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CONTEXT - Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for patients 65 years of age or older, primarily for musculoskeletal symptoms of osteoarthritis. Because NSAIDs frequently cause serious gastrointestinal (GI) and other complications among elderly patients, expert guidelines for osteoarthritis recommend acetaminophen-based regimens, which are safer and often as effective as NSAIDs.
OBJECTIVE - Evaluate a physician education program that communicated guidelines for management of osteoarthritis in elderly patients that emphasized avoidance of NSAIDs when possible. The program reviewed NSAID risks and benefits and recommended: re-evaluating continuous NSAID users, considering substitution of up to 4 g/d of acetaminophen for the NSAID, and trying topical agents and nonpharmacologic measures.
DESIGN AND SETTING - Randomized controlled trial among community-dwelling Tennessee Medicaid enrollees.
SUBJECTS - Study physicians had 5 or more patients who: were community-dwelling Medicaid enrollees 65 years of age or older; had used NSAIDs regularly for at least 180 days; had had no medical care encounters during this period suggesting an indication other than osteoarthritis; and had 1 year of baseline and follow-up data. The study thus included 209 physicians (103 intervention/106 control) with 1,566 qualifying regular NSAID users (768/798).
INTERVENTIONS - Face-to-face visit to study physicians by another physician, and reminder placements in the charts of patients eligible to have NSAID use reevaluated.
OUTCOMES - Change between baseline and follow-up years in: days of prescribed NSAIDs, acetaminophen, other drugs for musculoskeletal disorders, and GI drugs; outpatient visits and inpatient days of stay; SF36 measures of general health, physical function, and bodily pain (from 40% random patient sample); and over-the-counter NSAIDs (from the sample).
RESULTS - Intervention-attributable reduction of 7% (95% CI, 3% to 11%) in days of prescribed NSAIDs use with concomitant increase in acetaminophen use. No significant changes in other study endpoints. The intervention effect was greater among 75 physicians with a completed study visit, whose 564 patients had a 10% (95% CI, 6% to 14%) attributable reduction in NSAID use.
CONCLUSIONS - The educational program modestly reduced NSAID exposure in community-dwelling elderly patients without undesirable substitution of other medications or detectable worsening of musculoskeletal symptoms.
BACKGROUND - Over the past decade, calcium channel blockers (CCBs) and ACE inhibitors have been used increasingly in the treatment of hypertension. In contrast, beta-blocker and diuretic use has decreased. It has been suggested that pharmaceutical marketing has influenced these prescribing patterns. No objective analysis of advertising for antihypertensive therapies exists, however.
METHODS AND RESULTS - We reviewed the January, April, July, and October issues of the New England Journal of Medicine from 1985 to 1996 (210 issues). The intensity of drug promotion was measured as the proportion of advertising pages used to promote a given medication. Statistical analyses used the chi2 test for trend. Advertising for CCBs increased from 4.6% of advertising pages in 1985 to 26.9% in 1996, while advertising for beta-blockers (12.4% in 1985 to 0% in 1996) and diuretics (4.2% to 0%) decreased (all P<0.0001). A nonsignificant increase was observed in advertising for ACE inhibitors (3.5% to 4.3%, P=0.17). Although the total number of drug advertising pages per issue decreased from 60 pages in 1985 to 42 pages in 1996 (P<0.001), the number of pages devoted to calcium channel blocker advertisements nearly quadrupled.
CONCLUSIONS - Increasing promotion of CCBs has mirrored trends in physician prescribing. An association between advertising and prescribing patterns could explain why CCBs have supplanted better-substantiated therapies for hypertension.
Novel approaches to treat cholesterol are needed to effectively manage post-myocardial infarction patients in a public hospital setting. Although cardiologists were more likely to prescribe cholesterol-lowering agents than primary care practitioners, their impact on cholesterol reduction was still negligible.
BACKGROUND - Nurses routinely "dangle" patients to evaluate and promote tolerance to changes in body position and to determine whether the level of activity should progress. Although dangling is a widespread nursing intervention, little research has been done on it, and little is known about how nurses dangle patients.
OBJECTIVE - To describe dangling practices reported by critical care and acute care nurses.
METHODS - A structured interview tool, developed for the study, was used to interview 51 experienced critical care and acute nurses from seven states about dangling practices.
RESULTS - Most respondents said dangling was not routinely ordered and did not require a physician's order. The nurses described numerous strategies they used beforehand to promote tolerance to dangling, for example, premedicating for pain, and multiple interventions they used if patients did not seem to do well during dangling, for example, having patients take slow, deep breaths or move the feet and arms. Indicators of intolerance to dangling included marked changes in blood pressure, heart rate, and level of consciousness and patients' comments such as, "I can't stand it." Estimates of the duration of dangling varied widely, from 1 to 10 minutes; most respondents stated that duration varied "by feel" or depended on the patient's response. The most frequently mentioned personal rule about dangling was, "Get help if you're not sure how the patient will do."
CONCLUSIONS - Nurses have developed numerous approaches to dangling acutely ill patients. These approaches should be described and tested to improve nursing practice and patient outcomes.
In an attempt to identify the range of opinions influencing the diagnosis and therapy of patients with the adult respiratory distress syndrome (ARDS), a postal survey was mailed to 3,164 physician members of the American Thoracic Society Critical Care Assembly. The questionnaire asked opinions regarding the factors important in the diagnosis of ARDS and its treatment. Thirty-one percent of physicians surveyed responded within 4 weeks, the vast majority of which were board certified or eligible in Internal Medicine, Pulmonary Disease, and/or Critical Care Medicine. A known predisposing cause, measure of oxygenation efficiency, and a chest radiograph depicting pulmonary edema were reported to be the most important criteria for a clinical and research diagnosis of ARDS. Lung compliance and bronchoalveolar lavage neutrophil or protein content were reportedly less important. The initial treatment of patients with ARDS was reported to be most commonly accomplished using volume-cycled ventilation in the assist/control mode. Nearly half the responders reported using lower tidal volumes (5 to 9 mL/kg) than the traditionally recommended 10 to 15 mL/kg. Most respondents indicated they have intentionally allowed CO2 retention. On average, oxygen toxicity was thought to begin at an FIO2 between 0.5 and 0.6. It was reported that modest levels of positive end-expiratory pressure (PEEP) were used in incremental fashion as FiO2 requirements increased. Perceived indications for insertion of pulmonary artery catheters and compensation of the effects of PEEP on the pulmonary artery occlusion pressure varied widely among the responders. We conclude that reported practice patterns regarding the care of ARDS patients vary widely even within a relatively homogenous group of critical care practitioners.
OBJECTIVES - To describe the changes in antipsychotic drug use in nursing homes during the period surrounding the implementation of federal legislation designed to reduce unnecessary use (the Omnibus Budget Reconciliation Act of 1987 [OBRA-87]) and to identify nursing home characteristics associated with such changes.
DESIGN - Longitudinal study of 9432 Tennessee Medicaid enrollees 65 years of age or older who continuously resided in Tennessee from April 1, 1989, to September 30, 1991, a 30-month period surrounding implementation of OBRA-87.
MAIN OUTCOME MEASURES - Changes in the use of antipsychotic and other psychotropic drugs.
RESULTS - During the 30-month period, antipsychotic drug use decreased from 23.9 to 17.5 days per 100 days of residence, a 26.7% decline (P < .001), which resulted from both a decrease in new users (P < .001) and a reduction in long-term use of antipsychotic drugs (P < .001). There was no concomitant increase in other psychotropic drug use. A multivariate analysis revealed that changes in antipsychotic use were strongly associated with baseline antipsychotic use (P = .001) and third-shift staffing levels (P = .003). Nursing homes with baseline antipsychotic drug use and third-shift staffing above the median reduced antipsychotic drug use by 41%, compared with a 2% increase in nursing homes where both of these factors were below the median (P < .0001).
CONCLUSIONS - A substantial decrease in antipsychotic drug use coincided with the implementation of OBRA-87. Although this decrease is consistent with an improvement in quality of nursing home care, further research is needed to determine the effects of this legislation on resident outcomes.
To quantify physician practices in the care of patients with presumed pulmonary embolism or deep venous thrombosis, we analyzed heparin sodium orders, the intensity of anticoagulation, and complications in 65 patients with the diagnosis of deep venous thrombosis or pulmonary embolism. All patients were given heparin, for a mean (+/- SEM) period of 8.8 +/- 0.4 days. A high percentage of patients (60%) did not have a single partial thromboplastin time (PTT) greater than 1.5 times control within the first 24 hours of heparin therapy. Not until day 8 were 90% of PTTs in therapeutic range. We identified five common practices that led to delays in achieving a PTT greater than 1.5 times the laboratory control: (1) failure to start heparin therapy at the time of initial clinical suspicion, (2) choice of a heparin sodium bolus (mean, 5861 +/- 365 U) and continuous infusion (1026 +/- 148 U/h) insufficient to elevate the PTT to greater than 1.5 times control, (3) delay in obtaining the first PTT (mean, 11.7 +/- 1 h after start of heparin therapy), (4) insufficient heparin dosing in response to a low PTT, and (5) excessive and prolonged reductions in heparin therapy in response to a PTT greater than three times control, leading to subtherapeutic levels in 56% of subsequent PTTs. We think that poor understanding of heparin kinetics, overcautious behavior of physicians, and high heparin requirements in this selected population account for the findings.
OBJECTIVE - To describe the relative importance of factors influencing pediatricians' participation in Medicaid in North Carolina.
DESIGN - Questionnaire survey.
SETTING AND PARTICIPANTS - Nonacademic primary care pediatricians in direct patient care at least 50% of the time; 332 (85%) of the 389 eligible pediatricians responded.
MAIN OUTCOME MEASURES - Proportion of pediatricians who restricted Medicaid patients' access to their practices. The association between restricting access and the following factors was assessed: Medicaid reimbursement, pediatricians' demographic characteristics, knowledge of the Medicaid program, attitudes toward Medicaid patients and the Medicaid program, and beliefs about whether other physicians were available to care for Medicaid patients.
RESULTS - Twenty-nine percent of pediatricians restricted Medicaid patients' access to their practices. The proportion of pediatricians restricting access was 62% in cities, 13% in medium-sized towns, and 12% in small towns (P less than .001), but the proportion of pediatricians in cities who restricted access varied from 87% to 22%. Pediatricians who received a higher proportion of their usual fee were less likely to restrict Medicaid patients' access. The relationship between Medicaid payment and restricted access was substantially weakened after controlling for the following factors: (1) the size of the community, (2) pediatricians' attitudes toward Medicaid payment, (3) their perceptions that they were too busy to care for Medicaid patients, and (4) whether there were other resources for the care of Medicaid patients. At comparable levels of payment, rural pediatricians were about six times less likely than urban pediatricians to restrict access. Pediatricians who knew less about Medicaid reimbursement also restricted access more often. Whether or not they restricted access to new Medicaid patients, pediatricians provided acute, preventive, hospital, and emergency care to the Medicaid patients who were already in their practices.
CONCLUSIONS - Existing resources for the care of Medicaid patients, pediatricians' economic dependence on Medicaid, and the local norms of practice may be important factors in pediatricians' decision to participate in Medicaid. Increasing reimbursement will have only modest effects on Medicaid participation. Strategies to improve participation should also address pediatricians' knowledge of the Medicaid program and enlist the support of community physicians.