Comorbidity and repeat admission to hospital for adverse drug reactions in older adults: retrospective cohort study

Irrational Use of Medicines-A Summary of Key Concepts

Medicines play an integral part of healthcare delivery. However, they are expensive commodities and account for a significant proportion of overall health expenditure in most countries. Irrational use of medicines is a major challenge facing many health systems across the world. Such practices are likely to lead to poor health delivery that may put patients at risk and result in wastage of scarce resources that could have been used to tackle other pressing health needs. The concept of "rational use of medicine" can at times be confusing and not easily appreciated by patients, healthcare providers, policy makers, or the public, all of whom need to collaborate effectively to address this challenge. In this article, we summarize basic concepts such as rational medicine use, good prescribing and dispensing, and explore some of the factors that contribute to irrational use of medicines as well as potential impacts of such practices. This article has been written with the intention of offering a clear, concise, and easy to understand explanation of basic medicine use concepts for health professionals, patients, policy makers, and the public.

Adverse events in the intensive care unit: impact on mortality and length of stay in a prospective study

This study sought to evaluate the occurrence of adverse events and their impacts on length of stay and mortality in an intensive care unit (ICU). This is a prospective study carried out in a teaching hospital in Rio de Janeiro, Brazil. The cohort included 355 patients over 18 years of age admitted to the ICU between August 1, 2011 and July 31, 2012. The process we used to identify adverse events was adapted from the method proposed by the Institute for Healthcare Improvement. We used a logistical regression to analyze the association between adverse event occurrence and death, adjusted by case severity. We confirmed 324 adverse events in 115 patients admitted over the year we followed. The incidence rate was 9.3 adverse events per 100 patients-day and adverse event occurrence impacted on an increase in length of stay (19 days) and in mortality (OR = 2.047; 95%CI: 1.172-3.570). This study highlights the serious problem of adverse events in intensive care and the risk factors associated with adverse event incidence. Resumo: Este estudo teve como objetivo avaliar a ocorrência de eventos adversos e o impacto deles sobre o tempo de permanência e a mortalidade na unidade de terapia intensiva (UTI). Trata-se de um estudo prospectivo desenvolvido em um hospital de ensino do Rio de Janeiro, Brasil. A coorte foi formada por 355 pacientes maiores de 18 anos, admitidos na UTI, no período de 1º de agosto de 2011 a 31 de julho de 2012. O processo de identificação de eventos adversos baseou-se em uma adaptação do método proposto pelo Institute for Healthcare Improvement. A regressão logística foi utilizada para analisar a associação entre a ocorrência de evento adverso e o óbito, ajustado pela gravidade do paciente. Confirmados 324 eventos adversos em 115 pacientes internados ao longo de um ano de seguimento. A taxa de incidência foi de 9,3 eventos adversos por 100 pacientes-dia, e a ocorrência de evento adverso impactou no aumento do tempo de internação (19 dias) e na mortalidade (OR = 2,047; IC95%: 1,172-3,570). Este estudo destaca o sério problema dos eventos adversos na assistência à saúde prestada na terapia intensiva e os fatores de risco associados à incidência de eventos.

Social, Economic, and Medical Factors Associated With Solifenacin Therapy Compliance Among Workers Who Suffer From Lower Urinary Tract Symptoms

Purpose

The prevalence of hyperactive-type lower urinary tract symptoms is 45.2%, with shares of overactive bladder (OAB) and urge incontinence (UI) symptoms of 10.7% and 8.2%, respectively. We investigated the possible impact of a wide range of social, economic, and medical factors on compliance with solifenacin treatment in the working population.

Methods

Social, economic, and medical factors as well as the Overactive Bladder questionnaire – the OAB-q Short Form (OAB-q SF), bladder diaries, and uroflowmetry of 1,038 people who were administered solifenacin for a year were gathered from employer documentation.

Results

Among the subjects, 32% maintained their compliance with solifenacin treatment throughout the year. Only 65% of the patients had compliance exceeding 80%, and 17% of patients had compliance of ≥50%, yet less than 80% were still taking solifenacin 12 months after the beginning of this experiment. Working people whose compliance level was, at least, 80% had reliably higher (P≤0.01) average age, annual salary, and treatment efficacy, and a greater treatment satisfaction level, as well as a lack of satisfaction with other antimuscarinic treatments and higher rate of urge UI diagnosis. The same cohort also featured a lower level (P≤0.01) of caffeine abuse and lower share of salary spent purchasing solifenacin.

Conclusions

This study has shown that compliance with solifenacin treatment is associated with a number of significant medical, social, and economic factors. The medical factors included the type of urination disorder, severity of incontinence symptoms, presence of side effects, treatment efficacy and patients’ satisfaction with it, and experience using other antimuscarinic treatments. Among the social and economic factors, those with the strongest correlation to compliance were patient age, employment in medicine and education, annual income level, percentage of solifenacin purchase expenditures, and caffeine abuse. Factors with a weaker, but still significant, association were gender, employment in the transportation industry, and monthly income level.

Drug-drug interactions and adverse drug reactions in polypharmacy among older adults: an integrative review

OBJECTIVE

to identify and summarize studies examining both drug-drug interactions (DDI) and adverse drug reactions (ADR) in older adults polymedicated.

METHODS

an integrative review of studies published from January 2008 to December 2013, according to inclusion and exclusion criteria, in MEDLINE and EMBASE electronic databases were performed.

RESULTS

forty-seven full-text studies including 14,624,492 older adults (≥ 60 years) were analyzed: 24 (51.1%) concerning ADR, 14 (29.8%) DDI, and 9 studies (19.1%) investigating both DDI and ADR. We found a variety of methodological designs. The reviewed studies reinforced that polypharmacy is a multifactorial process, and predictors and inappropriate prescribing are associated with negative health outcomes, as increasing the frequency and types of ADRs and DDIs involving different drug classes, moreover, some studies show the most successful interventions to optimize prescribing.

CONCLUSIONS

DDI and ADR among older adults continue to be a significant issue in the worldwide. The findings from the studies included in this integrative review, added to the previous reviews, can contribute to the improvement of advanced practices in geriatric nursing, to promote the safety of older patients in polypharmacy. However, more research is needed to elucidate gaps.

OBJETIVO

identificar e sintetizar estudos que examinam as interações medicamentosas (IM) e reações adversas a medicamentos (RAM) em idosos polimedicados.

MÉTODOS

revisão integrativa de estudos publicados de janeiro de 2008 a dezembro de 2013, de acordo com critérios de inclusão e exclusão, nas bases de dados eletrônicas MEDLINE e EMBASE.

RESULTADOS

foram analisados 47 estudos de texto completo, incluindo 14,624,492 idosos (≥ 60 anos): 24 (51,1%) sobre RAM, 14 (29,8%) sobre IM e 9 estudos (19,1%) que investigaram tanto IM como RAM. Encontramos uma variedade de desenhos metodológicos. Os estudos revisados reforçaram que a polifarmácia é um processo multifatorial, e os preditores e a prescrição inadequada estão associados a resultados negativos de saúde, como aumento da frequência e tipos de RAM e IM envolvendo diferentes classes de drogas, além disso, alguns estudos mostram as intervenções mais bem-sucedidas para otimizar a prescrição.

CONCLUSÕES

IM e RAM entre idosos continuam a ser um problema significativo no mundo todo. Os resultados dos estudos incluídos nesta revisão integrativa, adicionado às revisões anteriores, podem contribuir para a melhoria das práticas avançadas de enfermagem geriátrica, para promover a segurança dos pacientes idosos em polifarmácia. No entanto, são necessárias mais pesquisas para elucidar lacunas.

OBJETIVO

identificar y resumir los estudios que analizan tanto las interacciones medicamentosas (IM) como las reacciones adversas a medicamentos (RAM) en los adultos mayores polimedicados.

MÉTODOS

revisión integradora de estudios publicados entre enero de 2008 a diciembre de 2013, siguiendo criterios de inclusión y exclusión, en las bases de datos electrónicas MEDLINE y EMBASE.

RESULTADOS

cuarenta y siete estudios de texto completo incluidos fueron analizados incluyendo 14,624,492 adultos mayores (≥ 60 años), de ellos 24 (51,1%) en relación con RAM, 14 (29,9%) con IM y 9 estudios (19,1%) que investigaron tanto IM como RAM. Encontramos una gran variedad de diseños metodológicos. Los estudios revisados reforzaron el concepto que la polifarmacia es un proceso multifactorial, y los predictores y la prescripción inadecuada se asocian con resultados negativos para la salud tales como el aumento de la frecuencia y tipos de RAM y IM implicando diferentes clases de fármacos, además que algunos estudios muestran cuales son las intervenciones más exitosas para optimizar la prescripción.

CONCLUSIONES

IM y RAM siguen siendo un problema importante en el mundo entero entre los adultos mayores. Los resultados de los estudios incluidos en esta revisión integradora, sumado a las revisiones previas, pueden contribuir a la mejora de las prácticas avanzadas de enfermería geriátrica, para promover la seguridad de los pacientes de mayor edad en la polifarmacia. Sin embargo, se necesita más investigación para esclarecer los vacíos de conocimiento.

[Comorbidity in elderly patients]

The term comorbidity, a concurrent damage to two or more organs or systems, is widely discussed in the literature. In elderly patients, any somatic illness is comorbid to cerebrovascular diseases that hampers early diagnosis and treatment of the latter. Due to the complicity and multicomponent structure of the pathogenesis of comorbidity, many drugs should be used to treat different patterns of the pathological process that results in polypragmasia often accompanied by complications. Therefore, a search for new ways in the treatment of these patients is still urgent.

Effectiveness of seasonal trivalent influenza vaccination against hospital-attended acute respiratory infections in pregnant women: A retrospective cohort study

BACKGROUND

Pregnant women are at risk of serious influenza infection. Although previous studies indicate maternal influenza vaccination can prevent hospitalisation in young infants, there is limited evidence of the effect in mothers.

METHODS

A cohort of 34,701 pregnant women delivering between 1 April 2012 and 31 December 2013 was created using birth records. Principal diagnosis codes from hospital emergency department (ED) and inpatient records were used to identify episodes of acute respiratory illness (ARI) during the 2012 and 2013 southern hemisphere influenza seasons. Cox regression models were used to calculate adjusted hazard ratios (aHRs) by maternal vaccination status, controlling for Indigenous status, socioeconomic level, medical conditions, and week of delivery.

RESULTS

3,007 (8.7%) women received a seasonal influenza vaccine during pregnancy. Vaccinated women were less likely to visit an ED during pregnancy for an ARI (9.7 visits per 10,000 person-days vs. 35.5 visits per 10,000 person-days; aHR: 0.19, 95% CI: 0.05-0.68). Vaccinated women were also less likely to be hospitalised with an ARI compared to unvaccinated women (16.2 hospitalisations per 10,000 person-days vs. 34.0 hospitalisations per 10,000 person-days; aHR: 0.35, 95% CI: 0.13-0.97).

CONCLUSIONS

Influenza vaccination during pregnancy was associated with significantly fewer hospital attendances for ARI in pregnant women.

Hospitalization in older patients due to adverse drug reactions -the need for a prediction tool

Adverse drug reactions (ADRs) represent a major burden on society, resulting in significant morbidity, mortality, and health care costs. Older patients living in the community are particularly susceptible to ADRs, and are at an increased risk of ADR-related hospitalization. This review summarizes the available evidence on ADR-related hospital admission in older patients living in the community, with a particular focus on risk factors for ADRs leading to hospital admission and the need for a prediction tool for risk of ADR-related hospitalization in these individuals. The reported proportion of hospital admissions due to ADRs has ranged from 6% to 12% of all admissions in older patients. The main risk factors or predictors for ADR-related admissions were advanced age, polypharmacy, comorbidity, and potentially inappropriate medications. There is a clear need to design intervention strategies to prevent ADR-related hospitalization in older patients. To ensure the cost-effectiveness of such strategies, it would be necessary to target them to those older individuals who are at highest risk of ADR-related hospitalization. Currently, there are no validated tools to assess the risk of ADRs in primary care. There is a clear need to investigate the utility of tools to identify high-risk patients to target appropriate interventions toward prevention of ADR-related hospital admissions.

Hospital re-admission associated with adverse drug reactions in patients over the age of 65 years

CONTEXT

Adverse drug reactions (ADRs) are responsible for 5 % of hospital admissions, but hospital re-admission induced by ADRs remains poorly documented.

OBJECTIVE

The aim of this study was to estimate the rate of hospital re-admission and the factors associated with re-admission in the patients over the age of 65 years. Secondary, we described the characteristics of cases of ADRs leading to re-admission for drugs other than chemotherapy agents.

METHODS

Data were extracted from hospital discharge summaries provided by the Department of Medical Information of Toulouse University Hospital. All patients over the age of 65 years admitted to the hospital in 2010 for an ADR, identified from ICD-10 codes, were selected. All subsequent admissions of members of this cohort within 1 year of discharge following the index admission were reviewed retrospectively. The risk factors associated with hospital re-admission for ADRs were analyzed. Medical records were used for descriptive analysis of re-admission due to drugs other than chemotherapy agents.

RESULTS

We found that 553 of the 1000 patients admitted for ADRs in 2010 were re-admitted to hospital within 1 year. Among them, 87 cases were re-admitted for ADRs (estimated rate of 87/1000 re-admission for an ADR within 1 year). A comparison of the patients re-admitted for ADRs (n = 87) with those of patients re-admitted for other causes (n = 410) suggested that only cancer increased the risk of re-admission for ADRs (OR = 7.69 [4.59-12.88] 95 % CI). ADRs due to the same drug combination were the suspected cause of repeat admission in half the cases (other than chemotherapy). Hospital re-admission was considered avoidable in four cases (22 %).

CONCLUSION

This study shows an estimated rate of re-admission for an ADR around 87/1000 within 1 year, and the same drug combination were the suspected cause of repeat admission in half the cases. At least, 11 % of cases were avoidable.

Profile of rheumatology patients willing to report adverse drug reactions: bias from selective reporting

BACKGROUND

Adverse drug reactions (ADRs) have a significant impact on human health and health care costs. The aims of our study were to determine the profile of rheumatology patients willing to report ADRs and to identify bias in such a reporting system.

METHODS

Semi-intensive ADRs reporting system was used in our study. Patients willing to participate (N=261) completed the questionnaire designed for the purpose of the study at the hospital admission. They were subsequently classified into two groups according to their ability to identify whether they had experienced ADRs during the previous month. Group 1 included 214 out of 261 patients who were able to identify ADRs, and group 2 consisted of 43 out of 261 patients who were not able to identify ADRs in their recent medical history.

RESULTS

Group 1 patients were more significantly aware of their diagnosis than the patients from group 2. Marginal significance was found between rheumatology patients with and without neurological comorbidities regarding their awareness of ADRs. The majority of patients reported ADRs of cytotoxic drugs. The most reported ADRs were moderate gastrointestinal discomforts.

CONCLUSION

We may draw a profile of rheumatological patients willing to report ADRs: 1) The majority of them suffer from systemic inflammatory diseases and are slightly more prone to neurological comorbidities. 2) They are predominantly aware of their diagnosis but less able to identify the drugs that may cause their ADRs. 3) They tend to report mainly moderate gastrointestinal ADRs; that is, other cohorts of patients and other types of ADRs remain mainly undetected in such a reporting, which could represent a bias. Counseling and education of patients as well as developing a network for online communication might improve patients' reporting of potential ADRs.

Challenges in personalised management of chronic diseases-heart failure as prominent example to advance the care process

Chronic diseases are the leading causes of morbidity and mortality in Europe, accounting for more than 2/3 of all death causes and 75 % of the healthcare costs. Heart failure is one of the most prominent, prevalent and complex chronic conditions and is accompanied with multiple other chronic diseases. The current approach to care has important shortcomings with respect to diagnosis, treatment and care processes. A critical aspect of this situation is that interaction between stakeholders is limited and chronic diseases are usually addressed in isolation.

Health care in Western countries requires an innovative approach to address chronic diseases to provide sustainability of care and to limit the excessive costs that may threaten the current systems. The increasing prevalence of chronic diseases combined with their enormous economic impact and the increasing shortage of healthcare providers are among the most critical threats. Attempts to solve these problems have failed, and future limitations in financial resources will result in much lower quality of care. Thus, changing the approach to care for chronic diseases is of utmost social importance.

Systems biology approaches for identifying adverse drug reactions and elucidating their underlying biological mechanisms

Small molecules are indispensable to modern medical therapy. However, their use may lead to unintended, negative medical outcomes commonly referred to as adverse drug reactions (ADRs). These effects vary widely in mechanism, severity, and populations affected, making ADR prediction and identification important public health concerns. Current methods rely on clinical trials and postmarket surveillance programs to find novel ADRs; however, clinical trials are limited by small sample size, whereas postmarket surveillance methods may be biased and inherently leave patients at risk until sufficient clinical evidence has been gathered. Systems pharmacology, an emerging interdisciplinary field combining network and chemical biology, provides important tools to uncover and understand ADRs and may mitigate the drawbacks of traditional methods. In particular, network analysis allows researchers to integrate heterogeneous data sources and quantify the interactions between biological and chemical entities. Recent work in this area has combined chemical, biological, and large-scale observational health data to predict ADRs in both individual patients and global populations. In this review, we explore the rapid expansion of systems pharmacology in the study of ADRs. We enumerate the existing methods and strategies and illustrate progress in the field with a model framework that incorporates crucial data elements, such as diet and comorbidities, known to modulate ADR risk. Using this framework, we highlight avenues of research that may currently be underexplored, representing opportunities for future work.

Promoting Safer Use of High-Risk Pharmacotherapy: Impact of Pharmacist-Led Targeted Medication Reviews

Background

Adverse drug reactions are a recognised cause of hospital admissions. A small group of medicines carry a higher risk of adverse outcomes and are more frequently involved in hospital admissions than other medicines. These ‘high-risk medicines’ have been identified in previous research. However, it is less clear how to reduce the risks associated with these known high-risk medicines, or which high-risk medicines should be prioritised when implementing risk reduction interventions. Previous research has questioned the efficacy of pharmacist-led medication reviews in reducing hospital admissions and drug-related morbidity and mortality.

Objectives

In this study, we aimed to identify high-risk medicines through medication review to reduce iatrogenic disease; to determine a short list of high-risk medicines to target in medication reviews to achieve the greatest impact on reducing iatrogenic disease and patient harm; and to determine whether pharmacist-conducted medication reviews of high-risk medicines are safe and effective.

Methods

A prospective cohort study was undertaken in 16 general practices in one Scottish health board. All patients prescribed a high-risk medicine were identified and received a medication review from a pharmacist (3643 patients from a total population of 38,399). The pharmacist decided whether it was appropriate to continue the high-risk medicine, or if the medicine should be stopped or amended. The pharmacist made recommendations to the patient’s general practitioner (GP) for medicines to be stopped or amended, which the GP could choose to accept or not. Patient outcomes for all of the pharmacist’s recommendations were identified 1 year later to determine the effectiveness of the recommendations.

Results

High-risk medicines were prescribed to 3643 patients from a total population of 38,399 patients. The pharmacist made 440 recommendations for GPs to stop or amend high-risk medicines. GPs accepted 214 recommendations and rejected 226, giving an acceptance rate of 49 %. The 440 recommendations were then followed up 1 year later. The risk of having an adverse outcome was significantly reduced when the pharmacist’s recommendation to stop or amend a high-risk medicine was followed compared with rejecting the pharmacist’s recommendation and continuing the high-risk medicine unchanged (p < 0.001). A total of 22 adverse outcomes occurred when the pharmacist’s advice was rejected. Of these, 21 would have been prevented if the pharmacist’s recommendation had been followed and three resulted in hospital admission.

Conclusions

This study demonstrated that medication reviews for high-risk medicines are safe and effective, with results achieved within 1 year of the initial review. It identified six high-risk medicines that could form the basis of targeted medication reviews in order to reduce iatrogenic disease. It also demonstrated that pharmacists are safe and effective at delivering medication reviews.

Acute Hospital Admissions Because of Health Care-Related Adverse Events: A Retrospective Study of 5 Specialist Departments

BACKGROUND

Health care-related adverse events (HCRAEs), which should not be confused with (blameworthy) medical errors, are common; they can lead to hospital admissions and can have grave consequences. Although they are sometimes potentially preventable, information is lacking on HCRAEs leading to admission to different departments.

AIM

This study aimed to gain insight into the incidence, type, severity, and preventability of HCRAEs (including adverse drug events) leading to hospitalization to the departments of internal medicine, surgery, orthopedics, neurology, and neurosurgery. Further, we explore if there are differences regarding these HCRAEs between these departments.

METHODS

We retrospectively evaluated the medical records of all patients admitted through the emergency department (ED) in a 6-month period to the departments of internal medicine, surgery, orthopedics, neurology, and neurosurgery. All patients admitted because of HCRAEs were included.

RESULTS

More than one-fifth (21.8%; range 12.0%-47.8%) of all admissions to the 5 departments were due to a HCRAE. Half (49.9%) of these HCRAEs were medication-related and 30.5% were procedure-related. In 6.5% of patients, the HCRAE led to permanent disability and another 4.4% of patients died during hospitalization. HCRAEs treated by internists and neurologists were usually medication-related, whereas HCRAEs treated by surgeons, orthopedic surgeons, and neurosurgeons were usually procedure-related.

CONCLUSION

Hospital admissions to different departments are often caused by HCRAEs, which sometimes lead to permanent disability or even death. Gaining insight into similarities and differences in HCRAEs occurring in different specialties is a starting point for improving clinical outcomes.

Predicting 30-day readmissions with preadmission electronic health record data

BACKGROUND

Readmission prevention should begin as early as possible during the index admission. Early identification may help target patients for within-hospital readmission prevention interventions.

OBJECTIVES

To develop and validate a 30-day readmission prediction model using data from electronic health records available before the index admission.

RESEARCH DESIGN

Retrospective cohort study of admissions between January 1 and March 31, 2010.

SUBJECTS

Adult enrollees of Clalit Health Services, an integrated delivery system, admitted to an internal medicine ward in any hospital in Israel.

MEASURES

All-cause 30-day emergency readmissions. A prediction score based on before admission electronic health record and administrative data (the Preadmission Readmission Detection Model-PREADM) was developed using a preprocessing variable selection step with decision trees and neural network algorithms. Admissions with a recent prior hospitalization were excluded and automatically flagged as "high-risk." Selected variables were entered into multivariable logistic regression, with a derivation (two-thirds) and a validation cohort (one-third).

RESULTS

The derivation dataset comprised 17,334 admissions, of which 2913 (16.8%) resulted in a 30-day readmission. The PREADM includes 11 variables: chronic conditions, prior health services use, body mass index, and geographical location. The c-statistic was 0.70 in the derivation set and of 0.69 in the validation set. Adding length of stay did not change the discriminatory power of the model.

CONCLUSIONS

The PREADM is designed for use by health plans for early high-risk case identification, presenting discriminatory power better than or similar to that of previously reported models, most of which include data available only upon discharge.

Drug-disease and drug-drug interactions: systematic examination of recommendations in 12 UK national clinical guidelines

OBJECTIVE

To identify the number of drug-disease and drug-drug interactions for exemplar index conditions within National Institute of Health and Care Excellence (NICE) clinical guidelines.

DESIGN

Systematic identification, quantification, and classification of potentially serious drug-disease and drug-drug interactions for drugs recommended by NICE clinical guidelines for type 2 diabetes, heart failure, and depression in relation to 11 other common conditions and drugs recommended by NICE guidelines for those conditions.

SETTING

NICE clinical guidelines for type 2 diabetes, heart failure, and depression

MAIN OUTCOME MEASURES

Potentially serious drug-disease and drug-drug interactions.

RESULTS

Following recommendations for prescription in 12 national clinical guidelines would result in several potentially serious drug interactions. There were 32 potentially serious drug-disease interactions between drugs recommended in the guideline for type 2 diabetes and the 11 other conditions compared with six for drugs recommended in the guideline for depression and 10 for drugs recommended in the guideline for heart failure. Of these drug-disease interactions, 27 (84%) in the type 2 diabetes guideline and all of those in the two other guidelines were between the recommended drug and chronic kidney disease. More potentially serious drug-drug interactions were identified between drugs recommended by guidelines for each of the three index conditions and drugs recommended by the guidelines for the 11 other conditions: 133 drug-drug interactions for drugs recommended in the type 2 diabetes guideline, 89 for depression, and 111 for heart failure. Few of these drug-disease or drug-drug interactions were highlighted in the guidelines for the three index conditions.

CONCLUSIONS

Drug-disease interactions were relatively uncommon with the exception of interactions when a patient also has chronic kidney disease. Guideline developers could consider a more systematic approach regarding the potential for drug-disease interactions, based on epidemiological knowledge of the comorbidities of people with the disease the guideline is focused on, and should particularly consider whether chronic kidney disease is common in the target population. In contrast, potentially serious drug-drug interactions between recommended drugs for different conditions were common. The extensive number of potentially serious interactions requires innovative interactive approaches to the production and dissemination of guidelines to allow clinicians and patients with multimorbidity to make informed decisions about drug selection.

Side effects of analgesia may significantly reduce quality of life in symptomatic multiple myeloma: a cross-sectional prevalence study

BACKGROUND

Pain is a common symptom in patients with multiple myeloma (MM). Many patients are dependent on analgesics and in particular opioids, but there is limited information on the impact of these drugs and their side effects on health-related quality of life (HRQoL).

METHOD

In a cross-sectional study, semi-structured interviews were performed in 21 patients attending the hospital with symptomatic MM on pain medications. HRQoL was measured using items 29 and 30 of the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30.

RESULTS

Patients were able to recall a median of two (range 0-4) analgesics. They spontaneously identified a median of two (range 1-5) side effects attributable to their analgesic medications. Patients' assessment of HRQoL based on the EORTC QLQ-C30 questions 29/30 was mean 48.3 (95 % CI; 38.7-57.9) out of 100. Patients' assessment of their HRQoL in the hypothetical situation, in which they would not experience any side effects from analgesics, was significantly higher: 62.6 (53.5-71.7) (t test, p = 0.001).

CONCLUSION

This study provides, for the first time, evidence that side effects of analgesics are common in symptomatic MM and may result in a statistically and clinically significant reduction of self-reported HRQoL.

Development and validation of a risk model for predicting adverse drug reactions in older people during hospital stay: Brighton Adverse Drug Reactions Risk (BADRI) model

Background

Older patients are at an increased risk of developing adverse drug reactions (ADR). Of particular concern are the oldest old, which constitute an increasingly growing population. Having a validated clinical tool to identify those older patients at risk of developing an ADR during hospital stay would enable healthcare staff to put measures in place to reduce the risk of such an event developing. The current study aimed to (1) develop and (2) validate an ADR risk prediction model.

Methods

We used a combination of univariate analysis and multivariate binary logistic regression to identify clinical risk factors for developing an ADR in a population of older people from a UK teaching hospital. The final ADR risk model was then validated in a European population (European dataset).

Results

Six-hundred-ninety patients (median age 85 years) were enrolled in the development stage of the study. Ninety-five reports of ADR were confirmed by independent review in these patients. Five clinical variables were identified through multivariate analysis and included in our final model; each variable was attributed a score of 1. Internal validation produced an AUROC of 0.74, a sensitivity of 80%, and specificity of 55%. During the external validation stage the AUROC was 0.73, with sensitivity and specificity values of 84% and 43% respectively.

Conclusions

We have developed and successfully validated a simple model to use ADR risk score in a population of patients with a median age of 85, i.e. the oldest old. The model is based on 5 clinical variables (≥8 drugs, hyperlipidaemia, raised white cell count, use of anti-diabetic agents, length of stay ≥12 days), some of which have not been previously reported.

Recommendations to prescribe in complex older adults: results of the CRIteria to assess appropriate Medication use among Elderly complex patients (CRIME) project

The occurrence of several geriatric conditions may influence the efficacy and limit the use of drugs prescribed to treat chronic conditions. Functional and cognitive impairment, geriatric syndromes (i.e. falls or malnutrition) and limited life expectancy are common features of old age, which may limit the efficacy of pharmacological treatments and question the appropriateness of treatment. However, the assessment of these geriatric conditions is rarely incorporated into clinical trials and treatment guidelines. The CRIME (CRIteria to assess appropriate Medication use among Elderly complex patients) project is aimed at producing recommendations to guide pharmacologic prescription in older complex patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes, and providing physicians with a tool to improve the quality of prescribing, independent of setting and nationality. To achieve these aims, we performed the following: (i) Existing disease-specific guidelines on pharmacological prescription for the treatment of diabetes, hypertension, congestive heart failure, atrial fibrillation and coronary heart disease were reviewed to assess whether they include specific indications for complex patients; (ii) a literature search was performed to identify relevant articles assessing the pharmacological treatment of complex patients; (iii) A total of 19 new recommendations were developed based on the results of the literature search and expert consensus. In conclusion, the new recommendations evaluate the appropriateness of pharmacological prescription in older complex patients, translating the recommendations of clinical guidelines to patients with a limited life expectancy, functional and cognitive impairment, and geriatric syndromes. These recommendations cannot represent substitutes for careful clinical consideration and deliberation by physicians; the recommendations are not meant to replace existing clinical guidelines, but they may be used to help physicians in the prescribing process.

Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies

Falls are the leading cause of injuries among older adults, aged 65 years and older. Furthermore, falls are an increasing public health problem because of ageing populations worldwide due to an increase in the number of older adults, and an increase in life expectancy. Numerous studies have identified risk factors and investigated possible strategies to prevent (recurrent) falls in community-dwelling older people and those living in long-term care facilities. Several types of drugs have been associated with an increased fall risk. Since drugs are a modifiable risk factor, periodic drug review among older adults should be incorporated in a fall prevention programme.

Prevalence and determinants of anticholinergic medication use in elderly dementia patients

BACKGROUND

People with dementia are sensitive to cognitive side effects of anticholinergic drugs. However, little is known about the prevalence of anticholinergic medications and its predictors in a nationally representative sample of community-based elderly dementia patients in the USA.

OBJECTIVES

The objectives of the study were to determine the prevalence and predictors of anticholinergic drugs use in elderly dementia patients.

METHODS

The study involved retrospective analysis of the 2005-2009 Medical Expenditure Panel Surveys (MEPS), a nationally representative sample of the non-institutionalized US population. The study evaluated annual prevalence of anticholinergic drug use during the study period and factors associated with the use of anticholinergics among community-dwelling persons aged 65 and older with dementia. The anticholinergic drugs were identified using the Anticholinergic Drug Scale (ADS). Multiple logistic regression within the conceptual framework of the Anderson Behavioral Model was performed to identify predictors associated with clinically significant anticholinergic drug (ADS level 2 or 3) use.

RESULTS

According to the MEPS, there were a total of 1.56 [95 % confidence interval (CI) 1.34, 1.73] million elderly dementia patients annually during the study period. Approximately, 23.3 % (95 % CI 19.2, 27.5) of elderly dementia patients used clinically significant anticholinergic agents (ADS level 2 or 3). Among the need factors, elderly dementia patients having mood disorders [odds ratio (OR) 2.19; 95 % CI 1.19, 4.06] and urinary incontinence (OR 6.58; 95 % CI 2.84, 15.29) were more likely to use drugs with clinically significant anticholinergic activities. Of the enabling factors, the odds of receiving higher-level anticholinergic drugs were significantly lower for patients who resided in the West region (OR 0.41; 95 % CI 0.17, 0.95) compared to the reference group, Northeast.

CONCLUSION

Over one in five elderly dementia patients used drugs with clinically significant anticholinergic effects. Mood disorder, urinary incontinence, and region were significantly associated with use of these drugs. Concerted efforts are needed to improve the quality of medication use by focusing on clinically significant anticholinergic agents.

ICD-10 codes used to identify adverse drug events in administrative data: a systematic review

BACKGROUND

Adverse drug events, the unintended and harmful effects of medications, are important outcome measures in health services research. Yet no universally accepted set of International Classification of Diseases (ICD) revision 10 codes or coding algorithms exists to ensure their consistent identification in administrative data. Our objective was to synthesize a comprehensive set of ICD-10 codes used to identify adverse drug events.

METHODS

We developed a systematic search strategy and applied it to five electronic reference databases. We searched relevant medical journals, conference proceedings, electronic grey literature and bibliographies of relevant studies, and contacted content experts for unpublished studies. One author reviewed the titles and abstracts for inclusion and exclusion criteria. Two authors reviewed eligible full-text articles and abstracted data in duplicate. Data were synthesized in a qualitative manner.

RESULTS

Of 4241 titles identified, 41 were included. We found a total of 827 ICD-10 codes that have been used in the medical literature to identify adverse drug events. The median number of codes used to search for adverse drug events was 190 (IQR 156-289) with a large degree of variability between studies in the numbers and types of codes used. Authors commonly used external injury (Y40.0-59.9) and disease manifestation codes. Only two papers reported on the sensitivity of their code set.

CONCLUSIONS

Substantial variability exists in the methods used to identify adverse drug events in administrative data. Our work may serve as a point of reference for future research and consensus building in this area.

Prediction of morbidity and mortality in patients with chronic hepatitis C by non-invasive liver fibrosis models

BACKGROUND & AIMS

Liver fibrosis is prognostic of outcomes among patients with chronic hepatitis C (CHC). We evaluated the accuracy of non-invasive markers and liver biopsy in predicting morbidity and mortality in CHC patients.

METHODS

Compensated CHC patients were evaluated over a 10-year period. Non-invasive markers including Hepascore, FIB-4, APRI and liver biopsy results were retrospectively collated. Follow-up morbidity and mortality data were obtained from the Western Australian Data Linkage System. The prognostic significance of baseline non-invasive markers and biopsy were assessed using Kaplan-Meier analysis.

RESULTS

A total of 406 subjects (64% male, mean age 48 ± 11 years) were followed up for 2385 person-years, during which there were 22 (5.4%) deaths including 14 (3.4%) who died from liver disease or required liver transplantation. Sixteen (3.9%) subjects developed liver decompensation. Hepascore and liver biopsy (P < 0.005) but not APRI or FIB-4 were predictive of overall and liver-related mortality as well as liver decompensation. A Hepascore>0.5 was associated with increased overall mortality [Hazard Ratio (95%CI) 6.7 (2.6-17), P < 0.001], liver-related mortality [32.8 (4.3-250), P = 0.001] and risk of future decompensation [11.8 (3.3-41), P < 0.001], whereas a Hepascore ≤0.5 was associated with a 99% probability of not dying from liver-related causes over 10 years. Hepascore had comparable accuracy with liver biopsy in predicting liver-related mortality with AUROC of 0.86 (95%CI 0.80-0.90) and 0.87 (0.79-0.96), respectively.

CONCLUSION

Hepascore is predictive of overall and liver-related mortality and morbidity in CHC patients with comparable accuracy to liver biopsy. Hepascore may be a useful prognostic marker in clinical practice.

Factors associated with transfers from healthcare facilities among readmitted older adults with chronic illness

OBJECTIVE

Because chronic illness accounts for a considerable proportion of Australian healthcare expenditure, there is a need to identify factors that may reduce hospital readmissions for patients with chronic illness. The aim of the present study was to examine a range of factors potentially associated with transfer from healthcare facilities among older adults readmitted to hospital within a large public health service in Melbourne, Australia.

METHODS

Data on readmitted patients between June 2006 and June 2011 were extracted from hospital databases and medical records. Adopting a retrospective case-control study design, a sample of 51 patients transferred from private residences was matched by age and gender with 55 patients transferred from healthcare facilities (including nursing homes and acute care facilities). Univariate and multivariate logistic regression analyses were used to compare the two groups, and to determine associations between 46 variables and transfer from a healthcare facility.

RESULTS

Univariate analysis indicated that patients readmitted from healthcare facilities were significantly more likely to experience relative socioeconomic advantage, disorientation on admission, dementia diagnosis, incontinence and poor skin integrity than those readmitted from a private residence. Three of these variables remained significantly associated with admission from healthcare facilities after multivariate analysis: relative socioeconomic advantage (odds ratio (OR) 11.30; 95% confidence interval (CI) 2.62-48.77), incontinence (OR 7.18; 95% CI 1.19-43.30) and poor skin integrity (OR 18.05; 95% CI 1.85-176.16).

CONCLUSIONS

Older adults with chronic illness readmitted to hospital from healthcare facilities are significantly more likely to differ from those readmitted from private residences in terms of relative socioeconomic advantage, incontinence and skin integrity. The findings direct efforts towards addressing the apparent disparity in management of patients admitted from a facility as opposed to a private residence.

Frequency of metabolic syndrome and 25-hydroxyvitamin D3 levels in patients with non-alcoholic fatty liver disease

AIM

It is known that insulin resistance has an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD) and that serum 25-hidroksivitamin D3 [25-(OH)D] levels are found low in the presence of insulin resistance. Metabolic syndrome (MetS) is characterized by insulin resistance. The purpose of the present study was to determine the levels of 25-(OH)D and the frequency of MetS in patients with NAFLD, and to evaluate the association of 25-(OH)D with the histology of NAFLD and metabolic parameters.

METHOD

Sixty-three patients with NAFLD confirmed by liver biopsy (29 females and 34 males, mean age 42.70±9.82 years) and 46 healthy controls (16 females and 30 males, mean age 37.54±8.56 years) were included in the study. International Diabetes Federation criteria were used for MetS diagnosis. Insulin resistance was determined according to the Homeostasis Model of Assessment (HOMA-IR) method. The groups were compared for 25-(OH)D levels and MetS frequencies. Correlation analysis was used to evaluate relationships between 25-(OH)D and metabolic parameters and/or NAFLD histology.

RESULTS

25-(OH)D levels were lower in the NAFLD group compared to the control group (36.06±13.07 ng/mL vs. 51.19±23.45 ng/mL, respectively, P<0.01), while MetS frequency was higher (66.7% vs. 15.2%, P<0.01). In the NAFLD group, 25-(OH)D levels were negatively correlated with non-alcoholic steatohepatitis scores and HOMA-IR (r=-0.317, P=0.011 and r=-0.437, P=0.001, respectively).

CONCLUSION

The present study demonstrated higher frequency of MetS and lower levels of 25-(OH)D in patients with NAFDL, and a negative association of 25-(OH)D levels with non-alcoholic steatohepatitis scores and insulin resistance.

Medication regimen complexity and hospital readmission for an adverse drug event

BACKGROUND

Adverse drug events (ADEs) are costly, dangerous, and often preventable. Little is known about the link between medication regimen complexity and rehospitalization as a result of an ADE.

OBJECTIVE

The objective of this study was to compare admission and discharge medication regimen complexity in 2 cohorts: patients readmitted for an ADE within 30 days and patients not readmitted for an ADE.

METHODS

The study used a retrospective parallel-group case-control design. Participants from 4 urban acute care hospitals were included in the revisit cohort if they were rehospitalized within 30 days as a result of an adverse event coded as accidental poisoning. The no-revisit cohort was formed by randomly sampling patients with the same disease classification codes as the revisit group but without history of a readmission within 30 days. Complexity of medication regimens at the initial admission and discharge was quantified with the medication regimen complexity index (MRCI).

RESULTS

The revisit group comprised 92 individuals and the no-revisit group, 228. The revisit group had a significantly higher MRCI score at admission and discharge than the no-revisit group (all P < .005). Receiver operating characteristic curves, used to determine a potential MRCI cutoff score for risk of an ADE, revealed MRCI scores of 8 or greater to optimally predict increased risk for readmission caused by an ADE.

CONCLUSIONS

Complex medication regimens at hospital admission are predictive of rehospitalizations for ADEs. This finding suggests that medication regimen complexity be considered as a target for interventions to decrease the risk for readmission.

New models of chronic kidney disease care including pharmacists: improving medication reconciliation and medication management

PURPOSE OF REVIEW

Patients with chronic kidney disease (CKD) are complex, have many medication-related problems (MRPs) and high rates of medication nonadherence, and are less adherent to some medications than patients with higher levels of kidney function. Nonadherence in CKD patients increases the odds of uncontrolled hypertension, which can increase the risk of CKD progression. This review discusses reasons for gaps in medication-related care for CKD patients, pharmacy services to reduce these gaps and successful models that incorporate pharmacist care.

RECENT FINDINGS

Pharmacists are currently being trained to deliver patient-centred care, including identification and management of MRPs and helping patients overcome barriers to improve medication adherence. A growing body of evidence indicates that pharmacist services for CKD patients, including medication reconciliation and medication therapy management, positively affect clinical and cost outcomes, including lower rates of decline in glomerular filtration rates, reduced mortality and fewer hospitalizations and hospital days, but more robust research is needed. Team-based models including pharmacists exist today and are being studied in a wide range of innovative care and reimbursement models.

SUMMARY

Opportunities are growing to include pharmacists as integral members of CKD and dialysis healthcare teams to reduce MRPs, increase medication adherence and improve patient outcomes.

Polypharmacy and comorbidity are associated with a lower early virologic response in hepatitis C patients treated with first generation protease inhibitor triple therapy: a preliminary analysis

BACKGROUND AND AIMS

The protease inhibitors (PIs) boceprevir and telaprevir are currently standard treatment as part of triple therapy regimens (TTx) for chronic HCV genotype 1 (GT1) patients. In this preliminary analysis, we have compared demographic variables, polypharmacy, and Charlson's comorbid index (CCI) with Rapid Virological Response (RVR) and extended RVR (eRVR) rates in HCV GT1 patients receiving PI containing TTx.

METHODS

Retrospective descriptive cohort study.

RESULTS

Among 74 HCV patients (46 M, 28 F; age: 54.43 ± 9.52 years; African Americans: 59.5 %) in this initial analysis, 44 % achieved RVR. All these RVR patients also achieved eRVR. Patients achieving RVR and eRVR were 50 ± 11.7 (mean ± SD) years old, compared to 58 ± 5.2 years without an RVR (p < 0.005). The average number of medications taken by patients achieving RVR and eRVR was 5 ± 2.7 compared to 9.24 ± 3.4 in patients not achieving RVR and eRVR (p < 0.005). Twenty-five percent of patients who were not on CYP3A4 inhibitors had an RVR and eRVR compared to 63.2 % who were taking CYP3A4 inhibitors (p = 0.001). Patients achieving RVR and eRVR had a lower CCI (1.61 ± 1.37) compared to those not achieving RVR and eRVR (2.8 ± 2.7; p = 0.02). Multivariate analysis also revealed a significant correlation between increased polypharmacy and CCI with lower RVR and eRVR rates.

CONCLUSIONS

These preliminary treatment data demonstrate that increased polypharmacy and higher degrees of comorbidity decrease RVR and eRVR rates among patients receiving first generation PI-containing TTx regimens.

[Chronic disease, mortality and disability in an elderly Spanish population: the FRADEA study]

INTRODUCTION

The objective of this study was to analyse the relationships between the major chronic diseases and multiple morbidity, with mortality, incident disability in basic activities of daily living, and loss of mobility in the elderly.

MATERIAL AND METHODS

A total of 943 participants were selected from the FRADEA Study, using available baseline data of chronic diseases, and at the follow-up visit of mortality, incident disability, and loss of mobility. The analysis was made of the unadjusted and adjusted association between the number of chronic diseases, the number of 14 pre-selected diseases, and the presence of two or more chronic diseases (multiple morbidity) with adverse health events recorded.

RESULTS

Participants with a higher number of diseases (OR 1.11; 95% CI: 1.02-1.22), and 14 pre-selected diseases (OR 1.19; 95% CI: 1.03-1.38) had a higher adjusted mortality risk, but not a higher incident disease or mobility loss risk. Subjects with multiple morbidity had a higher non-significant mortality risk (HR 1.45; 95% CI: 0.87-2.43), than those without multiple morbidity. Disability-free mean time in participants with and without multiple morbidity was 846±34 and 731±17 days, respectively (Log-rank χ(2) 7.45. P=.006), and with our without mobility loss was 818±32 and 696±13 days, respectively (Log rank χ(2) 10.99. P=.001).

CONCLUSIONS

Multiple morbidity was not associated with mortality, incident disability in ADL, or mobility loss in adults older than 70 years, although if mortality is taken into account, the number of chronic diseases is linear.

Adverse drug events as a cause of hospitalization in older adults

Older adults are about four to seven times more likely than younger persons to experience adverse drug events (ADEs) that cause hospitalization, especially if they are women and take multiple medications. The prevalence of drug-related hospitalizations has been reported to be as high as 31%, with large heterogeneity between different studies, depending on study setting (all hospital admissions or only acute hospital admissions), study population (entire hospital, specific wards, selected population and/or age groups), type of drug-related problem measured (adverse drug reaction or ADE), method of data collection (chart review, spontaneous reporting or database research) and method and definition used to detect ADEs. The higher risk of drug-related hospitalizations in older adults is mainly caused by age-related pharmacokinetic and pharmacodynamic changes, a higher number of chronic conditions and polypharmacy, which is often associated with the use of potentially inappropriate drugs. Other factors that have been involved are errors related to prescription or administration of drugs, medication non-adherence and inadequate monitoring of pharmacological therapies. A few commonly used drugs are responsible for the majority of emergency hospitalizations in older subjects, i.e. warfarin, oral antiplatelet agents, insulin and oral hypoglycaemic agents, central nervous system agents. The aims of the present review are to summarize recent evidence concerning drug-related hospitalization in older adults, to assess the contribution of specific medications, and to identify potential interventions able to reduce the occurrence of these drug-related events, as they are, at least partly, potentially preventable.

Estimating renal function to reduce the risk of adverse drug reactions

The aging process is characterized by relevant changes in pharmacokinetics. Renal function is known to decline with aging. However, as a result of reduced muscle mass, older individuals frequently have a depressed glomerular filtration rate (GFR) despite normal serum creatinine, and such a concealed renal insufficiency may impact significantly on the clearance of hydrosoluble drugs, as well as the risk of adverse drug reactions (ADRs) from hydrosoluble drugs. The assessment of renal function should thus be a mandatory item in the global examination of patient characteristics. Equations for estimating GFR have become very popular in recent years. However, different equations may yield significantly different estimated glomerular filtration rate (eGFR) values, which have important implications in dosing drugs cleared by the kidney. Current knowledge suggests that eGFR based on the Chronic Kidney Disease-Epidemiological Collaboration (CKD-EPI) study equation outperformed eGFR based on the Modification of Diet in Renal Disease (MDRD) study equation and creatinine clearance estimate based on the Cockcroft-Gault formula as a predictor of ADRs from kidney cleared drugs. More recently, the combined creatinine-cystatin C equation was shown to perform better than equations based on either of these markers alone in diagnosing CKD, even in older patients. However, its accuracy in predicting ADRs and usefulness in drug dosing is still to be investigated.

Strategies to reduce the risk of iatrogenic illness in complex older adults

Older patients are particularly vulnerable to adverse drug reactions (ADRs) because age is associated with changes in pharmacokinetics and pharmacodynamics that may alter drug metabolism. In addition, other conditions, commonly observed in older adults, may increase the risk of ADRs in the older population (including polypharmacy, comorbidity, cognitive and functional limitations). ADRs in older adults are frequently preventable, suggesting that screening and prevention programmes aimed at reducing the rate of iatrogenic illness are necessary in this population. The present study reviews available approaches that may be used to screen and prevent the occurrence of ADRs in older adults, including medication review, avoiding the use of potentially inappropriate medications, computer-based prescribing systems and comprehensive geriatric assessment. Available evidence on these approaches is mixed and controversial, and none of them showed a clear beneficial effect on patients' health outcomes. Limitation of these interventions is the lack of standardisation, and these differences may give reason for the variability of the results documented in randomised clinical studies. Interestingly, most of the available research is focused on a single intervention targeting either clinical or pharmacological factors causing ADRs. When these approaches are combined, positive effects on patients health outcomes can be shown, suggesting that integration of skills from different health care professionals is needed to address medical complexity of the older adults. The challenge for future research is to integrate valuable information obtained by existing instruments and methodologies in a complete and global approach targeting all potential factors involved in the onset of ADRs.

Prevalence and assessment of factors contributing to adverse drug reactions in wards of a tertiary care hospital, India

BACKGROUND

Adverse drug reactions account for the highest proportion among the causes of morbidity and mortality in clinical wards and are posing a considerable challenge. Hence, the objective of this study was to find out the prevalence of adverse drug reactions and the factors which contribute to their prevalence.

METHODS

A prospective patient record review was carried out at a tertiary care hospital in North India from August 2010-May 2011. A total of 1033 subjects admitted to hospital for any kind of treatment were included while patients admitted in the ward because of adverse drug reactions were excluded. The ward where we collected the data includes multispecialty and cardiovascular wards. The causality, severity, and preventability of adverse drug reactions were assessed using Naranjo, modified Hartwig, and Schumock and Thornton criteria, respectively. Kolmogorov-Smyrnov, chi -square and multiple logistic regression tests were used to determine adverse drug reactions ascribed to drugs.

RESULTS

Out of 1033 patients whose records were assessed, 167(16.2%) experienced one or more adverse drug reactions. The metabolic systems, which accounted for 49(24.6%) were most frequently affected by adverse drug reactions, followed by gastrointestinal, 45(22.6%); hematological, 28(14.1%) and cutaneous, 21(10.6%) systems. The drug classes most frequently associated with the reactions were antibiotics 40(20.1%), diuretics 35(17.6%) and anticoagulants 30(15.1%). According to the selected preventability scale, 72(36.2%) adverse drug reactions were classified as probably or definitely preventable. About 165(83%) of the reactions were type A, which represents augmentation of the pharmacological action of a drug. Number of drugs, length of hospitalization and number of diagnosis were identified as significant predisposing factors for ADRs.

CONCLUSION

The result of this study suggested that adverse drug reactions were significant causes of superimposed health problems that occur following hospitalization. The major risk factors associated with ADR include number of drugs, length of hospitalization and number of diagnosis. Based on the findings a rigorous study is recommended to determine the burden and identify the risk factors of adverse drug reactions to target interventions.

A new simple primary care morbidity score predicted mortality and better explains between practice variations than the Charlson index

OBJECTIVES

Adjustment for morbidity is important to ensure fair comparison of outcomes between patient groups and health care providers. The Quality and Outcomes Framework (QOF) in UK primary care offers potential for developing a standardized morbidity score for low-risk populations.

STUDY DESIGN AND SETTING

Retrospective cohort study of 653,780 patients aged 60 years or older registered with 375 practices in 2008 in a large primary care database (The Health Improvement Network). Half the practices were randomly selected to derive a morbidity score predicting 1-year mortality; the others assessed predictive performance.

RESULTS

Nine chronic conditions were robust copredictors (hazard ratio = ≥1.2) of mortality independent of age and sex, producing high predictive discrimination (c-statistic = 0.82). An individual's QOF score explained more between practice variation in mortality than the Charlson index (46% vs. 32%). At practice level, mean QOF score was strongly correlated with practice standardized mortality ratios (r = 0.64), explaining more variation in practice death rates than the Charlson index.

CONCLUSION

A simple nine-item score derived from routine primary care recording provides a morbidity index highly predictive of mortality and between practice variation in older UK primary care populations. This has utility in research and health care outcome monitoring and can be easily implemented in other primary and ambulatory care settings.

Which adverse events are related to health care during hospitalization in elderly inpatients?

BACKGROUND

Adverse events result in longer hospital stays and increase costs and mortality. We aimed to assess incidence of adverse events occurring during hospitalization in a post-emergency unit and to describe their characteristics.

METHODS

All adverse events occurring in patients during their hospitalization in a post-emergency unit in a French university hospital (20 beds) were systematically and consecutively recorded from September 2009 to February 2011. Patients with adverse events were compared to up to three control patients, matched for date of admission +/- age in the same unit.

RESULTS

We identified 56 patients with 64 adverse events, giving an incidence of 3.0/100 patients admitted/year. Fifty-one adverse events were drug-related. Patients had a median age of 82.5 years with a male/female ratio of 1/1.4. They presented a median Charlson score of 1 and the median number of medications was 6. The drugs most frequently involved in drug-related events were nervous system drugs (47%) and anti-infectives (22%). In multivariate analysis, a Charlson score ≥ 2 was associated with the occurrence of adverse events (OR 0.4; 95% CI [0.21 - 0.80]).

CONCLUSIONS

Systematic recording showed that adverse events were not rare in a post-emergency unit. Patients with comorbid conditions were less likely to present an adverse event, possibly because of greater precautions taken by the medical team.

Adverse drug reactions & their risk factors among Indian ambulatory elderly patients

BACKGROUND & OBJECTIVES

Several studies have reported adverse drug events ranging from 5 to 35 per cent in all age group from outpatient setting. However, adverse drug reactions (ADRs) particularly among a large sample of ambulatory elderly patients in India has not been reported. This study has attempted to identify ADRs and assessed their causality, preventability and severity, and also their risk factors in Indian ambulatory elderly patients.

METHODS

A 2 year long term prospective study included 4005 ambulatory elderly patients (60 yr or above; either sex) at a public teaching hospital. Suspected ADRs were assessed for causality, preventability and severity using Naranjo's probability scale, modified Schumock and Thornton's criteria, and modified Hartwig's criteria, respectively.

RESULTS

Of the total 4005 prescriptions, 406 were identified with ADRs, giving the occurrence of 10 per cent ADRs in elderly. The total number of ADRs was 422 in 406 prescriptions. Type A ADRs accounted for 46 per cent of the total ADRs. Majority of the ADRs (88.6%) were classified as 'probable'. The definitely preventable reactions were 22 per cent. The percentage of moderate reaction was 16 per cent. Only 1.6 per cent ADRs was severe in nature. The most common type of ADR was peripheral oedema. The most commonly offending class of drug was cardiovascular drugs (57.6%). Using logistic regression analysis, the risk factors which contributed to ADRs were age above 80 yr (OR=1.7), prescription of multiple drugs (OR=1.8), longer duration of treatment (OR=2.28) and multiple diagnoses (OR=1.8).

INTERPRETATION & CONCLUSIONS

In this study, 10 per cent ambulatory elderly patients were found to have ADRs. This indicates that the elderly patients should be closely monitored for ADRs, to avoid clinically significant harmful consequences. The awareness of risk factors of ADRs would help physicians to identify elderly patients with greater risk of ADRs and, therefore, might benefit from ADRs monitoring and reporting programme.

Delayed antibiotic prescribing and associated antibiotic consumption in adults with acute cough

BACKGROUND

Delayed antibiotic prescribing is promoted as a strategy to reduce antibiotic consumption, but its use and its effect on antibiotic consumption in routine care is poorly described.

AIM

To quantify delayed antibiotic prescribing in adults presenting in primary care with acute cough/lower respiratory tract infection (LRTI), duration of advised delay, consumption of delayed antibiotics, and factors associated with consumption.

DESIGN AND SETTING

Prospective observational cohort in general practices in 14 primary care networks in 13 European countries.

METHOD

GPs recorded clinical features and antibiotic prescribing for adults presenting with an acute infective illness with cough as the dominant symptom. Patients recorded their consumption of antibiotics from any source during the 28-day follow up.

RESULTS

Two hundred and ten (6.3%) of 3368 patients with usable consultation data were prescribed delayed antibiotics. The median recommended delay period was 3 days. Seventy-five (44.4%) of the 169 with consumption data consumed the antibiotic course and a further 18 (10.7%) took another antibiotic during the study period. 50 (29.6%) started their delayed course on the day of prescription. Clinician diagnosis of upper respiratory tract/viral infection and clinician's perception of patient's wanting antibiotics were associated with less consumption of the delayed prescription. Patient's wanting antibiotics was associated with greater consumption.

CONCLUSION

Delayed antibiotic prescribing was used infrequently for adults presenting in general practice with acute cough/LRTI. When used, the effect on antibiotic consumption was less than found in most trials. There are opportunities for standardising the intervention and promoting wider uptake.

Adverse Drug Reactions in Elderly Hospitalized Patients: A 12-Year Population-Based Retrospective Cohort Study

BACKGROUND:

Although research has identified some risk factors for first-time adverse drug reactions (ADRs), little is known about the risks associated with the number of ADRs. Modeling ADR counts is relatively complex because of the rarity of the events, requiring careful consideration of appropriate models that best present the observed data.

OBJECTIVE:

To determine the incidence of ADRs among elderly hospitalized patients, assess patient-related risk factors for the number of ADRs, and review drug classes commonly responsible for ADRs.

METHODS:

This retrospective cohort study used a population-based large administrative database on hospital separations from all acute care hospitals in the Canadian province of Newfoundland and Labrador. Patients aged 65 years or older with at least 1 hospital admission from April 1, 1995, to March 31, 2007, were included. Comorbidities, Charlson Comorbidity Index (CCI), and sociodemographic factors were assessed as predictors of ADR counts. A zero-inflated negative binomial regression model was used for analysis.

RESULTS:

The study cohort contained 64,446 patients. The incidence of ADRs was 15.2 per 1000 person-years (95% CI 14.8 to 15.7). Of those having an ADR, 15.4% had recurrent ADRs. The most common drug category implicated in ADRs was cardiovascular agents (17.7%). A dose-response relationship was found between CCI and ADR counts (rate ratio [RR] 1.67, 95% CI 1.41 to 1.98 for CCI 2-3; RR 2.38, 95% CI 1.98 to 2.87 for CCI 4-5; and RR 3.83, 95% CI 3.21-4.57 for CCI ≥6). Comorbid conditions including congestive heart failure (RR 1.58, 95% CI 1.33 to 1.89), diabetes (RR 2.42, 95% CI 1.64 to 3.56), and cancer (RR 3.12, 95% CI 2.58 to 3.76) were strong predictors. Rural areas (RR 1.22, 95% CI 1.01 to 1.46) were associated with increased risk for ADRs, whereas age and sex had no effect.

CONCLUSIONS:

Comorbidity from chronic diseases and severity of illness, rather than individual characteristics (advancing age and sex), increased the likelihood of ADRs. Changes in the delivery of care focusing on the monitoring of prescribed drugs in elderly patients with comorbidities could mitigate ADRs.

Differences in Complexity of Discharge Medication Regimens between Men and Women Discharged from Acute Care to Home following Total Joint Arthroplasty

Purpose

This study determined whether discharge medication regimens that patients managed at home following hip or knee total joint arthroplasty differed between men and women. Comparisons were made among overall complexity of the regimen and the separate components contributing to complexity: number of medications, dosage forms, dosing frequencies, and additional administration directions.

Methods

Patient demographics and discharge medication regimens for serially discharged patients were retrospectively collected for a 3-month period from medical records at a large urban acute care hospital. Complexity of discharge medication regimens was quantified with the Medication Regimen Complexity Index (MRCI), which accounts for each separate component of complexity.

Results

The serial sample comprised 105 men and 93 women discharged to home following total joint arthroplasty. Men and women did not differ by hospital length of stay or by proportions with the most common secondary diagnoses (hypertension, hyperlipidemia, diabetes). Women were discharged with significantly more complex medication regimens to manage at home than men ( P = .047). Among the individual components contributing to complexity, women were discharged with significantly more medications on their lists than men ( P = .006) and had significantly larger dosing frequency scores than men ( P = .01).

Conclusions

Women discharged to home following lower extremity total joint arthroplasty may be at greater risk for an adverse drug event than men due to increased medication regimen complexity. These findings suggest that attempts should be made to mitigate this risk through reduced regimen complexity, specifically targeting dosing frequency, increased education for patients with complex regimens, or increased monitoring.

Avaliação dos eventos adversos a medicamentos no contexto hospitalar

Este estudo teve como objetivo avaliar a ocorrência de eventos adversos a medicamentos em um hospital público e cardiológico, localizado no município do Rio de Janeiro e classificar os eventos adversos em relação à gravidade do dano. Trata-se de uma investigação baseada em revisão retrospectiva de prontuários. Foi analisada uma amostra aleatória de 112 prontuários de pacientes hospitalizados no período dezembro de 2007 a fevereiro de 2008. Enfermeiras revisoras selecionaram prontuários com potencial evento adverso a medicamento e um grupo de avaliadores confirmou a ocorrência dos eventos adversos e classificaram de acordo com o dano. A incidência de eventos adversos a medicamentos foi de 14,3%. Em 31,2% dos casos em que foi detectado o evento houve necessidade de intervenção para o suporte de vida. A detecção de eventos adversos nas instituições hospitalares possibilita conhecer falhas no sistema de medicação, bem como implementar estratégias para reduzi-las.

Risk factors for prescribing and transcribing medication errors among elderly patients during acute hospitalization: a cohort, case-control study

BACKGROUND

Medication errors are the cause of common and dangerous adverse effects on patients. They occur as a result of preventable failures in the prescribing (ordering), transcribing, dispensing and administration of medications.

OBJECTIVE

The aim of this study was to determine the relationship between patient characteristics and prescribing and transcribing medication errors during acute hospitalization of elderly patients in an internal medicine ward.

METHODS

A cohort case-control study was conducted in a 37-bed medical ward at a tertiary medical centre in Israel. The study included 137 patients in whom potentially harmful medication errors were detected, and 137 sex- and age-matched controls. Clinical data were collected and Charlson Comorbidity Index scores were calculated. Conditional logistic regression was used to identify factors associated with medication errors.

RESULTS

Independent factors associated with any type of medication error included Charlson Comorbidity Index score ≥8 (odds ratio [OR] 2.97 [95% CI 1.16, 7.61], p  =  0.023), number of medications ≥ 9 (OR 2.02 [95% CI 1.00, 4.05], p  =  0.049) [both upon admission] and length of hospital stay ≥ 13 days (OR 4.41 [95% CI 2.25, 8.62], p  <  0.0001). Independent factors associated with prescribing errors included Charlson Comorbidity Index score ≥ 8 (OR 6.34 [95% CI 1.63, 24.71], p  =  0.008) and length of hospital stay ≥13 days (OR 3.19 [95% CI 1.23, 8.26], p  =  0.017), while independent factors associated with transcribing errors included number of medications ≥9 (OR 2.58 [95% CI 1.02, 6.51], p  =  0.04) and length of hospital stay ≥ 13 days (OR 6.90 [95% CI 2.76, 17.23], p  <  0.0001). The median time to an error was 3 days, and was half as long for prescribing errors as for transcribing errors (2 and 4 days, respectively, p = 0.017).

CONCLUSIONS

The risk of medication errors among elderly patients during acute hospitalization in an internal medicine ward is associated with Charlson Comorbidity Index score (for prescribing errors), number of medications (for transcribing errors) and length of hospital stay (for both types of errors). Further study will determine whether these factors can be used to identify patients at risk and to prevent prescribing and transcribing medication errors.

Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans

OBJECTIVES

To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics.

DESIGN

Retrospective cohort.

SETTING

Veterans Affairs Medical Centers.

PARTICIPANTS

Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006.

MEASUREMENTS

Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications).

RESULTS

Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively).

CONCLUSION

ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.