To determine whether vascular and demographic factors predict worsening disability up to 8 years after lacunar stroke.
Methods:
SPS3 (Secondary Prevention of Small Subcortical Strokes) was a clinical trial in lacunar stroke patients with annual assessment of disability using the Older Americans Resources and Survey instrumental activities of daily living (IADL) scale (range 0–14). Generalized estimating equations modeled the likelihood of disability (IADL <14) over time, adjusting for demographics, medical risk factors, cognition, mood, stroke location, and geographic region in univariate and multivariable models. IADL assessments after recurrent stroke were censored. We stratified by study region and age quartile.
Results:
Among 2,820 participants, mean age was 63.4 years (SD 10.8), 63% were male, 36% had diabetes, 90% hypertension, and 10% prior stroke. Mean follow-up was 3.7 years. In multivariable models, female sex, education, diabetes, nonregular alcohol use, prior stroke, Cognitive Abilities Screening Instrument score, depression, mild cognitive impairment, and stroke location were associated with disability. The youngest age quartile had decreased odds of disability over time (odds ratio 0.90 per year, 95% confidence interval 0.85–0.95), whereas the oldest age quartile had increased odds (2.20, 95% confidence interval 1.75–2.75). Americans and Latin Americans had >2-fold greater odds of disability per year compared with Spaniards (p < 0.0001).
Conclusions:
In lacunar stroke patients, older age was associated with worsening long-term disability, even without recurrence. Worse long-term function was associated with diabetes, cognitive status, and prior stroke, and regional differences may be attributable to variations in health care delivery or scale interpretation.
A study was made of the effect of one-to-one educational meetings between prescribers and a pharmacist on the prescribing of antiulcer agents for outpatients in a health maintenance organization (HMO). Ten-minute presentations were developed that communicated the same basic facts through the use of case studies (vivid interventions) or statistical data (nonvivid interventions). After a control group (n = 8) was selected, prescribers (n = 16) were randomly assigned to receive vivid interventions or nonvivid interventions. Data on the prescribing of cimetidine, ranitidine, and sucralfate were collected for one month before the interventions and for two months afterward. Three clinical pharmacy professors independently evaluated prescriptions for appropriateness of indication, dosage, and duration. No differences in appropriateness were found between the two intervention groups, but in the first postintervention month the mean rate of inappropriate prescribing per control practitioner was 80%, versus less than 32% for the intervention groups (p less than 0.01). Each prescription in the first postintervention month entailed a mean cost of $31 per control practitioner for inappropriate prescribing, compared with less than $12 for the intervention groups (p less than 0.01). Mean costs of inappropriate prescriptions per practitioner per patient visit were $0.88 and less than or equal to $0.41 for the control and intervention groups, respectively (p less than 0.05). During postvisit month 2, inappropriate prescribing for both intervention groups increased slightly and was no longer significantly less than that in the control group. One-to-one educational meetings improved the prescribing of antiulcer agents for outpatients in an HMO.
Objective To examine the economic impact of a home chemotherapy program (HCP) for pediatric oncology patients. Rationale Factors that led to initiation of an HCP included availability of specially trained nurses and programmable ambulatory infusion devices at local home care agencies, routine central venous catheter placement, inpatient bed space shortages, and the availability of ondansetron. Setting Chemotherapy delivery in the home setting from June 1991 through June 1994. Design Charge data and nausea and vomiting severity data were collected for patients treated through the HCP. Methods Economic impact was calculated by incorporating and summing all charge categories associated with hospital admission for chemotherapy (HAC) versus delivery by the HCP. All data were adjusted for 1993 dollars, and reflect charges for the average patient size (1 m2). Charge data for each chemotherapy protocol delivered in the home were analyzed by calculating the differences between HAC and HCP charges using the following formula: charge difference (HAC - HCP) per protocol times the number of courses. Total economic impact was calculated by summing the differences in charges for each protocol. Results A total of 262 chemotherapy courses were given to 44 patients (mean age 9.5 ± 5.1 y) through the HCP, which represented 1012 patient care days and 24 different chemotherapy protocols. Monetary savings from the HCP ranged from $5180 per course of ifosfamide plus etoposide to $367 per course for high-dose methotrexate. Total monetary savings from the HCP during the 3-year period was $640 793. Successful control of nausea and vomiting with a combination of ondansetron plus methylprednisolone was achieved in approximately 80% of the patients receiving highly emetogenic chemotherapy protocols. Conclusions HCP for pediatric oncology patients results in substantial monetary savings to payors. Effective control of nausea and vomiting can be accomplished at home in the majority of patients with an ondansetron-based antiemetic regimen.
6034 Background: The RADAR team has recently characterized the frequency, severity, clinical features and quality of reporting of gemcitabine-associated pulmonary injury. Several factors may increase severity of gemcitabine toxicity in women: mg/m2 dosing, gives a higher systemic exposure in women due to their lower lean body mass per m2. (2) women have less pulmonary reserve. (3) Women are more likely to receive combined therapy with gemcitabine and a taxane and taxanes appear to increase the severity of gemcitabine-associated lung injury. Methods: We obtained reports of gemcitabine-associated lung injury from Medwatch or the medical literature. The case definition included use of gemcitabine as cancer chemotherapy and clinical findings, laboratory evidence, or imaging studies suggestive of lung injury. We used logistic regression to analyze a data model with response variable being death and explanatory variables being female gender, age, duration of therapy, and reporting source (clinical trial, case report, spontaneous report). Results: After removal of duplicate and null reports, there were 178 patients with gemicitabine-associated lung injury. The fatality rate was 80% in women and 55% in men. Female gender was associated with death in this cohort of patients with gemcitabine-associated lung injury with a high degree of statistical significance. Conclusions: Logistic regression analysis of fatalaties among 178 patients with gemcitabine-associated lung injury found a highly statistically significant association with female gender. Comparative pharmacokinetics of gemcitabine in women and men and metaanalysis of prospectively gathered gemcitabine toxicity data is warranted. No significant financial relationships to disclose.
