A model for improving medication use in home health care patients

Medication Management Models for Polymedicated Home-Dwelling Older Adults With Multiple Chronic Conditions: Protocol of a Systematic Review

Background

Older adults with multiple chronic diseases commonly require complex medication regimes. When combined with frailty, cognitive impairment, and changing pharmacological prescriptions, older adults’ polymedication regimes increase the risk of medication-related problems (MRPs) and hospitalization. Effective, well-organized medication management could avoid MRPs and their clinical outcomes.

Objective

Identify medication management models and analyze their impact on managing and preventing MRPs for polymedicated, home-dwelling older adults.

Methods

We will conduct a systematic review of published articles in relevant professional scientific journals from inception until March 31, 2019, in the following electronic databases,: Embase; Medline OvidSP; PubMed (NOT Medline[sb]); Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO; PsycINFO OvidSP; Cochrane Library, Wiley; and Web of Science. We will also hand search the bibliographies of all the relevant articles found and search for unpublished studies. We will consider publications in English, French, German, Spanish, Italian, and Portuguese. Retrieved articles will be screened for eligibility. Statistical analyses will be conducted following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statements. Data will be analyzed using SPSS Statistics for Windows, version 25.0 (IBM Corp), and Review Manager, version 5.5 (The Nordic Cochrane Centre, The Cochrane Collaboration).

Results

A preliminary search in Embase delivered 3272 references. This preliminary search allows us to complete our research strategy with equation development and to search the other databases. Relevant articles identified will allow for searching the reference lists for unpublished studies. The inclusion and exclusion criteria will be rigorously respected in the study selection. The entire study is expected to be completed by January 2020.

Conclusions

This review will provide an exhaustive view of medication management models that could be effective for polymedicated, home-dwelling older adults and will allow us to analyze their impact on managing and preventing MRPs.

Trial Registration

PROSPERO CRD42018117287; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=117287 (Archived by WebCite at http://www.webcitation.org/77fCfbCjT)

International Registered Report Identifier (IRRID)

DERR1-10.2196/13582

The Medication Management Model: An Effective Tool for Home Health Providers

Home health patients are at substantial risk for medication problems and errors. A medication management model designed specifically for use by home health agencies proved effective in a recent study conducted by Vanderbilt University: Medication use improved in 50% of intervention participants compared with 38% of controls. The model uses a structured collaboration between a clinical pharmacist and a home health nurse. It can help providers meet federal standards for medication review and improve clinical outcomes by identifying and preventing medication errors in their patients. This article presents findings from the study and strategies for implementation so other home health providers can adopt the model for use in their practices.

Inappropriate prescribing: a systematic overview of published assessment tools

BACKGROUND

Criteria to assess the appropriateness of prescriptions might serve as a helpful guideline during professional training and in daily practice, with the aim to improve a patient's pharmacotherapy.

OBJECTIVE

To create a comprehensive and structured overview of existing tools to assess inappropriate prescribing.

METHOD

Systematic literature search in Pubmed (1991-2013). The following properties of the tools were extracted and mapped in a structured way: approach (explicit, implicit), development method (consensus technique, expert panel, literature based), focused patient group, health care setting, and covered aspects of inappropriate prescribing.

RESULTS

The literature search resulted in 46 tools to assess inappropriate prescribing.Twenty-eight (61%) of 46 tools were explicit, 8 (17%) were implicit and 10 (22%) used a mixed approach. Thirty-six (78%) tools named older people as target patients and 10 (22%) tools did not specify the target age group. Four (8.5%) tools were designed to detect inappropriate prescribing in hospitalised patients, 9 (19.5%) focused on patients in ambulatory care and 6 (13%) were developed for use in long-term care. Twenty-seven (59%) tools did not specify the health care setting. Consensus methods were applied in the development of 19 tools (41%), the others were based on either simple expert panels (13; 28%) or on a literature search (11; 24%). For three tools (7%) the development method was not described.

CONCLUSION

This overview reveals the characteristics of 46 assessment tools and can serve as a summary to assist readers in choosing a tool, either for research purposes or for daily practice use.

Healthy aging: programs that make a difference-part 1

Health promotion and disease prevention programs are critical elements in helping older Americans remain healthy and independent. Over the past decade, the efforts of the Administration on Aging and other agencies around the country have focused on ensuring that older adults have access to community-based health promotion and disease prevention ("healthy aging") programs that can make a noticeable difference in the health and well-being of older adults. Community-based organizations and agencies that provide these healthy aging programs provide ideal partners for senior care pharmacists. Many healthy aging programs target the prevention and management of chronic conditions in which medication management plays a key role. Pharmacists who desire to work with aging service providers and serve community-dwelling older adults should be aware of these programs that are growing in importance within the aging network. This series describes several healthy aging, evidence-based programs and discusses collaborative opportunities for senior care pharmacists. Part 2 will review the concepts behind and research basis for chronic disease self-management programs for older adults and provide practice advice for pharmacists who want to collaborate with organizations that have implemented healthy aging programs.

Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool

BACKGROUND

Evidence-practice gaps, adverse medication-related incidents and unplanned medical admissions to hospital are common in elderly Australians. Many prescribing indicator tools designed to address some of these problems have been reported in the literature, the most common of which is the Beers list of inappropriate medications in the elderly. However, many of these tools are not appropriate for the Australian healthcare environment without modification and validation, and there appears to be a need for a tool based on Australian data.

OBJECTIVE

To develop a list of prescribing indicators for elderly (aged >65 years) Australians based on the most frequent medications prescribed to Australians, and the most frequent medical conditions for which elderly Australians consult medical practitioners.

METHOD

The most common reasons for elderly Australians to seek or receive healthcare were cross-referenced with the 50 highest-volume Pharmaceutical Benefits Scheme medications prescribed to Australians in 2006 to develop prescribing indicators in the elderly using Australian medication and medical condition information resources.

RESULTS

Forty-eight prescribing indicators were identified, consisting mainly of optimum as well as inappropriate medication choices for a large number of common medical conditions in the elderly.

CONCLUSION

A prescribing indicators tool was developed. This tool is envisaged as forming an important part of the medication review process, which is aimed at addressing the common problem of adverse medication-related events in elderly Australians.

Potentially inappropriate medication use in elderly patients receiving home health care: a retrospective data analysis

BACKGROUND

Previous medication management research has focused on hospital and long-term care facility settings, where drug-utilization reviews are used to reduce medication errors. Patients receiving home health care (HHC) are without the benefit of systematic drug-utilization reviews.

OBJECTIVE

The purpose of this study was to review medication use in elderly patients receiving HHC to identify the prevalence of potentially inappropriate medication (PIM) use, dangerous drug interactions (DDIs), and other patterns of medication use.

METHODS

This retrospective chart review was conducted using data from Medicare recipients aged > or =65 years who were patients of Scott & White Memorial Hospital and Clinic, Scott, Sherwood and Brindley Foundation, Temple, Texas, in 2002. Pharmacists compiled medication profiles based on admissions data. PIM use was identified using the Beers criteria. DDIs were identified using the Multidisciplinary Medication Management Project criteria. Polyphsarmsacy was identified in patients receiving > or =9 medications.

RESULTS

Data from 786 patients were included (mean [SD] age, 78 [7] years [range, 65-100 years; median, 78 years]; 36% men; 86% white; and 53% admitted to HHC after a hospital stay). The mean (SD) number of medications was 8.0 (3.7), with 39% of patients receiving polypharmacy. PIM use was identified in 31% of patients. DDIs were identified in 10% of patients, with a significantly higher prevalence in men (P < 0.01). Rates of PIM use and DDIs were 37% and 20%, respectively, in patients receiving polypharmacy.

CONCLUSION

In this retrospective data analysis in this population of elderly patients receiving HHC in 2002, PIM and DDI were prevalent, and polypharmacy was associated with increased rates of PIM use and DDIs.

Prevalence of inappropriate medication using Beers criteria in Japanese long-term care facilities

Background

The prevalence and risk factors of potentially inappropriate medication use among the elderly patients have been studied in various countries, but because of the difficulty of obtaining data on patient characteristics and medications they have not been studied in Japan.

Methods

We conducted a retrospective cross-sectional study in 17 Japanese long-term care (LTC) facilities by collecting data from the comprehensive MDS assessment forms for 1669 patients aged 65 years and over who were assessed between January and July of 2002. Potentially inappropriate medications were identified on the basis of the 2003 Beers criteria.

Results

The patients in the sample were similar in terms of demographic characteristics to those in the national survey. Our study revealed that 356 (21.1%) of the patients were treated with potentially inappropriate medication independent of disease or condition. The most commonly inappropriately prescribed medication was ticlopidine, which had been prescribed for 107 patients (6.3%). There were 300 (18.0%) patients treated with at least 1 inappropriate medication dependent on the disease or condition. The highest prevalence of inappropriate medication use dependent on the disease or condition was found in patients with chronic constipation. Multiple logistic regression analysis revealed psychotropic drug use (OR = 1.511), medication cost of per day (OR = 1.173), number of medications (OR = 1.140), and age (OR = 0.981) as factors related to inappropriate medication use independent of disease or condition. Neither patient characteristics nor facility characteristics emerged as predictors of inappropriate prescription.

Conclusion

The prevalence and predictors of inappropriate medication use in Japanese LTC facilities were similar to those in other countries.

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults

BACKGROUND

Use of potentially inappropriate medications is common in nursing facilities (NFs), in which frail older adults are particularly vulnerable to adverse drug effects. The community-dwelling elderly are generally healthier and have lower overall rates of medication use, but their prescribed medications are not subjected to the same degree of regulatory scrutiny as those of residents in NFs. Frail elderly (FE) adults who are nursing home eligible but are receiving home- and community-based services (HCBS) constitute a distinct group sharing a high disease burden and high levels of medication use with the NF population.

OBJECTIVE

The goal of this study was to examine the relationship between disease burden and inappropriate medication use in these 3 cohorts, with adjustment for demographic and clinical differences.

METHODS

We performed retrospective analyses of Medicaid claims data from May 2000 through April 2001 to identify 3 cohorts of Kansas Medicaid beneficiaries: community-dwelling older adults (the ambulatory cohort); persons receiving HCBS through the Kansas Frail Elderly Program (the FE cohort); and elderly NF residents (the NF cohort). Demographic, clinical, and medication data were extracted from the Medicaid claims data. Unconditionally inappropriate medications were identified using the 1997 Beers criteria. The Cumulative Illness Rating Scale for Geriatrics was used to calculate the disease burden sum, classified as 0 or 1, 2 or 3, 4 or 5, or > or =6 disease categories. Odds ratios for inappropriate medication use at each level of disease burden in each cohort were derived using multivariable models adjusted for demographic and clinical factors, including overall level of medication use.

RESULTS

The final sample included 3185 persons in the 3 cohorts (1163 ambulatory, 858 FE, 1164 NF). Inappropriate medication use was determined to have occurred in 21%, 48%, and 38% of the respective cohorts and was highest in FE cohort members with the greatest disease burden (61%). For the ambulatory and FE cohorts, inappropriate medication use rose as the disease burden increased. The same was not observed in the NF cohort, in whom rates of inappropriate medication use showed little variation regardless of disease burden.

CONCLUSIONS

The relationship between disease burden and inappropriate medication use varied by setting. Those members of the FE cohort with the highest disease burden had the greatest risk for inappropriate medication use.

The Authority/Pharmacotherapy Care model: an explanatory model of the drug use process in primary care

BACKGROUND

Drug utilization studies have proliferated and many variants exist. Few models have been presented that account for all of the different types of studies and approaches.

PURPOSE

This article presents the Authority/Pharmacotherapy Care model, a structural-functional model of the drug use process that illustrates the factors involved in drug utilization and the relationships between factors. The concepts of authority and transfer of authority underlie the relationships.

METHODS

The drug use process is presented at the microlevel from the viewpoint of an individual who requires treatment with prescription drugs. The various categories of activity/authority (ie, level of patient care) are those of the individual, physician, pharmacist, patient, and drug. Influencing factors, both internal and external, impact upon each level of care. Three aspects must be considered at each level, which are structures, processes, and outcomes, according to Donabedian's model.

RESULTS

The result is a structural-functional model that depicts all of the major points in the drug use process, which might be used as a framework to categorize drug utilization studies.

CONCLUSIONS

This model may be used to represent the drug use process, identify the types of drug use studies, determine pertinent factors involved in the process, understand the relationships between factors, and help in evaluating drug use.

The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence

OBJECTIVES

To provide an updated review of the literature on the extent of and risk factors for inappropriate prescribing in the elderly.

METHODS

A comprehensive review of the most recent publications in English assessing inappropriate prescriptions for elderly patients in the United States using the 1997 version of the Beers explicit criteria. The reviewed articles were obtained via an electronic search of the MEDLINE database for articles published between 1997 and 2001 and a manual search through major journals for articles referenced in those located through MEDLINE. Search terms were Beers, explicit criteria, inappropriate drug use, prescribing, prescriptions, medication use, elderly, and health outcomes.

RESULTS

Using the updated explicit criteria, a total of 11 empirical studies were identified, all of which were conducted using observational surveys or claims databases. The reported prevalence of elderly patients using at least one inappropriately prescribed drug ranged from a high of 40% for a population of nursing home patients to 21.3% for community-dwelling patients over age 65. Propoxyphene, amitriptyline, long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam, flurazepam), and dipyridamole are among the most commonly occurring inappropriate prescriptions. With a few exceptions, the most significant patient-related predictors of inappropriate prescribing include polypharmacy, poor health status, and female sex. Other potential risk factors include prescribing location, ethnicity, age, and referral status. Limited evidence was found of increased health care utilization and poorer quality of life resulting from inappropriate drug use in the elderly in Medicare health maintenance organization and emergency department settings.

CONCLUSION

The prevalence of inappropriate prescribing remains alarmingly high for the elderly in general and for nursing home residents in particular. This review identified some attributes of the elderly groups most vulnerable to inappropriate prescribing. Future research should document more evidence regarding the adverse impact of inappropriate prescribing on total health care costs and patient health outcomes.

Improving medication use in newly admitted home healthcare patients: a randomized controlled trial

OBJECTIVES

To test the efficacy of a medication use improvement program developed specifically for home health agencies. The program addressed four medication problems identified by an expert panel: unnecessary therapeutic duplication, cardiovascular medication problems, use of psychotropic drugs in patients with possible adverse psychomotor or adrenergic effects, and use of nonsteroidal antiinflammatory drugs (NSAIDs) in patients at high risk of peptic ulcer complications. It used a structured collaboration between a specially trained clinical pharmacist and the patients' home-care nurses to improve medication use.

DESIGN

Parallel-group, randomized controlled trial.

SETTING

Two of the largest home health agencies in the United States.

PARTICIPANTS

Study subjects were consenting Medicare patients aged 65 and older admitted to participating agency offices from October 1996 through September 1998, with a projected home healthcare duration of at least 4 weeks and at least one study medication problem.

INTERVENTION

Qualifying patients were randomized to usual care or usual care with the medication improvement program.

MEASUREMENTS

Medication use was measured during an in-home interview, with container inspection at baseline and at follow-up (between 6 and 12 weeks) by interviewers unaware of treatment assignment. The trial endpoint was the proportion of patients with medication use improvement according to predefined criteria at follow-up.

RESULTS

There were 259 randomized patients with completed follow-up interviews: 130 in the intervention group and 129 with usual care. Medication use improved for 50% of intervention patients and 38% of control patients, an attributable improvement of 12 patients per 100 (95% confidence interval (CI) = 0.0-24.0, P =.051). The intervention effect was greatest for therapeutic duplication, with improvement for 71% of intervention and 24% of control patients, an attributable improvement of 47 patients per 100 (95% CI = 20-74, P =.003). Use of cardiovascular medications also improved more frequently in intervention patients: 55% vs 18%, attributable improvement 37 patients per 100 (95% CI = 9-66, P =.017). There were no significant improvements for the psychotropic medication or NSAID problems. There was no evidence of adverse intervention effects: new medication problems, more agency nurse visits, or increased duration of home health care.

CONCLUSIONS

A program congruent with existing personnel and practices of home health agencies improved medication use in a vulnerable population and was particularly effective in reducing therapeutic duplication.

Possible medication errors in home healthcare patients

OBJECTIVE

To determine the frequency of possible medication errors in a population of older home healthcare patients according to expert panel objective criteria.

DESIGN

A cross-sectional survey.

SETTING

Two of the largest urban home healthcare agencies in the United States.

PARTICIPANTS

Home healthcare patients age 65 and older admitted to selected offices of these agencies between October 1996 and September 1998.

MEASUREMENTS

We used two sets of consensus-based expert panel criteria to define possible medication errors. The Home Health Criteria identify patients with patterns of medication use and signs and symptoms that indicate sufficient likelihood of a medication-related problem to warrant reevaluating the patient. The Beers criteria identify medications that experts have deemed generally inappropriate for older patients.

RESULTS

The 6,718 study subjects took a median of five drugs; 19% were taking nine or more medications. A possible medication error was identified for 19% of patients according to Home Health Criteria, 17% according to the Beers criteria, and 30% according to either. Possible errors increased linearly with number of medications taken. When patients taking one to three medications were compared with those taking nine or more drugs, the percentages with possible errors were, respectively, 10% and 32% for the Home Health Criteria, 8% and 32% for the Beers criteria, and 16% and 50% for both.

CONCLUSION

Nearly one-third of the home healthcare patients surveyed had evidence of a potential medication problem or were taking a drug considered inappropriate for older people. More-effective methods are needed to improve medication use in this vulnerable population.