Background: Few studies have evaluated percent time in therapeutic range (TTR) for warfarin managed via face-to-face (FF) to telephone (TELE) visits-all finding no difference between groups. Objective: Compare and evaluate TTR for warfarin in patients who received pharmacist-managed care via FF or TELE. Methods: Single-center, retrospective study. Eligible participants were ≥18 years old, on indefinite warfarin therapy, followed by clinical pharmacists via FF or TELE from 2010 to 2012. Primary outcome (TTR) calculated via Rosendaal method. Event data included rates of any bleeding, significant bleeding, deep vein thrombosis, pulmonary embolism, cerebrovascular accident, hospitalizations, and death. Clinics were also compared by location. Results: Two hundred subjects (90 FF and 110 TELE) were included. Mean TTR was 68.17% and 69.57% in FF and TELE groups, respectively. The FF group had statistically significant higher rates of any bleeding (48.9% vs 30.9%). Rates of significant bleeding in FF versus TELE were not significantly different (6.67% vs 2.73%). The majority followed FF with significant bleeding were at a higher bleeding risk than those followed via TELE. There were low rates of venous thromboembolism (1.1% and 1.8%). Conclusions: TTR was ≥65% for most subjects with minimal variability in TTR between clinics. Mean TTR results for each group were greater and above the threshold that has been commonly described in the literature as quality control, suggesting a progression in implementation of telephone-based anticoagulation management.

Background: Sedative-hypnotics, including benzodiazepines (BZDs) and benzodiazepine receptor agonists (BZD-RA), are considered potentially inappropriate medications (PIMs) in older adults. Academic detailing, an educational outreach delivered by trained clinicians to other clinicians to encourage evidence-based care, can promote deprescribing of PIMs. Objective: To evaluate the impact of academic detailing on sedative-hypnotic prescribing to older veterans. Methods: A retrospective analysis was performed to evaluate the impact of academic detailing on BZD and BZD-RA prescribing to veterans aged 75 years and older. Prescribing trends for primary care and mental health prescribers in the Veterans Health Administration (VA) Southeast Network were calculated for the 18 months before and after an initial academic detailing session for each prescriber. Pre–post interrupted time series analyses (ITSAs) were conducted, and period prevalence was calculated as the number of prescriptions per 1000 older veterans. Results: A total of 155 prescribers were followed for 36 months. BZD prevalence declined by 23% (69.08-53.33 per 1000 population; P < .001) and by 15% for BZD-RA (18.07-15.38 per 1000 population; P < .001). New starts on BZD declined by 54% (2.36-1.09 per 1000 population; P < .001) and new starts on BZD-RA declined by 53% (1.02-0.48 per 1000 population; P < .001). Alternative medications for insomnia increased by 23% (39.98-49.27 per 1000 population; P < .001). Findings from the ITSA confirmed those of the pre–post analysis with sustained effects in the postintervention period. Conclusions: Academic detailing was associated with reduced sedative-hypnotic prescribing in the primary care and mental health setting.

We describe a systematic approach for the robust optimal design of linear elastic structures subjected to unknown loading using minmax and topology optimization methods. Assuming only the loading region and norm, we distribute a given amount of material in the design domain to minimize the principal compliance, i.e. the maximum compliance that is produced by the worst-case loading scenario. We evaluate the principal compliance directly by satisfying the optimality conditions which take the form of a Steklov eigenvalue problem and thus we eliminate the need of an iterative nested optimization. To generate a well-posed topology optimization problem we use relaxation which requires homogenization theory. Examples are provided to demonstrate our algorithm.ii To Mom and Dad.iii

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