In the United States, patients presenting to physicians’ offices with chest pain and related symptoms frequently undergo extensive non-invasive and invasive cardiac testing to assess the likelihood of obstructive coronary artery disease (CAD). We hypothesized that use of a gene expression score (GES) would reduce diagnostic costs among non-acute symptomatic patients presenting to cardiologists. The IMPACT-CARD Trial (NCT01251302) prospectively enrolled 88 patients without known CAD who presented with chest pain and related symptoms and were referred to one of six cardiologists. The cardiologist’s diagnostic strategy was evaluated before and after GES testing, and diagnostic testing in a matched historical cohort of 83 patients was extracted from medical records. The GES is a previously validated, blood-based diagnostic test that determines the likelihood of obstructive CAD, with a negative predictive value of 96% among low GES (≤15) patients. We estimated per-procedure costs from commercially insured patients in a large, national health claims database. We applied these costs to the tests performed in the matched historical cohort and recommended in the prospective arm post-GES to calculate the cost of diagnostic evaluation in the trial. Given the rule-out nature of the GES, we focused this economic analysis on low GES patients. There were 52 low GES study patients. The total cost of cardiac diagnostic testing in these patients was lower than in the 52 matched controls ($2,450 versus $1,735 per patient, inclusive of the GES cost, p=0.23), though the difference was not statistically significant. This finding represents 29% savings ($715 per patient) in cardiac testing costs. No differences in clinical outcomes were observed between the groups. Physician use of the GES may be associated with reductions in diagnostic testing costs in low score patients. These savings reflect the potential economic utility of the GES in the diagnosis of obstructive CAD.

The authors examined agreement between drug treatment data and a discharge diagnosis of diabetes, considered whether agreement was modified by demographic variables and measures of comorbidity, and evaluated construct validity through consideration of relations with subsequent mortality. The study sample comprised 81,700 residents of New Jersey aged 65-99 years who had prescription drug coverage either through Medicaid or that state's Pharmacy Assistance for the Aged and Disabled program and had at least one hospitalization between July 1, 1989, and June 30, 1991. In this population, 16.4% filled a prescription for insulin or an oral hypoglycemic agent during the 120 days before admission, and 16.3% had a discharge diagnosis of diabetes. Overall agreement between these two indicators was modest (kappa = 0.67, 95% confidence interval 0.66-0.67) and was weaker in those aged 85 years and above (kappa = 0.58, 95% confidence interval 0.56-0.60), those in nursing homes (kappa = 0.42, 95% confidence interval 0.39-0.44), and those with a high level of comorbidity (modified Charlson index > or =5; kappa = 0.59, 95% confidence interval 0.56-0.62). Presence of a diagnosis of diabetes was associated with an apparent 24% reduction in the risk of death during the study interval (p<0.001), while prior treatment for diabetes had little relation to mortality (p = 0.15). These paradoxical associations with mortality and the lower agreement between discharge diagnoses and drug treatments associated with older age, nursing home residence, and comorbidity suggest limitations in the use of claims data to identify diabetes in the elderly.

Advanced age and its related comorbidity may affect both the patterns and goals of diabetes treatment. We examined the relationships of demographic variables and comorbidity with drug treatment for diabetes in the elderly. We studied both the 81,700 residents of New Jersey, aged 65–99 years, who were hospitalized between July 1, 1989 and June 30, 1991 and had prescription drug coverage either through Medicaid or the Pharmacy Assistance for the Aged and Disabled program, and a sample of 80,000 nonhospitalized elderly beneficiaries in these programs. Rates of utilization of insulin or oral hypoglycemic drugs in the 120 days before admission were substantially lower in those aged ≥85 or in nursing homes. Among patients with previously treated and diagnosed diabetes, the likelihood of treatment after discharge declined with older age (odds ratio [OR] for treatment in those aged ≥85 relative to 65–74 years: 0.57; 95% confidence interval [CI]: 0.45–0.72), nursing home residence (OR: 0.30; CI: 0.22–0.41), and higher levels of comorbidity (OR for modified Charlson index ≥5 relative to 0: 0.43; CI: 0.27–0.67). In patients who had a discharge diagnosis of diabetes but no prior treatment, those in nursing homes and those with greater comorbidity also had lower rates of diabetes treatment after discharge. Although the prevalence of diabetes increases with age and the risks of many consequences of diabetes remain high, the rate of drug treatment for diabetes declines with older age and greater comorbidity, perhaps because of concern about side effects or reduced treatment benefits due to competing risks of death. Absence of data from randomized clinical trials of diabetes treatment in the elderly appears to have resulted in considerable physician ambivalence on the benefits and risks of glycemic control in older diabetics.

Pharmacotherapy remains one of the most cost-effective interventions physicians can provide to manage the medical conditions of older patients. Because many older Americans have multiple diseases, the practitioner's goal is to maximize appropriate drug use while avoiding duplicative or interacting medications. Medicare managed care plans seek to provide appropriate medication for the older patient at a reasonable cost through such strategies as formularies, prior authorization, generic and therapeutic substitution, and drug utilization review. Yet, like the medications themselves, these strategies require careful attention to their risks and benefits to the individual patient.

Context.—Although clinical trials have demonstrated the benefits of lipid-lowering therapy, little is known about how these drugs are prescribed or used in the general population.Objective.—To estimate predictors of persistence with therapy for lipid-lowering drug regimens in typical populations of patients in the United States and Canada.Design.—A cohort study defining all prescriptions filled for lipid-lowering drugs during 1 year, as well as patients' demographic and clinical characteristics.Setting.—New Jersey's Medicaid and Pharmacy Assistance for the Aged and Disabled programs and Quebec's provincial medical care program.Patients.—All continuously enrolled patients older than 65 years who filled 1 or more prescriptions for lipid-lowering drugs (N=5611 in the US programs, and N = 1676 drawn from a 10% sample in Quebec).Main Outcome Measures.—Proportion of days during the study year for which patients had filled prescriptions for lipid-lowering drugs; predictors of good vs poor persistence with therapy.Results.—In both populations, patients failed to fill prescriptions for lipid-lowering drugs for about 40% of the study year. Persistence rates with 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors were significantly higher than those seen with cholestyramine (64.3% vs 36.6% of days with drug available, respectively). Patients with hypertension, diabetes, or coronary artery disease had significantly higher rates of persistence with lipid-lowering regimens. In New Jersey, multivariable analysis indicated that the poorest patients (those enrolled in Medicaid) had lower rates of drug use than less indigent patients (those enrolled in Pharmacy Assistance for the Aged and Disabled) after adjusting for possible confounders, despite virtually complete drug coverage in both programs. When rates of use were measured in the US population for the 5 years following the study year, only 52% of surviving patients who were initially prescribed lipid-lowering drugs were still filling prescriptions for this drug class.Conclusion.—In all populations studied, patients who were prescribed lipid-lowering drug regimens remained without filled prescriptions for over a third of the study year on average. Rates of persistence varied substantially with choice of agent prescribed, comorbidity, and socioeconomic status, despite universal coverage of prescription drug costs. After 5 years, about half of the surviving original cohort in the United States had stopped using lipid-lowering therapy altogether.

CONTEXT:Pharmacotherapy is among the most powerful interventions to improve health outcomes in the elderly. However, since some medications are less appropriate for older patients, systems approaches to improving pharmacy care may be an effective way to reduce inappropriate medication use.OBJECTIVE:To determine whether a computerized drug utilization review (DUR) database linked to a telepharmacy intervention can improve suboptimal medication use in the elderly.DESIGN:Population-based cohort design, April 1, 1996, through March 31, 1997.SETTING:Ambulatory care.PATIENTS:A total of 23269 patients aged 65 years and older throughout the United States receiving prescription drug benefits from a large pharmaceutical benefits manager during a 12-month period.INTERVENTION:Evaluation of provider prescribing through a computerized online DUR database using explicit criteria to identify potentially inappropriate drug use in the elderly. Computer alerts triggered telephone calls to physicians by pharmacists with training in geriatrics, whereby principles of geriatric pharmacology were discussed along with therapeutic substitution options.MAIN OUTCOME MEASURES:Contact rate with physicians and change rate to suggested drug regimen.RESULTS:A total of 43007 alerts were triggered. From a total of 43007 telepharmacy calls generated by the alerts, we were able to reach 19368 physicians regarding 24 266 alerts (56%). Rate of change to a more appropriate therapeutic agent was 24% (5860), but ranged from 40% for long half-life benzodiazepines to 2% to 7% for drugs that theoretically were contraindicated by patients' self-reported history. Except for rate of change of beta-blockers in patients with chronic obstructive pulmonary disease, all rates of change were significantly greater than the expected baseline 2% rate of change.CONCLUSIONS:Using a system integrating computers, pharmacists, and physicians, our large-scale intervention improved prescribing patterns and quality of care and thus provides a population-based approach to advance geriatric clinical pharmacology. Future research should focus on the demonstration of improved health outcomes resulting from improved prescribing choices for the elderly.

OBJECTIVE:To investigate resident and facility attributes associated with long-term care health outcomes in nursing homes.DATA SOURCES:Quarterly Management Minutes Questionnaire (MMQ) survey data for Medicaid case-mix reimbursement of nursing homes in Massachusetts from 1991 to 1994, for specification of outcomes and resident attributes. Facility attributes are specified from cost report data.STUDY DESIGN:Multivariate logistic and "state-dependence" regression models are estimated for survival, ADL functional status, incontinence status, and mental status outcomes from longitudinal residence histories of Medicaid residents spanning 3 to 36 months in length. Outcomes are specified to be a function of resident demographic and diagnostic attributes and facility-level operating and nurse staffing attributes.PRINCIPAL FINDINGS:The estimated parameters for resident demographic and diagnostic attributes showed a great deal of construct validity with respect to clinical expectations regarding risk factors for adverse outcomes. Few facility attributes were associated with outcomes generally, and none was significantly associated with all four outcomes.CONCLUSIONS:The absence of uniform associations between facility attributes and the various long-term care health outcomes studied suggests that strong facility performance on one health outcome may coexist with much weaker performance on other outcomes. This has implications for the aggregation of individual facility performance measures on multiple outcomes and the development of overall outcome performance measures.

Approximately half of all elderly patients have elevated blood pressure, and proper treatment of this disorder leads to decreased cardiovascular morbidity in patients 65 and older. This study examined the effect of initial drug choice and comorbidity on medication compliance. We conducted a retrospective follow-up of 8643 outpatients aged 65 to 99 with newly prescribed antihypertensive therapy (AHT) from 1982 to 1988 iri the New Jersey Medicaid and Medicare programs. Compliance was measured in terms of the number of days in which AHT was available to the patient during the 12 months following the initiation of therapy. Odds ratios (OR) and 95% confidence intervals (CI) for the outcome of good compliance (greater than or equal to 80%) were calculated.Tn a logistic regression model, good compliance (greater than or equal to 80%) was significantly associated with use of newer agents such as angiotensin converting enzyme inhibitors (OR 1.9, 95% CI 1.6 to 2.2) and calcium channel blockers (OR 1.7, 95% CI 1.5 to 2.1) as compared to thiazides, the presence of comorbid cardiac disease (OR 1.2, 95% CI 1.1 to 1.2), and multiple physician visits (OR 2.2, 95% CT 1.8 to 2.5). Good compliance was inversely associated with use of multiple pharmacies (OR 0.4, 95% Cf 0.4 to 0.5) and number of medications prescribed overall (OR 0.8, 95% CI 0.7 to 0.9).Drug choice, comorbidity, and health services utilization were significantly associated with AHT compliance and represent important considerations in the management of high blood pressure. Noncompliance may be an important cause of treatment failure in elderly hypertensives. (C) 1997 American Journal of Hypertension, Ltd.

While physiologic and epidemiologic evidence link diuretic therapy with hyperuricemia, no previous study has quantified the risk for initiation of treatment specific for hyperuricemia or gout among elderly patients taking thiazide diuretics. We performed a retrospective cohort study of 9249 enrollees aged 65 or older in the New Jersey Medicaid program who were newly started on an antihypertensive medication from November 1981 through February 1989 and who had no prior use of anti-gout therapy (allopurinol, colchicine, or a uricosuric) during the preceding one-year period. We used Cox proportional hazards analysis to determine the risk for the initiation of anti-gout therapy in patients using various antihypertensive treatment regimens relative to no antihypertensive exposure. Patient follow-up extended for up to two years. Antihypertensive exposure was characterized over the entire period of follow-up according to the following categories: thiazide diuretic therapy alone; non-thiazide antihypertensive therapy; thiazide diuretic therapy in combination with any non-thiazide antihypertensive agent(s); and no antihypertensive use. Antihypertensive exposure was entered into the model as a time-varying covariate. Estimates of risk were adjusted for age, sex, race, nursing home residence, number of prescriptions filled, intensity of physician use, hospitalization history, and year of antihypertensive treatment initiation. The adjusted relative risk for the initiation of anti-gout therapy was 1.00 (95% CI, 0.65 – 1.53) for non-thiazide antihypertensive therapy alone, 1.99 (95% CI, 1.21 – 3.26) for thiazide diuretic therapy, and 2.29 (95% CI, 1.55 – 3.37) for thiazide diuretic therapy in combination with any non-thiazide agent(s). Risk for anti-gout therapy was significantly increased for thiazide doses of ≥25 mg/day (in hydrochlorothiazide equivalents); no significant increase in risk was seen for lower doses. We conclude that use of thiazide diuretics in doses of 25 mg/day or higher is associated with a significantly increased risk for initiation of anti-gout therapy. Such treatment may reflect the occurrence of clinical sequelae of diuretic-induced hyperuricemia or the inappropriate treatment of asymptomatic hyperuricemia.

Pharmacotherapy represents one of the most important ways in which the practice of geriatric medicine differs from conventional medical care. The older patients is a major consumer of prescription and nonprescription medications, and proper use of these agents can lead to more cost-effective strategies in reaching optimal health. A key difference in distinguishing appropriate from inappropriate drug use is evident in the themes of polymedicine and polypharmacy. Polymedicine describes the use of medications for an older population for the treatment of multiple co-morbid conditions, while polypharmacy represents a less-than-desirable state with duplicative medications, drug-to-drug interactions, and inadequate attention to pharmacokinetic and pharmacodynamic principles. The purpose of this paper is to outline strategies toward optimal medication use as a key to successful aging. Specifically, we discuss themes of cost-effective prescribing, the role of medication compliance, overuse and underuse of medication, over-the-counter products, alcohol abuse, and preventive medicine. In addition, we discuss policy implications and responsibility for ensuring the high quality of pharmaceutical care. The reader should have a practical understanding of the pertinent issues in geriatric clinical pharmacology and its relationship to successful aging.

OBJECTIVE: The objective of this study was to examine how often treatment for hyperlipidemia followed the use of thiazides, compared with the use of other antihypertensive drugs, in older patients.DESIGN: Retrospective follow‐up of all health claims filed over a 12‐month period.SETTING: New Jersey Medicaid and Medicare programs.PARTICIPANTS: A total of 9274 enrollees, aged 65 to 99, who were newly initiated on antihypertensive medications from 1981–1989.MEASUREMENTS: We measured rates of lipid‐reducing agent (LRA) initiation among patients in the 2 years following antihypertensive initiation (thiazide, non‐thiazide drug, or combinations of the two) compared with rates among patients not currently taking antihypertensive agents. We used Cox regression analyses to estimate relative risks (RR), accounting for switching in antihypertensive therapy and for time when drug therapy was not currently available according to pharmacy refill records.RESULTS: There were 226 patients (2.4%) in the cohort who were started on LRA during the follow‐up period. After adjusting for potential confounders, we found no significant relationship between LRA initiation and overall thiazide use (RR 1.47, 95% CI 0.89‐2.40), or other antihypertensive use, relative to no current exposure. However, use of high‐dose thiazides (≥50 mg) was associated significantly with LRA initiation (RR 1.97, 95% CI 1.12‐3.45). Factors associated with decreased incidence of LRA use included age ≥ 85 (RR 0.59, 95% CI 0.36‐0.96), black race (RR 0.58, 95% CI 0.37‐0.91), and nursing home residency (RR 0.20, 95% CI 0.11‐0.35).CONCLUSION: Use of low‐cost and effective thiazide diuretics in older hypertensives was not associated with more common initiation of lipid‐reducing agents, except with high‐dose use of thiazides currently seen as inappropriate in most cases. Age and race were important determinants of LRA use.