Geriatrics Commons^™

Changes In Anticoagulant Utilization Among United States Nursing Home Residents With Atrial Fibrillation From 2011 To 2016, Matthew Alcusky, David D. Mcmanus, Anne L. Hume, Marc Fisher, Jennifer Tjia, Kate L. Lapane

Jennifer Tjia

Background: Nursing home residents with atrial fibrillation are at high risk for ischemic stroke and bleeding events. The most recent national estimate (2004) indicated less than one third of this high-risk population was anticoagulated. Whether direct-acting oral anticoagulant ( DOAC ) use has disseminated into nursing homes and increased anticoagulant use is unknown.

Methods and Results: A repeated cross-sectional design was used to estimate the point prevalence of oral anticoagulant use on July 1 and December 31 of calendar years 2011 to 2016 among Medicare fee-for-service beneficiaries with atrial fibrillation residing in long-stay nursing homes. Nursing home residence was determined …

Recurrent Clostridium Difficile Infection Among Medicare Patients In Nursing Homes: A Population-Based Cohort Study, Marya D. Zilberberg, Andrew F. Shorr, William M. Jesdale, Jennifer Tjia, Kate L. Lapane

Jennifer Tjia

We explored the epidemiology and outcomes of Clostridium difficile infection (CDI) recurrence among Medicare patients in a nursing home (NH) whose CDI originated in acute care hospitals. We conducted a retrospective, population-based matched cohort combining Medicare claims with Minimum Data Set 3.0, including all hospitalized patients age > /=65 years transferred to an NH after hospitalization with CDI 1/2011-11/2012. Incident CDI was defined as ICD-9-CM code 008.45 with no others in prior 60 days. CDI recurrence was defined as (within 60 days of last day of CDI treatment): oral metronidazole, oral vancomycin, or fidaxomicin for > /=3 days in part D file; …

Guideline-Based Prescribing In Frail Elderly Patients, Jennifer Tjia, Kate L. Lapane

Jennifer Tjia

No abstract provided.

Association Of A Communication Training Program With Use Of Antipsychotics In Nursing Homes, Jennifer Tjia, Jacob N. Hunnicutt, Laurie Herndon, Carolyn R. Blanks, Kate L. Lapane, Susan Wehry

Jennifer Tjia

Importance: Off-label antipsychotic prescribing in nursing homes (NHs) is common and is associated with increased risk of mortality in older adults. Prior large-scale, controlled trials in the NH setting failed to show meaningful reductions in antipsychotic use.

Objective: To quantify the influence of a large-scale communication training program on NH antipsychotic use called OASIS.

Design, Setting, and Participants: This investigation was a quasi-experimental longitudinal study of NHs in Massachusetts enrolled in the OASIS intervention. Participants were residents living in NHs between March 1, 2011, and August 31, 2013. The data were analyzed from December 2015, to March 2016, and from …

Pain And Pharmacologic Pain Management In Long-Stay Nursing Home Residents, Jacob N. Hunnicutt, Christine M. Ulbricht, Jennifer Tjia, Kate L. Lapane

Jennifer Tjia

Prior studies estimate that >40% of long-stay nursing home (NH) residents experience persistent pain, with 20% of residents in pain receiving no analgesics. Strengthened NH surveyor guidance and improved pain measures on the Minimum Data Set (MDS) 3.0 were introduced in March 2009 and October 2010, respectively. This study aimed to provide estimates after these important initiatives of: 1) prevalence and correlates of persistent pain; and 2) prevalence and correlates of untreated or undertreated persistent pain. We identified 1,387,405 long-stay residents in United States NHs between 2011-2012 with 2 MDS assessments 90 days apart. Pain was categorized as persistent (pain …

A Delphi Process To Address Medication Appropriateness For Older Persons With Multiple Chronic Conditions, Terri R. Fried, Kristina Niehoff, Jennifer Tjia, Nancy Redeker, Mary K. Goldstein

Jennifer Tjia

BACKGROUND: Frameworks exist to evaluate the appropriateness of medication regimens for older patients with multiple medical conditions (MCCs). Less is known about how to translate the concepts of the frameworks into specific strategies to identify and remediate inappropriate regimens.

METHODS: Modified Delphi method involving iterative rounds of input from panel members. Panelists (n = 9) represented the disciplines of nursing, medicine and pharmacy. Included among the physicians were two geriatricians, one general internist, one family practitioner, one cardiologist and two nephrologists. They participated in 3 rounds of web-based anonymous surveys.

RESULTS: The panel reached consensus on a set of markers …

Hospice And Pain Management In Nursing Home Residents With Cancer, Jacob N. Hunnicutt, Jennifer Tjia, Kate L. Lapane

Jennifer Tjia

Background: The prevalence of untreated pain in nursing home residents with cancer is unacceptably high. Hospice may increase the likelihood of receiving pain management at the end of life.

Objectives: To estimate whether receipt of hospice in nursing homes increases the receipt of pain management for nursing home residents with cancer at the end of life.

Methods: We conducted a cross-sectional study on a national sample of Medicare decedents who had cancer and were nursing home residents during the last 90 days of life in 2011–2012. We used the last Minimum Data Set (MDS) 3.0 assessment before death and the …

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.

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 …

Adverse Drug Events Post-Hospital Discharge In Older Patients: Types, Severity, And Involvement Of Beers Criteria Medications, Abir O. Kanaan, Jennifer L. Donovan, Nerissa P. Duchin, Terry S. Field, Jennifer Tjia, Sarah L. Cutrona, Shawn J. Gagne, Lawrence D. Garber, Peggy Preusse, Leslie R. Harrold, Jerry H. Gurwitz

Jennifer Tjia

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

Design: Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges.

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

Participants: Hospitalized patients aged 65 years and older who were discharged to home.

Measurements: Possible drug-related incidents occurring during the 45-day period post-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 …

Dissemination Of Evidence-Based Atypical Antipsychotic Information To Nursing Homes, Celeste A. Lemay, Jennifer Tjia, Kathleen M. Mazor, Terry S. Field, Abir O. Kanaan, Jennifer L. Donovan, Jerry H. Gurwitz

Jennifer Tjia

Background: Accumulating evidence demonstrates minimal benefit and increased risk of off-label use of atypical antipsychotic medications for dementia-related behaviors. Optimal strategy for disseminating evidence-based guides to nursing home (NH) stakeholders is unclear. Our objective is to describe the impact of differing dissemination efforts in Connecticut NHs.

Methods: Forty-three Connecticut NHs were randomized to one of 3 arms receiving incrementally intensive dissemination strategies of the Agency for Healthcare Research and Quality Comparative Effectiveness Review Summary Guide on the off-label use of atypical antipsychotic drugs, which was included in a toolkit informed by a needs assessment of NHs. All NHs received the …

Reducing Rehospitalizations Through Automated Alerts To Primary Care Providers And Staff When Older Patients Are Discharged From The Hospital: A Randomized Trial, Jerry H. Gurwitz, Terry S. Field, Jessica Ogarek, Jennifer Tjia, Sarah L. Cutrona, Leslie R. Harrold, Jennifer L. Donovan, Abir O. Kanaan, Shawn J. Gagne, Peggy Preusse, Lawrence D. Garber

Jennifer Tjia

Background: Inadequate continuity of care places older patients at very high risk during transitions from the hospital to ambulatory setting.

Methods: We conducted a randomized controlled trial of an HIT-based transitional care intervention in patients aged 65 and older discharged from hospital to home. All patients were senior plan members of a Massachusetts-based health plan, and cared for by a multispecialty medical group using the EpicCare Ambulatory Medical Record. In addition to notifying providers about the patient’s recent transition, the system provided information about new drugs added during the inpatient stay, warnings about drug-drug interactions, recommendations for dose changes and …

Understanding Antipsychotic Drug Use In The Nursing Home Setting, Celeste A. Lemay, Alice F. Bonner, Christina Compher, Terry S. Field, Jonathan Freedlander, Susan Joslin, Kathleen M. Mazor, Jennifer Tjia, Jerry H. Gurwitz

Jennifer Tjia

Introduction: The increasing prevalence of antipsychotic medication use in residents of nursing homes (NH) in the absence of psychiatric diagnoses is concerning. To address these concerns, it is essential to explore how these medications are being prescribed and managed in the NH setting. Our objectives were to understand the decision-making process that influences prescribing and factors that trigger administration of antipsychotic medications to residents with dementia in NHs and to explore why residents remain on antipsychotic medications over an extended period of time.

Methods: Interviews with prescribers, caregivers, and family members, on-site observations in study facilities, and review of NH …

Intervention To Reduce Adverse Outcomes Among Older Adults Discharged From Skilled Nursing Facilities To Home, Terry S. Field, Jessica Ogarek, Abir O. Kanaan, Jennifer L. Donovan, Peggy Preusse, Devi Sundaresan, Shawn J. Gagne, Lawrence D. Garber, Jennifer Tjia, Sarah L. Cutrona, Jerry H. Gurwitz

Jennifer Tjia

Background: Older adults may be at risk for adverse outcomes after discharge from skilled nursing facilities (SNF), but little research has focused on this transition.

Objective: To assess the impact of an alert system on the rates of adverse outcomes among older adults discharged from SNFs to home.

Methods: Within a multispecialty group practice, we tracked 30-day re-hospitalizations after SNF discharges during an intervention that provided discharge alerts to primary care physicians. We compared them to discharges from the pre-intervention period matched on age, gender and SNF. For the first 100 intervention discharges and their matches, we performed chart reviews …

Statin Discontinuation Among Nursing Home Residents With Advanced Dementia, Jennifer Tjia, Sarah L. Cutrona, Daniel J. Peterson, Becky A. Briesacher

Jennifer Tjia

Background: Statin use in elderly individuals with life-limiting illness such as advanced dementia is controversial.

Objective: To describe factors associated with statin discontinuation and estimate impact of discontinuation on 28-day hospitalizations in nursing home (NH) residents with advanced dementia.

Methods: Retrospective cohort study of NH residents ≥ 65 years with recent progression to advanced dementia from 5 large U.S. states drawn from the 2007-2008 Minimum Data Set 2.0. We identified residents using statins. Clinical characteristics and 28-day hospitalization risk were compared for residents discontinuing and continuing statins. Multivariable Cox proportional hazard models identified factors associated with time to statin discontinuation …

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 …

Do Antipsychotic Dose Reduction Trials Result In Worsening Behavior Among Nursing Home Residents With Dementia: A Systematic Review Of The Literature, Jennifer Tjia, Abir O. Kanaan, Jennifer L. Donovan

Jennifer Tjia

Background: While federal regulations require gradual dose reduction trials of antipsychotics prescribed for behavior management in nursing home (NH) residents with dementia, widespread concern about precipitating behavioral disturbances limits implementation. We conducted a systematic review of clinical trials reducing antipsychotic drug use in NH residents to determine best dose reduction practices and risk of behavior escalation.

Methods: A comprehensive literature search was conducted in MEDLINE, EMBASE, and International Pharmaceutical Abstracts between January 1970 and October 2011 using the terms “antipsychotic agent or neuroleptic agent,” “dementia,” “nursing homes,” and “withdrawal.” One investigator reviewed abstracts for inclusion based on: English-language, …