Making Medication Changes Research Articles

Factors influencing central nervous system medication deprescribing and behavior change in hospitalized older adults.

Central nervous system (CNS) medications are linked to higher morbidity and mortality in older adults. Hospitalization allows for deprescribing opportunities. This qualitative study investigates clinician and patient perspectives on CNS medication deprescribing during hospitalization using a behavioral change framework, aiming to inform interventions and identify recommendations to enhance hospital deprescribing processes. This qualitative study focused on hospitalists, primary care providers, pharmacists, and patients aged ≥60 years hospitalized on a general medicine service and prescribed ≥1 CNS medications. Using semi-structured interviews and focus groups, we aimed to evaluate patient medication knowledge, prior deprescribing experiences, and decision-making preferences, as well as provider processes and tools for medication evaluation and deprescribing. Rapid qualitative analysis applying the Capability, Opportunity, Motivation, and Behavior (COM-B) framework revealed themes influencing deprescribing behavior in patients and providers. A total of 52 participants (20 patients and 32 providers) identified facilitators and barriers across deprescribing steps and generated recommended strategies to address them. Clinicians and patients highlighted the opportunity for CNS medication deprescribing during hospitalizations, facilitated by multidisciplinary teams enhancing clinicians' capability to make medication changes. Both groups also stressed the importance of intensive patient engagement, education, and monitoring during hospitalizations, acknowledging challenges in timing and extent of deprescribing, with some patients preferring decisions deferred to outpatient clinicians. Hospitalist and pharmacist recommendations centered on early pharmacist involvement for medication reconciliation, expanding pharmacy consultation and clinician education on deprescribing, whereas patients recommended enhancing shared decision-making through patient education on medication adverse effects, tapering plans, and alternatives. Hospitalists and PCPs also emphasized standardized discharge instructions and transitional care calls to improve medication review and feedback during care transitions. Clinicians and patients highlighted the potential advantages of hospital interventions for CNS medication deprescribing, emphasizing the necessity of addressing communication, education, and coordination challenges between inpatient and outpatient settings.

Clinician Ordering and Management Patterns of Urine Toxicology Results at a Cancer Center

ContextOpioid therapy is a cornerstone for treatment of cancer-related pain, but standardized management practices for patients with cancer and aberrant urine drug test (UDT) results are lacking. ObjectivesTo identify the prevalence of UDT ordering (both screening and definitive testing) in the oncology setting and to examine clinician management practices for patients with cancer on opioid therapy with aberrant definitive UDT results. MethodsWe conducted a retrospective chart review of patients with cancer on opioid therapy at an academic cancer center in the United States. Outcomes included UDT ordering patterns and clinician management practices in response to aberrant definitive UDT results. ResultsOur study revealed an overall UDT ordering rate of 3.7% among 10,371 patients with cancer on opioid therapy. Among 143 patients for whom definitive UDTs were ordered, oncologists only ordered 14 (9.8%) UDTs, while palliative care ordered the majority (n = 129; 90.2%). Fifty-five (38.5%) patients had aberrant results, and the most common aberrancy was presence of illicit drugs 22 [15.4%]. Clinicians rarely made medication changes (20 [36.4%]) when UDT results were aberrant, and in the setting of possible fentanyl use (n = 8), only 3 (37.5%) patients were started/switched to methadone, and none were started/switched to buprenorphine. ConclusionOverall UDT ordering was infrequent for patients with cancer on opioid therapy, especially by oncologists, and clinicians rarely made prescribing changes when definitive UDT results were aberrant. More definitive guidance related to UDT ordering and opioid management are needed for patients with cancer and aberrant UDT results.

Patient perspectives on telemedicine use in rheumatology during the COVID-19 pandemic: survey results from the COVID-19 Global Rheumatology Alliance.

The COVID-19 pandemic resulted in rapid adoption of telemedicine in rheumatology. We described perspectives of patients with rheumatic diseases related to telemedicine use. An anonymous online survey for people with rheumatic diseases was launched in January 2021. We collected data on reasons for telemedicine use, perceived benefits, disadvantages and obstacles of telemedicine, perceived telemedicine effectiveness for different clinical tasks, level of satisfaction with telemedicine use, and future preferences for telemedicine. We summarized results with descriptive statistics and identified themes in free text responses to describe perspectives of telemedicine qualitatively. We received 596 complete responses (85% female and 47% 41-60years old). During the COVID-19 pandemic, 78% (467/596) of respondents used telemedicine, and 61% (283/467) of telemedicine users reported that telemedicine was as effective or more effective than an in-person visit. Younger participants and those in North America reported effectiveness and satisfaction with telemedicine at higher frequencies. Participants reported similar effectiveness to in-person visits for making medication changes and discussing disease symptoms or complications. Most respondents found telemedicine at least as effective as in-person visits. Participants found telemedicine to be effective for specific scenarios, such as making medication changes and discussion of disease activity. Telemedicine may continue to be of importance in the care of patients with rheumatic diseases post pandemic, but likely for specific subsets of patients for specific visit indications. Key Points • Most patients with rheumatic disease found telemedicine as effective as in-person visits, particularly for some indications.

1034-P: Access to Continuous Glucose Monitoring Systems in a Primary Care Clinic for Underserved Patients with Type 2 Diabetes—A Pilot Study

B-Disparities in diabetes care are well documented. Continuous Glucose Monitoring Systems (CGMs) have improved patient experience without the need for finger sticks and have been shown to effectively lower Hemoglobin A1c (HbA1c), decrease clinical inertia and decrease the number of hypoglycemic events. Medically underserved and historically marginalized persons are disproportionately affected by diabetes, yet limited data exist on use of CGMs in this population. M-We report a pilot initiative that brought CGM access (FreeStyle Libre 2) to a Federally Qualified Community Health Center (FQHC). Patients with type 2 diabetes and an HBA1c >8.0% were referred to be enrolled in CGM. Each patient had an initial nurse visit for device placement of FreeStyle Libre (FSL) and several follow up visits to review glycemic trends and make medication changes with a provider. Baseline HBA1c was collected and repeated at the end of the study. Provider and patient surveys were distributed at each visit. R-Fifty participants were enrolled in the CGM study and had FSL placed. The CGM active time was greater than 50% in 76% of participants and those who continued with CGM had an increase in active time. Initial mean A1C for the entire cohort was 9.64% and average glucose after 2 weeks was 195 mg/dl. Hypoglycemia, especially overnight, reduced overtime. The use of CGM data was associated with clinician-initiated medication changes. Provider surveys revealed an increase in likelihood of medication changes based on glycemic trends and patients reported better understanding of their disease process. C-This pilot study demonstrates the feasibility of utilizing diabetes technology (FreeStyle Libre 2) in underserved patients at a primary care clinic staffed with internal medicine residents, physicians, and nurse practitioners. CGM is beneficial in under resourced primary care outpatient settings to determine glycemic trends and make appropriate medication recommendations. Disclosure R.G.Sgroi: None. S.Gumireddy: None. W.Tan: None. R.Kaplan: None. Y.Milambwe: None. L.H.Rosoph: None. D.A.Salama: None. C.R.Feher: None. N.J.Rennert: None.

A Multidisciplinary Quality Improvement Program to Improve Diabetes Care at a Free Clinic.

To evaluate the effectiveness of an intensive, multidisciplinary patient-centered approach involving a pharmacist and a dietician in a population of uninsured free clinic patients with diabetes and hypertension. A single-center retrospective chart review of a quality improvement project. All patients had diagnoses of diabetes and hypertension and a most recent hemoglobin A1c ≥ 9.0%. Patients met individually with a pharmacist and a dietician during 6 encounters over 12 months. The pharmacist made medication changes, encouraged lifestyle reflections, and helped patients create and track self-management goals. The dietician helped patients plan strategies for diet and exercise. The primary outcome was a change in mean hemoglobin A1c. Of 30 enrolled patients, 17 completed three months of treatment, and seven completed 12 months. The 17 patients who completed three months of treatment had the following characteristics: mean age 55.5 years; mean hemoglobin A1c 11.5%; 82% were taking two or more antidiabetic medications; 59% were taking two or more antihypertensive medications. Significant reductions in mean hemoglobin A1c values were observed at three months (-3.4%, P<0.0001) and twelve months (-4.0%, P=0.0156). Reductions in systolic blood pressure were also observed at three months (-6 mmHg, P=0.1060) and twelve months (-17 mmHg, P=0.2188). Large and significant hemoglobin A1c reductions were observed in free clinic patients with diabetes refractory to traditional medical management. Goal-oriented patient empowerment effectively improves a wide range of patient outcomes in the free clinic setting. Other free clinics can implement this collaborative, multidisciplinary model with access to similar personnel.

Abstract 12185: Medication Changes And Reasons For No Medication Change Among Outpatients With Heart Failure With Reduced Ejection Fraction: Results From CHART-HF

Introduction: Underuse and under-dosing of guideline-directed medical therapy (GDMT) for HFrEF in US outpatient practice is well documented. Yet changes to GDMT and clinician-reported reasons for not making medication changes are not well described. Methods: US cardiologists were recruited from the Schlesinger Group, a nationwide panel of physicians who participate in web-based surveys. The cardiologists conducted anonymized chart reviews of their own randomly selected patients meeting eligibility criteria. Eligible patients had HFrEF&lt;45% without end-stage kidney disease, and an outpatient cardiology visit between 2017-2019. For each index outpatient visit, cardiologists abstracted data on medication changes and reported their primary rationale for not making a change in each specific therapy. Results: Overall, 238 cardiologists participated and reviewed outpatient visits for 458 patients under their care (median age 64 years, 65% male). Before the index visit, proportions of patients not prescribed beta-blocker, MRA, ARNI, and SGLT2i were 17%, 58%, 72%, and 86%, respectively. Across medications, proportions of patients with medication initiation ranged from 5-11%, medication discontinuation from 0-11%, with variable rates of dose changes (Figure, Panel A). Among patients receiving medication, for each therapy, the most common clinician-reported reason for no medication change was patient clinical stability (43-57%). Other reasons for no medication change included already being at target dose (29-44% of cases), and perceived risk of intolerance (6-11%) (Figure, Panel B) . Conclusions: We observed relatively few medication changes made among these HFrEF patients. Patient stability and perceived risk of intolerance were frequently cited by cardiologists as reasons for not making guideline-directed medication changes, suggesting clinical inertia as a major barrier to closing gaps in GDMT.

New Prescriptions After Hospitalization: A Bitter Pill or Just What the Doctor Ordered?

New Prescriptions After Hospitalization: A Bitter Pill or Just What the Doctor Ordered?

Too many pills, too many sick older Australians: Working together is key.

Australians living in aged care facilities are clinically complex, with multiple comorbidities treated with multiple medicines. Over the past 12 months, there has been unprecedented focus onharm from medications in aged care. This led the Australian Government to fund enhancements to the Residential Medication Management Review (RMMR) program. The aim of this article is to discuss howthe enhanced RMMR program will address barriers and support general practitioners to make medication changes for older Australians. These enhancements are intended to provide a complete cycle of care over nine months, with ongoing collaboration within the healthcare team including residents. This will allow a team approach to medication changes and monitoring resident response over time. Progress reports will provide a history of outcomes with respect to successful and unsuccessful medication changes. Successful outcomes for residents rely on the healthcare team working together.

Rivaroxaban-induced skin necrosis: a case report

Background: Even though rivaroxaban has been mainly associated with hemorrhage-related adverse effects, rivaroxaban-induced skin necrosis has received less attention or went unrecognized. Little has been documented about hypersensitivity reactions caused by the treatment with rivaroxaban. Case Presentation: This paper reports a skin necrosis with an apparent similarity to skin adverse events caused by the different anticoagulants. It happened in a 30-year-old female patient during rivaroxaban treatment. The correlation of the skin lesions to the used drug was made by the act of repeated discontinuation and reuse of rivaroxaban and the noticed remission and exacerbation of skin necrosis. Conclusion: This case highlights the vigilance required by healthcare in recognizing potential adverse effects of newly marketed drugs and in making medication changes whenever necessary.

Anti-hypertensive medications and injurious falls in an older population of low socioeconomic status: a nested case-control study

BackgroundThis study aimed to determine whether the number of anti-hypertensive medication classes or any change in anti-hypertensive medication were associated with injurious fall among the community-dwelling older population of low socioeconomic status.MethodsUsing data from electronic medical records, we performed a nested case-control study among older Singapore residents (≥60) of low socioeconomic status (N = 210). Controls (n = 162) were matched to each case (n = 48) by age and gender. Variables with p < 0.10 in univariate analysis were included in multivariate analysis. We used conditional logistic regression to assess the associations of the number of anti-hypertensive medication classes and change in anti-hypertensive medication with injurious falls. We also performed stepwise regressions as sensitivity analyses. p < 0.05 was considered statistically significant.ResultsThe mean (±SD) age of participants was 78.1 (± 8.33) years; 127 (60.4%) were female, 189 (90.0%) were Chinese. Those on ≥2 anti-hypertensive medication classes had an increased risk of experiencing an injurious fall compared to those not on any anti-hypertensive medication (OR = 5.45; CI:1.49–19.93; p = 0.01). Among those who were taking anti-hypertensive medication, those who had a change in the medication 180-day prior to injurious fall had a significantly increased risk of experiencing an injurious fall compared to those that did not report any change in anti-hypertensive medication (OR = 3.88; CI:1.23–12.19; p = 0.02). Sensitivity analyses generated consistent findings.ConclusionBoth ≥2 anti-hypertensive medication classes and change in anti-hypertensive medication were associated with an increased risk of experiencing an injurious fall among the older population of low socioeconomic status. Our findings could guide prescribers to exercise caution in the initiation of anti-hypertensive medications or in making medication changes, especially among the older population of low socioeconomic status.

Polimedication: applicability of a computer tool to reduce polypharmacy in nursing homes.

In order to minimize the expenditure of time, our group devised a pilot computer tool (Polimedication) that automatically processes lists of medication providing the corresponding Screening Tool of Older Persons' potentially inappropriate Prescriptions alerts and facilitating standardized reports. The drug lists for 115 residents in Santa Marta Nursing Home (Fundación San Rosendo, Ourense, Spain) were processed. The program detected 10.04 alerts/patient, of which 74.29% were not repeated. After reviewing these alerts, 12.12% of the total (1.30 alerts/patient) were considered relevant. The largest number of alerts (41.48%) involved neuroleptic drugs. Finally, the patient's family physician or psychiatrist accepted the alert and made medication changes in 62.86% of the relevant alerts. The largest number of changes (38.64%) also involved neuroleptic drugs. The mean time spent in the generation and review of the warnings was 6.26 minute/patient. Total changes represented a saving of 32.77 € per resident/year in medication. The application of Polimedication tool detected a high proportion of potentially inappropriate prescriptions in institutionalized elderly patients. The use of the computerized tool achieved significant savings in pharmaceutical expenditure, as well as a reduction in the time taken for medication review.

Using the Person-Based Approach to optimise a digital intervention for the management of hypertension.

BackgroundFor behaviour-change interventions to be successful they must be acceptable to users and overcome barriers to behaviour change. The Person-Based Approach can help to optimise interventions to maximise acceptability and engagement. This article presents a novel, efficient and systematic method that can be used as part of the Person-Based Approach to rapidly analyse data from development studies to inform intervention modifications. We describe how we used this approach to optimise a digital intervention for patients with hypertension (HOME BP), which aims to implement medication and lifestyle changes to optimise blood pressure control.MethodsIn study 1, hypertensive patients (N = 12) each participated in three think-aloud interviews, providing feedback on a prototype of HOME BP. In study 2 patients (N = 11) used HOME BP for three weeks and were then interviewed about their experiences. Studies 1 and 2 were used to identify detailed changes to the intervention content and potential barriers to engagement with HOME BP. In study 3 (N = 7) we interviewed hypertensive patients who were not interested in using an intervention like HOME BP to identify potential barriers to uptake, which informed modifications to our recruitment materials. Analysis in all three studies involved detailed tabulation of patient data and comparison to our modification criteria.ResultsStudies 1 and 2 indicated that the HOME BP procedures were generally viewed as acceptable and feasible, but also highlighted concerns about monitoring blood pressure correctly at home and making medication changes remotely. Patients in study 3 had additional concerns about the safety and security of the intervention. Modifications improved the acceptability of the intervention and recruitment materials.ConclusionsThis paper provides a detailed illustration of how to use the Person-Based Approach to refine a digital intervention for hypertension. The novel, efficient approach to analysis and criteria for deciding when to implement intervention modifications described here may be useful to others developing interventions.

Bullous Pemphigoid-like Skin Eruption during Treatment with Rivaroxaban: A Clinical Case Study.

Little has been documented about hypersensitivity reactions caused by treatment with rivaroxaban. This paper reports a bullous pemphigoid-like skin eruption that occurred in a 76-year-old female patient during rivaroxaban treatment. This case highlights the vigilance required by healthcare workers in recognising potential adverse effects of newly marketed drugs and in making medication changes when necessary. A bullous pemphigoid-like eruption due to treatment with rivaroxaban has not, to the best of the Authors’ knowledge, been reported previously in the literature.LEARNING POINTSRivaroxaban can cause a bullous eruption apparently similar to epithelial toxic necrolysis (or to Stevens-Johnson syndrome).There is an apparent similarity between skin adverse events caused by the different anticoagulants.The anticoagulant responsible for the skin side-effects can be identified on clinical grounds by the correct differential diagnosis.

Telepsychiatrists' Medication Treatment Strategies in the Children's Attention-Deficit/Hyperactivity Disorder Telemental Health Treatment Study.

The purpose of this study was to examine the prescribing strategies that telepsychiatrists used to provide pharmacologic treatment in the Children's Attention-Deficit/Hyperactivity Disorder (ADHD) Telemental Health Treatment Study (CATTS). CATTS was a randomized controlled trial that demonstrated the superiority of a telehealth service delivery model for the treatment of ADHD with combined pharmacotherapy and behavior training (n=111), compared with management in primary care augmented with a telepsychiatry consultation (n=112). A diagnosis of ADHD was established with the Computerized Diagnostic Interview Schedule for Children (CDISC), and comorbidity for oppositional defiant disorder (ODD) and anxiety disorders (AD) was established using the CDISC and the Child Behavior Checklist. Telepsychiatrists used the Texas Children's Medication Algorithm Project (TCMAP) for ADHD to guide pharmacotherapy and the treat-to-target model to encourage their assertive medication management to a predetermined goal of 50% reduction in ADHD-related symptoms. We assessed whether telepsychiatrists' decision making about making medication changes was associated with baseline ADHD symptom severity, comorbidity, and attainment of the treat-to-target goal. Telepsychiatrists showed high fidelity (91%) to their chosen algorithms in medication management. At the end of the trial, the CATTS intervention showed 46.0% attainment of the treat-to-target goal compared with 13.6% for the augmented primary care condition, and significantly greater attainment of the goal by comorbidity status for the ADHD with one and ADHD with two comorbidities groups. Telepsychiatrists' were more likely to decide to make medication adjustments for youth with higher baseline ADHD severity and the presence of disorders comorbid with ADHD. Multiple mixed methods regression analyses controlling for baseline ADHD severity and comorbidity status indicated that the telepsychiatrists also based their decision making session to session on attainment of the treat-to-target goal. Telepsychiatry is an effective service delivery model for providing pharmacotherapy for ADHD, and the CATTS telepsychiatrists showed high fidelity to evidence-based protocols.

A failure to communicate: a qualitative exploration of care coordination between hospitalists and primary care providers around patient hospitalizations.

Care coordination between adult hospitalists and primary care providers (PCPs) is a critical component of successful transitions of care from hospital to home, yet one that is not well understood. The purpose of this study was to understand the challenges in coordination of care, as well as potential solutions, from the perspective of hospitalists and PCPs in North Carolina. We conducted an exploratory qualitative study with 58 clinicians in four hospitalist focus groups (n = 32), three PCP focus groups (n = 19), and one hybrid group with both hospitalists and PCPs (n = 7). Interview guides included questions about care coordination, information exchange, follow-up care, accountability, and medication management. Focus group sessions were recorded, transcribed verbatim, and analyzed in ATLAS.ti. The constant comparative method was used to evaluate differences between hospitalists and PCPs. Hospitalists and PCPs were found to encounter similar care coordination challenges, including (1) lack of time, (2) difficulty reaching other clinicians, (3) lack of personal relationships with other clinicians, (4) lack of information feedback loops, (5) medication list discrepancies, and (6) lack of clarity regarding accountability for pending tests and home health. Hospitalists additionally noted difficulty obtaining timely follow-up appointments for after-hours or weekend discharges. PCPs additionally noted (1) not knowing when patients were hospitalized, (2) not having hospital records for post-hospitalization appointments, (3) difficulty locating important information in discharge summaries, and (4) feeling undervalued when hospitalists made medication changes without involving PCPs. Hospitalists and PCPs identified common themes of successful care coordination as (1) greater efforts to coordinate care for "high-risk" patients, (2) improved direct telephone access to each other, (3) improved information exchange through shared electronic medical records, (4) enhanced interpersonal relationships, and (5) clearly defined accountability. Hospitalists and PCPs encounter similar challenges in care coordination, yet have important experiential differences related to sending and receiving roles for hospital discharges. Efforts to improve coordination of care between hospitalists and PCPs should aim to understand perspectives of clinicians in each setting.

Mrs. GH, A Resident Who Challenged Us

Mrs. GH, A Resident Who Challenged Us

Further Evaluating the Acceptability of Group Visits in an Uninsured or Inadequately Insured Patient Population With Uncontrolled Type 2 Diabetes

The purpose of the study was to evaluate perceptions of care delivered through group visits to disadvantaged patients with type 2 diabetes. One hundred eighty-six patients with uncontrolled type 2 diabetes were randomly assigned to receive care in group visits or usual care for 12 months. Their perceptions of the care they received were measured at baseline and 6 and 12 months by the Primary Care Assessment Tool (PCAT), the Diabetes-Specific Locus of Control (DLC) survey, and the Trust in Physician Scale (TPS). Compared to patients in usual care, group visit patients' PCAT scores were higher in the domains of ongoing care (P = .001), community orientation (P < .0001), and cultural competence (P = .022). In addition, group patients had higher scores for the Powerful-Other Health Professional subscale of the DLC survey (P = .010). Patients assigned to group visits had generally more positive perceptions about their care in the areas of ongoing care, community orientation of care, and cultural competence of care than did those in usual care. The perception that one's health professional is powerful, however, has been associated with a reluctance of patients to make medication changes on their own in previous studies. These findings suggest the need for modification in the way that group visits are conducted to empower and activate patients while still delivering continuous, culturally competent, and community-oriented care.

Geriatric Outcomes Are Improved by a Geriatric Trauma Consultation Service

Traumatic injuries in older patients are complex and have significant impact on the individual, their family, and trauma centers. We hypothesized that greater attention to the timely identification and comprehensive management of comorbid conditions would improve outcomes in the care of the older injured patient. This was a prospective, descriptive study of all patients 65 years of age and older admitted to the trauma service. Each elder was seen by a specialist in geriatrics ideally within 24 hours of admission to the trauma service. A standardized consult was developed for the electronic medical record and utilized in every case. Data were obtained from the trauma registry to characterize the nature of injury, injury severity, and outcome. Data from the geriatric consult were compiled to determine the impact of age- associated conditions on the outcome. There were 285 injured patients, aged 65 years and older. Of these, 114 were seen in consultation. Age range was 65 to 96 years, with an average of 77.7 years. Injury Severity Score range was 3 to 75, with an average of 9.3. There were an equal number of male and female patients. Falls and motor vehicle collisions predominated. Geriatricians identified the following: 14% of patients presented with alcohol issues; 36% of patients exhibited signs of delirium; and 46% of patients presented with new medical conditions. Geriatricians assisted with advanced care planning in 15% of cases; disposition decisions to promote function in 49%; made medication changes in 65%; decreased inappropriate medications in 20%; and assisted with pain management in 42%. Trauma surgeons followed one or more recommendations in 91%. Outcomes of older patients can be improved through geriatricians' expertise by addressing new and existing medical issues and reducing hospital-acquired complications such as functional decline, falls, delirium, and death.

Impact of Physician Telephone Management of Nursing Home Residents Before the Initial Assessment: A Pilot Study

To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes.Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999.Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed.Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), P = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), P = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit.In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes.

Impact of Physician Telephone Management of Nursing Home Residents Before the Initial Assessment: A Pilot Study

<h3>Objective</h3> To describe physician telephone management of newly admitted nursing home residents before direct evaluation by the physician, and the effect on resident outcomes. <h3>Design</h3> Retrospective chart review of 111 consecutive discharge records from two proprietary community nursing homes in Baltimore, Maryland in 1999. <h3>Measurements</h3> Data regarding the admission process were collected, with an emphasis on physician telephone orders at admission and all subsequent telephone orders before the first physician visit. Physicians were categorized as attending physicians or on-call physicians. Unexpected outcomes defined as an unplanned admission to an acute hospital or an unanticipated death within 14 days of admission to the nursing home were identified. The relationships among resident, physician, and admission characteristics and unexpected outcomes were analyzed. <h3>Results</h3> Most residents (97 of 111 (87%)) were admitted from an acute hospital, and the remaining 13% were admitted from home or another nursing home. An attending physician confirmed admission orders for 87 of 111 (78%) residents, and an on-call physician confirmed admission orders for the remainder. Physicians changed medications at the time of admission, as compared with preadmission medications, in 58 of 111 (52%) residents and ordered laboratory studies or radiographs in 59 of 111 (53%). On-call physicians were just as likely to make both types of changes as attending physicians. In the time interval after the initial telephone contact but before the first physician visit, medication changes were made in 35 of 111 (32%) residents and testing was ordered in 16 of 111 (14%). Nineteen of 111 (17%) residents were either readmitted to the hospital or died within 14 days of admission to the nursing home. These unexpected outcomes were statistically less likely to occur in the group of residents for whom physicians made medication changes at the time of admission as compared to the group for whom no medication changes were made [6 of 58 (10%) versus 13 of 53 (25%), <i>P</i> = 0.04, respectively], and in the group for whom tests were ordered at the time of admission as compared to not ordered [4 of 59 (7%) versus 15 of 51 (29%), <i>P</i> = 0.002, respectively]. There were no differences in the likelihood of unexpected outcomes when physicians made medication changes or ordered tests after the time of admission but before the first physician visit. <h3>Conclusions</h3> In this study, physicians made adjustments in medications and ordered tests for newly admitted nursing home patients before seeing the resident in the majority of cases. Unexpected outcomes including readmission to the hospital or death within 14 days of admission were less common among those residents when such changes were made at the time of admission. Further studies are needed to identify those changes as well as those resident and physician characteristics that might lead to improved outcomes.