Etoposide

Medication Overload: America’s Other Drug Problem. How the drive to prescribe is harming older adults.

Author/s: 
Executive Summary of the Lown Institute

In the last year, older adults in the U.S. sought medical care nearly 5 million times due to serious side effects from one or more medications. More than a quarter million of these visits resulted in hospitalizations, at a cost of $3.8 billion (see Appendix A in the full report). These numbers point to a rapidly growing epidemic of medication overload among older Americans. Over the last decade, adults age 65 and older have been hospitalized for serious drug side effects, called adverse drug events (ADEs), about 2 million times. To put this in context, there were 3.2 million opioid-related hospitalizations across the entire population during the same period.1 The trend of increasing ADEs is not propelled by drug abuse, but by the rising number of medications prescribed to older adults (called “polypharmacy” in the scientific literature). More than 40 percent of older adults take five or more prescription medications a day, a threefold increase over the past two decades.2,3 The greater the number of medications—most of which are prescribed for legitimate reasons—the greater the risk for serious adverse reactions in older patients. Medication overload is causing widespread yet unseen harm to our parents and our grandparents. It is every bit as serious as the opioid crisis, yet its scope remains invisible to many patients and health care professionals. While some clinicians are trying to reduce the burden of medications on their individual patients, no professional group, public organization, or government agency to date has formally assumed responsibility for addressing this national problem. If current trends continue, we estimate that medication overload will be responsible for at least 4.6 million hospitalizations between 2020 and 2030. It will cost taxpayers, patients and families an estimated $62 billion. Over the next decade, medication overload is expected to cause the premature death of 150,000 older Americans. In this report, the Lown Institute calls for the development of a national strategy to address medication overload and help older people avoid its devastating effects on the quality and length of their lives. A subsequent National Action Plan for Addressing Medication Overload will lay out a national strategy to address the epidemic of prescribing and ensure the safety of millions of older adults who are now at risk of preventable harm and premature death.

Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People

Introduction to the guidelines The Center of Excellence for Transgender Health (CoE) at the University of California – San Francisco is proud to present these Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. Transgender people have a gender identity that differs from the sex which they were assigned at birth, and are estimated to represent 0.5% of the U.S. population.[1] Numerous needs assessments have demonstrated that transgender people encounter a range of barriers to accessing primary health care. A 2006 survey of more than 600 transgender people in California found that 30% postponed seeking medical care due to prior disrespect or discrimination, and that 10% were primary care outright.[2] The 2011 National Transgender Discrimination Survey of more than 6000 transgender people in all 50 U.S. states found several noteworthy disparities, including 28% who delayed care due to past discrimination and 19% who were denied care outright. Most alarmingly, 50% of respondents reported having to teach their providers about their own healthcare.[3] These guidelines aim to address these disparities by equipping primary care providers and health systems with the tools and knowledge to meet the health care needs of their transgender and gender nonconforming patients. These guidelines expand on the original UCSF Primary Care Protocol for Transgender Care, which since its launch in 2011 has served thousands of providers and policymakers across the U.S. and around the world; the page on hormone administration alone received more than 5000 visitors in the month of November, 2015. These Guidelines complement the existing World Professional Association for Transgender Health Standards of Care and the Endocrine Society Guidelines in that they are specifically designed for implementation in every day evidence-based primary care, including settings with limited resources.[4,5] The overall structure and list of topics for inclusion were developed in consultation with the CoE’s Medical Advisory Board (MAB), a diverse group of expert clinicians from a variety of academic and community based settings. Also contributing to the overall design and structure was a review of the range of consultation requests received by the CoE since the 2011 launch of the original Protocol. The guidelines were then written using an authorship – peer review approach. Primary authors from both within and outside the MAB were invited for individual topics, after which a peer review and modified consensus process was used to arrive at the final guidelines presented here. The diverse authorship allows the development of a broadly applicable document, rather than one that solely reflects the practice at a single academic medical center, such as UCSF. These guidelines would not be possible without the contributions of our Medical Advisory Board and other authors and reviewers, as well as the support of my CoE colleagues JoAnne Keatley, MSW and E. Michael Reyes, MD, MPH, as well as Lissa Moran who assisted immensely with literature reviews, bibliography management, version control, copy editing, formatting, and compiling peer reviewer comments. Ben Zovod also assisted with literature reviews, bibliography management, and compiling peer reviewer comments. Their dedication and hours of hard work has resulted in a final product that is relevant, broadly applicable, evidence based, and scientifically sound. I hope you find these guidelines useful and welcome any feedback or questions, which are June 17, 2016 2 Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People helpful in framing future revisions. Thank you for caring about the health of transgender and gender nonconforming people. Madeline B. Deutsch, MD, MPH Editor Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People Director of Clinical Services Center of Excellence for Transgender Health Associate Professor of Clinical Family and Community Medicine Department of Family and Community Medicine University of California, San Francisco Madeline.Deutsch@ucsf.edu

Electronic Nicotine Delivery Systems (ENDS)

Electronic nicotine delivery systems (ENDS), also called electronic cigarettes, e-cigarettes, vaping devices, or vape pens, are battery-powered devices used to smoke or “vape” a flavored solution which usually contains nicotine. The American Academy of Family Physicians (AAFP) recognizes the alarmingly increased use of ENDS, especially among youth and young adults, as well as its use by those attempting to quit smoking tobacco.

The AAFP calls for further research to assess ENDS’ safety, quality, and efficacy as a potential cessation device. The AAFP also recommends that the marketing and advertising of ENDS to children and youth cease immediately. The AAFP encourages members to screen for ENDS use starting with school-age children, to discuss the potential harms of ENDS, and to recommend cessation interventions with e-cigarette users. The AAFP encourages members to inform patients who use ENDS, especially children, that the majority of these products contain nicotine and are addictive.  (2014 COD) (April 2019 BOD)

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