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Background: Little is known about the contribution of patient behavior to incomplete laboratory monitoring, and the reasons for patient non-completion of ordered laboratory tests remain unclear., Objective: To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests., Design: Mixed-Methods study including a quantitative assessment of the frequency of patient completion of ordered monitoring tests combined with qualitative, semi-structured, patient interviews., Participants: Quantitative assessment included patients 18 years or older from a large multispecialty group practice, who were prescribed a medication requiring monitoring. Qualitative interviews included a subset of show and no-show patients prescribed a cardiovascular, anticonvulsant, or thyroid replacement medication., Main Measures: Proportion of recommended monitoring tests for each medication not completed, factors associated with patient non-completion, and patient-reported reasons for non-completion., Key Results: Of 27,802 patients who were prescribed one of 34 medications, patient non-completion of ordered tests varied (range: 0-24 %, by drug-test pair). Factors associated with higher odds of test non-completion included: younger patient age (< 40 years vs. ≥ 80 years, adjusted odds ratio [AOR] 1.52, 95 % confidence interval [95 % CI] 1.27-1.83); lower medication burden (one medication vs. more than one drug, AOR for non-completion 1.26, 95 % CI 1.15-1.37), and lower visit frequency (0-5 visits/year vs. ≥ 19 visits/year, AOR 1.41, 95 % CI 1.25 to 1.59). Drug-test pairs with black box warning status were associated with greater odds of non-completion, compared to drugs without a black box warning or other guideline for testing (AOR 1.91, 95 % CI 1.66-2.19). Qualitative interviews, with 16 no-show and seven show patients, identified forgetting as the main cause of non-completion of ordered tests., Conclusions: Patient non-completion contributed to missed opportunities to monitor medications, and was associated with younger patient age, lower medication burden and black box warning status. Interventions to improve laboratory monitoring should target patients as well as physicians.

Background: Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients., Methods: The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, 1997, 1999, 2001, 2003, 2005)., Results: The average age of the study sample was 71 years, and 54% were men. The average length of stay decreased by nearly one third over the 10-year study period, from 7.2 days in 1995 to 5.0 days in 2005 (P <.001). Younger patients (<65 years), men, and patients with an uncomplicated hospital stay had significantly shorter lengths of stay than respective comparison groups. Lengths of stay shorter than the median were not associated with significantly higher odds of hospital readmission at 7 or 30 days postdischarge, or with mortality in the year after discharge. In contrast, longer lengths of stay were associated with significantly higher odds of short-term mortality. These findings did not vary by year under study., Conclusions: Length of stay in patients hospitalized for acute myocardial infarction decreased significantly between 1995 and 2005. Declining length of stay is not associated with an increased risk for early readmission or all-cause mortality., (Copyright © 2010. Published by Elsevier Inc.)

Objectives: To develop guidelines to monitor high-risk medications and to assess the prevalence of laboratory testing for these medications among a multispecialty group practice., Study Design: Safety intervention trial., Methods: We developed guidelines for the laboratory monitoring of high-risk medications as part of a patient safety intervention trial. An advisory committee of national experts and local leaders used a 2-round Internet-based Delphi process to select guideline medications based on the importance of monitoring for efficacy, safety, and drug-drug interactions. Test frequency recommendations were developed by academic pharmacists based on a literature review and local interdisciplinary consensus. To estimate the potential effect of the planned intervention, we determined the prevalence of high-risk drug dispensings and laboratory testing for guideline medications between January 1, 2008, and July 31, 2008., Results: Consensus on medications to include in the guidelines was achieved in 2 rounds. Final guidelines included 35 drugs or drug classes and 61 laboratory tests. The prevalence of monitoring ranged from less than 50.0% to greater than 90.0%, with infrequently prescribed drugs having a lower prevalence of recommended testing (P <.001 for new dispensings and P <.01 for chronic dispensings, nonparametric test for trend). When more than 1 test was recommended for a selected medication, monitoring within a medication sometimes differed by greater than 50.0%., Conclusions: Even among drugs for which there is general consensus that laboratory monitoring is important, the prevalence of monitoring is highly variable. Furthermore, infrequently prescribed medications are at higher risk for poor monitoring.

Objective: To evaluate antidiabetic drug treatment patterns and glycemic control among patients diagnosed with type 2 diabetes mellitus., Study Design: Retrospective study using the automated databases of a 200 000-member HMO., Methods: The study population consisted of patients > or =18 years of age with documented type 2 diabetes mellitus from January 1, 2002, through December 31, 2002. We determined the proportion of patients who had optimal glycemic control (glycosylated hemoglobin <7%) during the 6 months after the initial documentation of diabetes during calendar year 2002 (index date)., Results: Of the 4282 patients who met the inclusion criteria, 1050 (25%) received 1 oral agent, 486 (11%) received 2 oral agents, 56 (1%) received > or =3 oral agents, 84 (2%) received insulin and an oral agent, and 107 (2%) received insulin exclusively within 90 days after the index date. Among the 1075 patients receiving antidiabetic drug therapy who had a laboratory test result documented, 414 (39%) had optimal glycemic control. Optimal control was most frequent among patients receiving 1 oral agent (47%) and least frequent among patients receiving > or =3 oral agents (13%) (P <.01). Patients with a prior history of suboptimal glycemic control were less likely to have optimal glycemic control., Conclusions: Multiple oral antidiabetic agents may serve as a marker for more severe, uncontrolled diabetes. The vast majority of patients treated with multiple oral antidiabetic agents had suboptimal glycemic control, suggesting a need for intensified efforts to treat this particular group of patients to recommended goal levels.

Background: How patients respond to medical errors may influence how physicians approach disclosure of medical errors, but information on patients' responses is limited. Research is needed on how the circumstances that surround a medical error affect how patients respond., Objective: To investigate whether patients' tendency to forgive a physician following a medical error varied under different circumstances., Study Design: Cross-sectional survey., Methods: We mailed a questionnaire to 1500 randomly selected health plan members; the response rate was 66%. Questionnaire items assessed the likelihood of forgiveness following a medical error under 12 circumstances drawn from a review of the literature., Results: Respondents were most likely to forgive a physician if the patient failed to provide complete information (93% would or might forgive) and least likely to forgive if the error was due to efforts to keep costs down (11% would or might forgive). Most respondents would not forgive a physician when the physician was tired or distracted (68%), was incomplete in data collection (76%), lacked knowledge (78%), or failed to follow up (85%). Men were more likely to forgive than women; the most educated respondents were most likely to forgive., Conclusions: Our findings suggest that patients are not likely to forgive a physician in circumstances in which they suspect incompetence, inattention, or a lack of caring on the part of the physician involved. A more comprehensive understanding of forgiveness and the effect of forgiveness on the physician-patient relationship following a medical error is needed.

Objective: To examine various strategies for the identification of adverse drug events (ADEs) among older persons in the ambulatory clinical setting., Design: A cohort study of Medicare enrollees (n = 31,757 per month) receiving medical care from a large multispecialty group practice during a 12-month observation period (July 1, 1999 through June 30, 2000)., Measurements: Possible drug-related incidents occurring in the ambulatory clinical setting were detected using signals from multiple sources., Results: During the tracking period, there were 1,523 identified ADEs, of which 421 (28%) were considered preventable. Across all sources, 23,917 signals were found; 12,791 (53%) were potential incidents that led to review of a patient's medical record and 2,266 (9%) were presented to physician reviewers. Although the positive predictive value (PPV) for reports from providers was high compared with other sources (54%), only 11% of the ADEs and 6% of the preventable ADEs were identified through this source. PPVs for other sources ranged from a low of 4% for administrative incident reports to a high of 12% for free-text review of electronic notes. Computer-generated signals were the source for 31% of the ADEs and 37% of the preventable ADEs. Electronic notes were the source for 39% of the ADEs and 29% of the preventable ADEs. There was little overlap in the ADEs identified across all sources., Conclusion: Our findings emphasize the limitations of voluntary reporting by health care providers as the principal means for detection of ADEs and suggest that multiple strategies are required to detect ADEs in geriatric ambulatory patients.

Objective: To determine the effects of lipid-lowering agent (LLA) class and drug plan design option on persistence with LLAs among elderly patients enrolled in a managed care plan., Methods: A retrospective cohort study was conducted among 310 older adult members enrolled in a health maintenance organization operating in New England who were dispensed an LLA between July 1, 1994, and June 30, 1996. Survival analysis was used to examine differences in discontinuation of LLAs between different classes of LLAs and drug benefit plans as well as patient sex, age, prior hospitalization for coronary heart disease (CHD), hypertension, diabetes mellitus, and the number of other medications., Results: The overall LLA discontinuation rate increased with time from 18% (95% confidence interval [CI], 13.8%-22.4%) at 6 months to 46% (95% CI, 39.7%- 52.5%) at 12 months and 66% (95% CI, 59.2%-73.0%) at 18 months. The likelihood of discontinuation increased from 54% (95% CI, 44.8%-63.6%) at 12 months to 77% (95% CI, 67.5%-85.5%) at 18 months in nonstatin users and from 39% (95% CI, 30.4%-47.6%) at 12 months to 57 % (95% CI, 47.3%-66.9%) at 18 months in statin users (P = 0.001). Among patients prescribed a statin at initial prescription (n = 182), the 12-month discontinuation rates were 33% (95% CI, 23.0%-43.6%) for those with full drug benefit coverage and 50% (95% CI, 34.8%-65.1%) for those with 1,000 dollars per year maximum coverage, while the 21-month discontinuation rates were 60% (95% CI, 46.3%-72.9%) for those with full coverage and 86% (95% CI, 73.7%-98.7%) for those with 1,000 dollars per year maximum coverage (P = 0.023). Adjusting for plan design and hypertension, statin users were less likely to discontinue compared with users of other LLAs (rate ratio [RR] = 0.58; 95% CI, 0.40-0.82; P = 0.002). Among patients dispensed a statin, full-coverage members were less likely to discontinue compared with members having an annual 1,000 dollars maximum drug coverage, adjusting for diabetes and hypertension (RR = 0.58; 95% CI, 0.34-0.98; P = 0.041). This finding was among a small sample after subanalyses, and further research is warranted. Plan design was not determined to be significantly associated with discontinuation of other LLAs., Conclusions: Our findings suggest that persistence with LLAs is low among older patients regardless of scope of drug benefit coverage or the drug class. Addressing the challenges of maintaining adherence to prescribed therapeutic regimens in the elderly will require a multifaceted approach; deficiencies will not be eliminated simply through the provision of prescription drug benefit coverage.

Context: Adverse drug events, especially those that may be preventable, are among the most serious concerns about medication use in older persons cared for in the ambulatory clinical setting., Objective: To assess the incidence and preventability of adverse drug events among older persons in the ambulatory clinical setting., Design, Setting, and Patients: Cohort study of all Medicare enrollees (30 397 person-years of observation) cared for by a multispecialty group practice during a 12-month study period (July 1, 1999, through June 30, 2000), in which possible drug-related incidents occurring in the ambulatory clinical setting were detected using multiple methods, including reports from health care providers; review of hospital discharge summaries; review of emergency department notes; computer-generated signals; automated free-text review of electronic clinic notes; and review of administrative incident reports concerning medication errors., Main Outcome Measures: Number of adverse drug events, severity of the events (classified as significant, serious, life-threatening, or fatal), and whether the events were preventable., Results: There were 1523 identified adverse drug events, of which 27.6% (421) were considered preventable. The overall rate of adverse drug events was 50.1 per 1000 person-years, with a rate of 13.8 preventable adverse drug events per 1000 person-years. Of the adverse drug events, 578 (38.0%) were categorized as serious, life-threatening, or fatal; 244 (42.2%) of these more severe events were deemed preventable compared with 177 (18.7%) of the 945 significant adverse drug events. Errors associated with preventable adverse drug events occurred most often at the stages of prescribing (n = 246, 58.4%) and monitoring (n = 256, 60.8%), and errors involving patient adherence (n = 89, 21.1%) also were common. Cardiovascular medications (24.5%), followed by diuretics (22.1%), nonopioid analgesics (15.4%), hypoglycemics (10.9%), and anticoagulants (10.2%) were the most common medication categories associated with preventable adverse drug events. Electrolyte/renal (26.6%), gastrointestinal tract (21.1%), hemorrhagic (15.9%), metabolic/endocrine (13.8%), and neuropsychiatric (8.6%) events were the most common types of preventable adverse drug events., Conclusions: Adverse drug events are common and often preventable among older persons in the ambulatory clinical setting. More serious adverse drug events are more likely to be preventable. Prevention strategies should target the prescribing and monitoring stages of pharmaceutical care. Interventions focused on improving patient adherence with prescribed regimens and monitoring of prescribed medications also may be beneficial.

Background: The prevalence of atrial fibrillation (AF) increases dramatically with advancing patient age, and, as a result, this condition is common in persons residing in the long-term care setting., Objectives: To assess the knowledge and attitudes of physicians regarding the use of warfarin for stroke prevention in patients with atrial fibrillation in long-term care facilities., Methods: We surveyed physicians actively providing primary care to older patients in 30 long-term care facilities located in New England, Quebec, and Ontario. Physicians were requested to complete a structured questionnaire about use of warfarin therapy for stroke prevention in patients with AF residing in long-term care facilities. The questionnaire included two clinical scenarios designed to provide substantial contrasts in patient characteristics including underlying comorbidity, functional status, bleeding risk, and stroke risk., Results: A total of 269 physicians were asked to participate in the survey, and 182 (67.7%) completed the questionnaire between February 1, 1995, and July 31, 1995. Only 47% of respondents indicated that the benefits of warfarin therapy "greatly outweigh the risks" in this setting; the remainder of physicians indicated that benefits only "slightly outweigh the risks" (34%) or that risks "outweigh benefits" (19%). The most frequently cited contraindications to warfarin use were: excessive risk of falls (71%), history of gastrointestinal bleeding (71%), history of other non-central nervous system bleeding (36%), and history of cerebrovascular hemorrhage (25%). Among the 164 physicians who reported using the international normalized ratio to monitor warfarin therapy, 27% indicated a target range with a lower limit less than 2, 71% indicated a target range between 2 and 3, and 2% indicated an upper limit greater than 3. Among respondents who answered questions about the two clinical scenarios, estimates of the risk of a stroke without warfarin therapy and the risk of an intracranial hemorrhage with therapy varied widely., Conclusions: Our findings suggest that many uncertainties surround the decision to prescribe warfarin to patients with AF in the long-term care setting, as well as questions about the appropriate intensity of this treatment when it is prescribed. Concerns about the risks of bleeding appear to prevail over stroke prevention when physicians make such prescribing decisions.