To determine the extent of potentially inappropriate outpatient prescribing for elderly patients, as defined by the Beers criteria, Curtis and colleagues conducted a retrospective cohort study using the prescription claims database of a large, national pharmaceutical benefit manager. Among 765 423 elderly subjects in the database who filed 1 or more claims during 1999, 21% filled a prescription for 1 or more drugs of concern, more than 15% filled prescriptions for 2 drugs of concern, and 4% filled prescriptions for 3 or more of the drugs within the same year. The most commonly prescribed classes were psychotropic drugs and neuromuscular agents. The common use of potentially inappropriate drugs should serve as a reminder to monitor their use closely.
Noninvasive diagnostic testing for significant coronary artery disease (CAD) appears to be less accurate in women than in men. If a woman has a low to intermediate likelihood of CAD, has a normal baseline electrocardiogram (ECG), and is able to exercise, then either an exercise treadmill test or treadmill stress echocardiography are appropriate initial diagnostic tests. Exercise radionuclide studies or exercise echocardiography are preferred for women with an abnormal baseline ECG or those who have undergone revascularization. An electron beam computed tomographic scan with a 0 calcium score can help rule out obstructive CAD. A score greater than 0 can also be used in predicting posttest probability of disease in women.
Seventy-one trials of self-management education for chronic diseases were assessed. Trial methods varied substantially and were suboptimal. Patients with diabetes who were involved with self-management education programs demonstrated significant reductions in glycosylated hemoglobin level, patients with diabetes had small but significant improvement in systolic blood pressure, and patients with asthma experienced significantly fewer attacks. While there was a trend toward a small benefit, arthritis self-management education programs were not associated with statistically significant effects. There was evidence for publication bias.
Deep venous thrombosis (DVT) is a common complication in the clinical course of patients with cancer. The medical records of 529 consecutive cancer patients with DVT were reviewed for outcomes and costs, which are largely undescribed in this population. Bleeding occurred in 12.5% of patients, and pulmonary embolus in 4.3%. Ten patients (1.9%) died from the DVT or from its treatment. The most common serious clinical outcome was recurrence, which occurred in 17.2% of patients. The risk of recurrence was almost doubled (32%) among patients with inferior vena cava filters. The mean cost of hospitalization for DVT was $20 065 in 2002 US dollars. The frequency of serious clinical outcomes and the high cost of therapy of DVT warrant development of more effective agents and less costly management strategies.
Hormone therapy (HT) provides the most effective relief of menopausal symptoms but increases the risks of cardiovascular disease (CVD), venous thrombosis, and breast cancer. Col and colleagues developed a Markov model to identify which women should benefit from short-term HT, using findings from the Women's Health Initiative. Short-term HT is associated with small losses in survival but gains in quality-adjusted life expectancy (QALE) among women with estrogen-responsive menopausal symptoms. Among women at low CVD risk, HT extended QALE if menopausal symptoms lowered quality of life by as little as 4%. Among women at elevated CVD risk, HT extended QALE only if symptoms lowered quality of life by at least 12%.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2004;164(15):1599. doi:10.1001/archinte.164.15.1599