Increased Risk Of Hospitalization Research Articles

A pharmaco-economic analysis of patients with schizophrenia switching to generic risperidone involving a possible compliance loss

BackgroundAs schizophrenia patients are typically suspicious of, or are hostile to changes they may be reluctant to accept generic substitution, possibly affecting compliance. This may counteract drug costs savings due to less symptom control and increased hospitalization risk. Although compliance losses following generic substitution have not been quantified so far, one can estimate the possible health-economic consequences. The current study aims to do so by considering the case of risperidone in Germany.MethodsAn existing DES model was adapted to compare staying on branded risperidone with generic substitution. Differences include the probability of non-compliance and medication costs. Incremental probability of non-compliance after generic substitution was varied between 2.5% and 10%, while generic medication costs were assumed to be 40% lower. Effect of medication price was assessed as well as the effect of applying compliance losses to all treatment settings. The probability of staying on branded risperidone being cost-effective was calculated for various outcomes of a hypothetical study that would investigate non-compliance following generic substitution of risperidone.ResultsIf the incremental probability of non-compliance after generic substitution is 2.5%, 5.0%, 7.5% and 10% respectively, incremental effects of staying on branded risperidone are 0.004, 0.007, 0.011 and 0.015 Quality Adjusted Life Years (QALYs). Incremental costs are €757, €343, -€123 and -€554 respectively. Benefits of staying on branded risperidone include improved symptom control and fewer hospitalizations. If generic substitution results in a 5.2% higher probability of non-compliance, the model predicts staying on branded risperidone to be cost-effective (NICE threshold of ₤30,000 per QALY gained). Compliance losses of more than 6.9% makes branded risperidone the dominant alternative. Results are sensitive to the locations at which compliance loss is applied and the price of generic risperidone. The probability that staying on branded risperidone is cost-effective would increase with larger compliance differences and more patients included in the hypothetical study.ConclusionThe model predicts that it is cost-effective to keep a patient with schizophrenia in Germany on branded risperidone instead of switching him/her to generic risperidone (assuming a 40% reduction in medication costs), if the incremental probability of becoming non-compliant after generic substitution exceeds 5.2%.

Characteristics and outcomes of injury-related ED visits among older adults

Objectives The objectives of this study were to examine the epidemiology of injury among older adults treated in emergency departments (EDs) and to explore the effect of advanced age and nursing home residence on associated outcomes. Methods A secondary data analysis of a nationally representative sample from the National Hospital Ambulatory Care Survey was conducted using available sampling weights and data from the US Census Bureau. Weighted multivariate logistic regression was used to explore factors associated with injury outcomes, including hospitalization and receipt of potentially inappropriate medications. Results Nearly 21 million injury-related ED patient visits were made by older adults during the study period. Nearly 10% of episodes were identified as adverse events, which increased hospitalization risk 3-fold. Potentially inappropriate medications were provided during nearly 12% of encounters. Conclusions Injury reductions among elders could be achieved by reducing adverse events, whereas quality could be improved by reducing potentially inappropriate medication use in the ED.

A Longitudinal Study of Medication Nonadherence and Hospitalization Risk in Schizophrenia

Previous cross-sectional studies have suggested an association between medication nonadherence and hospitalization for individuals with schizophrenia. However, such analyses typically measure adherence averaged over long time periods. We investigated the temporal relationship between nonadherence and hospitalization risk using a daily measure of medication availability. Our observational cohort included 1191 patients with schizophrenia (ICD-9 criteria) enrolled in Maine and New Hampshire Medicaid programs who initiated atypical antipsychotic therapy between January 1, 2001, and December 31, 2003. Pharmacy claims were used to define days with gaps in medication availability. We tested the association of gaps in medication availability with all-cause, mental health, and schizophrenia-specific hospitalization using a Cox regression model. Compared to individuals with available medication, individuals in the first 10 days following a missed prescription refill had a hazard ratio of 1.54 (95% CI = 1.02 to 2.32) for mental health hospitalization and 1.77 (95% CI = 1.16 to 2.71) for schizophrenia hospitalization. Similarly, medication gaps of more than 30 days were associated with 50% increased hazard for all 3 hospitalization outcomes. Switching and augmenting therapy, previous hospitalization, and clinical severity measures were also associated with substantially increased hazard of hospitalization. Our findings indicate that patients may be at significantly increased risk for hospitalization as early as the first 10 days following a missed medication refill. Patients who switched or augmented medications or were previously hospitalized also demonstrated increased hospitalization risk. Clinicians and Medicaid programs should consider using pharmacy claims to monitor medication use and target adherence interventions to reduce relapses in this vulnerable population.

Time-dependent increase in risk of hospitalisation with infection among Swedish RA patients treated with TNF antagonists

Objectives:The degree to which treatment with tumour necrosis factor (TNF) antagonists may be associated with increased risks for serious infections is unclear. An observational cohort study was performed using prospectively...

Psychiatric morbidity and acute hospitalization in elderly people

Few studies have investigated the association of psychiatric morbidity with acute hospitalization risk in elderly people. We examined this association using population-based data for 1092 older adults aged > or =60 years in Singapore, including subjects who reported at least one acute hospitalization from any medical condition(s) in the 12 months prior to interview (N = 136). Psychiatric morbid/comorbid disorders were diagnosed using the Geriatric Mental State examination. In a multivariate analysis, comorbid psychiatric disorders were independently associated with hospitalization [adjusted odds ratio 2.76, 95% confidence interval 1.20-6.33], after controlling for age, ethnicity, employment status, number of medical comorbidities, number of activities of daily living limitations, hearing and visual impairment, SF-12 Physical and Mental Component Summary scores, social, productive, fitness and health activities, and regular visits to health-care providers. Neither dementia diagnosis nor cognitive impairment measured by the Mini-mental State Examination was associated with increased hospitalization risk. Psychiatric morbidity in old age was significantly associated with increased hospitalization risk. This finding underlines the importance of treating psychiatric illness to reduce the risk of acute hospitalization in elderly patients.

Clinical Outcomes and Dialysis Adequacy in Adolescent Hemodialysis Patients

The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative guidelines recommend that adult hemodialysis (HD) patients receive a minimum dialysis dose by single-pooled Kt/V (spKt/V) of 1.2 or greater. There are no data to support a minimum spKt/V dose for children on HD therapy. We aim to determine the association of spKt/V with mortality and hospitalization in adolescents. Clinical characteristics of adolescent HD patients aged 12 to 18 years old included in the 2000/2001 End-Stage Renal Disease Clinical Performance Measures Project were linked to US Renal Data System data from October 1, 1999, to October 15, 2001. Hospitalization risks after adjustment for time on dialysis therapy, access, hemoglobin level, albumin level, and height were determined by means of Poisson regression. spKt/V was analyzed by the adult target (< versus > or = 1.2) and by intervals. There were 613 patients with 477 patient-years of follow-up, during which there were 14 deaths and 185 hospitalizations covering 1,108 days. After adjustment, patients with an spKt/V less than 1.2 had increased hospitalization risk (1.59; 95% confidence interval, 0.98 to 2.56; P = 0.06) compared with those with an spKt/V of 1.2 or greater. Compared with patients with an spKt/V of 1.2 to 1.4, patients with an spKt/V less than 1.2 had increased adjusted risk for hospitalization (2.46; 95% confidence interval, 1.23 to 4.94; P = 0.01). Increases in spKt/V beyond 1.4 were not associated with improved outcomes. Applying the current adequacy guideline to adolescent HD patients is justified by the increased hospitalization risk of those who fail to attain an spKt/V of 1.2 or greater. However, attaining an spKt/V in excess of 1.4 was not associated with greater benefit.

Conventional and Atypical Antipsychotics and the Risk of Hospitalization for Ventricular Arrhythmias or Cardiac Arrest

Conventional antipsychotic drugs have been implicated as a cause of ventricular arrhythmias and cardiac arrest, but no definitive information is available regarding atypical antipsychotics. We compared the effect of conventional and atypical antipsychotics on the risk of hospitalization for ventricular arrhythmias and cardiac arrest. We conducted a case-control study on residents of nursing homes in 6 US states by using data from the Minimum Data Set linked to Medicare inpatient claims. Cases were residents hospitalized for ventricular arrhythmias or cardiac arrest between July 4, 1998, and December 30, 1999. For each case, we identified up to 5 controls residing in the same facility during the same period. The sample consisted of 649 cases and 2962 controls. Use of conventional antipsychotics was associated with a nearly 2-fold increase in risk of hospitalization for ventricular arrhythmias or cardiac arrest (adjusted odds ratio, 1.86; 95% confidence interval, 1.27-2.74). There was no increased risk associated with the use of atypical antipsychotics (odds ratio, 0.87; 95% confidence interval, 0.58-1.32). The risk of hospitalization for ventricular arrhythmias or cardiac arrest was highest among conventional users with cardiac disease (odds ratio, 3.27; 95% confidence interval, 1.95-5.47). However, cardiac disease and conventional antipsychotics did not show a synergistic effect (synergy index, 1.19). Conventional but not atypical antipsychotics are associated with an increased risk of hospitalization for ventricular arrhythmias and cardiac arrest. The prescription of conventional antipsychotics in patients with cardiac disease should be carefully weighed.

Medication Compliance in Schizophrenia: Small Compliance Gaps Count

Older studies have linked medication noncompliance in schizophrenic patients with increased risks for relapse and hospitalization. However, these

Gender and Hospitalization Patterns Among HIV-Infected Drug Users Before and After the Availability of Highly Active Antiretroviral Therapy

We examined highly active antiretroviral therapy (HAART) era and pre-HAART era hospitalization rates among 604 HIV-infected drug users in a prospective study in Bronx, New York. Medical history and risk behaviors were elicited by semiannual interviews. Standardized medical record review abstracted discharge diagnoses for all hospitalizations. Hospitalization rates from January 1997 to December 2000 were compared with rates from January 1992 to December 1996. The rate of hospitalizations per 100 patient-years in the HAART era was 49.3 compared with 44.1 in the pre-HAART era (P = 0.13). Among women, the rate was significantly higher in the HAART era than in the pre-HAART era (68.1 vs. 49.4 hospitalizations per 100 patient-years, respectively; P = 0.01). In the second era, HAART users had lower rates than those who did not use HAART (37.2 vs. 83.4 hospitalizations per 100 patient-years, respectively; P < 0.001) for both HIV-associated and non-HIV-associated illnesses. Multivariate analysis revealed that in the HAART era, female gender (relative risk ratio = 1.72, P = 0.03) and not using HAART (relative risk ratio = 1.82, P = 0.02) independently predicted increased hospitalization risk. In the pre-HAART era, women were at independently higher risk of hospitalization (relative risk ratio = 1.36, P = 0.05). Among HIV-infected drug users, those who use HAART have a decreased risk of hospitalization; those who do not use HAART remain at high risk of continuing morbidity from both HIV-related and non-HIV-related illness and have high hospitalization rates.

Nonsteroidal antiinflammatory drugs as a trigger of clinical heart failure.

Two recent studies estimated that users of nonsteroidal antiinflammatory drugs (NSAIDs) have a two-fold increase in risk of hospitalization for congestive heart failure and that this effect is larger among patients with preexisting cardiovascular diseases. To evaluate the association between NSAID use and the risk of first-diagnosed episode of heart failure, we conducted a case-control study nested in a population-based cohort of individuals 40-84 years of age and registered in the U.K. General Practice Research Database at 1 January 1996. We excluded patients with a diagnosis of heart failure or cancer before that time and followed source members until a first-time recorded diagnosis of heart failure or cancer, or until 31 December 1996 if no disease occurred. The analysis included 857 confirmed cases and 5000 controls frequency-matched to cases by age (interval of 1 year) and sex. The estimated adjusted relative risk of heart failure associated with prescription of NSAIDs was 1.6 (95% confidence interval = 1.2-2.1). The relative risk was greater during the first month of therapy and was independent of treatment indication. The relative risk was 1.9 (1.3-2.8) among patients with prior history of hypertension, diabetes or renal failure and 1.3 (0.9-1.9) among individuals without these conditions. Initiation of NSAID therapy may double the risk of developing heart failure in susceptible individuals. Patients with renal failure, diabetes or hypertension when taking NSAIDs might be at a greater risk of developing heart failure than patients without those conditions.

Increased Hospitalization Risk for Recently Widowed Older Women and Protective Effects of Social Contacts

SUMMARY This study examines effects of recent widowhood on health for a nationally representative sample of older women in the United States. Mediating effects of social connectedness on the health of recently widowed women are also explored. Using data from the 1984–1990 Longitudinal Study of Aging and Medicare claims, discrete-time hazard models estimate the risk of hospitalization for any 30-day period for women who were married at the time of the baseline survey (n = 1,138). Compared to women who are not recently widowed, those recently widowed have a 40% higher risk of hospitalization. Social connectedness, measured by having phoned a friend/neighbor or family member in the period prior to the baseline survey, significantly decreases hospitalization risk for the recently widowed. The findings indicate that recent widowhood has a large adverse effect on the health of older women. Results highlight the need to provide additional support to recently widowed older women.

Self-reported Asthma is Associated with Increased Risk of Hospitalization and/or Death Due to Coronary Heart Disease among Never Smoking Men and Women.

P61 Inflammation is thought to play a crucial role in the pathogenesis of coronary atherosclerosis. Asthma is a chronic inflammatory disease and a major cause of pulmonary morbidity and mortality. However, very few prospective studies exist evaluating the question of whether asthma is related to increased risk of cardiovascular diseases, and none were restricted to never smokers. We examined the prospective association between self-reported asthma diagnosis and risk of hospitalization and/or death due to coronary heart disease (CHD, ICD-9 codes 410-414) in a large population-based sample. Data on self-reported health conditions, including asthma, and cardiovascular risk factors were collected at a health maintenance organization (HMO) in the San Francisco Bay Area between 1979 and 1985. The sample included 14,047 never smoking women and 7,989 never smoking men aged 35-89 years (mean ± SD, 50.4 ± 11.9 years), 56% Caucasian, who were free of known CHD at baseline. Of those, 652 women (4.6%) and 410 men (5.1%) self-reported physician-diagnosed asthma. Follow-up for hospitalization and/or death was available through the end of 1998 (median=13.4 years). Using Cox proportional hazards regression, we censored persons leaving the health plan at their last known date of HMO membership. Compared to subjects with no-known history of asthma, and after adjustment for age, sex, race, education level, alcohol consumption, body mass index, serum cholesterol, systolic blood pressure and diabetes, self-reported asthma was significantly associated with higher risk of hospitalization and /or death due to CHD (RR=1.33; 95% CI=1.05-1.67; p=0.02). Also in multivariate analysis, asthma under treatment at the time of the baseline examination was more strongly associated with CHD risk (RR=1.82; 95% CI=1.23-2.69; p=0.003). No interactions were found between self-reported asthma or asthma under treatment and patient sex. We conclude that, in a large representative population-based sample of non-smokers, self-reported asthma was associated with increased risk of coronary heart disease.

Lower Extremity Performance in Nondisabled Older Persons as a Predictor of Subsequent Hospitalization

This study examines, in initially nondisabled older persons, the impact of reduced lower extremity performance on subsequent hospitalizations. A 4-year prospective cohort study was conducted among 3381 persons, aged 71 years and older, who initially reported no disability. At baseline, lower extremity performance was measured by an assessment of standing balance, a timed 2.4-m walk, and a timed test of rising from a chair five times. Data on subsequent hospital admissions and discharge diagnoses over 4 years were obtained from the Medicare database. During the follow-up period, nondisabled persons with poor lower extremity performance spent significantly more days in the hospital (17.7 days) than those with intermediate and high performance (11.6 and 9.7 days, respectively). Poor lower extremity performance in nondisabled persons significantly predicted subsequent hospitalization over 4 years (relative risk for hospitalization in those with poor vs high performance: 1.78; 95% confidence interval, 1.45-2.17). This increased hospitalization risk could not be explained by several indicators of baseline health status. Increased hospitalization risks were especially found for geriatric conditions, such as dementia, decubitus ulcer, hip fractures, other fractures, pneumonia, dehydration, and acute infections. Even in persons who are currently nondisabled, a simple measure of lower extremity performance is predictive of subsequent hospitalization, especially for geriatric conditions.

High-risk clients and mental health care management

A framework characterizing high-risk psychiatric patients by their probability of hospitalization and lengthy stay is introduced. Risk curves are then developed for each patient showing the potential impact of mental health ease management on patient risk. Preliminary empirical analysis reveals that although most patients benefit from the case management intervention, some 30% of the client population may face an increase in risk of hospitalization and lengthy stay.