Targeting High-risk Patients Research Articles

Adverse drug events in older adults: will risk factor algorithms translate into effective clinical interventions?

Adverse drug events (ADEs) are a common and costly problem. For example, an estimated 1.5 million preventable ADEs occur in the USA annually at a cost in excess of US$4 billion [1]. Older adults are often at particular risk owing to accumulated medical comorbidies, complex medi cation regimens, declining functional status and physiologic changes associated with less-predictable pharmacokinetics and pharmacodynamics [2,3]. One proposed ADE-reduction strategy involves the development of algorithms to identify patients at high risk. A recent example is the GerontoNet score, an algorithm designed to predict ADE risk among hospitalized older adults [4]. As is common in ADE risk algorithms, the number of medications taken by the patient dominates the score: receiving eight or more medications yields 4 points, and between five and seven medications garners 1 point. Then, 1 additional point is received for each of the following: heart failure, renal failure, liver disease and four or more medical conditions. Finally, patients with a history of prior ADE receive 2 points, which yields a potential score from 0 to 10. There are at least two general applications where ADE risk algorithms, such as the GerontoNet score, could prove to be effective. The most commonly described approach involves targeting high-risk patients for a concurrent or retrospective review by another clinician, often a clinical pharmacist, who would make recommendations to the primary prescribers. A second approach is to make ADE risk scores available via real-time decision support systems, which could assist prescribers in making risk–benefit decisions for new medications, choosing optimal dosing schedules and implementing appropriate monitoring plans. So are there any reasons why we should not be rushing to implement ADE risk algorithms in practice? After all, it seems pretty straightforward. Make scores available in real-time to prescribers and dispatch clinical pharmacists to patients with high scores – and the problem is solved. While risk algorithms are promising, there are several reasons why their use may not translate into significant ADE reductions in real-world practice. First, the utility of ADE risk algorithms in guiding clinical intervention is contingent upon the magnitude of risk stratification achieved. For example, ADE frequency was 2% with GerontoNet scores of 0–1, and gradually increased to 21.7% with scores ≥8 [4]. Unfortunately, this impressive level of stratification has not been consistently replicated. Some prominent investigators have even concluded that ADE risk stratification approaches are unlikely to be productive [5]. There are many potential reasons why ADE risk algorithms may not demonstrate consistent risk stratification. Perhaps the most fundamental is that risk prediction is not Expert Rev. Clin. Pharmacol. 4(6), 655–657 (2011)

Screening for methicillin-resistant Staphylococcus aureus (MRSA) carriage on admission to a geriatric hospital

Our objective is to identify risk factors for carriage of MRSA on admission to a geriatric hospital where MRSA is endemic. A prospective screening for MRSA carriage was conducted by swabbing anterior nares and anal skin for 6 weeks. One hundred and thirty-eight patients aged over 65 were enrolled after obtaining their informed consent. Swabs of anterior nares and anal skin of patients were submitted for culture for MRSA. The demographic, administrative, and clinical data for each participant were recorded, and their association with MRSA carriage was determined by stepwise regression analysis. MRSA was recovered from 11 patients (11/138 patients, 8.0%), and from anal skin in 8 of them. Without screening of anal skin, 5 out of 11 carriers had been missed. Multivariate analysis revealed that hypoalbuminemia (adjusted risk ratio, RR=6.39, 95% confidence interval, CI=1.08–37.84) and bedridden status (RR=8.26, CI=1.04–65.31) were independent risk factors. Screening of elderly patients for gastrointestinal colonization on admission had implications for early detection of the reservoir of MRSA. Systematic selective screening for MRSA carriage targeting high-risk patients with hypoalbuminemia or bedridden status would be useful for infection control of this resistant organism.

190: Targeting High-Risk Patients for Rapid HIV Testing: Emergency Physicians Are Not Effective and Patients Targeted Are More Frequently Uninsured

190: Targeting High-Risk Patients for Rapid HIV Testing: Emergency Physicians Are Not Effective and Patients Targeted Are More Frequently Uninsured

Skipped Treatments, Markers of Nutritional Nonadherence, and Survival Among Incident Hemodialysis Patients

Skipping hemodialysis treatments and failing to adhere to prescribed diets are thought to injure hemodialysis patients. We examined predictors of hemodialysis skipping and laboratory measures of nonadherence and then examined the association of dialysis skipping and serum potassium and phosphate levels with survival. Of 739 patients, 67 were classified as skippers because they were absent for greater than 3% of scheduled treatments. Black race (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.30 to 3.92), current smoking (OR, 1.79; 95% CI, 1.02 to 3.13), and use of illicit drugs (OR, 3.96; 95% CI, 2.16 to 7.24) were associated with skipping. White race, increased serum phosphate level, greater creatinine level, and lower body mass index increased the likelihood of a serum potassium level greater than 5.0 mEq/L (mmol/L); younger age, greater serum potassium level, and greater serum creatinine level were associated with a serum phosphate level greater than 5.5 mg/dL (>1.78 mmol/L). Skipping was associated with an increased risk for death (hazard ratio [HR], 1.69; 95% CI, 1.24 to 2.31), as were phosphate level greater than 5.5 mg/dL (HR, 1.59; 95% CI, 1.16 to 2.17) and potassium level greater than 5.0 mEq/L (HR, 1.50; 95% CI, 1.10 to 2.06). Skipping was associated with a lower likelihood of kidney transplantation in those younger than 65 years (OR, 0.41; 95% CI, 0.18 to 0.93). These findings show that hemodialysis patients of black race and those with current tobacco or illicit drug use are at risk for skipping dialysis treatments. Skipping treatments and markers of poor dietary adherence are strongly associated with greater risk for death. Targeting high-risk patients to understand reasons for nonadherence and to intervene could prevent premature death.

Quality improvement initiatives: issues in moving from diabetes guidelines to policy.

To outline the principles that direct the Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) dedicated to diabetes quality improvement (QUERI-DM). We discuss the VA initiatives aimed at improving diabetes care for veterans as well as general issues that should be considered in quality improvement initiatives. We specifically describe some of the epidemiological, statistical, and organizational issues that have guided our quality improvement (QI) programs. The five principles that have guided the QUERI-DM process are: 1) treating clinical guidelines and goals distinct from quality standards and quality improvement priorities; 2) targeting high-risk patients and high-impact quality issues; 3) profiling processes over outcomes; 4) targeting processes that will improve patient outcomes; and 5) paying attention to the loci of practice variation. The authors recommend that all five principles be considered when moving from practice guidelines to performance measures and QI initiatives. Targeting high-priority problems and high-risk groups can greatly improve the effectiveness and efficiency of QI interventions.

Targeting high-risk hypertensive patients with RAS blockade: application of findings

Targeting high-risk hypertensive patients with RAS blockade: application of findings

2.P.45 Targeting high risk patients with hypercholesterolemia: The efficacy and safety of simvastatin 80 mg/d

2.P.45 Targeting high risk patients with hypercholesterolemia: The efficacy and safety of simvastatin 80 mg/d