Adding medications in the emergency department: effect on knowledge of medications in older adults

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system

OBJECTIVES

To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up.

DESIGN

Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package.

SETTING

Three academic emergency departments that each implemented EQUIPPED over three successive years.

PARTICIPANTS

Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects.

INTERVENTION(S)

EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge.

MAIN OUTCOME MEASURE(S)

Implementation process components assembled through successive implementation.

RESULTS

Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model.

CONCLUSIONS

Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

Do older people know why they take benzodiazepines? A national French cross-sectional survey of long-term consumers

OBJECTIVES

Benzodiazepines and non-benzodiazepine hypnotics (or Z-drugs) (BZD/Z) are widely prescribed for older patients despite major side effects and risks when chronically used. The patient's understanding of the treatment is one of the keys to good adherence. The purpose of the study was to assess the knowledge of BZD/Z treatment among older people who were taking BZD/Z for the long term by studying the concordance between the declared reason for taking BZD/Z and its indication.

METHODS

This was a cross-sectional, pharmacoepidemiologic ancillary of a national study. Data were collected through a semi-structured interview. All patients from the main study were included. "Good knowledge" was considered when patients gave an indication for each BZD/Z that was similar to its marketing authorisation. Univariate and multivariate analyses were carried out to adequately determine profiles and characterise associations.

RESULTS

More than half of the patients (61.6%) had a good knowledge regarding their treatment. The presence of a psychiatric disorder, a mean duration of BZD/Z use of less than 120 months, a desire to stop treatment, educational status and number and type of BZD/Z used were significantly associated (P < .05) with good knowledge. In the multivariate analysis, only a psychiatric disorder, educational status and taking at least one hypnotic drug were associated with good knowledge.

CONCLUSIONS

At the time of shared medical decision, it appears essential to improve the knowledge of the treatment by the patient. The rate of patients with good knowledge of their BZD/Z treatment remains low and even lower than what was previously found in the literature for other drug classes. In contrast to patients with good knowledge, these data highlight the characteristics of patients with poor knowledge of their BZD/Z treatment, which may allow populations at risk to be targeted and enable education measures to be strengthened.

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review

OBJECTIVES

To systematically review clinical outcomes associated with medication regimen complexity in older people.

DESIGN

Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library.

SETTING

Hospitals, home, and long-term care.

PARTICIPANTS

English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity.

MEASUREMENTS

Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool.

RESULTS

Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff.

CONCLUSION

Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

INTRODUCTION

Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes.

AREAS COVERED

A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared.

EXPERT OPINION

Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Looking beyond polypharmacy: quantification of medication regimen complexity in the elderly

BACKGROUND

Polypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied.

OBJECTIVE

Our aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels.

METHODS

We retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity.

RESULTS

The mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r=0.94, P<0.001) and the number of daily doses (r=0.87, P<0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P<0.001). Positive correlations were observed between the Cumulative Illness Rating Scale-Geriatrics score and both the number of medications and the MRCI score (r=0.40, r=0.46, P<0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P<0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r=-0.188, P= 0.028); however, no such correlation was found regarding the number of medications at discharge.

CONCLUSIONS

The MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.

Accuracy of reporting current medications by cancer patients presenting to an emergency center

BACKGROUND

Due to high coexistence of comorbidity, cancer patients take many medications and are susceptible to negative consequences of polypharmacy. To avoid adverse events during care transitions, patients need to correctly communicate their medications. The emergency center (EC) presents opportunities to assess patients' knowledge of medications and reconcile medication profiles.

OBJECTIVE

The purpose was to evaluate the medication knowledge of cancer patients presenting to the EC and to identify factors associated with higher knowledge.

DESIGN AND MEASUREMENTS

For the cross-sectional self-administered survey, 254 patients were enrolled and gave name, dose, frequency, route, and indication for medications. Responses were checked for accuracy against outpatient pharmacy dispensing records within or outside M. D. Anderson Cancer Center. Demographic data was obtained from medical records. For each patient, we calculated a patient medication knowledge (PMK-overall) score indicating percentage of correct responses.

RESULTS

Median PMK-overall score was 80%. Patients who used a medication aid to fill out the survey were 6.5 times more likely to have a high level of medication knowledge, or PMK-overall score > or = 80%. Predictors of using a medication aid included lower education level, solid tumor, more than five medications, married, and using a medication list at home.

CONCLUSIONS

Though our findings may not be generalizable to settings outside the EC, we found cancer patients to have high levels of medication knowledge. Future studies should validate the use of PMK scores to predict medication adherence and other outcomes. Patients should be encouraged to use a medication aid when presenting information to the health care system.

How much do ED patients know about medication prescribed for them on discharge? A pilot study in Turkey

INTRODUCTION

Hospital emergency departments provide health care to patients with various ailments and illnesses. If necessary, doctors write prescriptions for patients who visit emergency departments for their use after discharge from hospitals. It is important to inform patients about their prescribed medications because compliance with the prescription plays an important role in the success of the treatment. If a patient must use more than one medication, this might result in negative drug interactions. These undesirable developments may adversely affect the treatment process and cause many unplanned patient visits to emergency departments. This study was carried out to determine patient knowledge as related to the names, dosage, frequency, purpose and course of medications given on discharge from emergency departments.

METHODS

Study subjects were patients who came to the emergency department between the hours of 8 am and 8 pm during a period of 1 month. Data were collected through use of a questionnaire.

RESULTS

In this study, it was found that 37% of the patients (37 patients) had no knowledge at all about the prescribed medications; however, out of 63 patients, 61.9% had knowledge of when to take the medications, 57.1% knew the purpose of the particular medications, and 52.3% were aware of the appropriate dosage. Furthermore, 31.7% knew the name of the medications and 25.3% knew something about their prescribed course.

CONCLUSION

Upon discharge from emergency departments, patients should be fully and properly informed about their prescribed medications through a written document. Providing patients with information concerning the correct use of their prescribed medications enables them to use the medications appropriately, thereby increasing not only their satisfaction but also their compliance with the treatment plan. As a result, this vital information may help to decrease rehospitalizations.

Rural residence and prescription medication use by community-dwelling older adults: a review of the literature

CONTEXT

Due to various barriers to health care access in the rural setting, there is concern that rural older adults might have lower access to prescribed medications than their urban counterparts.

PURPOSE

To review published research reports to determine prevalence and mean medication use in rural, noninstitutionalized older adults and assess whether rural-urban differences exist.

METHODS

PubMed, Ageline, Cinahl, PsycInfo, International Pharmaceutical Abstracts, Agricola, and Institute for Scientific Information Web of Science - Social Science Index were searched. English-language articles through May 2005 involving a sample of rural, noninstitutionalized older adults and analyses of overall medication prevalence and/or intensity were included. Review articles, conference abstracts, dissertations, books, and articles targeting nonprescription or specific therapeutic categories were excluded. A total of 206 citations were identified and 26 met the inclusion criteria.

FINDINGS

Reported prevalence of prescription medication use by rural older adults varied between 62% and 96%, with 2-6 prescriptions per person. Multivariate analyses results were equally inconsistent. Controlling for insurance, most US studies suggest there is no rural-urban difference in access to prescribed medications. However, this finding may not be generalizable across all regions in the United States or other countries.

CONCLUSIONS

Geographic location may not be as important a variable for medication usage as for other health services utilization.

Risk of medication errors at hospital discharge and barriers to problem resolution

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identify medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication.

What do discharged patients know about their medication?

Patient's knowledge is a necessity for empowering patients to perform self-care, especially when dealing with new, ill-defined and unknown situations. The aim of this paper is to assess patients' reported as opposed to correct knowledge about medication therapy after discharge from hospital and to identify factors that increase correct knowledge. Three hundred and forty-one patients were interviewed 7-14 days after discharge from six internal wards in a large medical facility in Israel. Most patients (73%) were aware of the course and purpose of their medication. They were, however, unaware of side effects, needed lifestyle changes, and correct medication schedules. A large difference was found between levels of reported and correct knowledge about various issues regarding medication treatment. No significant correlation was found between correct knowledge about medication therapy at discharge, and gender, age, education, patient satisfaction and wish for more counseling. The only factor which significantly affected levels of correct knowledge was whether the patient had received medication counseling during hospitalization. The findings illuminate the gap between patients' perception of knowledge and actual knowledge. The study indicates the need for patient counseling during hospitalization, with respect to medication therapy.

Inadequate analgesia in emergency medicine

Review of emergency department pain management practices demonstrates pain treatment inconsistency and inadequacy that extends across all demographic groups. This inconsistency and inadequacy appears to stem from a multitude of potentially remediable practical and attitudinal barriers that include (1) a lack of educational emphasis on pain management practices in nursing and medical school curricula and postgraduate training programs; (2) inadequate or nonexistent clinical quality management programs that evaluate pain management; (3) a paucity of rigorous studies of populations with special needs that improve pain management in the emergency department, particularly in geriatric and pediatric patients; (4) clinicians' attitudes toward opioid analgesics that result in inappropriate diagnosis of drug-seeking behavior and inappropriate concern about addiction, even in patients who have obvious acutely painful conditions and request pain relief; (5) inappropriate concerns about the safety of opioids compared with nonsteroidal anti-inflammatory drugs that result in their underuse (opiophobia); (6) unappreciated cultural and sex differences in pain reporting by patients and interpretation of pain reporting by providers; and (7) bias and disbelief of pain reporting according to racial and ethnic stereotyping. This article reviews the literature that describes the prevalence and roots of oligoanalgesia in emergency medicine. It also discusses the regulatory efforts to address the problem and their effect on attitudes within the legal community.

Knowledge of prescription medications among elderly emergency department patients

STUDY OBJECTIVE

We determine how knowledgeable elderly (>65 years old) patients seen in the emergency department are of their prescription medications.

METHODS

Patients older than 65 years who presented to the ED of an urban teaching hospital were interviewed concerning their prescription medications and the indications for their use. Medications and dosages were verified through the patients' pharmacies. Medication indications were assessed for accuracy by referencing the Physicians' Desk Reference.

RESULTS

Data on 88 patients were collected over a period of 2 months. Eleven patients were excluded from the study because of logistics (9) and rescinding of consent (2). Patients averaged 5.9 prescription medications on presentation to the ED. Patients correctly identified 78.4% (359/458) of these medications. Thirty-three (42.8%) patients were able to correctly identify all of their prescription medications. Furthermore, patients correctly identified 65.5% (236/359) of dosages (25 [32.5%] patients named all dosages correctly), 91.4% (328/359) of dosing intervals (44 [57.1%] patients named all intervals correctly), and 83.3% (299/359) of indications (49 [63.3%] patients named all indications correctly).

CONCLUSION

Elderly patients presenting to the ED have only a fair knowledge of their prescription medications.