood dyscrasias are common but ticlopidine-induced cholestatic jaundice has been reported only rarely. We present a case report on a patient who has ticlopidine-induced cholestatic jaundice.

Is the bladder "an unreliable witness" in elderly males with persistent lower urinary tract symptoms?

AIM: We sought to study the usefulness of lower urinary tract symptoms and postvoid residual urine volume in the diagnosis of voiding dysfunction in elderly men. METHODS: The symptoms and postvoid residual urine volume of 126 men aged 65 years or older referred for urodynamic studies were obtained. Their accuracy in the diagnosis of detrusor instability, bladder outlet obstruction and impaired detrusor contractility was quantified. RESULTS: For the diagnosis of detrusor instability, urgency and urge incontinence with frequency and/or nocturia had a sensitivity of 73.0% and a specificity of 60.0%. For the diagnosis of bladder outlet obstruction, poor stream with frequency and/or nocturia had a sensitivity of 51.9% and a specificity of 71.6%. Using poor stream and residual urine volume of more than 50 ml occurring together, the sensitivity was 31.1% and specificity was 89.7%. For the diagnosis of impaired detrusor contractility, poor stream had a sensitivity of 44.8% and a specificity of 56.7%. With residual urine volume of more than 50 ml, a sensitivity of 96.6% and specificity of 80.4% was obtained. CONCLUSION: Based on our findings, we conclude that the bladder does appear to be an "unreliable witness" in elderly men for the diagnosis of bladder outlet obstruction, though this is less so with impaired detrusor contractility. No conclusion can be drawn for the detrusor instability as we did not use ambulatory urodynamic studies.

Clinical utility of a portable ultrasound scanner in the measurement of residual urine volume.

BACKGROUND: Post-voiding residual urine volume is an important investigation in the management of voiding dysfunction. Catheterisation is widely regarded as the "gold" standard method of measurement. We investigated the performance of a portable ultrasound scanner (Bladder Scan BVI-2500), as an alternative method of measurement. METHODS: This study was prospective in nature. One hundred measurements of post-voiding residual urine volume by ultrasound were compared with measurements by catheterisation. RESULTS: The mean absolute error of the scanner was 52 mL. For volumes below 200 mL and 100 mL, this was 36 mL and 24 mL respectively. A decision regarding whether to decompress the bladder by catheterisation would have also been correct in 86% to 89% of instances, depending on the cut-off value of the residual volume used. In other words, the ultrasound measurement would have been correct in 9 out of 10 clinical cases. CONCLUSION: We recommend the routine use of portable ultrasound scanners of similar accuracy in the measurement of post-voiding residual urine volume.

Carer-assisted intermittent urethral catheterisation in the management of persistent retention of urine in elderly women.

Carer-assisted clean intermittent urethral catheterisation is an effective and safe treatment option for persistent urinary retention in a study of 56 elderly female patients (aged 65 years and above) with cognitive impairment and other disabilities. With this method of treatment, 54% of the patients were able to void spontaneously and were continent after a median period of 6 weeks with a range of 1 to 40 weeks. Twenty-seven per cent had significant improvement in the symptoms of urinary incontinence and the residual urine volumes became progressively smaller. However, 19% failed the programme. The recovery of spontaneous voiding was found to be significantly influenced by the age of the patient, the carer performing the intermittent catheterisation and the development of catheter-related urinary tract infection. Twenty-five per cent of the study patients developed symptomatic urinary tract infection which was associated with a delay in the recovery of spontaneous voiding. Its development was also found to be significantly associated with the presence of pre-existing diabetes mellitus, the person doing the catheterisation, the presence of dementia and with more predisposing common medical conditions.

The epidemiology of varicella and its complications.

The automated records of over 250,000 members of a health maintenance organization were analyzed to assess the epidemiology of varicella and its complications between 1 July 1990 and 30 June 1992. All complications were verified by review of full-text medical records. The incidence rates of varicella in persons < 15 years of age were 20%-50% lower than published figures, probably reflecting underreporting. The rates in those > or = 15 years old, however, were greater than those reported for 1972-1978 (607 vs. 291/10(5) years, 15-19 years old; 175 vs. 33/10(5) years, > or = 20 years old). The rates of hospitalization for uncomplicated varicella, skin superinfections, and pneumonia in children were, respectively, 15, 11, and 4 times higher than previous estimates. Hospitalization rates for adults with pneumonia and uncomplicated varicella were > 5 times higher than prior figures. Thus, varicella in adults and varicella complications in general may be more frequent than previously estimated.