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Gillette C, Prunty L, Wolcott J, Broedel-Zaugg K. A new lexicon for polypharmacy: Implications for research, practice, and education. Res Social Adm Pharm 2014; 11:468-71. [PMID: 25280463 DOI: 10.1016/j.sapharm.2014.08.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 08/17/2014] [Accepted: 08/17/2014] [Indexed: 10/24/2022]
Abstract
Previous research suggests that polypharmacy is a significant challenge for health care systems. However, polypharmacy has been defined in at least 24 distinct ways, which has understandably caused confusion among researchers, educators, and students in health care. Previous definitions of polypharmacy capture what could be both inappropriate therapy, i.e. too many medications, as well as evidence-based therapy that is appropriate. Previous research has tried to focus on the number of medications a patient is prescribed to define polypharmacy; however only focusing on the number of medications a patient is taking may be of limited value in determining whether that patient will experience an adverse event. This paper proposes a lexicon change for polypharmacy. It suggests that in future research, polypharmacy be defined as patients going to more than one pharmacy for their prescriptions. The authors also proffer a new term, 'extraordinary prescribing,' to define patients who are taking medications that are either grossly excessive or not beneficial for that patient. This definition is different than the current use of polypharmacy because the number of medications a patient is taking is irrelevant, especially if that patient has multiple chronic diseases. This paper is meant to start a dialog within the health services research community to inform future research that examines why inefficient prescribing may harm patients and the broader health care system.
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Affiliation(s)
- Chris Gillette
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA.
| | - Leesa Prunty
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
| | - Janet Wolcott
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
| | - Kimberly Broedel-Zaugg
- Marshall University School of Pharmacy, Department of Pharmacy Practice, Administration, and Research, 1 John Marshall Dr., Huntington, WV 25755, USA
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152
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Naveiro-Rilo JC, Diez-Juárez D, Flores-Zurutuza ML, Molina-Mazo R, Alberte-Pérez C. [Intervention in elderly patients with multiple morbidities and multiple medications: results of the prescription and the quality of life]. ACTA ACUST UNITED AC 2014; 29:256-62. [PMID: 25129527 DOI: 10.1016/j.cali.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the effect of an intervention using STOPP/START criteria and the Garfinkel algorithm on prescription and the health-related quality of life (HRQoL) in elderly patients with multimorbidity and prescribed multiple medications. MATERIAL AND METHOD A before-after intervention study on 381 patients over 67 years old and prescribed multiple medications by 71 Primary Care doctors. INTERVENTION The doctors were trained in the STOPP / START criteria and Garfinkel algorithm. Each doctor then reviewed all the drugs of their selected patients and then made appointments with them for an initial medical consultation and clinical assessment. Treatment was modified according to the criteria and the HRQoL measured using the SF-12 questionnaire. Two months later, in a second medical consultation, a new clinical assessment was made and the HRQoL was measured. The dimensions of the HRQoL between the first and the second consultation were compared using the paired Student-t test. RESULTS The intervention involved the removal of a mean of 1.5 drugs per patient. The dose was modified in 4% of drugs, and 8.9% of patients were prescribed a new drug. Non-Steroidal Anti-inflammatory drugs (NSAID), psychoactive drugs and proton pump inhibitors were the most modified. Social Function and Physical Component Summary of the HRQOL improved significantly (P<.05) after intervention. CONCLUSION The intervention using the Garfinkel algorithm and STOPP -START criteria improved HRQoL and reduced the number of prescribed drugs.
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153
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Kennedy AG, Chen H, Corriveau M, MacLean CD. Improving population management through pharmacist-primary care integration: a pilot study. Popul Health Manag 2014; 18:23-9. [PMID: 25029631 DOI: 10.1089/pop.2014.0043] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Pharmacists have unique skills that may benefit primary care practices. The objective of this demonstration project was to determine the impact of integrating pharmacists into patient-centered medical homes, with a focus on population management. Pharmacists were partnered into 5 primary care practices in Vermont 1 day per week to provide direct patient care, population-based medication management, and prescriber education. The main measures included a description of drug therapy problems identified and cost avoidance models. The pharmacists identified 708 drug therapy problems through direct patient care (336/708; 47.5%), population-based strategies (276/708; 38.9%), and education (96/708; 13.6%). Common population-based strategies included adjusting doses and discontinuing unnecessary medications. Pharmacists' recommendations to correct drug therapy problems were accepted by prescribers 86% of the time, when data about acceptance were known. Of the 49 recommendations not accepted, 47/49 (96%) were population-based and 2/49 (4%) were related to direct patient care. The cost avoidance model suggests $2.11 in cost was avoided for every $1.00 spent on a pharmacist ($373,092/$176,690). There was clear value in integrating pharmacists into primary care teams. Their inclusion prevented adverse drug events, avoided costs, and improved patient outcomes. Primary care providers should consider pharmacists well suited to offer direct patient care, population-based management, and prescriber education to their practices. To be successful, pharmacists must have full permission to document findings in the primary care practices' electronic health records. Given that many pharmacist services do not involve billable activities, sustainability requires identifying alternative funding mechanisms that do not rely on a traditional fee-for-service approach.
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Affiliation(s)
- Amanda G Kennedy
- 1 Division of General Internal Medicine, University of Vermont College of Medicine , Burlington, Vermont
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154
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Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging 2014; 30:893-900. [PMID: 24062215 DOI: 10.1007/s40266-013-0118-4] [Citation(s) in RCA: 132] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.
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Affiliation(s)
- Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA,
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155
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Pharmacist services provided in general practice clinics: A systematic review and meta-analysis. Res Social Adm Pharm 2014; 10:608-22. [DOI: 10.1016/j.sapharm.2013.08.006] [Citation(s) in RCA: 205] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 08/30/2013] [Accepted: 08/30/2013] [Indexed: 11/23/2022]
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156
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Jódar-Sánchez F, Martín JJ, López del Amo MP, García L, Araújo-Santos JM, Epstein D. Cost-utility analysis of a pharmacotherapy follow-up for elderly nursing home residents in Spain. J Am Geriatr Soc 2014; 62:1272-80. [PMID: 24891096 DOI: 10.1111/jgs.12890] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To compare the cost-effectiveness of a pharmacotherapy follow-up for elderly nursing home (NH) residents with that of usual care. DESIGN Prospective observational study with a concurrent control group conducted over 12 months. SETTING Fifteen NHs in Andalusia assigned to control (n = 6) or intervention (n = 9). PARTICIPANTS Residents aged 65 and older. INTERVENTION Pharmacotherapy follow-up. MEASUREMENTS Negative outcomes associated with medication, health-related quality of life, cost, quality-adjusted life-year (QALY), and incremental cost-effectiveness ratio (ICER). ICERs were estimated for three scenarios: unadjusted cost per QALY (first scenario), costs adjusted for baseline prescribed medication and QALYs adjusted for baseline utility score (second scenario), and costs and QALYs adjusted for a fuller set of baseline characteristics (third scenario). RESULTS Three hundred thirty-two elderly residents were enrolled: 122 in the control group and 210 in the intervention group. The general practitioner accepted 88.7% (274/309) of pharmacist recommendations. Pharmacist interventions reduced the average number of prescribed medication by 0.47 drugs (P < .001), whereas the average prescribed medication increased by 0.94 drugs in the control group (P < .001). Both groups reported a lower average EuroQol-5D utility score after 12 months (intervention, -0.0576, P = .002; control, -0.0999, P = .003). For the first scenario, usual care dominated pharmacotherapy follow-up (was less effective and more expensive). Adjusted ICERs were € 3,899/QALY ($5,002/QALY) for the second scenario and € 6,574/QALY ($8,433/QALY) for the third scenario. For a willingness to pay of € 30,000/QALY ($38,487/QALY), the probabilities of the pharmacotherapy follow-up being cost-effective were 35% for the first scenario, 78% for the second, and 76% for the third. CONCLUSION Pharmacotherapy follow-up is considered cost-effective for elderly NH residents in Spain.
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157
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Potential drug interactions and chemotoxicity in older patients with cancer receiving chemotherapy. J Geriatr Oncol 2014; 5:307-14. [PMID: 24821377 DOI: 10.1016/j.jgo.2014.04.002] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 01/28/2014] [Accepted: 04/21/2014] [Indexed: 11/22/2022]
Abstract
PURPOSE Increased risk of drug interactions due to polypharmacy and aging-related changes in physiology among older patients with cancer is further augmented during chemotherapy. No previous studies examined potential drug interactions (PDIs) from polypharmacy and their association with chemotherapy tolerance in older patients with cancer. METHODS This study is a retrospective medical chart review of 244 patients aged 70+ years who received chemotherapy for solid or hematological malignancies. PDI among all drugs, supplements, and herbals taken with the first chemotherapy cycle were screened for using the Drug Interaction Facts software, which classifies PDIs into five levels of clinical significance with level 1 being the highest. Descriptive and correlative statistics were used to describe rates of PDI. The association between PDI and severe chemotoxicity was tested with logistic regressions adjusted for baseline covariates. RESULTS A total of 769 PDIs were identified in 75.4% patients. Of the 82 level 1 PDIs identified among these, 32 PDIs involved chemotherapeutics. A large proportion of the identified PDIs were of minor clinical significance. The risk of severe non-hematological toxicity almost doubled with each level 1 PDI (OR=1.94, 95% CI: 1.22-3.09), and tripled with each level 1 PDI involving chemotherapeutics (OR=3.08, 95% CI: 1.33-7.12). No association between PDI and hematological toxicity was found. CONCLUSIONS In this convenience sample of older patients with cancer receiving chemotherapy we found notable rates of PDI and a substantial adjusted impact of PDI on risk of non-hematological toxicity. These findings warrant further research to optimize chemotherapy outcomes.
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158
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The Impact of a Structured Pharmacist Intervention on the Appropriateness of Prescribing in Older Hospitalized Patients. Drugs Aging 2014; 31:471-81. [DOI: 10.1007/s40266-014-0172-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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159
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Garcia BH, Storli SL, Småbrekke L. A pharmacist-led follow-up program for patients with coronary heart disease in North Norway--a qualitative study exploring patient experiences. BMC Res Notes 2014; 7:197. [PMID: 24679131 PMCID: PMC3974183 DOI: 10.1186/1756-0500-7-197] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 03/27/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Coronary heart disease (CHD) is one of the leading causes of death worldwide. Scientific literature shows that prevention of CHD is inadequate. The clinical pharmacist's role in patient-centred care has been shown favourable in a large amount of studies, also in relation to reduction of risk factors related to CHD. We developed and piloted a pharmacist-led follow-up program for patients with established CHD after hospital discharge from a hospital in North Norway. The aim of the present study was to explore how participants in the follow-up program experienced the program with regard to four main topics; medication knowledge, feeling of safety and comfort with medications, the functionality of the program and the clinical pharmacist's role in the interdisciplinary team. METHODS We performed semi-structured thematic interviews with four patients included in the program. After verbatim transcribing, we analysed the interviews using "qualitative content analyses" by Graneheim and Lundman. Trial registration http://www.clinicaltrials.gov: NCT01131715. RESULTS All participants appreciated the follow-up program because their medication knowledge had increased, participation had made them feel safe, they were reassured about the appropriateness of their medications, and they had become more involved in their own medication. The participants reported that the program was well structured and the clinical pharmacist was said to be an important caretaker in the health-care system. The importance of collaboration between pharmacists and physicians, both in hospital and primary care, was emphasized. CONCLUSION Our results indicate that the follow-up program was highly appreciated among the four participants included in this study. The results must be interpreted in the context of the health care system in Norway today. Here, few pharmacists are working in hospitals or in close relation to the general practitioners. In addition, physicians are short of time in order to supply appropriate medication information, both in hospital and primary care. Involving pharmacists in follow-up of patients with CHD seems to be highly appreciated among patients and may be a step towards improving patient care. The study is limited by the low number of participants.
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Affiliation(s)
- Beate Hennie Garcia
- Hospital Pharmacy of North Norway Trust, PO 6147, Langnes, 9291 Tromsø, Norway
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
| | - Sissel Lisa Storli
- Department of Health and Care Sciences, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
| | - Lars Småbrekke
- Department of Pharmacy, Faculty of Health Sciences, University of Tromsø, N-9037 Tromsø, Norway
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160
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Rojas-Fernandez CH, Patel T, Lee L. An interdisciplinary memory clinic: a novel practice setting for pharmacists in primary care. Ann Pharmacother 2014; 48:785-95. [PMID: 24651163 DOI: 10.1177/1060028014526857] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pharmacists have developed innovative practices in various settings as singular providers or as members of multidisciplinary or interdisciplinary teams. Examples include pharmacists practicing in heart failure, hypertension, or hyperlipidemia clinics. There is a paucity of literature describing pharmacists in interdisciplinary memory clinics and specifically pharmacists practicing in interdisciplinary, primary care-based memory clinics. New practice models should be disseminated to guide others in the development of similar models given the complexity of this population. Patients with dementia are more difficult to manage because of cognitive impairment, behavioral and psychological symptoms, the common presence of multiple comorbidities, and related polypharmacy and caregiver issues. These challenges require expertise in neurodegenerative disorders and geriatrics. The purpose of this article is to describe the role of clinical pharmacists providing care to patients with cognitive complaints in a primary care-based, interdisciplinary memory clinic, with a focus on how the pharmacist practices and is integrated in this collaborative care setting. Patients are assessed using an interdisciplinary approach, with team consensus for assessment and planning of care. Pharmacists' activities include assessment of (1) appropriateness of medications based on frailty, (2) medications that can impair cognition and/or function, (3) medication adherence and management skills, and (4) vascular risk factor control. Pharmacists provide education regarding medications and diseases, ensure appropriate transitions in care, and conduct home visits. Pharmacist participation in this clinic represents a novel opportunity to advance pharmacy practice in primary care, interdisciplinary models. Work is ongoing to describe outcomes attributable to pharmacist participation in this clinic.
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161
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Dunn RL, Harrison D, Ripley TL. The beers criteria as an outpatient screening tool for potentially inappropriate medications. ACTA ACUST UNITED AC 2014; 26:754-63. [PMID: 22005141 DOI: 10.4140/tcp.n.2011.754] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To determine the impact of using the Beers criteria (sometimes known as the Beers list) as an outpatient screening tool on the number or dosage of Beers criteria medications identified in patients' medication profiles immediately before an outpatient appointment. DESIGN Nonrandomized, prospective pre-/post pilot study. SETTING Six individual medicine and medicine-specialty clinics at a major academic medical center. PARTICIPANTS All subjects were 65 years of age or older. INTERVENTIONS Subjects 65 years of age or older had their medication profiles screened using the Beers criteria- medications potentially inappropriate for use in the elderly- prior to and directly after a scheduled appointment with their physician. Respective physicians were notified of any Beers criteria medications before the appointments. Physician options were to discontinue, continue, or change the dose of the medications identified with the option for justification of their decision. MAIN OUTCOME MEASURE The difference from baseline (preappointment) to follow-up (postappointment) in the number or dosage of Beers criteria medications identified in patients' profiles. RESULTS 120 eligible charts were reviewed. The average age of subjects was 74 years. Overall, 37.5% of subjects were on potentially inappropriate medications (PIMs) as defined by the Beers criteria. Sixty-three PIMs were flagged out of 120 profiles. For the primary outcome, 8/63 and 0/63 PIMs were discontinued or had a dosage change, respectively. This intervention resulted in a statistically significant reduction in the mean number of Beers criteria medications (P = 0.032). CONCLUSION Use of the Beers criteria as a clinical intervention tool in an outpatient setting may be an effective method to reduce the number of PIMs prescribed in an elderly population.
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Affiliation(s)
- Rebecca L Dunn
- Department of Pharmacy: Clinical and Administrative Sciences, University of Oklahoma Health Sciences Center College of Pharmacy, Oklahoma City, Oklahoma
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162
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Shade MY, Berger AM, Chaperon C. Potentially inappropriate medications in community-dwelling older adults. Res Gerontol Nurs 2014; 7:178-92. [PMID: 24530281 DOI: 10.3928/19404921-20140210-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/13/2013] [Indexed: 11/20/2022]
Abstract
Potentially inappropriate medication (PIM) use is a significant worldwide public health problem. Community-dwelling older adults are susceptible to the negative outcomes associated with the use of PIMs. A database search (January 1991-June 2013) produced 19 prospective correlational and 10 intervention studies. The current state of the science reveals that conceptual clarity is lacking regarding the use of PIMs. The prevalence of PIM use is well documented in an abundance of descriptive studies. However, researchers have not examined an intervention's effects on health outcomes in community-dwelling older adults. Although independent older adults can acquire PIMs outside of a provider, current interventions aim to change the behavior of the prescribing physician and pharmacist. Nurses need to collaborate with other disciplines in PIM use research. Priority needs are to design interventions that reduce the use of PIMs and negative health outcomes.
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163
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Chew C, Chiang J, Yeoh TT. Impact of outpatient interventions made at an ambulatory cancer centre oncology pharmacy in Singapore. J Oncol Pharm Pract 2014; 21:93-101. [DOI: 10.1177/1078155213519836] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives To evaluate the clinical significance of interventions made by pharmacists in an oncology pharmacy in Singapore and their acceptance rate and to identify common drug-related problems and workflow-related interventions. Methods A two-month prospective intervention study was conducted at National Cancer Centre Singapore. During the study, pharmacists documented the reason for intervening and its related drug(s). Each intervention was evaluated for its clinical significance by an expert panel: two oncologists and a pharmacist using a five-point scale. The Kendall’s test of concordance and Cohen’s weighted kappa were employed for analysis of agreement among the respondents. Other variables were analysed using descriptive statistics. Results A total of 331 interventions were recorded: 147 cases were due to missing chemotherapy orders while 184 cases had potential drug-related problems. Among the 184 cases, 60 cases were related to clarification of orders, while the others had drug-related problems. The Kendall’s concordance coefficient was calculated to be 0.612 ( p < 0.001) while weighted kappa test results showed fair agreement across the evaluators. Acceptance rate of interventions was 93%. Most commonly documented drugs requiring interventions were carboplatin, trastuzumab and capecitabine. Conclusions About half of the documented interventions by pharmacists were evaluated as clinically ‘significant’ or ‘very significant’.
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Affiliation(s)
- Cindy Chew
- Department of Pharmacy, National Cancer Centre Singapore, Singapore
| | - Joen Chiang
- Department of Pharmacy, National Cancer Centre Singapore, Singapore
| | - TT Yeoh
- Department of Pharmacy, National Cancer Centre Singapore, Singapore
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164
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Williams AM, Dopheide JA. Nonpsychiatric medication interventions initiated by a postgraduate year 2 psychiatric pharmacy resident in a patient-centered medical home. Prim Care Companion CNS Disord 2014; 16:14m01680. [PMID: 25834765 DOI: 10.4088/pcc.14m01680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 07/23/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Studies have demonstrated the benefits of incorporating comprehensive medication management into primary care, but no study describes the types of nonpsychiatric medication-related interventions provided by a psychiatric pharmacist while providing comprehensive medication management. METHOD A chart review of Center for Community Health patients enrolled in the University of Southern California Psychiatric Pharmacy Clinic, Los Angeles, between July 1, 2013, and January 10, 2014, was conducted. Progress notes were reviewed to collect medication recommendations and interventions. The number and types of interventions were compared between groups based on substance abuse history, comorbid medical conditions, number of psychiatric diagnoses, and number of medications. An anonymous survey was distributed to primary care providers (PCPs) regarding perceptions and attitudes toward a postgraduate year 2 psychiatric pharmacy resident's interventions pertaining to nonpsychiatric medications. RESULTS 177 nonpsychiatric medication interventions were documented. Fifty interventions required PCP approval, and 45% of those were accepted. Having a diagnosis of diabetes (P < .0001), hypertension (P < .0001), gastroesophageal reflux disease (P < .0001), ≥ 9 medications (P < .0001), or ≥ 5 medical diagnoses (P < .0001) were all associated with an increased mean number of interventions. Of the PCPs, 66% viewed the psychiatric pharmacist as a resource for addressing medical interventions by providing drug information. The PCPs were agreeable to having a psychiatric pharmacist provide drug information and monitor the patient but reported mixed opinions on whether a psychiatric pharmacist should comanage nonpsychiatric conditions. CONCLUSIONS Psychiatric pharmacists can successfully collaborate with PCPs in primary care clinics to provide comprehensive medication management that optimizes pharmacotherapy for patients with medical and psychiatric conditions. Continued efforts are needed to promote interdisciplinary approaches to provide comprehensive medication management services for patients with both psychiatric and medical disorders.
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Affiliation(s)
- Andrew M Williams
- University of Southern California School of Pharmacy, Los Angeles (both authors); and University of Southern California Keck School of Medicine, Los Angeles (Dr Dopheide)
| | - Julie A Dopheide
- University of Southern California School of Pharmacy, Los Angeles (both authors); and University of Southern California Keck School of Medicine, Los Angeles (Dr Dopheide)
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165
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Muth C, Beyer M, Fortin M, Rochon J, Oswald F, Valderas JM, Harder S, Glynn LG, Perera R, Freitag M, Kaspar R, Gensichen J, van den Akker M. Multimorbidity's research challenges and priorities from a clinical perspective: the case of 'Mr Curran'. Eur J Gen Pract 2013; 20:139-47. [PMID: 24160250 DOI: 10.3109/13814788.2013.839651] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Older patients, suffering from numerous diseases and taking multiple medications are the rule rather than the exception in primary care. A manifold of medical conditions are often associated with poor outcomes, and their multiple medications raise additional risks of polypharmacy. Such patients account for most healthcare expenditures. Effective approaches are needed to manage such complex patients in primary care. This paper describes the results of a scoping exercise, including a two-day workshop with 17 professionals from six countries, experienced in general practice and primary care research as well as epidemiology, clinical pharmacology, gerontology and methodology. This was followed by a consensus process investigating the challenges and core questions for multimorbidity research in primary care from a clinical perspective and presents examples of the best research practice. Current approaches in measuring and clustering multimorbidity inform policy-makers and researchers, but research is needed to provide support in clinical decision making. Multimorbidity presents a complexity of conditions leading to individual patient's needs and demanding complex processes in clinical decision making. The identification of patterns presupposes the development of strategies on how to manage multimorbidity and polypharmacy. Interventions have to be complex and multifaceted, and their evaluation poses numerous methodological challenges in study design, outcome measurement and analysis. Overall, it can be seen that complexity is a main underlying theme. Moreover, flexible study designs, outcome parameters and evaluation strategies are needed to account for this complexity.
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Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University , Frankfurt/Main , Germany
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166
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Balducci L, Goetz-Parten D, Steinman MA. Polypharmacy and the management of the older cancer patient. Ann Oncol 2013; 24 Suppl 7:vii36-40. [PMID: 24001761 PMCID: PMC6278993 DOI: 10.1093/annonc/mdt266] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aging is associated with polymorbidity and polypharmacy. In the absence of a consensual definition, polypharmacy has been defined according to the number of drugs that an individual takes or to the presence of the risk of at least one severe drug interaction. In older cancer patients, polypharmacy is at least as common as it is in individuals of the same age without cancer. The management of cancer itself may result in the addition of more medications to counteract the adverse effects of antineoplastic treatment. Polypharmacy may be necessary to control the multiple health conditions of the older person, but it may represent a risk factor for more complications from antineoplastic therapy, and it may affect the outcome of cancer treatment. Polypharmacy is also associated with increased cost. The criteria proposed for the management of polypharmacy include the assessment that all medical conditions are properly treated, the avoidance of drug interactions, and of drugs that may compromise the outcome of antineoplastic treatment and the choice of drugs with the lowest risk of complications in older individuals.
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Affiliation(s)
- L Balducci
- H. Lee Moffitt Cancer Center and Research Institute, University of South Florida College of Medicine,12902 Magnolia Drive,Tampa, FL 33612, USA.
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167
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Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 2013; 13:57-65. [PMID: 24073682 DOI: 10.1517/14740338.2013.827660] [Citation(s) in RCA: 1054] [Impact Index Per Article: 95.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Polypharmacy, defined as the use of multiple drugs or more than are medically necessary, is a growing concern for older adults. MEDLINE and EMBASE databases were searched from January 1, 1986 to June 30, 2013) to identify relevant articles in people aged > 65 years. AREAS COVERED We present information about: i) prevalence of polypharmacy and unnecessary medication use; ii) negative consequences of polypharmacy; and iii) interventions to improve polypharmacy. EXPERT OPINION International research shows that polypharmacy is common in older adults with the highest number of drugs taken by those residing in nursing homes. Nearly 50% of older adults take one or more medications that are not medically necessary. Research has clearly established a strong relationship between polypharmacy and negative clinical consequences. Moreover, well-designed interprofessional (often including clinical pharmacist) intervention studies that focus on enrolling high-risk older patients with polypharmacy have shown that they can be effective in reducing aspects of unnecessary prescribing with mixed results on distal health outcomes.
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Affiliation(s)
- Robert L Maher
- Duquesne University, Pharmacy , 321 Bayer Building, 600 Forbes Avenue, Pittsburgh, PA 15209 , USA
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168
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Powell AA, Bloomfield HE, Burgess DJ, Wilt TJ, Partin MR. A Conceptual Framework for Understanding and Reducing Overuse by Primary Care Providers. Med Care Res Rev 2013; 70:451-72. [DOI: 10.1177/1077558713496166] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Primary care providers frequently recommend, administer, or prescribe health care services that are unlikely to benefit their patients. Yet little is known about how to reduce provider overuse behavior. In the absence of a theoretically grounded causal framework, it is difficult to predict the contexts under which different types of interventions to reduce provider overuse will succeed and under which they will fail. In this article, we present a framework based on the theory of planned behavior that is designed to guide overuse research and intervention development. We describe categories of primary care provider beliefs that lead to the formation of intentions to assess the appropriateness of services, and propose factors that may affect whether the presence of assessment intentions results in an appropriate recommendation. Interventions that have been commonly used to address provider overuse behavior are reviewed within the context of the framework.
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Affiliation(s)
- Adam A. Powell
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Hanna E. Bloomfield
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Diana J. Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Timothy J. Wilt
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Melissa R. Partin
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Friesner DL, Scott DM, Dewey MW, Johnson TA, Kessler ML. What types of nursing facilities are more likely to adopt a pharmacist's medication review recommendations? ACTA ACUST UNITED AC 2013; 28:490-501. [PMID: 23906893 DOI: 10.4140/tcp.n.2013.490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Few studies in the literature have analyzed the determinants of pharmacist drug therapy recommendations in nursing facility settings, and those that have focus primarily on accepted/rejected recommendations by disease state. OBJECTIVE To identify the set of nursing facility characteristics that are more likely to adopt a pharmacist's medication review recommendations. DESIGN Cross-sectional, retrospective methods are used to examine 53 licensed nursing facilities receiving medication review services from a small independent consultant pharmacist practice with no ties to vendor pharmacy functions. SETTING Nursing facilities in rural areas of central and western Minnesota in 2008. INTERVENTION Medication review services. MAIN OUTCOME MEASURES The number of recommendations made and accepted, which are aggregated to the level of the nursing facility. Poisson regression analysis is used to identify those nursing facility characteristics that predict total recommendations and total accepted recommendations. Data obtained from Medicare's Web site on each nursing facility's operating characteristics and quality indicators serve as covariates. RESULTS At the 5% level, patient census (positively), greater certified nursing assistant staffing hours (positively), multisite facilities (positively), resident residency councils (negatively), and greater perceptions of registered nurse quality (negatively) predict a greater number of recommendations. Patient census (positively), greater licensed practical nurse staffing (negatively), having residency councils (negatively), and greater perceptions of registered nurse quality (negatively) significantly predict the number of accepted and implemented recommendations. CONCLUSION Institutional specific factors, most notably, quality-of-care indicators, may affect a nursing facility's acceptance of a pharmacist's drug therapy review.
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Affiliation(s)
- Daniel L Friesner
- Department of Pharmacy Practice, North Dakota State University College of Pharmacy, Nursing, and Allied Sciences, Fargo, ND, USA
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170
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Awalom MT, Kidane ME, Abraha BW. Physicians' views on the professional roles of pharmacists in patient care in Eritrea. Int J Clin Pharm 2013; 35:841-6. [PMID: 23857429 DOI: 10.1007/s11096-013-9820-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 06/25/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A collaborative relationship between physicians and pharmacists is crucial in the patient oriented role of pharmacists. In order to get an optimal patient outcome, strong cooperation between pharmacists and physicians is necessary. It is evident that in patient-oriented activities of pharmacists, their roles should be appropriately perceived and welcomed by physicians. This survey, thus, aimed to explore the perception of Eritrean physicians towards the professional roles of pharmacists in patient care. SETTING The study was conducted in all hospitals in Asmara. METHOD A self administered questionnaire was distributed to the physicians working in Asmara hospitals. The instrument contained questions to evaluate the physicians' level of agreement using a 5-point Likert type scale. MAIN OUTCOME MEASURE Opinions of physicians on the professional role of pharmacists. RESULTS Out of the 55 questionnaires distributed 50 were completed and returned, giving a response rate of 90.91 %. Most of the physicians accepted the reprofessionalization of pharmacy profession (88 %); majority disagreed that pharmacists are using their full potential in patient care (60 %); physicians strongly agreed or agreed that they should accept pharmacists' recommendations on patients' medication (96 %). CONCLUSIONS Generally the physicians appreciated the professional role of pharmacists in patient care. They agreed with the idea of re-professionalization of pharmacy into patient care. For conclusive evidence nationwide study is recommended.
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Freund J, Meiman J, Kraus C. Using electronic medical record data to characterize the level of medication use by age-groups in a network of primary care clinics. J Prim Care Community Health 2013; 4:286-93. [PMID: 24327665 DOI: 10.1177/2150131913495243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Our primary aim was to characterize the level of medication use across age-groups by examining electronic medical record data for a large number of patients receiving care in primary care clinics. A secondary aim was to identify factors associated with higher levels of medication use or polypharmacy. METHODS We conducted a retrospective query of electronic medical record data from a clinical data warehouse, evaluating 114 012 patients seen in primary care clinics at least once in the previous 6 months. Medication use was evaluated in 3 different categories: level 1 (0-4 medications), level 2 (5-9 medications), and level 3 (≥ 10 medications). Multivariate analysis was used to analyze different patient demographics and comorbidities for association with level of medication use. RESULTS At ages 18 to 24 years, 15% (male) to 23% (female) of patients were taking greater than 5 medications, a trend that continued to increase with older cohorts. Female patients were more likely to have level 2 (odds ratio [OR] = 1.76) and level 3 (OR = 2.73) use compared with men. Level 2 and level 3 use was associated with other patient characteristics, including number of patient encounters (level 2 OR = 2.99; level 3 OR = 8.08 for >7 encounters) and common chronic conditions such as chronic pain (level 2 OR = 2.56; level 3 OR = 6.40), diabetes (level 2 OR = 2.4; level 3 OR = 4.61), heart disease (level 2 OR = 1.99; level 3 OR = 3.65), hypertension (level 2 OR = 2.27; level 3 OR = 2.87), and dyslipidemia (level 2 OR = 1.82; level 3 OR = 2.12). CONCLUSION Electronic medical record data may be an important tool for providing more comprehensive information regarding medication usage. Medication usage assessed by electronic medical records, even among the youngest cohort, appears to be greater than other sources of medication usage indicate. Higher levels of medication use were associated with a number of factors, including gender, body mass index, number of patient encounters, and comorbid conditions.
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Hasan SS, Wong PS, Ahmed SI, Chong DWK, Mai CW, Pook P, Kairuz T. Perceived impact of clinical placements on students' preparedness to provide patient-centered care in Malaysia. CURRENTS IN PHARMACY TEACHING & LEARNING 2013. [DOI: 10.1016/j.cptl.2013.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Papastergiou J, Zervas J, Li W, Rajan A. Home medication reviews by community pharmacists: Reaching out to homebound patients. Can Pharm J (Ott) 2013; 146:139-42. [PMID: 23795196 DOI: 10.1177/1715163513487830] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lee JK, Slack MK, Martin J, Ehrman C, Chisholm-Burns M. Geriatric patient care by U.S. pharmacists in healthcare teams: systematic review and meta-analyses. J Am Geriatr Soc 2013; 61:1119-27. [PMID: 23796001 DOI: 10.1111/jgs.12323] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To conduct a systematic review and meta-analyses to examine the effects of pharmacists' care on geriatric patient-oriented health outcomes in the United States (U.S.). DESIGN Studies examining U.S. pharmacists' patient care services from inception of the databases through July 2012 were searched. The databases searched include PubMed/MEDLINE, Ovid/MEDLINE, ABI/INFORM, Health Business Fulltext Elite, Academic Search Complete, International Pharmaceutical Abstracts, PsycINFO, Cochrane Database, and Clinical Trials.gov. Studies reporting pharmacists' intervention for geriatric patients, comparison groups, and patient-oriented outcomes were assessed. Dual review for inclusion and data extraction were performed. SETTING University of Arizona College of Pharmacy. MEASUREMENTS Study and participant characteristics, pharmacist intervention, and outcomes with data for meta-analyses were collected. A forest plot was constructed to obtain a pooled standardized mean difference using a random effects model. RESULTS One hundred fifty-two articles were reviewed, with 20 resulting studies included in the final meta-analyses. Study sample size ranged from 36 to 4,218, with mean age of subjects being 65 and older. The studies were most frequently conducted in ambulatory care clinics, followed by inpatient settings; the majority focused on multiple diseases and conditions. Pharmacist activities varied widely, with technical interventions used most often. Favorable results were found in all outcome categories, and meta-analyses conducted for therapeutic, safety, hospitalization, and adherence were significant (P < .001), favoring pharmacist care over comparison. Some identifiable variability existed between included studies. CONCLUSION Pharmacist intervention has favorable effects on therapeutic, safety, hospitalization, and adherence outcomes in older adults. Pharmacists should be involved in team-based care of older adults.
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Affiliation(s)
- Jeannie K Lee
- Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona 85721, USA.
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175
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Abstract
The prevalence of human immunodeficiency virus (HIV) infection among people older than 50 years is increasing. Older HIV-infected patients are particularly at risk for polypharmacy because they often have multiple comorbidities that require pharmacotherapy. Overall, there is not much known with respect to both the impact of aging on medication use in HIV-infected individuals, and the potential for interactions with highly active antiretroviral therapy (HAART) and coadministered medications and its clinical consequences. In this review, we aim to provide an overview of polypharmacy with a focus on its impact on the HIV-infected older adult population and to also provide some clinical considerations in this high-risk population.
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Affiliation(s)
- Lauren J Gleason
- Division of Geriatrics and Aging, Highland Hospital, Rochester, NY 14620, USA
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176
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Gillespie U, Alassaad A, Hammarlund-Udenaes M, Mörlin C, Henrohn D, Bertilsson M, Melhus H. Effects of pharmacists' interventions on appropriateness of prescribing and evaluation of the instruments' (MAI, STOPP and STARTs') ability to predict hospitalization--analyses from a randomized controlled trial. PLoS One 2013; 8:e62401. [PMID: 23690938 PMCID: PMC3656885 DOI: 10.1371/journal.pone.0062401] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 03/21/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Appropriateness of prescribing can be assessed by various measures and screening instruments. The aims of this study were to investigate the effects of pharmacists' interventions on appropriateness of prescribing in elderly patients, and to explore the relationship between these results and hospital care utilization during a 12-month follow-up period. METHODS The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalization was investigated, was used. The criteria from the instruments MAI, STOPP and START were applied retrospectively to the 368 study patients (intervention group (I) n = 182, control group (C) n = 186). The assessments were done on admission and at discharge to detect differences over time and between the groups. Hospital care consumption was recorded and the association between scores for appropriateness, and hospitalization was analysed. RESULTS The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for I but not for C (1.42 to 0.93 vs. 1.46 to 1.66 respectively, p<0.01). The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for I but not for C (0.36 to 0.09 vs. 0.42 to 0.45 respectively, p<0.001). The summated score for MAI was reduced for I but not for C (8.5 to 5.0 and 8.7 to 10.0 respectively, p<0.001). There was a positive association between scores for MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively). No association was detected between the scores of the tools and total re-visits to hospital. CONCLUSION The interventions significantly improved the appropriateness of prescribing for patients in the intervention group as evaluated by the instruments MAI, STOPP and START. High scores in MAI and STOPP were associated with a higher number of drug-related readmissions.
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Affiliation(s)
- Ulrika Gillespie
- Division of Pharmacokinetics and Drug Therapy, Department of Pharmaceutical Biosciences, Uppsala University and Uppsala University Hospital, Uppsala, Sweden.
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An educational intervention to reduce the use of potentially inappropriate medications among older adults (EMPOWER study): protocol for a cluster randomized trial. Trials 2013; 14:80. [PMID: 23514019 PMCID: PMC3621099 DOI: 10.1186/1745-6215-14-80] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/01/2013] [Indexed: 12/16/2022] Open
Abstract
Background Currently, far too many older adults consume inappropriate prescriptions, which increase the risk of adverse drug reactions and unnecessary hospitalizations. A health education program directly informing patients of prescription risks may promote inappropriate prescription discontinuation in chronic benzodiazepine users. Methods/Design This is a cluster randomized controlled trial using a two-arm parallel-design. A total of 250 older chronic benzodiazepine users recruited from community pharmacies in the greater Montreal area will be studied with informed consent. A participating pharmacy with recruited participants represents a cluster, the unit of randomization. For every four pharmacies recruited, a simple 2:2 randomization is used to allocate clusters into intervention and control arms. Participants will be followed for 1 year. Within the intervention clusters, participants will receive a novel educational intervention detailing risks and safe alternatives to their current potentially inappropriate medication, while the control group will be wait-listed for the intervention for 6 months and receive usual care during that time period. The primary outcome is the rate of change in benzodiazepine use at 6 months. Secondary outcomes are changes in risk perception, self-efficacy for discontinuing benzodiazepines, and activation of patients initiating discussions with their physician or pharmacist about safer prescribing practices. An intention-to-treat analysis will be followed. The rate of change of benzodiazepine use will be compared between intervention and control groups at the individual level at the 6-month follow-up. Risk differences between the control and experimental groups will be calculated, and the robust variance estimator will be used to estimate the associated 95% confidence interval (CI). As a sensitivity analysis (and/or if any confounders are unbalanced between the groups), we will estimate the risk difference for the intervention via a marginal model estimated via generalized estimating equations with an exchangeable correlation structure. Discussion Targeting consumers directly as catalysts for engaging physicians and pharmacists in collaborative discontinuation of benzodiazepine drugs is a novel approach to reduce inappropriate prescriptions. By directly empowering chronic users with knowledge about risks, we hope to imitate the success of individually targeted anti-smoking campaigns. Trial registration ClinicalTrials.gov identifier: NCT01148186
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178
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Halme AS, Beland SG, Preville M, Tannenbaum C. Uncovering the source of new benzodiazepine prescriptions in community-dwelling older adults'. Int J Geriatr Psychiatry 2013; 28:248-55. [PMID: 22565497 DOI: 10.1002/gps.3818] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Accepted: 03/22/2012] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Initiatives to reduce benzodiazepine use have been largely unsuccessful despite strong associations with adverse outcomes. Curtailing incident use of benzodizepines is an alternate strategy that has yet to be explored. This study aims to determine the source of incident benzodiazepine prescriptions by comparing the risk of receiving a new prescription upon hospital discharge versus after an ambulatory care clinic visit. METHODS Data were derived from 1189 community-dwelling adults aged 65 years naive to benzodiazepine consumption, enrolled in the Étude sur la Santé des Ainés, a prospective 3-year cohort study conducted in Québec, Canada. Health survey questionnaires were linked with provincial administrative databases of prescription and health service claims. Analysis with multivariate Poisson regression models compared the risk of incident benzodiazepine use post-hospitalization versus after an ambulatory care visit. Models were adjusted for sex, age, antidepressant use, and concomitant drugs. Sub-analyses were conducted for chronic prescriptions. RESULTS Incident benzodiazepine use was 11% over a 2-year period, with 18.3% of prescriptions leading to chronic use (> 90 days). Hospitalization conferred a 2.7-fold greater risk of incident use than an outpatient visit (OR 2.66, 95% CI 1.78-3.98) and a 4.7-fold (OR 4.74, 95% CI 1.63-13.78) increased risk of chronic use, after adjusting for potential confounders. Despite the increased risk, only 13% of new prescriptions originated post-hospital discharge, with the remainder prescribed during outpatient visits. CONCLUSION Interventions are required to curb incident benzodiazepine prescriptions at their source both in hospitals and in ambulatory care settings.
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Affiliation(s)
- Alex S Halme
- Faculties of Medicine and Pharmacy, University of Montreal, Montreal, Canada
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179
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Alldred DP, Raynor DK, Hughes C, Barber N, Chen TF, Spoor P. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev 2013:CD009095. [PMID: 23450597 DOI: 10.1002/14651858.cd009095.pub2] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND There is a substantial body of evidence that prescribing for care home residents is suboptimal and requires improvement. Consequently, there is a need to identify effective interventions to optimise prescribing and resident outcomes in this context. OBJECTIVES The objective of the review was to determine the effect of interventions to optimise prescribing for older people living in care homes. SEARCH METHODS We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register; Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library (Issue 11, 2012); Cochrane Database of Systematic Reviews, The Cochrane Library (Issue 11, 2012); MEDLINE OvidSP (1980 on); EMBASE, OvidSP (1980 on); Ageline, EBSCO (1966 on); CINAHL, EBSCO (1980 on); International Pharmaceutical Abstracts, OvidSP (1980 on); PsycINFO, OvidSP (1980 on); conference proceedings in Web of Science, Conference Proceedings Citation Index - SSH & Science, ISI Web of Knowledge (1990 on); grey literature sources and trial registries; and contacted authors of relevant studies. We also reviewed the references lists of included studies and related reviews (search period November 2012). SELECTION CRITERIA We included randomised controlled trials evaluating interventions aimed at optimising prescribing for older people (aged 65 years or older) living in institutionalised care facilities. Studies were included if they measured one or more of the following primary outcomes, adverse drug events; hospital admissions;mortality; or secondary outcomes, quality of life (using validated instrument); medication-related problems; medication appropriateness (using validated instrument); medicine costs. DATA COLLECTION AND ANALYSIS Two authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. A narrative summary of results was presented. MAIN RESULTS The eight included studies involved 7653 residents in 262 (range 1 to 85) care homes in six countries. Six studies were cluster-randomised controlled trials and two studies were patient-randomised controlled trials. The interventions evaluated were diverse and often multifaceted. Medication review was a component of seven studies, three studies involved multidisciplinary case-conferencing, two studies involved an educational element for care home staff and one study evaluated the use of clinical decision support technology. Due to heterogeneity, results were not combined in a meta-analysis. There was no evidence of an effect of the interventions on any of the primary outcomes of the review (adverse drug events, hospital admissions and mortality). No studies measured quality of life. There was evidence that the interventions led to the identification and resolution of medication-related problems. There was evidence from two studies that medication appropriateness was improved. The evidence for an effect on medicine costs was equivocal. AUTHORS' CONCLUSIONS Robust conclusions could not be drawn from the evidence due to variability in design, interventions, outcomes and results. The interventions implemented in the studies in this review led to the identification and resolution of medication-related problems, however evidence of an effect on resident-related outcomes was not found. There is a need for high-quality cluster-randomised controlled trials testing clinical decision support systems and multidisciplinary interventions that measure well-defined, important resident-related outcomes.
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Koyama A, Steinman M, Ensrud K, Hillier TA, Yaffe K. Ten-year trajectory of potentially inappropriate medications in very old women: importance of cognitive status. J Am Geriatr Soc 2013; 61:258-63. [PMID: 23320787 DOI: 10.1111/jgs.12093] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine which older adults tend to receive potentially inappropriate medications (PIMs), how this may differ according to cognitive status, and how the trajectories of PIM use change over time. DESIGN Ten-year longitudinal cohort study. SETTING Three clinical sites in the United States. PARTICIPANTS One thousand four hundred eighty-four community-dwelling women aged 75 and older. MEASUREMENTS At follow-up, cognitive status was ascertained and classified as normal, mild cognitive impairment (MCI), or dementia. Beers 2003 criteria and other literature were used to identify PIMs from detailed medication inventory performed at three time points. Anticholinergic load was measured using the Anticholinergic Cognitive Burden Scale (ACB), which assigns medications a value from 0 to 3 depending on anticholinergic properties. RESULTS At baseline, 23.9% of women were taking at least one PIM and the mean ± SD ACB score was 1.41 ± 1.69. The most frequently reported PIMs were anticholinergics (15.2%), benzodiazepines (8.6%), and antispasmodics (8.0%). Over 10 years, PIM use increased for women with dementia (24.9-33.1%; P = .02) but remained fairly constant for women with MCI (23.9-23.0%; P = .84) and normal cognitive status (22.2-19.8%; P = .17). Mean ACB score increased significantly (P < .001) over time for all groups (dementia: 1.28-2.05; MCI: 0.98-1.66; normal: 0.99-1.48). CONCLUSION PIM use and anticholinergic load in a community-dwelling population of older women was high, especially in women who later developed dementia. Future guidelines should limit PIM use and seek safer alternatives.
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Affiliation(s)
- Alain Koyama
- Northern California Institute for Research and Education, San Francisco, California, USA.
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181
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Pharmacist-Led Medication Review to Identify Medication-Related Problems in Older People Referred to an Aged Care Assessment Team. Drugs Aging 2012; 29:593-605. [PMID: 22715865 DOI: 10.1007/bf03262276] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Topinková E, Baeyens JP, Michel JP, Lang PO. Evidence-based strategies for the optimization of pharmacotherapy in older people. Drugs Aging 2012; 29:477-94. [PMID: 22642782 DOI: 10.2165/11632400-000000000-00000] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Geriatric pharmacotherapy represents one of the biggest achievements of modern medical interventions. However, geriatric pharmacotherapy is a complex process that encompasses not only drug prescribing but also age-appropriate drug development and manufacturing, appropriate drug testing in clinical trials, rational and safe prescribing, reliable administration and assessment of drug effects, including adherence measurement and age-appropriate outcomes monitoring. During this complex process, errors can occur at any stage, and intervention strategies to improve geriatric pharmacotherapy are targeted at improving the regulatory processes of drug testing, reducing inappropriate prescribing, preventing beneficial drug underuse and use of potentially harmful drugs, and preventing adverse drug interactions. The aim of this review is to provide an update on selected recent developments in geriatric pharmacotherapy, including age discrimination in drug trials, a new healthcare professional qualification and shared competence in geriatric drug therapy, the usefulness of information and communication technologies, and pharmacogenetics. We also review optimizing strategies aimed at medication adherence focusing on complex elderly patients. Among the current information technologies, there is sufficient evidence that computerized decision-making support systems are modestly but significantly effective in reducing inappropriate prescribing and adverse drug events across healthcare settings. The majority of interventions target physicians, for whom the scientific concept of appropriate prescribing and the acceptability of the alert system used play crucial roles in the intervention's success. For prescribing optimization, results of educational intervention strategies were inconsistent. The more promising strategies involved pharmacists or multidisciplinary teams including geriatric medicine services. However, methodological weaknesses including population and intervention heterogeneity do not allow for comprehensive meta-analyses to determine the clinical value of individual approaches. In relation to drug adherence, a recent meta-analysis of 33 randomized clinical trials in older patients found behavioural interventions had significant effects, and these interventions were more effective than educational interventions. For patients with multiple conditions and polypharmacy, successful interventions included structured medication review, medication regimen simplification, administration aids and medication reminders, but no firm conclusion in favour of any particular intervention could be made. Interventions to optimize geriatric pharmacotherapy focused most commonly on pharmacological outcomes (drug appropriateness, adverse drug events, adherence), providing only limited information about clinical outcomes in terms of health status, morbidity, functionality and overall healthcare costs. Little attention was given to psychosocial and behavioural aspects of pharmacotherapy. There is sufficient potential for improvements in geriatric pharmacotherapy in terms of drug safety and effectiveness. However, just as we require evidence-based, age-specific, pharmacological information for efficient clinical decision making, we need solid evidence for strategies that consistently improve the quality of pharmacological treatments at the health system level to shape 'age-attuned' health and drug policy.
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Affiliation(s)
- Eva Topinková
- Department of Geriatric Medicine, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic.
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Egede LE, Gebregziabher M, Dismuke CE, Lynch CP, Axon RN, Zhao Y, Mauldin PD. Medication nonadherence in diabetes: longitudinal effects on costs and potential cost savings from improvement. Diabetes Care 2012; 35:2533-9. [PMID: 22912429 PMCID: PMC3507586 DOI: 10.2337/dc12-0572] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the longitudinal effects of medication nonadherence (MNA) on key costs and estimate potential savings from increased adherence using a novel methodology that accounts for shared correlation among cost categories. RESEARCH DESIGN AND METHODS Veterans with type 2 diabetes (740,195) were followed from January 2002 until death, loss to follow-up, or December 2006. A novel multivariate, generalized, linear, mixed modeling approach was used to assess the differential effect of MNA, defined as medication possession ratio (MPR) ≥0.8 on healthcare costs. A sensitivity analysis was performed to assess potential cost savings at different MNA levels using the Consumer Price Index to adjust estimates to 2012 dollar value. RESULTS Mean MPR for the full sample over 5 years was 0.78, with a mean of 0.93 for the adherent group and 0.58 for the MNA group. In fully adjusted models, all annual cost categories increased ∼3% per year (P = 0.001) during the 5-year study time period. MNA was associated with a 37% lower pharmacy cost, 7% lower outpatient cost, and 41% higher inpatient cost. Based on sensitivity analyses, improving adherence in the MNA group would result in annual estimated cost savings ranging from ∼$661 million (MPR <0.6 vs. ≥0.6) to ∼$1.16 billion (MPR <1 vs. 1). Maximal incremental annual savings would occur by raising MPR from <0.8 to ≥0.8 ($204,530,778) among MNA subjects. CONCLUSIONS Aggressive strategies and policies are needed to achieve optimal medication adherence in diabetes. Such approaches may further the so-called "triple aim" of achieving better health, better quality care, and lower cost.
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Affiliation(s)
- Leonard E Egede
- Center for Disease Prevention and Health Interventions for Diverse Populations, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA.
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184
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Zeeh J. [Polypharmacy in old age--too much of a good thing?]. MMW Fortschr Med 2012; 154:46-49. [PMID: 23270056 DOI: 10.1007/s15006-012-1599-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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185
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Moczygemba LR, Barner JC, Gabrillo ER. Outcomes of a Medicare Part D telephone medication therapy management program. J Am Pharm Assoc (2003) 2012; 52:e144-52. [DOI: 10.1331/japha.2012.11258] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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186
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Al Salmi Z. Clinical Audit of Pharmaceutical Care provided by a Clinical Pharmacist in Cardiology and Infectious Disease in-patients at the Royal Hospital, Muscat/Oman. Oman Med J 2012; 24:89-94. [PMID: 22334851 DOI: 10.5001/omj.2009.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2009] [Accepted: 03/12/2009] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To characterise the pharmaceutical care provided by a clinical pharmacists working in a tertiary health care institute, where the extent to which the pharmacist contributes to changes in prescribing patterns use of medications, and patient knowledge was described. METHODS A retrospective single cohort study design was used. Qualitative and quantitative evaluation of a documented pharmaceutical care plan was undertaken. Electronic pharmaceutical care descriptor (Microsoft Access® database) was used for analysis. 167 patients [mean age of 53 yrs, 70% male] from a Medical Health Centre in a tertiary hospital where a clinical pharmacist had provided a medication review. The study patients were those who had either been admitted to cardiology or infectious disease wards. RESULTS There were 291 pharmaceutical care issues [PCIs; mean per patient (2)] comprising of 67% (n=194) relating to treatment monitoring and 33% (n=97) relating to treatment changes, representing a total of 291 drug therapy problems [DTPs; mean per patient (2)]. The resolution rate of DTPs was 70%, where 61% of recommended changes and 75% of recommended monitoring were implemented. CONCLUSION The clinical pharmacist successfully addressed most PCIs while attending ward rounds, reviewing in-patient prescriptions and counselling discharged patients. The electronic pharmaceutical care plan was very effective in recording the pharmacist's ward activities and the pharmaceutical care provided. However, further studies are required in order to explore long-term clinical pharmacists in-put using a well established electronic care plan; part of Al-Shifa computer system in Omani health centres.
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Affiliation(s)
- Zaher Al Salmi
- Department of Pharmacy, Royal Hospital, Muscat, Sultanate of Oman
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187
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Thorpe JM, Thorpe CT, Kennelty KA, Gellad WF, Schulz R. The impact of family caregivers on potentially inappropriate medication use in noninstitutionalized older adults with dementia. THE AMERICAN JOURNAL OF GERIATRIC PHARMACOTHERAPY 2012; 10:230-41. [PMID: 22683399 PMCID: PMC3413778 DOI: 10.1016/j.amjopharm.2012.05.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 05/17/2012] [Accepted: 05/18/2012] [Indexed: 11/23/2022]
Abstract
BACKGROUND The risk of potentially inappropriate medication (PIM), both prescription and over-the-counter, use in dementia patients is high. Informal caregivers often facilitate patients' use of medications, but the effect of caregiver factors on PIM use has not been a focus of previous research. OBJECTIVE The aim of this study was to examine PIM use in dementia patients and caregivers and identify caregiver risk factors for PIM use in dementia patients. METHODS We conducted a secondary data analysis of the baseline wave of the Resources for Enhancing Alzheimer's Caregiver's Health study. The sample comprised 566 persons with dementia aged 65 and older and their coresiding family caregiver. PIM was defined using the 2003 Beers criteria and was examined in both dementia patients and their caregivers. Caregiver and patient risk factors included a range of sociodemographic and health variables. RESULTS In dementia patients, 33% were taking at least 1 PIM, and 39% of their caregivers were also taking a PIM. In fully adjusted models, the following caregiver factors were associated with an increased risk of dementia patient PIM use: caregiver's own PIM use, spouse caregivers, Hispanic caregivers, and greater number of years that the caregiver has lived in the United States. Increased caregiver age was associated with a decreased risk of PIM use in patients. CONCLUSIONS PIM use may be higher in dementia patients and their informal caregivers compared with the general older adult population. Further, patterns of medication use in 1 member of the dyad may influence PIM risk in the other dyad member. These results suggest that interventions to increase appropriate medication use in dementia patients and their caregivers should target both members of the dyad and target over-the-counter agents along with prescription medications.
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Affiliation(s)
- Joshua M. Thorpe
- VA Pittsburgh Healthcare System and the Center for Health Equity Research and Promotion, Pittsburgh, PA 15206, USA
- University of Pittsburgh School of Pharmacy, Department of Pharmacy & Therapeutics, Pittsburgh, PA 15261, USA
| | - Carolyn T. Thorpe
- VA Pittsburgh Healthcare System and the Center for Health Equity Research and Promotion, Pittsburgh, PA 15206, USA
- University of Pittsburgh School of Pharmacy, Department of Pharmacy & Therapeutics, Pittsburgh, PA 15261, USA
| | - Korey A. Kennelty
- University of Wisconsin-Madison School of Pharmacy, Division of Social & Administrative Sciences, Madison, WI 53705, USA
| | - Walid F. Gellad
- VA Pittsburgh Healthcare System and the Center for Health Equity Research and Promotion, Pittsburgh, PA 15206, USA
- University of Pittsburgh School of Medicine, Department of Medicine (General Medicine), Pittsburgh, PA 15213, USA
- RAND Corporation, Pittsburgh, PA 15213, USA
| | - Richard Schulz
- University of Pittsburgh School of Medicine, Dept. of Psychiatry, Pittsburgh, PA 15260, USA
- University Center for Social and Urban Research, University of Pittsburgh, PA 15260, USA
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Dreischulte T, Guthrie B. High-risk prescribing and monitoring in primary care: how common is it, and how can it be improved? Ther Adv Drug Saf 2012; 3:175-84. [PMID: 25083235 PMCID: PMC4110851 DOI: 10.1177/2042098612444867] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The safety of medication use in primary care is an area of increasing concern for health systems internationally. Systematic reviews estimate that 3-4% of all unplanned hospital admissions are due to preventable drug-related morbidity, the majority of which have been attributed to shortcomings in the prescribing and monitoring stages of the medication use process. We define high-risk prescribing as medication prescription by professionals, for which there is evidence of significant risk of harm to patients, and which should therefore either be avoided or (if avoidance is not possible) closely monitored and regularly reviewed for continued appropriateness. Although prevalence estimates vary depending on the instrument used, cross-sectional studies conducted in primary care equivocally show that it is common and there is evidence that it can be reduced. Quality improvement strategies, such as clinical decision support, performance feedback and pharmacist-led interventions have been shown to be effective in reducing prescribing outcomes but evidence of improved patient outcomes remains limited. The increasing implementation of electronic medical records in primary care offer new opportunities to combine different strategies to improve medication safety in primary care and to integrate services provided by different stakeholders. In this review article, we describe the spectrum of high-risk medication use in primary care, review approaches to its measurement and summarize research into its prevalence. Based on previously developed interventions to change professional practice, we propose a systematic approach to improve the safety of medication use in primary care and highlight areas for future research.
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Affiliation(s)
- Tobias Dreischulte
- University of Dundee - Population Health Sciences, Kirsty Semple Way, Dundee, UK
| | - Bruce Guthrie
- University of Dundee - Population Health Sciences, Kirsty Semple Way, Dundee, UK
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Prithviraj GK, Koroukian S, Margevicius S, Berger NA, Bagai R, Owusu C. Patient Characteristics Associated with Polypharmacy and Inappropriate Prescribing of Medications among Older Adults with Cancer. J Geriatr Oncol 2012; 3:228-237. [PMID: 22712030 DOI: 10.1016/j.jgo.2012.02.005] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES: To identify patient characteristics associated with polypharmacy and inappropriate medication (PIM) use among older patients with newly diagnosed cancer. DESIGN: Cross-Sectional Study. SETTING: Ambulatory oncology clinics at an academic medical center. PARTICIPANTS: 117 patients aged ≥ 65 years with newly diagnosed histologically confirmed stage I-IV cancer were enrolled between April 2008 and September 2009. MEASUREMENTS: Medication review, included patient self-report and medical records. Polypharmacy was defined as the concurrent use of ≥ five medications, (Yes/No). PIM use was defined as use of ≥ one medication included in the 2003 update of Beers Criteria, (Yes/No). RESULTS: The prevalence of polypharmacy and PIM use were 80% and 41%, respectively. Three independent correlates of medication use were identified. An increase in comorbidity count by one, ECOG-PS score by one, and PIM use by one, was associated with an increase in medication use by 0.48 (P=0.0002), 0.79 (P=0.01) and 1.22 (P=0.006), respectively. Two independent correlates of PIM use were identified. The odds of using PIMs decreased by 10% for one unit increase in Body Mass Index [Odds Ratio (OR) 0.90, 95% CI = (0.84, 0.97)], and increased by 18% for each increase in medication count by one [OR 1.18, 95% CI = (1.04, 1.34)]. CONCLUSION: There was a high prevalence of polypharmacy and PIM use in older patients with newly diagnosed cancer. Given the co-occurrence of polypharmacy with poor performance status and multi-morbidity, multi-dimensional interventions are needed in the geriatric-oncology population to improve health and cancer outcomes.
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Affiliation(s)
- Gopi K Prithviraj
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio
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Abstract
The elderly are at risk for polypharmacy, which is associated with significant consequences such as adverse effects, medication nonadherence, drug-drug and drug-disease interactions, and increased risk of geriatric syndromes. Providers should evaluate all existing medications at each patient visit for appropriateness and weigh the risks and benefits of starting new medications to minimize polypharmacy.
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Affiliation(s)
- Bhavik M Shah
- Jefferson School of Pharmacy, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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Latter S, Smith A, Blenkinsopp A, Nicholls P, Little P, Chapman S. Are nurse and pharmacist independent prescribers making clinically appropriate prescribing decisions? An analysis of consultations. J Health Serv Res Policy 2012; 17:149-56. [PMID: 22734082 DOI: 10.1258/jhsrp.2012.011090] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Legislation and health policy enabling nurses and pharmacists to prescribe a comprehensive range of medicines has been in place in the UK since 2006. Our objective was to evaluate the clinical appropriateness of prescribing by these professionals. METHODS A modified version of the Medication Appropriateness Index (MAI) was used by 10 medical, seven pharmacist and three nurse independent raters to evaluate a sample of 100 audio-recorded consultations in which a medicine was prescribed by a nurse or pharmacist. Raters were current prescribers with recognized experience in prescribing. Consultations were recorded in nine clinical practice settings in England. RESULTS Raters' analysis indicated that, in the majority of instances, nurses and pharmacists were prescribing clinically appropriately on all of the ten MAI criteria (indication, effectiveness, dosage, directions, practicality, drug-drug interaction, drug-disease interaction, duplication, duration, cost). Highest mean 'inappropriate' ratings were given for correct directions (nurses 12%; pharmacists 11%) and the cost of the drug prescribed (nurses 16% pharmacists 22%). Analysis of raters' qualitative comments identified two main themes: positive views on the overall safety and effectiveness of prescribing episodes; and potential for improvement in nurses' and pharmacists' history-taking, assessment and diagnosis skills. CONCLUSIONS Nurses and pharmacists are generally making clinically appropriate prescribing decisions. Decisions about the cost of drugs prescribed and assessment and diagnostic skills are areas for quality improvement.
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Affiliation(s)
- Sue Latter
- Faculty of Health Sciences, University of Southampton, Southampton, UK.
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Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O'Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 2012:CD000259. [PMID: 22696318 PMCID: PMC11338587 DOI: 10.1002/14651858.cd000259.pub3] [Citation(s) in RCA: 1369] [Impact Index Per Article: 114.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact. OBJECTIVES To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011). SELECTION CRITERIA Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included. DATA COLLECTION AND ANALYSIS All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors. MAIN RESULTS We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention. AUTHORS' CONCLUSIONS Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.
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Affiliation(s)
- Noah Ivers
- Department of Family Medicine, Women’s College Hospital, Toronto, Canada. 2Norwegian Knowledge Centre for the Health Services,Oslo,
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Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2012:CD008165. [PMID: 22592727 DOI: 10.1002/14651858.cd008165.pub2] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence there is growing interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients. OBJECTIVES This review sought to determine which interventions alone, or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people. SEARCH METHODS A range of literature databases including MEDLINE and EMBASE were searched in addition to handsearching reference lists. Search terms included polypharmacy, Beers criteria, medication appropriateness and inappropriate prescribing. SELECTION CRITERIA A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older where a validated measure of appropriateness was used (e.g. Beers criteria or Medication Appropriateness Index - MAI). DATA COLLECTION AND ANALYSIS Three authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals. MAIN RESULTS Electronic searches identified 2200 potentially relevant citations, of which 139 were examined in detail. Following assessment, 10 studies were included. One intervention was computerised decision support and nine were complex, multifaceted pharmaceutical care provided in a variety of settings. Appropriateness of prescribing was measured using the MAI score postintervention (seven studies) and/or Beers criteria (four studies). The interventions included in this review demonstrated a reduction in inappropriate medication use. A mean difference of -6.78 (95% CI -12.34 to -1.22) in the change in MAI score in favour of the intervention group (four studies). Postintervention pooled data (five studies) showed a mean reduction of -3.88 (95% CI -5.40 to -2.35) in the summated MAI score and a mean reduction of -0.06 (95% CI -0.16 to 0.04) in the number of Beers drugs per patient (three studies). Evidence of the effect of the interventions on hospital admissions (four studies) was conflicting. Medication-related problems, reported as the number of adverse drug events (three studies), reduced significantly (35%) postintervention. AUTHORS' CONCLUSIONS It is unclear if interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in a clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing and medication-related problems.
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Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN. Deprescribing Trials: Methods to Reduce Polypharmacy and the Impact on Prescribing and Clinical Outcomes. Clin Geriatr Med 2012; 28:237-53. [DOI: 10.1016/j.cger.2012.01.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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196
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Peron EP, Marcum ZA, Boyce R, Hanlon JT, Handler SM. Year in review: medication mishaps in the elderly. ACTA ACUST UNITED AC 2012; 9:1-10. [PMID: 21459304 DOI: 10.1016/j.amjopharm.2011.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2011] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly. METHODS The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From the literature search, this paper also generated a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly. RESULTS Three studies focused on types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of undertreatment of chronic conditions by over one third (from 32.9% to 22.3%, P < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patients ≥ 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, P < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders, which found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs 12.3%, respectively; P < 0.001). Moreover, blacks used more complementary and alternative medicine (CAM) than whites for the treatment of hypertension (30.5% vs 24.7%, respectively; P = 0.005). In multivariable analyses stratified by race, blacks who used CAM were more likely than those who did not to have low antihypertensive medication adherence (prevalence rate ratio = 1.56; 95% CI, 1.14-2.15; P = 0.006). The remaining two studies addressed some form of medication-related adverse patient events. A case-control study of Medicare Advantage patients revealed for the first time that the use of skeletal muscle relaxants was associated significantly with an increased fracture risk (adjusted odds ratio = 1.40; 95% CI, 1.15-1.72; P < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a 1-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. Results indicated that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs 36%, respectively, P = 0.004). CONCLUSION Information from these studies may advance health professionals' understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.
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Affiliation(s)
- Emily P Peron
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA
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197
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Lauffenburger JC, Vu MB, Burkhart JI, Weinberger M, Roth MT. Design of a medication therapy management program for Medicare beneficiaries: qualitative findings from patients and physicians. ACTA ACUST UNITED AC 2012; 10:129-38. [PMID: 22284582 DOI: 10.1016/j.amjopharm.2012.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 12/15/2011] [Accepted: 01/03/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND The quality of pharmacologic care provided to older adults is less than optimal. Medication therapy management (MTM) programs delivered to older adults in the ambulatory care setting may improve the quality of medication use for these individuals. OBJECTIVES We conducted focus groups with older adults and primary care physicians to explore (1) older adults' experiences working with a clinical pharmacist in managing medications, (2) physician perspectives on the role of clinical pharmacists in facilitating medication management, and (3) key attributes of an effective MTM program and potential barriers from patient and provider perspectives. METHODS Five focus groups (4 with older adults, 1 with physicians) were conducted by a trained moderator using a semistructured interview guide. Each participant completed a demographic questionnaire. Sessions were recorded, transcribed verbatim, and analyzed using qualitative analysis software for theme identification. RESULTS Twenty-eight older adults and 8 physicians participated. Older adults valued the professional, trusting nature of their interactions with the pharmacist. They found the clinical pharmacist to be a useful resource, thorough, personable, and a valuable team member. Physicians believe that the clinical pharmacist fills a unique role as a specialized practitioner, contributing meaningfully to patient care. Physicians emphasized the importance of effective communication, pharmacist access to the medical record, and a mutually trusting relationship as key attributes of a program. Potential barriers to an effective program include poor communication and lack of familiarity with the patient's history. The lack of a sustainable reimbursement model was cited as a barrier to widespread implementation of MTM. CONCLUSIONS This study provides information to assist pharmacists in designing MTM programs in the ambulatory setting. Key attributes of an effective program include being comprehensive and addressing all medication-related needs over time. The clinical pharmacist's ability to build trusting relationships with patients and providers is essential.
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Affiliation(s)
- Julie C Lauffenburger
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Mohile SG, Klepin HD, Rao AV. Considerations and controversies in the management of older patients with advanced cancer. Am Soc Clin Oncol Educ Book 2012:321-328. [PMID: 24451757 DOI: 10.14694/edbook_am.2012.32.168] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The incidence of cancer increases with age. Oncologists need to be adept at assessing physiologic and functional capacity in older patients in order to provide safe and efficacious cancer treatment. Assessment of underlying health status is especially important for older patients with advanced cancer, for whom the benefits of treatment may be low and the toxicity of treatment high. The comprehensive geriatric assessment (CGA) is the criterion standard for evaluation of the older patient. The combined data from the CGA can be used to stratify patients into categories to better predict risk for chemotherapy toxicity as well as overall outcomes. The CGA can also be used to identify and follow-up on possible functional consequences from treatment. A variety of screening tools might be useful in the oncology practice setting to identify patients who may benefit from further testing and intervention. In this chapter, we discuss how the principles of geriatrics can help improve the clinical care of older adults with advanced cancer. Specifically, we discuss assessing tolerance for treatment, options for chemotherapy scheduling and dosing for older patients with advanced cancer, and management of under-recognized symptoms in older patients with cancer.
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Affiliation(s)
- Supriya Gupta Mohile
- From the Geriatric Oncology Program at the James Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; Wake Forest School of Medicine, Winston-Salem, NC; Division of Geriatrics, Duke University Medical Center, Durham NC
| | - Heidi D Klepin
- From the Geriatric Oncology Program at the James Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; Wake Forest School of Medicine, Winston-Salem, NC; Division of Geriatrics, Duke University Medical Center, Durham NC
| | - Arati V Rao
- From the Geriatric Oncology Program at the James Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY; Wake Forest School of Medicine, Winston-Salem, NC; Division of Geriatrics, Duke University Medical Center, Durham NC
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Pharmacists’ Research Contributions in the Fight against HIV/AIDs. AIDS Res Treat 2012. [PMID: 23193465 PMCID: PMC3501816 DOI: 10.1155/2012/869891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pharmacists have made many contributions to HIV/AIDs research and are still showing their significance as members of the healthcare team through innovative clinical trials. Pharmacists are showing advances in several healthcare settings including inpatient, outpatient, and community pharmacies. Because of the complex regimens of highly active antiretroviral therapy (HAART), the increased life span of patients living with HIV, and other concomitant medications taken for comorbid disease states, there is a high risk for health-related complications and the development of adverse events. These adverse events may lead to decreased adherence to HAART, which may cause the development of HIV drug resistance. Pharmacists are providing examples through growing research on how they help combat medication-related errors and also continue to contribute as healthcare providers as a part of a holistic healthcare team.
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Andro M, Estivin S, Gentric A. [Medicinal prescriptions in geriatrics: overuse, misuse, underuse. Qualitative analysis from the prescriptions of 200 patients admitted in an acute care geriatric unit]. Rev Med Interne 2011; 33:122-7. [PMID: 22209618 DOI: 10.1016/j.revmed.2011.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 10/12/2011] [Accepted: 11/28/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE In the elderly three modalities of suboptimal drug prescriptions are known: overuse, misuse, underuse. PATIENTS AND METHODS This prospective observational study was conducted between September 2008 and March 2009. The prescriptions of 200 patients aged over 75 years admitted in the acute care geriatric unit at the teaching hospital of Brest (France) have been qualitatively analyzed to assess the prevalence of the three types of suboptimal prescription. RESULTS A strong prevalence of overuse (77% of the patients), underuse (64.5%) and at minor degree of misuse (47.5%) were evidenced. Overuse and misuse were more frequent in polypathogical and polymedicated patients living in nursing home. Underuse was more prevalent in polypathological patients living at home. No significant relation was found between suboptimal prescriptions, age, gender or cognitive status. CONCLUSION This study demonstrates the strong prevalence of overuse, misuse and underuse prescriptions in hospitalized elderly patient and analyses the most frequently implicated drugs and the different factors predisposing to these suboptimal prescriptions. This way of analysis of prescriptions could be a pertinent method to improve drug prescription in the elderly.
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Affiliation(s)
- M Andro
- Service de médecine interne gériatrique, hôpital de la Cavale Blanche, CHRU de Brest, boulevard Tanguy-Prigent, Brest cedex, France.
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