Outpatient Medication Errors Common, Difficult To Detect Among Transplant Patients

Medication errors appear to be common, often hidden and associated with adverse events among patients receiving outpatient care after an organ transplant, according to a report in the March issue of Archives of Surgery, one of the JAMA/Archives journals. The health care system is involved with nearly one-third of these errors.

Medication use is increasingly common – more than 60 percent of U.S. adults ages 45 to 64 reported using at least one prescription drug during the previous month when surveyed from 1999 to 2000, according to background information in the article. Medication errors are common as well, with adverse drug events reported among 6.5 percent of hospitalized patients. “It seems logical that the additional degrees of freedom introduced in the outpatient setting by the patient, caretaker, outside pharmacy or third-party payer will result in greater confusion and error,” the authors write. “Examples of the types of serious errors anecdotally reported to date in this setting include mix-ups between sound-alike and look-alike drugs, similar looking packaging and inappropriate dosing.”

Amy L. Friedman, M.D., and colleagues at the Yale University School of Medicine, New Haven, Conn., documented medication errors that occurred among all recipients of liver, kidney and pancreas transplants who were tracked by the Yale New Haven Organ Transplantation Center between April 1, 2004, and March 31, 2005. “At every encounter, the home medication regimen is reviewed with the patient by a nurse-coordinator, physician associate or physician and compared with the regimen prescribed at the last interaction with the patient,” the authors write. Encounters include outpatient or emergency department visits, admission to the hospital or phone conversations.

During the study period, the researchers identified 149 medication errors in 93 patients, who were taking an average of 10.9 medications each. The most frequent type of error (56 percent of all errors) was patient error. An additional 13 percent of the errors were prescription errors; 13 percent were delivery errors; 10 percent were availability errors, when a patient did not have at least a 24-hour supply of a medication; and 8 percent were reporting errors, which occurred when a patient could not give the researchers enough information to identify the type, dosage, or frequency of a medication. Adverse events were associated with 48 (32 percent) of the errors, including 17 hospitalizations, three outpatient procedures, nine episodes of rejection and six failed transplants.

The researchers also pinpointed the root causes of the errors. “The root cause was defined as a specific underlying cause that can reasonably be identified, that is in the control of the transplant team to fix and for which effective recommendations for preventing recurrences could be generated,” the authors write. The root causes were identified as the patient in 68 percent of the errors, financial issues in 5 percent and health care providers in 27 percent, including 10 percent caused by the transplant team itself.

Understanding the root causes of medication errors, which often stem from communication failures, should help remove the judgmental lens through which non-adherence to drug therapies is often viewed, the authors conclude. “We should strive to continue to eliminate health care system – based errors through centralized records and other streamlining methods to improve processes. In doing so, it seems likely that our patients will gain confidence in us and our ability to help them navigate a complex and confusing system.” This will both improve patient safety and facilitate the shift from a culture of blame to a culture of prevention, they note.

###

(Arch Surg. 2007;142:278-283.)

This research was funded under a grant from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Contact: Jacqueline Weaver
JAMA and Archives Journals

LeMaitre Vascular Receives IDE Approval To Begin The ‘Unite’ UniFit Abdominal Stent Graft Pivotal Study

LeMaitre Vascular,
Inc. (Nasdaq: LMAT) today announced that it has received approval from the
United States Food and Drug Administration (FDA) for an investigational
device exemption (IDE) supplement to conduct its UNITE Aorto-Uni-Iliac
Stent Graft Clinical Trial. This pivotal study will evaluate the safety and
effectiveness of the company’s UniFit Abdominal Stent Graft in the
treatment of aorto, aorto-iliac, and/or iliac aneurysms. LeMaitre Vascular
had previously received conditional FDA approval for its IDE supplement.

“Although we had initiated two study sites based upon conditional
approval, many other hospitals, though eager to participate, have been
waiting for the FDA to remove conditions. We expect that this new approval
will help us drive enrollment through a broad range of study sites,” said
George W. LeMaitre, the company’s Chairman, President and CEO. “We believe
surgeons need a singled-body aorto-uni-iliac stent graft to help combat
aneurysmal disease and we are excited to begin implanting devices in our
pivotal study.”

LeMaitre Vascular intends to enroll 90 patients in up to 14 centers.
These patients must be followed for at least one year prior to LeMaitre
Vascular’s submission to the FDA of an application for PMA approval. The
primary effectiveness endpoint of the study is based on aneurysm exclusion
as evaluated through one-year follow-up. The UNITE study compares the
safety and efficacy of the UniFit Abdominal Stent Graft against open
surgical abdominal aorta repair, because there are currently no
aorto-uni-iliac endovascular stent grafts indicated for the primary
treatment of aorto, aorto-iliac, and/or iliac aneurysms.

The UniFit Abdominal Stent Graft is a single-bodied aorto-uni-iliac
stent graft used to treat an aortic aneurysm, a weakening and ballooning of
the aorta, through a minimally invasive endovascular procedure. The
device’s encapsulated design prevents its stents from contacting the blood
stream or the vessel wall. This design allows a wider range of stent graft
sizes, including tapered and custom grafts, to fit a wider range of patient
anatomies than many competing products. The UniFit Abdominal Stent Graft is
currently sold in the European Union and a small number of other foreign
jurisdictions and is not available for sale in the United States.

The FDA’s IDE approval applies only to the investigational use of
UniFit Abdominal Stent Grafts that have been sterilized with ethylene oxide
gas, a relatively common means of sterilizing medical devices. LeMaitre
Vascular also sterilizes its UniFit Abdominal Stent Grafts sold outside the
United States with hydrogen peroxide, a newer and generally faster means of
sterilizing medical devices. Hydrogen peroxide sterilization enables the
more rapid production of customized stent grafts. LeMaitre Vascular intends
to continue to work with the FDA to resolve their questions regarding this
method of sterilization with the intent of ultimately seeking PMA approval
of the hydrogen peroxide-sterilized UniFit Abdominal Stent Graft.

About LeMaitre Vascular

LeMaitre Vascular develops, manufactures and markets medical devices
for the treatment of peripheral vascular disease. The company’s principal
executive offices are located at 63 Second Avenue, Burlington,
Massachusetts 01803.

Certain statements set forth above that are not clearly historical in
nature are forward-looking statements within the meaning of the Private
Securities Litigation Reform Act of 1995, including, but not limited to the
likelihood and timing of enrollment in the UNITE study, the likelihood that
the UNITE study will successfully meet its endpoints, the possibility of
receiving approval for the sale of the UniFit Abdominal Stent Graft in the
Unites States, and the potential market demand in the United States for the
UniFit Abdominal Stent Graft. Although LeMaitre Vascular believes that such
statements are based on reasonable assumptions within the bounds of its
knowledge of its business and operations, these forward-looking statements
are neither promises nor guarantees. LeMaitre Vascular’s business is
subject to significant risks and uncertainties and there can be no
assurance that its actual results will not differ materially from its
expectations. These risks and uncertainties include, among others: the risk
that the results of LeMaitre Vascular’s UNITE study will be unfavorable;
the risk that these results, even if favorable, will not be accepted by the
FDA or other relevant agencies and the device will not be approved for sale
in the relevant timeframe, if at all; risks associated with LeMaitre
Vascular’s ability to successfully commercialize its UniFit Abdominal Stent
Graft in the United States if the device is approved for use in the United
States; and other risk factors that are discussed in LeMaitre Vascular’s
Annual Report on Form 10-K filed with the Securities and Exchange
Commission. The forward-looking statements made in this release are made
only as of the date hereof and LeMaitre Vascular disclaims any intention or
responsibility for updating predictions or expectations contained in this
release.

LeMaitre Vascular, Inc.
lemaitre

Scientists Discover That Widely Available Drug Also Helps Fight Kidney Disease

(Santa Barbara, Calif.) A widely available drug may be effective in treating kidney disease, report scientists at the University of California, Santa Barbara. They describe the discovery in the online edition of the Proceedings of the National Academies of Science published the week of March 20.

The drug is rapamycin, also called sirolimus, and is currently used as an immunosuppressant, to help prevent rejection of a new, transplanted kidney.

Over 600,000 people in the U.S., and 12 million worldwide, are affected by the inherited kidney disease known as ADPKD, short for autosomal dominant polycystic kidney disease. In the U.S., the number of individuals affected by ADPKD is greater than the number affected by cystic fibrosis, muscular dystrophy, hemophilia, Down’s syndrome, and sickle cell anemia combined. The disease is characterized by the proliferation of cysts that eventually debilitate the kidney, causing kidney failure in half of all patients by the time they reach age 50.

Currently no treatment exists to prevent or slow cyst formation, and most ADPKD patients require kidney transplants or life long dialysis for survival, explained Thomas Weimbs, director of the laboratory where the discovery was made. Weimbs is assistant professor in the Department of Molecular, Cellular and Developmental Biology at UCSB.

The scientists studied the effects of rapamycin on mice. “When we administered rapamycin to mice with PKD and looked at their kidneys afterwards, we were absolutely amazed,” said Weimbs. “The kidneys were smaller, had smaller cysts and had retained their function.”

“We have known the genetic mutations that cause PKD for over a decade,” explained Weimbs. “The genetic mutations are located in the gene for the polycystin-1 protein. Unfortunately, the function of polycystin-1 has remained poorly understood, which has made it difficult to devise a treatment strategy for this disease.”

Weimbs and his research team found that polycystin-1 controls an important regulatory protein called mTOR. A defect in polycystin-1 leads to over activation of mTOR. This, in turn, causes excess growth and proliferation of kidney cells, which results in the formation of thousands of cysts that eventually destroy the kidney.

Fortunately, a highly effective inhibitor of mTOR is well known. This drug, rapamycin, was originally discovered in the 1970s in soil from Easter Island. It is used for immunosuppression in kidney transplant patients to prevent rejection of the new kidney.

Weimbs and his colleagues wondered about treating kidney patients with rapamycin. Most kidney transplant patients keep their diseased kidneys in place and the transplanted kidney is an additional, third kidney. So his colleagues, David A. Goldfarb and Andrew Novick, at the Cleveland Clinic in Ohio, suggested studying transplant patients who had received rapamycin to help their bodies accept the new kidney.

The research team identified a group of four rapamycin-treated patients and found that their polycystic kidneys shrank in size by 25 percent over two years. The polycystic kidneys in a control group showed no change.

“Even though we only had a very small number of patients, this result is highly encouraging because it points in the right direction,” said Weimbs.

It shows, for the first time, a connection between polycystin-1 and mTOR, and strongly suggests that rapamycin may be a promising drug for treating PKD, explained Weimbs. “The fact that rapamycin is already clinically approved for other uses will facilitate future clinical trials of the drug.”

Co-authors on the paper with Weimbs are: Jonathan M. Shillingford and Seng Hui Low in the Department of Molecular and Cellular Biology at UCSB; Claire H. Larson at the Department of Cell Biology, Lerner Research Institute, Cleveland Clinic, Cleveland Ohio; Ryan Hedgepeth, Andrew C. Novick, and David A. Goldfarb at the Glickman Urological Institute, Cleveland Clinic, Cleveland, Ohio; Noel S. Murcia and Nicole Brown at the Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio; Chris A. Flask at the Department of Radiology and Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio; Albrecht Kramer-Zucker and Gerd Walz at the Department of Medicine, Nephrology, University Hospital Freiburg, Freiburg, Germany; Klaus B. Piontek and Gregory G. Germino at the Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md.

###

Note: Thomas Weimbs is available by email at weimbslifesci.ucsb.edu or by phone at (805) 893 4144.

Contact: Gail Gallessich
gail.gia.ucsb.edu
University of California, Santa Barbara

Statins May Be Too Risky For Those With Brain Hemorrhage History

Patients with a history of brain hemorrhage may find that the risk of recurrence is much higher than the benefits they could gain from statins, researchers from Massachusetts General Hospital and Harvard Medical School, Boston, wrote in Archives of Neurology.

The authors explained that generally, statin use has been accepted as an effective way of significantly reducing stroke and heart disease risk. However, widespread use of the drug is a controversial subject.

The researchers wrote:

“A particular subgroup of patients for whom the advisability of statin use is unclear are those at high risk for intracerebral hemorrhage (or a stroke caused by bleeding within the brain). The reason for added concern is the increased incidence of intracerebral hemorrhage observed among subjects randomized to statin therapy in a clinical trial of secondary stroke prevention.”

M. Brandon Westover, M.D., Ph.D., wrote:

“Because intracerebral hemorrhage sufferers commonly have co-morbid [co-occurring] cardiovascular risk factors that would otherwise warrant cholesterol-lowering medication, it is important to weigh the risks and benefits of statin therapy in this population.”

A Markov decision model was used by the investigators to evaluate the risks and benefits. Simulated patients, based on previous research, were assigned to states that correspond to risk of disease, and could consequently experience a range of combination of events which might lead to the raised risk of stroke or heart disease, change in quality of life, or even death.

They wrote:

“Our analysis indicates that in settings of high recurrent intracerebral hemorrhage risk, avoiding statin therapy may be preferred. For lobar intracerebral hemorrhage [bleeding in the cerebrum] in particular, which has a substantially higher recurrence rate than does deep intracerebral hemorrhage, statin therapy is predicted to increase the baseline annual probability of recurrence from approximately 14% to approximately 22%, offsetting the cardiovascular benefits for both primary and secondary cardiovascular prevention.”

The benefits and risks of using statins were more evenly balanced for patients with intracerebral hemorrhage – a kind of stroke caused by bleeding deep inside the brain that has a low recurrence rate. The authors wrote “Consequently, the optimal treatment option may vary with specific circumstances.”

Scientists do not know why a hemorrhagic stroke is more likely among statin users with a history of brain hemorrhage. Perhaps, a drop in cholesterol levels, or potential anti-clotting properties of statins increase their risk of brain bleeding, the authors suggest.

The scientists concluded:

“In summary, mathematical decision analysis of the available data suggests that, because of the high risk of recurrent intracerebral hemorrhage in survivors of prior hemorrhagic stroke, even a small amplification of this risk by use of statins suffices to recommend that they should be avoided after intracerebral hemorrhage. In the absence of data from a randomized clinical trial (ideally comparing various agents and doses), the current model provides some guidance for clinicians facing this difficult decision.”

Arch Neurol Published online January 10, 2011. doi:10.1001/archneurol.2010.356.
Accompanying Editorial – Do No Harm With Statin Treatment
Larry B. Goldstein, M.D., of Duke University and Durham VA Medical Center, Durham, N.C., in an accompanying editorial, wrote:

“The question prompting the decision analysis model reported by Westover et al epitomizes a common conundrum faced by clinicians – the need to make a therapeutic decision for a given patient in the absence of guidance from specific, high-quality clinical trial data.

In this case, exploratory data from two clinical trials (Heart Protection Study and SPARCL) suggest, but do not prove, a statin-associated increased risk of brain hemorrhage that may reduce the overall benefit of treatment in patients with a history of cerebrovascular disease.”

Dr. Goldstein added that the available data are..:

“..generally consistent with the conclusion of the decision analysis -the risk of statin therapy likely outweighs any potential benefit in patients with (at least recent) brain hemorrhage and should generally be avoided in this setting,” Dr. Goldstein writes. “Until and unless there are data to the contrary, or warranted by specific clinical circumstances, the use of statins in patients with hemorrhagic stroke should be guided by the maxim of nonmaleficence – Primum non nocere.”

Arch Neurol. Published online January 10, 2011. doi:10.1001/archneurol.2010.349.

Achieving Dignity In Care Means Ensuring Quality Of Care, UK

Help the Aged has responded to news of plans for nursing quality to be measured for compassion of care. The charity has highlighted the link between quality of care provision and the dignity of patients.

Charlotte Potter, Senior Policy Officer at Help the Aged, said:

‘Help the Aged has long campaigned on the need to measure quality of care in relation to dignity. Patients, in particular older people, cite dignity as a primary area of concern for them when accessing healthcare.

‘The NHS needs to be held to account when it puts the dignity of its users at risk. Incidents of older people left in pain, ignored, or distressed by a lack of privacy in hospitals emerge with such frequency they cannot be dismissed as isolated cases.

‘Help the Aged therefore welcomes the Secretary of State’s recognition of the need to measure quality of nursing care and not just numbers of people treated and discharged.

‘However nurses are only one piece of the puzzle. Ensuring the dignity of patients will depend on many other factors including the behaviour of all staff, from doctors to porters, and the ward environment. If the Government is serious about tackling the issue of dignity in care, they must take all these factors into account.’

Notes

Right care, Right deal’ is the new national campaign launched to build public awareness and support for the need for brave and innovative solutions for the social care system. With the Government indicating that social care is an urgent political priority, and in advance of the expected green paper later in 2008, the campaign combines three of the UK’s largest charities working with and for older people and their families and carers, and will urge the government to renew its vision for the future of social care in England. Visit rightcare

Help the Aged is the charity fighting to free disadvantaged older people in the UK and overseas from poverty, isolation, neglect and ageism. It campaigns to raise public awareness of the issues affecting older people and to bring about policy change. The Charity delivers a range of services: information and advice, home support and community living, including international development work. These are supported by its paid-for services and fundraising activities – which aim to increase funding in the future to respond to the growing unmet needs of disadvantaged older people. Help the Aged also funds vital research into the health issues and experiences of older people to improve the quality of later life.

Help the Aged urgently needs donations and support to help it in the increasingly challenging fight to free disadvantaged older people from poverty, isolation and neglect.

Help the Aged

Trans Fats Hinder Multiple Steps In Blood Flow Regulation Pathways

Partially hydrogenated vegetable oils in processed foods contain trans fatty acids that interfere with the regulation of blood flow. A new report reveals a new way in which these “trans fats” gum up the cellular machinery that keeps blood moving through arteries and veins.

In the August 2009 issue of the international journal Atherosclerosis, University of Illinois emeritus veterinary biosciences professor Fred Kummerow reports for the first time that trans fats interfere with more than one key enzyme in the regulation of blood flow.

Kummerow begins by describing the two main causes of heart disease – sudden blood clots in the coronary arteries, and atherosclerosis, the buildup of plaque in the arteries to the point where it interferes with blood flow.

“The arteries of someone who dies from atherosclerosis look like old scrub boards as a result of the formation of plaques,” Kummerow said. “They look corrugated, and this plaque buildup continues to the point where it will stop blood flow.”

Trans fats contribute to both of these causes of heart disease, Kummerow said.

Trans fats are made through hydrogenation, which involves bubbling hydrogen through hot vegetable oil, changing the arrangement of double bonds in the essential fatty acids in the oil and “saturating” the “unsaturated” carbon chain with hydrogen. Because double bonds are rigid, altering them can straighten or twist fat molecules into new configurations that give the fats their special qualities, such as the lower melting point of margarine that makes it creamy at room temperature.

Kummerow, 94, has spent nearly six decades studying lipid biochemistry, and is a long-time advocate for a ban on trans fats in food.

While the body can use trans fats as a source of energy for maintenance and growth, Kummerow said, trans fats interfere with the body’s ability to perform certain tasks critical to good health. Because these effects are less obvious, many researchers have missed the underlying pathologies that result from a diet that includes trans fats, he said.

Trans fats displace – and cannot replace – the essential fatty acids linoleic acid (omega-6) and linolenic acid (omega-3), which the body needs for a variety of functions, including blood flow regulation. Studies have shown that trans fats also increase low-density lipoproteins (LDLs) in the blood, a factor which some believe contributes to heart disease.

Trans fats are associated with increased inflammation in the arteries. And trans fats have been found to change the composition of cell membranes, making them more leaky to calcium. Inflammation, high LDL cholesterol and calcified arteries are the signature ingredients of atherosclerosis.

Trans fats also were shown to interfere with an enzyme that converts the essential fatty acid linoleic acid into arachidonic acid, which is needed for the production of prostacyclin (a blood-flow enhancer) and thromboxane (which regulates the formation of blood clots needed for wound healing). While some in the food oil industry believed this problem could be overcome simply by adding more linoleic acid to partially hydrogenated fats, in 2007 Kummerow’s team reported that extra linoleic acid did not overcome the problem.

“Trans fats inhibited the synthesis of arachidonic acid from linoleic acid, even when there was plenty of linoleic acid available,” he said.

The new study reports that in addition to interfering with the production of arachidonic acid from linoleic acid, trans fats also reduce the amount of prostacyclin needed to keep blood flowing. Thus blood clots may more easily develop, and sudden death is possible.

According to the American Heart Association, each year more than 330,000 people in the U.S. die from coronary heart disease before reaching a hospital or while in an emergency room. Most of those deaths are the result of sudden cardiac arrest, the Heart Association reports.

“This is the first time that trans fatty acids have been shown to interfere with yet another part of the blood-flow process,” Kummerow said. This study adds another piece of evidence to a long list that points to trans fats as significant contributors to heart disease, he said.

Kummerow believes the U.S. Food and Drug Administration’s new requirement (begun in 2006) that trans fats be included on food labels is inadequate and misleading. Anything less than one-half gram of trans fats per serving can be listed as zero grams, Kummerow said, so people are often getting the mistaken impression that their food is trans fat-free.

“Go to the grocery store and compare the labels on the margarines,” he said. “Some of them say zero trans fat. That’s not true. Anything with partially hydrogenated oils in it contains trans fat.”

“Partially hydrogenated fats can be made trans fat-free,” Kummerow said. “The industry would be helped by an FDA ban on trans fat that would save labeling costs, medical costs and lives.”

Source:
Diana Yates
University of Illinois at Urbana-Champaign

Swine Flu: The Seasonal Vaccine Offers Some Protection

Preliminary research published today on BMJ reports that the 2008-2009 seasonal flu vaccine (trivalent inactivated vaccine (TIV)) provides some protection against swine flu, particularly the most severe forms of the disease.

But the authors caution that the results should be considered carefully “and in no way indicate that seasonal vaccine should replace vaccination against pandemic influenza A/H1N1 2009.”

The World Health Organization raised the level of influenza pandemic alert from phase three to phase six in June 2009, when this new flu virus appeared. By July 2009, 122 countries reported almost 100,000 confirmed cases of swine flu.

Dr Jose Luis Valdespino from Mexico led this study to investigate the link between the 2008-2009 seasonal flu vaccine with cases of influenza A/H1N1 during the epidemic, in a hospital in Mexico City.

The researchers explain that the seasonal vaccine offers some protection because it boosts existing antibodies in individuals who have previously been exposed to a similar flu virus, either by infection or vaccination.

Valdespino and colleagues studied the health outcomes: hospitalization, mechanical ventilation and death. They compared 60 patients with swine flu and 180 control patients with other diseases. Both groups of patients informed the authors directly (by telephone or via a close relative) whether they had received the 2008-2009 seasonal flu vaccine.

Findings indicated that the uninfected participants were significantly more likely to have received the seasonal flu vaccine. This suggests that it protected them against particularly severe forms of swine flu. However the authors say the results should be considered objectively. They argue that given the small sample size “it will be key to conduct similar studies in other settings to confirm or refute our results.”

In a supplementary editorial, Dr Menno de Jong from the Academic Medical Centre of the University of Amsterdam agrees with Dr Valdespino. He explains that the results do not imply that there is no need for a specific vaccine against swine flu.

In addition, Dr de Jong discusses the issue of vaccine production. He argues that vaccines may not be available in time, even in countries that have amounted sufficient quantities, so that “vaccinated people may be protected only after the peak of the pandemic has passed.” He comments that “to protect against seasonal and pandemic strains, vaccines and vaccine production need to improve.”

“Partial protection of seasonal trivalent inactivated vaccine against novel pandemic influenza A/H1N1 2009: case-control study in Mexico City”
Lourdes Garcia-Garcia, research professor,Jose Luis Valdespino-GГіmez, epidemiologist, Eduardo Lazcano-Ponce, research professor, Aida Jimenez-Corona, research professor, Anjarath Higuera-Iglesias, epidemiologist, Pablo Cruz-Hervert, research professor, Bulmaro Cano-Arellano, engineer, Antonio Garcia-Anaya, engineer, Elizabeth Ferreira-Guerrero, epidemiologist, Renata Baez-SaldaГ±a, research professor,Leticia Ferreyra-Reyes, research professor, Samuel Ponce-de-LeГіn-Rosales, infectious diseases specialist,Celia Alpuche-Aranda, infectious diseases specialist, Mario Henry Rodriguez-LГіpez, research professor,Rogelio Perez-Padilla, research professor, Mauricio Hernandez-Avila, epidemiologist
BMJ 2009; 339:b3928
doi:10.1136/bmj.b3928

“The future of influenza vaccines”
Menno D de Jong, professor of clinical virology, Rogier W Sanders,assistant professor of microbiology and immunology
BMJ 2009; 339:b4014
bmj

Stephanie Brunner (B.A.)

Bringing Immunity To Every Community Project Aims To Increase Immunization

The American Nurses Association (ANA), the largest nursing organization in the U.S., is contributing to national efforts to eliminate the scourge of vaccine-preventable diseases through its new Bringing Immunity to Every Community project, which focuses on maximizing registered nurses’ key role in increasing vaccination rates.

Under a partnership arrangement with the Centers for Disease Control and Prevention (CDC) National Center for Immunization and Respiratory Diseases, Bringing Immunity to Every Community aims to increase the knowledge and competency of the nation’s 3.1 million registered nurses in immunization; encourage nurses to be vaccinated; and position nurses as leading advocates for immunization among health care professionals, patients and the public.

A major component of the two-year initiative is a new Web site, ANAimmunize, launched today that will be a one-stop shop for resources nurses need to be competent, educated advocates for immunizations. The site is designed as a gallery of nurse-specific resources, categorized out by nursing specialties, settings, and roles in immunization. It will also be a place for ANA to connect with nurses through interactive elements, such as an RSS news feed, link to social media sites, a personal vaccine assessment tool, and an online survey.

“Bringing Immunity to Every Community and the new Web site is an extension of our commitment to see registered nurses serve as leaders not only in encouraging their patients and the public to get recommended and necessary vaccinations, but in setting the example for health care workers to get vaccinated,” said ANA President Rebecca M. Patton, MSN, RN, CNOR.

“The more knowledge we have as nurses, the better able we will be to answer our patients’ questions, address their concerns, and correct common misconceptions about immunizations.”

Vaccines are among the most successful and cost-effective public health tools available for preventing disease and death. They not only help protect vaccinated individuals, but also entire communities by preventing and reducing the spread of infectious diseases.

With preventing disease and enhancing wellness a fundamental core of nursing, ANA is naturally positioned to raise awareness of the benefits of immunization, especially among parents to ensure that infants are fully immunized. ANA also has long been a leading voice for increasing seasonal influenza vaccination rates among patients and health care professionals who treat them. The immunization effort has taken on increased urgency over the past year with the public health emergency posed by the H1N1 pandemic. ANA urged all members to get both the seasonal influenza and H1N1 vaccines to protect themselves, their patients and their families.

Source
American Nurses Association

The Lower The Better Where Blood Pressure Is Concerned

The Minister for Health and Ageing, Tony Abbott, today launched a new book showcasing the best in Australian health research from recent years. The ’10 of the Best’ book highlights ten world-leading medical research projects and includes the largest ever study of the effects of blood pressure lowering medications on the major killers, stroke and heart attack.

The George Institute for International Health established the Blood Pressure Lowering Treatment Trialists’ Collaboration in 1995. The results of this collaboration are a cornerstone of blood pressure guidelines in Australia and around the world. Most notably, the project highlights the need for renewed efforts to achieve better blood pressure control.

The research, has also uncovered important differences in the effectiveness of different types of blood pressure lowering drugs. Most recently, the work of the collaboration has provided important insight into possible differences in the protection provided by two drug classes often considered interchangeable – ACE inhibitors and angiotensin receptor blockers.

Principal investigator of the study, Dr Bruce Neal, Senior Director at The George Institute said, “This has been a huge research effort spanning over a decade. The results have had direct clinical implications for hundreds of millions of people with high blood pressure worldwide.” He added that, “While we have identified differences between drug classes, the most important finding is that aggressive treatment to drive blood pressure down to really low levels provides the greatest protection. The number of drugs, not the choice of drugs, is more important for most people.”

Worldwide, high blood pressure (or hypertension) is responsible for around 7 million deaths annually. With an estimated 600 million people having hypertension, this study makes a major contribution to our knowledge on how best to prevent the growing epidemic of death and disability from blood pressure related disease. Results of the study have been published in the Lancet on two occassions and include data from over 160,000 individuals in more than 50 countries, including Australia and New Zealand.

The ’10 of the best’ booklet was written for the general public to demonstrate the benefits of medical research resulting from public investment.

Australia is a world leader in health and medical research – on a per capita basis, our research output is twice the OECD average. Medical research makes good health and economic sense. A report by Access Economics shows that for every $1 invested in medical research, $5 is returned to the Australian economy.

The ’10 of the Best’ has been developed by the National Health and Medical Research Council (NHMRC). The booklet is available on the web at nhmrc.au/ and also by calling the NHMRC on 1800-020-103.

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The George Institute for International Health is an internationally-recognised health research body, undertaking high impact research across a broad health landscape. The Institute is centrally involved with Australian community health issues in Aboriginal health, ethnic community health, road safety and injury, mental health, ageing, healthcare access, clinical practice in Australian hospitals and health policy development.

It is also a leader in the clinical trials, health policy and capacity-building areas. Its research has a direct, practical impact on a wide range of healthcare, health policy, safety and socio-cultural issues facing Australians.

The Institute is affiliated with The University of Sydney, Sydney South West Area Health Services, and collaborates in its research with other prestige research institutes, clinical authorities and policy centres around the world.

Associate Professor Bruce Neal

Bruce Neal is a Senior Director, Research and Development at The George Institute for International Health, Associate Professor in the Faculty of Medicine at the University of Sydney, Heart Foundation Career Development Fellow and an Honorary Consultant Epidemiologist at the Royal Prince Alfred Hospital. Bruce completed his medical training at Bristol University in the UK in 1990 and spent four years in clinical posts during which time he gained membership of the UK Royal College of Physicians. Prior to taking up his current post in 1999, he spent four years working as an epidemiologist at the Clinical Trials Research Unit in Auckland, New Zealand, where he completed his PhD in Medicine.

Contact: Emma Orpilla

Research Australia

Nursing Home Or Hospital: State Policy Has Big Impact On Elderly

For the first time on a national scale, a team led by Brown University researchers has traced the connections between state nursing home policies and a critical decision in the care of nursing home residents – whether to send these frail elderly to the hospital.

In their groundbreaking analysis, researchers found that state policies unwittingly create financial incentives for nursing homes to hospitalize residents – even though hospital stays can be disorienting or dangerous. Previous studies have shown that about one-third of hospital stays by nursing home residents can be prevented.

This study – which included virtually every nursing home in the nation with 25 or more beds – resulted in two major findings. The lower the state Medicaid reimbursement rate to nursing homes, the more likely those homes were to hospitalize residents. Hospitalization odds were also significantly higher in states that reimburse nursing homes for holding the beds of hospitalized residents. Results are published in the current online edition of Health Services Research.

“The message is clear: State policies have a significant impact on the lives of very vulnerable people,” said Orna Intrator, an associate professor of community health at Brown and the lead author of the article. “While hospital stays can be life saving for nursing home residents, they remove these seniors from familiar surroundings and expose them to life-threatening infections.”

The study was led by Vincent Mor, chairman of Brown’s Department of Community Health, and conducted by faculty in the University’s nationally recognized Center for Gerontology and Health Care Research.

For the project, Mor and the study team investigated the affects of two types of state policies on nursing home hospitalizations. One was Medicaid payment policies, which determine how much homes are paid per resident, per day for care through the federal program for the poor and disabled. The second was “bed-hold” policies. Currently, 36 states reimburse nursing homes for holding the beds of patients admitted to the hospital in order to guarantee that these residents can return home after recovery. For reserving a bed, states reimburse nursing homes anywhere from 25 percent to 100 percent of the Medicaid daily payment rate to offset lost revenue.

To conduct the study, the Brown team tracked the status of 570,614 residents aged 65 and older living in 8,997 urban, freestanding nursing homes located in 48 states. Residents were followed for a five-month period to see how many were hospitalized. Researchers found that, on average, 17 percent of all residents were admitted to hospitals at least once during those five months, with rates varying from a low of 8 percent in Utah to a high of 25 percent in Louisiana.

Researchers found a strong link between the size of Medicaid payments and the number of hospital admissions. The higher the Medicaid per-diem payment for nursing homes, researchers found, the lower the odds of hospitalization for residents. States with the lowest hospitalization rates tended to be located in the West and in New England – Utah, New Mexico, Maine, New Hampshire and Oregon. States with the highest hospitalization rates tend to be located in the South and the Midwest – Louisiana, Mississippi, Texas, Kentucky, and Oklahoma.

“We think the reason we see this relationship is that in states with higher payment rates, nursing home operators can afford to keep more medical professionals, such as nurse practitioners, on staff,” Mor said. “With more staff, and more skilled staff, homes are better able to treat residents on site and they’re better able to practice preventive care to head off problems such as pneumonia, bed sores or urinary tract infections.”

Researchers saw a similar – and surprising – relationship between bed-hold policies and hospitalizations. The odds of hospitalization were 36 percent higher in states with bed-hold policies. Mor and Intrator explained the result this way: Because homes get some money from the state for holding a bed, the financial penalty for hospitalizing residents is reduced.

“This is a complex problem with no simple solution,” Intrator said. “But one answer is a pay-for-performance system that rewards nursing homes for reducing – and maintaining low – hospital admission rates. This sort of system could improve the quality of life of nursing home residents and avoid preventable illnesses.”

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Other members of the Brown team include Zhanlian Feng, senior research analyst, and Susan Miller, associate professor of community health, both of the Center for Gerontology and Health Care Research, and Mark Schleinitz, M.D., an assistant professor of community health at Brown Medical School and a physician at Rhode Island Hospital. David Grabowski of Harvard Medical School and Jaqueline Zinn of the Fox School of Business and Management at Temple University also served as investigators on the team.

The National Institute on Aging funded the work.

Contact: Wendy Lawton
Brown University