A method for assessing drug therapy appropriateness

Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

Medication inappropriateness for older adults receiving hospice care: a pilot survey

OBJECTIVE

To test the feasibility and reliability of a tool and methodology for evaluating expert clinicians' perceptions about the application of the Beers criteria in hospice.

DESIGN

A pilot survey.

SETTING

A national medication therapy management provider specializing in hospice care.

PARTICIPANTS

Thirty-five participants from a multidisciplinary panel were invited to complete the survey. They were selected to represent acute, long-term care, and community practice settings with various levels of experience and judgment.

INTERVENTION

Respondents were asked to complete the survey by rating their agreement or disagreement with the inappropriateness of the medications or medication classes for hospice patients, using a five-point Likert scale from strongly agree (1) to strongly disagree (5), with the midpoint (3) expressing equivocation.

MAIN OUTCOME MEASURES

Feasibility as measured by the percentage of returned and completed surveys. A secondary aim was to measure inter-rater reliability and response.

RESULTS

Twenty-four clinicians (69%) completed the survey, including 13 clinical pharmacists, 6 nurses, and 5 physicians. Twenty-nine responses (2%) were furnished by imputation methods. The intraclass correlation for medication inappropriateness for hospice patients was 0.89 (0.81-0.95), indicating "good" inter-rater reliability. Short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines were considered appropriate for use in older hospice patients, but they are considered inappropriate according to the Beers criteria.

CONCLUSION

We established a viable methodology for evaluating clinician judgment about medication inappropriateness in older hospice patients. Some medications routinely considered to be inappropriate may be appropriate at end of life; different criteria may be needed to determine medication inappropriateness in hospice care.

Inappropriate prescribing in older people

Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.

Inappropriate prescribing in geriatric patients

Inappropriate prescribing in older people is a common condition associated with significant morbidity, mortality, and financial costs. Medication use increases with age, and this, in conjunction with an increasing disease burden, is associated with adverse drug reactions. This review outlines why older people are more likely to develop adverse drug reactions and how common the problem is. The use of different tools to identify and measure the problem is reviewed. Common syndromes seen in older adults (eg, falling, cognitive impairment, sleep disturbance) are considered, and recent evidence in relation to medication use for these conditions is reviewed. Finally, we present a brief summary of significant developments in the recent literature for those caring for older people.

Evaluating the clinical appropriateness of nurses' prescribing practice: method development and findings from an expert panel analysis

BACKGROUND

The number of nurses independently prescribing medicines in England is rising steadily. There had been no attempt systematically to evaluate the clinical appropriateness of nurses' prescribing decisions.

AIMS

(i) To establish a method of assessing the clinical appropriateness of nurses' prescribing decisions; (ii) to evaluate the prescribing decisions of a sample of nurses, using this method.

METHOD

A modified version of the Medication Appropriateness Index (MAI) was developed, piloted and subsequently used by seven medical prescribing experts to rate transcripts of 12 nurse prescriber consultations selected from a larger database of 118 audio-recorded consultations collected as part of a national evaluation. Experts were also able to give written qualitative comments on each of the MAI dimensions applied to each of the consultations.

ANALYSIS

Experts' ratings were analysed using descriptive statistics. Qualitative comments were subjected to a process of content analysis to identify themes within and across both MAI items and consultations.

RESULTS

Experts' application of the modified MAI to transcripts of nurse prescriber consultations demonstrated validity and feasibility as a method of assessing the clinical appropriateness of nurses' prescribing decisions. In the majority of assessments made by the expert panel, nurses' prescribing decisions were rated as clinically appropriate on all nine items in the MAI.

CONCLUSION

A valid and feasible method of assessing the clinical appropriateness of nurses' prescribing practice has been developed using a modified MAI and transcripts of audio-recorded consultations sent to a panel of prescribing experts. Prescribing nurses in this study were generally considered to be making clinically appropriate prescribing decisions. This approach to measuring prescribing appropriateness could be used as part of quality assurance in routine practice, as a method of identifying continuing professional development needs, or in future research as the expansion of non-medical prescribing continues.

A composite screening tool for medication reviews of outpatients: general issues with specific examples

Regular performance of medication reviews is prominent among methods that have been advocated to reduce the extent and seriousness of drug-related problems, such as adverse drug reactions, drug-disease interactions, drug-drug interactions, drug ineffectiveness and cost ineffectiveness. Several screening tools have been developed to guide practising healthcare professionals and researchers in reviewing the medication patterns of elderly patients; however, each of these tools has its own limitations. This review discusses a wide range of general prescription-, treatment- and patient-related issues that should be taken into account when reviewing medication patterns by implicit screening. These include generic and therapeutic substitution; potentially superfluous or inappropriate medications; potentially inappropriate dosages or duration of treatment; drug-disease and drug-drug interactions; under-treatment; making use of laboratory test results; patient adherence, experiences and habits; appropriate dosage forms and packaging. A broad selection of specific examples and references that can be used as a basis for explicit screening of medication patterns in outpatients is also offered.

Evaluation of medication reviews conducted by community pharmacists: a quantitative analysis of documented issues and recommendations

What is already known about this subject? There is conflicting evidence concerning the potential benefits of pharmacist-led medication review. Little work has been published on the completeness of medication reviews provided by community pharmacists. What this study adds. The 60 community pharmacists taking part in a large randomized controlled trial showed considerable variation in the completeness of the reviews they recorded for intervention patients. Overall, pharmacists recorded only a minority of the potential issues present in these patients. The frequency with which pharmacists recorded issues was not related to key characteristics or to the number of reviews completed.

AIMS

To describe issues noted and recommendations made by community pharmacists during reviews of medicines and lifestyle relating to coronary heart disease (CHD), and to identify and quantify missed opportunities for making further recommendations and assess any relationships with demographic characteristics of the pharmacists providing the reviews.

METHODS

All issues and recommendations noted by 60 community pharmacists during patient consultations were classified and quantified. Two independent reviewers studied a subsample of cases from every participating pharmacist and identified and classified potential issues from the available data. The findings of the pharmacists and the reviewers were compared. Relevant pharmacist characteristics were obtained from questionnaire data to determine relationships to the proportion of potential issues noted.

RESULTS

A total of 2228 issues and 2337 recommendations were noted by the pharmacists in the 738 patients seen, a median of three per patient (interquartile range 2-4). The majority of the recommendations made (1719; 74%) related to CHD. In the subsample of 169 patients (23% of the total), the reviewers identified 1539 potential issues, of which pharmacists identified an average of 33.8% (95% confidence interval 30.1, 36.4). No relationship was found between the proportion of issues noted and potentially relevant factors such as pharmacists' characteristics and their experience of doing reviews.

CONCLUSIONS

The majority of issues and recommendations noted by pharmacists related to CHD, although pharmacists recorded only a minority of the issues identified by reviewers. Variation between pharmacists in the completeness of reviews was not explained by review or other relevant experience.

A comprehensive appropriateness of prescribing questionnaire was validated by nominal consensus group

OBJECTIVE

To develop and validate a comprehensive Appropriateness of Prescribing Evaluation Questionnaire (APEQ) suitable for human and computer use.

STUDY DESIGN AND SETTING

This study was part of an ongoing research program examining the effectiveness and cost-effectiveness of computerized prescribing decision support for providers, patients, and drug policy. A nominal group consensus process involved physicians, both primary care physicians and specialists, pharmacists, drug plan managers, patients, patient advocates, and pharmaceutical industry. Structured case scenarios of musculoskeletal problems were used to evaluate APEQ's validity and responsiveness.

RESULTS

Seventeen panelists evaluated 72 patient scenarios in two rounds. Their ratings of appropriateness, assessed by ANOVA, showed significant agreement with the experts' scores in the two rounds, which evaluated appropriateness and responsiveness, respectively. Interrater and intrarater agreement was moderate to good.

CONCLUSION

This formal assessment suggests that APEQ has reasonable validity, reliability, and responsiveness. Such tools could be very useful in e-prescribing and e-claims reimbursement environments and should be further explored.

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial

OBJECTIVES

To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing.

DESIGN

Randomized, controlled trial, with the patient as unit of randomization.

SETTING

Acute GEM unit.

PARTICIPANTS

Two hundred three patients aged 70 and older.

INTERVENTION

Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients.

MEASUREMENTS

Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge.

RESULTS

Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR)=9.1, 95% confidence interval (CI)=4.2-21.6 and OR=6.1, 95% CI=2.2-17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria.

CONCLUSION

Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes.

Appropriate prescribing in older people

As people age they almost invariably develop diseases which lead to the prescription of drugs – both to prevent disease progression and for symptomatic relief. Unfortunately, drug treatment in later life is also problematic. There is a dearth of evidence on the efficacy of drugs in people over the age of 80, and members of this age group are at highest risk of adverse drug reactions (ADR).

Prevalence of inappropriate prescribing in primary care

OBJECTIVE

To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved.

SETTING

A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen.

METHOD

Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients' own GPs. The GPs were asked to provide baseline information regarding the patients' medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded.

RESULTS

212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as 'not indicated', 6% were rated as 'ineffective', 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug-drug interactions, 8.6% had clinically significant drug-disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics.

CONCLUSION

The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

BACKGROUND

The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness.

OBJECTIVE

The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program.

METHODS

A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated.

RESULTS

Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study (P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period.

CONCLUSIONS

By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.

Conflicts and concordance between measures of medication prescribing quality

BACKGROUND

Several instruments commonly are used to assess the quality of medication prescribing. However, little is known about the relationship between these instruments or the concordance of their quality assessments when applied to the same group of patients.

METHODS

We assessed 3 indicators of prescribing quality in a cohort of 196 veterans age 65 and older who were taking 5 or more medications. These 3 indicators assessed whether each patient was (1) taking any medication from the drugs-to-avoid criteria of Beers et al, (2) taking any medication with a score of 3 or more on the Medication Appropriateness Index (MAI), and/or (3) taking 9 or more medications (polypharmacy). Kappa statistics were used to assess agreement between measures.

RESULTS

Mean age was 74.6 years, and patients used a mean of 8.1 medications. Six percent of drugs were rated inappropriate by the Beers drugs-to-avoid criteria, whereas 23% of drugs received an MAI score of 3 or more. Overall agreement between these metrics was 78%, little more than expected by chance (kappa statistic 0.14, P<0.01). At the level of the patient, the proportion of subjects taking one or more inappropriate drugs was 37% by drugs-to-avoid criteria and 82% by MAI, whereas 37% had polypharmacy of >or=9 drugs. Prescribing was classified as inappropriate by all 3 metrics in 18% of patients and as appropriate by all 3 metrics in 13%. Together, this level of agreement was slightly better than chance (3-way kappa statistic 0.08, P=0.03). Agreement remained low in sensitivity analyses using different cutoffs for the Beers criteria, a range of thresholds for MAI scores, and different definitions of polypharmacy, with kappa statistics<or=0.30 for all comparisons.

CONCLUSIONS

Commonly used measures of drug prescribing quality yield widely discordant results. Because the overall quality of prescribing may not be readily inferred from a single measure, multidimensional approaches will likely be necessary for robust assessment of prescribing quality.

Patients' evaluation of the appropriateness of their hypertension management--a qualitative study

BACKGROUND

The existing appropriateness measures for prescribing used in the United States and the United Kingdom use clinical attributes. Treatment and care from a patient's perspective need to be evaluated in terms of whether they are more likely to lead to an outcome of a life worth living, in social, psychological, and physical terms. However, it is unclear whether patients specifically evaluate their prescribed medication and treatment. If so, do they use only clinical attributes or a combination of clinical and nonclinical attributes?

OBJECTIVES

The aim of this study was to explore if patients evaluated their hypertension management, and if they did, investigate what attributes were involved in the evaluation.

METHODS

Semistructured interviews, which focused on personal experiences of hypertension and its management were undertaken with patients (n=28). The aim of the interviews was to obtain, in a narrative format, the experiences, beliefs, and information that patients considered important when discussing the management of hypertension. Data analysis used a constant comparative method.

RESULTS

All patients considered their hypertension management regimen appropriate, but were able to mention only 2 categories of attributes to justify their decision (the relationship with their General Practitioner and lowering of their blood pressure). Further series attributes were mentioned by the patient during the course of their interview; these attributes were considered to be involved in their evaluation. These implicit attributes were categorized as anxieties and concerns regarding treatment and diagnosis, explanation of the consequences of treatment, choice of antihypertensives, and the side effects experienced.

CONCLUSIONS

Patient's evaluation of appropriateness was constructed from both explicit and implicit attributes. Implicit attributes, those not consciously known to the patient still, could be involved in the process of evaluating hypertension, its treatment, and care. Although the nonmedical attributes that are considered by patients can be categorized, it has to be remembered that it is the inherent meaning held by each individual patient involved when an evaluation is made.

Polypharmacy and prescribing quality in older people

OBJECTIVES

To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients.

DESIGN

Cross-sectional study.

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

One hundred ninety-six outpatients aged 65 and older who were taking five or more medications.

MEASUREMENTS

Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses.

RESULTS

Mean age was 74.6, and patients used a mean+/-standard deviation of 8.1+/-2.5 medications (range 5-17). Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative. Medication underuse was observed in 125 patients (64%). Together, inappropriate use and underuse were simultaneously present in 82 patients (42%), whereas 25 (13%) had neither inappropriate use nor underuse. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate.

CONCLUSION

Inappropriate medication use and underuse were common in older people taking five or more medications, with both simultaneously present in more than 40% of patients. Inappropriate medication use is most frequent in patients taking many medications, but underuse is also common and merits attention regardless of the total number of medications taken.

Is it possible to measure prescribing quality using only prescription data?

A large number of prescribing quality indicators based on register data have been proposed and many are used routinely in quality management. Often the content and face validity of indicators have been assessed by consensus methods, but studies analysing other validity aspects are scarce. Prescription data are frequently used for indicators, but they do not provide any direct information about disease and patient factors important for judging the quality of prescribing. If register-based proxies for diagnoses, disease severity or risk factors are employed, validation is essential. The concurrent validity of indicators should be assessed by comparing to a "gold standard" quality assessment at the patient level using all available clinical information. The validity of frequently used quality indicators of asthma treatment has been questioned and should be further investigated. NSAID prescribing indicators are currently under evaluation. In the future, detailed clinical information from practice databases and computerised hospital records will be an important data source for indicators and for validation studies. Furthermore, the statistical and epidemiological properties of prescribing quality indicators need more attention.

Inappropriate drug use by Portuguese elderly outpatients--effect of the Beers criteria update

OBJECTIVE

To characterize the use of medicines and to evaluate the inappropriateness of drugs in elderly outpatient population.

SETTING

Twelve community pharmacies in different districts of Lisbon-Portugal.

METHOD

Observational cross-sectional survey, in a sample of 213 elderly outpatients (age>or=65-years-old) presenting a prescription with two or more drugs, for their own use.

MAIN OUTCOME MEASURES

Drug use pattern and prevalence of potentially inappropriate medication.

RESULTS

We have studied 213 outpatients, who were taking a total of 1,543 drugs, with an average of 7.23 per patient. The drugs were distributed mainly in the following 3 ATC (Anatomical Therapeutic Chemical Classification) classes: C (cardiovascular system), N (nervous system) and A (alimentary tract). Using the 1997 Beers Explicit criteria, 75 occurrences of inappropriate medicines were detected in 59 patients (27.7%), while with the 2003 Beers Explicit criteria we detected 114 cases of inappropriate medication in 82 patients (38.5%). The occurrence of inappropriate medicines was significantly associated with the consumption of a high number of drugs. According to the ATC Classification, more than one half of the cases of inappropriateness were related with long acting benzodiazepines and with ticlopidine. The 2003 version detected a significantly higher prevalence of inappropriate drug use having potentially adverse outcomes of high severity.

CONCLUSIONS

The application of the updated Beers criteria lead to higher rates of potentially inappropriate medication, and especially those responsible for more severe adverse outcomes. The results suggest that there is a need for interventions to improve instructions for safe drug use in the elderly patients and to decrease the number of medications whenever it is possible. This study suggests a high prevalence of potentially inappropriate drug use by the elderly patients of Lisbon region, Portugal.

Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults

BACKGROUND

Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents.

OBJECTIVES

The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients.

METHODS

Data were derived from a 1-year prospective study of home care clients aged > or =65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases.

RESULTS

Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications.

CONCLUSIONS

Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.

Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults

BACKGROUND

Adverse events from inappropriate medications are preventable risk factors for nursing home admissions.

OBJECTIVE

We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home.

METHODS

A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months.

RESULTS

Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26-1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20-2.47) for inappropriate narcotics and 2.68 (99% CI 2.55-2.82) for other narcotics, compared with no narcotic use.

CONCLUSION

Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.

Evidence-based guideline. Improving medication management for older adult clients

All providers and professionals who care for older adults have an important role to play in the process of managing medications. The evidence-based guideline "Improving Medication Management for Older Adult Clients" (Bergman-Evans, 2004) provides assessments and interventions that are useful across settings. By focusing on reducing inappropriate prescribing, decreasing polypharmacy, avoiding adverse events, and maintaining function, professionals and providers have the opportunity to improve outcomes for this important population.

Validation of a comprehensive classification tool for treatment-related problems

OBJECTIVE

Several drug-related problem classification systems can be found in the literature. However, it is generally agreed that a comprehensive, well constructed and validated instrument is currently lacking. The aim of this study is the development and validation of a comprehensive treatment-related problems assessment and classification tool for use in teaching, practicing and researching pharmaceutical care and to improve identification, resolving and preventing of treatment-related problems.

METHOD

The development and validation involved five steps starting with literature search to define a treatment related problem and also to form a database of treatment-related problems identified in the literature. In the next step, all problems that were identified in the first step and passed the evaluation of the three authors were pooled together and then divided into groups according to their common or shared construct, in the third step a suitable assessment method was developed according to the construct of the different problems, in the next step the developed instrument was validated for content, internal and external validity. Finally the tool was finalized and tested for reproducibility and inter-rater agreement.

RESULTS

The final validated version included six main categories for treatment-related problems (Indication, Effectiveness, Safety, Knowledge, Adherence and Miscellaneous). These categories include a total of nine subcategories and a total of 29 treatment related problems.

CONCLUSION

The treatment-related problems assessment and classification tool introduced in this paper was applied to actual patient cases and proved to be valid. This tool also has several features that are new.

Identification of potential drug-related problems in the elderly: the role of the community pharmacist

OBJECTIVE

The high prevalence of multiple drug use combined with age-related changes in pharmacokinetics and pharmacodynamics makes older adults more vulnerable to drug-related problems (DRPs). This pharmacy-based study was performed to identify potential DRPs from prescription records of the elderly and the role of the pharmacist in this process.

METHOD

The study was performed from June 2002 to February 2003 in 16 community pharmacies in the Netherlands. Medication assessment of elderly patients aged 65 and over using six or more drugs concomitantly took place on the date of inclusion. Ten types of potential DRPs, grouped into three categories, were determined. The three groups were patient-related, prescriber-related or drug-related potential DRPs. We looked at the occurrence, nature and determinants of differential potential DRPs.

RESULTS

The mean number of prescriptions per patient was 8.7. In total 3.9 potential DRPs per elderly person were identified. The distribution of the potential DRPs over the three categories was: patient related 4.7%, prescriber related 55.7% and drug related 39.6%. Use of NSAIDs (OR 29.9; 95% CI 4.1-219) and digoxin (OR 15.7; 95% CI 4.9-50.5) were associated with the highest risk for potential DRPs.

CONCLUSION

In this vulnerable group of elderly patients potential DRPs frequently occur. Community pharmacists can play an important role in the identification, assessment and prevention of potential DRPs in the elderly. It is useful to investigate which part of potential DRPs can be avoided by the intervention of the community pharmacist in collaboration with the prescriber and the patient.

Measuring the appropriateness of prescribing in primary care: are current measures complete?

BACKGROUND AND OBJECTIVES

Appropriateness of prescribing is often assessed by standard instruments. We wished to establish whether judgements of appropriateness that included patients' perspectives and contextual factors could lead to different conclusions when compared with commonly used instruments. To explore the predictive accuracy of these instruments.

METHODS

The design was interviews of patients, audio recordings of the consultation and interviews of the doctors, in varied primary care practices in England. Participants were patients who were likely to discuss a medication issue. The outcome measures were judgements of appropriateness made by the researchers and by two instruments: the Prescribing Appropriateness Index and the Medication Appropriateness Index. Implications for the predictive accuracy of the measures was also investigated.

RESULTS

From 35 cases there was agreement between the judges and the instruments in 22 cases, 16 were appropriate and 6 inappropriate. Of 10 cases classified as inappropriate by the instruments the judges thought four were appropriate. Of 18 cases classified as appropriate by the instruments, two were considered inappropriate by the judges. In seven cases the prescribing decisions could not be classified by the instruments because the decision was to not prescribe.

CONCLUSIONS

Current measures of appropriateness of prescribing depend predominantly on pharmacological criteria, and so do not represent cases that would be judged appropriate when including the patient's views and contextual factors. If most prescribing is appropriate then use of these measures may lead to more false negatives than real negatives. The instruments should be renamed as measures of 'pharmacological appropriateness' and are useful where the incidence of this type of inappropriate prescribing is relatively high.

Pharmacy practice, research, education, and advocacy for older adults

In the United States, older adults have become the fastest growing segment of the population and are expected to double in number to 70 million by 2030. As a whole, older adults have different health care needs than younger patients, and some of these needs should be met by pharmacists. Clinical pharmacy practice affecting older adults occurs in a variety of settings, including community, ambulatory care, primary care, hospital, assisted living, nursing home, home health care, hospice, and Alzheimer's disease units. Although specialty training in geriatrics or gerontology is not required for pharmacists to care for older adults, it is extremely helpful. Pharmacy education related to the care of older adults has improved slightly in the past several years but will need to increase even more to provide all pharmacists with the basic skills and knowledge to care for this unique group of patients. In addition, pharmacotherapy research targeting older adults needs to increase. Although it can be challenging, funding for this type of research is available. Patient and political advocacy is also important to support this growing population.

Bon usage des antibiotiques à l’hôpital

INTRODUCTION

The rationalization of medical practices for antibiotic use in hospitals is necessary to improve both the cost-efficiency and effectiveness of health care. This study sought to investigate the impact of implementation of local management guidelines for inpatient community-acquired pneumonia (CAP).

METHODS

This retrospective, comparative study measured the quality of antibiotic prescriptions with the 10-item Medication Appropriateness Index (MAI). Clinical and demographic characteristics, as well as process-of-care and outcome indicators, were recorded for all patients with CAP admitted to a medical ward at the Nantes university hospital during two 12-month periods: before (Period A, 39 patients) and after (Period B, 50 patients) implementation of local guidelines.

RESULTS

The MAI was significantly higher during period B than period A (5.1 points compared with 2.2, p=0.0001). Guideline implementation shortened the mean duration of antibiotic treatment (13.1 versus 16.0 days, p=0.0003) and of intravenous treatment (3.4 versus 4.7 days, p=0.04). The mean duration of hospital stay also fell substantially (7.4 versus 15.0 days, p=0.0001), as did the mean cost of antibiotics (35.4 versus 64.1 euros, p=0.003).

DISCUSSION

The MAI confirmed that antimicrobial practices varied significantly and that appropriate local guidelines improved the quality of antibiotic prescriptions and saved hospitalization costs.

CONCLUSION

The MAI, which assesses the appropriateness of antibiotic use in hospitals, could be an interesting tool for prospective use as an indicator of quality-of-care improvement and for more efficient use of available health care resources.

Qualidade do uso de medicamentos por idosos: uma revisão dos métodos de avaliação disponíveis

O artigo apresenta diferentes métodos de avaliação da adequação da terapia farmacológica para idosos, a partir da revisão da literatura no período de 1990 a 2003. Na década de 1990, foi criada uma variedade de métodos os quais são classificados, de acordo com a utilização de critérios, em implícitos, explícitos e aqueles que combinam ambos. São apresentadas as vantagens e desvantagens de cada método e observa-se que os métodos que utilizam combinação de critérios permitem uma melhor avaliação, uma vez que incorporam um maior número de elementos envolvidos no processo de utilização de medicamentos. A adequação ou adaptação destes métodos à realidade brasileira e a incorporação dos mesmos às práticas avaliativas em saúde podem se constituir em um passo fundamental na promoção do uso racional de medicamentos no país.

Potentially inappropriate prescribing before and after nursing home admission among patients with and without dementia

OBJECTIVES

This study was designed to describe changes in the prevalence of potentially inappropriate medication prescribing before and after nursing home admission, and to compare prevalence among residents with and without dementia. This paper extends the research on inappropriate medication prescribing among residents entering a nursing home, with the added feature of comparison by dementia status.

METHODS

This retrospective cohort study was conducted using data from 59 randomly selected nursing homes in Maryland. Dually eligible (Medicare/Medicaid) residents aged > or = 65 years who were admitted to one of these nursing homes from 1992 to 1995 were eligible for inclusion in the cohort. An expert panel of physicians determined dementia status at admission. Potentially inappropriate prescribing, as defined by the 1997 Beers criteria, was compared using Medicaid prescription claims for up to 12 months before and after admission to characterize monthly prescribing patterns.

RESULTS

The study group included 546 dually eligible nursing home residents with > or = 1 paid prescription claim for the 12 months before or after their admission date. A total of 372 (68%) residents were white, 443 (81%) were unmarried, 408 (75%) were female, and 334 (61%) were diagnosed with dementia at admission. Before nursing home admission, the mean monthly prevalence of potentially inappropriate medications for residents with and without dementia was 20% and 23%, respectively. After admission, the mean monthly prevalence increased to 28% among residents without dementia and decreased to 19% among residents with dementia. After adjusting for the mean number of other prescriptions, sociodemographic factors, and number of comorbid conditions, residents with dementia were as likely as residents without dementia to receive a potentially inappropriate drug before admission (prevalence ratio, 0.97; 95% CI, 0.58-1.62). After admission, residents with dementia were 27% less likely than residents without dementia to receive a potentially inappropriate drug, although the difference did not reach statistical significance (prevalence ratio, 0.73; 95% CI, 0.53-1.01).

CONCLUSIONS

Inappropriate medication prescribing was similar before nursing home admission among patients with and without dementia. After admission, the prevalence was lower among residents with dementia, but it did not reach statistical significance.

Patterns of drug prescription in a geriatric evaluation and management unit as compared with the general medical wards: a randomised study

OBJECTIVE

This study's objective was to determine whether patients treated in a geriatric evaluation and management unit (GEMU) had a more appropriate drug profile than patients treated in the general medical wards (MW).

METHODS

Frail elderly patients admitted as emergencies to the medical department were randomised to treatment in the GEMU (n=127) or MW (n=127). Drugs used at inclusion and discharge were registered retrospectively and analysed with regard to polypharmacy, number of drugs withdrawn or started, potential drug-drug interactions (DDIs), number of anticholinergic drugs prescribed, and the number of inappropriate drug prescriptions according to Beers' criteria. Utilisation of psychotropic and cardiovascular drugs was compared in detail according to prespecified hypotheses.

RESULTS

The number of patients with polypharmacy did not differ significantly between the GEMU and MW. The median number of scheduled drugs withdrawn per patient was higher in the GEMU than in the MW (p=0.005). Drugs with anticholinergic effects (p=0.003); cardiovascular drugs (p<0.001), particularly digitalis glycosides (p<0.001); and antipsychotic drugs (p=0.009) were withdrawn more often in the GEMU. The median number of scheduled drugs started was higher in the GEMU than in the MW (p=0.03). In particular, antidepressants (p<0.001) and estriol (p=0.001) were started more often in the GEMU than in the MW. Fewer GEMU than MW patients had potential DDIs at discharge (p=0.009).

CONCLUSION

Drug treatment in the GEMU as compared with the MW was more appropriate in terms of prescription of fewer drugs with anticholinergic effects and fewer potential DDIs. There were distinct differences in treatment patterns of cardiovascular and psychotropic drugs.

Unnecessary drug use in frail older people at hospital discharge

OBJECTIVES

To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients.

DESIGN

Cross-sectional.

SETTING

Eleven Veterans Affairs Medical Centers.

PARTICIPANTS

Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study.

MEASUREMENTS

Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary.

RESULTS

Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38-0.96), multiple prescribers (AOR=3.35, 95% CI=1.16-9.68), and nine or more medications (AOR=2.24, 95% CI=1.25-3.99).

CONCLUSION

A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.

The validity of explicit indicators of prescribing appropriateness

OBJECTIVE

To assess, from the perspective of UK hospital doctors, the content validity and operational validity of a set of 14 previously developed explicit indicators of the appropriateness of long-term prescribing started during a hospital admission.

METHOD

A combination of data extraction from medical records and qualitative interviews with a maximum variability sample of hospital doctors.

PARTICIPANTS

The indicators were applied to 132 new prescriptions, intended for long-term use, prescribed for 61 patients; 36 doctors, of various grades, were purposively selected for interview.

RESULTS

Appropriate prescribing was viewed as prescribing that was indicated, necessary, evidence based (using a broad meaning of 'evidence') and of acceptable cost and risk-benefit ratio. These concepts applied to individual drugs for individual patients, rather than at a more general, public health level. Where drugs had failed an indicator, rationales were explored. Often, it was missing data in the medical notes that had resulted in the drug failing the indicator.

CONCLUSIONS

The 14 indicators were considered to have content validity, reflecting all aspects of appropriate prescribing discussed by the doctors. Their operational validity was less clear-cut, due to the lack of necessary data in the medical notes. This has implications for the use of explicit indicators for assessing prescribing appropriateness, as these hospital doctors did not consider that the data required for objective, systematic assessment of prescribing would ever be recorded in hospital medical notes.

Reliability of a modified medication appropriateness index in primary care

OBJECTIVE

To evaluate the inter-group and intra-group reliability of a modified Medication Appropriateness Index (MAI) for use in primary care.

METHODS

Elderly (>65 years) polypharmacy (> or =5 drugs) patients in Copenhagen County participated in the study. Information concerning their medical history and information regarding each drug taken by them was provided by their own general practitioners. A MAI was scored by two groups of evaluators for every drug. To evaluate inter-group agreement, 211 drugs taken by 30 patients were rated according to the ten criteria making up the MAI. Both evaluator groups provided summaries of comments on the medication of each patient. Intra-group agreement was determined from MAI ratings performed twice at two different times on 86 drugs taken by ten patients. Agreement and chance-adjusted agreement were determined, the latter through kappa statistics. The proportion of positive (ppos) and negative (pneg) agreement was also determined.

RESULTS

The overall chance-adjusted inter-group agreement (kappa) was moderate. The agreement was good on the criteria practical directions and drug-disease interaction, moderate on the criteria dosage and duration, fair on the criteria indication, effectiveness, duplication and expense, and poor on the criterion drug-drug interaction. The overall chance-adjusted intra-group agreement was good for all criteria and very good for the criteria indication and practical directions.

CONCLUSION

The MAI is used to quantify appropriate and inappropriate prescribing and changes in prescribing quality in intervention studies. However, caution should be used when comparing results across different settings and evaluators. Our study suggests that the index should only be used in intervention studies if the same group rates the appropriateness pre- and post-intervention.

Development and Face Validity of Explicit indicators of Appropriateness of Long Term Prescribing

OBJECTIVES

To develop a set of explicit and operationalisable indicators of appropriate prescribing and assess their face validity using clinical pharmacists practising in secondary and primary care.

METHOD

Appropriateness indicators were derived from the literature, applied to data in the hospital clinical records of all newly prescribed long-term drugs for 50 randomly selected patients, further refined and then applied to another 25 randomly selected patients. A pre-piloted postal questionnaire was sent to 200 hospitals and primary care pharmacists, asking them to assess the indicators as to their importance for the assessment of appropriateness of long-term prescribing initiated in hospitals.

RESULTS

Fourteen indicators were developed and piloted. Of the 16 original indicators, 5 were discarded, as they were unable to be operationalised, and 2 were subdivided to reflect the routinely available data. Eighty-six pharmacists with individual patient-focussed clinical duties took part in the assessment of the face validity (response rate 43%). Eleven indicators achieved a median importance rating of 1 (very important), and three indicators a median importance rating of 2 on a 5-point scale. The three most important indicators overall were "indication included in discharge summary", "questionable high-risk therapeutic combination" and "hazardous drug-drug combination".

CONCLUSION

It was possible to develop and operationalise 14 indicators of the appropriateness of long-term prescribing commenced in hospital practice, all of which were considered to have face validity by an expert panel of clinical pharmacists. The development of these explicit indicators highlighted the incompleteness of the patient's record. Further work is needed to assess their validity and reliability, before their use in research or audit can be recommended.

Polypharmacy trends in office visits by the elderly in the United States, 1990 and 2000

BACKGROUND

Polypharmacy has been extensively studied internationally and reported to be increasing among the elderly. Within the United States, few studies have examined polypharmacy trends in the elderly population and even fewer studies addressed those at-risk for polypharmacy.

OBJECTIVES

To examine the trends in office-based visits in the United States by the elderly involving polypharmacy and identify elderly at-risk for polypharmacy.

METHODS

Data from the 1990 and 2000 National Ambulatory Medical Care Surveys were used to examine polypharmacy visit trends in the elderly. The Bonferroni inequality method was used to analyze the visit estimates and visit rates. Logistic regression analysis was used to model predisposing, enabling, and need factors associated with polypharmacy visits in the elderly using the 2000 survey data.

RESULTS

Office visits involving polypharmacy for elderly patients were estimated to have nearly quadrupled from 10.1 million in 1990 to 37.5 million in 2000. The proportion of visits by elderly patients involving polypharmacy was 7% in 1990 and 19% in 2000. The increase was consistent among all demographic groups and remained significant even after controlling for elderly population increase. Medication classes involved in polypharmacy remained consistent during the study period and included cardiovascular, hormonal, pain, and gastrointestinal medications. Analysis of the 2000 survey data revealed that several need (multiple diagnoses, chronic problems, and specific disease states), predisposing (female gender), and enabling factors (primary care provider visit and health insurance coverage) were associated with polypharmacy visits in the elderly.

CONCLUSIONS

The study found a significant increase in elderly patients' office visits involving polypharmacy in the United States. The study also found that several need, predisposing, and enabling factors were associated with polypharmacy visits in the elderly. These findings suggest opportunities to review and manage elderly patients' medications as recommended by Healthy People 2010, a national agenda to improve the health of Americans.

Inter-rater reliability of explicit indicators of prescribing appropriateness

OBJECTIVE

To assess the inter-rater reliability of 14 explicit indicators of appropriate long-term prescribing.

METHOD

All available data required for the assessment of 59 long-term prescriptions started during a hospital admission for 25 patients were transcribed from the patients' medical records. These transcripts were presented in a standardised format and random order to four raters (two doctors and two pharmacists) who used the indicators to judge the appropriateness of each prescription. Debriefing interviews were held with each rater. An a priori level of acceptable agreement between the raters was set at a weighed kappa of 0.70.

RESULTS

There was no apparent difference between pharmacists and doctors for all findings, so data were combined. Two indicators showed poor agreement, three showed moderate agreement, and nine showed substantial or near perfect agreement, exceeding a weighted kappa of 0.70. There was excellent positive agreement as to which prescriptions were judged appropriate by the indicators, but much worse negative agreement as to which prescriptions were judged to be inappropriate. In the interviews, the raters remarked on the difficulty of applying explicit indicators when they routinely made implicit judgements about data in the medical records.

CONCLUSION

Nine of the indicators achieved the required level of reliability and the negative agreement levels showed that this was the area that required greater improvement in future developments of the indicators. Further work needs to be conducted to investigate ways of the improving instructions on how to make explicit judgements and reducing the need for implicit or subjective assessments.

Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial

BACKGROUND

Poorly executed transfers of older patients from hospitals to long-term care facilities carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission.

OBJECTIVE

This study was conducted to assess the impact of adding a pharmacist transition coordinator on evidence-based medication management and health outcomes in older adults undergoing first-time transfer from a hospital to a long-term care facility.

METHODS

This randomized, single-blind, controlled trial enrolled hospitalized older adults awaiting transfer to a long-term residential care facility for the first time. Patients were randomized either to receive the services of the pharmacist transition coordinator (intervention group) or to undergo the usual hospital discharge process (control group). The intervention included medication-management transfer summaries from hospitals, timely coordinated medication reviews by accredited community pharmacists, and case conferences with physicians and pharmacists. The primary outcome was the quality of prescribing, measured using the Medication Appropriateness Index (MAI). Secondary outcomes were emergency department visits, hospital readmissions, adverse drug events, falls, worsening mobility, worsening behaviors, increased confusion, and worsening pain.

RESULTS

One hundred ten older adults (67 women, 43 men; mean [SD] age, 82.7 [6.4] years) were recruited from 3 metropolitan hospitals and assigned to 85 metropolitan long-term care facilities. Fifty-six patients were randomized to the intervention group and 54 to the control group; 44 patients in each group were evaluable at 8-week follow-up. There were no significant differences in baseline characteristics between treatment groups, with the exception of the number of medications discontinued during hospitalization: a mean of 1.1 more drugs was discontinued in the control group compared with the intervention group (P = 0.011). The majority of patients (35 [62.5%] in the intervention group, 41 [76.0%] in the control group) changed physicians as part of the transition to a long-term care facility. At 8-week follow-up, there was no change in MAI from baseline in the intervention group, whereas it had worsened in the control group (mean [95% CI], 2.5 [1.4-3.7] vs 6.5 [3.9-9.1], respectively; P = 0.007). Patients who received the intervention and were alive at follow-up exhibited a significant protective effect of the intervention against worsening pain (relative risk ratio [95% CI], 0.55 [0.32-0.94]; P = 0.023) and hospital usage (i.e., the combination of emergency department visits and hospital readmissions) (0.38 [0.15-0.99]; P = 0.035), but did not differ from control patients in terms of adverse drug events (1.05 [0.66-1.68]), falls (1.19 [0.71-1.99]), worsening mobility (0.39 [0.13-1.15]), worsening behaviors (0.52 [0.25-1.10]), or increased confusion (0.59 [0.28-1.22]). When data for patients who had died were included, the intervention had no effect on hospital usage in all patients (0.58 [0.28-1.21]).

CONCLUSIONS

Older people transferring from hospital to a long-term care facility are vulnerable to fragmentation of care and adverse events. In this study, use of a pharmacist transition coordinator improved aspects of inappropriate use of medicines across health sectors.

Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention

BACKGROUND

There is limited information from randomized controlled studies about the influence of pharmacist interventions on diabetes control.

OBJECTIVE

To evaluate the effect of a pharmacist intervention on improving diabetes control; secondary endpoints were medication appropriateness and self-reported adherence.

METHODS

A randomized, controlled, multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics. Seventy-seven subjects, > or =18 years old with a hemoglobin (Hb) A(1c) > or =9% at baseline and taking at least one oral diabetes medication, were randomized to receive a pharmacist intervention (n = 43) or usual care (n = 34) for 6 months followed by a 6-month usual-care observation period for both groups. Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence. HbA(1c), medication appropriateness, and self-reported adherence were assessed at baseline, 6 months, and 12 months.

RESULTS

The mean HbA(1c) did not differ between groups over the 12-month period (p = 0.61). A reduction in HbA(1c) was noted for both groups over time compared with baseline (p = 0.001); however, control subjects relied more heavily on provider visits. Medication appropriateness was not improved for diabetes medications (p = 0.65). Self-reported adherence was not significantly improved by the intervention.

CONCLUSIONS

This pharmacist intervention did not significantly improve diabetes control, but did allow for similar HbA(1c) control with fewer physician visits. Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed.

Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents

BACKGROUND

There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use.

OBJECTIVE

The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged >or=68 years, as determined by the relationship of these criteria to health service use in older community residents.

METHODS

Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an in-home interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services.

RESULTS

A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P<0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry.

CONCLUSIONS

Our data suggest that in representative community residents aged >or=68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria).

Potentially Inappropriate Drug Prescribing Among First-Visit Elderly Outpatients in Taiwan

STUDY OBJECTIVE

To determine the prevalence and risk factors of potentially inappropriate drug prescribing among first-visit elderly outpatients.

DESIGN

Cross-sectional survey.

SETTING

An urban tertiary care and academic medical center in southern Taiwan.

PATIENTS

Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001.

MEASUREMENTS AND MAIN RESULTS

Potentially inappropriate drug prescribing was assessed according to updated Beers criteria. Ninety-seven potentially inappropriate drugs were identified in 93 (10.5%) patients. The most common classes were sedative-hypnotics (18.6%) and muscle relaxants (17.5%). Twenty (20.6%) of these inappropriate drugs had a high severity potential according to the Beers criteria. Patients prescribed potentially inappropriate drugs were more likely to be prescribed several drugs versus those who were not prescribed potentially inappropriate drugs (4.0+/-1.9 vs 2.8+/-1.4, p<0.001). Multiple logistic regression analysis revealed an interaction between age and the number of prescribed drugs on the risk of having potentially inappropriate drugs prescribed. In patients who were prescribed four agents or less, the risk was not associated with increasing age; in those who were prescribed five drugs or more, the risk was positively associated with increasing age.

CONCLUSION

Potentially inappropriate drug prescribing among first-visit elderly outpatients was relatively low. Increasing patient age combined with increased number of drugs prescribed was associated with increased risk of having potentially inappropriate drugs prescribed.

Pharmaceutical care for elderly patients shared between community pharmacists and general practitioners: a randomised evaluation. RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) [ISRCTN16932128]

BACKGROUND

This trial aims to investigate the effectiveness and cost implications of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community. As the UK government has proposed that by 2004 pharmaceutical care services should extend nationwide, this provides an opportunity to evaluate the effect of pharmaceutical care for the elderly.

DESIGN

The trial design is a randomised multiple interrupted time series. We aim to recruit 700 patients from about 20 general practices, each associated with about three community pharmacies, from each of the five Primary Care Trusts in North and East Yorkshire. We shall randomise the five resulting groups of practices, pharmacies and patients to begin pharmaceutical care in five successive phases. All five will act as controls until they receive the intervention in a random sequence. Until they receive training community pharmacists will provide their usual dispensing services and so act as controls. The community pharmacists and general practitioners will receive training in pharmaceutical care for the elderly. Once trained, community pharmacists will meet recruited patients, either in their pharmacies (in a consultation room or dispensary to preserve confidentiality) or at home. They will identify drug-related issues/problems, and design a pharmaceutical care plan in conjunction with both the GP and the patient. They will implement, monitor, and update this plan monthly. The primary outcome measure is the 'Medication Appropriateness Index'. Secondary measures include adverse events, quality of life, and patient knowledge and compliance. We shall also investigate the cost of pharmaceutical care to the NHS, to patients and to society as a whole.