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Relationship between Warfarin Use and Characteristics of Long-Term Care (LTC) Residents with Atrial Fibrillation (AF)
Results: Under the new guideline, insulin dollar purchases in pen delivery systems increased from under 1% of total insulin purchases to 32% over the period from July 2009 to June 2010 (based on linear fit of monthly values). Cost per day for all products declined from $13.00 to $9.50 over the 12 month period. The mean cost per day for pen-only users was $7.04 and $11.79 for vial-only users. The regression analysis across nursing facilities showed a high correlation (R 5 0.47, P \ .01) between percent of pen utilization and lower cost per day. Based on the linear fit, the cost per day decreased from $14.10 to $5.84 as pen utilization increased from zero to 100%. Conclusion/Discussion: Higher insulin pen utilization in Medicare patients with length of stay 30 days or less was associated with a marked decrease in cost per day for four basal and short acting insulin products. Disclosures: Gary R. Bazalo, MS, MBA and Richard C. Weiss, MS are consultants to Novo Nordisk. Jon R. Bouchard, MS, RPh is an employee of Novo Nordisk. All other authors have stated there are no disclosures to be made that are pertinent to this abstract. Relationship between Warfarin Use and Characteristics of Long-Term Care (LTC) Residents with Atrial Fibrillation (AF) Presenting Author: Marjorie V. Neidecker, PhD, RN, Informagenics, LLC & The Ohio State University Author(s): Marjorie V. Neidecker, PhD, RN, Winnie Nelson, PharmD, MS, Aarti Patel, PharmD, Tommy Philpot, PharmD, CGP, FASCP; and Gregory Reardon, RPh, PhD Introduction/Objective: To evaluate the association of warfarin use with characteristics of residents across 2 LTC databases. Design/Methodology: LTC residents from 2 databases, the nationally representative National Nursing Home Survey (NNHS) 2004 and the AnalytiCareÔ multistate database, who had a current diagnosis for AF (ICD95427.3X) were studied. Additional inclusion criteria for the AnalytiCare analysis were age .18 years and the presence of a full Minimum Data Set (MDS) assessment during the period 1/1/07–6/30/08. Comorbidity, current medications, and other resident data were analyzed and potential medication interactions were identified. Potential associations between resident characteristics (demographics, physical function, stroke, and bleeding risk factors) and warfarin use were evaluated by multivariate logistic regression. Results: There were 1454 and 3757 eligible residents with AF in the NNHS and AnalytiCare databases, respectively; median ages were 85 and 83 years; 70% and 63% of residents were female, respectively. Warfarin use was recorded in 34% of NNHS residents (95% CI: 31.1–36.8%) and 45% of AnalytiCare residents (CI: 43.0–46.1%). In NNHS 71% of residents (CI: 68.1–73.4%) received any anticoagulant or antiplatelet agent, including aspirin. Factors independently and significantly associated with being prescribed warfarin in NNHSAF included: venous thromboembolism (VTE) (OR54.81, 95% CI: 2.51–9.22) and cerebrovascular accident (OR52.01, CI: 1.48–2.72); in AnalytiCare these included: VTE (OR51.91, CI: 1.36–2.68) and congestive heart failure (CHF) (OR51.42, CI: 1.24–1.64). Factors associated with not being prescribed warfarin in NNHS were: gastrointestinal (GI) bleeding (OR50.42, CI: 0.19–0.94), renal disease (OR50.45, CI: 0.23-0.90), non-Hispanic black race (OR50.51, CI: 0.28–0.92), dementia (OR50.67, CI: 0.48–0.94), and lowest activity of daily living (ADL) functioning (OR50.75, CI: 0.56–0.997); in AnalytiCare these included hospice or \6 months to live (OR50.40, CI: 0.23–0.68), residence in south central US (OR50.48, CI: 0.34–0.69), and dementia/cognitive impairment (OR50.53, CI: 0.46–0.62). GI bleeding and nonHispanic race were also significant (P\.02). One or more pharmacotherapeutic agents with a high potential for warfarin interaction were being prescribed concurrently in 59% (CI: 54.0–63.6%) of warfarin users in NNHS and 85% (CI: 82.9–86.3%) in AnalytiCare. Conclusion/Discussion:. Presence or history of VTE, previous cerebrovascular accident, or CHF were strongly associated with greater use of warfarin for LTC residents with AF. Dementia/cognitive impairment, GI bleeding, nonHispanic black race, limited life expectancy, renal disease, and south central region, were strongly associated with less use of warfarin or were significant in both databases. Concurrent use of interacting medications was common in warfarin users. Author Disclosures: Marjorie V Neidecker, PhD, RN is employee of Informagenics, LLC, which is a paid consultant for Ortho McNeil Janssen. POSTER ABSTRACTS
Dr. Winnie Nelson is employee of Johnson & Johnson and is a stockholder in the company. Dr. Aarti Patel is an employee of Johnson & Johnson. Tommy Philpot, PharmD was provided funding from Johnson & Johnson as an independent, contracted consultant for the project. Gregory Reardon, RPh, PhD is a consultant to Ortho-McNeil Janssen. Restless Leg Syndrome Masquerading as Hypersexuality Presenting Author: Ritesh Kohli, MD, Bridgeport Hospital/Yale New Haven Health System Geriatrics Author(s): Ritesh Kohli, MD, Vivian Argento, MD, Beata Skudlarska, MD, CMD, Wendy Grey, RN; and Mithil Choksey, MD Introduction/Objective: Restless leg syndrome (RLS) can occur in patients with dementia. Coexistence of dementia with restless legs makes it difficult to diagnose .This article outlines a case report in our hospital when a patient of dementia with RLS was misinterpreted as hyper sexuality. Design/Methodology: 92 year elderly male with PMH of HTN, CHF, COPD, Alzheimer’s Dementia, who is a long term care resident in Extended Care Facility was sent to ER for evaluation of behavioral disturbance on the allegation by a female resident that he attempted to sexually assault her. The nurse on the floor who responded to the female resident’s call within less than a minute found the patient standing close at the foot of the bed, appeared restless, and was attempting to stretch his legs. Due to the allegation of the assault, patient was send to ER for evaluation .In the ED, examination findings were unremarkable. MMSE was 18/30 with recent recall 0/3. Patient was alert and oriented only to place and person. Attention and concentration were normal. There is no evidence of hallucinations or paranoid ideation. The patient did not fully understand why he was brought to the ER and, when asked specifically if he had any medical complaints presently, responded that he had mild cough and cold. Investigations revealed mild anemia with mildly abnormal Kidney function. Review of systems- Collateral history obtained by nursing staff suggested that patient appears more restless at night, has difficulty falling asleep, and seen frequently wandering at night often entering other residents room requiring frequent redirection. Patients family revealed that he had a history of RLS and was started on neurontin 100 mg bid for the last 2 years but they don’t feel that it is improving his condition. Results: The RLS is characterized by (1) an urge to move the limbs, usually associated with abnormal sensations in the legs; (2) symptoms are worse at rest; (3) they are relieved by movements; (4) they mainly occur in the evening or at night. The restless legs syndrome (RLS) is a frequent, often unrecognized disorder in the elderly with dementia. Specific diagnostic criteria have been developed for cognitively impaired elderly persons where we specifically look for signs of leg discomfort such as rubbing or kneading the legs, excessive motor activity such as repetitive kicking, foot tapping and these signs exclusively present or worsen during periods of rest and diminished with activity. Diagnosis is essentially by clinical history using simple diagnostic criteria. Follow up with the nursing home staff revealed that patients leg movements had decreased although there was no complete resolution but he has decreased restless wandering at night. Conclusion/Discussion: RLS is a common overlooked disorder in dementia patients, and it may be disabling in severe cases. Older adults with dementia are unable to understand and reliably answer the RLS diagnostic interview making the diagnosis more difficult. Recognition, diagnosis and treatment offers improved quality of life and as our case demonstrates may decrease burden on nursing staff and caregivers. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Reviewing Readmissions to Hospital from a Skilled Nursing Facility Presenting Author: Catherine M. Glew, BM, BS, CMD, Lehigh Valley Health Network Author(s): Catherine M. Glew, BM, BS, CMD Introduction/Objective: As part of a Lehigh Valley Health Network (LVHN) initiative to examine causes of readmissions to hospital within B23
Dr. Winnie Nelson is employee of Johnson & Johnson and is a stockholder in the company. Dr. Aarti Patel is an employee of Johnson & Johnson. Tommy Philpot, PharmD was provided funding from Johnson & Johnson as an independent, contracted consultant for the project. Gregory Reardon, RPh, PhD is a consultant to Ortho-McNeil Janssen. Restless Leg Syndrome Masquerading as Hypersexuality Presenting Author: Ritesh Kohli, MD, Bridgeport Hospital/Yale New Haven Health System Geriatrics Author(s): Ritesh Kohli, MD, Vivian Argento, MD, Beata Skudlarska, MD, CMD, Wendy Grey, RN; and Mithil Choksey, MD Introduction/Objective: Restless leg syndrome (RLS) can occur in patients with dementia. Coexistence of dementia with restless legs makes it difficult to diagnose .This article outlines a case report in our hospital when a patient of dementia with RLS was misinterpreted as hyper sexuality. Design/Methodology: 92 year elderly male with PMH of HTN, CHF, COPD, Alzheimer’s Dementia, who is a long term care resident in Extended Care Facility was sent to ER for evaluation of behavioral disturbance on the allegation by a female resident that he attempted to sexually assault her. The nurse on the floor who responded to the female resident’s call within less than a minute found the patient standing close at the foot of the bed, appeared restless, and was attempting to stretch his legs. Due to the allegation of the assault, patient was send to ER for evaluation .In the ED, examination findings were unremarkable. MMSE was 18/30 with recent recall 0/3. Patient was alert and oriented only to place and person. Attention and concentration were normal. There is no evidence of hallucinations or paranoid ideation. The patient did not fully understand why he was brought to the ER and, when asked specifically if he had any medical complaints presently, responded that he had mild cough and cold. Investigations revealed mild anemia with mildly abnormal Kidney function. Review of systems- Collateral history obtained by nursing staff suggested that patient appears more restless at night, has difficulty falling asleep, and seen frequently wandering at night often entering other residents room requiring frequent redirection. Patients family revealed that he had a history of RLS and was started on neurontin 100 mg bid for the last 2 years but they don’t feel that it is improving his condition. Results: The RLS is characterized by (1) an urge to move the limbs, usually associated with abnormal sensations in the legs; (2) symptoms are worse at rest; (3) they are relieved by movements; (4) they mainly occur in the evening or at night. The restless legs syndrome (RLS) is a frequent, often unrecognized disorder in the elderly with dementia. Specific diagnostic criteria have been developed for cognitively impaired elderly persons where we specifically look for signs of leg discomfort such as rubbing or kneading the legs, excessive motor activity such as repetitive kicking, foot tapping and these signs exclusively present or worsen during periods of rest and diminished with activity. Diagnosis is essentially by clinical history using simple diagnostic criteria. Follow up with the nursing home staff revealed that patients leg movements had decreased although there was no complete resolution but he has decreased restless wandering at night. Conclusion/Discussion: RLS is a common overlooked disorder in dementia patients, and it may be disabling in severe cases. Older adults with dementia are unable to understand and reliably answer the RLS diagnostic interview making the diagnosis more difficult. Recognition, diagnosis and treatment offers improved quality of life and as our case demonstrates may decrease burden on nursing staff and caregivers. Disclosures: All authors have stated there are no disclosures to be made that are pertinent to this abstract.
Reviewing Readmissions to Hospital from a Skilled Nursing Facility Presenting Author: Catherine M. Glew, BM, BS, CMD, Lehigh Valley Health Network Author(s): Catherine M. Glew, BM, BS, CMD Introduction/Objective: As part of a Lehigh Valley Health Network (LVHN) initiative to examine causes of readmissions to hospital within B23