Medicine and Health Sciences Commons^™

Scramble Or Script: Responding To New Medicare Billing For Medications In Hospice, Jennifer Tjia, Shaida Talebreza, Maija Reblin, Anna Beck, Lee Ellington

Jennifer Tjia

No abstract provided.

Use Of Medications Of Questionable Benefit In Advanced Dementia, Jennifer Tjia, Becky Briesacher, Daniel Peterson, Qin Liu, Susan Andrade, Susan Mitchell

Jennifer Tjia

IMPORTANCE: Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized. OBJECTIVES: To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data …

Use Of Atypical Antipsychotics In Nursing Homes And Pharmaceutical Marketing, Camilla Pimentel, Jennifer Donovan, Terry Field, Jerry Gurwitz, Leslie Harrold, Abir Kanaan, Celeste Lemay, Kathleen Mazor, Jennifer Tjia, Becky Briesacher

Jennifer Tjia

OBJECTIVES: To describe the current extent and type of pharmaceutical marketing in nursing homes (NHs) in one state and to provide preliminary evidence for the potential influence of pharmaceutical marketing on the use of atypical antipsychotics in NHs.

DESIGN: Nested mixed-methods, cross-sectional study of NHs in a cluster randomized trial.

SETTING: Forty-one NHs in Connecticut.

PARTICIPANTS: NH administrators, directors of nursing, and medical directors (n = 93, response rate 75.6%).

MEASUREMENTS: Quantitative data, including prescription drug dispensing data (September 2009-August 2010) linked with Nursing Home Compare data (April 2011), were used to determine facility-level prevalence of atypical antipsychotic use, facility-level …

Rationales That Providers And Family Members Cited For The Use Of Antipsychotic Medications In Nursing Home Residents With Dementia, Alice Bonner, Terry Field, Celeste Lemay, Kathleen Mazor, Daniel Andersen, Christina Compher, Jennifer Tjia, Jerry Gurwitz

Jennifer Tjia

OBJECTIVES: To describe the rationales that providers and family members cite for the use of antipsychotic medications in people with dementia living in nursing homes (NHs). DESIGN: Qualitative, descriptive study. SETTING: Twenty-six medium-sized and large facilities in five Centers for Medicare and Medicaid Services regions. PARTICIPANTS: Individuals diagnosed with dementia who received an antipsychotic medication. MEASUREMENTS: Data were collected from medical record abstraction and interviews with prescribers, administrators, direct care providers, and family members. Textual data from medical record abstraction and responses to open-ended interview questions were analyzed using directed content analysis techniques. A coding scheme was developed, and coded …

Statin Discontinuation In Nursing Home Residents With Advanced Dementia, Jennifer Tjia, Sarah Cutrona, Daniel Peterson, George Reed, Susan Andrade, Susan Mitchell

Jennifer Tjia

OBJECTIVES: To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days.

DESIGN: Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files.

SETTING: All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida).

PARTICIPANTS: NH residents with dementia.

MEASUREMENTS: Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. …

Appropriateness Of Psychopharmaco-Logical Medication, Kate Lapane, Jacob Hunnicutt, Jennifer Tjia

Jennifer Tjia

No abstract provided.

Factors Associated With Ordering Laboratory Monitoring Of High-Risk Medications, Shira Fischer, Jennifer Tjia, George Reed, Daniel Peterson, Jerry Gurwitz, Terry Field

Jennifer Tjia

BACKGROUND: Knowledge about factors associated with provider ordering of appropriate testing is limited.

OBJECTIVE: To determine physician factors associated with ordering recommended laboratory monitoring tests for high-risk medications.

METHODS: Retrospective cohort study of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between 1 January 2008 and 31 December 2008. Analyses are based on administrative claims and electronic medical records. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables are physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. Additional variables …

Systematic Review Of The Use Of Online Questionnaires Of Older Adults, Meegan Remillard, Kathleen Mazor, Sarah Cutrona, Jerry Gurwitz, Jennifer Tjia

Jennifer Tjia

OBJECTIVES: To describe methodological approaches to population targeting and sampling and to summarize limitations of Internet-based questionnaires in older adults.

DESIGN: Systematic literature review.

SETTING: Studies using online questionnaires in older adult populations.

PARTICIPANTS: English-language articles using search terms for geriatric, age 65 and over, Internet survey, online survey, Internet questionnaire, and online questionnaire in PubMed and EBSCO host between 1984 and July 2012. Inclusion criteria were study population mean age 65 and older and use of an online questionnaire for research. Review of 336 abstracts yielded 14 articles for full review by two investigators; 11 articles met inclusion criteria. …

Antipsychotic Use In Nursing Homes Varies By Psychiatric Consultant, Jennifer Tjia, Terry Field, Celeste Lemay, Kathleen Mazor, Michelle Pandolfi, Ann Spenard, Shih-Yieh Ho, Abir Kanaan, Jennifer Donovan, Jerry Gurwitz, Becky Briesacher

Jennifer Tjia

BACKGROUND: The relationship between psychiatric consultation and antipsychotic prescribing in nursing homes (NH) is unknown. OBJECTIVE: To identify the association between psychiatric consultant groups and NH-level antipsychotic prescribing after adjustment for resident case-mix and facility characteristics. RESEARCH DESIGN AND SUBJECTS: Nested cross-sectional study of 60 NHs in a cluster randomized trial. We linked facility leadership surveys to October 2009-September 2010 Minimum Data Set, Nursing Home Compare, the US Census, and pharmacy dispensing data. MEASURES: The main exposure is the psychiatric consultant group and the main outcome is NH-level prevalence of atypical antipsychotic use. We calculated annual means and interquartile ranges …

Use Of Mechanical Ventilation By Patients With And Without Dementia, 2001 Through 2011, Tara Lagu, Marya Zilberberg, Jennifer Tjia, Penelope Pekow, Peter Lindenauer

Jennifer Tjia

Increasing demand for US critical care resources, including beds, intensivists, and invasive mechanical ventilation (IMV),has placed substantial strain on the critical care system. Since 2000, elderly patients treated in the intensive care unit have received higher intensity care (and have experienced lower mortality rates) than historical cohorts. Yet certain populations of elderly patients exposed to intensive care experience substantial long-term adverse effects, including functional decline and excess mortality. Patients with dementia receiving IMV, for example, are at high risk for delirium, which confers a 3.2-fold increased risk of 6-month mortality. The increasing use of aggressive therapies suggests that demand for …

An Electronic Health Record-Based Intervention To Increase Follow-Up Office Visits And Decrease Rehospitalization In Older Adults, Jerry Gurwitz, Terry Field, Jessica Ogarek, Jennifer Tjia, Sarah Cutrona, Leslie Harrold, Shawn Gagne, Peggy Preusse, Jennifer Donovan, Abir Kanaan, George Reed, Lawrence Garber

Jennifer Tjia

OBJECTIVES: To assess the effect of an electronic health record-based transitional care intervention involving automated alerts to primary care providers and staff when older adults were discharged from the hospital.

DESIGN: Randomized controlled trial.

SETTING: Large multispecialty group practice.

PARTICIPANTS: Individuals aged 65 and older discharged from hospital to home.

INTERVENTION: In addition to notifying primary care providers about the individual's recent discharge, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and laboratory monitoring of high-risk medications, and alerts to the primary care provider's support staff to schedule …

Knowledge Of And Perceived Need For Evidence-Based Education About Antipsychotic Medications Among Nursing Home Leadership And Staff, Celeste Lemay, Kathleen Mazor, Terry Field, Jennifer Donovan, Abir Kanaan, Becky Briesacher, Sarah Foy, Leslie Harrold, Jerry Gurwitz, Jennifer Tjia

Jennifer Tjia

BACKGROUND/OBJECTIVES: Antipsychotic use is common in US nursing homes, despite evidence of increased risk of morbidity and mortality, and limited efficacy in older adults with dementia. Knowledge, attitudes, and beliefs regarding antipsychotic use among nursing home staff are unclear. The study aim was to describe nursing home leadership and direct care staff members' knowledge of antipsychotic risks, beliefs and attitudes about the effectiveness of antipsychotics and nonpharmacologic management of dementia-related behaviors, and perceived need for evidence-based training about antipsychotic medication safety. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Survey of leadership and direct care staff of nursing homes in Connecticut was conducted …

Adverse Drug Events After Hospital Discharge In Older Adults: Types, Severity, And Involvement Of Beers Criteria Medications, Abir Kanaan, Jennifer Donovan, Nerissa Duchin, Terry Field, Jennifer Tjia, Sarah Cutrona, Shawn Gagne, Lawrence Garber, Peggy Preusse, Leslie Harrold, Jerry Gurwitz

Jennifer Tjia

OBJECTIVES: To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period after hospitalization in older adults.

DESIGN: Clinical pharmacists reviewed the ambulatory records of 1,000 consecutive discharges.

SETTING: A large multispecialty group practice closely aligned with a Massachusetts-based health plan.

PARTICIPANTS: Hospitalized individuals aged 65 and older discharged home.

MEASUREMENTS: Possible drug-related incidents occurring during the 45-day period after hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according …

Antipsychotic Use Among Nursing Home Residents, Becky Briesacher, Jennifer Tjia, Terry Field, Daniel Peterson, Jerry Gurwitz

Jennifer Tjia

The prescribing of antipsychotic medications persists at high levels in US nursing homes (NHs) despite extensive data demonstrating marginal clinical benefits and serious adverse effects, including death.1- 2 However, imprecise and outdated data have limited the understanding of the current state of antipsychotic medication prescribing in NHs.3 We analyzed recent and detailed NH prescription data to address: (1) What is the current level of antipsychotic use? (2) Does antipsychotic use in NHs display geographic variation? and (3) Which antipsychotics are most commonly prescribed?

Potentially Inappropriate Use Of Antipsychotics In Community-Dwelling Adults With Dementia More Common In Those With Low Income, Jennifer Tjia

Jennifer Tjia

Comment on: The essential and potentially inappropriate use of antipsychotics across income groups: an analysis of linked administrative data. [Can J Psychiatry. 2012]

Studies To Reduce Unnecessary Medication Use In Frail Older Adults: A Systematic Review, Jennifer Tjia, Sarah Velten, Carole Parsons, Sruthi Valluri, Becky Briesacher

Jennifer Tjia

BACKGROUND: Overuse of unnecessary medications in frail older adults with limited life expectancy remains an understudied challenge.

OBJECTIVE: To identify intervention studies that reduced use of unnecessary medications in frail older adults. A secondary goal was to identify and review studies focusing on patients approaching end of life. We examined criteria for identifying unnecessary medications, intervention processes for medication reduction, and intervention effectiveness.

METHODS: A systematic review of English articles using MEDLINE, EMBASE, and International Pharmaceutical Abstracts from January 1966 to September 2012. Additional studies were identified by searching bibliographies. Search terms included prescription drugs, drug utilization, hospice or palliative …

Dementia And Risk Of Adverse Warfarin-Related Events In The Nursing Home Setting, Jennifer Tjia, Terry Field, Kathleen Mazor, Jennifer Donovan, Abir Kanaan, George Reed, Peter Doherty, Leslie Harrold, Jerry Gurwitz

Jennifer Tjia

BACKGROUND: Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events. OBJECTIVES: To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics. METHODS: A prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes …

Predicting Nursing Home Adherence To A Clinical Trial Intervention: Lessons For The Conduct Of Cluster Randomized Trials, Jennifer Tjia, Kathleen Mazor, Terry Field, Peter Doherty, Ann Spenard, Jerry Gurwitz

Jennifer Tjia

OBJECTIVES: To describe factors predictive of nursing home (NH) adherence to a clinical trial intervention. DESIGN: Post hoc analysis of a cluster randomized trial (CRT) evaluating a structured communication intervention to improve nurse-physician telephone communication in NHs. SETTING: NH. PARTICIPANTS: All eligible licensed nursing staff in all participating NHs. MEASUREMENTS: Adherence was defined as active participation for at least 3 months of the 12-month trial. NH characteristics hypothesized to affect trial outcomes (profit status, bed size, nursing staff time, NH quality, and leadership turnover) were measured a priori. The association between intervention adherence, NH characteristics and preintervention questionnaire response rate …

Diagnostic E-Codes For Commonly Used, Narrow Therapeutic Index Medications Poorly Predict Adverse Drug Events, Charles Leonard, Kevin Haynes, A. Localio, Sean Hennessy, Jennifer Tjia, Abigail Cohen, Stephen Kimmel, Harold Feldman, Joshua Metlay

Jennifer Tjia

OBJECTIVE: We sought to examine the validity of specific hospital discharge codes in identifying drug toxicity precipitating hospitalization, among elderly users of high-risk medications. STUDY DESIGN AND SETTING: We conducted a cross-sectional evaluation assessing the diagnostic test characteristics of International Classification of Diseases-9 External-Cause-of-Injury codes (E-codes) compared with a reference standard of medical record review. This study was nested within a prospective cohort of elders using warfarin, digoxin, or phenytoin as identified in the Pharmaceutical Assistance Contract for the Elderly benefit program. RESULTS: We identified 4,803 subjects contributing 11,409 person-years of exposure to at least one of three drug groups. …

A Comparison Of Outcomes Resulting From Generalist Vs Specialist Care For A Single Discrete Medical Condition: A Systematic Review And Methodologic Critique, Gerald Smetana, Bruce Landon, Andrew Bindman, Helen Burstin, Roger Davis, Jennifer Tjia, Eugene Rich

Jennifer Tjia

BACKGROUND: Studies of clinical outcomes for generalist vs specialist care for diagnoses within a specialist's narrow domain have tended to favor specialty care. METHODS: A MEDLINE search from January 1, 1980, through April 1, 2005, and a hand search of retrieved bibliographies of English-language studies that compared generalist vs specialist care for individual patients with a single discrete medical condition were performed. Two reviewers determined eligibility for each study and abstracted data onto a standardized instrument. RESULTS: A total of 49 articles met our inclusion criteria: 24 studies favored specialty care, 13 found no difference in outcomes, 7 varied by …

A Systematic Review Of Validated Methods For Identifying Heart Failure Using Administrative Data, Jane Saczynski, Susan Andrade, Leslie Harrold, Jennifer Tjia, Sarah Cutrona, Katherine Dodd, Robert Goldberg, Jerry Gurwitz

Jennifer Tjia

PURPOSE: To identify and describe the validity of algorithms used to detect heart failure (HF) using administrative and claims data sources.

METHODS: A systematic review of PubMed and Iowa Drug Information Service searches of the English language was performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for the identification of patients with HF using and claims data. Abstracts and articles were reviewed by two study investigators to determine their relevance on the basis of predetermined criteria.

RESULTS: The initial search strategy identified 887 abstracts. Of these, 499 full articles were reviewed and 35 …

Growth In Dementia-Associated Hospitalizations Among The Oldest Old In The United States: Implications For Ethical Health Services Planning, Marya Zilberberg, Jennifer Tjia

Jennifer Tjia

As the world population ages, an epidemic of neurologic diseases, such as Alzheimer-type dementia and Parkinson disease, is predicted. The most rapid population growth has been observed in the 85 years and older group ... Concurrent with this population growth, we have witnessed a vast expansion of health care utilization and expenditures, with the consequent close scrutiny and attempts to rein in this supply-driven juggernaut. ... We conducted this analysis to gain a better understanding of the current trends in dementia-associated hospitalizations among the 85 years and older population in the United States and its implications for future health care …

Medication Discrepancies Upon Hospital To Skilled Nursing Facility Transitions, Jennifer Tjia, Alice Bonner, Becky Briesacher, Sarah Mcgee, Eileen Terrill, Kathleen Miller

Jennifer Tjia

BACKGROUND: Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE: To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. DESIGN: Cross-sectional study. PARTICIPANTS: Patients admitted to SNF for subacute care. MEASUREMENTS: Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders. RESULTS: Of 2,319 medications reviewed on admission, 495 (21.3%) had a …

Challenge Of Changing Nursing Home Prescribing Culture, Jennifer Tjia, Jerry Gurwitz, Becky Briesacher

Jennifer Tjia

This article described a framework for improving prescribing in nursing homes (NH) by focusing on the whole facility as a system that has created a "prescribing culture." We offered this paradigm as an alternative to focused interventions that target prescribers only. We used the example of atypical antipsychotics to illustrate the approach. We also highlighted elements of the NH culture change movement that are germane to medication prescribing, and illustrated which elements of NH culture were shown to be associated with suboptimal quality of care. We concluded by describing current models, including our study funded by the Agency for Healthcare …

A Systematic Review Of Validated Methods For Identifying Cerebrovascular Accident Or Transient Ischemic Attack Using Administrative Data, Susan Andrade, Leslie Harrold, Jennifer Tjia, Sarah Cutrona, Jane Saczynski, Katherine Dodd, Robert Goldberg, Jerry Gurwitz

Jennifer Tjia

PURPOSE: To perform a systematic review of the validity of algorithms for identifying cerebrovascular accidents (CVAs) or transient ischemic attacks (TIAs) using administrative and claims data. METHODS: PubMed and Iowa Drug Information Service searches of the English language literature were performed to identify studies published between 1990 and 2010 that evaluated the validity of algorithms for identifying CVAs (ischemic and hemorrhagic strokes, intracranial hemorrhage, and subarachnoid hemorrhage) and/or TIAs in administrative data. Two study investigators independently reviewed the abstracts and articles to determine relevant studies according to pre-specified criteria. RESULTS: A total of 35 articles met the criteria for evaluation. …

Daily Medication Use In Nursing Home Residents With Advanced Dementia, Jennifer Tjia, Margaret Rothman, Dan Kiely, Michele Shaffer, Holly Holmes, Greg Sachs, Susan Mitchell

Jennifer Tjia

OBJECTIVES: To describe the pattern and factors associated with daily medication use in nursing home (NH) residents with advanced dementia. DESIGN: Prospective cohort study. SETTING: Twenty-two Boston-area NHs. PARTICIPANTS: NH residents with advanced dementia (N=323). MEASUREMENTS: Data from residents' records were used to determine the number or daily medications, specific drugs prescribed, and use of drugs deemed "never appropriate" in patients with advanced dementia. Resident characteristics associated with the use of more daily medications and drugs deemed inappropriate were examined. RESULTS: Residents were prescribed a mean of 5.9 +/- 3.0 daily medications, and 37.5% received at least one medication considered …

Deeply Discounted Medications: Implications Of Generic Prescription Drug Wars, Jessica Czechowski, Jennifer Tjia, Darren Triller

Jennifer Tjia

OBJECTIVE: To describe the history of generic prescription pricing programs at major pharmacy chains and their potential implications on prescribing, quality of care, and patient safety. DATA SOURCES: Publicly available generic prescription discount program drug lists as of May 1, 2009. SUMMARY: Fierce competition among major pharmacy chains such as Walgreens, CVS, and Walmart has led to a generic prescription pricing war with unclear public health implications. Introduced in 2006, currently 7 of the 10 largest pharmacy chains advertise a version of a deeply discounted medication (DDM) program, accounting for more than 25,000 locations nationally. By early 2008, almost 70 …

Cholinesterase Inhibitor And Memantine Use In Newly Admitted Nursing Home Residents With Dementia, Carole Parsons, Becky Briesacher, Jane Givens, Yong Chen, Jennifer Tjia

Jennifer Tjia

OBJECTIVES: To quantify the use of cholinesterase inhibitors (ChEIs) and memantine in nursing home (NH) residents with dementia upon NH admission and 3 months later and to examine factors associated with reduction in therapy.

DESIGN: Retrospective cohort study.

SETTING: Nationwide sample of U.S. NHs.

PARTICIPANTS: Three thousand five hundred six NH residents with dementia newly admitted in 2006.

MEASUREMENTS: Data from pharmacy dispensing records were used to determine ChEI and memantine medication use upon NH admission and at 3-month follow-up. The Minimum Data Set was used to determine resident- and facility-level characteristics. Severity of dementia was defined using the Cognitive …

Interest In Breast Cancer Chemoprevention Among Older Women, Jennifer Tjia, Ellyn Micco, Katrina Armstrong

Jennifer Tjia

OBJECTIVES: The study aim is to describe interest in breast cancer chemoprevention among older women without a history of breast cancer and to determine whether aging-related factors such as diminished life expectancy, increasing comorbidity and medication burden attenuate chemoprevention interest. DESIGN: Cross-sectional survey. SETTING: University of Pennsylvania Health System. PARTICIPANTS: Four-hundred fifty-seven community-dwelling women aged 60-65 years old who were potentially eligible for breast cancer chemoprevention according to guidelines linking risk and eligibility to age. MEASUREMENTS: Interest in breast cancer chemopre vention, Gail model breast cancer risk, perceived breast cancer risk, breast cancer worry, self-reported health status and comorbidities, and …

Medicare Part D And Changes In Prescription Drug Use And Cost Burden: National Estimates For The Medicare Population, 2000 To 2007, Becky Briesacher, Yanfang Zhao, Jeanne Madden, Fang Zhang, Alyce Adams, Jennifer Tjia, Dennis Ross-Degnan, Jerry Gurwitz, Stephen Soumerai

Jennifer Tjia

CONTEXT: The full effect of Medicare Part D, after the initial policy transition period and across the United States Medicare population, remains unclear.

OBJECTIVE: To estimate nationally representative changes in prescription drug use and out-of-pocket drug costs 2 years after implementation of Part D.

DESIGN, SETTING, AND PARTICIPANTS: We examined study outcomes over 8 years (2000 to 2007) and estimated changes after Part D, accounting for earlier trends. Our analyses used the community-dwelling sample of the Medicare Current Beneficiary Survey (unweighted unique n=38,798). Actual post-Part D outcomes were compared with projected values using 2000 to 2005 data. Subgroup analyses and …