Biomedical subjects

Nancy Perrin

Publications and source records attributed to Nancy Perrin.

12 recordsLinked to original sources

PubMed2006

Improved therapeutic monitoring with several interventions: a randomized trial.

BACKGROUND: Medication errors are frequently related to failure to appropriately select medications or adjust for laboratory parameters. Differences between guideline recommendations and actual frequency of therapeutic laboratory monitoring are substantial. This study evaluated interventions to improve laboratory monitoring at initiation of medication therapy. METHODS: This cluster-randomized trial compared 3 interventions to usual care for 10 medications in 15 primary care clinics in a health maintenance organization with an electronic medical record system. Eligible patients, identified from electronic databases, had not received recommended laboratory monitoring within 5 days after new dispensing of a study medication. Interventions were an electronic medical record reminder to the prescribing health care professional, an automated voice message to the patient, and a pharmacy team outreach to the patient. Primary outcome was completion of all recommended baseline laboratory monitoring. RESULTS: A total of 961 patients participated in the study. At 25 days, 95 (48.5%) of 196 patients in the electronic medical record reminder group, 177 (66.3%) of 267 in the automated voice message group, 214 (82.0%) of 261 in the pharmacy team outreach group, and 53 (22.4%) of 237 in the usual care group had completed all recommended baseline laboratory monitoring (P<.001). After adjustments, the hazard ratios for completing laboratory monitoring compared with usual care were 2.5 (95% confidence interval, 1.8-3.5) for electronic medical record reminder, 4.1 (95% confidence interval, 3.0-5.6) for automated voice message, and 6.7 (95% confidence interval, 4.9-9.0) for pharmacy team outreach. CONCLUSIONS: All 3 interventions were effective in increasing laboratory monitoring when initiating new medications in primary care. Further work is necessary to determine if these interventions improve patient outcomes.

Adult↗

PubMed2006

The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation.

BACKGROUND: Considerable effort and attention have focused on medication safety in elderly persons; one approach that has been understudied in the outpatient environment is the use of computerized provider order entry with clinical decision support. The objective of this study was to examine the effects of computerized provider order entry with clinical decision support in reducing the use of potentially contraindicated agents in elderly persons. METHODS: With data from a 39-month period of a natural experiment, we evaluated changes in medication dispensing using interrupted time series analysis to estimate changes, controlling for prealert prescribing trends. The setting was a large health maintenance organization in the Pacific Northwest. All adult enrollees of the health plan participated. The intervention was computerized alerts cautioning against using certain medications in elderly persons. The main outcome measure was dispensing per 10,000 members per month. RESULTS: Following the implementation of the drug-specific alerts, a large and persistent reduction (5.1 prescriptions per 10,000, P=.004), a 22% relative decrease from the month before alert implementation, in the exposure of elderly patients to nonpreferred medications was observed. We found no evidence of a decrease in use of nonpreferred agents for nonelderly patients. The reduction seen in use of nonpreferred agents for elderly persons was driven primarily by decreases in dispensing for tertiary tricyclic agents. CONCLUSIONS: We found that alerts in an outpatient electronic medical record aimed at decreasing prescribing of medication use in elderly persons may be an effective method of reducing prescribing of contraindicated medications. The effect of the alerts on patient outcomes is less certain and deserves further investigation.

Adult↗

PubMed2006

Reducing warfarin medication interactions: an interrupted time series evaluation.

BACKGROUND: Computerized decision support reduces medication errors in inpatients, but limited evidence supports its effectiveness in reducing the coprescribing of interacting medications, especially in the outpatient setting. The usefulness of academic detailing to enhance the effectiveness of medication interaction alerts also is uncertain. METHODS: This study used an interrupted time series design. In a health maintenance organization with an electronic medical record, we evaluated the effectiveness of electronic medical record alerts and group academic detailing to reduce the coprescribing of warfarin and interacting medications. Participants were 239 primary care providers at 15 primary care clinics and 9910 patients taking warfarin. All 15 clinics received electronic medical record alerts for the coprescription of warfarin and 5 interacting medications: acetaminophen, nonsteroidal anti-inflammatory medications, fluconazole, metronidazole, and sulfamethoxazole. Seven clinics were randomly assigned to receive group academic detailing. The primary outcome, the interacting prescription rate (ie, the number of coprescriptions of warfarin-interacting medications per 10 000 warfarin users per month), was analyzed with segmented regression models, controlling for preintervention trends. RESULTS: At baseline, nearly a third of patients had an interacting prescription. Coinciding with the alerts, there was an immediate and continued reduction in the warfarin-interacting medication prescription rate (from 3294.0 to 2804.2), resulting in a 14.9% relative reduction (95% confidence interval, -19.5 to -10.2) at 12 months. Group academic detailing did not enhance alert effectiveness. CONCLUSIONS: This study, using a strong and quasi-experimental design in ambulatory care, found that medication interaction alerts modestly reduced the frequency of coprescribing of interacting medications. Additional efforts will be required to further reduce rates of inappropriate prescribing of warfarin with interacting drugs.

Acetaminophen↗

PubMed2006

Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people.

OBJECTIVES: To examine the effect of replacing drug-specific computerized prescribing alerts with age-specific alerts on rates of dispensing potentially inappropriate medications in older people and to determine whether group academic detailing enhances the effectiveness of these alerts. DESIGN: Cluster-randomized trial of group academic detailing and interrupted time-series analysis. SETTING: Fifteen clinics of a staff-model health maintenance organization. PARTICIPANTS: Seven practices (113 clinicians, 24,119 patients) were randomly assigned to receive age-specific prescribing alerts plus the academic detailing intervention; eight practices (126 clinicians, 26,805 patients) received alerts alone. Prior implementation of drug-specific alerts established a downward trend in use of target medications that served as the baseline trend for the present study. INTERVENTION: The computerized age-specific alerts occurred at the time of prescribing a targeted potentially inappropriate medication (e.g., tertiary tricyclic amine antidepressants, long-acting benzodiazepines, propoxyphene) and suggested an alternative medication. Clinicians at seven sites were randomized to group academic detailing, an interactive educational program delivering evidence-based information. MEASUREMENTS: Number of target medications dispensed per 10,000 patients per quarter, 2 years before and 1.5 years after the replacement of drug-specific with age-specific alerts. RESULTS: Age-specific alerts resulted in a continuation of the effects of the drug-specific alerts without measurable additional effect (P=.75 for level change), but the age-specific alerts led to fewer false-positive alerts for clinicians. Group academic detailing did not enhance the effect of the alerts. CONCLUSION: Age-specific alerts sustained the effectiveness of drug-specific alerts to reduce potentially inappropriate prescribing in older people and resulted in a considerably decreased burden of the alerts.

Aged↗

PubMed2006

Expression and ambivalence over expression of negative emotion: cross-sectional associations with psychosocial factors and health-related quality of life in postmenopausal women.

Inhibition of emotional expression has been associated with the incidence and progression of breast cancer and other chronic illnesses. The important health-related factor, however, may be ambivalence about the expression of emotions rather than repression itself. This cross-sectional analysis of baseline data from 159,557 participants in the Women's Health Initiative examined the influence of expression of negative emotion and ambivalence about expression of emotion on psychosocial factors and health-related quality of life measured by the Medical Outcomes Study Short-form 36 (SF-36). Overall, observed correlations were modest but in the expected direction; that is, greater ambivalence about negative emotional expression was associated with worse general health and poorer psychosocial risk profile. Ambivalence about expressing negative emotion was more highly correlated with psychosocial factors and health-related quality of life than emotional expression. In general, our analysis supports prior studies suggesting that ambivalence may be more important to consider in studies of health-related outcomes than expression.

Aged↗

PubMed2005

Symptom experiences of residents dying in assisted living.

OBJECTIVES: To identify the end-of-life symptom experiences of residents who died in assisted living, to describe family satisfaction with the end-of-life care, and to compare end-of-life symptom distress across 4 settings: assisted living, private home, nursing home, and hospital. DESIGN: In-person interviews with family members of people aged 65 or older who had died 2 to 4 months earlier in an assisted-living facility. Symptom distress reports were compared with data from prior studies in other settings. SETTING: A mixed urban-rural community in the Northwest. PARTICIPANTS: Twenty-five family members who self-identified as closely involved in the care or decision making for a relative who died in an assisted-living facility. MEASUREMENTS: A 28-item interview guide composed of demographic questions, the modified Family Memorial Symptom Assessment Scale-Global Distress Index (FMSAS-GDI), and open-ended items describing the decedent's last days and family satisfaction with care and symptom management. RESULTS: Symptoms experienced by at least 75% of decedents were lack of energy, loss of appetite, dry mouth, drowsiness, and pain. Symptom experiences in assisted living were comparable to those in other settings. Families overall were satisfied with end-of-life care in assisted living, but had concerns about communication among providers, inadequate monitoring of their decedent, and lack of staff knowledge specific to symptom management. CONCLUSION: Residents dying in assisted-living settings have similar symptom distress experiences as people dying in other, more studied settings. As residents and families alike overwhelmingly support resident deaths in their assisted living "home," policies, structures, and processes are needed to ensure that end-of-life care needs are met.

Aged, 80 and over↗

PubMed2005

Cost-effectiveness of an intervention to prevent depression in at-risk teens.

CONTACT: Depression is common in adolescent offspring of depressed parents and can be prevented, but adoption of prevention programs is dependent on the balance of their incremental costs and benefits. OBJECTIVE: To examine the incremental cost-effectiveness of a group cognitive behavioral intervention to prevent depression in adolescent offspring of depressed parents. DESIGN: Cost-effectiveness analysis of a recent randomized controlled trial. SETTING: Kaiser Permanente Northwest, a large health maintenance organization. PARTICIPANTS: Teens 13 to 18 years old at risk for depression. INTERVENTIONS: Usual care (n = 49) or usual care plus a 15-session group cognitive therapy prevention program (n = 45). MAIN OUTCOME MEASURES: Clinical outcomes were converted to depression-free days and quality-adjusted life-years. Total health maintenance organization costs, costs of services received in other sectors, and family costs were combined with clinical outcomes in a cost-effectiveness analysis comparing the intervention with usual care for 1 year after the intervention. RESULTS: Average cost of the intervention was $1632, and total direct and indirect costs increased by $610 in the intervention group. However, the result was not statistically significant, suggesting a possible cost offset. Estimated incremental cost per depression-free day in the base-case analysis was $10 (95% confidence interval, -$13 to $52) or $9275 per quality-adjusted life-year (95% confidence interval, -$12 148 to $45 641). CONCLUSIONS: Societal cost-effectiveness of a brief prevention program to reduce the risk of depression in offspring of depressed parents is comparable to that of accepted depression treatments, and the program is cost-effective compared with other health interventions commonly covered in insurance contracts.

Adolescent↗

PubMed2005

Men as caregivers at the end of life.

BACKGROUND: Few studies have focused on men as caregivers at the end-of-life. The objective of this secondary data analysis was to examine the experiences of men involved in end-of-life caregiving, focusing on caregiver strain. METHODS: We used a random sample of Oregon death certificates to telephone survey family caregivers of Oregonians who had died 2 to 5 months earlier in private homes, nursing homes, and other community-based settings. Measurements included single-item indicators and embedded scales to measure caregiver strain and perceived decedent symptom distress. For the 25 husbands, sons, wives, and daughters who reported the highest levels of strain, we also analyzed caregivers' description of the decedent's last few days of life. RESULTS: The sample included 1384 caregiver interviews from a pool of 3048 death certificates. Men constituted 29% of the caregivers, including 15% sons, 9% husbands, and 5% others. In a linear regression model, male gender was a significant predictor of lower caregiver strain (p < 0.001). The strongest predictor of high end-of-life caregiver strain was the severity of the decedents' symptom distress. The qualitative analysis revealed that men used fewer words than women did to describe their experiences, and, despite subsequently reporting the highest levels of caregiving strain, only 15% of men spontaneously mentioned their own struggles. CONCLUSIONS: As caregivers at the end of life, men are less common and less likely to report caregiver strain and decedent symptom distress. Health care professionals should actively ask men about these issues and listen carefully, as their responses may be brief and understated.

Aged↗

PubMed2005

Modeling ADHD child and family relationships.

Little information is available on how to help families manage common negative sequelae of attention deficit/hyperactivity disorder (ADHD). This article is a report of the extent to which a theoretical formulation of child behavior, maternal distress, and family conflict was explained by data obtained from a community sample of families with children and adolescents with ADHD. Structural equation modeling was used to test the theoretical model. The primary variables of interest were (a) child behavior problems, (b) maternal distress, and (c) family conflict. The results suggest that maternal distress may mediate the relationship between child behavior problems and family conflict, indicating the critical importance of mothers in ADHD families and the need to provide them with additional support.

Adaptation, Psychological↗

PubMed2005

Service needs of families with children with ADHD.

This article describes service use, perceived helpfulness of services, and the services requested of 157 families living with a child or adolescent with attention-deficit/hyperactivity disorder (ADHD) and specifically asks if service use and service need is a function of certain social demographic factors. Whereas these data suggest that ADHD is a fairly universal experience, as indicated by the high rate of service use across ethnic groups, income status, sex, and family composition, single-mother families used the most services, Hispanic families used the fewest, and families with boys with ADHD used more services than families with girls with ADHD. Income was not a significant factor in any services used or services requested. This study lends strength to the argument that more specialized services for certain groups are needed in venues with local community services, such as schools, where the majority of these children and families are already seeking help.

Adolescent↗

PubMed2005

Expression and ambivalence over expression of negative emotion:psychometric analysis in the Women's Health Initiative.

Inhibition of emotional expression has been associated with the incidence and progression of breast cancer and other chronic illnesses. Others have theorized that it may not be repression itself, but rather ambivalence over the expression of emotions that is the important health-related factor. The Women's Health Initiative (WHI), a long-term, national study focusing on disease prevention among postmenopausal women, is unique in its assessment of expression and ambivalence of negative emotion in a large study sample of multiethnic, older women. Psychological factors such as expression of negative emotion and ambivalence about expression of emotion are also determined by social patterning. The current study examined the psychometric properties of the instruments used to measure each construct and variation across race/ethnicity and age. The analysis suggests that the scales can be used with confidence in diverse ethnic and age groups. Examining ambivalence about expression of negative emotion in future longitudinal research will further elucidate its role in predicting disease incidence and recovery, both important in reducing the public health burden of chronic disease.

Aged↗

PubMed2002

A comparison of two methods for identifying frail Medicare-aged persons.

This article compares the efficacy of two screening methods to identify frail Medicare-aged persons using self-report questionnaire data: a clinical judgment method developed by nurse and social worker professionals in a community-based long-term care department and an empirical research method previously developed by the Center for Health Research using computer formulas and stepwise logistic regression coefficients. A sub-aim was to see whether the empirical method proved robust over time by measuring aggregate utilization and mortality in frail and nonfrail cohorts, which would increase the interest of physicians, managed care organizations, and other agencies providing service to Medicare beneficiaries.

Activities of Daily Living↗