Mismanaging prescription medications among rural elders: the effects of socioeconomic status, health status, and medication profile indicators

Connection between Depression and Inability to Fill Prescriptions in Rural FQHC Patients with Chronic Disease

The purpose of this paper was to (1) examine the rates of elevated depression symptoms among a sample of rural Federally Qualified Health Center (FQHC) patients with chronic disease and (2) determine if an inability to afford general prescription medications within the past 12 months is a significant predictor of depression symptoms among these patients. These data came from Project EDUCATE, an ongoing five-year study designed to be a large-scale, multifocal examination of the needs and experiences of rural FQHC patients with hypertension and/or diabetes. A total of 497 rural FQHC patients completed surveys (including a series of psychosocial questions, the Multigroup Ethnic Identity Measure and the Center for Epidemiologic Studies Depression scale) as part of phase one of the project; 438 of these with complete data are included in the current analytic sample. Results revealed that 53.0% of the sample screened positive for depression, and over half of those who screened positive reported not being able to afford their prescription medications at least once within the past 12 months (51.3% vs. 26.3% non-depressed). Further, even after controlling for age, ethnic identity attachment, sex, education level, employment status, income, insurance status, recent inability to afford needed medical care, hypertensive status, mental health diagnosis, and family history of mental illness, patients who could not afford to fill their prescriptions in the past 12 months were 2.6 times as likely to screen positive for depression (OR_ADJ = 2.476, p = 0.002) as those who could afford their medications. Overall, results of this study suggest that, among rural patients diagnosed with chronic disease, depressive symptomatology may be alarmingly high and an inability to afford medications may be an important risk factor for depression symptoms. These results highlight the need for increased attention to prescription medication affordability among rural patients with chronic disease in order to reduce the risk of comorbid depression.

Risk factors for 30-d readmission after colorectal surgery: a systematic review

BACKGROUND

Readmission rates after colorectal surgery remain an ongoing clinical concern. Recent initiation of penalties for excess readmissions in medical patients has encouraged surgeons to reduce readmissions for surgical patients. We conducted a systematic review of the published literature for the purpose of identifying patient-related risk factors for 30-d readmissions after colorectal surgery.

METHODS

PubMed and Web of Science were queried for relevant English-language studies published before January 1, 2015, evaluating 30-d hospital readmissions after colorectal surgery in adult patients. Studies were included in this review only if they used a multivariable model to assess various patient-associated predictors and were excluded if the study size was less than 100 patients.

RESULTS

A total of 20 clinical research studies made up of 8 (40%) chart reviews and 12 (60%) administrative data met inclusion criteria. Most studies took place in the United States, and a variety of procedures (e.g., colectomy, rectal resection, stoma creation) and indications for surgery (e.g., cancer, inflammatory bowel disease, diverticular disease) were evaluated. The average ages of included patients was between 37 and 78 y and 36%-97% were men. Readmission rates ranged from 9%-25%. Overall, older age, comorbid conditions, preoperative immunosuppressive therapy, postoperative complications, and nonhome discharge were the most consistent and strongest predictors of readmission.

CONCLUSIONS

These identifiable risk factors highlight targets for interventions in an effort to reduce unplanned readmissions. Determining the most efficacious and cost-efficient means to reduce these preventable hospitalizations could save millions of valuable health care dollars.

Food insecurity is associated with cost-related medication non-adherence in community-dwelling, low-income older adults in Georgia

Low-income older adults are at increased risk of cutting back on basic needs, including food and medication. This study examined the relationship between food insecurity and cost-related medication non-adherence (CRN) in low-income Georgian older adults. The study sample includes new Older Americans Act Nutrition Program participants and waitlisted people assessed by a self-administered mail survey (N = 1000, mean age 75.0 + so - 9.1 years, 68.4% women, 25.8% African American). About 49.7% of participants were food insecure, while 44.4% reported practicing CRN. Those who were food insecure and/or who practiced CRN were more likely to be African American, low-income, younger, less educated, and to report poorer self-reported health status. Food insecure participants were 2.9 (95% CI 2.2, 4.0) times more likely to practice CRN behaviors than their counterparts after controlling for potential confounders. Improving food security is important inorder to promote adherence to recommended prescription regimens.

Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review

Background

In all OECD countries, there is a trend to increasing patients' copayments in order to balance rising overall health-care costs. This systematic review focuses on inequalities concerning the amount of out-of-pocket payments (OOPP) associated with income, education or gender in the Elderly aged 65+.

Methods

Based on an online search (PubMed), 29 studies providing information on OOPP of 65+ beneficiaries in relation to income, education and gender were reviewed.

Results

Low-income individuals pay the highest OOPP in relation to their earnings. Prescription drugs account for the biggest share. A lower educational level is associated with higher OOPP for prescription drugs and a higher probability of insufficient insurance protection. Generally, women face higher OOPP due to their lower income and lower labour participation rate, as well as less employer-sponsored health-care.

Conclusions

While most studies found educational and gender inequalities to be associated with income, there might also be effects induced solely by education; for example, an unhealthy lifestyle leading to higher payments for lower-educated people, or exclusively gender-induced effects, like sex-specific illnesses. Based on the considered studies, an explanation for inequalities in OOPP by these factors remains ambiguous.

Unmet Needs for the Older Americans Act Nutrition Program

This study documents the size of unmet needs for Older Americans Act Nutrition Program (OAANP) and characteristics of program participants and waitlisted people based on the data from the Georgia client database systems. About 60% of those who requested the OAANP service between July and early November, 2008 ( n = 4,952) were on waitlists. Waitlisted people, especially those on the Home-Delivered Meals (HDM) waitlist, were more likely to report poorer sociodemographic characteristics, poorer self-reported health status, food insecurity, and nutritional risk. Requesting HDM was the foremost significant factor associated with unmet needs. Other race/not disclosing race information and living alone also increased the odds of being on the waitlists. There is a critical unmet need for the OAANP in Georgia, especially among those targeted by the Older Americans Act and requesting HDM. Federal and state policy makers, administrators, and program providers should better understand and meet the need of nutritionally vulnerable older Georgians.

Patients at-risk for cost-related medication nonadherence: a review of the literature

OBJECTIVE

Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.

DESIGN

We conducted searches of four databases (MEDLINE, CINAHL, Sciences Citations Index Expanded, and EconLit) from 2001 to 2006 for English-language original studies. Articles were selected if the study included an explicit measure of CRN and reported results on covarying characteristics.

MAIN RESULTS

We found 19 studies with empirical support for concluding that certain patients may be susceptible to CRN: research has established consistent links between medication nonadherence due to costs and financial burden, but also to symptoms of depression and heavy disease burden. Only a handful of studies with limited statistical methods provided evidence on whether patients understand the health risks of CRN or to what extent clinicians influence patients to keep taking medications when faced with cost pressures. No relationship emerged between CRN and polypharmacy.

CONCLUSION

Efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage. Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare's new drug benefit.

Outcomes of antipsychotic drug use in community-dwelling elders with dementia

This study used administrative data from a large health care insurer in the southeast United States to describe the utilization pattern and health care outcomes of antipsychotic drug use in community-dwelling elders with dementia. Claims data from 959 unique cases were analyzed to address research aims. Overall, 27% of the sample was dispensed antipsychotic drugs, with the most prevalent type being atypical antipsychotic drugs. Individuals on any type of antipsychotic drug experienced more delirium, depression, hip fracture, falls, and syncope than those not on these drugs, even after controlling for age, sex, comorbidity, and number of other drugs prescribed. Implications for practice are discussed.

Longitudinal Examination of Homebound Older Adults Who Experience Heightened Food Insufficiency: Effect of Diabetes Status and Implications for Service Provision

PURPOSE

Healthful eating is important for optimal diabetes self-care. However, the level of food sufficiency may influence the degree of adherence to dietary self-care behaviors through the affordability of nutritionally appropriate food. This study examines whether homebound older adults with diabetes were at greater risk for heightened food insufficiency over 1 year, despite regular receipt of home-delivered meals.

DESIGN AND METHODS

This was a longitudinal study of a randomly recruited sample of 268 homebound older adults in the Nutrition and Function Study (NAFS) who regularly received home-delivered meals and completed baseline and 1-year in-home assessments. Based on an economic context model, self-reported data were collected on fundamental and proximate factors, food-sufficiency status, and intervening events. Determinants of heightened food insufficiency were examined with multivariate logistic regression models.

RESULTS

Not only did food-sufficiency status diminish over time in this sample, but it became or remained worse for older adults with diabetes. In addition to diabetes status, heightened food insufficiency was associated with perceived inadequacy of economic resources.

IMPLICATIONS

Health care providers and nutrition programs should attempt to identify high-risk older adults - those who have diabetes and are at risk of food insufficiency - and develop community linkages and strategies that integrate nutrition with diabetes care plans, thus supporting a multidisciplinary, chronic care model to improve diabetes management and outcomes.

Health outcomes and polypharmacy in elderly individuals: an integrated literature review

The purpose of this integrated literature review was to determine the extent of research available related to polypharmacy and its effect on the health outcomes of the elderly population. A search of the Cumulative Index of Nursing and Allied Health Literature and Medline was conducted for studies published between 1995 and 2003 that linked polypharmacy and outcomes in the elderly population. The 16 studies in this integrative literature review were conducted in the United States, Canada, Australia, and Europe. Polypharmacy was shown to be a statistically significant predictor of hospitalization, nursing home placement, death, hypoglycemia, fractures, impaired mobility, pneumonia, and malnutrition. The effect of polypharmacy on elderly individuals is significant as demonstrated by this literature review. Nurses are in a unique position to monitor and potentially eliminate adverse effects of a complex medication regimen. Nursing research on polypharmacy and its effects on nursing-sensitive outcomes will help define guidelines for prevention and intervention.

Prospective study of black-white differences in food insufficiency among homebound elders

OBJECTIVE

This study examines race differences in the association of sociodemographic and health-related characteristics with change in food sufficiency status over 1 year in homebound older adults.

METHOD

Using sociodemographic and health-related data collected during two in-home assessments as part of the North Carolina Nutrition and Function Study, logistic regression models (binary and nominal outcomes) adjusted for covariates and examined the characteristics associated with 1-year change in risk (RFI) and presence (FI) of food insufficiency among a random sample of 268 home-delivered meals participants.

RESULTS

Not having enough money for food and having to prepare cheaper and smaller meals was associated with increased RFI and FI at 1 year; having to borrow money for food, loss of food stamps, and inadequate income increased the odds among Whites, and increased medication use among Blacks.

DISCUSSION

The findings suggest that race, independent of other characteristics, is associated with diminished food sufficiency over 1 year.

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.

Use of Prescription Drugs: Rising or Declining?

Prescribing practices are a reflection of health professionals' abilities to discriminate among the various choices of drugs and determine the ones that will most benefit their patients. As selective as practitioners must be, they cannot limit themselves to knowing only those drugs that fit within the dominant paradigm of acute care. They must broaden their exposure to incorporate knowledge of drugs that permeate clients' lives through media and self-administration. Health promotion drug use is just emerging as a prescriptive activity, but it will become more significant in the future. Primary and secondary prevention drug uses are in flux, and tertiary prevention drug use is likely to overwhelm our system, particularly with the baby boom generation, until our society can switch its focus to more health promotion and disease prevention. It is imperative that health professionals develop shared decision-making capabilities for client education and appropriate prescribing. Only when the health care system exhibits a true client-provider partnership will the "five rights"-right drug, right dose, right route, right time, right client-be accurately applied. With the increasing and overwhelming costs of prescription drugs, health practitioners cannot afford to sit idle; as professionals and stakeholders, they must engage health policy makers and persuade these entities to share their concerns and views, and help their clients, the profession, and themselves.

Elders who delay medication because of cost: health insurance, demographic, health, and financial correlates

PURPOSE

Prescription medication use is essential to the health and well-being of many elderly persons. However, the cost of medications may be prohibitive and contribute to noncompliance with medical recommendations. This study identifies community-dwelling elders who reported a delay in medication use because of prescription medication cost.

DESIGN AND METHODS

This was a cross-sectional study of a nationwide sample of 6,535 elders participating in the Asset and Health Dynamics Among the Oldest Old (AHEAD) study. Participants reported if they had taken less medication than prescribed or if they had not filled prescriptions because of cost in the past 2 years. This response was then compared with the self-report of multiple variables, including demographic, health status, health insurance coverage, and financial variables.

RESULTS

Elders who were most vulnerable to medication delay as a result of cost included those with Medicare coverage only, low income, high out-of-pocket prescription costs, and poor health as well as African American elders and those aged 65-80 years.

IMPLICATIONS

This study provides important information about community-dwelling elders that reported a delay in medication use because of cost. As a Medicare prescription benefit has been passed, it will be important to monitor how these changes affect the elders identified at risk for medication delay.

Age and Medication Acceptance

Patients' willingness to take a newly prescribed medication is an important, but little studied, part of the medication process. The authors studied the impact of patient age on the perceived importance and interaction of three factors known to influence young people: severity of their medical condition, extent of possible medication side effects, and level of trust in their physician. A convenience sample of 170 French adults aged 18 to 93 rated their likelihood of taking a medication intended to alleviate physical suffering in 27 scenarios in which three levels (low, moderate, and high) of each of the above three factors were combined in an orthogonal factorial design. Among younger participants, high trust in the physician was not considered a sufficient reason for high acceptance of a new medication; it had to be accompanied by low side effects. Among very elderly participants, high trust led to high acceptance almost irrespective of the severity of possible side effects. Among the middle aged, trust and side effects had largely independent effects. To promote patients' acceptance of newly prescribed medications, physicians need to establish trust, but not abuse its power in elderly patients.

The relationship of medication regimen to hospital readmissions for older adults with heart failure

The purpose of this part of a longitudinal study was to examine whether medication therapy for older adults with heart failure predicted days to readmission post-hospital discharge. Using a prospective, predictive design, a convenience sample included 127 older adults with heart failure who had been recently discharged from two hospitals in northeastern Ohio. One hundred five patients were prescribed diuretics, 49 angiotensin-converting enzyme inhibitors, 23 b blockers, and 47 digoxin. There were no significant differences between readmitted and non-readmitted patients with regard to the use of the specific classes of cardiac medications. None of the specific classes of cardiac medications predicted the number of days between the initial hospital discharge and readmission 3 months later. The use of a small, non-probability sample and exclusion of variables limit the results of the study. Effective case management with teaching about heart failure must address changes involved with heart failure and the use of medication therapy. More research is needed about treatment protocols in various regions of the United States.

Meeting the needs of rural populations through interdisciplinary partnerships

This article describes the organization and outcomes of a Rural Health Outreach Initiative (RHOI) designed to increase collaboration between the medical education and health care delivery sectors to improve the quality of health care delivery and health outcomes in rural communities. Two inter-related partnership strategies were utilized in rural communities to address the health and social service needs of rural populations. The partnerships were created through the efforts of a rural health professions education program located in a community-based medical school. The two partnership models were implemented at the same time and target the same rural populations. Both strategies relied upon interdisciplinary collaborations to achieve their goals and outcomes. One strategy involved the creation of partnerships among rural medical students and the projects they initiate, using the model of community oriented primary care (COPC). The second strategy involved the establishment of partnerships by a variety of rural, community-based entities that resulted from a three-year Health Resources and Services Administration Rural Health Outreach grant that supported a "mini-grant" program. This article summarizes the process and results of these innovative collaborations that occurred at two levels: (1) between health and service institutions representing multiple disciplines and (2) between academic institutions and local communities. Specific attention is given to projects that resulted from the work of the partnerships that address the needs of older adults residing in the rural communities. The two strategies are compared and implications for the success of similar efforts are discussed.