1
|
Barnay T, Baudot FO. Work accident effect on the use of psychotropic drugs: the case of benzodiazepines. HEALTH ECONOMICS REVIEW 2023; 13:48. [PMID: 37872453 PMCID: PMC10594863 DOI: 10.1186/s13561-023-00464-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 10/11/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND A work accident constitutes a shock to health, likely to alter mental states and affect the use of psychotropic drugs. We focus on the use of benzodiazepines, which are a class of drugs commonly used to treat anxiety and insomnia. Prolonged use can lead to dependence. Our objective is to determine the extent to which work accidents lead to benzodiazepine use and overuse (i.e. exceedance of medical guidelines). METHOD We use a two-step selection model (the Heckman method) based on data from the French National Health Data System (Système National des Données de Santé, SNDS). Our study sample includes all general plan members who experienced a single work accident in 2016 (and not since 2007). This sample includes 350,000 individuals in the work accident group and more than 1.1 million people randomly drawn from the population without work accidents from 2007 to 2017 (the non-work accident group). RESULTS The occurrence of a work accident leads to an increase in benzodiazepine use and overuse the following year. The selection model shows a clear influence of the accident on the use probability (+ 39%), but a very slight impact on the risk of overuse among users (+ 1.7%), once considered the selection effect. The effect on overuse risk is higher for more severe accidents and among women. CONCLUSION The increase in the risk of benzodiazepine overuse is due to an increase in the likelihood of using benzodiazepines after a work accident that leads to overuse, rather than an increase in likelihood of overuse among people who use benzodiazepines. Results call for targeting the first-time prescription to limit the risk of overuse after a work accident.
Collapse
Affiliation(s)
- Thomas Barnay
- ERUDITE, Université Paris-Est Créteil, 61 Avenue du Général de Gaulle, Créteil, 94010, France
| | - François-Olivier Baudot
- ERUDITE, Université Paris-Est Créteil, 61 Avenue du Général de Gaulle, Créteil, 94010, France.
- Direction de la Stratégie, des Études et des Statistiques, Caisse Nationale de l'Assurance Maladie, 50 Avenue du Professeur André Lemierre, Paris, 75986, France.
| |
Collapse
|
2
|
Silverstein WK, Lin Y, Dharma C, Croxford R, Cheung MC. Physician Factors Associated with Inappropriate Vitamin B12 Prescribing in Ontario, Canada. J Gen Intern Med 2021; 36:2888-2890. [PMID: 32909232 PMCID: PMC8390716 DOI: 10.1007/s11606-020-06185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/24/2020] [Indexed: 10/23/2022]
Affiliation(s)
- William K Silverstein
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada. .,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Yulia Lin
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology & Hematology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | | | | | - Matthew C Cheung
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology & Hematology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| |
Collapse
|
3
|
Achterhof AB, Rozsnyai Z, Reeve E, Jungo KT, Floriani C, Poortvliet RKE, Rodondi N, Gussekloo J, Streit S. Potentially inappropriate medication and attitudes of older adults towards deprescribing. PLoS One 2020; 15:e0240463. [PMID: 33104695 PMCID: PMC7588126 DOI: 10.1371/journal.pone.0240463] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/26/2020] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Multimorbidity and polypharmacy are current challenges when caring for the older population. Both have led to an increase of potentially inappropriate medication (PIM), illustrating the need to assess patients' attitudes towards deprescribing. We aimed to assess the prevalence of PIM use and whether this was associated with patient factors and willingness to deprescribe. METHOD We analysed data from the LESS Study, a cross-sectional study on self-reported medication and on barriers and enablers towards the willingness to deprescribe (rPATD questionnaire). The survey was conducted among multimorbid (≥3 chronic conditions) participants ≥70 years with polypharmacy (≥5 long-term medications). A subset of the Beers 2019 criteria was applied for the assessment of medication appropriateness. RESULTS Data from 300 patients were analysed. The mean age was 79.1 years (SD 5.7). 53% had at least one PIM (men: 47.8%%, women: 60.4%%; p = 0.007). A higher number of medications was associated with PIM use (p = 0.002). We found high willingness to deprescribe in both participants with and without PIM. Willingness to deprescribe was not associated with PIM use (p = 0.25), nor number of PIMs (p = 0.81). CONCLUSION The willingness of older adults with polypharmacy towards deprescribing was not associated with PIM use in this study. These results suggest that patients may not be aware if they are taking PIMs. This implies the need for raising patients' awareness about PIMs through education, especially in females, in order to implement deprescribing in daily practice.
Collapse
Affiliation(s)
- Alexandra B. Achterhof
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Zsofia Rozsnyai
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
- Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Katharina Tabea Jungo
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Carmen Floriani
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| | | | - Nicolas Rodondi
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, section Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sven Streit
- Institute of Primary Health Care Bern (BIHAM), University of Bern, Bern, Switzerland
| |
Collapse
|
4
|
Black CD, Thavorn K, Coyle D, Bjerre LM. The Health System Costs of Potentially Inappropriate Prescribing: A Population-Based, Retrospective Cohort Study Using Linked Health Administrative Databases in Ontario, Canada. PHARMACOECONOMICS - OPEN 2020; 4:27-36. [PMID: 31218653 PMCID: PMC7018908 DOI: 10.1007/s41669-019-0143-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The aim of this study was to determine the health system costs from hospitalizations, emergency department (ED) visits, and medications due to potentially inappropriate prescribing (PIP) in Ontario, Canada, at the population-level. METHODS A retrospective cohort of individuals ≥ 66 years of age and prescribed at least one medication from April 2002 to March 2015 was identified using linked population-level health administrative databases from Ontario, Canada. Patients were identified as having PIP or no PIP by applying a subset of the Screening Tool of Older Persons' Potentially Inappropriate Prescribing/Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria. The number of days spent in hospital, new medications prescribed, and ED visits in the 90 days following PIP or patient index date were captured, as well as the total costs from each of these health services. Count regression models were used to generate incidence rate ratios (IRRs) for each outcome given the presence of PIP versus no PIP and combined with the prevalence of PIP to generate population attributable fractions (PAFs). The PAF was then multiplied by the cost for each health service to obtain the costs attributable to PIP in the whole cohort, and by age and sex. RESULTS PIP was associated with an increased rate of hospitalization (IRR 2.77, 95% confidence interval [CI] 2.72-2.82), ED visits (IRR 1.87, 95% CI 1.82-1.92), and newly prescribed medications (IRR 1.13, 95% CI 1.13-1.14), resulting in PAFs of 55.7, 37.9, and 5.0% for each outcome, respectively. PIP was associated with 38.8% of the total spent on these healthcare services ($1.22 billion) in the 90 days after PIP. Costs attributable to PIP decreased with age despite increasing prevalence. CONCLUSIONS PIP in older adults is a significant source of health system costs from healthcare service use beyond medication costs, with a significant portion of hospitalizations and ED visit costs attributable to PIP. Future work should focus on identifying strategies and priorities for intervention.
Collapse
Affiliation(s)
- Cody D Black
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, 501 Smyth Box 511, Ottawa, ON, K1H 8L6, Canada
- ICES uOttawa, ICES, Administrative Services Building, 1st Floor, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Room 101, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
| | - Lise M Bjerre
- ICES uOttawa, ICES, Administrative Services Building, 1st Floor, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada.
- Department of Family Medicine, University of Ottawa, 600 Peter Morand Cresc. Suite 201, Ottawa, ON, K1G 5Z3, Canada.
- Bruyère Research Institute, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada.
| |
Collapse
|
5
|
Black CD, Thavorn K, Coyle D, Smith G, Bjerre LM. Health system costs of potentially inappropriate prescribing in Ontario, Canada: a protocol for a population-based cohort study. BMJ Open 2018; 8:e021727. [PMID: 29950472 PMCID: PMC6020945 DOI: 10.1136/bmjopen-2018-021727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Adverse drug events (ADEs) are common in older persons and contribute significantly to emergency department visits, hospitalisations and mortality. ADEs are often due to potentially inappropriate prescriptions (PIP) or potentially inappropriate omissions (PIO), and are avoidable if inappropriate prescriptions or omissions are identified and prevented. Identifying PIP/PIO at the population level through the application of PIP/PIO assessment tools to health administrative data can provide a unique opportunity to assess the economic burden of PIP/PIO on the healthcare system beyond medication costs which is yet to be done. The objective of this study is to assess the economic burden associated with PIP/PIO and to estimate the incremental costs associated with distinct PIP/PIO in the province of Ontario. METHODS AND ANALYSIS We will conduct a retrospective cohort study using Ontario's health administrative databases. Eligible patients aged 66 years and older who were prescribed at least one medication between 1 April 2003 and 31 March 2014 (approximately 2.4 million patients) will be included. Population attributable fraction methodology will be used to assess the overall burden of PIP in Ontario, while regression analyses will be used to estimate the incremental costs of having specific PIP criteria and aid in prioritising targets for intervention. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Board at Sunnybrook Health Sciences Centre, Toronto, Canada. Dissemination will occur via publication, presentation at national and international conferences, and knowledge exchange with various stakeholders.
Collapse
Affiliation(s)
- Cody D Black
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Douglas Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Glenys Smith
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
| | - Lise M Bjerre
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- ICES uOttawa, Institute for Clinical Evaluative Sciences, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
6
|
Niznik J, Zhao X, Jiang T, Hanlon JT, Aspinall SL, Thorpe J, Thorpe C. Anticholinergic Prescribing in Medicare Part D Beneficiaries Residing in Nursing Homes: Results from a Retrospective Cross-Sectional Analysis of Medicare Data. Drugs Aging 2018; 34:925-939. [PMID: 29214512 DOI: 10.1007/s40266-017-0502-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Prescribing of medications with anticholinergic properties in older nursing home residents is relatively common, despite an association with an increased risk for falls, delirium, and other outcomes. Few studies have investigated what factors influence different levels of prescribing of these agents. OBJECTIVES The primary objective was to identify factors associated with low- and high-level anticholinergic burden in nursing home residents. A secondary objective was to examine in detail the contribution of different medications to low versus high burden to aid in determining which drugs to target in interventions. METHODS This was a retrospective, cross-sectional analysis of a national sample of 2009-2010 Medicare Part A and B claims, Part D prescription drug events, and Minimum Data Set (MDS) v2.0 assessments. The cohort included 4730 Medicare beneficiaries aged ≥ 65 years with continuous Medicare Parts A, B, and D enrollment, admitted for non-skilled stays of ≥ 14 days between 1 January 2010 and 30 September 2010. Anticholinergic burden was defined using the Anticholinergic Cognitive Burden (ACB) scale. Medication scores were summed at the patient level and categorized as high (score ≥ 3), low (score 1-2), or none. Baseline predisposing factors (age, sex, race/ethnicity), enabling factors (prior year hospitalization, emergency department, primary care, specialist visits; region; Medicaid/low-income subsidy), and medical need factors (dementia severity, anti-dementia medication, Charlson co-morbidity index [CCI], select comorbidities) were evaluated for association with anticholinergic burden using multinomial logistic regression. RESULTS Overall, 29.6% of subjects had a high anticholinergic burden and 35.2% had a low burden. High burden was most often (72%) due to one highly anticholinergic medication rather than a cumulative effect. In adjusted analyses, factors associated with increased risk of both low and high anticholinergic burden included comorbidity, antidementia medication, depression, hypertension, and prior year hospitalization. Older age was associated with decreased odds of high anticholinergic burden. Urinary incontinence and prior year specialist visit were associated with increased odds of high anticholinergic burden. Severe and nonsevere dementia were associated with decreased odds of low burden but increased odds of high burden. CONCLUSION Almost two-thirds of nursing home patients have some degree of anticholinergic burden. Several medical need variables are significantly associated with increased risk for low and high anticholinergic burden. Interventions should be developed to optimize prescribing for residents at increased risk of receiving medications with anticholinergic properties. Future study is needed to evaluate the difference in the risk of adverse outcomes associated with various levels of anticholinergic burden.
Collapse
Affiliation(s)
- Joshua Niznik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA. .,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA. .,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, USA
| | - Tao Jiang
- University of Pittsburgh, Pittsburgh, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, USA.,Geriatric Research Education and Clinical Center, Pittsburgh, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,VA Center for Medication Safety, Pittsburgh, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Joshua Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| | - Carolyn Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA, USA.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, USA
| |
Collapse
|
7
|
Health status and drug use 1 year before and 1 year after skilled nursing home admission during the first quarter of 2013 in France: a study based on the French National Health Insurance Information System. Eur J Clin Pharmacol 2017; 74:109-118. [PMID: 28975381 DOI: 10.1007/s00228-017-2343-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 09/25/2017] [Indexed: 01/24/2023]
Abstract
PURPOSE Changes in prescribing practices following skilled nursing home (SNH) admission have not been clearly described in France. The study aimed to evaluate health status and drug use 1 year before and 1 year after admission to SNH. METHOD People ≥ 65 years old admitted to SNH in the first quarter of 2013, covered by the national health insurance general scheme (69% of the population of this age) and still alive 1 year after admission were identified in a specific database (Resid-ehpad). Linking with the National Health Insurance Information System (SNIIRAM) allowed analysis of their health status, identified by algorithms, and changes in their use of reimbursed drugs. RESULTS In a population of 11,687 residents (mean age: 86 years, women: 76%), the most prevalent diseases were cardiovascular/neurovascular diseases (45%) and dementias (35%). The use of certain chronic treatments (≥ 3 reimbursements/year) increased significantly (p < 0.001) after nursing home admission: antidepressants: 34 to 46%, anxiolytics: 32 to 42%, hypnotics/sedatives: 18 to 24%, antipsychotics: 10 to 21% (14 to 30% in patients with dementia). The use of lipid-modifying agents and agents acting on the renin-angiotensin system decreased significantly (33 to 24% and 44 to 37%, respectively, p < 0.001). The use of antibacterials (≥ 1 reimbursement/year) increased also significantly (p < 0.001): 45 to 61%, including quinolones (13 to 20%) and third-generation cephalosporins (10 to 18%). CONCLUSION These results reveal increased prescribing of psychotropic drugs and antibacterials in SNH, requiring the development or sustainability of actions designed to improve prescribing practices in older people targeted by these treatments.
Collapse
|
8
|
Sanders LMJ, Hortobágyi T, van Staveren G, Taxis K, Boersma F, Klein HC, Bossers WJR, Blankevoort CG, Scherder EJA, Van der Zee EA, van Heuvelen MJG. Relationship between drug burden and physical and cognitive functions in a sample of nursing home patients with dementia. Eur J Clin Pharmacol 2017; 73:1633-1642. [PMID: 28921380 PMCID: PMC5684292 DOI: 10.1007/s00228-017-2319-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 08/03/2017] [Indexed: 11/24/2022]
Abstract
Purpose The Drug Burden Index (DBI) is a tool to quantify the anticholinergic and sedative load of drugs. Establishing functional correlates of the DBI could optimize drug prescribing in patients with dementia. In this cross-sectional study, we determined the relationship between DBI and cognitive and physical functions in a sample of patients with dementia. Methods Using performance-based tests, we measured physical and cognitive functions in 140 nursing home patients aged over 70 with all-cause dementia. We also determined anticholinergic DBI (AChDBI) and sedative DBI (SDBI) separately and in combination as total drug burden (TDB). Results Nearly one half of patients (48%) used at least one DBI-contributing drug. In 33% of the patients, drug burden was moderate (0 < TDB < 1) whereas in 15%, drug burden was high (TDB ≥ 1). Multivariate models yielded no associations between TDB, AChDBI, and SDBI, and physical or cognitive function (all p > 0.05). Conclusions A lack of association between drug burden and physical or cognitive function in this sample of patients with dementia could imply that drug prescribing is more optimal for patients with dementia compared with healthy older populations. However, such an interpretation of the data warrants scrutiny as several dementia-related factors may confound the results of the study. Electronic supplementary material The online version of this article (10.1007/s00228-017-2319-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- L M J Sanders
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - T Hortobágyi
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - G van Staveren
- Emergency Department, Medical Center Leeuwarden, Henri Dunantweg 2, 8934 AD, Leeuwarden, The Netherlands
| | - K Taxis
- Groningen Research Institute of Pharmacy (GRIP), University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - F Boersma
- Department of General Practice, Elderly Care Medicine, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - H C Klein
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - W J R Bossers
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - C G Blankevoort
- Department of Geriatric Psychiatry, Lentis, Hereweg 80, 9725 AG, Groningen, The Netherlands
| | - E J A Scherder
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,Department of Clinical Neuropsychology, VU University Amsterdam, Van der Boechorstraat 1, 1081 BT, Amsterdam, The Netherlands
| | - E A Van der Zee
- Groningen Institute for Evolutionary Life Sciences (GELIFES), University of Groningen, Nijenborgh 7, 9747 AG, Groningen, The Netherlands
| | - M J G van Heuvelen
- Center for Human Movement Sciences, University Medical Center Groningen, University of Groningen, Antonius Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| |
Collapse
|
9
|
Karlsson S, Rahm Hallberg I, Midlöv P, Fagerström C. Trends in treatment with antipsychotic medication in relation to national directives, in people with dementia - a review of the Swedish context. BMC Psychiatry 2017; 17:251. [PMID: 28705243 PMCID: PMC5513361 DOI: 10.1186/s12888-017-1409-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 06/29/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The aim of this study was to explore trends in treatment with antipsychotic medication in Swedish dementia care in nursing homes as reported in the most recent empirical studies on the topic, and to relate these trends to directives from the national authorities. METHODS The study included two scoping review studies based on searches of electronic databases as well as the Swedish directives in the field. RESULTS During the past decade, directives have been developed for antipsychotic medication in Sweden. These directives were generic at first, but have become increasingly specific and restrictive with time. The scoping review showed that treatment with antipsychotic drugs varied between 6% and 38%, and was higher in younger older persons and in those with moderate cognitive impairment and living in nursing homes for people with dementia. A decreasing trend in antipsychotic use has been seen over the last 15 years. CONCLUSIONS Directives from the authorities in Sweden may have had an impact on treatment with antipsychotic medication for people with dementia. Treatment with antipsychotic medication has decreased, while treatment with combinations of psychotropic medications is common. National directives may possibly be even more effective, if applied in combination with systematic follow-ups.
Collapse
Affiliation(s)
- Staffan Karlsson
- Department of Health Sciences, Lund University, -221 00 Lund, SE Sweden
- School of Health and Welfare, Halmstad University, -301 18 Halmstad, SE Sweden
| | | | - Patrik Midlöv
- Department of Clinical Sciences, Malmo, Lund University, -221 00 Lund, SE Sweden
| | - Cecilia Fagerström
- Blekinge Centre of Competence, -371 81 Karlskrona, SE Sweden
- Department of Health and Caring Sciences, Linnaeus University, -391 82 Kalmar, SE Sweden
| |
Collapse
|
10
|
Morin L, Laroche ML, Texier G, Johnell K. Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review. J Am Med Dir Assoc 2016; 17:862.e1-9. [PMID: 27473899 DOI: 10.1016/j.jamda.2016.06.011] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/06/2016] [Accepted: 06/08/2016] [Indexed: 01/07/2023]
Abstract
IMPORTANCE As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided. OBJECTIVES To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents. EVIDENCE REVIEW We searched in PubMed and EMBASE databases (1990-2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. FINDINGS A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%-49.1%], increasing from 30.3% in studies conducted during 1990-1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5-55.5) than those reported in North America (26.8%, 95% CI 16.5-37.1) or in other countries (29.8%, 95% CI 19.3-40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use. CONCLUSIONS AND RELEVANCE This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.
Collapse
Affiliation(s)
- Lucas Morin
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden.
| | - Marie-Laure Laroche
- University Hospital of Limoges, Service de Pharmacologie, Toxicologie et Pharmacovigilance, Limoges, France; Université de Limoges, Faculté de Médecine, Limoges, France
| | - Géraldine Texier
- University Hospital of Rennes, Palliative Care Support Team, Rennes, France
| | - Kristina Johnell
- Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| |
Collapse
|
11
|
Murphy Y, Wilson E, Goldner EM, Fischer B. Benzodiazepine Use, Misuse, and Harm at the Population Level in Canada: A Comprehensive Narrative Review of Data and Developments Since 1995. Clin Drug Investig 2016; 36:519-30. [DOI: 10.1007/s40261-016-0397-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
12
|
Bjerre LM, Ramsay T, Cahir C, Ryan C, Halil R, Farrell B, Thavorn K, Catley C, Hawken S, Gillespie U, Manuel DG. Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases. BMJ Open 2015; 5:e010146. [PMID: 26608642 PMCID: PMC4663446 DOI: 10.1136/bmjopen-2015-010146] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to population-wide health administrative data could provide an opportunity to assess the impact of PIP on individual patients as well as on the healthcare system. This would open new possibilities for interventions to monitor and optimise medication management on a broader, population-level scale. METHODS AND ANALYSIS The aim of this study is to describe the occurrence of PIP in Ontario's older population (aged 65 years and older), and to assess the health outcomes and health system costs associated with PIP-more specifically, the association between PIP and the occurrence of ED visits, hospitalisations and death, and their related costs. This will be done within the framework of a population-based retrospective cohort study using Ontario's large health administrative and population databases. Eligible patients aged 66 years and older who were issued at least 1 prescription between 1 April 2003 and 31 March 2014 (approximately 2 million patients) will be included. ETHICS AND DISSEMINATION Ethical approval was obtained from the Ottawa Health Services Network Ethical Review Board and from the Bruyère Research Institute Ethics Review Board. Dissemination will occur via publication, presentation at national and international conferences, and ongoing exchanges with regional, provincial and national stakeholders, including the Ontario Drug Policy Research Network and the Ontario Ministry of Health and Long-Term Care. TRIAL REGISTRATION NUMBER Registered with clinicaltrials.gov (registration number: NCT02555891).
Collapse
Affiliation(s)
- Lise M Bjerre
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy Ramsay
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Catriona Cahir
- Economic and Social Research Institute, Trinity College Dublin, Dublin, Ireland
| | - Cristín Ryan
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Roland Halil
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Barbara Farrell
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
| | - Kednapa Thavorn
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Steven Hawken
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Douglas G Manuel
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES@ uOttawa, Ottawa, Ontario, Canada
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
13
|
Roughead EE, Gilbert AL, Woodward MC. Medication Use by Australian War Veterans in Residential Aged-Care Facilities. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2008.tb00788.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Andrew L Gilbert
- Sansom Institute, School of Pharmacy and Medical Sciences; University of South Australia
| | | |
Collapse
|
14
|
Santos APAL, Silva DT, Alves-Conceição V, Antoniolli AR, Lyra DP. Conceptualizing and measuring potentially inappropriate drug therapy. J Clin Pharm Ther 2015; 40:167-76. [PMID: 25682702 DOI: 10.1111/jcpt.12246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice. METHODS A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT. RESULTS AND DISCUSSION From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1 = 0·479) and substantial for abstracts (κ2 = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature. WHAT IS NEW AND CONCLUSION This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.
Collapse
Affiliation(s)
- A P A L Santos
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Pharmacy College, Federal University of Sergipe, São Cristóvão, Brazil
| | | | | | | | | |
Collapse
|
15
|
Maxwell CJ, Stock K, Seitz D, Herrmann N. Persistence and adherence with dementia pharmacotherapy: relevance of patient, provider, and system factors. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2014; 59:624-31. [PMID: 25702361 PMCID: PMC4304581 DOI: 10.1177/070674371405901203] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This paper provides a comprehensive review of studies examining adherence and (or) persistence with dementia pharmacotherapy during the past decade, including a summary of the key patient-, drug-, system-, and provider-level factors associated with these measures. Estimates of adherence and 1-year persistence to these drugs have ranged from 34% to 94% and 35% to 60%, respectively. Though many studies reported nonsignificant associations, there are data suggesting that patient age, sex, ethnoracial background, socioeconomic status, and region-specific reimbursement criteria, as well as the extent and quality of interactions among patients, caregivers, and providers, may influence persistence with pharmacotherapy. As many studies relied on administrative data, limited information was available regarding the relevance of patient's cognitive and functional status or the importance of caregiver involvement or assistive devices to adherence or persistence.
Collapse
Affiliation(s)
- Colleen J Maxwell
- Professor, Schools of Pharmacy and Public Health & Health Systems, University of Waterloo, Waterloo, Ontario
| | - Kathryn Stock
- Student, School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario
| | - Dallas Seitz
- Assistant Professor, Division of Geriatric Psychiatry, Queen's University and Providence Care, Kingston, Ontario
| | - Nathan Herrmann
- Head, Division of Geriatric Psychiatry, Sunnybrook Health Sciences Centre, Toronto, Ontario
| |
Collapse
|
16
|
Maxwell CJ, Vu M, Hogan DB, Patten SB, Jantzi M, Kergoat MJ, Jetté N, Bronskill SE, Heckman G, Hirdes JP. Patterns and determinants of dementia pharmacotherapy in a population-based cohort of home care clients. Drugs Aging 2014; 30:569-85. [PMID: 23605786 DOI: 10.1007/s40266-013-0083-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Little is known about the needs of older home care clients with dementia or their key quality of care issues, including their use of pharmacotherapy for Alzheimer's disease. OBJECTIVES The objectives of this study were to (1) describe the sociodemographic, psychosocial, and health characteristics of clients with dementia (relative to two control subgroups) from a population-based home care cohort; and, (2) determine the distribution and associated characteristics of cholinesterase inhibitor (ChEI) and/or memantine use among dementia clients overall and according to medication class, comorbid illness, and year of assessment. METHODS This cross-sectional study included all home care clients aged 50 years or older assessed with the Resident Assessment Instrument-Home Care (RAI-HC) in Ontario, Canada from January 2003 to December 2010. Multivariable logistic regression models were used to identify factors associated with receiving a dementia medication (a ChEI and/or memantine). RESULTS There were 104,802 (21.5 %) clients with a diagnosis of dementia, 92,529 (18.9 %) cognitively impaired clients without a dementia diagnosis, and 290,929 (59.6 %) cognitively intact clients. Relative to the comparison groups, dementia clients were more likely to have reported conflicts with others, a distressed caregiver, greater levels of cognitive and functional impairment, and to exhibit wandering, aggressive behaviors, anxiety, hallucinations or delusions, and swallowing problems. Approximately half of dementia clients were taking a dementia medication, most commonly donepezil. Characteristics most strongly associated with use of ChEI monotherapy included age greater than 64 (especially 75-84), absence of economic barriers, availability of a primary caregiver, year of assessment, moderate to severe cognitive impairment, relative independence in function, health stability, no depressive symptoms or hallucinations/delusions, no recent hospitalization, use of at least 9 medications, the absence of chronic health and neurological conditions, and the use of an antipsychotic or antidepressant. For combination therapy, strong positive associations were observed for younger age, year of assessment, increasing cognitive impairment, presence of a primary caregiver, male sex, absence of economic barriers, use of at least 9 medications, and various indicators of positive health status (e.g., stability in health, absence of chronic health and neurological conditions, and no recent hospitalization). The percentage of clients receiving ChEIs increased with cognitive impairment scores but declined slightly at the highest level of impairment, whereas the percentage receiving memantine increased with cognitive impairment level. The number and percentage of dementia clients receiving any pharmacotherapy increased during the study interval. CONCLUSIONS We observed a relatively high prevalence of dementia-specific pharmacotherapy among Ontario long-stay home care clients as well as significant variation in utilization patterns by select sociodemographic, functional, and clinical characteristics, and over time. While physicians generally followed recommended guidelines regarding appropriate dementia pharmacotherapy, continued efforts to monitor practice patterns are required among vulnerable older adults across care settings.
Collapse
Affiliation(s)
- Colleen J Maxwell
- School of Pharmacy, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Dosa D, Cai S, Gidmark S, Thomas K, Intrator O. Potentially Inappropriate Medication Use in Veterans Residing in Community Living Centers: Have We Gotten Better? J Am Geriatr Soc 2013; 61:1994-9. [DOI: 10.1111/jgs.12516] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- David Dosa
- Center of Innovation; Providence Veterans Affairs Medical Center; Providence Rhode Island
- Department of Medicine; Brown University; Providence Rhode Island
- Department of Health Services, Policy and Practice; Brown University; Providence Rhode Island
| | - Shubing Cai
- Center of Innovation; Providence Veterans Affairs Medical Center; Providence Rhode Island
- Department of Health Services, Policy and Practice; Brown University; Providence Rhode Island
| | - Stefanie Gidmark
- Center of Innovation; Providence Veterans Affairs Medical Center; Providence Rhode Island
| | - Kali Thomas
- Department of Health Services, Policy and Practice; Brown University; Providence Rhode Island
| | - Orna Intrator
- Center of Innovation; Providence Veterans Affairs Medical Center; Providence Rhode Island
- Department of Health Services, Policy and Practice; Brown University; Providence Rhode Island
| |
Collapse
|
18
|
Abstract
This article describes British Columbia's regulatory model for assisted living and used time series analysis to examine individuals' use of health care services before and after moving to assisted living. The 4,219 assisted living residents studied were older and predominantly female, with 73 per cent having one or more major chronic conditions. Use of health care services tended to increase before the move to assisted living, drop at the time of the move (most notably for general practitioners, medical specialists, and acute care), and remain low for the 12-month follow-up period. These apparent positive effects are not trivial; the cohort of 1,894 assisted living residents used 18,000 fewer acute care days in the year after, compared to the year before, their move. Future research should address whether and how assisted living affects longer-term pathways of care for older adults and ultimately their function and quality of life.
Collapse
|
19
|
Fiss T, Thyrian JR, Fendrich K, van den Berg N, Hoffmann W. Cognitive impairment in primary ambulatory health care: pharmacotherapy and the use of potentially inappropriate medicine. Int J Geriatr Psychiatry 2013; 28:173-81. [PMID: 22505357 DOI: 10.1002/gps.3806] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 03/07/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Drug intake is associated with a risk of drug-related problems, for example, the intake of potentially inappropriate medication (PIM), especially for cognitively impaired individuals. The proportion of PIM taken by immobile individuals, especially patients with suspicion of dementia in the AGnES studies (German: Arzt-entlastende Gemeinde-nahe E-Health-gestützte Systemische Intervention), and possible determinants were analyzed. METHODS In a community-based, prospective cohort study in the ambulatory healthcare sector, a sample of 342 patients aged ≥65 years were screened for dementia and received a home medication review. The screening for dementia was positive in 111 cases (32.5%). Data assessment included sociodemographic variables and medical diagnoses. The German PRISCUS list was used to detect PIM and drug-condition interactions. RESULTS Potentially inappropriate medication in dementia was identified in 22 (19.8%) patients with suspicion of dementia. A multivariate binary logistic regression revealed that the number of drugs taken (one to four drugs: OR = 0.059; 95% CI 0.006-0.55, p = 0.0133; Ref.: >9 drugs) and female gender (OR = 10.362; 95% CI: 1.28-83.87) were risk factors for PIM intake in patient with suspicion of dementia. CONCLUSIONS Inappropriate medication use in a community-based sample positively screened for dementia appears to be determined by sex and the number of drugs taken. The intake of fewer than five drugs and receiving support with regard to drug intake protects from the intake of PIM. Patients could benefit from medication management in a collaborative network of healthcare professionals. The implementation of systematic medication review and drug documentation should be extended and standardized in both research studies and routine primary health care.
Collapse
Affiliation(s)
- Thomas Fiss
- German Center for Neurodegenerative Diseases (DZNE), Greifswald, Germany.
| | | | | | | | | |
Collapse
|
20
|
Cestac P, Tavassoli N, Vellas B, Rolland Y. Improving Medication Use in the Nursing Homes: A European Perspective. J Am Med Dir Assoc 2013; 14:6-9. [DOI: 10.1016/j.jamda.2012.09.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 09/11/2012] [Indexed: 11/26/2022]
|
21
|
Hodgkinson B, Koch S, Nay R, Nichols K. Strategies to reduce medication errors with reference to older adults. INT J EVID-BASED HEA 2012; 4:2-41. [PMID: 21631752 DOI: 10.1111/j.1479-6988.2006.00029.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background In Australia, around 59% of the general population uses prescription medication with this number increasing to about 86% in those aged 65 and over and 83% of the population over 85 using two or more medications simultaneously. A recent report suggests that between 2% and 3% of all hospital admissions in Australia may be medication related with older Australians at higher risk because of higher levels of medicine intake and increased likelihood of being admitted to hospital. The most common medication errors encountered in hospitals in Australia are prescription/medication ordering errors, dispensing, administration and medication recording errors. Contributing factors to these errors have largely not been reported in the hospital environment. In the community, inappropriate drugs, prescribing errors, administration errors, and inappropriate dose errors are most common. Objectives To present the best available evidence for strategies to prevent or reduce the incidence of medication errors associated with the prescribing, dispensing and administration of medicines in the older persons in the acute, subacute and residential care settings, with specific attention to persons aged 65 years and over. Search strategy Bibliographic databases PubMed, Embase, Current contents, The Cochrane Library and others were searched from 1986 to present along with existing health technology websites. The reference lists of included studies and reviews were searched for any additional literature. Selection criteria Systematic reviews, randomised controlled trials and other research methods such as non-randomised controlled trials, longitudinal studies, cohort or case-control studies, or descriptive studies that evaluate strategies to identify and manage medication incidents. Those people who are involved in the prescribing, dispensing or administering of medication to the older persons (aged 65 years and older) in the acute, subacute or residential care settings were included. Where these studies were limited, evidence available on the general patient population was used. Data collection and analysis Study design and quality were tabulated and relative risks, odds ratios, mean differences and associated 95% confidence intervals were calculated from individual comparative studies containing count data where possible. All other data were presented in a narrative summary. Results Strategies that have some evidence for reducing medication incidents are: • computerised physician ordering entry systems combined with clinical decision support systems; • individual medication supply systems when compared with other dispensing systems such as ward stock approaches; • use of clinical pharmacists in the inpatient setting; • checking of medication orders by two nurses before dispensing medication; • a Medication Administration Review and Safety committee; and • providing bedside glucose monitors and educating nurses on importance of timely insulin administration. In general, the evidence for the effectiveness of intervention strategies to reduce the incidence of medication errors is weak and high-quality controlled trials are needed in all areas of medication prescription and delivery.
Collapse
Affiliation(s)
- Brent Hodgkinson
- School of Population Health, University of Queensland, Brisbane, Queensland, Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, Victoria, and School of Education, University of Queensland, Brisbane, Queensland, Australia
| | | | | | | |
Collapse
|
22
|
Bell CM, Brener SS, Comrie R, Anderson GM, Bronskill SE. Quality measures for medication continuity in long-term care facilities, using a structured panel process. Drugs Aging 2012; 29:319-27. [PMID: 22462630 DOI: 10.2165/11599150-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Patient transitions, such as transfers between acute and long-term care (LTC), aposare times when the likelihood of communication failure between healthcare providers is increased. Employing appropriate health quality indicators helps support improvement efforts. To date, few quality indicators that evaluate the continuity of medication use between acute and LTC facilities have been described. OBJECTIVE The aim of the study was to develop quality indicators signalling the potential discontinuation of previously prescribed medications for chronic diseases when residents return to LTC following an acute-care hospitalization. METHODS A literature review for the selection of potential indicators was conducted, followed by a three-step process: (i) initial screening round that rated the indicators; (ii) a 1-day in-person consensus meeting in which the panel refined the parameters regarding the proposed quality indicators; and (iii) a final anonymous survey that assessed consensus among panel members. The study setting was a survey and consensus meeting with national representation, held in Toronto, ON, Canada. A ten-member expert panel with broad geographical and clinical representation participated and was made up of registered nurses, physicians, pharmacists, policy makers and academic researchers. A 75% agreement threshold was required for consensus, as measured on a 9-point Likert-type scale. The panel evaluated quality indicators for effectiveness, relevance and feasibility, using currently available healthcare administrative data. RESULTS The panel reached consensus on four quality indicators to assess the unintentional discontinuation of medications prescribed to LTC residents for chronic diseases upon return to LTC after an acute-care admission. The selected indicators were (i) HMG-CoA reductase inhibitors (statins) for all indications; (ii) anticoagulants (e.g. warfarin) for the indication of atrial fibrillation; (iii) proton-pump inhibitors for the indication of post-gastrointestinal haemorrhage; and (iv) thyroxine for all indications. The panel identified three additional treatment groups for future consideration as quality indicators: anti-Parkinson's disease, anti-diabetes and antidepressant medications. CONCLUSION A novel set of quality indicators has been developed to evaluate medication continuity between acute and LTC facilities. The adoption and implementation of these indicators in clinical practice can help inform quality improvement efforts at various local and regional levels.
Collapse
Affiliation(s)
- Chaim M Bell
- St Michaels Hospital, Keenan Research Centre in the Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | | | | | | | | |
Collapse
|
23
|
|
24
|
Haasum Y, Fastbom J, Johnell K. Institutionalization as a risk factor for inappropriate drug use in the elderly: a Swedish nationwide register-based study. Ann Pharmacother 2012; 46:339-46. [PMID: 22318931 DOI: 10.1345/aph.1q597] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Few studies have investigated institutionalization as a potential risk factor for potentially inappropriate drug use (PIDU). Sweden now has unique possibilities for comparisons of drug use in large populations of institutionalized and home-dwelling elderly through linkage of the Swedish Prescribed Drug Register (SPDR) with the Swedish Social Services Register. OBJECTIVE To compare PIDU in institutionalized versus home-dwelling elderly persons in Sweden. METHODS We conducted a cross-sectional retrospective study of 1,260,843 home-dwelling and 86,721 institutionalized elderly individuals. We analyzed data on age, sex, and dispensed drugs for individuals aged 65 years or older registered in the SPDR from July to September 2008. Data on type of housing were retrieved from the Social Services Register. The main outcome measures of PIDU were use of anticholinergic drugs, long-acting benzodiazepines, concurrent use of 3 or more psychotropics, and potentially serious drug-drug interactions (DDIs). RESULTS Thirty percent of the institutionalized and 12% of the home-dwelling elderly were exposed to PIDU. Living in an institution was strongly associated with overall PIDU (OR 2.36; 95% CI 2.29 to 2.44), use of anticholinergic drugs (OR 2.58; 95% CI 2.48 to 2.68), long-acting benzodiazepines (OR 1.50; 95% CI 1.41 to 1.60), and concurrent use of 3 or more psychotropics (OR 7.26; 95% CI 6.96 to 7.59), after controlling for age, sex, and number of drugs (used as proxy for comorbidity). However, institutionalization was associated with a lower probability of potentially serious DDIs (OR 0.60; 95% CI 0.55 to 0.65). CONCLUSIONS Our results indicate that institutionalization is a potential risk factor for PIDU. This implies that more cautious prescribing is warranted in institutions, where the frailest and most vulnerable elderly individuals reside. Research is needed to identify underlying risk factors for PIDU within these settings.
Collapse
Affiliation(s)
- Ylva Haasum
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm Gerontology Research Center, Stockholm, Sweden.
| | | | | |
Collapse
|
25
|
García-Gollarte F, Baleriola-Júlvez J, Ferrero-López I, Cruz-Jentoft AJ. Inappropriate Drug Prescription at Nursing Home Admission. J Am Med Dir Assoc 2012; 13:83.e9-15. [DOI: 10.1016/j.jamda.2011.02.009] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 02/06/2011] [Accepted: 02/16/2011] [Indexed: 01/13/2023]
|
26
|
Southern WN, Bellin EY, Arnsten JH. Longer lengths of stay and higher risk of mortality among inpatients of physicians with more years in practice. Am J Med 2011; 124:868-74. [PMID: 21745651 PMCID: PMC3159750 DOI: 10.1016/j.amjmed.2011.04.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 11/23/2010] [Accepted: 04/04/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND More physician years in practice have been associated with less frequent guideline adherence, but it is unknown whether years in practice are associated with patient outcomes. METHODS We examined all inpatients on the teaching service of an urban hospital from July 1, 2002 through June 30, 2004. Admissions were assigned to attending physicians quasi-randomly. Years in practice was defined as the number of years the attending physician held a medical license. We divided physicians into 4 groups (0-5, 6-10, 11-20, and >20 years in practice), and used negative binomial and logistic regression to adjust for patient characteristics and estimate associations between years in practice and length-of-stay, readmission, and mortality. RESULTS Fifty-nine physicians and 6572 admissions were examined. Although the 4 inpatient groups had similar demographic and clinical characteristics, physicians with more years in practice had longer mean lengths of stay (4.77, 5.29, 5.42, and 5.31 days for physicians with 0-5, 6-10, 11-20, and >20 years in practice, respectively, P=.001). After adjustment, inpatients of physicians with more than 20 years in practice had higher risk for both in-hospital mortality (odds ratio 1.71; 95% confidence interval, 1.06-2.76) and 30-day mortality (odds ratio 1.51, 95% confidence interval, 1.06-2.16) than inpatients of physicians with 0-5 years in practice. CONCLUSION Inpatient care by physicians with more years in practice is associated with higher risk of mortality. Quality-of-care interventions should be developed to maintain inpatient skills for physicians.
Collapse
Affiliation(s)
- William N Southern
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA.
| | | | | |
Collapse
|
27
|
Lowry E, Woodman RJ, Soiza RL, Mangoni AA. Clinical and demographic factors associated with antimuscarinic medication use in older hospitalized patients. Hosp Pract (1995) 2011; 39:30-6. [PMID: 21441756 DOI: 10.3810/hp.2011.02.371] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Antimuscarinic drug prescribing scoring systems might better identify patients at risk of adverse drug reactions. The recently developed Anticholinergic Risk Scale (ARS) score is significantly associated with the number of antimuscarinic side effects in older outpatients. We sought to identify the clinical and demographic patient-level correlates of the ARS, including a modified version adjusted for daily dose, in elderly hospitalized patients. METHODS Clinical and demographic patient characteristics known to be associated with antimuscarinic prescribing, ARS and dose-adjusted ARS scores, and full medication exposure on admission were recorded in 362 consecutive patients (aged 83.6 ± 6.6 years) admitted to 2 geriatric units (NHS Grampian, Aberdeen, Scotland, UK) between February 1, 2010 and June 30, 2010. RESULTS Each year of increasing age was associated with reduced number of antimuscarinic drugs (incidence rate ratio [IRR], 0.963; 95% confidence interval [CI], 0.948-0.980; P < 0.001), non-antimuscarinic drugs (IRR, 0.991; 95% CI, 0.985-0.997; P = 0.006), and total number of drugs (IRR, 0.988; 95% CI, 0.983-0.994; P < 0.001). Multivariate Poisson regression showed that increasing age and history of dementia were negatively associated with the ARS score (IRR, 0.97; 95% CI, 0.94-0.99; P = 0.001 and IRR, 0.62; 95% CI, 0.41-0.92; P = 0.019, respectively). By contrast, institutionalization (IRR, 1.32; 95% CI, 1.00-1.74; P = 0.050), Charlson comorbidity index (IRR, 1.06; 95% CI, 1.01-1.11; P = 0.015), and total number of non-antimuscarinic drugs (IRR, 1.13; 95% CI, 1.08-1.18; P < 0.001) were all positively associated with the ARS score. Similar results were observed for the dose-adjusted ARS score. CONCLUSION Institutionalization, comorbidities, and non-antimuscarinic polypharmacy show independent positive associations with the ARS and dose-adjusted ARS scores in older hospitalized patients. Increasing age and dementia are negatively associated with the ARS score.
Collapse
Affiliation(s)
- Estelle Lowry
- Division of Applied Medicine, University of Aberdeen, Aberdeen, Scotland, United Kingdom
| | | | | | | |
Collapse
|
28
|
Parsons C, Lapane K, Kerse N, Hughes C. Prescribing for older people in nursing homes: a review of the key issues. Int J Older People Nurs 2011; 6:45-54. [DOI: 10.1111/j.1748-3743.2010.00264.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
29
|
Ruggiero C, Lattanzio F, Dell'Aquila G, Gasperini B, Cherubini A. Inappropriate drug prescriptions among older nursing home residents: the Italian perspective. Drugs Aging 2010; 26 Suppl 1:15-30. [PMID: 20136166 DOI: 10.2165/11534630-000000000-00000] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Older people take up a large proportion of health care, including drugs, and evidence shows that drug prescribing to this group is often inappropriate. Negative consequences of potential inappropriate drug prescription (PIDP) include adverse drug events, high healthcare service utilization and high costs for the patients and society. Although nursing home residents are the most vulnerable persons exposed to PIDP, few observational studies have investigated the prevalence, the factors associated with and the consequences of PIDP. Epidemiological studies assessing PIDP mainly based on the Beers' criteria showed that approximately half of US and Canadian nursing home residents have at least one PIDP in this setting. The most frequent inappropriate prescriptions concern neuroleptics and long-term benzodiazepines. Nursing home residents aged 80 years or more, those taking a low number of drugs, cognitive or communication problems are less exposed to PIDP compared with residents younger than 80 years, living in facilities with a high number of beds and a lower registered nurse-to-resident ratio. In European countries, the prevalence of PIDP among older nursing home residents was comparable to or higher than that observed in US and Canadian nursing homes. To date, the issue of PIDP has never been investigated in a representative sample of Italian nursing home residents. In a preliminary study performed by our group in 496 nursing home residents randomly selected from 40 nursing homes in Umbria, the prevalence of residents taking at least one or two inappropriate medications was 28% and 7%, respectively. The prevalence of PIDP considering diagnosis (18%) as well as those regardless of diagnosis (17%), as determined by Beers' criteria, were equally distributed in older Italian nursing home residents and no difference was found between sexes. Overall, this review reveals that the prevalence of PIDP is high in both North American and European nursing homes and highlights the urgent need for intervention trials testing strategies to reduce the health and social burden of PIDP.
Collapse
Affiliation(s)
- Carmelinda Ruggiero
- Institute of Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy.
| | | | | | | | | |
Collapse
|
30
|
Chai CY, Chen CH, Lin HW, Lin HC. Association of increasing surgeon age with decreasing in-hospital mortality after coronary artery bypass graft surgery. World J Surg 2010; 34:3-9. [PMID: 20020288 DOI: 10.1007/s00268-009-0291-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this study was to investigate the relation between surgeon age and in-hospital mortality for patients who underwent a coronary artery bypass graft (CABG) using a nationwide population-based data set. METHODS This study used data from the 2004 Taiwan National Health Insurance Research Database. The study sample comprised 3766 patients hospitalized for CABG surgery and was divided into three equal-sized surgeon age groups: <40, 40 to 45, and >45 years. A conditional (fixed-effect) logistic regression was performed to examine the relation between surgeon age and in-hospital mortality after adjusting for surgeon CABG caseload and characteristics of patients and surgeons as well as the clustering effect among surgeons. RESULTS Patients who underwent CABG performed by surgeons in the <40 years age group had significantly higher in-hospital mortality rates (5.4%) than those operated on by surgeons in the 40- to 45-year age group (3.5%) and surgeons in the >45-year age group (2.6%). Regression shows that the adjusted odds ratio of in-hospital mortality for patients operated on by surgeons in the <40-year age group was 1.47 (p < 0.05) times that for surgeons in the 40- to 45-year age group and 1.82 (p < 0.05) times that for surgeons in the >45-year age group. CONCLUSION We conclude that older surgeons are more likely to achieve better clinical performance with CABG surgery because of their greater clinical experience.
Collapse
Affiliation(s)
- Chiah-Yang Chai
- Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | | | | | | |
Collapse
|
31
|
Murray LM, Laditka SB. Care Transitions by Older Adults From Nursing Homes to Hospitals: Implications for Long-Term Care Practice, Geriatrics Education, and Research. J Am Med Dir Assoc 2010; 11:231-8. [DOI: 10.1016/j.jamda.2009.09.007] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 09/03/2009] [Accepted: 09/09/2009] [Indexed: 10/19/2022]
|
32
|
Olsson J, Bergman Å, Carlsten A, Oké T, Bernsten C, Schmidt IK, Fastbom J. Quality of Drug Prescribing in Elderly People in Nursing Homes and Special Care Units for Dementia. Clin Drug Investig 2010; 30:289-300. [DOI: 10.2165/11534320-000000000-00000] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
33
|
Trivalle C, Cartier T, Verny C, Mathieu AM, Davrinche P, Agostini H, Becquemont L, Demolis P. Identifying and preventing adverse drug events in elderly hospitalised patients: a randomised trial of a program to reduce adverse drug effects. J Nutr Health Aging 2010; 14:57-61. [PMID: 20082055 DOI: 10.1007/s12603-010-0010-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Evaluate the impact of educational intervention in decreasing ADEs in elderly patients in a hospital setting. DESIGN Randomised prospective study. SETTING The study was performed in France in the Paris area, in 16 rehabilitation geriatric centres of APHP (Assistance Publique - Hôpitaux de Paris). Patient capacity per centre varied from 15 to 57 with a total of 526. PARTICIPANTS All the patients > or = 65 years hospitalized during the 4 week study period were included. MEASUREMENTS During a first 2 week phase without intervention ADE's were recorded in all centres. Then units were then randomised for an educational intervention or not. The educational phase lasted 1 week, without ADE tracking. Then, both types of units (I+ and I-) recorded ADEs for 2 weeks. Possible drug-related incidents were detected using a standardized check list (nurses) and a weekly review of all charts by investigators. Possible drug-related incidents were analysed by a group of reviewers selected from the authors to classify them as ADE or not. RESULTS 576 patients (mean age: 83.6 +/- 7.9 years) were consecutively included. The mean number of drugs at inclusion was 9.4 +/- 4.24 drugs per patient. 223 out of 755 events were considered "probable" ADEs (29.5%). Among the 223 ADEs, 62 (28%) could have been prevented. The main outcome of this trial was the change in the proportion of ADEs in elderly patients in the intervention-units, compared to the control group. The main errors were: to high a dose (26%), double therapy (21%), under dose (13%), inappropriate drug (13%), drug-drug interaction (6%), previous same adverse drug reaction (3%) and miscellaneous (11.18%). After a specific educational intervention program, there were fewer ADEs in the intervention group (n = 38, 22%) than in the control group (n = 63, 36%; p = 0.004). CONCLUSION Educational programs could help reduce the prevalence of ADEs by 14% and encourage physicians to change outdated prescription habits.
Collapse
Affiliation(s)
- C Trivalle
- Pole Vieillissement, Readaptation et Accompagnement, Hopital Paul Brousse, (APHP), Villejuif, France.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Huey ED, Taylor JL, Luu P, Oehlert J, Tinklenberg JR. Factors associated with use of medications with potential to impair cognition or cholinesterase inhibitors among Alzheimer's disease patients. Alzheimers Dement 2009; 2:314-21. [PMID: 19595905 DOI: 10.1016/j.jalz.2006.08.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2005] [Revised: 04/04/2006] [Accepted: 08/08/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this study was to use a signal detection method to examine the prevalence of, and patient characteristics associated with, medication with potential to impair cognition and cholinesterase inhibitor use in patients with Alzheimer's disease. METHODS A cross-sectional study was conducted of 1,954 patients with a diagnosis of probable or possible Alzheimer's disease. Concurrent medications were measured, specifically: (1) a medication with potential to impair cognition or (2) a cholinesterase inhibitor. Predictor variables included age, gender, ethnic group, education, age of symptom onset, number of prescriptions, number of medical diagnoses, Mini-Mental State Examination (MMSE), Blessed-Roth Dementia Rating Scale (BRDRS), probable versus possible AD diagnosis. RESULTS Fifteen percent of the Alzheimer's disease patients were on a medication with potential to impair cognition, and 44% were on a cholinesterase inhibitor. Patient characteristics associated with the prescription of a medication with potential to impair cognition included total number of prescription medications, low education, low MMSE, older age, reported lack of vitamin use, and more medical diagnoses. Patient characteristics associated with the prescription of a cholinesterase inhibitor included reported use of vitamins, the total number of prescription medications, fewer medical diagnoses, lower age of symptom onset, and higher education. CONCLUSIONS Determining the patient characteristics associated with the prescription of a medication with potential to impair cognition can help clinicians identify patients who are at risk for drug-related morbidity. Patient characteristics unassociated with dementia appear to influence the prescription of cholinesterase inhibitors. Signal detection analysis is well suited to this type of research.
Collapse
Affiliation(s)
- Edward D Huey
- Cognitive Neuroscience Section, National Institute of Neurological disorders and Stroke, National Institutes of Health, Bethesda, MD 20892-1440, USA.
| | | | | | | | | |
Collapse
|
35
|
Fall-related injuries in a nursing home setting: is polypharmacy a risk factor? BMC Health Serv Res 2009; 9:228. [PMID: 20003327 PMCID: PMC2797789 DOI: 10.1186/1472-6963-9-228] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Accepted: 12/11/2009] [Indexed: 11/19/2022] Open
Abstract
Background Polypharmacy is regarded as an important risk factor for fallingand several studies and meta-analyses have shown an increased fall risk in users of diuretics, type 1a antiarrhythmics, digoxin and psychotropic agents. In particular, recent evidence has shown that fall risk is associated with the use of polypharmacy regimens that include at least one established fall risk-increasing drug, rather than with polypharmacy per se. We studied the role of polypharmacy and the role of well-known fall risk-increasing drugs on the incidence of injurious falls. Methods A retrospective observational study was carried out in a population of elderly nursing home residents. An unmatched, post-stratification design for age class, gender and length of stay was adopted. In all, 695 falls were recorded in 293 residents. Results 221 residents (75.4%) were female and 72 (24.6%) male, and 133 (45.4%) were recurrent fallers. 152 residents sustained no injuries when they fell, whereas injuries were sustained by 141: minor in 95 (67.4%) and major in 46 (32.6%). Only fall dynamics (p = 0.013) and drugs interaction between antiarrhythmic or antiparkinson class and polypharmacy regimen (≥7 medications) seem to represent a risk association for injuries (p = 0.024; OR = 4.4; CI 95% 1.21 - 15.36). Conclusion This work reinforces the importance of routine medication reviews, especially in residents exposed to polypharmacy regimens that include antiarrhythmics or antiparkinson drugs, in order to reduce the risk of fall-related injuries during nursing home stays.
Collapse
|
36
|
Christian JB, Vanhaaren A, Cameron KA, Lapane KL. Alternatives for Potentially Inappropriate Medications in the Elderly Population: Treatment Algorithms for Use in the Fleetwood Phase III Study. ACTA ACUST UNITED AC 2009; 19:1011-28. [PMID: 16553485 DOI: 10.4140/tcp.n.2004.1011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To provide estimates of the prevalence of potentially inappropriate medications used in eligible nursing facilities, to describe the development of evidence-based treatment algorithms for recommending safer alternative treatments to potentially inappropriate medications, and to provide the actual treatment algorithms developed for the Fleetwood Phase III study. DESIGN Literature review, cross-sectional design. SETTING Thirty North Carolina nursing facilities eligible for Fleetwood Phase III. PATIENTS, PARTICIPANTS Algorithms developed for use by all pharmacists in the long-term care pharmacy serving the intervention facilities site for the Fleetwood Phase III study. INTERVENTIONS Pharmacists are prospectively intervening directly with the prescriber to recommend a safer alternative to inappropriate medications using the standardized treatment algorithms developed for the study. MAIN OUTCOME MEASURE(S) Prevalence of potentially inappropriate medications used among residents and the development of 14 treatment algorithms suggesting appropriate alternatives to inappropriate medications. RESULTS The percentage of potentially inappropriate medications used ranged from 0% to 13.2% at baseline in March 2002. We also found that evidence-based treatment algorithms were well received by consultant pharmacists at the intervention sites of the Fleetwood Phase III study. CONCLUSION We have provided prevalence rates of potentially inappropriate medication use in nursing homes and developed treatment algorithms for pharmacists to use when making clinical recommendations regarding safer alternatives to potentially inappropriate medications in the elderly population. We are in the process of evaluating the effect of pharmacists' prospective interventions by using these standardized evidence-based treatment algorithms to reduce the prevalence of inappropriate medication use in intervention facilities.
Collapse
|
37
|
Parasca A, Doogue MP, Woodman RJ, Mangoni AA. Hypoalbuminaemia and impaired renal function are associated with increased anticholinergic drug prescribing. Int J Clin Pract 2009; 63:1110-4. [PMID: 19570127 DOI: 10.1111/j.1742-1241.2009.02067.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND A higher anticholinergic risk score (ARS) is associated with an increased risk of anticholinergic adverse effects in elderly patients. It is unknown whether factors other than the use of anticholinergic drugs determine the ARS. METHODS A comprehensive medical record review was conducted in 155 consecutive hospitalised patients (median age 79.0 years, interquartile range 66.0-86.0). Information was collected on: demographics; clinical characteristics (including medications and their doses); history of anticholinergic-induced adverse effects; and biochemical markers of hepatic and renal function (serum albumin concentrations and estimated glomerular filtration rate, eGFR). The ARS was calculated for each patient using a standard scoring approach and Poisson regression was used for identifying variables associated with the ARS. RESULTS Patients with an ARS >or= 3 had a lower eGFR (p = 0.012) and were receiving more non-anticholinergic drugs (p < 0.001) than patients with an ARS < 3. In addition to being prescribed more anticholinergic drugs, patients with ARS >or= 3 were prescribed high doses of these drugs more often than patients with ARS < 3 (41.3% vs. 26.9%, p = 0.034). A higher number of non-anticholinergic drugs (p < 0.001), a lower serum albumin concentration (p = 0.014), and a lower eGFR (p = 0.012) were independently associated with a higher ARS. CONCLUSIONS Polypharmacy, hypoalbuminaemia and low eGFR are independently associated with the ARS. Patients with a higher ARS are also prescribed higher doses of anticholinergic medications than those with lower ARS.
Collapse
Affiliation(s)
- A Parasca
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | | | | | | |
Collapse
|
38
|
Franson KL, Dubois EA, de Kam ML, Burggraaf J, Cohen AF. Creating a culture of thoughtful prescribing. MEDICAL TEACHER 2009; 31:415-419. [PMID: 19089722 DOI: 10.1080/01421590802520931] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND In the Netherlands 170,000 patients yearly fall victim to poor communication between health care professionals,with 44% of patients receiving inappropriate therapy as a result. Evidence indicates that this problem may be due to physicians learning to communicate therapeutic content by unstructured means during training. AIM To introduce a structured format for creating and communicating therapeutic plans; to provide for students opportunities to practice and feedback on their abilities. METHODS We developed the Individualized Therapy Evaluation and Plan (ITEP) for therapeutic decision-making and communication based on the subjective objective assessment and plan note. The therapeutic plans from students of the 2003 cohort were assessed with one simple and one complex case using a 15-point criteria form. Over the next 3 years students were given more practice using the ITEP and the average score on the complex case was tracked and compared to the 2003 cohort. RESULTS In cohort 2003, 82% of the students satisfactorily completed the simple case, while only 32% did so with the complex case. In subsequent years, the average scores on the complex case significantly improved from 3.8 to 6.8 with increasing practice. CONCLUSIONS Students can select a simple drug regimen, but without practice using the ITEP will not help to deal with multiple disease states.
Collapse
Affiliation(s)
- Kari L Franson
- Centre for Human Drug Research, Zernikedreef 10, Leiden, The Netherlands.
| | | | | | | | | |
Collapse
|
39
|
Abstract
OBJECTIVES With advancing age, physiologic changes occur that affect drug metabolism. Possibly the most predictable function decline in geriatric population is renal function. METHODS The prescribing habits of physicians and the attention given to patient renal function was investigated. Data was collected from two nursing facilities in southeastern Georgia. RESULTS Based on two models of prescribing habits and using logistic regression estimates, we concluded that physicians do not follow recommendations for dose adjustment of renally excreted medications in these two facilities. CONCLUSION We recommend that physicians consider evaluating current medications and establishing a base line for renal function and degree of decline.
Collapse
|
40
|
Tsuyuki RT, McLean DL, McAlister FA. Management of hypertension in elderly long-term care residents. Can J Cardiol 2009; 24:912-4. [PMID: 19052671 DOI: 10.1016/s0828-282x(08)70698-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To determine the adequacy of hypertension management in institutionalized elderly patients. METHODS Retrospective chart review of all patients with a physician-documented diagnosis of hypertension at 15 long-term care facilities in Edmonton, Alberta. RESULTS Of 2063 long-term care residents, 733 (36%) were diagnosed with hypertension (mean age 84 years), and 566 (77%) of this cohort were receiving antihypertensive medication. The most frequently prescribed antihypertensive drugs were angiotensin-converting enzyme inhibitors (341 patients [60%]). Of the long-term residents prescribed antihypertensive therapy, 274 (48%) were on one medication, 203 (36%) were on two and 89 (16%) received three or more agents. Blood pressure readings were taken every 14 days on average (interquartile range two to 31 days). Overall, 467 (64%) of these residents with a diagnosis of hypertension achieved target blood pressure. CONCLUSION Hypertension treatment and control rates are better in elderly patients who are institutionalized than those reported in studies of patients who reside in the community. Determining the reasons for this discrepancy will be important for the design of strategies to improve hypertension control rates in the community.
Collapse
Affiliation(s)
- Ross T Tsuyuki
- Department of Medicine, University of Alberta, Alberta, Canada
| | | | | |
Collapse
|
41
|
Potentially inappropriate prescribing for the elderly: effects of geriatric care at the patient and health care system level. Med Care 2008; 46:167-73. [PMID: 18219245 DOI: 10.1097/mlr.0b013e318158aec2] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Many studies have identified patient characteristics associated with potentially inappropriate prescribing in the elderly (PIPE), however, little attention has been directed toward how health care system factors such as geriatric care may affect this patient safety issue. OBJECTIVE This study examines the association between geriatric care and PIPE in a community dwelling elderly population. RESEARCH DESIGN Cross-sectional retrospective database study. SUBJECTS Veterans age > or =65 years who received health care in the VA system during Fiscal Years (FY99-00), and also received at medications from the Veterans Administration in FY00. MEASURES PIPE was identified using the Zhan adaptation of the Beers criteria. Geriatric care penetration was calculated as the proportion of patients within a facility who received at least 1 geriatric outpatient clinic or inpatient visit. ANALYSES Logistic regression models with generalized estimating equations were used to assess the relationship between geriatric care and PIPE after controlling for patient and health care system characteristics. RESULTS Patients receiving geriatric care were less likely to have PIPE exposure (odds ratio, 0.64; 95% confidence interval, 0.59-0.73). There was also a weak effect for geriatric care penetration, with a trend for patients in low geriatric care penetration facilities having higher risk for PIPE regardless of individual geriatric care exposure (odds ratio, 1.14; 95% confidence interval, 0.99-1.30). CONCLUSIONS Although geriatric care is associated with a lower risk of PIPE, additional research is needed to determine if heterogeneity in the organization and delivery of geriatric care resulted in the weak effect of geriatric care penetration, or whether this is a result of low power.
Collapse
|
42
|
Medications Prescribed by Specialists in Nursing Homes. J Am Med Dir Assoc 2008; 9:137-8. [DOI: 10.1016/j.jamda.2007.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2007] [Revised: 10/31/2007] [Accepted: 11/01/2007] [Indexed: 11/23/2022]
|
43
|
Bierman AS, Pugh MJV, Dhalla I, Amuan M, Fincke BG, Rosen A, Berlowitz DR. Sex differences in inappropriate prescribing among elderly veterans. ACTA ACUST UNITED AC 2007; 5:147-61. [PMID: 17719517 DOI: 10.1016/j.amjopharm.2007.06.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Previous studies have suggested that older women may be more likely than older men to receive potentially inappropriate prescriptions. A better understanding of sex differences in inappropriate prescribing can help inform the development of effective interventions. OBJECTIVE This study was conducted to assess sex differences in rates of inappropriate prescribing before and after accounting for potentially appropriate indications and to examine sex differences in predictors of inappropriate drug use. METHODS This was a retrospective cohort study of administrative data from the national Veterans Health Administration (VA). Participants were veterans aged >or=65 years who had >or=1 patient visit at VA outpatient facilities in fiscal year 1999 (FY99) and 2000 (FY00). The main outcome measure was the diagnosis-adjusted prevalence of 33 potentially inappropriate medications as judged by the Beers criteria in FY00: overall, by individual drug, and in 3 categories grouped by potential indication ("always avoid," "rarely appropriate," and "some indications"). RESULTS The study population included 965,756 patients (946,641 men and 19,115 women). Women were more likely than men to receive inappropriate medications overall and in all 3 categories, even after accounting for diagnoses that may have justified the prescription. Women were more likely to receive 16 of the 33 medications (analgesics, psychotropic drugs, and anticholinergic agents), and men were more likely to receive 3 of the 33. After controlling for sociodemographic characteristics, number of medications, and care characteristics, women remained more likely to receive inappropriate drugs. Receipt of geriatric care was equally protective for men and women, although only a small proportion received this care. Psychiatric comorbidity was associated with inappropriate prescribing for men but not for women. CONCLUSIONS Analgesic, psychotropic, and anticholinergic medications that should be avoided contributed to higher rates of inappropriate drug use among older women than among older men. Targeted efforts to avoid these medications in older women may help reduce overall rates of inappropriate prescribing. Sex-stratified reporting of quality indicators that assess inappropriate prescribing among community-dwelling elders would help monitor the effectiveness of improvement efforts.
Collapse
Affiliation(s)
- Arlene S Bierman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.
| | | | | | | | | | | | | |
Collapse
|
44
|
King MA, Roberts MS. The influence of the Pharmaceutical Benefits Scheme (PBS) on inappropriate prescribing in Australian nursing homes. ACTA ACUST UNITED AC 2007; 29:39-42. [PMID: 17268937 DOI: 10.1007/s11096-005-5618-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2005] [Accepted: 12/01/2005] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To determine the prevalence of inappropriate prescribing, defined by applying modified Beers' criteria, and to examine the influence of the Pharmaceutical Benefits Scheme (PBS), Australia's national scheme for subsidising medicines, on inappropriate prescribing. METHODS Cross-sectional survey of nursing home records, including 7-days data from medication charts. SETTING Fiveteen randomly selected nursing homes (998 residents) in Southeast Queensland and Northern New South Wales, Australia. MAIN OUTCOME MEASURES The prevalence of inappropriate prescribing as defined by modified Beers' criteria and its correlation with PBS restrictions. RESULTS 18.5% of residents were ordered one or more inappropriate medications, and 1.5% of residents were ordered two or more. The level of PBS restriction and the percentage of residents ordered a medication were highly correlated (p = -0.87, P < 0.001). Medications in Beers' criteria that were not listed (subsidised) on the PBS were not ordered for any resident. PBS medicines with subsidies restricted to certain populations or indications were ordered for 0% to 0.1% of residents. Dextropropoxyphene, diazepam, amitriptyline and methyldopa were the only medications in Beers' criteria prescribed to more than 0.5% of residents. Dextropropoxyphene was only subsidised for war veterans, with a caution warning of its potential to cause drug dependence, while diazepam, amitriptyline and methyldopa were listed on the PBS without any subsidy restrictions. CONCLUSION Increases in the level of PBS restriction were associated with decreases in the prevalence of inappropriate prescribing, The targeting of drug subsidies to reduce inappropriate prescribing warrants further investigation.
Collapse
Affiliation(s)
- Michelle A King
- Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, United Kingdom.
| | | |
Collapse
|
45
|
Lapane KL, Hughes CM, Quilliam BJ. Does incorporating medications in the surveyors' interpretive guidelines reduce the use of potentially inappropriate medications in nursing homes? J Am Geriatr Soc 2007; 55:666-73. [PMID: 17493185 DOI: 10.1111/j.1532-5415.2007.01153.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To quantify the association between including specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes and the prevalence of use. DESIGN Quasi-experimental. SETTING One thousand one hundred forty-one nursing homes in four U.S. states. PARTICIPANTS Residents living in one of the included nursing homes in operation during 1997 (before Beers; n=130,250) and 2000 (after Beers; n=164,889). INTERVENTION Inclusion of specific medications deemed potentially inappropriate in the surveyors' interpretive guidelines for nursing homes. MEASUREMENTS Logistic regression models adjusting for clustering effects of residents residing in homes provided estimates of the relationship between the survey process and use of any medications targeted as potentially inappropriate as part of the survey process, as well as those deemed inappropriate but not included. RESULTS The use of any potentially inappropriate medication decreased from 42.5% in 1997 to 39.8% in 2000. After adjustment for resident characteristics, residents were less likely to receive any potentially inappropriate medication (odds ratio (OR)=0.85, 95% confidence interval (95% CI)=0.84-0.87), those considered high-severity drugs (those with a high likelihood of a clinically significant adverse event) (OR=0.67, 95% CI=0.65-0.69), or Beers' medications not included in the surveyors' guidelines (OR=0.76, 95% CI=0.74-0.79) in 2000 than in 1997 after the changes to the drug regulations and interpretive guidelines. CONCLUSION Targeting specific drugs in the surveyor's interpretive guidelines as a method to reduce potentially inappropriate medication use may not produce desired gains in medication-use quality improvement. Alternative strategies for nursing homes should be evaluated.
Collapse
Affiliation(s)
- Kate L Lapane
- Department of Community Health, Brown Medical School, Providence, Rhode Island 02903, USA.
| | | | | |
Collapse
|
46
|
Saab YB, Hachem A, Sinno S, El-Moalem H. Inappropriate medication use in elderly lebanese outpatients: prevalence and risk factors. Drugs Aging 2007; 23:743-52. [PMID: 17020398 DOI: 10.2165/00002512-200623090-00004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Inappropriate use of medications has become an international cause for concern in geriatric patients, who are at high risk of drug-related morbidity. This study is the first attempt to determine the prevalence of inappropriate drug use in elderly Lebanese outpatients, using community pharmacy data, and to identify factors that predict potentially inappropriate drug intake in this population. METHODS Records of elderly patients aged > or =65 years were selected from different community pharmacies. Each patient profile was reviewed and to confirm patient record information, in-person interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, courses of therapy were assessed and classified as either appropriate or inappropriate. Courses of therapy that were judged inappropriate were further classified according to the specific area of inappropriate use (i.e. Beers' criteria, duplicate therapy, indication, dose, dose frequency including missing doses, duration and discontinuation of therapy, adverse effects, drug-drug and/or drug-disease interactions, and poor memory). Statistical analyses were performed to estimate the prevalence of inappropriate medication use and to identify potentially predictive factors of such use arising from patients' sociodemographic characteristics, health factors and drug regimen intake. RESULTS A total of 350 elderly patient profiles were reviewed, from which 277 evaluable records were obtained. More than half (59.6%) of the patients taking drugs at the time of the study were taking at least one inappropriate medication. Inappropriate medication use was most frequently identified in terms of Beers' criteria (22.4%), missing doses (18.8%) or incorrect frequency of administration of drugs (13.0%). Factors predicting potentially inappropriate drug intake included female sex (65.7% vs 53.3% for males, p = 0.03) and alcohol intake (p = 0.007). There were also significant associations between the likelihood of use of an inappropriate drug and (i) increased number of medical illnesses (p < 0.00002); and (ii) consumption of an over-the-counter drug (OTC) and/or prescription drug (p = 0.048 and p = 0.0035, respectively). The likelihood of use of an inappropriate drug was higher again when patients concurrently used both OTC and prescription drugs (p < 0.0002). CONCLUSION The present study is the first to describe and assess inappropriate medication use by elderly outpatients in the Lebanese community setting. With increasing availability of newer and more appropriate medications, use of potentially inappropriate drugs may decrease. Pharmacists have a major role to play in counselling patients about the importance of appropriate drug use.
Collapse
Affiliation(s)
- Yolande B Saab
- School of Pharmacy, Lebanese American University, Byblos, Lebanon.
| | | | | | | |
Collapse
|
47
|
Ulfvarson J, Bardage C, Wredling RAM, von Bahr C, Adami J. Adherence to drug treatment in association with how the patient perceives care and information on drugs. J Clin Nurs 2007; 16:141-8. [PMID: 17181676 DOI: 10.1111/j.1365-2702.2005.01477.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This study was to explore concordance with drugs prescribed and the patient's self-reported drug consumption, in relation to the older patient's perceived care and information given. BACKGROUND Lack of adherence to prescriptions may lead to therapeutic failure with risks for relapse, unnecessary suffering and increased costs. DESIGN A cross-sectional study with structured interviews of 200 patients who had recently been treated in a medical ward. METHODS Patients' medical records were studied to obtain information on their current use of drugs. The data were analyzed by logistic regression, adherence being the dependent response variable. RESULTS The mean age of the study group was 79 years. The number of drugs reported in the medical chart ranged from one to 17 with a mean of 6.9. The patients reported a drug consumption ranging from 0 to 24 with a mean of 7.3. When comparing the interview results with the information in the medical charts, 30% of the patients showed adherence. An association was found between adherence and self-reported health status. Patients in the non-adherent group reported a higher consumption of drugs. Patients felt that the opportunity to ask questions of either the responsible physicians or of the nurses was influential in decreasing risk. CONCLUSION In this study, the patient's total drug consumption was considered. The study showed a large discrepancy between the drugs stated in the medical chart and patient's self-reported drug consumption. The study failed to show that perceived information or educational level had an impact on the results but implicate that the quality of information influences adherence. RELEVANCE TO CLINICAL PRACTICE It is of importance to recognize patients at risk for non-adherence. Decreased health status and many drugs are the main risk factors for patients being non-adherent, and should be recognized as such.
Collapse
|
48
|
Laroche ML, Charmes JP, Nouaille Y, Fourrier A, Merle L. Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use. Drugs Aging 2006; 23:49-59. [PMID: 16492069 DOI: 10.2165/00002512-200623010-00005] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Potentially inappropriate medication use is a major safety issue in the elderly and may cause a substantial proportion of drug-related hospital admissions. Hospitalisation could result in a change in the quantity and type of drugs, but its effect on potentially inappropriate drug use is still unknown. The aim of this study was to estimate the potentially inappropriate medication prevalence in patients > or =70 years of age at admission to and at discharge from an acute medical geriatric unit, and to identify the factors associated with no longer being a potentially inappropriate drug user at hospital discharge. METHODS A prospective drug surveillance study was undertaken in 2018 elderly patients (> or =70 years of age) admitted to an acute medical geriatric unit in Limoges University Hospital, France. Prescribing patterns were established at admission and at discharge. Potentially inappropriate medication use was evaluated according to a list derived from the Beers criteria and adapted to French practice. "To be no longer a potentially inappropriate drug user at discharge" was defined as using at least one potentially inappropriate medication at admission and not using it at discharge. RESULTS The numbers of drugs used at admission/discharge were 6.2 +/- 3.1/5.4 +/- 2.5. The prevalence of potentially inappropriate medication use decreased from 66% (95% CI 63.8, 68.0) at admission to 43.6% (95% CI 41.3, 45.9) at discharge. At discharge, 535 subjects were no longer potentially inappropriate medication users. Multivariate analysis showed that no longer being a potentially inappropriate medication user was associated with the number of drugs used (4-6 drugs vs < or =3 odds ratio [OR] 1.20; 95% CI 0.86, 1.68; 7-9 drugs vs < or =3 OR 1.37; 95% CI 0.97, 1.93; > or =10 drugs vs < or =3 OR 1.64; 95% CI 1.10, 2.44), age (80-89 years vs 70-79 years OR 1.38; 95% CI 1.03, 1.85; > or =90 years vs 70-79 years OR 1.69; 95% CI 1.22, 2.83), cerebral vasodilator use (OR 2.87; 95% CI 2.31, 3.57), analgesic use (OR 1.54; 95% CI 1.06, 2.25) and concomitant use of psychotropic drugs of the same therapeutic class (OR 1.94; 95% CI 1.29, 2.92). CONCLUSION Hospitalisation in geriatric services results in a reduction in potentially inappropriate medication use. Improved pharmacological education of practitioners, especially with regard to drug adverse effects, is desirable to improve management of geriatric patients.
Collapse
|
49
|
Abstract
BACKGROUND Undertreatment of hyperlipidemia has received considerable attention. However, little is known about trends in overprescribing of lipid lowering agents. We examined these trends and their associations with physician, practice, and organisational factors. METHODS 2034 physicians were surveyed twice: baseline (1996-7) and follow up (1998-9). On each occasion they were asked: "For what percentage of 50 year old men without other cardiac risk factors would you recommend an oral agent for total cholesterol of 240, LDL 150, and HDL 50 after 6 months on a low cholesterol diet?" During the survey period the National Cholesterol Education Program guidelines did not recommend prescribing for these patients. Binomial and multinomial logistic regressions assessed baseline overprescribing and longitudinal changes in overprescribing, accounting for complex sampling. RESULTS 39% of physicians recommended prescribing at baseline (round 1), increasing at follow up (round 2) to 51% (p < 0.001). Physicians who were more likely to overprescribe at baseline were less likely to be board certified (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.38 to 0.63; p < 0.001), were in solo or two-physician practices (OR 1.88, 95% CI 1.46 to 2.41; p < 0.001), had more revenue from Medicare (OR 1.10, 95% CI 1.03 to 1.17; p = 0.004) or Medicaid (OR 1.09, 95% CI 1.01 to 1.18; p = 0.03), or were family physicians (OR 1.87, 95% CI 1.35 to 2.58; p < 0.001). Physicians with large increases in overprescibing were more likely than those with small increases in overprescribing to be international medical graduates (OR 2.09, 95% CI 1.20 to 3.64; p = 0.011) and to spend more hours in patient care (OR 1.14, 95% CI 1.03 to 1.26; p = 0.016). CONCLUSIONS Overprescribing of lipid lowering agents is commonplace and increased. At baseline and longitudinally, overprescribing was primarily associated with physician and practice characteristics and not with organisational factors.
Collapse
Affiliation(s)
- M A Smith
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 505 WARF Bldg, 610 Walnut St, Madison, WI 53726-2397, USA.
| | | | | |
Collapse
|
50
|
Terrell KM, Heard K, Miller DK. Prescribing to older ED patients. Am J Emerg Med 2006; 24:468-78. [PMID: 16787807 DOI: 10.1016/j.ajem.2006.01.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 01/07/2006] [Accepted: 01/15/2006] [Indexed: 11/28/2022] Open
Abstract
The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.
Collapse
Affiliation(s)
- Kevin M Terrell
- Department of Emergency Medicine, Indiana University Center for Aging Research, Regenstrief Institute, Inc, School of Medicine, Indianapolis, IN 46202, USA.
| | | | | |
Collapse
|