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Objective: The current literature on unilateral coronal craniosynostosis is replete with repair techniques and surgical outcomes; however, information regarding neurodevelopment remains unclear. Therefore, the aim of this systematic review and meta-analysis was to comprehensively assess the neurodevelopmental outcomes of patients with unicoronal craniosynostosis compared with their healthy peers or normative data., Methods: A systematic review of the Ovid MEDLINE, Embase, Web of Science, Scopus, Cochrane Library, and ClinicalTrials.gov databases from database inception to January 19, 2022, was performed. Included studies assessed neurodevelopment of patients with unicoronal craniosynostosis. Two independent reviewers selected studies and extracted data based on a priori inclusion and exclusion criteria. Results of developmental tests were compared with normative data or controls to generate Hedges' g statistics for meta-analysis. The quality of included studies was evaluated using the National Institutes of Health Assessment Tool., Results: A total of 19 studies were included and analyzed, with an overall fair reporting quality. A meta-analysis of 325 postoperative patients demonstrated that scores of general neurodevelopment were below average but within one standard deviation of the norm (Hedges' g = -0.68 [95% CI -0.90 to -0.45], p < 0.001). Similarly, postoperative patients exhibited lower scores in verbal, psychomotor, and mathematic outcome assessments., Conclusions: This systematic review and meta-analysis found that patients with unicoronal craniosynostosis had poorer neurodevelopment, although scores generally remained within the normal range. These data may guide implementation of regular neurocognitive assessments and early learning support of patients with unicoronal craniosynostosis.

The increasing number of retrospective database studies related to medication compliance and persistence (C&P), and the inherent variability within each, has created a need for improvement in the quality and consistency of medication C&P research. This article stems from the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) efforts to develop a checklist of items that should be either included, or at least considered, when a retrospective database analysis of medication compliance or persistence is undertaken. This consensus document outlines a systematic approach to designing or reviewing retrospective database studies of medication C&P. Included in this article are discussions on data sources, measures of C&P, results reporting, and even conflict of interests. If followed, this checklist should improve the consistency and quality of C&P analyses, which in turn will help providers and payers understand the impact of C&P on health outcomes.

An increasing number of nursing home litigations have been filed as a result of the growing nursing home population and laws regulating their care. Understanding the litigation process and developing an awareness of the issues examined by attorneys and experts for both the plaintiff and defense are important for nurses working in long-term care. Knowing the standards of care and the litigation process can prepare nurses to anticipate and successfully defend their positions.

Objective: To examine advantages of and obstacles to electronic prescribing in the ambulatory care environment., Data Sources: MEDLINE and International Pharmaceutical Abstract searches were conducted for the period from January 1980 to September 2000. Key words were electronic prescribing, computerized physician order entry, prior authorization, drug utilization review, and consumer satisfaction. In September 2000, a public search engine (www.google.com) was used to find additional technical information. In addition, pertinent articles were cross-referenced to identify other resources., Data Extraction: Articles, symposia proceedings, and organizational position statements published in the United States on electronic prescribing and automation in healthcare are cited., Data Synthesis: Electronic prescribing can eliminate the time gap between point of care and point of service, reduce medication errors, improve quality of care, and increase patient satisfaction. Considerable funding requirements, segmentation of healthcare markets, lack of technology standardization, providers' resistance to change, and regulatory indecisiveness create boundaries to the widespread use of automated prescribing. The potential solutions include establishing a standardizing warehouse or a router and gaining stakeholder support in implementation of the technology., Conclusions: Electronic prescribing can provide immense benefits to healthcare providers, patients, and managed care. Resolution of several obstacles that limit feasibility of this technology will determine its future.

Objective: To determine whether differences in the provision of pharmacy services exist among different types of Internet pharmacies., Design: Survey of selected pharmacies with a presence on the Internet. Data were abstracted onto a data collection form for further analysis. Data collection was limited to 3 weeks., Setting: U.S.-based Internet pharmacies that allow patients to purchase prescription medications online. Pharmacies were identified using a metasearch engine with the search terms "Internet pharmacy" and "Internet pharmacist.", Intervention: Survey., Main Outcome Measures: Comparisons of availability of 10 commonly used products representing a variety of product categories, prescription verification methods, and privacy issues; and determinations of site navigability, drug information and provider access, and payment methods. Sites were categorized as "chain pharmacy extensions," "mail order pharmacies," "independent pharmacy extensions," and "online pharmacies.", Results: Thirty-three sites were reviewed. There was significant variation among the four types of pharmacies selling prescriptions over the Internet. Most pharmacies provided all of the drugs in the survey. Patients were required to provide their own prescription at 88% of the sites, and 75% of sites used mail or fax to verify prescription integrity. More than 50% of sites had privacy policies posted, and 64% used cookies. Chain pharmacy extensions required completion of an average of 10.2 pages to order drugs versus 2.4 to 4 pages for all other site types. Drug information was written at an eighth-grade reading level at 36% of the sites. More than two-thirds of the sites provided a toll-free telephone for a health care professional. Nearly 80% of the sites accepted health insurance, and 95% accepted credit cards; however, only 40% used a secure transmission mechanism for patient or payment information., Conclusion: Internet pharmacies provide varying levels of service. Policies regarding the use of the Internet for obtaining medications should focus on improving the privacy of consumer information and ensuring the secure transmission of financial information.

Providing drug information to consumers is an essential component of medical and pharmaceutical care. In recent years, profit-based consumer-oriented drug information centers (DICs) or drug hot lines have developed to fill this need. This study compared the services and information provided by DICs for consumers with those provided by DICs for health care professionals. The two consumer-oriented DICs provided-accurate and professional information, similar in content to that provided by the health care professional DICs. Although the data were too small for statistical analysis, it appears that the consumer-oriented DICs offer a valuable service.

The impact of a decision analysis model on pharmacists' preferences for a drug therapy was studied. Three hundred forty members of the American College of Clinical Pharmacy were randomly assigned to receive either a copy of a drug therapy review alone (control group) or the review plus a decision analysis of the same clinical problem (experimental group). The disease selected was pseudomembranous colitis, and the drugs to be considered were vancomycin, metronidazole, and bacitracin. The review and the decision analysis recommended metronidazole as the best agent. Each subject completed a short questionnaire, read the review or the review plus the analysis, and completed a follow-up questionnaire. Both questionnaires asked the subjects to rank the agents in order of preference. There were 164 usable responses, 86 from the control group and 78 from the experimental group; the total response rate was 48.2%. The difference in the proportion of respondents in each group who chose metronidazole as the most preferred agent, both before and after the intervention, was not significant. Of the 40 experimental-group subjects who ranked metronidazole as their second or third choice in the pretest, 16 (40%) ranked it as the most preferred agent in the posttest. Ten of these 16 stated that the model influenced their decision. Decision analysis plus a drug therapy review had no greater impact on pharmacists' opinions on the selection of drug therapy for pseudomembranous colitis than did the review alone. The model did influence some of those who changed their opinion.

Fax technology is the transmission of text and graphic data between two locations via telephone lines. The advantages of this technology include the speed with which a document can be sent anywhere in the world and the decreased cost versus traditional courier and Telex services. Several different types of machines exist, but standard operating parameters are set by the Consultative Committee for International Telephone and Telegraph (CCITT). There are four categories of machines, called Groups, which aid in classifying the various fax units. Group 3 machines are the most common comprising about 75% of the market. Standard features vary between and within groups, depending on the manufacturer and model. Features such as polling, document broadcasting, security levels, and computer linkage are discussed. The healthcare industry has been slow to adopt fax technology. Applications in hospital pharmacy are the main focus of attention of some hospital administrators and directors of pharmacy. A few studies have shown decreased medication order turnaround time after implementation of a fax-based pharmacy order system. However, problems such as order clarity and legibility, elevated nursing expectations and increased use of paper can decrease its usefulness. Overall, facsimile technology will find a place in the healthcare arena and may become an integral part of the modern pharmacy department.

Approximately one-quarter of people with HIV (PWH) in the U.S. receive coverage through the Medicare program; however, no prior real-world study has examined antiretroviral therapy (ART) gaps and adherence and associated factors in this population. This retrospective cohort analysis used 2013–2018 national Medicare fee-for-service claims data to identify all PWH initiated on a new ART regimen including protease inhibitors [PI], non-nucleoside reverse transcriptase inhibitors [NNRTIs], or integrase strand transfer inhibitors [INSTIs] between 1/1/2014 and 12/31/2017. Study outcomes included ART adherence (based on proportion of days covered [PDC]), continuous treatment gaps ranging from 1 to 6 days to ≥ 180 days, and discontinuation (continuous gap ≥ 90 days) in the 12-month follow-up period. Multivariable regressions were used to assess factors associated with ART adherence and discontinuation. The final sample included 48,627 PWH (mean age: 54.5 years, 74.4% male, 47.5% White, 89.8% disabled). Approximately 53.0% of PWH had a PDC ≥ 0.95, 30.2% had a PDC between 0.70 and < 0.95, and 16.8% had PDC < 0.70. Treatment gaps of at least ≥ 7-days (55.2%) and ≥ 30-days (26.2%) were common and 10.1% PWH discontinued treatment. Younger age, female sex, Black race, higher comorbidity score, mental health conditions, and substance use disorder were associated with higher odds of lower adherence and discontinuation (all p-values < 0.05). In conclusion, suboptimal adherence and treatment gaps in ART use were commonly observed among PWH in Medicare. Interventions and policies to mitigate barriers to adherence are urgently needed in this population to both improve their survival and increase the potential for ending the HIV epidemic in the US. [ABSTRACT FROM AUTHOR]

Introduction: Associations between increased functional disability and higher healthcare resource utilization (HCRU) and costs were reported in patients with psoriatic arthritis (PsA). We assessed characteristics/outcomes of patients with PsA receiving tofacitinib monotherapy vs combination therapy with conventional synthetic disease-modifying antirheumatic drugs., Methods: Claims data from Optum ® Clinformatics ® Data Mart (OC) and Merative™ MarketScan ® (MS) databases between December 2017 and February 2020 were analyzed. Outcomes assessed were adherence/persistence by therapy type (monotherapy/combination therapy); HCRU/costs (per patient per month) by periods on-treatment (sum time on tofacitinib) and off-treatment (sum time off tofacitinib [gap of > 60 days]) plus therapy type., Results: This analysis included 274 and 395 tofacitinib-treated patients in OC (70.4% female, mean age 54.4 years) and MS (68.9% female, mean age 51.4 years), respectively. Percentages of patients with a proportion of days covered ≥ 0.8 at 12 months for monotherapy vs combination therapy were OC, 44.5% vs 53.8%; MS, 36.4% vs 45.7%. Generally similar trends were seen over 24 months and for medication possession ratio ≥ 0.8. Median (95% confidence interval) times to treatment discontinuation for monotherapy vs combination therapy were OC, 10.1 (7.4-11.8) vs 16.7 (8.3-26.6) months; MS, 6.9 (5.6-9.4) vs 11.0 (6.1-13.9) months. During off-treatment vs on-treatment periods, numerical decreases were observed for all-cause (OC, $5383 vs $6149; MS, $4145 vs $5180) and PsA-related costs (OC, $3237 vs $4515; MS, $2703 vs $3907) regardless of therapy type. During off-treatment vs on-treatment periods, numerical increases in outpatient visits for all-cause (OC, 2.37 vs 2.05; MS, 2.15 vs 1.99) and PsA-related visits (OC, 0.60 vs 0.46; MS, 0.47 vs 0.44) were observed, and PsA-related medications numerically decreased (OC, 1.21 vs 1.53; MS, 1.05 vs 1.48)., Conclusion: In this USA-based claims analysis, tofacitinib adherence was numerically lower for patients with PsA receiving monotherapy vs combination therapy. Costs numerically decreased off-treatment vs on-treatment, irrespective of therapy type, driven by lower medication costs., (© 2024. The Author(s).)

Introduction: Optimal adherence thresholds can vary across medications and disease states. The objective of the study was to determine the optimal threshold of the proportion of days covered (PDC) for tumor necrosis factor (TNF) inhibitors in patients with rheumatoid arthritis (RA)., Methods: Patients with RA initiating self-administered TNF inhibitors were identified using 2012-18 Medicare fee-for-service claims. Time-varying PDC was calculated every day for the preceding 90 days during follow-up. Oral and injected glucocorticoid use, hospitalizations, emergency room (ER) visits, serious infections, and a composite of these were measured as outcomes. Time to first occurrence of each outcome as a function of time-varying PDC for TNF inhibitors was evaluated using Cox regression. Incident/dynamic time-dependent receiver operating characteristic curves and Youden's J index were used to obtain the optimal PDC threshold for outcomes at 365 days., Results: Of the 1190 patients who met the study inclusion criteria, almost 75% (865 patients) experienced at least one of the outcomes. Increasing PDC by 10% was significantly associated with decreased risks of the composite outcome (HR 0.98, 95% CI 0.96-1.00), oral glucocorticoid use (HR 0.93, 95% CI 0.91-0.96), and hospitalization (HR 0.96, 95% CI 0.94-0.99) but an increased risk of ER visits (HR 1.04, 95% 1.01-1.07). Optimal PDC thresholds for the composite outcome, oral glucocorticoid use, and hospitalization were 0.64, 0.59, and 0.56, respectively., Conclusions: Increased PDC was associated with a decreased risk of adverse outcomes, except ER visits. The optimal PDC for TNF inhibitors in Medicare patients with RA based on clinical outcomes was about 60%. Key Points • The optimal proportion of days covered threshold for tumor necrosis factor inhibitors at 365 days based on clinical outcomes was found to be about 60%, which is lower than the traditional 80% used to define adherence. • Increased adherence was associated with decreased risks of oral glucocorticoid use, hospitalization, and the composite outcome. However, it was also associated with an increased risk of emergency room visits. • The mean time-varying 90-day proportion of days covered decreased throughout the study starting 92% at day 1 of follow-up to 62% at day 365., (© 2024. The Author(s).)

The aim of the current study was to understand how the canine heartworm disease preventive ProHeart® 12 (extended-release injectable moxidectin, PH 12), impacts heartworm preventive purchase compliance and veterinary practice revenue over time compared to monthly heartworm disease preventives. This was a preliminary observational purchase compliance and revenue study based on a retrospective review of transaction data from 4,615 general practices across the United States. The review period was from September 2018 to August 2020. Anonymous transaction records of over 13 million canine patients were analyzed. Of these, only 3.5 million (25.7%) patients purchased any heartworm preventive, as has been presented in other studies. Practices that implemented PH 12 demonstrated the most growth in canine heartworm prevention revenue, patients, and patient compliance levels during the 12-month observation period, compared to previous year. These practices saw year over year growth in percent patients receiving heartworm protection, as well as 10% and 15% growth in the proportion of preventive patients compliant for more than 6 months and 12 months respectively. In contrast, practices that did not bring on PH 12 and only dispensed monthly heartworm preventives saw a decline in the proportion of canine preventive patients that were compliant for more than 6 months. Similarly, PH 12 practices experienced 15% growth in preventive revenue, and practices that did not bring on PH 12 only experienced 3.9% growth in preventive revenue. PH 12 was single-handedly responsible for all growth in patients compliant for more than 6 months in this study. Growth in protection of canine patients with PH 12 proves a helpful tool where mitigation strategies have thus far failed to curb increasing canine heartworm disease prevalence in the US. [ABSTRACT FROM AUTHOR]

Hypothesis: We aimed to identify practice trends and association between physician training and administration of perioperative steroids for cochlear implantation (CI) as it relates to hearing preservation., Background: Perioperative steroid therapy regimens are postulated to protect residual hearing and improve hearing preservation outcomes in CI., Methods: A 27-question online survey was developed by the senior authors using the Qualtrics Survey Tool, then distributed via email from September to November 2022 to otolaryngologists specializing in otology or neurotology and who practice in the United States or Canada., Results: The survey was sent to 463 physicians, 162 (35.0%) of whom completed the survey. One hundred forty-four (31.1%) responses underwent analysis. All physicians administering preoperative steroids (n = 31) prefer preoperative oral prednisone. Of 143 physicians administering intraoperative steroids, 54.5% prefer intraoperative intravenous dexamethasone. More than half (77.6%) of 85 physicians administering postoperative steroids prefer postoperative oral prednisone. Postoperative steroid administration (p < 0.006) and taper utilization (p < 0.041) were greater among physicians who complete greater than 40 CIs annually (n = 47 [71.2%]; n = 30 [49.2%]) than physicians who complete up to 40 CIs annually (n = 37 [48.7%]; n = 20 [31.3%]), respectively. Physicians practicing for 5 to 20 years after residency are more prevalent in using postoperative steroid tapers than physicians practicing for fewer than 5 years after and more than 20 years after residency (n = 37 [51.4%] versus n = 14 [25.5%], p < 0.001)., Conclusion: Consensus is needed about the optimal steroid treatment for CI patients., Level of Evidence: 4., Competing Interests: Sources of support and disclosure of funding: There are no financial disclosures, commercial associations, or other conditions posing a conflict of interest to report for any of the above authors., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: Famciclovir is a recommended option for herpes simplex virus (HSV) and varicella‐zoster virus (VZV) prophylaxis in cytomegalovirus (CMV) low‐risk solid organ transplant (SOT) recipients in current guidelines; however there is currently no data evaluating its use in SOT recipients. We conducted a multicenter provider survey on antiviral prophylaxis in CMV low‐risk SOT recipients and evaluated the efficacy and safety of once daily famciclovir antiviral prophylaxis. Methods: Two‐part analysis consisting of a national provider survey and a retrospective chart review of 78 kidney transplant recipients at a single institution. Results: Providers from 45 transplant centers within the United States responded to the survey. Across all organs, acyclovir 400 mg twice daily was utilized by the majority of respondents (70.4%), with most using prophylaxis for a duration of 3 months (68.8%). No respondents reported use of famciclovir at their institution. In the retrospective review there were no documented cases of HSV/VZV/CMV infection during the 3 months of famciclovir prophylaxis, and only one patient (1.3%) later developed VZV infection at 12 months post‐transplant. One patient (1.3%) required premature discontinuation of famciclovir due to concern for acute interstitial nephritis. Conclusion: Nationwide, the most common antiviral prophylaxis used in CMV low‐risk SOT recipients is acyclovir 400 mg twice daily. Among patients receiving once daily famciclovir for CMV low‐risk antiviral prophylaxis, there was no HSV/VZV/CMV infection while on prophylaxis. Once daily famciclovir may provide an effective and convenient once daily dosing regimen for antiviral prophylaxis in CMV low‐risk SOT recipients. [ABSTRACT FROM AUTHOR]

Background: Although informal caregivers such as family and friends provide people with cancer needed physical care and emotional support, little is known about which individuals have access to such caregivers. The purpose of this article is to provide a nationally representative description of the sociodemographic characteristics of cancer survivors who have or had an informal caregiver in the United States. Methods: Cross‐sectional data were taken from the Experiences With Cancer Survivorship Supplement of the Medical Expenditure Panel Survey in 2011, 2016, and 2017. People were cancer survivors from diagnosis until the end of life. The study population consisted of adult survivors of cancer other than nonmelanoma skin cancer who were treated for cancer less than 3 years before the survey and were living in the community (n = 720). The main outcome measure was whether or not the cancer survivor reported having an informal caregiver. Results: In the United States, 55.2% of cancer survivors reported having an informal caregiver during or after their cancer treatment. The relationship of the caregiver to the survivor varied by sex: males were more likely to have a spouse as their caregiver, and females were more likely to have a child as their caregiver. In multivariate analyses, cancer survivors who were female, were married, were of a race/ethnicity other than White, or were in poor health were more likely to have an informal caregiver. Conclusions: Future research can examine whether those without informal caregivers might need more formal support as they undergo cancer treatment and transition into cancer survivorship. In the first known national study of US cancer survivors who are currently in treatment or have gone through treatment less than 3 years ago, 55.2% report having an informal caregiver. Cancer survivors who are female, are married, are of a race/ethnicity other than White, or are in poor health are more likely to have an informal caregiver. [ABSTRACT FROM AUTHOR]

Objective: To describe medication-related quality of care (MRQOC) for Australian aged care residents.Design: Retrospective cohort using an administrative healthcare claims database.Setting: Australian residential aged care.Participants: A total of 17 672 aged care residents who were alive at 1 January 2013 and had been a permanent resident for at least 3 months.Main Outcome Measures: Overall, 23 evidence-based MRQOC indicators which assessed the use of appropriate medications in chronic disease, exposure to high-risk medications and access to collaborative health services.Results: Key findings included underuse of recommended cardiovascular medications, such as the use of statins in cardiovascular disease (56.1%). Overuse of high-risk medications was detected for medications associated with falls (73.5%), medications with moderate to strong anticholinergic properties (46.1%), benzodiazepines (41.4%) and antipsychotics (33.2%). Collaborative health services such as medication reviews were underutilised (42.6%).Conclusion: MRQOC activities in this population should be targeted at monitoring and reducing exposure to antipsychotics and benzodiazepines, improving the use of preventative medications for cardiovascular disease and improving access to collaborative health services. Similarity of suboptimal MRQOC between Australia and other countries (UK, USA, Canada and Belgium) presents an opportunity for an internationally collaborative approach to improving care for aged care residents. [ABSTRACT FROM AUTHOR]

Global prevalence of nutraceuticals is noticeably high. The American market is flooded with nutraceuticals claiming to be of natural origin and sold with a therapeutic claim by major online retail stores such as Amazon and eBay. The objective of this commentary is to highlight the possible problems of online-sold nutraceuticals in the United States with respect to claim, adulterants, and safety. Furthermore, there is a lack of strict regulatory laws governing the sales, manufacturing, marketing, and label claims of nutraceutical formulations currently sold in the U.S. market. Major online retail stores and Internet pharmacies aid the widespread sale of nutraceuticals. Finally, according to the literature, many of these products were found to be either counterfeit or adulterated with active pharmaceutical ingredients (API) and mislabeled as being safe and natural. Therefore, regulatory authorities along with the research community should intervene to draw attention to these products and their possible effects. [ABSTRACT FROM AUTHOR]

An important component of hypertension management is the initiation and continuation of antihypertensive medications. Non-adherence during the long-term use of antihypertensive medications is well studied. However, there is a paucity of research about the frequency and clinical consequences of failing to take the first dose of an antihypertensive, a treatment challenge known as initial medication non-adherence (IMN). This systematic literature review summarizes the published evidence from 2010 to 2019 on the prevalence, associated factors, consequences, and solutions for IMN to antihypertensive medications in the United States. Of the fifteen studies identified, nine studies reported the prevalence of IMN, two studies examined patient-reported reasons for IMN, and four studies evaluated interventions aimed to lower IMN. It is estimated that 5-34% of patients do not obtain their new antihypertensive medications. Factors and reasons cited include patient demographics, patient beliefs or perceptions about medications, cost or financial barriers, and clinical characteristics, such as a new hypertension diagnosis or higher co-morbid disease burden. The clinical, economic, and patient-reported outcomes of IMN are not well researched. In addition, interventions to address IMN have yielded inconsistent results. Significant opportunities exist for further research into this dimension of patient behavior to better understand and address IMN to new antihypertensive medications., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background and Objectives: Previous research has been inconclusive about whether opioid-dependent patients with psychiatric comorbidities have shorter treatment retention and higher relapse rates. This study aims to evaluate the impact of mental health comorbidities on adherence to buprenorphine using a large, national health insurance claims data base.Methods: We used MarketScan® data from 2012 to 2014 to perform this analysis. Inclusion criteria included all patients with an opioid use disorder-related ICD-9 code who had been prescribed buprenorphine (n = 2947). Medication adherence was defined using the Medication Possession Ratio ≥.8 (MPR) and logistic regression was used to examine the association between medication adherence and mental health diagnoses, which included Alzheimer's/dementia, schizophrenia, other psychosis, major depressive disorder/bipolar disorder (MDDBP), anxiety disorder, personality disorder, and mental health disorder not elsewhere specified (NOS).Results: Of the 2947 patients included in our analysis, the most common diagnoses were anxiety disorder: n = 648 (22.0%), MDDBP: n = 467 (15.9%), and mental health disorder NOS: n = 959 (32.5%). Patients diagnosed with MDDBP were significantly less likely to adhere to opioid pharmacotherapy (OR = .805, 95%CI = .651, .994) than patients without MDDBP.Conclusions and Scientific Significance: The presence of a psychiatric comorbidity can significantly affect adherence to buprenorphine. These trends illustrate the need for clinicians treating opioid use disorder with buprenorphine to screen for psychiatric disorders and monitor their medication adherence. There may also be opportunities to design interventions to help this vulnerable population adhere to buprenorphine and other forms of opioid pharmacotherapy. (Am J Addict 2017;26:859-863). [ABSTRACT FROM AUTHOR]

Abstract: Limited evidence exists regarding the relationships between adherence, as defined in Pharmacy Quality Alliance (PQA) medication adherence measures, health care utilization, and economic outcomes. PQA adherence measures for hypertension, cholesterol, and diabetes are of particular interest given their use in Medicare Star Ratings to evaluate health plan performance.The objective of this study was to assess the relationship between adherence and utilization and cost among Medicare Supplemental beneficiaries included in the aforementioned PQA measures over a 1-year period.Retrospective cohort study.Three cohorts (hypertension, cholesterol, and diabetes) of eligible individuals from the Truven Health MarketScan Commercial Claims and Encounters Research Databases (2009-2015) were used to assess associations between adherence and health care expenditure and utilization for Medicare Supplemental beneficiaries.Generalized linear models with log link and negative binomial (utilization) or gamma (expenditure) distributions assessed relationships between adherence (≥80% proportion of days covered) and health care utilization and expenditure (in 2015 US dollars) while adjusting for confounding variables. Beta coefficients were used to compute cost ratios and rate ratios.Adherence for all 3 disease cohorts was associated with lower outpatient and inpatient visits. During the 1-year study period, adherence was associated with lower outpatient, inpatient, and total expenditures across the cohorts, ranging from 9% lower outpatient costs (diabetes cohort) to 41.9% lower inpatient costs (hypertension cohort). Savings of up to $324.53 per member per month in total expenditure were observed for the hypertension cohort.Our findings indicate adherence is associated with lower health care utilization and expenditures within 1 year., Competing Interests: Patrick J. Campbell, David R. Axon, Ann M. Taylor, Terri Warholak, and Chanadda Chinthammit, all received funding from Pharmacy Quality Alliance, Merck Sharpe & Dohme Corp., and Tabula Rasa HealthCare Group. Patrick J. Campbell is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ. Matthew Pickering was formerly with the Pharmacy Quality Alliance. Heather Black is an employee of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ. Chanadda Chinthammit is an employee of Eli Lilly and Company. Patrick J. Campbell and Chanadda Chinthammit completed this work during their employment at the University of Arizona. Karen Smith has no conflicts of interest to declare., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: Although antimuscarinics form the first-line therapy in overactive bladder (OAB), little is known regarding antimuscarinic discontinuation among OAB patients in nursing homes. This study examined treatment patterns and predictors of antimuscarinic discontinuation among long-term nursing home (LTNH) residents with OAB., Methods: The study cohort included LTNH residents (defined as residents staying ≥ 101 consecutive days) from the Minimum Data Set linked 2013-2015 Medicare claims data. Patients with OAB were defined by OAB-related claims and medication codes. Treatment patterns and discontinuation (medication gap ≥ 30 days) were characterized by examining OAB-specific antimuscarinics prescribed during LTNH stays. The Andersen Behavioral Model was used to identify predisposing, enabling and need factors that predict discontinuation. Kaplan-Meier curves and multivariable Cox proportional hazards regression model were used to assess the unadjusted and adjusted times to discontinuation, respectively, among different antimuscarinics., Results: The mean age of the study cohort (n = 11,012) was 81.6 years (± 8.5), 74.6% were female, and 89.8% were non-Hispanic White. The mean duration of nursing home stay was 530.1 (± 268.4) days. The most commonly prescribed OAB-specific antimuscarinic was oxybutynin (69.8%). Overall, 66.5% of the study cohort discontinued the index antimuscarinic. Multivariable Cox PH regression analysis revealed that compared to LTNH residents who initiated treatment with oxybutynin, treatment discontinuation was lower with solifenacin or fesoterodin and discontinuation was more frequent when treatment was initiated with tolterodine, darifenacin or trospium compared with oxybutynin. In addition, several need factors (comorbidities, medication use and anticholinergic burden, etc.) were associated with antimuscarinic discontinuation., Conclusion: About  two-thirds of LTNH residents with OAB discontinued their index antimuscarinic during their nursing home stay. There was significant variation in discontinuation based on the index antimuscarinic agent with lowest risk of discontiuation with solifenacin and fesoterodin. Concerted efforts to optimize antimuscarinic use are needed to improve the management of OAB in nursing homes.

Objective. Approximately one third of patients with diabetic peripheral neuropathy (DPN) also experience neuropathic pain, resulting in a significant health care burden, and reduced quality of life. Pregabalin, duloxetine, and tapentadol extendedrelease are approved for treating diabetic peripheral neuropathic pain (DPNP), but many other medications are commonly used "off-label" with various degrees of success. We examined US health insurance claims to determine the current DPNP treatment patterns. Methods. This retrospective analysis used the MarketScan claims database to identify adults with continuous health plan enrollment for 12 months preand postindex who were initially diagnosed with DPN between 2006 and 2011 and were provided a prescription for a medication reported to be beneficial for treating DPNP (anticonvulsants, antidepressants, opioids, or topical agents). We evaluated the frequency and types of medication dispensed within 1 year after first diagnosis, treatment adherence, and patterns of treatment alteration. Results. Overall, 12,074 patients met inclusion criteria, with 66.6% initiating an anticonvulsant (gabapentin 45.0%; pregabalin 21.6%), and 5.2% initiating duloxetine. Patients commonly received less than the recommended dose of prescribed medication, and adherence was suboptimal for all treatments. It is estimated that up to 50% of patients discontinued their initial treatment within 3 months of initiation. Conclusions. Newly diagnosed patients with DPNP are most commonly prescribed anticonvulsants. Many patients receive lower than recommended dosages, potentially resulting in poor outcomes. Initial treatments are frequently discontinued, indicating low levels of satisfaction and/or poor tolerability. New therapies with improved efficacy and better tolerability are urgently needed for DPNP. [ABSTRACT FROM AUTHOR]

Background medication adherence is one determining factor of treatment success. Poor medication adherence mitigates optimum clinical benefits and increases total health care costs. Current evidence suggests that for population-based adherence interventions to be effective, a multidisciplinary, multifactorial approach that can be tailored for each individual should be adopted. In the United States, national organizations such as the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services include medication adherence as a metric of health care system performance Aim of the Commentary This article provides an overview of efforts at Kaiser Permanente Colorado to impact medication adherence-related metrics. Described interventions are supported by electronic data gathering processes with an emphasis on the role of pharmacists. [ABSTRACT FROM AUTHOR]

This study evaluated the relationships between compliance with oral hypoglycemic agents and health care/short-term disability costs in a large manufacturing company. The retrospective analysis used an observational cohort drawn from active employees of Ford Motor Company. The study population consisted of 4978 individuals who were continuously eligible for 3 years (between 2001-2007) and who received a prescription for an oral hypoglycemic agent during that time. Medical, pharmacy, and short-term disability claims data were obtained from the University of Michigan Health Management Research Center data warehouse. Pharmacy claims/refill data were used to calculate the proportion of days covered (PDC); an individual was classified as compliant if his/her PDC was ≥80%. Model covariates included age, sex, work type, and Charlson comorbidity scores. The impact of compliance on disability and health care costs was measured by comparing the costs of the compliant with those of the noncompliant during a 1-year follow-up. Among these employees, compliant patients had lower medical, higher pharmacy, and lower short-term disability costs than did the noncompliant. After adjusting for demographics and comorbidity, noncompliance was associated with statistically higher short-term disability costs ($1840 vs. $1161, P<0.0001), longer short-term disability duration, and an increase in short-term disability incidence (21.5% of the noncompliant had a claim compared to 16.0% of the compliant, P<0.0001). These results suggest that medication compliance may be important in curtailing the rise of health care/disability costs in the workplace. Employers concerned with the total costs associated with diabetes should not overlook the impact of compliance on short-term disability. ( Population Health Management 2014;17:35-41) [ABSTRACT FROM AUTHOR]

Objectives: To estimate the rate of and risk factors associated with cost-related medication nonadherence among older adults., Design: Cross-sectional analysis of the 2017 National Health Interview Survey (NHIS)., Setting: Nationally representative health interview survey in the United States., Participants: Survey respondents, aged 65 years or older (n = 5701 unweighted) in the 2017 wave of the NHIS., Measurements: Self-reported, cost-related medication nonadherence (due to cost: skip dose, reduce dose, or delay or not fill a prescription) and actions taken due to cost-related medication nonadherence (ask for lower-cost prescription, use alternative therapy, or buy medications from another country) were quantified. We used a series of multivariable logistic regression analyses to identify factors associated with cost-related medication nonadherence. We also reported analyses by chronic disease subgroups., Results: In 2017, 408 (6.8%) of 5901 older adults, representative of 2.7 million older adults nationally, reported cost-related medication nonadherence. Among those with cost-related medication nonadherence, 44.2% asked a physician for lower-cost medications, 11.5% used alternative therapies, and 5.3% bought prescription drugs outside the United States to save money. Correlates independently associated with a higher likelihood of cost-related medication nonadherence included: younger age, female sex, lower socioeconomic levels (eg, low income and uninsured), mental distress, functional limitations, multimorbidities, and obesity (P < .05 for all). Similar patterns were found in subgroup analyses., Conclusion: Cost-related medication nonadherence among older adults is increasingly common, with several potentially modifiable risk factors identified. Interventions, such as medication therapy management, may be needed to reduce cost-related medication nonadherence in older adults. J Am Geriatr Soc 67:2463-2473, 2019., (© 2019 The American Geriatrics Society.)

Siliciclastic intervals in Lower Permian carbonate-siliciclastic cyclothems in western Kansas record climate control on facies progression, deposition and preservation. The 26 000 km2 study area comprises seven marine-continental (carbonate-siliciclastic) cyclothems caused by glacioeustasy. Core data and a three-dimensional geological model provide a detailed view of the sub-surface on a gently sloping ramp. Siliciclastic intervals in the cyclothems are fine-grained red beds with extensive pedogenic features, indicating a continental origin. Bed geometry (sheet-like deposits that thin to the east), lateral grading, grain size (very fine-grained sand to silt) and grain angularity (sub-angular to angular) suggest that the sediment is loess sourced from the west, probably the Ancestral Rocky Mountains. There is a repeated record of glacial-cycle-scale, climate-controlled cyclicity within siliciclastic intervals that has not been recognized previously. Aeolian silt grain size coarsens upward towards the middle, then fines upward in each siliciclastic interval. When sea-level was high (interglacial) and carbonate production flourished, aeolian sedimentation nearly ceased, suggesting increased vegetation and rainfall at the source. As sea-level fell, fine-grained siliciclastic sediments were deposited under relatively dry, but seasonally wet conditions on an exposed ramp. Laterally graded coarser grained siliciclastic sediments with diagnostic fabrics indicate drier conditions with seasonal rainfall during a continued relative fall in sea-level. The coarsest siliciclastic sediments were deposited during the lowest sea-level and driest conditions, but still with sufficient seasonal moisture to allow vegetative cover and bioturbation. Subsequent upward fining is correlated with sedimentological indications of wetter conditions during relative sea-level rise. Unlike common sequence stratigraphic models that relate siliciclastic sediment accumulation to base-level rise, continental deposits were preserved because plants and pedogenesis stabilized aeolian sediment. The aggradational landscape formed by this process had several metres of positive relief that reduced accommodation for overlying marine carbonate strata. Thus, this mechanism for continental siliciclastic aggradation has a significant effect on sequence stratigraphic architecture. [ABSTRACT FROM AUTHOR]

Summary: This study evaluated whether patients treated with bisphosphonates in the US Military Health System were more compliant with treatment given monthly versus weekly. While medication compliance did improve with treatment given monthly, overall compliance with bisphosphonates was still suboptimal suggesting the need for further strategies to improve compliance with treatment for osteoporosis. Introduction: The study objective was to evaluate the relationship between bisphosphonate dosing interval and medication compliance among new users initiating oral bisphosphonates. Methods: We conducted a retrospective observational cohort study of administrative claims data in the US Military Health System to examine medication compliance among 22,363 new users of oral bisphosphonates starting weekly (68%) or monthly (32%) therapy. Medication compliance during the first year of treatment was measured using two methods: (1) medication possession ratio (MPR) with compliance defined as ≥80% of days covered and (2) time to first gap of more than 30 days following initiation. Logistic regression and a proportional hazards model were used to detect differences in medication compliance between cohorts. Results: After the first year of therapy, 57% of subjects were not compliant with bisphosphonates (MPR <80%), while 84% experienced a gap in treatment of more than 30 days. After adjustment for study covariates, the odds of a patient being compliant with treatment was 21% higher among monthly users compared to weekly users (OR 1.207, 95% confidence interval (CI) 1.119-1.257). Similarly, the risk of experiencing a 30-day gap in treatment was 6% lower among monthly users compared to weekly users (HR 0.934, 95% CI 0.905-0.964). Conclusions: Patients receiving oral bisphosphonates on a monthly basis showed higher rates of medication compliance compared to weekly dosing in our study. However, compliance with bisphosphonates among all new users was suboptimal, suggesting the need for improved strategies to enhance compliance with oral bisphosphonates in the US Military Health System. [ABSTRACT FROM AUTHOR]

Background: Electronic monitoring devices (EMDs) are regarded as the "gold standard" for assessing medication adherence in research. Although EMD data provide rich longitudinal information, they are typically not used to their maximum potential. Instead, EMD data are usually combined into summary measures, which lack sufficient detail for describing complex medication-taking patterns. This paper uses recently developed methods for analyzing EMD data that capitalize more fully on their richness. Methods: Recently developed adaptive statistical modeling methods were used to analyze EMD data collected with medication event monitoring system (MEMS™) caps in a clinical trial testing the effects of motivational interviewing on adherence to antihypertensive medications in a cohort of hypertensive African-Americans followed for 12 months in primary care practices. This was a secondary analysis of EMD data for 141 of the 190 patients from this study for whom MEMS data were available. Results: Nonlinear adherence patterns for 141 patients were generated, clustered into seven adherence types, categorized into acceptable (for example, high or improving) versus unacceptable (for example, low or deteriorating) adherence, and related to adherence self-efficacy and blood pressure. Mean adherence self-efficacy was higher across all time points for patients with acceptable adherence in the intervention group than for other patients. By 12 months, there was a greater drop in mean post-baseline blood pressure for patients in the intervention group, with higher baseline blood pressure values than those in the usual care group. Conclusion: Adaptive statistical modeling methods can provide novel insights into patients' medication-taking behavior, which can inform development of innovative approaches for tailored interventions to improve medication adherence [ABSTRACT FROM AUTHOR]

Background: Poor adherence is estimated to cause 125 thousand deaths per year and is linked to 10% of all hospital stays in the U.S. Up to one third of elderly hypertensive patients don't have adherence, which is responsible for high proportion of hospitalizations. Hypertension is also related to poor performance in tests that assess cognitive functions. On the other hand, poor cognitive performance is associated with low adherence to treatment. Objective: To assess the association between cognitive function, anxiety and psychiatric disorders with adherence to drug treatment in patients with hypertension. Methodology and Principal Findings: This a cohort studies with 56 adult patients with uncontrolled hypertension who participated of all meetings of a pharmaceutical intervention in a randomized clinical trial of pharmaceutical care. Cognitive function was measured by the Mini Mental State Examination (Mini-mental). The memory was measured by digit and word spans, tower and church shadow test, short story test and metamemory. Anxiety and psychiatric disorders were evaluated by the State Trace Anxiety Inventory and the Self-Report Questionnaire, respectively. The participants were classified as adherent or non-adherent to the drug treatment, according to the identification of plasma levels of hydrochlorothiazide. All non-adherent patients (n = 12) and 35 out 44 (79.5%) patients with adherence to treatment had at least one memory test with an altered score (P = 0.180). Participants with an unsatisfactory score in the Mini-mental had six-fold higher risk of non-adherence to treatment when compared to those with a normal score (RR = 5.8; CI 95%: 1.6-20.8; P = 0.007). The scores of anxiety and psychiatric disorders were not associated with adherence to the pharmacological treatment. Conclusion: Cognitive deficit impairs adherence to drug therapy and should be screened as part of a program of pharmaceutical care to improve adherence to treatment. [ABSTRACT FROM AUTHOR]

Over 485,000 people in the United States have chronic kidney disease, a progressive kidney disease that may lead to hemodialysis. Hemodialysis involves a complex regimen of treatment, medication, fluid, and diet management. In 2005, over 312,000 patients were undergoing hemodialysis in the United States. Dialysis nonadherence rates range from 8.5% to 86%. Dialysis therapy treatment nonadherence, including treatment, medication, fluid, and diet nonadherence, significantly increases the risk of morbidity and mortality. The purpose of this paper is to systematically review randomized-controlled trial intervention studies designed to increase treatment, medication, fluid, and diet adherence in adult hemodialysis patients. A search of Cumulative Index of Nursing and Allied Health Literature (CINAHL) (1982 to May 2008), MEDLINE (1950 to May 2008), PsycINFO (1806 to May 2008), and all Evidence-Based Medicine (EBM) Reviews (Cochran DSR, ACP Journal Club, DARE, and CCTR) was conducted to identify randomized-controlled studies that tested the efficacy of interventions to improve adherence in adult hemodialysis patients. Eight randomized-controlled trials met criteria for inclusion. Six of the 8 studies found statistically significant improvement in adherence with the intervention. Of these 6 intervention studies, all studies had a cognitive component, with 3 studies utilizing cognitive/behavioral intervention strategies. Based on this systematic review, interventions utilizing a cognitive or cognitive/behavioral component appear to show the most promise for future study. [ABSTRACT FROM AUTHOR]

OBJECTIVES:No community-based, large-scale studies have examined the extent of prescribing acid-reducing medications or adherence and persistence to these medication regimens.METHODS:We conducted a retrospective cohort study of patients with Barrett's esophagus (BE) and gastroesophageal reflux disease (GERD) without BE, diagnosed between 2000 and 2005, who had undergone an upper endoscopy within 1 year through a managed care plan in the United States. We identified filled prescriptions for oral proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) within 365 days after the index date of BE or GERD, and several measures of adherence (medication-ownership ratio (MOR)) and persistence (length of therapy, fill–refill ratio, discontinuation rate) for PPI treatment.RESULTS:We identified 10,159 patients with BE and 48,965 GERD patients with no BE. The mean duration of filled PPI prescriptions accounted for only 30.2% of the available year after the index date, whereas that of either PPI or H2RA prescriptions accounted for only 31.7%. PPI prescriptions were filled by 66.6 and 60.4% of patients with and without BE, respectively. These proportions declined significantly between 2000 and 2005. For those with at least one prescription, the median duration of therapy was 241 days for PPIs and 159 for H2RAs. Both groups had low MOR and length of treatment and high discontinuation rates; however, adherence and persistence were significantly higher in BE than in non-BE patients, and significantly lower in 2005 than in 2000.CONCLUSIONS:The use of prescription PPIs or H2RAs, as well as adherence and persistence with these medications, is lower than expected. The absence of BE and more recent diagnosis are associated with even lower prescription rates. [ABSTRACT FROM AUTHOR]

To study the impact of nonadherence to antiepileptic drugs (AEDs) on health care utilization and direct medical costs in a Medicaid population. A retrospective cohort design was employed using state Medicaid claims data from Florida, Iowa, and New Jersey during the period from January 1997 to June 2006. Patients aged ≥18 years with one or more neurologist visit with an epilepsy diagnosis and two or more pharmacy claims for AEDs were included. Medication possession ratio (MPR) was used to evaluate AED adherence with MPR ≥ 0.80 considered adherent and <0.80 considered nonadherent. The association of nonadherence with utilization outcomes [hospitalizations, inpatient days, emergency department (ED), and outpatient visits] was assessed with univariate and multivariate Poisson regressions. Quarterly per-patient inpatient, outpatient, ED, and pharmacy costs were calculated across nonadherent and adherent quarters for the younger than 65 population (under-65) and cost differences were computed. Adjusted incremental costs of nonadherence were estimated with multivariate Tobit regression models. A total of 33,658 patients were included (28,470 under-65), together contributing 388,564 treated quarters (26% nonadherent). In multivariate analyses, AED nonadherence was associated with significantly higher incidence of hospitalizations [incident rate ratio (IRR) = 1.39, 95% confidence interval (CI) = 1.37–1.41], inpatient days (IRR = 1.76, 95% CI = 1.75–1.78), and ED visits (IRR = 1.19, 95% CI = 1.18–1.21). Nonadherence was associated with cost increases related to serious outcomes, including inpatient ($4,320 additional cost per quarter, 95% CI = $4,077–$4,564) and ED services ($303 additional cost per quarter, 95% CI = $273–$334), but lower costs for outpatient and pharmacy services, likely because of nonadherent behavior. Nonadherence to AEDs appears to be associated with serious outcomes, as evidenced by increased utilization and costs of inpatient and ED services. [ABSTRACT FROM AUTHOR]

In the US, the Medicare Modernization Act of 2003 required that Medicare Part D insurers provide medication therapy management (MTM) services ( MTMS) to selected beneficiaries, with the goals of providing education, improving adherence, or detecting adverse drug events and medication misuse. These broad goals and variety in MTM programmes available make assessment of these programmes difficult. The objectives of this article are to review the definitions of MTMS proposed by various stakeholders, and to summarize and evaluate the outcomes of MTMS consistent with those that may be offered in Medicare Part D or reimbursed by State Medicaid programmes. MTM programmes are approved by the Centers for Medicare and Medicaid Services (CMS). Pharmacy, medical and insurance organizations have provided guidelines and definitions for MTM programmes, distinguishing them from other types of community pharmacy activities. MTM has been distinguished from disease state management because of the focus on medications and multiple conditions. It differs from patient counselling because it is delivered independent of dispensing and involves collaboration with patients and providers. There is no consensus on the recommended mode of delivery (i.e. face-to-face or by telephone) for MTM. A MEDLINE search was conducted to identify articles published after 2000 using the search terms 'medication therapy management' and "medication management". Studies with outcomes evaluating community-based programmes consistent with MTMS, regardless of MTMS reimbursement source, were included in the review. Seven publications describing four MTMS were identified. For each of the identified articles, we describe the study design, service setting, inclusion criteria and outcomes. An additional three surveys describing multiple MTMS were identified and are summarized. Finally, ongoing efforts by CMS to evaluate the success of MTMS in the US are described. To dale, there are limited outcomes available for MTMS. The wide variety of MTMS offered means that evaluations of individual programmes are necessary. Despite the potential benefits of MTMS, there are numerous challenges to providing MTMS, including reimbursement, justification of the service and stakeholder acceptance of the services, There remains a need for adequately funded, prospective, controlled studies of MTM programmes using strong designs to advance our knowledge of the effectiveness of various interventions and methods of delivery, and for naturalistic studies assessing the impact of CMS approved MTM programmes. [ABSTRACT FROM AUTHOR]

The article focuses on the importance of preconception counseling (PC) for women with type 2 diabetes in the U.S. The American Diabetes Association (ADA) recommends that PC should include the risks of congenital malformations and the use of contraception. Based on several studies, 62% of women with type I diabetes received PC. According to a study, women with type II diabetes who seek PC are older, more obese and non-Caucasian.

The article examines the ways of preventing occupational exposure to antineoplastic drugs in health care settings in the U.S. Government agencies released safety guidelines to protect healthcare workers from the drugs' harmful effects. The National Institute for Occupational Safety and Health promoted a program that urged safe handling of the medications during their use.

The article explores the economic costs of acute otitis media (AOM) and the microbiology shift with a focus on appropriate antibiotic selection in the post-heptavalent pneumococcal conjugate vaccine (PCV7) era. Total annual costs of AOM in the U.S. are estimated to range from $1.4 billion to $4.1 billion. The shift in AOM microbiology has led to three meaningful changes in AOM etiology. In vitro and in vivo data are needed when evaluating different antibiotics for AOM. Amoxicillin, because of its low cost and proven safety, is still considered the first-line therapy for uncomplicated AOM in all major guidelines. Amoxicillin/clavulanate, unlike amoxicillin, has significant activity against β-lactamase-producing Haemophilus influenzae.

Background Self-management programs have been widely reported to help patients manage symptoms and contain utilization of health care resources for several chronic conditions, but to date no systematic review across multiple chronic diseases has been reported. We evaluated the efficacy of patient self-management educational programs for chronic diseases and critically reviewed their methodology. Methods We searched MEDLINE and HealthSTAR for the period January 1, 1964, through January 31, 1999, then hand searched the reference section of each article for other relevant publications. We included studies if a self-management education intervention for a chronic disease was reported, a concurrent control group was included, and clinical outcomes were evaluated. Two authors reviewed each study and extracted the data on clinical outcomes. Results We included 71 trials of self-management education. Trial methods varied substantially and were suboptimal. Diabetic patients involved with self-management education programs demonstrated reductions in glycosylated hemoglobin levels (summary effect size, 0.45; 95% confidence interval [CI], 0.17-0.74); diabetic patients had improvement in systolic blood pressure (summary effect size, 0.20; 95% CI, 0.01-0.39); and asthmatic patients experienced fewer attacks (log rate ratio, 0.59; 95% CI, 0.35-0.83). Although we found a trend toward a small benefit, arthritis self-management education programs were not associated with statistically significant effects. Evidence of publication bias existed. Conclusions Self-management education programs resulted in small to moderate effects for selected chronic diseases. In light of evidence of publication bias, further trials that adhere to a standard methodology would help clarify whether self-management education is worthwhile. [ABSTRACT FROM AUTHOR]

The fastest growing marital status category in America is divorced, with the number of divorced individuals quadrupling between 1970 and 1996. The majority of children in divorced families live with a single parent and often lose contact with the noncustodial parent. A recent review of the literature suggests that many noncustodial fathers fail to keep contact with their children and become delinquent in child support payments because of their dissatisfaction with the custody arrangement. However, there has been little examination of how custody arrangements are typically determined or settled. In addition, divorces that involve spousal violence bring further complications to child custody, visitation, and child support decisions. This study included a 20% random sample of court records for all divorces settled in one county judicial circuit court during 1998. The purpose of this study was to examine characteristics of divorcing adults as well as characteristics of child custody arrangements, visitation, and child support decisions. Contrary to popular belief, findings from this study indicate that divorce actions were almost always settled through agreement of the divorcing parties rather than by adjudication. About 38% of the couples had children in common and between 78 and 92% of cases were settled through agreement, which suggests that fathers are in fact agreeing to the custody arrangement, rather than being forced into it. About one in five records overall noted spousal violence, and there was no significant difference in settlement methods for couples with or without spousal violence. Cases with children and spousal violence were significantly more likely to have also mentioned substance use and postdecree activity. This study suggests a need for more focused attention on divorce cases with spousal violence to reduce postdecree court involvement and safety of children and adult victims, as well as further study into what causes noncustodial parents to lose contact with their children. [ABSTRACT FROM AUTHOR]