Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel’s recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

National Institutes of Health Pathways to Prevention Workshop: Physical Activity and Health for Wheelchair Users

Health benefits of physical activity are well recognized in the general population for reducing the risk of chronic health conditions. Less is known about the effects of physical activity on people currently using or who may use wheeled mobility devices in the future, specifically individuals with multiple sclerosis, cerebral palsy, and spinal cord injury who are at increased likelihood for use of a wheeled mobility device. On December 1-3, 2020, the National Institutes of Health convened the Pathways to Prevention workshop: "Can Physical Activity Improve the Health of Wheelchair Users?" to consider the available scientific evidence on the clinical benefits and harms of physical activity for people currently using or who may use wheeled mobility devices in the future, with the aim of developing recommendations to fill gaps in the evidence base. A multidisciplinary team of content area experts developed the agenda and an evidence-based practice center prepared the evidence report. An independent panel, selected by the National Institutes of Health, attended the workshop; convened to develop recommendations on the basis of the systematic review, presentations, and public comments received during the workshop; and revised recommendations based on public comments received. This final report summarizes the panel's findings and identifies current gaps in knowledge. The panel made recommendations for new research efforts, including novel methods and new research infrastructure to improve the evidence base about the effects of physical activity on people currently using or who may use wheeled mobility devices in the future.

Affordability of Medical Care Among Medicare Enrollees

Importance

Cost-sharing requirements can discourage patients from seeking care and impose financial hardship. The Medicare program serves many older and disabled individuals with multimorbidity and limited resources, but little has been known about the affordability of care in this population.

Objective

To examine the affordability of medical care among Medicare enrollees, in terms of the prevalence of delaying medical care because of costs and having problems paying medical bills, and risk factors for these outcomes.

Design Setting and Participants

Cross-sectional analyses conducted from November 1, 2019, to October 15, 2021, used logistic regression to compare the probability of outcomes by demographic and health characteristics. Data were obtained from the 2017 nationally representative Medicare Current Beneficiary Survey (response rate, 61.7%), with respondents representing 53 million community-dwelling Medicare enrollees.

Main Outcomes and Measures

New questions about medical care affordability were included in the 2017 Medicare Current Beneficiary Survey: difficulty paying medical bills, ongoing medical debt, and contact by collection agencies. A companion survey question asked whether individuals had delayed seeking medical care because of worries about costs.

Results

Respondents included 10 974 adults aged 65 years or older and 2197 aged 18 to 64 years; 54.2% of all respondents were women. The weighted proportions of Medicare enrollees with annual incomes below $25 000K were 30.7% in the older population and 67.4% in the younger group. Self-reported prevalence of delaying care because of cost was 8.3% (95% CI, 7.4%-9.1%) among enrollees aged 65 years or older, 25.2% (95% CI, 21.8%-28.6%) among enrollees younger than 65 years, and 10.9% (95% CI, 9.9%-11.9%) overall. Similarly, 7.4% (95% CI, 6.6%-8.2%) of older enrollees had problems paying medical bills, compared with 29.8% (95% CI, 25.6%-34.1%) among those younger than 65 years and 10.8% (95% CI, 9.8%-11.9%) overall. Regarding specific payment problems, 7.9% (95% CI, 7.0%-8.9%) of enrollees overall experienced ongoing medical debt, contact by a collection agency, or both. In adjusted analyses, older adults with incomes $15 000 to $25 000 per year had odds of delaying care more than twice as high as those with incomes greater than $50 000 (odds ratio, 2.47; 95% CI, 1.82-3.39), and their odds of problems paying medical bills were more than 3 times as high (odds ratio, 3.37; 95% CI, 2.81-5.21). Older adults with 4 to 10 chronic conditions were more than twice as likely to have problems paying medical bills as those with 0 or 1 condition.

Conclusions and Relevance

The findings of this study suggest that unaffordability of medical care is common among Medicare enrollees, especially those with lower incomes, or worse health, or who qualify for Medicare based on disability. Policy reforms, such as caps on patient spending, are needed to reduce Medical cost burdens on the most vulnerable enrollees.

Roadmap to 2030 for Drug Evaluation in Older Adults

Changes that accompany older age can alter the pharmacokinetics (PK), pharmacodynamics (PD), and likelihood of adverse effects (AEs) of a drug. However, older adults, especially the oldest or those with multiple chronic health conditions, polypharmacy, or frailty, are often under-represented in clinical trials of new drugs. Deficits in the current conduct of clinical evaluation of drugs for older adults and potential steps to fill those knowledge gaps are presented in this communication. The most important step is to increase clinical trial enrollment of older adults who are representative of the target treatment population. Unnecessary eligibility criteria should be eliminated. Physical and financial barriers to participation should be removed. Incentives could be created for inclusion of older adults. Enrollment goals should be established based on intended treatment indications, prevalence of the condition, and feasibility. Relevant clinical pharmacology data need to be obtained early enough to guide dosing and reduce risk for participation of older adults. Relevant PK and PD data as well as patient-centered outcomes should be measured during trials. Trial data should be analyzed for differences in PK, PD, effectiveness, and safety arising from differences in age or from the presence of conditions common in older adults. Postmarket evaluations with real-world evidence and drug labeling updates throughout the product lifecycle reflecting new knowledge are also needed. A comprehensive plan is needed to ensure adequate evaluation of the safety and effectiveness of drugs in older adults.

Evaluation of the Cost-effectiveness of Drug Treatment for Alzheimer Disease in a Simulation Model That Includes Caregiver and Societal Factors

IMPORTANCE

The possibility of widespread use of a novel effective therapy for Alzheimer disease (AD) will present important clinical, policy, and financial challenges.

OBJECTIVE

To describe how including different patient, caregiver, and societal treatment-related factors affects estimates of the cost-effectiveness of a hypothetical disease-modifying AD treatment.

DESIGN, SETTING, AND PARTICIPANTS

In this economic evaluation, the Alzheimer Disease Archimedes Condition Event Simulator was used to simulate the prognosis of a hypothetical cohort of patients selected from the Alzheimer Disease Neuroimaging Initiative database who received the diagnosis of mild cognitive impairment (MCI). Scenario analyses that varied costs and quality of life inputs relevant to patients and caregivers were conducted. The analysis was designed and conducted from June 15, 2019, to September 30, 2020.

EXPOSURES

A hypothetical drug that would delay progression to dementia in individuals with MCI compared with usual care.

MAIN OUTCOMES AND MEASURES

Incremental cost-effectiveness ratio (ICER), measured by cost per quality-adjusted life-year (QALY) gained.

RESULTS

The model included a simulated cohort of patients who scored between 24 and 30 on the Mini-Mental State Examination and had a global Clinical Dementia Rating scale of 0.5, with a required memory box score of 0.5 or higher, at baseline. Using a health care sector perspective, which included only individual patient health care costs, the ICER for the hypothetical treatment was $192 000 per QALY gained. The result decreased to $183 000 per QALY gained in a traditional societal perspective analysis with the inclusion of patient non-health care costs. The inclusion of estimated caregiver health care costs produced almost no change in the ICER, but the inclusion of QALYs gained by caregivers led to a substantial reduction in the ICER for the hypothetical treatment, to $107 000 per QALY gained in the health sector perspective. In the societal perspective scenario, with the broadest inclusion of patient and caregiver factors, the ICER decreased to $74 000 per added QALY.

CONCLUSIONS AND RELEVANCE

The findings of this economic evaluation suggest that policy makers should be aware that efforts to estimate and include the effects of AD treatments outside those on patients themselves can affect the results of the cost-effectiveness analyses that often underpin assessments of the value of new treatments. Further research and debate on including these factors in assessments that will inform discussions on fair pricing for new treatments are needed.

Differences in Perceived and Predicted Bleeding Risk in Older Adults With Atrial Fibrillation: The SAGE-AF Study

Background Little research has evaluated patient bleeding risk perceptions in comparison with calculated bleeding risk among oral anticoagulant users with atrial fibrillation. Our objective was to investigate underestimation of bleeding risk and to describe the characteristics and patient-reported outcomes associated with underestimation of bleeding risk. Methods and Results In the SAGE-AF (Systematic Assessment of Geriatric Elements in Atrial Fibrillation) study, a prospective cohort study of patients ≥65 years with atrial fibrillation, a CHA2DS2-VASc risk score ≥2 and who were on oral anticoagulant therapy, we compared patients' self-reported bleeding risk with their predicted bleeding risk from their HAS-BLED score. Among the 754 participants (mean age 74.8 years, 48.3% women), 68.0% underestimated their bleeding risk. Participants who were Asian or Pacific Islander, Black, Native American or Alaskan Native, Mixed Race or Hispanic (non-White) (adjusted OR [AOR], 0.45; 95% CI, 0.24-0.82) and women (AOR, 0.62; 95% CI, 0.40-0.95) had significantly lower odds of underestimating their bleeding risk than respective comparison groups. Participants with a history of bleeding (AOR, 3.07; 95% CI, 1.73-5.44) and prior hypertension (AOR, 4.33; 95% CI, 2.43-7.72), stroke (AOR, 5.18; 95% CI, 1.87-14.40), or renal disease (AOR, 5.05; 95% CI, 2.98-8.57) had significantly higher odds of underestimating their bleeding risk. Conclusions We found that more than two-thirds of patients with atrial fibrillation on oral anticoagulant therapy underestimated their bleeding risk and that participants with a history of bleeding and several comorbid conditions were more likely to underestimate their bleeding risk whereas non-Whites and women were less likely to underestimate their bleeding risk. Clinicians should ensure that patients prescribed oral anticoagulant therapy have a thorough understanding of bleeding risk.

Temporal Trends and Patient Characteristics Associated with 30-Day Hospital Readmission Rates after a First Acute Myocardial Infarction

BACKGROUND

Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction.

METHODS

We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts.

RESULTS

The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient's hospitalization for a first acute myocardial infarction.

CONCLUSIONS

We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed.

Identifying prescribing cascades in Alzheimer's disease and related dementias: The calcium channel blocker-diuretic prescribing cascade

PURPOSE

Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blocker-diuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans.

METHODS

We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCB-users within 365-days from cohort entry.

RESULTS

There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diuretic-users among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCB-diuretic cascade).

CONCLUSIONS

We describe an approach to identify prescribing cascades in persons with ADRD, which can be used to assess the proportion of prescribing cascades in large cohorts. We determined the proportion of CCB-diuretic prescribing cascades was low.

Evidence of a gabapentinoid and diuretic prescribing cascade among older adults with lower back pain

BACKGROUND/OBJECTIVES

Gabapentinoids are commonly prescribed to relieve pain. The development of edema, an established adverse effect of gabapentinoids, may lead to a potentially harmful prescribing cascade whereby individuals are subsequently prescribed diuretics and exposed to diuretic-induced adverse events. The frequency of this prescribing cascade is unknown. Our objective was to measure the association between new dispensing of a gabapentinoid and the subsequent dispensing of a diuretic in older adults with new low back pain.

DESIGN

Population-based cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

A total of 260,344 community-dwelling adults aged 66 years or older, newly diagnosed with low back pain between April 1, 2011, and March 31, 2019.

MEASUREMENTS

Exposure status was assigned using dispensed medications in the 1 week after low back pain diagnosis. Older adults newly dispensed a gabapentinoid (N = 7867) were compared with older adults who were not newly dispensed a gabapentinoid (N = 252,477). Hazard ratios (HRs) with 95% confidence intervals (CIs) for dispensing of a diuretic within 90 days of follow-up among older adults prescribed gabapentin relative to those who were not.

RESULTS

Older adults newly dispensed a gabapentinoid had a higher risk of being subsequently dispensed a diuretic within 90 days compared with older adults who were not prescribed a gabapentinoid (2.0% vs. 1.3%). After covariate adjustment, new gabapentinoid users had a higher rate of being dispensed a diuretic compared with those not prescribed a gabapentinoid (HR: 1.44, 95% CI: 1.23, 1.70). The rate of diuretic prescription among new gabapentinoid users increased with increasing gabapentinoid dosages.

CONCLUSIONS

We have demonstrated the presence of a potentially inappropriate and harmful prescribing cascade. Given the widespread use of gabapentinoids, the population-based scale of this problem may be substantial. Increased awareness of this prescribing cascade is required to reduce the unnecessary use of diuretics and the exposure of patients to additional adverse drug events.

Validation of an electronic algorithm for Hodgkin and non-Hodgkin lymphoma in ICD-10-CM

PURPOSE

Lymphoma is a health outcome of interest for drug safety studies. Studies using administrative claims data require the accurate identification of lymphoma cases. We developed and validated an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM)-based algorithm to identify lymphoma in healthcare claims data.

METHODS

We developed a three-component algorithm to identify patients aged ≥15 years who were newly diagnosed with Hodgkin (HL) or non-Hodgkin (NHL) lymphoma from January 2016 through July 2018 among members of four Data Partners within the FDA's Sentinel System. The algorithm identified potential cases as patients with ≥2 ICD-10-CM lymphoma diagnosis codes on different dates within 183 days; ≥1 procedure code for a diagnostic procedure (e.g., biopsy, flow cytometry) and ≥1 procedure code for a relevant imaging study within 90 days of the first lymphoma diagnosis code. Cases identified by the algorithm were adjudicated via chart review and a positive predictive value (PPV) was calculated.

RESULTS

We identified 8723 potential lymphoma cases via the algorithm and randomly sampled 213 for validation. We retrieved 138 charts (65%) and adjudicated 134 (63%). The overall PPV was 77% (95% confidence interval: 69%-84%). Most cases also had subtype information available, with 88% of cases identified as NHL and 11% as HL.

CONCLUSIONS

Seventy-seven percent of lymphoma cases identified by an algorithm based on ICD-10-CM diagnosis and procedure codes and applied to claims data were true cases. This novel algorithm represents an efficient, cost-effective way to target an important health outcome of interest for large-scale drug safety and public health surveillance studies.

Effect of a Multifaceted Clinical Pharmacist Intervention on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications: A Randomized Clinical Trial

IMPORTANCE

The National Action Plan for Adverse Drug Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids.

OBJECTIVE

To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018.

INTERVENTIONS

The pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail.

MAIN OUTCOMES AND MEASURES

The study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome.

RESULTS

There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02781662.

Identifying key prescribing cascades in older people (iKASCADE): a transnational initiative on drug safety through a sex and gender lens-rationale and design

PURPOSE

To describe the objectives, methods and expected impact of an international consortium (iKASCADE) whose purpose is to improve drug safety for older adults by addressing prescribing cascades through a sex and gender lens.

METHODS

To create a comprehensive, internationally relevant inventory of prescribing cascades affecting older adults, the consortium has created a modified Delphi procedure where international experts in prescribing and managing pharmacotherapy for older adults will rank a list of prescribing cascades as to their clinical importance. We will use administrative and clinical data on older adults to evaluate the frequency of prescribing cascades by sex internationally, in the hospital, long-term care and community settings. Finally, we will use semi-structured interviews and realistic, country-specific vignettes, each incorporating a prescribing cascade with identified sex differences, to explore how socially constructed gender roles contribute to the experience, presentation and management of prescribing cascades.

RESULTS

The consortium will synthesize the quantitative and qualitative results to produce a position paper and products-aimed at knowledge users within and outside of academia-designed to elevate the importance of integrating a gender dimension in the identification and prevention of prescribing cascades.

CONCLUSION

Findings will improve our understanding of how adverse drug events are different between older women and men and inform the development and dissemination of tailored knowledge translation products to reduce the frequency and impact of prescribing cascades.

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization

BACKGROUND/OBJECTIVES

We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk.

DESIGN

Prospective cohort analysis.

SETTING AND PARTICIPANTS

32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations.

METHODS

We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs.

RESULTS

We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47).

CONCLUSIONS AND IMPLICATIONS

AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction

Background:

Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities.

Methods and Results:

Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years.

Conclusions:

Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population.

Risk of In-Hospital Falls among Medications Commonly Used for Insomnia in Hospitalized Patients

STUDY OBJECTIVES

To investigate the risk of in-hospital falls among patients receiving medications commonly used for insomnia in the hospital setting.

METHODS

Retrospective cohort study of all adult hospitalizations to a large academic medical center from 1/2007 to 7/2013. We excluded patients admitted for a primary psychiatric disorder. Medication exposures of interest, defined by pharmacy charges, included benzodiazepines, non-benzodiazepine benzodiazepine receptor agonists (BZRAs), trazodone, atypical antipsychotics, and diphenhydramine. In-hospital falls were ascertained from an online patient safety reporting system.

RESULTS

Among the 225,498 hospitalizations (median age = 57 years; 57.9% female) in our cohort, 84,911 (37.7%) had exposure to at least one of the five medication classes of interest; benzodiazepines were the most commonly used (23.5%), followed by diphenydramine (8.3%), trazodone (6.6%), BZRAs (6.4%), and atypical antipsychotics (6.3%). A fall occurred in 2,427 hospitalizations (1.1%). The rate of falls per 1,000 hospital days was greater among hospitalizations with exposure to each of the medications of interest, compared to unexposed: 3.6 versus 1.7 for benzodiazepines (adjusted hazard ratio [aHR] 1.8, 95%CI 1.6-1.9); 5.4 versus 1.8 for atypical antipsychotics (aHR 1.6, 95%CI 1.4-1.8); 3.0 versus 2.0 for BZRAs (aHR 1.5, 95%CI 1.3-1.8); 3.3 versus 2.0 for trazodone (aHR 1.2, 95%CI 1.1-1.5); and 2.5 versus 2.0 for diphenhydramine (aHR 1.2, 95%CI 1.03-1.5).

CONCLUSIONS

In this large cohort of hospitalizations at an academic medical center, we found an association between each of the sedating medications examined and in-hospital falls. Benzodiazepines, BZRAs, and atypical antipsychotics had the strongest associations.

Antidopaminergic-Antiparkinsonian Medication Prescribing Cascade in Persons with Alzheimer's Disease

OBJECTIVES

Persons living with Alzheimer's disease (AD) may be at increased risk for prescribing cascades due to greater multimorbidity, polypharmacy, and the need for more complex care. Our objective was to assess the proportion of the antidopaminergic-antiparkinsonian medication prescribing cascades among persons living with Alzheimer's disease.

SETTING

Two large administrative claims databases in the United States.

PARTICIPANTS

We identified patients aged ≥50 on January 1, 2017, who were dispensed a drug used to treat Alzheimer's disease for at least 1 day in the 365 days prior to or on cohort entry date and who had medical and pharmacy coverage in the 365 days prior to the cohort entry date. We excluded individuals with a recent institutional stay. We identified incident antidopaminergic (antipsychotic/metoclopramide) use in the 183 days following cohort entry and identified subsequent incident antiparkinsonian drug use within 8 to 365 days.

RESULTS

There were 121,538 patients with Alzheimer's disease eligible for inclusion. Approximately 62% were women with a mean age of 79.5 (SD ± 8.6). The mean number of drugs dispensed was 9.2 (SD ± 4.9). There were 36 incident antiparkinsonian users among 4,534 incident antipsychotic/metoclopramide users (0.8%).

CONCLUSION

We determined that the proportion of antidopaminergic-antiparkinsonian medication prescribing cascades, widely considered as high-priority, was low. Our approach can be used to assess the proportion of prescribing cascades in populations considered to be at high risk and to prioritize system-level interventional efforts to improve medication safety in these patients.

Cost-related Medication Nonadherence and Its Risk Factors Among Medicare Beneficiaries

BACKGROUND

Unaffordability of medications is a barrier to effective treatment. Cost-related nonadherence (CRN) is a crucial, widely used measure of medications access.

OBJECTIVES

Our study examines the current national prevalence of and risk factors for CRN (eg, not filling, skipping or reducing doses) and companion measures in the US Medicare population.

RESEARCH DESIGN

Survey-weighted analyses included logistic regression and trends 2006-2016.

SUBJECTS

Main analyses used the 2016 Medicare Current Beneficiary Survey. Our study sample of 12,625 represented 56 million community-dwelling beneficiaries.

MEASURES

Additional outcome measures were spending less on other necessities in order to pay for medicines and use of drug cost reduction strategies such as requesting generics.

RESULTS

In 2016, 34.5% of enrollees under 65 years with disability and 14.4% of those 65 years and older did not take their medications as prescribed due to high costs; 19.4% and 4.7%, respectively, experienced going without other essentials to pay for medicines. Near-poor older beneficiaries with incomes $15-25K had 50% higher odds of CRN (vs. >$50K), but beneficiaries with incomes <$15K, more likely to be eligible for the Part D Low-Income Subsidy, did not have significantly higher risk. Three indicators of worse health (general health status, functional limits, and count of conditions) were all independently associated with higher risk of CRN.

CONCLUSIONS

Changes in the risk profile for CRN since Part D reflect the effectiveness of targeted policies. The persistent prevalence of CRN and associated risks for sicker people in Medicare demonstrate the consequences of high cost-sharing for prescription fills.

Prescribing cascades in persons with Alzheimer's disease: engaging patients, caregivers, and providers in a qualitative evaluation of print educational materials

Introduction

Prescribing cascades occur when the side effect of a drug is misinterpreted as a new medical condition, and a second drug is prescribed to address the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades due to greater multimorbidity, polypharmacy, and complexity of care. The objective of this study was to evaluate educational materials about prescribing cascades in persons with AD, and elicit input on their use in a future trial.

Methods

We interviewed community-dwelling adults with either an AD diagnosis or a prescription drug used to treat AD (n = 12), caregivers of patients meeting the same criteria (n = 14), and providers (n = 15). We coded interview transcripts and organized themes according to the communication-human information processing model. We revised the materials based on the interviews, and surveyed participating caregivers and providers for their reactions to the revised materials.

Results

Analysis of patients', caregivers', and providers' comments suggest: (a) Providers had conflicting views about the messaging of materials; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patient/caregiver-initiated conversations; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried that mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect the clinical encounter; (g) Participants felt that materials would improve patient/caregiver engagement. When surveyed, most providers found the revised materials informative and actionable, and most caregivers found them understandable and useful.

Conclusions

This evaluation of educational materials about prescribing cascades in patients with AD provides strong support for engaging caregivers to communicate with providers about prescribing cascades. By giving patients and caregivers a basic description of the prescribing cascade concept, our educational materials may help them prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future trial.

Lay summary

Patient, caregiver and provider thoughts on educational materials about prescribing and medication safety Prescribing cascades occur when the side effect of a medication is misinterpreted as a new medical condition, and a second medication is prescribed to treat the side effect. Persons with Alzheimer's disease (AD) are at increased risk of prescribing cascades because they often have more medical conditions, more medications, and more complex care. The goal of this study was to evaluate mailed educational materials about prescribing cascades in persons with AD, and get input on their use in a future study. We interviewed 12 adults with AD, or prescribed a medication to treat AD, 14 caregivers of persons with AD, and 15 providers. We reviewed the interview transcripts to identify important findings about our educational materials. We edited the materials based on the interviews, and sent participating caregivers and providers a questionnaire to get their reactions to the new materials. Important findings from the interviews suggest: (a) Providers had conflicting views about the recommendations given; (b) Caregivers were likely to read letters addressed to patients; (c) Providers were likely to ignore letters, but were receptive to patients/caregivers introducing the topic; (d) Patients and caregivers had difficulty understanding prescribing cascades; (e) Providers worried mailed materials would undermine trust; (f) Participants had mixed views on how materials might affect a doctor's appointment; (g) Participants felt strongly that materials would improve patient/caregiver engagement. When surveyed, almost all providers found the revised materials informative and actionable; and most caregivers found them understandable and useful. These findings provide strong support for engaging caregivers to communicate with providers about prescribing cascades. The educational materials may help patients and caregivers prepare for a conversation with the provider, who can then tailor the discussion of the possible cascade to the specific needs of the individual patient and caregiver. However, evidence on whether materials can stimulate such conversations awaits testing in a future study.

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study

BACKGROUND/OBJECTIVES

In the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.

DESIGN

Pragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.

SETTING

A total of 86 primary care practices within 10 U.S. healthcare systems.

PARTICIPANTS

A random subsample of 743 persons aged 75 and older.

MEASUREMENTS

The well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.

RESULTS

Participants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.

CONCLUSIONS

STRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being.

Noncardiac-Related Morbidity, Mobility Limitation, and Outcomes in Older Adults With Heart Failure

BACKGROUND

To examine the individual and combined associations of noncardiac-related conditions and mobility limitation with morbidity and mortality in adults with heart failure (HF).

METHODS

We conducted a retrospective cohort study in a large, diverse group of adults with HF from five U.S. integrated healthcare delivery systems. We characterized patients with respect to the presence of noncardiac conditions (<3 vs ≥3) and/or mobility impairment (defined by the use/nonuse of a wheelchair, cane, or walker), categorizing them into four subgroups. Outcomes included all-cause death and hospitalizations for HF or any cause.

RESULTS

Among 114,553 adults diagnosed with HF (mean age: 73 years old, 46% women), compared with <3 noncardiac conditions/no mobility limitation, adjusted hazard ratios (HR) for all-cause death among those with <3 noncardiac conditions/mobility limitation, ≥3 noncardiac conditions/no mobility limitation, ≥3 noncardiac conditions/mobility limitation (vs) were 1.40 (95% CI, 1.31-1.51), 1.72 (95% CI, 1.69-1.75), and 1.93 (95% CI, 1.85-2.01), respectively. We did not observe an increased risk of any-cause or HF-related hospitalization related to the presence of mobility limitation among those with a greater burden of noncardiac multimorbidity. Consistent findings regarding mortality were observed within groups defined according to age, gender, and HF type (preserved, reduced, mid-range ejection fraction), with the most prominent impact of mobility limitation in those <65 years of age.

CONCLUSIONS

There is an additive association of mobility limitation, beyond the burden of noncardiac multimorbidity, on mortality for patients with HF, and especially prominent in younger patients.