Health Service Use, Costs, and Adverse Events Associated with Potentially Inappropriate Medication in Old Age in Germany: Retrospective Matched Cohort Study

Drug Allergies in Older Adults: A Major Problem in a Specific Population

INTRODUCTION

The use of medications in older adults is increasing due to the prevalence of chronic diseases. Data on the characteristics of drug allergies (DAs) in older adults are limited. This study investigated the prevalence and clinical characteristics of DAs in patients aged 65 years and older.

METHODS

Patient records were examined retrospectively between January 2018 and December 2022. The study included 200 patients aged ≥18 years who met the criteria for diagnosis of type B drug reactions. The patients were divided into two groups: the adult group (18-64 years) and the older adult group (≥65 years).

RESULTS

Advanced age was an independent risk factor for the development of anaphylaxis and immediate and delayed hypersensitivity reactions (odds ratio [OR] = 4.296; 95% confidence interval [CI] = 1.700-10.855; p = 0.002, OR = 3.800; 95% CI = 1.247-11.579; p = 0.019, OR = 3.028; 95% CI = 1.248-7.343; p = 0.014, respectively). Older adults had higher rates of comorbidities and polypharmacy (p < 0.001, p = 0.016, respectively), beta-lactam antibiotic allergy (p < 0.001), and hospitalization and intensive care unit (ICU) admission for DAs (p = 0.024, p = 0.045, respectively).

CONCLUSION

Older age was an independent risk factor for anaphylaxis and both immediate and delayed reactions. Older adults had higher rates of comorbidities, polypharmacy, beta-lactam antibiotic triggers, and hospitalization and ICU admission.

Potentially Inappropriate Medication Use in Primary Care in Switzerland

Importance

Potentially inappropriate medication (PIM) exposes patients to an increased risk of adverse outcomes. Many lists of explicit criteria provide guidance on identifying PIM and recommend alternative prescribing, but the complexity of available lists limits their applicability and the amount of data available on PIM prescribing.

Objective

To determine PIM prevalence and the most frequently prescribed PIMs according to 6 well-known PIM lists and to develop a best practice synthesis for clinicians.

Design, Setting, and Participants

This cross-sectional study used anonymized electronic health record data of Swiss primary care patients aged 65 years or older with drug prescriptions from January 1, 2020, to December 31, 2021, extracted from a large primary care database in Switzerland, the FIRE project. Data analyses took place from October 2022 to September 2023.

Exposure

PIM prescription according to PIM criteria operationalized for use with FIRE data.

Main Outcomes and Measures

The primary outcomes were PIM prevalence (percentage of patients with 1 or more PIMs) and PIM frequency (percentage of prescriptions identified as PIMs) according to the individual PIM lists and a combination of all 6 lists. The PIM lists used were the American 2019 Updated Beers criteria, the French list by Laroche et al, the Norwegian General Practice Norwegian (NORGEP) criteria, the German PRISCUS list, the Austrian list by Mann et al, and the EU(7) consensus list of 7 European countries.

Results

This study included 115 867 patients 65 years or older (mean [SD] age, 76.0 [7.9] years; 55.8% female) with 1 211 227 prescriptions. Among all patients, 86 715 (74.8%) were aged 70 years or older, and 60 670 (52.4%) were aged 75 years or older. PIM prevalence among patients 65 years or older was 31.5% (according to Beers 2019), 15.4% (Laroche), 16.1% (NORGEP), 12.7% (PRISCUS), 31.2% (Mann), 37.1% (EU[7]), and 52.3% (combined list). PIM prevalence increased with age according to every PIM list (eg, according to Beers 2019, from 31.5% at age 65 years or older to 37.4% for those 75 years or older, and when the lists were combined, PIM prevalence increased from 52.3% to 56.7% in those 2 age groups, respectively). PIM frequency was 10.3% (Beers 2019), 3.9% (Laroche), 4.3% (NORGEP), 2.4% (PRISCUS), 6.7% (Mann), 9.7% (EU[7]), and 19.3% (combined list). According to the combined list, the 5 most frequently prescribed PIMs were pantoprazole (9.3% of all PIMs prescribed), ibuprofen (6.9%), diclofenac (6.3%), zolpidem (4.5%), and lorazepam (3.7%). Almost two-thirds (63.5%) of all PIM prescriptions belonged to 5 drug classes: analgesics (26.9% of all PIMs prescribed), proton pump inhibitors (12.1%), benzodiazepines and benzodiazepine-like drugs (11.2%), antidepressants (7.0%), and neuroleptics (6.3%).

Conclusions and Relevance

In this cross-sectional study of adults aged 65 or older, PIM prevalence was high, varied considerably depending on the criteria applied, and increased consistently with age. However, only few drug classes accounted for the majority of all prescriptions that were PIM according to any of the 6 PIM lists, and by considering this manageable number of drug classes, clinicians could essentially comply with all 6 PIM lists. These results raise awareness of the most common PIMs and emphasize the need for careful consideration of their risks and benefits and targeted deprescribing.

Telemedicine in Nursing Home Residents Requiring a Call to an Emergency Medical Communication Center

OBJECTIVES

To compare the proportion of nursing home residents dispatched to an emergency department (ED) after a call to the emergency medical communication center (EMCC) according to the availability or nonavailability of telemedicine.

DESIGN

This prospective, observational trial was conducted in the EMCC and 74 nursing homes in a French county.

SETTING AND PARTICIPANTS

All nursing home residents who needed to contact the EMCC between June 2019 and April 2020 were included in the study. We excluded calls notifying the death of a resident, for completing data from a previous call, and for nursing home staff.

METHODS

The primary outcome was the proportion of residents dispatched to an ED after their first call to the EMCC. The secondary outcomes were the proportion of second calls, proportion of residents dispatched to an ED after a second call, and proportion of death within 30 days.

RESULTS

We included 3103 calls in the final analysis (355 from equipped nursing homes and 2748 from unequipped nursing homes). The proportion of patients dispatched to an ED after the first call was lower among telemedicine-equipped than among telemedicine-unequipped nursing homes (41% vs 50%; odds ratio, 0.71; 95% CI, 0.56-0.90). The proportion of a second call for the same purpose within 72 hours, proportion of dispatching to an ED at the second call, and proportion of deaths within 30 days were similar between the groups.

CONCLUSION AND IMPLICATIONS

The use of telemedicine by nursing home residents requiring a call to the EMCC is associated with a reduction in the number of dispatches to an ED without any increase in the number of 72-hour callbacks or 30-day mortality rates.

The association between healthcare expenditures and potentially inappropriate medication use in hospitalized older adults in Ethiopia

BACKGROUND

Evidence shows that potentially inappropriate medication (PIM) use in older adults significantly increases the utilization of healthcare resources. PIM is widely prescribed in older adults, however little is known about its association with healthcare resource utilization in Africa, particularly Ethiopia. Therefore, the primary aim of this study was to examine the presence of an association between healthcare expenditure and the frequency of PIM used.

METHODS

This observational study was conducted from 06 September 2021 to 30 December 2022. A total of 151 hospitalized older adult patients were included in the study. The data collection format was designed to capture relevant information. STATA V.15.0 was used for analysis. Descriptive statistics and a generalized linear model regression were conducted. Statistical significance was set at a p-value < 0.05. The findings are presented in tables, figures, and text.

RESULTS

The total healthcare expenditure was higher in PIM users (385,368.6 ETB) than in non-PIM users (131,267.7 ETB). The median expenditures for medical supplies (p = 0.025), investigations (p = 0.033), and total healthcare expenditure (p = 0.023) were significantly higher in patients with two and more PIMs than in those with no or one PIM. However, after model adjustment, the total healthcare expenditure was not significantly different across the frequency of PIMs used. Number of medications (adjusted B = 0.068, 95% CI: 0.035, 0.101, p < 0.001) and taking blood and blood-forming organ class of medication (adjusted B = 0.151, 95% CI: 0.005, 0.297, p = 0.042) were associated with higher total healthcare expenditure, whereas the total healthcare expenditure was significantly lower in those patients with diseases of the nervous system (adjusted B = -0.307, 95% CI: -0.502, -0.112, p = 0.002) and respiratory system (adjusted B = -0.196, 95% CI: -0.327, -0.065, p = 0.003).

CONCLUSION

The total healthcare expenditure is nearly three times higher in PIM users. However, its association with the frequency of PIM use was not statistically significant in the final model. Deprescribing medications after evaluating the benefit-risk ratio may help to reduce the healthcare expenditures of older adult patients. Further similar, adequately powered, comparative study is also warranted to identify the actual effect of PIM use on healthcare expenditures in the local context.

Adverse drug reactions in geriatric psychiatry-retrospective cohort study of a 6-year period

OBJECTIVE

To investigate the frequency and characteristics of adverse drug reactions (ADRs) that occurred on the gerontopsychiatric ward of Hannover Medical School over a 6-year period.

DESIGN

Retrospective monocentric cohort study.

RESULTS

Six hundred thirty-four patient cases (mean age 76.6 ± 7.1 years; 67.2% female) were analysed. In total, 92 ADRs in 56 patient cases were registered in the study population. The overall ADR prevalence, the ADR prevalence upon hospital admission, and the ADR prevalence during hospitalisation were 8.8%, 6.3%, and 4.9%, respectively. The most frequent ADRs were extrapyramidal symptoms, alterations in blood pressure or heart rate, and electrolyte disturbances. Of note, two cases of asystole and one case of obstructive airway symptoms related to general anaesthesia in the context of electroconvulsive therapy (ECT) were detected. The presence of coronary heart disease was associated with an increased risk of ADR occurrence (odds ratio (OR) 2.92, 95% confidence interval (CI) 1.37-6.22), while the presence of dementia was associated with a decreased risk of ADR development (OR 0.45, 95% CI 0.23-0.89).

CONCLUSIONS

Type and prevalence of ADRs in the present study were largely in accordance with previous reports. By contrast, we did not observe a relationship between advanced age or female sex and ADR occurrence. We detected a risk signal for cardiopulmonary ADRs related to general anaesthesia in the context of ECT that warrants further investigation. Elderly psychiatric patients should be carefully screened for cardiopulmonary comorbidities before initiation of ECT.

Potentially inappropriate medicine use and predicting risk factors in hospitalized older adult patients: findings of a prospective observational study from Ethiopia

BACKGROUND

Older patients are fragile and more susceptible to medication-related problems requiring a strict assessment of their medicine list. The present study was conducted with the intention to assess the quality use of medicines in older adult patients by detecting potentially inappropriate medicine use and its predictive risk factors.

METHODS

This prospective cross-sectional study involved 162 older medical patients admitted to Jimma Medical Center. A data abstraction format is employed to capture relevant information. Each patient was assessed for the presence of potentially inappropriate medicine using the 2019 American Geriatrics Associations Beers Criteria. Descriptive statistics and logistic regression analysis were conducted using STATA 15.0. A p value < 5% was considered a cutoff point for declaring statistical significance.

RESULTS

Over the hospital stay, 103 (63.6%) participants were on polypharmacy (5-9 concurrent medicines per patient), while 16 (9.9%) were on hyper polypharmacy (≥ 10 concurrent medicines per patient). On medicine use assessment using the Beers criteria, at least one potentially inappropriate medicine was detected in 118 (73%) participants. Overall, 191 potentially inappropriate medicines (range, 0 to 4) were identified, and 27 (14.1%) of these were associated with avoiding recommendations. Furosemide [83 (43%)], tramadol [26 (14.5%)], and spironolactone [22 (11.4%)] were the top three most frequent potentially inappropriate medicines identified. In terms of mode of prescription, 187 (96.9%) potentially inappropriate medicines were prescribed on a scheduled basis. Older adult patients with thrombocytopenia had a lower probability of taking potentially inappropriate medicine, while the odds of potentially inappropriate medicine use were 7.35 times higher in patients diagnosed with heart failure.

CONCLUSIONS

Nearly three-fourths of the participants had potentially inappropriate medicine in their medicine list. Therefore, generating local evidence on the clinical, economic, and humanistic consequences may help in determining whether the Beers criteria should be taken into account when prescribing medicine to older adults. Interventions targeting older adult patients with heart failure might reduce inappropriate medicine use.

The role of qualification and quality management in the prescription of antipsychotics and potentially inappropriate medication (PIM) in nursing home residents in Germany: results of the HIOPP-3-iTBX study

BACKGROUND

Nursing home residents (NHR) show high rates of polypharmacy. The HIOPP-3-iTBX study is the first cRCT on medication optimization in nursing homes (NH) in Germany. The intervention did not result in a reduction of PIM and/or antipsychotics. This analysis looks at structure quality in the HIOPP-3-iTBX study participants.

AIMS

Evaluation of structure quality as part of a cluster-randomized controlled intervention study.

METHODS

Structure quality in multiprofessional teams from n = 44 NH (n = 44 NH directors, n = 91 family doctors (FD), and n = 52 pharmacies with n = 62 pharmacists) was assessed using self-designed questionnaires at baseline. Main aspects of the questionnaires related to the qualification of participants, quality management, the medication process and size of the facilities. All completed questionnaires were included. number of PIM/antipsychotics was drawn from the baseline medication analysis in 692 NHR. Data were analyzed by descriptive statistics and mixed model logistic regression.

RESULTS

The presence of a nurse with one of the additional qualifications pain nurse or Zertifiziertes Curriculum (Zercur) Geriatrie in the participating NH was associated with a lower risk for the prescription of PIM/antipsychotics. No association between any characteristic in the other participants at baseline was observed.

CONCLUSIONS AND DISCUSSION

The results support the known role of nursing qualification in the quality and safety of care. Further studies need to look more closely at how use is made of the additional qualifications within the multiprofessional teams. Perspectively, the results can contribute to the development of quality standards in NH in Germany.

Comparing prevalence and types of potentially inappropriate medications among patient groups in a post-acute and secondary care hospital

Reducing potentially inappropriate medications (PIMs) is a challenge in post-acute care hospitals. Some PIMs may be associated with patient characteristics and it may be useful to focus on frequent PIMs. This study aimed to identify characteristic features of PIMs by grouping patients as in everyday clinical practice. A retrospective review of medical records was conducted for 541 patients aged 75 years or older in a Japanese post-acute and secondary care hospital. PIMs on admission were identified using the Screening Tool for Older Person's Appropriate Prescriptions for Japanese. The patients were divided into four groups based on their primary disease and reason for hospitalization: post-acute orthopedics, post-acute neurological disorders, post-acute others, and subacute. Approximately 60.8% of the patients were taking PIMs, with no significant difference among the four patient groups in terms of prevalence of PIMs (p = 0.08). However, characteristic features of PIM types were observed in each patient group. Hypnotics and nonsteroidal anti-inflammatory drugs were common in the post-acute orthopedics group, multiple antithrombotic agents in the post-acute neurological disorders group, diuretics in the post-acute others group, and hypnotics and diuretics in the subacute group. Grouping patients in clinical practice revealed characteristic features of PIM types in each group.

Patient perspectives on, and effects of, medication management in geriatric fallers (the EMMA study): protocol for a mixed-methods pre-post study

INTRODUCTION

Pharmacotherapy is critical in geriatric fallers owing to the vulnerability of this population. Comprehensive medication management can be an important strategy to reduce the medication-related risk of falling in this patient group. Patient-specific approaches and patient-related barriers to this intervention have rarely been explored among geriatric fallers. This study will focus on establishing a comprehensive medication management process to provide better insights into patients' individual perceptions regarding their fall-related medication as well as identifying organisational and medical-psychosocial effects and challenges of this intervention.

METHODS AND ANALYSIS

The study design is a complementary mixed-methods pre-post study which follows the approach of an embedded experimental model. Thirty fallers aged at least 65 years who were on five or more self-managed long-term drugs will be recruited from a geriatric fracture centre. The intervention consists of a five-step (recording, reviewing, discussion, communication, documentation) comprehensive medication management, which focuses on reducing the medication-related risk of falling. The intervention is framed using guided semi-structured pre-post interventional interviews, including a follow-up period of 12 weeks. These interviews will assess patients' perceptions of falls, medication-related risks and gauge the postdischarge acceptability and sustainability of the intervention. Outcomes of the intervention will be measured based on changes in the weighted and summated Medication Appropriateness Index score, number of fall-risk-increasing drugs and potentially inadequate medication according to the Fit fOR The Aged and PRISCUS lists. Qualitative and quantitative findings will be integrated to develop a comprehensive understanding of decision-making needs, the perspective of geriatric fallers and the effects of comprehensive medication management.

ETHICS AND DISSEMINATION

The study protocol was approved by the local ethics committee of Salzburg County, Austria (ID: 1059/2021). Written informed consent will be obtained from all patients. Study findings will be disseminated through peer-reviewed journals and conferences.

TRIAL REGISTRATION NUMBER

DRKS00026739.

Potentially inappropriate medication including drug-drug interaction and the risk of frequent falling, hospital admission, and death in older adults - results of a large cohort study (getABI)

Introduction: With growing age, multiple chronic diseases may result in polypharmacy. Drugs that should be avoided in older adults are called potentially inappropriate medications (PIM). Beyond PIM, drug-drug interactions (DDI) are known to be related to adverse drug events. This analysis examines the risk of frequent falling, hospital admission, and death in older adults associated with PIM and/or DDI (PIM/DDI) prescription. Materials and methods: This post hoc analysis used data of a subgroup of the getABI study participants, a large cohort of community-dwelling older adults. The subgroup comprised 2120 participants who provided a detailed medication report by telephone interview at the 5-year getABI follow-up. The risks of frequent falling, hospital admission, and death in the course of the following 2 years were analysed by logistic regression in uni- and multivariable models with adjustment for established risk factors. Results: Data of all 2,120 participants was available for the analysis of the endpoint death, of 1,799 participants for hospital admission, and of 1,349 participants for frequent falling. The multivariable models showed an association of PIM/DDI prescription with frequent falling (odds ratio (OR) 1.66, 95% confidence interval (CI) 1.06-2.60, p = 0.027) as well as with hospital admission (OR 1.29, 95% CI 1.04-1.58, p = 0.018), but not with death (OR 1.00, 95% CI 0.58-1.72, p = 0.999). Conclusion: PIM/DDI prescription was associated with the risk of hospital admission and frequent falling. No association was found with death by 2 years. This result should alert physicians to provide a closer look at PIM/DDI prescriptions.

Risk factors for potentially inappropriate medication use in older adults: a cohort study

BACKGROUND

Much of the knowledge on the use of potentially inappropriate medications (PIM) in older adults is derived from cross-sectional studies, with little known about the risk factors over time.

AIM

Longitudinal analysis was applied to estimate the occurrence and risk factors of PIM use among older adults in a 10-year follow-up.

METHOD

Longitudinal study with 418 older adult residents of a capital city of Central-West Brazil. The PIM were classified according to the Beers criteria 2019. The usage rate was calculated at baseline (2008) and at the 10-year follow-up moment (2018). Analysis of predictors (sociodemographic, self-rated health, hospitalization, number of comorbidities, polypharmacy, diabetes, hypertension, hypercholesterolemia and nutritional status) was performed using Generalized Estimating Equation (GEE) models.

RESULTS

Mean age at baseline was 70.6 years (SD 7.1) and 76% were women; 221 older adults took part in the follow up. The rate of PIM use was 50.4% at baseline and 57.5% at the 10-year follow-up. Multiple analysis showed that PIM use in the cohort was statistically higher in the older adults with a history of hospitalization (RR_adj 1.20; 95% CI 1.01-1.40), with three or more diseases (RR_adj 1.41; 95% CI 1.14-1.74), with polypharmacy (RR_adj 1.81; 95% CI 1.47-2.24) and with diabetes mellitus (RR_adj 1.24; 95% CI 1.05-1.47).

CONCLUSION

A high level of potentially inappropriate medication use was observed, reaching 50% of the older adults, with a 7% increase in the prevalence over the 10-year follow-up period. Hospitalization, multimorbidities, polypharmacy and diabetes mellitus were associated with the use of these medications. Interventions for surveillance of the deprescribing process need to be encouraged to avoid potential harm caused by the use of medications.

The Sex-Specific Impact of the FORTA (Fit-fOR-The-Aged) List on Medication Quality and Clinical Endpoints in Older Hospitalized Patients: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Little is known about the sex-specific impact of drug optimization tools such as the Fit fOR The Aged (FORTA) list on drug use and relevant clinical endpoints in older people.

OBJECTIVE

We aimed to detect gender differences of interventional effects on medication quality and related clinical effects in the VALFORTA trial.

PATIENTS AND METHODS

A sex-specific analysis of data from 409 patients (147 men and 262 women, mean age 79.4 and 82.7 years, respectively) in acute geriatric care comparing the control and FORTA intervention groups was performed. Changes of the FORTA score (sum of over- and undertreatment errors per patient), the incidence of adverse drug events (ADEs) during hospitalization, and several clinically relevant endpoints [e.g., the Barthel index (BI)] were tested for equivalence at a 20% margin. "Success" or "failure" for the development of these clinical endpoints was defined and their frequencies compared by a risk reduction analysis.

RESULTS

Sex differences were insignificant for the reduction of the FORTA score, the improvement of BI, or over- and undertreatment errors (p > 0.05). In women only, the FORTA intervention significantly increased the number of patients without an ADE (p = 0.010). Statistical sex equivalence was found for the improvement of the FORTA scores, BI, and the number of prevented events (e.g., falls, confusion, or renal failure) (p < 0.05), but not for the improvement of specific mistreatments or over- and undertreatment scores under altered inclusion criteria (p > 0.05).

CONCLUSIONS

Both sexes benefit equally from the FORTA intervention regarding the amelioration of the quality of drug treatment as well as several clinically relevant outcomes. In addition, the positive impact of the FORTA intervention on the number of adverse drug events appears to be greater in women.

TRIAL REGISTRATION NUMBER

DRKS00000531.

Healthcare Costs Associated with Potentially Inappropriate Medication Prescribing Detected by Computer Algorithm Among Older Patients

INTRODUCTION

Potentially inappropriate medication prescribing (PIP) among older patients is associated with an increased risk of adverse events and hospitalization, and sometimes increased healthcare costs.

OBJECTIVE

The aim of this study was to explore the association between healthcare costs and PIP exposure among older patients.

METHODS

Analyses were conducted using data from the Multidomain Alzheimer Preventive Trial (MAPT). A computer algorithm was constructed to detect PIP based on various different explicit criteria-based tools, and the results were expressed in number of medication-related potential non-compliances (MRNCs). A prescription was considered potentially inappropriate if there were one or more MRNCs. We performed a cost analysis from the French National Health Insurance perspective, and also performed a multivariate analysis to identify the association between healthcare costs and PIP (number of MRNCs).

RESULTS

The computer algorithm analyzed medication prescribing from included patients (N = 1525 aged 75.3 ± 4.4 years; 64% women [n = 978]). PIP was associated with increased total healthcare costs and non-medication healthcare costs after adjusting for potential confounders. We also noted that healthcare costs tended to increase with the number of MRNCs. The mean additional healthcare costs were €517, €921, and €1669 per patient and year for patients with one or two MRNCs, three or four MRNCs, and five or more MRNCs, respectively, in comparison with patients with appropriate medication prescriptions.

CONCLUSION

These observations led us to conclude that interventions focused on reducing PIP could result in savings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00672685.

Characterization of potentially inappropriate medications use in Indian elderly population and their impact on quality of life using Beers criteria

Background

Polypharmacy is principal cause of potentially inappropriate medications (PIMs) in elderly patients, which include over prescribing, under prescribing, and misprescribing.

Methods

Elderly subjects (≥60 years), of either sex, receiving two or more medications for one or more chronic ailments, attending Geriatrics Outpatient Department (OPD), at All India Institute of Medical Sciences (AIIMS) New Delhi, were included. Their prescriptions were assessed for PIMs by using Beers criteria 2015 and were further followed up at least once in 6 months for adverse events, telephonically. The results were analyzed by using suitable regression models and correlation analysis.

Results

Three hundred eighty patients average age of 65.4 ± 4.7 years were enrolled. Eighty-eight percent of the people were having greater than or equal to two ailments. Each patient was prescribed 6.7 ± 2.1 medications with 65% of prescriptions having one or more PIMs. Out of the total prescribed drugs, 15% were satisfying Beers criteria for PIMs. There were 63 adverse drug reactions (ADRs) reported. A statistically significant correlation was observed among comorbidities, number of prescribed medications, PIMs, and ADRs. Quality of life (QOL) of the elderly patients was negatively corelated with polypharmacy and female sex.

Conclusion

A risk-benefit analysis of prescribed medications is part and parcel of prescribing, especially in elderly patients. In order to decrease further risks associated with inappropriate prescribing, there is need for indigenous guidelines and intensive training.

The effects of a pharmacist-led medication review in a nursing home: A randomized controlled trial

BACKGROUND

In this study, an intensive review of pharmaceutical care for elderly patients was conducted in a Veterans Administration nursing home in Taiwan and its effects were evaluated.

METHODS

One hundred participants were enrolled in this randomized controlled study with even distribution. The inclusion criteria were age 65 years or older, prescriptions for at least 5 oral medicines daily, and ≥2 chronic diseases, for the period May 2013 to October 2014. Subjects were excluded if they had previously been included in an intensive medication review conducted by a pharmacist. The primary outcomes were numbers of drugs prescribed, potential inappropriate medications, and numbers of drug-related problems. The secondary outcomes were self-reported medical usages, measurements of quality of life, results of a satisfaction survey, and health status.

RESULTS

A total of 80 cases (42 in the intervention group with medication reconciliation and 38 in the control group without medication reconciliation) completed the study. Baseline characteristics were not statistically different between the 2 groups. The overall prevalence of potential inappropriate medication was 74.3%. There were no differences between the 2 groups, with the exception of "medical problems," which showed a significantly higher prevalence in the intervention group (P < .05). The intervention group reported greater satisfaction regarding pharmacist visits and medication compliance (P < .01). The mean number of drug-related problems was significantly lower after the intervention (P < .01).

CONCLUSION

In this study, the intensive review of the elderly patients' medications revealed that the only significant effect of pharmaceutical care was on "all outcomes." A possible reason for this is the rather advanced ages of some patients who needed a considerable number of medications to treat several chronic diseases. Another reason may be the small sample size. However, participants who received the pharmacist intervention did have higher satisfaction with medication reconciliation and fewer drug-related problems.

Potentially inappropriate medication use among older adult patients on follow-up at the chronic care clinic of a specialized teaching hospital in Ethiopia. A cross-sectional study

Background

Older adult patients are prone to potentially inappropriate medication use (PIMU); its use has been associated with multiple adverse consequences. As a result, it is crucial to determine the magnitude and factors associated with PIMU. The present study was mainly aimed to determine and assess the magnitude and predictors of potentially inappropriate medication use in older adult patients on follow-up at the chronic care clinic of Jimma medical center.

Methods

A retrospective cross-sectional study was conducted involving 219 patients aged 65 years and above on treatment follow-up. Data was collected using a checklist. The 2019 updated American Geriatric Society (AGS) Beers Criteria® and Screening Tool of Older People’s Potentially Inappropriate Prescriptions criteria and Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria (version 2) were employed to assess PIMU. SPSS IBM (v22) was used for data entry and analysis. Categorical variables were described using frequency and percentage, whereas continuous variables were described using mean with standard deviation (SD) or median with interquartile range (IQR). Logistic regression was conducted to identify predictors of PIMU.

Results

The average number of medications prescribed per patient was 4.0 (IQR = 2.0). At least one PIMU was identified in 182 (83.1%) and 99 (45.2%) patients, based on Beers and STOPP criteria, respectively. Additionally, potential prescription omission (PPO) was observed in 24 (10.9%) patients. The risk of Beers PIMU was increased with age [AOR = 1.21, p <  0.001], hypertension [AOR = 4.17, p <  0.001], and polypharmacy [AOR = 14.10, p <  0.001], while a decrease in the risk was noted in patients with a diagnosis of ischemic stroke [AOR = 0.133, p = 0.01] and asthma [AOR = 0.03, p <  0.001]. Using STOPP criteria, hypertension [AOR = 2.10, p = 0.04], diabetes mellitus [AOR = 2.26, p = 0.04], ischemic heart disease [AOR = 2.84, p = 0.04], peripheral neuropathy [AOR = 10.61, p <  0.001], and polypharmacy [AOR = 6.10, p <  0.001] significantly increased the risk of PIMU.

Conclusions

Regardless of the screening tool used to assess, the present study revealed PIMU in the large proportion of the participants. Multiple medication use and certain disease condition had increased the probability of PIMU. Hence, it is imperative to use screening tools for reviewing medications prescribed in older adult patients to ensure safety of medication therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02463-9.

Systematic Review and Meta-Analysis on the Associations of Polypharmacy and Potentially Inappropriate Medication With Adverse Outcomes in Older Cancer Patients

BACKGROUND

Both polypharmacy and potentially inappropriate medication (PIM) intake are highly prevailing in older cancer patients. However, only studies on the association of polypharmacy and postoperative complications have been meta-analyzed previously.

METHODS

A systematic review and a meta-analysis of prospective/retrospective observational studies reporting associations of polypharmacy or PIM with at least one out of five predefined adverse health outcomes in a population of older cancer patients (≥60 years) were carried out. PubMed and Web of Science were used to search for relevant studies published between January 1991 and March 2020. Data were pooled by adopting a random-effects model.

RESULTS

Overall, 42 publications were included in the systematic review. Meta-analyses could be performed on 39 studies about polypharmacy and 13 studies about PIM. Polypharmacy was found to be statistically significantly associated with all-cause mortality (risk ratio [95% confidence interval]: 1.37 [1.25-1.50]), hospitalization (1.53 [1.37-1.71]), treatment-related toxicity (1.22 [1.01-1.47]), and postoperative complications (1.73 [1.36-2.20]). The association of polypharmacy with prolongation of hospitalization was not statistically significant at the p < .05 significance level (1.62 [0.98-2.66]). With respect to PIM, a statistically significant association with all-cause mortality (1.43 [1.08-1.88]) was observed but not with other adverse outcomes.

CONCLUSIONS

Polypharmacy was found to be associated with several adverse outcomes and PIM use with all-cause mortality in older cancer patients. However, these results should be interpreted with caution because about three-quarters of the studies identified did not adjust for comorbidity and are prone to confounding by indication.

A Systematic Review of Potentially Inappropriate Medications Use and Related Costs Among the Elderly

OBJECTIVE

Potentially inappropriate medications (PIMs) use is a common phenomenon among older adults. This paper aimed to perform a systematic literature review to assess PIMs use and related costs among elderly persons.

METHODS

This study was a systematic review. PubMed, Scopus, and the Institute for Scientific Information engines were used to search for all relevant studies published until 2020. Studies were excluded if they did not estimate the cost of PIMs for the elderly. In addition, non-English articles, editorials, letters, and review articles were excluded. All eligible articles were assessed for methodological quality. Finally, we extracted general characteristics from each eligible study.

RESULTS

This study showed that the prevalence of PIMs use among older adults was more than 30%. Drugs related to the central nervous system and cardiovascular disease, benzodiazepines, analgesics, and nonsteroidal anti-inflammatory drugs were most commonly used as PIMs. These studies concluded that PIMs could impose a high economic burden on the elderly and society. The mean cost for older adults with PIMs use was almost USD$2000 more than the mean cost for older adults without PIMs. Additionally, the total cost of PIMs use for all elderly persons in Canada in 2013 was estimated at USD$419 million.

CONCLUSIONS

Focusing on the most common PIMs, such as benzodiazepines and nonsteroidal anti-inflammatory drugs, helps implementing cost-effective strategies for reducing PIMs use and decreasing their clinical and economic effects.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT

Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people.

OBJECTIVE

To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship.

METHODS

Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship.

RESULTS

17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship.

CONCLUSION

Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

Polypharmacy, potentially inappropriate medication and pharmacogenomics drug exposure in the Rhineland Study

AIM

High medication use may contribute to the efficiency of drug therapy in general, but it could also increase the burden of adverse drug reactions. We aimed to assess medication use and the prevalence of three risk factors for adverse drug reactions: the use of polypharmacy, potentially inappropriate medication in the elderly and pharmacogenomic polymorphisms affecting the metabolism of drugs.

METHODS

Cross-sectional interview-based medication data (including over-the-counter drugs) was collected in a large population-based cohort (≥30 years of age) in Bonn, Germany.

RESULTS

Analyses were based on the first 5000 participants of the Rhineland Study (mean age 55 years, 57% women). Of our participants, 66.0% reported the use of a drug regularly, which increased to 87.4% in participants aged ≥65 years (n = 1301). The rates of use of polypharmacy, potentially inappropriate medication and pharmacogenomic drugs were 15.9%, 6.4% and 20.5%, respectively. In participants <65 years, 16.0% (95% CI 14.8, 17.3) had at least one risk factor. In participants aged ≥65 years, 54.1% (95% CI 51.4, 56.8) had at least one and 27.4% (95% CI 25.0, 29.9) had at least two risk factors. Extrapolating these numbers to the German population implies that around 9 million of the 17 million individuals aged 65 years or older are potentially at an elevated risk for adverse drug reactions, of which 4.6 million are at a potentially highly elevated risk for adverse drug reactions.

CONCLUSION

Our study shows that drug use is common and the individual risk for an adverse drug reaction in our population is high. This suggests room for improvement in general medication use.

Effectiveness and organizational conditions of effectiveness of telemedicine in nursing homes. A study protocol of a comparative prospective cohort (EFFORT study)

The profile of nursing home (NH) residents has changed over the past decade with more dependency, more severe chronic diseases and more treatments prescribed. For residents, the major consequence is the higher risk of unplanned hospitalization. French guidelines recommend the development of interactive telemedicine (InT) in NHs in order to improve access to care, and to decrease the rate of avoidable unplanned hospitalizations.

Methods and analysis: The aim of this study is to analyze the impact of an InT protocol delivered in NHs on the rate of unplanned hospitalizations, and on the quality of life at work and the organizational conditions of effectiveness of telemedicine in NHs. We will perform a mixed methods study combining a cluster non-randomized controlled trial in two matched parallel arms (telemedicine group and control group) and qualitative analysis of the evolution of organizational and professional contexts in NHs.

Ethics and dissemination: The study protocol was approved and sponsored by the French Ministry of Health. The study received ethical approval from the Bordeaux University Hospital Institutional Review Board. We will communicate the final results to the public via conferences and results will also be submitted for publication in international peer-reviewed scientific journals.

Trial registration number NCT03486977

Comparison of healthcare resource utilization and costs of patients with HR+/HER2- advanced breast cancer treated with ribociclib versus other CDK4/6 inhibitors

AIMS

To assess healthcare resource utilization (HRU) and healthcare costs among women with hormone receptor-positive and human epidermal growth factor receptor 2-negative advanced breast cancer (HR+/HER2- aBC) treated with cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors.

METHODS

Women with HR+/HER2- aBC, initiating CDK4/6 inhibitor treatment were identified using IBM MarketScan Commercial and Medicare Supplemental databases (Q1/2000-Q3/2018). Based on the first CDK4/6 inhibitor patients received (index therapy), three cohorts were identified: abemaciclib, palbociclib, and ribociclib. The baseline period (six months preceding treatment initiation) was used to describe patient characteristics. All-cause HRU and direct total healthcare costs (medical and pharmacy) from treatment initiation until the earliest of the end of index therapy, continuous health plan enrollment, or data availability, were compared for the ribociclib cohort versus the abemaciclib and palbociclib cohorts, separately, using weighted regression analyses balanced on baseline covariates.

RESULTS

Average age at treatment initiation was ∼60 years and the majority of patients were postmenopausal (abemaciclib: 92%; palbociclib: 92%; ribociclib: 79%). Average follow-up duration was 3.9, 8.8, and 5.9 months for the abemaciclib, palbociclib, and ribociclib cohorts, respectively. After reweighting, HRU was not statistically different between the ribociclib and abemaciclib cohorts, however, the ribociclib cohort incurred significantly lower total healthcare costs (-$5,452; 95% CI: -$8,726; -$1,139, p = .01). Medical costs (driven by outpatient costs) and pharmacy costs (driven by CDK4/6 inhibitor costs) were significantly lower for the ribociclib cohort. Among the reweighted ribociclib and palbociclib cohorts, HRU and total healthcare costs were not statistically different, although the ribociclib cohort had lower outpatient costs per-patient-per-month (-$1,245, 95% CI: -$2,349; -$37, p = .04).

LIMITATIONS

Due to the retrospective, observational design, treatment cohorts were not randomly assigned.

CONCLUSIONS

During CDK4/6 inhibitor therapy, ribociclib patients tended to incur lower medical and pharmacy costs than abemaciclib patients. Among ribociclib and palbociclib patients, HRU and healthcare costs were similar.

Association Between Potentially Inappropriate Medications and Hospital Encounters Among Older Adults: A Meta-Analysis

BACKGROUND

Potentially inappropriate medications (PIMs) are defined by the American Geriatric Society as medications that should be avoided in the elderly in general, or in specific situations. However, PIM use remains high among aging populations and may result in increased utilization of healthcare resources.

OBJECTIVE

The aim of this meta-analysis was to evaluate the impact of PIM use on hospital encounters among older adults.

METHODS

We searched Medline and Scopus from January 1991 to April 2019 using keywords and MeSH terms related to PIMs. Studies were included if they compared the odds of hospital encounters between PIM and non-PIM groups. Hospital encounters could be either hospital admissions or emergency department (ED) visits. Using random-effects meta-analytic methods, we calculated the pooled odds of any hospital encounter in PIM versus non-PIM users.

RESULTS

A total of 21 studies evaluating 3,137,188 patients were included. The proportion of patients on PIMs was > 20% in most (n = 18) studies, median follow up was 12 months, and the mean age of patients ranged from 72 to 86 years. Upon meta-analysis, PIM use was associated with increased odds of both hospital admissions (OR 1.52; 95% CI 1.40-1.65) and ED visits (OR 1.72, 95% CI 1.33-2.24).

CONCLUSION

PIM use among older patients was associated with more hospital encounters. These unnecessary encounters likely cause a substantial burden to the healthcare system and patients.

Factors associated with drug prescribing practices in long-term care patients with cognitive impairment

PURPOSE

To examine factors associated with prescribing anti-dementia medicines (ADM), atypical antipsychotics (A-APM), typical antipsychotics (T-APM), anxiolytics and other psychostimulants (OP) in the residents of long-term care institutions (LTCIs).

METHODS

A cross-sectional survey of a country-representative sample of randomly selected LTCIs in Poland, conducted in 2015-2016. First, we identified 1035 residents with cognitive impairment (CI) among all 1587 residents. Next, we randomly selected 20 residents from each institution. Study sample consists of 455 residents with CI: 214 recruited from 11 nursing homes and 241 from 12 residential homes. We used InterRAI-LTCF questionnaire and drug dispensary cards administered on the day of data collection to assess use of drugs. Multiple correspondence analysis (MCA), descriptive and logistic regression analyses were performed.

RESULTS

The residents were treated with ADM (13.4%), OP (14.3%), antipsychotics (46.4%) including A-APM (24.2%) and T-APM (27.9%), and anxiolytics (28.4%). Hydroxyzine was used most often among anxiolytics (71.3%). Prescribing of ADM was more likely in Alzheimer's disease (OR = 4.378; 95%CI 2.173-8.823), while OP in other dementia (OR = 1.873; 95%CI 1.007-3.485). Administration of A-APM was more likely in older residents (OR = 1.032, 95%CI 1.009-1.055), and when delusions appeared (OR = 2.082; 95%CI 1.199-3.613), while there were no neuropsychiatric factors increasing the odds of T-APM use. Prescribing of anxiolytics was less likely in moderate CI (by 47.2%) than in residents with mild CI.

CONCLUSION

Current practices of prescribing psychotropics are inadequate in Polish LTCIs, especially in terms of use of T-APM and hydroxyzine. More attention should be given to motivate physicians to change their prescribing practices.

Potentially inappropriate medications in Chinese older adults: a comparison of two updated Beers criteria

Background Beers criteria have been into the mainstay to characterize the potentially inappropriate medication since its first publication, but the recent version, Beers 2019, is yet to be validated by clinical studies nationally. Objective To identify the prevalence and the predictors of potentially inappropriate medications in hospitalized geriatric patients based on the Beers 2019 and 2015 criteria. Setting Nanjing Drum Tower Hospital, a 3000-bed tertiary care teaching hospital in China. Method We conducted a cross-sectional study from July 1, 2018 to December 31, 2018. Data from all hospitalized patients aged ≥ 65 years were collected from the hospital database. Inappropriate prescriptions were identified using the Beers 2019 criteria and the Beers 2015 criteria. Main outcome measure Prevalence Ratio (PR) and predictors of potentially inappropriate medications. Results The prevalence of inappropriate prescriptions based on the Beers 2019 criteria was 64.80%. This result was slightly higher than that of the Beers 2015 criteria (64.31%). The most commonly encountered inappropriate prescriptions identified using the two criteria were proton-pump inhibitors. The kappa coefficient was 0.826 (p < 0.001) indicating a strong coherence between the two criteria. The most important factor associated with inappropriate medications use was the number of prescribed drugs (PR 5.17, 95% CI 2.89-8.43; PR 4.58, 95% CI 1.93-7.25). Conclusion This study showed a high prevalence of potentially inappropriate medication in the Chinese geriatric population, which was associated with the number of prescribed drugs. The predictors identified in this research might help pharmacists to detect high-risk drugs and intervene in time.

Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs

BACKGROUND/OBJECTIVES

To examine the prevalence of potentially inappropriate medication (PIM) prescribing and its association with healthcare utilization and related expenditures utilizing nationally representative data from the United States.

DESIGN

Retrospective cohort study.

SETTING

The 2011-2015 Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Community-dwelling sample of U.S. adults aged 65 and older during the first round of each MEPS cycle.

MEASUREMENTS

A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to estimate the prevalence of PIM prescribing over the study period. Negative binomial models were assembled to examine associations between PIM exposure and healthcare utilization including hospitalizations, emergency department (ED) visits, and outpatient provider visits. Generalized linear models with the log link function and gamma distribution were used to analyze associations between PIM exposure and healthcare expenditures. Sensitivity analyses were conducted utilizing inverse probability treatment weighting using propensity scores for being prescribed a PIM.

RESULTS

The period prevalence of PIM prescribing over the 5-year sample was 34.4%. PIM prescribing was positively associated with hospitalizations (adjusted incidence rate ratio [aIRR] = 1.17; 95 confidence interval [CI] = 1.08-1.26; P < .001), ED visits (aIRR = 1.26; 95% CI = 1.17-1.35; P < .001), and outpatient provider visits (aIRR = 1.18; 95% CI = 1.14-1.21; P < .001). PIM exposure was associated with higher marginal costs within outpatient visits ($116; 95% CI = $105-$243; P < .001), prescription medications ($128; 95% CI = $72-$199; P < .001), and total healthcare expenditures ($458; 95% CI = $295-$664; P < .001). Similar results were found in our propensity score analyses.

CONCLUSION

PIMs continue to be prescribed at a high rate among older adults in the United States. Our results suggest that receipt of PIMs is associated with higher rates of healthcare utilization and increased costs across the healthcare continuum. Further work is needed to implement evidence-based deprescribing interventions that may in turn reduce unnecessary healthcare utilization.

Prescribing potentially inappropriate medications for the elderly according to Beers Criteria: systematic review

The study aimed to perform a systematic review to identify and evaluate the prevalence of potentially inappropriate medicines (PIM) prescriptions for the elderly, according to Beers Criteria, in hospitalized elderly individuals aged 65 years or older. Five databases consulted: VHL; Cochrane Library; CINAHL; MEDLINE and Web of Science. Nineteen articles identified, selected based on eligibility criteria. The mean age was 78.2 years and the most used criterion for the identification of PIM for the elderly was Beers 2015 (57.9%). A total of 221,879 elderly received a prescription for PIM, the mean prevalence was 65.0%, for the gastrointestinal system (15.3%) and proton-pump inhibitors (27.7%) highlighted as the main class of medicine prescribed. It concluded that the Beers Criteria have made it possible to identify the high prevalence in the prescription of PIM. The results of this review may help in the decision making of health professionals, to avoid the administration of PIM and to propose best practices to ensure the safety of the elderly hospitalized.

Impact of medication review via tele-expertise on unplanned hospitalizations at 3 months of nursing homes patients (TEM-EHPAD): study protocol for a randomized controlled trial

Background

Inappropriate drug prescribing causes preventable drug-related adverse events that result in increased morbidity and mortality, additional costs and diminished quality of life. Numerous initiatives have been launched to improve the quality of drug prescribing and safeguard the security of drug administration processes in nursing homes. Against the backdrop of implementation of telemedicine services, the focus of the present work is to evaluate the impact of a telemedication review carried out by a hospital physician and pharmacist as part of the telemedicine offer.

Methods

The present study is a randomized controlled clinical trial. A total of 364 patients will be randomized into two groups: (1) an experimental group (182 patients) benefiting from a telemedication review using tele-expertise and (2) a control group (182 patients) receiving standard care. The primary endpoint will be rate of all-cause unplanned hospital admissions occurring within 3 months of randomization. The secondary endpoints will be rate of unplanned admissions at 6 months, patient quality of life, incidence of behavioral disturbances, number of falls, number of residents prescribed at least one inappropriate medication, nursing staff satisfaction, proposed medication reviews and their acceptability rate, characteristics of patients whose general practitioners have taken account of tele-expertise, efficacy of tele-expertise as compared to standard prescription and acceptability and satisfaction surveys of participating caregivers.

Discussion

In the literature, various studies have investigated the utility of structured medication review processes, but outcome measures are heterogeneous, and results vary widely. Medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Incremental cost-effectiveness ratios will be used to compare the cost and effectiveness of the experimental strategy and that of standard care. Our approach, involving the combination of an acceptability survey and a mixed-method (qualitative and quantitative) satisfaction survey, is particularly innovative. The results of this randomized trial are expected to confirm that medication review using tele-expertise has potential as a worthwhile care management strategy for nursing home residents.

Trial registration

Clinicaltrials.gov NCT03640845; registered August 21, 2018 (Clinicaltrials.gov NCT03640845).

[Potentially inappropriate medication in a German practice network-who prescribes what to whom?]

BACKGROUND

Potentially inappropriate medication (PIM) carries the risk of increased drug side effects for older people. The prevalence data are known but no descriptive analyses of prescription behavior as a starting point for reducing PIM have yet been conducted.

OBJECTIVE

The aim of the study was to analyze PIM prescription in the outpatient sector and to identify risk groups where increased awareness of the issue is needed.

MATERIAL AND METHODS

The basis for the investigation was the data set of the AOK Bavaria health insurance, which contains anonymized prescription data of a practice network for patients aged 65 years and older from 2010 to 2014. The Priscus list was used to identify the PIM.

RESULTS

There were 410,934 prescriptions during the investigation period. The prevalence of PIM was 5.60%. Family doctors prescribed 5.39% PIM and specialists for neurology, psychiatry and psychotherapy (NPP) prescribed 16.36% PIM. Regardless of the medical discipline, PIM from the drug groups psycholeptics, psychoanaleptics and antihypertensive drugs were most frequently prescribed. For men and women PIM accounted for 4.50% and 6.31%, respectively, of the prescriptions during the period. In terms of age groups older women received PIM most frequently.

CONCLUSION

In the case of specialists for NPP a high prevalence of prescriptions for PIM could be established; however, in absolute terms family doctors prescribed significantly more PIM overall. This mainly affected women and especially those between 80 and 84 years old. In the future family doctors should be made more aware with respect to the prescription of psychopharmaceuticals and antihypertensive drugs to older women.

[Efficacy of decision support systems to improve medication safety - results of the evaluation of the "Arzneimittelkonto NRW"]

Polypharmacy increases the risk of adverse drug reactions, especially in the elderly. Therefore, the reduction of potentially inadequate medication (PIM), an improvement in drug therapy safety and, in general, a more rational use of drugs is an objective of various interventions. The aim of this prospective single-arm interventional study is to investigate the potential of a decision support system (DSS; "Arzneimittelkonto NRW") to improve medication safety in outpatient care. 15 primary care physicians participating in the study recruited 874 patients. Prescription data and results of medication safety tests were available for 654 patients. Data of at least 12 months were available for 86% of these patients. PIM prevalence declined within 12 months (-11.3%), but not at a statistically significant level. The number of prescriptions after the introduction of the DSS is significantly below the prescription volume before the introduction of the DSS (-14.1%). Constantly high alteration rates of up to 85% were observed, for example, on drug interaction system warnings made by the DSS. Technical decision support systems have the potential to support a safer and cost-saving drug use. For the first time, this pilot study provides evidence for this in the context of standard outpatient care in Germany. However, further investigations are necessary to establish a robust body of evidence. A particular focus should be on the qualitative monitoring of the studies and the involvement of other actors in the care process.

Sociodemographic, clinical and pharmacological profiles of medication misuse and dependence in hospitalised older patients in Norway: a prospective cross-sectional study

OBJECTIVES

Timely recognition of medication misuse and dependence is crucial to avoid both adverse drug events and increasing health expenditure. Yet the detection of these disorders in older people remains challenging due to the paucity of evidence on characteristics of patients at risk. This study investigates sociodemographic, pharmacological and clinical characteristics and factors associated with prolonged medication use, misuse and dependence in hospitalised older patients, focusing on three commonly prescribed central nervous system depressants (CNSDs): opioid analgesics, benzodiazepines and z-hypnotics.

DESIGN

A prospective, cross-sectional study complying with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

SETTING

Somatic departments of the Akershus University Hospital, Norway.

PARTICIPANTS

246 patients aged 65-90 were included.

OUTCOME MEASURES

Prolonged use was defined as using CNSDs for ≥4 weeks. Misuse and dependence were assessed with the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria for substance abuse and dependence. We used descriptive statistics to report patients' characteristics and logistic regression to demonstrate factors associated with prolonged use, and misuse or dependence.

RESULTS

Forty per cent of participants reported using CNSDs for ≥4 weeks. The odds of prolonged use were higher for patients aged 75-84 (OR=2.32, 95% CI 1.16 to 4.65) and ≥85 (OR=3.33, 95% CI 1.25 to 8.87) vs <75 years, for pain intensity (OR=1.02, 95% CI 1.01 to 1.04), and polypharmacy versus no polypharmacy (OR=5.16, 95% CI 2.13 to 12.55). The odds were lower for patients who completed secondary education (OR=0.33, 95% CI 0.13 to 0.83) compared with those with only basic education. Factors associated with misuse or dependence were pain intensity (OR=1.02, 95% CI 1.01 to 1.04) and concurrent use of ≥2 CNSDs (OR=3.99, 95% CI 1.34 to 11.88).

CONCLUSION

CNSD overuse is prevalent among hospitalised older patients, despite clear guidelines and recommendations. Our findings underline a need for stronger focus on responsible prescribing, timely detection and prevention of this issue, with special attention towards older patients, those with enhanced pain, polypharmacy and/or concurrent use of several CNSDs.

TRIAL REGISTRATION NUMBER

NCT03162081.

Comparison of Real-World Treatment Outcomes With Vedolizumab Versus Infliximab in Biologic-Naive Patients With Inflammatory Bowel Disease

Background

Little is known about long-term real-world effectiveness of vedolizumab versus infliximab in biologic-naive patients with inflammatory bowel disease (IBD).

Methods

Biologic-naive IBD patients who received vedolizumab or infliximab in the US Explorys Universe database (May 2014–September 2018) were weighted using Entropy-balancing.

Results

Persistence rates were higher for vedolizumab (N = 542) versus infliximab (N = 1,179) cohort at 12 (84.5% vs 77.5%; P = 0.0061) and 24 (77.6% vs 64.6%; P = 0.0005) months post-maintenance therapy. Healthcare resource utilization composite end point rates were lower in vedolizumab versus infliximab cohort at 12 (36.2% vs 48.2%; P &lt; 0.0001) and 24 (46.9% vs 59.9%; P &lt; 0.0001) months post-treatment initiation.

Conclusions

Biologic-naive IBD patients who received vedolizumab had better long-term real-world effectiveness measures versus infliximab patients.

The Severity of Dependence Scale detects medication misuse and dependence among hospitalized older patients

Background

In older patients, timely recognition and treatment of medication misuse and dependence are crucial to secure medication safety and to avoid increasing health expenditure. Nonetheless, the detection of this condition remains challenging due to the paucity of screening instruments validated for older people.

This study assesses diagnostic accuracy, reliability, validity and the factor structure of the Severity of Dependence Scale (SDS) in detecting medication misuse and dependence among hospitalized older patients, focusing on prescribed central nervous system depressants (CNSDs): opioid analgesics, benzodiazepines and z-hypnotics.

Methods

246 adults aged 65–90 were recruited consecutively from somatic departments of the Akershus University Hospital, Norway. Among these, 100 patients were identified as prolonged users of CNSDs. Diagnostic accuracy and validity of the SDS were assessed using DSM-IV criteria for substance abuse and dependence as the reference standard. We also performed an exploratory factor analysis and assessment of internal consistency using Cronbach’s alpha.

Results

The area under the ROC curve was 0.86 (95%CI = 0.79–0.93; p < 0.001). A score of 5.5 was determined as the optimal cutoff for detecting CNSD misuse and dependence among older patients. Cronbach’s alpha obtained was satisfactory (α = 0.73). There was a significant positive correlation between the SDS score and DSM-IV criteria for substance abuse and dependence (Pearson’s correlation coefficient = 0.61, p < 0.001). The uni-dimensionality of the SDS was documented.

Conclusions

The SDS is reliable, valid and capable of detecting medication misuse and dependence among hospitalized older patients, with good diagnostic performance. The scale thus holds promise for use in both clinical and research contexts.

Trial registration

ClinicalTrials.gov Identifier: NCT03162081. Registered 3 May 2017.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1182-3) contains supplementary material, which is available to authorized users.

Analysis of prevalence, risk factors, and potential costs of unnecessary drug therapy in patients with chronic diseases at the outpatient setting

Background: Patients with chronic diseases require long-term use of medications and are at risk for prescription of unnecessary drugs.Objective: To determine the prevalence, risk factors, and costs associated with unnecessary drugs in patients with chronic diseases at outpatient settings.Methods: Clinical and demographic data, unnecessary drug therapy and prices of drugs were obtained from 2,677 patients from the outpatient setting of six major hospitals in Jordan. Multivariate logistic regression was used to determine risk factors associated with unnecessary drug therapy.Results: A total of 936 unncessary medications were identified with an average of one unnecessary medication per every three patients. Monthly costs of unnecessary medications, at the national level, were estimated to range between JD 438,930.24 [(618,821.41 USD) (payer's perspective)] and JD 744,765.5 [(1,050,000.19 USD) (patient's perspective)]. Unnecessary drug was associated with cardiac catheterization (adjusted odds ratio [AOR] = 1.29, 95% CI: 1.01-1.71, p = 0.041), increased number of medications (AOR = 3.11, 95% CI: 2.51-3.86, p < 0.001), and inadequate knowledge/understanding of drug use (AOR = 2.4, 95% CI: 1.24-4.64, p = 0.009).Conclusion: Unnecessary drug therapy is common in the outpatient setting. Identified risk factors should be specifically targeted to reduce its burden.

The effectiveness of integrative healthcare for chronic disease: A systematic review

BACKGROUND

The past few decades have witnessed a surge in consumer, clinician and academic interest in the field of integrative healthcare (IHC). Yet, there is still uncertainty regarding the effectiveness of IHC for complex, long-term health conditions.

OBJECTIVE

To assess the effectiveness of IHC for the management of any chronic health condition.

METHODS

Seven databases and four clinical trial registries were searched from inception through to May 2018 for comparative/controlled clinical trials investigating the effectiveness of IHC for any chronic disease, and assessing any outcome. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool.

RESULTS

The search yielded 6,926 results. Eight studies met the inclusion criteria. All studies had at least three design features that carried an uncertain/high risk of bias. Differences in physiological, psychological and functional outcomes, and quality of life between patients receiving IHC and patients receiving conventional/usual care were varied and inconsistent. Changes in patient satisfaction with care were inconclusive. No studies reported the effectiveness of IHC on workforce- or administration-related parameters. Evidence from one trial suggested IHC may be more cost-effective than conventional care.

CONCLUSIONS

The findings indicate some promising effects for the use of IHC to manage chronic disease. However, the uncertain/high risk of bias across multiple domains, diverse and inconsistent findings, and heterogeneity of outcome measures and study populations prevents firm conclusions from being reached. Along with conducting further well-designed, long-term studies in this field, there is a need to ensure interventions closely align with the definition/principles of IHC.

The association of potentially inappropriate medication use on health outcomes and hospital costs in community-dwelling older persons: a longitudinal 12-year study

AIMS

To determine (1) whether potentially inappropriate medication (PIM) use defined by the Meds75 + database is associated with fracture-specific hospitalisations and all-cause mortality, and (2) the association between PIM use and all-cause hospitalisation costs in a 12-year follow-up of a nationwide sample of people aged ≥ 65 years in Finland.

METHODS

This is a longitudinal study of 20,666 community-dwelling older persons with no prior purchases of PIMs within a 2-year period preceding the index date (1 Jan 2002), who were followed until the end of 2013. Data were obtained from the Finnish Prescription Register, and it was accompanied by information on inpatient care, causes of deaths and socioeconomic status from other national registers. Propensity score matching (PSM) analysis was used to account for potential selection effect in PIM use. Cox proportional hazards regression was used to identify the time to the first fracture or death by comparing PIM-users (n = 10,333) with non-users (n = 10,333). The association between PIM use and hospital costs was analysed with a fixed effects linear model.

RESULTS

PIM use was weakly associated with an increased risk of fractures and death. The association was stronger in the first PIM-use periods. Hospitalised PIM-users had 15% higher hospital costs compared to non-users during the 12-year follow-up.

CONCLUSION

PIM initiation was associated with an increased risk of fracture-specific hospitalisation and mortality and PIM-users had higher hospital costs than non-users. Health care providers should carefully consider these issues when prescribing PIM for older persons.

Healthcare resource utilization in patients with metastatic melanoma receiving first-line therapy with dabrafenib + trametinib versus nivolumab or pembrolizumab monotherapy

OBJECTIVE

To compare healthcare resource utilization (HRU) between patients with metastatic melanoma (MM) initiated on first-line (1L) combination therapy with the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib (D + T; oral) and those initiated on 1 L monotherapy with the anti-PD1 monoclonal antibodies nivolumab or pembrolizumab (N/P; intravenous).

METHODS

Patients with melanoma initiated on D + T or N/P from Q1/2014 to Q2/2016 (defined as 1 L treatment for MM) were identified in the Truven MarketScan database. Entropy balancing was used to reweight the N/P cohort in order to make it comparable to the D + T cohort with respect to the mean and variance of baseline covariates. HRU outcomes during 1 L therapy, reported per patient-year (PPY), were described and compared between the two cohorts post-weighting (i.e. independently of baseline covariates).

RESULTS

Of the 445 patients included, 202 and 243 were initiated on D + T and N/P, respectively. After weighting, patients initiated on N/P had more outpatient visits for drug administration during 1 L therapy than those initiated on D + T (difference = 18.6 visits PPY [95% CI = 16.0-21.1]). Patients initiated on N/P also had more outpatient office visits for reasons other than drug administration (difference = 8.1 visits PPY [95% CI = 1.9-13.7]). No significant differences were observed for other HRU parameters (i.e. inpatient admissions, inpatient days, and emergency department visits during 1 L therapy).

CONCLUSIONS

HRU during 1 L therapy was generally similar between patients initiated on D + T and N/P. Nonetheless, patients initiated on N/P had more outpatient visits, including more outpatient visits for reasons unrelated to drug administration.

Prediction of Drug-Related Risks Using Clinical Context Information in Longitudinal Claims Data

OBJECTIVES

To develop and internally validate prediction models for medication-related risks arising from overuse, misuse, and underuse that utilize clinical context information and are suitable for routine risk assessment in claims data (i.e., medication-based models predicting the risk for hospital admission apparent in routine claims data or MEDI-RADAR).

METHODS

Based on nationwide claims from health-insured persons in Germany between 2010 and 2012, we drew a random sample of people aged ≥65 years (N = 22,500 randomly allocated to training set, N = 7500 to validation set). Individual duration of drug supply was estimated from prescription patterns to yield time-varying drug exposure windows. Together with concurrent medical conditions (ICD-10 diagnoses), exposure to the STOPP/START (screening tool of older persons' potentially inappropriate prescriptions/screening tool to alert doctors to the right treatment) criteria was derived. These were tested as time-dependent covariates together with time-constant covariates (patient demographics, baseline comorbidities) in regularized Cox regression models.

RESULTS

STOPP/START variables were iteratively refined and selected by regularization to include 2 up to 11 START variables and 8 up to 31 STOPP variables in parsimonious and liberal selections in the prediction modeling. The models discriminated well between patients with and without all-cause hospitalizations, potentially drug-induced hospitalizations, and mortality (parsimonious model c-indices with 95% confidence intervals: 0.63 [0.62-0.64], 0.67 [0.65-0.68], and 0.78 [0.76-0.80]).

CONCLUSIONS

The STOPP/START criteria proved to efficiently predict medication-related risk in models possessing good performance. Timely detection of such risks by routine monitoring in claims data can support tailored interventions targeting these modifiable risk factors. Their impact on older peoples' medication safety and effectiveness can now be explored in future implementation studies.

The impact of potentially inappropriate medication on the development of health care costs and its moderation by the number of prescribed substances. Results of a retrospective matched cohort study

Background

In the growing population of the elderly, drug-related problems are considered an important health care safety issue. One aspect of this is the prescription of potentially inappropriate medication (PIM) which is considered to increase health care costs.

Objective

Using data from the Health Economics of Potentially Inappropriate Medication (HEPIME) study, we aimed to analyze how the number of prescribed substances moderates the association of PIM use as defined by the German PRISCUS list and health care costs applying a longitudinal perspective.

Methods

An initial number of 6,849,622 insurants aged 65+ of a large German health insurance company were included in a retrospective matched cohort study. Based on longitudinal claims data from the four separate quarters of a 12-month pre-period, 3,860,842 individuals with no exposure to PIM in 2011 were matched to 508,212 exposed individuals. Exposure effects of PIM use on health care costs and the number of prescribed substances were measured based on longitudinal claims data from the four separate quarters of the 12-month post-period.

Results

After successful balancing for the development of numerous matching variables during the four quarters of the pre-period, exposed individuals consumed 2.1 additional prescribed substances and had higher total health care costs of 1,237 € when compared to non-exposed individuals in the 1st quarter of the post-period. Controlling for the number of prescribed substances, the difference in total health care costs between both study groups was 401 €. The average effect of one additionally prescribed substance (other than PIM) on total health care costs was increased by an amount of 137 € for those being exposed to a PIM. In quarters 2–4 of the post-period, the differences between both study groups tended to decrease sequentially.

Conclusions

PIM use has an increasing effect on the development of health care costs. This cost-increasing effect of PIM use is moderated by the number of prescribed substances.

Costs of potentially inappropriate medication use in residential aged care facilities

Background

The potential harms of some medications may outweigh their potential benefits (inappropriate medication use). Despite recommendations to avoid the use of potentially inappropriate medications (PIMs) in older adults, the prevalence of PIM use is high in different settings including residential aged care. However, it remains unclear what the costs of these medications are in this setting. The main objective of this study was to determine the costs of PIMs in older adults living in residential care. A secondary objective was to examine if there was a difference in costs of PIMs in a home-like model of residential care compared to an Australian standard model of care.

Methods

Participants included 541 participants from the Investigation Services Provided in the Residential Environment for Dementia (INSPIRED) Study. The INSPIRED study is a cross-sectional study of 17 residential aged care facilities in Australia. 12 month medication costs were determined for the participants and PIMs were identified using the 2015 updated Beers Criteria for older adults.

Results

Of all of the medications dispensed in 1 year, 15.9% were PIMs and 81.4% of the participants had been exposed to a PIM. Log-linear models showed exposure to a PIM was associated with higher total medication costs (Adjusted β = 0.307, 95% CI 0.235 to 0.379, p < 0.001). The mean proportion (±SD) of medication costs that were spent on PIMs in 1 year was 17.5% (±17.8) (AUD$410.89 ± 479.45 per participant exposed to a PIM). The largest PIM costs arose from proton-pump inhibitors (34.4%), antipsychotics (21.0%) and benzodiazepines (18.7%). The odds of incurring costs from PIMs were 52% lower for those residing in a home-like model of care compared to a standard model of care.

Conclusions

The use of PIMs for older adults in residential care facilities is high and these medications represent a substantial cost which has the potential to be lowered. Further research should investigate whether medication reviews in this population could lead to potential cost savings and improvement in clinical outcomes. Adopting a home-like model of residential care may be associated with reduced prevalence and costs of PIMs.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0704-8) contains supplementary material, which is available to authorized users.

Inappropriate Prescribing in Older Hospitalized Adults: A Comparison of Medical Specialties

OBJECTIVES

To evaluate the prevalence and number of potentially inappropriate medications (PIMs) in hospitalized older adults, comparing prescription patterns of medical specialties.

DESIGN

Retrospective cohort study.

SETTING

Tertiary general hospital.

PARTICIPANTS

All older adults hospitalized from January through May 2015 (N = 1,900).

MEASUREMENTS

Information on medications prescribed during the first and last days of hospitalization was collected and evaluated regarding PIMs using Beers and Screening Tool of Older People's Prescriptions (STOPP) criteria. Medical specialties (internal medicine, cardiology, gastroenterology, infectious disease, nephrology, neurology, pneumology) were compared regarding the prevalence of PIMs and the increase in the number of PIMs during hospitalization.

RESULTS

The number of individuals with PIMs increased significantly according to both criteria (62.3% to 66.6% according to Beers criteria, 43.4% to 50.0% according to STOPP criteria). The most common PIMs were sliding-scale insulin (26.9%), clonazepam (9.5%), and periciazine (6.4%) using Beers criteria and spironolactone (10.3%), acetylsalicylic acid (9.8%), and periciazine (8.7%) using STOPP criteria. Neurology, infectious disease, and pneumology had the highest numbers of PIMs, and neurology, pneumology, and cardiology had a greater increase in PIMs during hospitalization than the other specialties.

CONCLUSION

This study demonstrates the high and growing prevalence of PIMs in the hospital environment, according to Beers and STOPP criteria. Educational measures and specific pharmaceutical interventions for each specialty are needed to change this situation.