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Fillenbaum GG, Hanlon JT, Landerman LR, Artz MB, O'Connor H, Dowd B, Gross CR, Boult C, Garrard J, Schmader KE. Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents. ACTA ACUST UNITED AC 2004; 2:92-101. [PMID: 15555485 DOI: 10.1016/s1543-5946(04)90014-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2004] [Indexed: 11/22/2022]
Abstract
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).
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Affiliation(s)
- Gerda G Fillenbaum
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC 27710, USA.
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102
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Abstract
Aging is a major factor in the over-consumption of drugs: although individuals aged >65 years account for approximately 15% of the population, almost one-third of all prescriptions are made out for this age group. This over-consumption is responsible for a number of potential hazards, such as iatrogenic pathology, poor compliance and drug interactions; it is also an economic burden. Most studies report an average of five drugs prescribed per individual, regardless of outpatient or inpatient status. Cardiovascular and psychotropic drugs are the most widely prescribed classes. Analgesic and nonsteroidal anti-inflammatory drugs are also very common. These are also the classes responsible for the highest number of adverse events in the elderly. There are numerous reasons for this over-consumption; in some cases, it is attributable to the patient himself (multiple diseases, deterioration of bodily functions, poor compliance, misuse, etc.), while in others, the prescribing physician, family or professional caregivers are at fault. The development of new drugs and the information made available regarding them can also be implicated. Studies comparing actual prescriptions with reference indications have shown that some are inappropriate: one meta-analysis showed that for 21.3% of patients in institutions and 40% of patients in convalescent homes, at least one prescription was inadequate; and in another analysis, the same applied to 12.5% of patients living at home. The potential seriousness of this over-consumption by elderly patients, even more so than in adults, calls for a detailed analysis of the situation and rational, regularly reviewed, realistic prescribing.
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103
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Rancourt C, Moisan J, Baillargeon L, Verreault R, Laurin D, Grégoire JP. Potentially inappropriate prescriptions for older patients in long-term care. BMC Geriatr 2004; 4:9. [PMID: 15488143 PMCID: PMC529256 DOI: 10.1186/1471-2318-4-9] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Accepted: 10/15/2004] [Indexed: 12/12/2022] Open
Abstract
Background Inappropriate medication use is a major healthcare issue for the elderly population. This study explored the prevalence of potentially inappropriate prescriptions (PIPs) in long-term care in metropolitan Quebec. Methods A cross sectional chart review of 2,633 long-term care older patients of the Quebec City area was performed. An explicit criteria list for PIPs was developed based on the literature and validated by a modified Delphi method. Medication orders were reviewed to describe prescribing patterns and to determine the prevalence of PIPs. A multivariate analysis was performed to identify predictors of PIPs. Results Almost all residents (94.0%) were receiving one or more prescribed medication; on average patients had 4.8 prescribed medications. A majority (54.7%) of treated patients had a potentially inappropriate prescription (PIP). Most common PIPs were drug interactions (33.9% of treated patients), followed by potentially inappropriate duration (23.6%), potentially inappropriate medication (14.7%) and potentially inappropriate dosage (9.6%). PIPs were most frequent for medications of the central nervous system (10.8% of prescribed medication). The likelihood of PIP increased significantly as the number of drugs prescribed increased (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 1.33 – 1.43) and with the length of stay (OR: 1.78, CI: 1.43 – 2.20). On the other hand, the risk of receiving a PIP decreased with age. Conclusion Potentially inappropriate prescribing is a serious problem in the highly medicated long-term care population in metropolitan Quebec. Use of explicit criteria lists may help identify the most critical issues and prioritize interventions to improve quality of care and patient safety.
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Affiliation(s)
- Carol Rancourt
- Health Economics and Outcomes Research, Merck Frosst Canada Ltd, Montreal, Qc, H9H 3L1, Canada
| | - Jocelyne Moisan
- Population Health Research Unit and Faculty of Pharmacy, Université Laval, Hôpital St-Sacrement, 1050 Chemin Ste-Foy, Québec, Qc, G1S 4L8, Canada
| | - Lucie Baillargeon
- Family Medicine Unit, Centre hospitalier universitaire de Québec, 2701 boul. Laurier, Québec, Qc, G1V 4G2, Canada
| | - René Verreault
- Geriatric Research Unit, and Faculty of Medicine, Université Laval, Hôpital St-Sacrement, 1050 Chemin Ste-Foy Québec, Qc, G1S 4L8, Canada
| | - Danielle Laurin
- Geriatric Research Unit and Faculty of Pharmacy, Université Laval, Hôpital St-Sacrement, 1050 Chemin Ste-Foy Québec, Qc, G1S 4L8, Canada
| | - Jean-Pierre Grégoire
- Population Health Research Unit and Faculty of Pharmacy, Université Laval, Hôpital St-Sacrement, 1050 Chemin Ste-Foy, Québec, Qc, G1S 4L8, Canada
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104
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Abstract
Although many patients are surviving longer than in the past, a cancer diagnosis may shatter the dream of a dignified old age for elderly patients. Cancer diagnosis and treatment often produce psychologic stresses resulting from the actual symptoms of the disease, as well as perceptions of the disease and its stigma. Concerns related to cancer have particular meaning for aging individuals who undergo these situations in the context of retirement, widowhood, other medical disabilities and other losses. Today, patients and families are more interested in treatment issues, and quality of life, both during and after treatment. In this article we discuss late life depression, anxiety and delirium as they relate to elderly patients coping with cancer.
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Affiliation(s)
- Andrew J Roth
- Department of Psychiatry and Behavioral Sciences, Box 421, Memorial Sloan-Kettering Cancer Center, 1242 2nd Avenue, New York, NY 10021, USA.
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105
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Oster G, Berger A, Dukes E, Edelsberg J, McCarberg B. Use of potentially inappropriate pain-related medications in older adults with painful neuropathic disorders. ACTA ACUST UNITED AC 2004; 2:163-70. [PMID: 15561648 DOI: 10.1016/j.amjopharm.2004.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2004] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although older adults with painful neuropathic disorders (PNDs) would appear to be at elevated risk for receiving potentially inappropriate pain-related medications, the extent of such drug use in this population is unknown. OBJECTIVE The goal of this study was to assess the use of potentially inappropriate pain-related medications among patients with PNDs aged >or=65 years. METHODS Using a large, integrated US health insurance database, we identified all persons aged >or=65 years with >or=2 medical encounters involving diagnoses of PNDs during calendar year 2000. Patients with <30 days of continuous eligibility for health benefits during the study year were excluded from the sample. Use of potentially inappropriate pain-related medications (as defined by the 1997 Beers criteria) was then examined based on information contained in paid pharmacy claims for all remaining patients. RESULTS We identified 22,668 patients with PNDs aged >or=65 years (mean [SD] age, 73.9 [6.0] years; 58.6% female). Almost one half (11,233 [49.6%]) of patients received >or=1 potentially inappropriate pain-related medication, including propoxyphene (26.7%) and amitriptyline (10.2%). Women were more likely than men to receive these medications (54.2% vs 43.0%, respectively; P<0.01), and use increased with age (47.6%, 51.8%, and 52.8% in those aged 65-74 years, 75-84 years, and >or=85 years, respectively; overall comparison, P<0.01). Among patients with only 1 PND, the use of potentially inappropriate medications was highest among those with postherpetic neuralgia (70.1%). CONCLUSIONS Use of potentially inappropriate pain-related medications among older adults with PNDs is common. Further research is needed to ascertain whether the benefits of these agents outweigh their risks in this population.
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Affiliation(s)
- Gerry Oster
- Policy Analysis, Inc., Brookline, Massachusetts 02445, USA.
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106
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Chrischilles EA, Carter BL, Lund BC, Rubenstein LM, Chen-Hardee SS, Voelker MD, Park TR, Kuehl AK. Evaluation of the Iowa Medicaid pharmaceutical case management program. J Am Pharm Assoc (2003) 2004; 44:337-49. [PMID: 15191244 DOI: 10.1331/154434504323063977] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To test the effect of pharmaceutical case management (PCM) on medication safety and health care utilization. DESIGN Prospective cohort design with 9-month follow-up period (enrollment from October 1, 2000, through July 1, 2001, with follow-up through July 1, 2002). SETTING Iowa Medicaid program. PARTICIPANTS 2,211 noninstitutionalized, continuously eligible Iowa Medicaid patients taking four or more chronic medications including at least one agent commonly used in at least 1 of 12 specific diseases who were cared for by pharmacists in 117 pharmacies. INTERVENTIONS Reimbursement for PCM services (initial patient assessment, written recommendations to physician, follow-up assessments and communication of progress and new problems to physician). MAIN OUTCOME MEASURES Use of high-risk medications, Medication Appropriateness Index (MAI) score, health care utilization. RESULTS Pharmacists in 114 pharmacies had eligible patients during at least one quarter during the study period; 28 pharmacies were classified as high intensity based on the number of PCM patients they managed. A total of 524 of the eligible patients received 1,599 PCM services; 90% of claims were filed by pharmacists, and the remainder by physicians. Nearly one half (46.1%) of medications and 92.1% of patients had at least one medication problem before PCM. By closeout, the percentage of medications with problems decreased in 8 of 10 MAI domains for those who received PCM. Compared with baseline, mean MAI score improved significantly from 9.4 to 8.3 among PCM recipients (P < .001). Percentage of PCM recipients using high-risk medications decreased significantly compared with PCM eligibles who did not receive the service. In the 28 pharmacies that adopted the new service most intensely, patients had a significant decrease in high-risk medication use, compared with patients of low-intensity pharmacies (P < .001). No difference was observed between PCM recipients and PCM eligibles who did not receive PCM in health care utilization or charges, even after including reimbursements for PCM. CONCLUSION Medication safety problems were prevalent in this high-risk population. The PCM program improved medication safety during a 9-month follow-up period.
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Affiliation(s)
- Elizabeth A Chrischilles
- Health Effectiveness Research Center, Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA.
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107
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Sketris IS, Kephart GC, Frail DM, Skedgel C, Allen MJ. The Effect of Deinsuring Chlorpropamide on the Prescribing of Oral Antihyperglycemics for Nova Scotia Seniors’ Pharmacare Beneficiaries. Pharmacotherapy 2004; 24:784-91. [PMID: 15222669 DOI: 10.1592/phco.24.8.784.36073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
On behalf of the Nova Scotia Seniors' Pharmacare Program, the Drug Evaluation Alliance of Nova Scotia developed a multicomponent intervention plan to facilitate the removal of chlorpropamide as an insured benefit. Chlorpropamide has caused serious hypoglycemia in seniors to a greater extent than some other agents. Pharmacy administrative claims were used to compute monthly use rates for insulin and each oral antihyperglycemic drug from January 1, 2000-December 30, 2002, in an intervention cohort (patients receiving chlorpropamide) and a control cohort (patients receiving an antihyperglycemic agent other than chlorpropamide). Initially, 630 patients were receiving chlorpropamide therapy. By the time chlorpropamide was deinsured, only 10% of the treatment cohort continued receiving chlorpropamide; shortly after deinsurance, no beneficiaries continued receiving the drug. The antihyperglycemics with the greatest increase in prescription were glyburide and gliclazide. The deinsuring of chlorpropamide and the educational strategies that accompanied it resulted in the selection of more appropriate antihyperglycemics for Nova Scotia seniors.
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Affiliation(s)
- Ingrid S Sketris
- College of Pharmacy, Dalhousie University, Halifax, Nova Scotia, Canada.
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108
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Grasso BC, Rothschild JM, Genest R, Bates DW. What do we know about medication errors in inpatient psychiatry? JOINT COMMISSION JOURNAL ON QUALITY AND SAFETY 2003; 29:391-400. [PMID: 12953603 DOI: 10.1016/s1549-3741(03)29047-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework. METHODS English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies. RESULTS Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings. CONCLUSIONS Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.
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109
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Abstract
Falls among older people constitute a serious public health problem, which has a substantial impact on both the person and on healthcare services. Falls assessment can be divided into a number of types. Community nurses are well placed to use falls risk checklists to identify older people who may be at risk of falling and then offer these individuals a more in-depth assessment. In addition, community nurses have a role to play in assessing older people who have recently fallen to prevent future falls and potential injury. Falls prevention programmes centre on the identification of risk factors and the planning and delivery of interventions designed to eliminate or ameliorate these risks. A falls assessment should include a review of intrinsic factors such as mobility, lower extremity functioning, vision, medications, footwear and past medical history. It is also important to consider extrinsic factors such as tripping, slipping and other environmental hazards.
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Affiliation(s)
- John Unsworth
- Centre for Primary and Community Care Learning, Northumbria University.
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