Medicine and Health Sciences 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 …

Angina Characteristics As Predictors Of Trajectories Of Quality Of Life Following Acute Coronary Syndrome In The Transitions, Risks And Actions In Coronary Events-Center For Outcomes Research And Education Cohort (Trace-Core), Lisa Nobel, Jennifer Tjia, Jane S. Saczynski, Molly E. Waring, Milena D. Anatchkova, Arlene Ash, Catarina I. Kiefe, Jeroan Allison

Jennifer Tjia

BACKGROUND: To describe longitudinal trajectories of health-related quality of life (HRQoL) after hospitalization with an acute coronary syndrome (ACS), their associations with baseline angina characteristics, and associations with anxiety, depression, and cognitive impairment.

METHODS: TRACE-CORE participants (N=1,613) completed the SF-36 during hospitalization for ACS and 1, 3, & 6 months post-discharge. Latent growth curves identified trajectories of physical and mental components of HRQOL (MCS and PCS) and sequential multiple logistic regression estimated associations between trajectories and angina characteristics.

RESULTS: Participants (N=1613) had mean age 63.3 (SD 11.4) years, 33.0% female, and 78.2% non-Hispanic white. We identified 2 MCS trajectories: AVERAGE …

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 …

Self-Reported Colorectal Cancer Screening Of Medicare Beneficiaries In Family Medicine Vs. Internal Medicine Practices In The United States: A Cross-Sectional Study, Angela (Young) Higgins, Anna R. B. Doubeni, Karon L. Phillips, Adeyinka O. Laiyemo, Becky A. Briesacher, Jennifer Tjia, Chyke A. Doubeni

Jennifer Tjia

BACKGROUND: The benefit of screening for decreasing the risk of death from colorectal cancer (CRC) has been shown, yet many patients in primary care are still not undergoing screening according to guidelines. There are known variations in delivery of preventive health care services among primary care physicians. This study compared self-reported CRC screening rates and patient awareness of the need for CRC screening of patients receiving care from family medicine (FPs) vs. internal medicine (internists) physicians.

METHODS: Nationally representative sample of non-institutionalized beneficiaries who received medical care from FPs or internists in 2006 (using Medicare Current Beneficiary Survey). The main …

A Mixed-Methods Study To Characterize Pharmaceutical Marketing In The Nursing Home Setting: Off-Label Use Of Atypical Antipsychotics, Camilla Benedicto, Jennifer L. Donovan, Terry S. Field, Jerry H. Gurwitz, Sarah Foy, Leslie R. Harrold, Abir O. Kanaan, Celeste A. Lemay, Kathleen M. Mazor, Jennifer Tjia, Sruthi Valluri, Becky A. Briesacher

Jennifer Tjia

Background: Despite FDA warnings that atypical antipsychotic medications are associated with an increased risk of death when used to treat behavioral disorders in older adults with dementia, they are prescribed to nearly one-third of older U.S. nursing home (NH) residents. Reasons for their high use in NHs are poorly understood, but may include pharmaceutical marketing efforts in the NH setting.

Methods: This study is nested within an ongoing cluster randomized trial to improve the use of atypical antipsychotics in NHs. We analyzed semistructured interviews (n = 36) and surveys (n = 139) of administrators, directors of nursing and medical directors …

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

Jennifer Tjia

Background

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

Objective

To determine physician factors correlated with ordering of recommended laboratory monitoring tests for high-risk medications, accounting for patient characteristics.

Methods

Analysis of the administrative claims and electronic medical records of patients prescribed a high-risk medication requiring laboratory monitoring in a large multispecialty group practice between January 1, 2008 and December 31, 2008. The outcome is a physician order for each recommended laboratory test for each prescribed medication. Key predictor variables include physician characteristics, including age, gender, specialty training, years since completing training, and prescribing volume. We …

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, …

Patient Adherence To Laboratory Tests To Monitor Medication Therapy: A Mixed-Methods Study, Shira H. Fischer, Terry S. Field, Shawn J. Gagne, Kathleen M. Mazor, Peggy Preusse, George Reed, Daniel J. Peterson, Jerry H. Gurwitz, Jennifer Tjia

Jennifer Tjia

Background

Little is known about the contribution of patient behavior to incomplete laboratory monitoring and the reasons for patient non-completion of ordered laboratory tests remain unclear.

Objective

To describe factors, including patient-reported reasons, associated with non-completion of ordered laboratory tests.

Design

Mixed-methods study including a quantitative assessment of the frequency of patient adherence to ordered monitoring tests combined with qualitative, semi-structured, patient interviews.

Participants

Quantitative assessment included patients 18 years or older from a large multispecialty group practice prescribed a medication requiring monitoring. Qualitative interviews included a subset of adherent and non-adherent patients prescribed a cardiovascular, anti-convulsant, or thyroid replacement …

Knowledge Of And Perceived Need For Evidence-Based Educational Materials About Antipsychotic Medication Safety By Nursing Home Staff, Celeste A. Lemay, Sarah Foy, Kathleen M. Mazor, Leslie R. Harrold, Jennifer L. Donovan, Abir O. Kanaan, Becky A. Briesacher, Jerry H. Gurwitz, Jennifer Tjia

Jennifer Tjia

Background: Given the widespread overuse of antipsychotic medications among US nursing home (NH) residents, we sought to identify knowledge of and perceived need for the AHRQ Comparative Effectiveness Research Summary Guide (CERSG) “Off-Label Use of Atypical Antipsychotic Drugs”.

Methods: We conducted a baseline needs assessment with 12 NHs participating in a randomized controlled trail evaluating evidence dissemination strategies. Using a mixed method approach, we conducted in-depth assessments of knowledge, attitudes, and practice behavior using telephone interviews with NH leadership (administrators, directors of nursing [DON], and medical directors), and questionnaires with NH leadership, consultant pharmacists and direct care staff. …

Technological Resources And Personnel Costs Required To Implement An Automated Alert System For Primary Care Physicians When Patients Transition From Hospitals To Home, Terry S. Field, Lawrence D. Garber, Shawn J. Gagne, Jennifer Tjia, Peggy Preusse, Jennifer L. Donovan, Abir O. Kanaan, Jerry H. Gurwitz

Jennifer Tjia

Background With the adoption of electronic medical records by medical group practices, there are opportunities to improve the quality of care for patients discharged from hospitals. However, there is little guidance for medical groups outside of integrated hospital systems to automate the flow of patient information during transitions in care.

Objective To describe the technological resources, expertise and time needed to develop an automated system providing information to primary care physicians when their patients transition from hospitals to home.

Development Within a medical group practice, we developed an automated alert system that provides notification of discharges, reminders of the need …

Healthcare Preferences Among Lesbians: A Focus Group Analysis, Margaret R. Seaver, Karen M. Freund, Leslie M. Wright, Jennifer Tjia, Susan M. Frayne

Jennifer Tjia

OBJECTIVE: The healthcare needs of lesbians are not well understood. We sought to characterize lesbians' experiences with, and preferences for, women's healthcare. METHODS: We conducted three age-stratified focus groups (18-29, 30-50, and >50 years) with a total of 22 participants using a semistructured interview guide to elicit lesbians' experiences and preferences. We analyzed transcripts of these audiotaped sessions using the constant comparative method of grounded theory. Community-dwelling women who self-identified as lesbian and responded to advertisements were selected on first-come basis. RESULTS: Participants voiced experiences and preferences for healthcare that emerged into three themes: desired models of care, desired processes …