Effect of collaborative dementia care on potentially inappropriate medication use: Outcomes from the Care Ecosystem randomized clinical trial.

INTRODUCTION: Potentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD). METHODS: Secondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications. RESULTS: Of 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P < 0.0001). Number needed to prevent an increase in 1 PIM was 3. Total medications, PIMs for dementia or cognitive impairment, CNS-active PIMs, anticholinergics, benzodiazepines, and opioids were also fewer. Anti-dementia medication regimens were modified more frequently. CONCLUSION: The CE medication review intervention embedded in collaborative dementia care optimized medication use among PLWD. HIGHLIGHTS: Compared to usual care (UC), the Care Ecosystem (CE) medication review intervention prevented increases in potentially inappropriate medications (PIMs). Use of anticholinergics, benzodiazepines, and opioids were significantly reduced, with a trend for antipsychotics. Anti-dementia medications were adjusted more frequently. The CE medication review intervention embedded in collaborative dementia care optimized medication use.

Development of an adaptive, personalized, and scalable dementia care program: Early findings from the Care Ecosystem.

Katherine Possin and colleagues report on the implementation, development, and early findings of the Care Ecosystem, an adaptive, personalized, and scalable dementia care program.

Is the sympathetic system involved in shock-induced gut and lung injury?

BACKGROUND: ß-blockade (BB) has been shown to prevent bone marrow (BM) dysfunction after trauma and hemorrhagic shock (HS). The impact of the sympathetic system and the role of BB on shock-induced distant organ injury is not known. This study will determine if BB has systemic effects and can diminish gut and lung injury after trauma and HS. METHODS: Male Sprague-Dawley rats were subjected to lung contusion (LC) followed by 45 minute of HS. Animals (n = 6 per group) were then randomized to either receive propranolol (LCHS + BB) immediately after resuscitation or not (LCHS). Gut permeability was evaluated in by diffusion of Mr 4,000 of fluorescein dextran (FD4) from a segment of small bowel into peripheral blood. Villous injury and lung injury were graded histologically by a blinded reader. Plasma-mediated effects of BB were evaluated in vitro by an assessment of BM progenitor growth. RESULTS: Animals undergoing LCHS had significantly higher plasma levels of FD4 compared with control animals (mean [SEM], 2.8 [0.4] µg/mL vs. 0.8 [0.2] µg/mL). However, animals receiving BB had a significant reduction in plasma FD4 compared with the LCHS group. With the use of BB after LCHS, both ileal and lung injury scores were similar to control. In addition, BM progenitor growth was inhibited by the addition of LCHS plasma, and LCHS + BB plasma showed no inhibition of BM progenitor growth. CONCLUSION: Propranolol can protect against the detrimental effects of trauma and HS on gut permeability, villous, and lung injury. The effects of BB are likely systemic and appear to be mediated through plasma. BB likely blunts the exaggerated sympathetic response after shock and injury. Propranolol's reduction of both BM dysfunction and distant organ injury further demonstrates the importance of the sympathetic nervous system and its role in potentiating end organ dysfunction after severe trauma.

Student-run low-income family medicine clinic: controlling costs while providing comprehensive medication management.

OBJECTIVES: To evaluate the impact of implementing cost-control measures on drug use and financial performance of a student-run safety net clinic and to assess the effect of the measures on patient care. METHODS: Medication histories and patient information were obtained from the University of Nebraska Medical Center's student-run safety net clinics' (SHARING and GOODLIFE) computer databases and internal medication cost documents for all patients treated with medications at the clinics from April 1, 2006, through March 31, 2008. Main outcome measures were cost, use, and source of all medications and the resultant financial savings between the pre- and post-periods. RESULTS: 200 patients were treated with medications during the 2-year period (164 patients before April 1, 2007, and 137 after). A majority of clinic patients were treated for chronic conditions, including 62% for hypertension, 54% for diabetes, 46% for dyslipidemia, and 26% for depression. The average monthly cost to the clinics for medications decreased from $5,444.87 before April 1, 2007, to $3,714.05 (P = 0.002) after. With these changes, the cost per prescription from any delivery method decreased from $15.28 to $13.02 (P < 0.001) and the average cost per prescription decreased from $27.32 to $20.27 (P < 0.001) after formulary implementation. The number of prescriptions per patient per month was unchanged. CONCLUSION: Medication management with a closed formulary in a diverse uninsured population reduced expenditures, with the largest savings coming from using prescriptions more efficiently while also providing a similar level of medical care.