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Deardorff WJ, Jing B, Growdon ME, Blank LJ, Bongiovanni T, Yaffe K, Boscardin WJ, Boockvar KS, Steinman MA. Impact of Hospitalizations on Problematic Medication Use Among Community-Dwelling Persons With Dementia. J Gerontol A Biol Sci Med Sci 2024; 79:glae207. [PMID: 39155601 PMCID: PMC11419320 DOI: 10.1093/gerona/glae207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization. METHODS We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008 to 2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from the 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks prehospitalization (baseline) to 4 months posthospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, prehospital chronic medications, and timepoint. RESULTS Among 1 475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR = 79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to posthospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs 1.40, difference 0.12 (95% CI -0.03, 0.26), p = .12). Results were consistent across medication domains and certain subgroups. In one prespecified subgroup, individuals on <5 prehospital chronic medications showed a greater increase in posthospital problematic medications compared with those on ≥5 medications (p = .04 for interaction, mean increase from baseline to posthospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications). CONCLUSIONS Hospitalizations had a small, nonstatistically significant effect on longer-term problematic medication use among PWD.
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Affiliation(s)
- W James Deardorff
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Bocheng Jing
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Matthew E Growdon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Leah J Blank
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tasce Bongiovanni
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kristine Yaffe
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Kenneth S Boockvar
- Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Geriatrics Research Education and Clinical Center, Birmingham, Alabama, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Mortelmans L, Goossens E, De Cock AM, van den Bemt P, Dilles T. Nurses' responses to patients' medication self-management problems in hospital and the use of recommendations. Br J Clin Pharmacol 2024; 90:2684-2690. [PMID: 39086169 DOI: 10.1111/bcp.16204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/19/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024] Open
Abstract
This study aimed to describe the use of recommendations as a guide for healthcare providers to support patients experiencing medication self-management problems and to evaluate their feasibility, user-friendliness and usefulness. Between March and August 2023, 58 hospitalized patients completed a self-assessment on medication self-management problems. The problems addressed in this self-assessment were based on a list of frequently encountered medication self-management problems from previous research. Consequently, 18 nurses responded to the reported problems using the recommendations. Nurses evaluated the feasibility, user-friendliness and usefulness of these recommendations through a survey. A total of 217 medication self-management problems were reported by 58 patients. Nurses intervened in 52% of the problems using the recommendations. According to nurses, the recommendations were user-friendly and feasible but required a substantial time investment. Considering these pilot-based results, the recommendations have the potential to be a valuable resource for nurses in practice, though this potential requires further exploration.
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Affiliation(s)
- Laura Mortelmans
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Research Foundation Flanders (FWO), Brussels, Belgium
| | - Eva Goossens
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Department of Patient Care, Antwerp University Hospital (UZA), Antwerp, Belgium
| | - Anne-Marie De Cock
- Department of Geriatrics, ZNA, Antwerp, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Patricia van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, The Netherlands
| | - Tinne Dilles
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Xiao Y, Hsu YJ, Hannum SM, Abebe E, Kantsiper ME, Pena IM, Wessell AM, Dy SM, Howell EE, Gurses AP. Assessing patient work system factors for medication management during transition of care among older adults: an observational study. BMJ Qual Saf 2024:bmjqs-2024-017297. [PMID: 39179376 DOI: 10.1136/bmjqs-2024-017297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 07/29/2024] [Indexed: 08/26/2024]
Abstract
OBJECTIVE To develop and evaluate measures of patient work system factors in medication management that may be modifiable for improvement during the care transition from hospital to home among older adults. DESIGN, SETTINGS AND PARTICIPANTS Measures were developed and evaluated in a multisite prospective observational study of older adults (≥65 years) discharged home from medical units of two US hospitals from August 2018 to July 2019. MAIN MEASURES Patient work system factors for managing medications were assessed during hospital stays using six capacity indicators, four task indicators and three medication management practice indicators. Main outcomes were assessed at participants' homes approximately a week after discharge for (1) Medication discrepancies between the medications taken at home and those listed in the medical record, and (2) Patient experiences with new medication regimens. RESULTS 274 of the 376 recruited participants completed home assessment (72.8%). Among capacity indicators, most older adults (80.6%) managed medications during transition without a caregiver, 41.2% expressed low self-efficacy in managing medications and 18.3% were not able to complete basic medication administration tasks. Among task indicators, more than half (57.7%) had more than 10 discharge medications and most (94.7%) had medication regimen changes. Having more than 10 discharge medications, more than two medication regimen changes and low self-efficacy in medication management increased the risk of feeling overwhelmed (OR 2.63, 95% CI 1.08 to 6.38, OR 3.16, 95% CI 1.29 to 7.74 and OR 2.56, 95% CI 1.25 to 5.26, respectively). Low transportation independence, not having a home caregiver, low medication administration skills and more than 10 discharge medications increased the risk of medication discrepancies (incidence rate ratio 1.39, 95% CI 1.01 to 1.91, incidence rate ratio 1.73, 95% CI 1.13 to 2.66, incidence rate ratio 1.99, 95% CI 1.37 to 2.89 and incidence rate ratio 1.91, 95% CI 1.24 to 2.93, respectively). CONCLUSIONS Patient work system factors could be assessed before discharge with indicators for increased risk of poor patient experience and medication discrepancies during older adults' care transition from hospital to home.
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Affiliation(s)
- Yan Xiao
- College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, Texas, USA
| | - Yea-Jen Hsu
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susan M Hannum
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Ephrem Abebe
- College of Pharmacy, Purdue University, West Lafayette, Indiana, USA
| | | | - Ivonne Marie Pena
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Andrea M Wessell
- Patient Safety Organization, DARTNet Institute, Charleston, South Carolina, USA
| | - Sydney M Dy
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Eric E Howell
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Ayse P Gurses
- Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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4
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Japelj N, Kerec Kos M, Jošt M, Knez L. Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards. Front Pharmacol 2024; 15:1376002. [PMID: 39185310 PMCID: PMC11341450 DOI: 10.3389/fphar.2024.1376002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/12/2024] [Indexed: 08/27/2024] Open
Abstract
Introduction Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards. Methods A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS). Results At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge. Discussion Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.
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Affiliation(s)
- Nuša Japelj
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Mojca Kerec Kos
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
| | - Maja Jošt
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
| | - Lea Knez
- Faculty of Pharmacy, University of Ljubljana, Ljubljana, Slovenia
- Department of Pharmacy, University Clinic Golnik, Golnik, Slovenia
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Mortelmans L, Dilles T. The development and evaluation of a medication diary to report problems with medication use. Heliyon 2024; 10:e26127. [PMID: 38375256 PMCID: PMC10875575 DOI: 10.1016/j.heliyon.2024.e26127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose The study aimed to develop and evaluate a medication diary for patients to report problems with medication use to enable shared-decision making and improve medication adherence. Methods Based on a search for existing diaries, a review of the content, and a list of medication self-management problems compiled from previous research, a paper and pencil version of a medication diary was developed. The diary was reviewed for clarity and overall presentation by five healthcare providers and nine patients. Afterwards, user-friendliness was evaluated by 69 patients with polypharmacy discharged from hospital during a quantitative prospective study. Results The medication diary consists of several parts: (1) a medication schedule allowing patients to list their medicines, (2) information sheets allowing patients to write down specific medication-related information, (3) a monthly overview to indicate daily whether medication-related problems were experienced, (4) problem sheets elaborating on the problems encountered, (5) space for specific medication-related questions for healthcare providers to facilitate shared-decision making. The review phase resulted in minor textual adjustments and one extra problem in the problem sheet. Most participants, who tested the medication diary for two months, found the diary user-friendly (80%) and easy to fill in (89%). About 40% of participants reported problems with medication use. Half of the patients indicated that the diary can facilitate discussing problems with healthcare providers. Conclusion The medication diary offers patients the opportunity to report problems regarding their medication use in a proven user-friendly manner and to discuss these problems with healthcare providers. Reporting and discussing problems with medication use can serve as a first step towards making shared decisions on how to address the problems encountered.
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Affiliation(s)
- Laura Mortelmans
- Department of Nursing Science and Midwifery, Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Research Foundation Flanders (FWO), Brussels, Belgium
| | - Tinne Dilles
- Department of Nursing Science and Midwifery, Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Weir DL, Ma X, McCarthy L, Tang T, Lapointe-Shaw L, Wodchis WP, Fernandes O, McDonald EG. Medication clusters at hospital discharge and risk of adverse drug events at 30 days postdischarge: A population-based cohort study of older adults. Br J Clin Pharmacol 2023; 89:3715-3752. [PMID: 37565499 DOI: 10.1111/bcp.15872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/22/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023] Open
Abstract
AIMS Certain combinations of medications can be harmful and may lead to serious adverse drug events (ADEs). Identifying potentially problematic medication clusters could help guide prescribing and/or deprescribing decisions in hospital. The aim of this study is to characterize medication prescribing patterns at hospital discharge and determine which medication clusters were associated with an increased risk of ADEs in the 30-day posthospital discharge. METHODS All residents of the province of Ontario in Canada aged 66 years or older admitted to hospital between March 2016 and February 2017 were included. Identification of medication clusters prescribed at hospital discharge was conducted using latent class analysis. Cluster identification and categorization were based on medications dispensed up to 30-day posthospitalization. Multivariable logistic regression was used to assess the potential association between membership to a particular medication cluster and ADEs postdischarge, while also evaluating other patient characteristics. RESULTS In total, 188 354 patients were included in the study cohort. Median age (interquartile range) was 77 (71-84) years, and patients had a median (IQR) (interquartile range [IQR]) of 9 (6-13) medications dispensed prior to admission. Within the study population, 6 separate clusters of dispensing patterns were identified: cardiovascular (14%), respiratory (26%), complex care needs (12%), cardiovascular and metabolic (15%), infection (10%), and surgical (24%). Overall, 12 680 (7%) patients had an ADE in the 30 days following discharge. After considering other patient characteristics, those belonging to the respiratory cluster had the highest risk of ADEs (adjusted odds ratio: 1.12, 95% confidence interval: 1.08-1.17) compared with all the other clusters, while those in the complex care needs cluster had the lowest risk (adjusted odds ratio: 0.82, 95% confidence interval: 0.77-0.87). CONCLUSION This study suggests that ADEs post hospital discharge can be linked with identifiable medication clusters. This information may help clinicians and researchers better understand patient populations that are more or less likely to benefit from peri-hospital discharge interventions aimed at reducing ADEs.
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Affiliation(s)
- Daniala L Weir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Xiaomeng Ma
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Health System Performance Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lisa McCarthy
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Pharmacy, Trillium Health Partners, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Terence Tang
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Pharmacy, Trillium Health Partners, Toronto, Ontario, Canada
- Department of Internal Medicine, Trillium Health Partners, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Health System Performance Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
| | | | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
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Young RA, Gurses AP, Fulda KG, Espinoza A, Daniel KM, Hendrix ZN, Sutcliffe KM, Xiao Y. Primary care teams' reported actions to improve medication safety: a qualitative study with insights in high reliability organising. BMJ Open Qual 2023; 12:e002350. [PMID: 37777254 PMCID: PMC10546137 DOI: 10.1136/bmjoq-2023-002350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/11/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND Our aim was to understand actions by primary care teams to improve medication safety. METHODS This was a qualitative study using one-on-one, semistructured interviews with the questions guided by concepts from collaborative care and systems engineering models, and with references to the care of older adults. We interviewed 21 primary care physicians and their team members at four primary care sites serving patients with mostly low socioeconomic status in Southwest US during 2019-2020. We used thematic analysis with a combination of inductive and deductive coding. First, codes capturing safety actions were incrementally developed and revised iteratively by a team of multidisciplinary analysts using the inductive approach. Themes that emerged from the coded safety actions taken by primary care professionals to improve medication safety were then mapped to key principles from the high reliability organisation framework using a deductive approach. RESULTS Primary care teams described their actions in medication safety mainly in making standard-of-care medical decisions, patient-shared decision-making, educating patients and their caregivers, providing asynchronous care separate from office visits and providing clinical infrastructure. Most of the actions required customisation at the individual level, such as limiting the supply of certain medications prescribed and simplifying medication regimens in certain patients. Primary care teams enacted high reliability organisation principles by anticipating and mitigating risks and taking actions to build resilience in patient work systems. The primary care teams' actions reflected their safety organising efforts as responses to many other agents in multiple settings that they could not control nor easily coordinate. CONCLUSIONS Primary care teams take many actions to shape medication safety outcomes in community settings, and these actions demonstrated that primary care teams are a reservoir of resilience for medication safety in the overall healthcare system. To improve medication safety, primary care work systems require different strategies than those often used in more self-contained systems such as hospital inpatient or surgical services.
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Affiliation(s)
| | - Ayse P Gurses
- Johns Hopkins University Medical School, Anesthesiology and Critical Care Medicine, Baltimore, Maryland, USA
| | - Kimberly G Fulda
- Family Medicine and Osteopathic Manipulative Medicine, UNTHSC, Fort Worth, Texas, USA
| | - Anna Espinoza
- Family Medicine and Osteopathic Manipulative Medicine, UNTHSC, Fort Worth, Texas, USA
| | - Kathryn M Daniel
- College of Nursing and Health Innovation, UT Arlington, Arlington, Texas, USA
| | - Zachary N Hendrix
- College of Nursing and Health Innovation, UT Arlington, Arlington, Texas, USA
| | | | - Yan Xiao
- College of Nursing and Health Innovation, UT Arlington, Arlington, Texas, USA
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Mortelmans L, Goossens E, De Cock AM, Petrovic M, van den Bemt P, Dilles T. The Development of Recommendations for Healthcare Providers to Support Patients Experiencing Medication Self-Management Problems. Healthcare (Basel) 2023; 11:healthcare11111545. [PMID: 37297685 DOI: 10.3390/healthcare11111545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Medication self-management problems such as the inability to correctly obtain, understand, organize, administer or monitor medication can result in negative patient outcomes. However, supportive tools for healthcare providers to assist patients with medication self-management problems are lacking. This study aimed to develop recommendations for healthcare providers to support patients with polypharmacy who experience medication self-management problems. A three-phase study was conducted starting with (1) the mapping of medication self-management problems, followed by (2) a scoping review providing a list of relevant interventions and actions for each respective problem and (3) a three-round modified e-Delphi study with experts to reach consensus on the relevance and clarity of the recommended interventions and actions. The cut-off for consensus on the relevance and clarity of the recommendations was set at 80% expert agreement. Experts could propose additional recommendations based on their professional experience and expertise. The experts (n = 23) involved were healthcare professionals (i.e., nurses, pharmacists, and physicians) with specific expertise in medication management of patients with polypharmacy. Simultaneous with the second e-Delphi round, a panel of patients with polypharmacy (n = 8) evaluated the usefulness of recommendations. Results obtained from the patient panel were fed back to the panel of healthcare providers in the third e-Delphi round. Descriptive statistics were used for data analysis. Twenty medication self-management problems were identified. Based on the scoping review, a list of 66 recommendations for healthcare providers to support patients with the identified medication self-management problems was composed. At the end of the three-round e-Delphi study, the expert panel reached consensus on the relevance and clarity of 67 recommendations, clustered according to the six phases of the medication self-management model by Bailey et al. In conclusion, this study resulted in a guidance document including recommendations that can serve as a resource for healthcare providers to support patients with polypharmacy in case of medication self-management problems. Future research should focus on the evaluation of the feasibility and user-friendliness of the guide with recommendations in clinical practice.
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Affiliation(s)
- Laura Mortelmans
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
- Research Foundation Flanders (FWO), 1000 Brussels, Belgium
| | - Eva Goossens
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
- Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
- Department of Patient Care, Antwerp University Hospital (UZA), 2610 Antwerp, Belgium
| | - Anne-Marie De Cock
- Department of Geriatrics, ZNA, 2020 Antwerp, Belgium
- Department of Family Medicine and Population Health, University of Antwerp, 2610 Antwerp, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, 9000 Ghent, Belgium
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, 9000 Ghent, Belgium
| | - Patricia van den Bemt
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Tinne Dilles
- Centre for Research and Innovation in Care (CRIC), Nurse and Pharmaceutical Care (NuPhaC), Department of Nursing Science and Midwifery, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Antwerp, Belgium
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Pedretti RFE, Hansen D, Ambrosetti M, Back M, Berger T, Ferreira MC, Cornelissen V, Davos CH, Doehner W, de Pablo Y Zarzosa C, Frederix I, Greco A, Kurpas D, Michal M, Osto E, Pedersen SS, Salvador RE, Simonenko M, Steca P, Thompson DR, Wilhelm M, Abreu A. How to optimize the adherence to a guideline-directed medical therapy in the secondary prevention of cardiovascular diseases: a clinical consensus statement from the European Association of Preventive Cardiology. Eur J Prev Cardiol 2023; 30:149-166. [PMID: 36098041 DOI: 10.1093/eurjpc/zwac204] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/20/2022] [Accepted: 09/07/2022] [Indexed: 01/27/2023]
Abstract
A key factor to successful secondary prevention of cardiovascular disease (CVD) is optimal patient adherence to treatment. However, unsatisfactory rates of adherence to treatment for CVD risk factors and CVD have been observed consistently over the last few decades. Hence, achieving optimal adherence to lifestyle measures and guideline-directed medical therapy in secondary prevention and rehabilitation is a great challenge to many healthcare professionals. Therefore, in this European Association of Preventive Cardiology clinical consensus document, a modern reappraisal of the adherence to optimal treatment is provided, together with simple, practical, and feasible suggestions to achieve this goal in the clinical setting, focusing on evidence-based concepts.
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Affiliation(s)
| | - Dominique Hansen
- REVAL/BIOMED, Hasselt University, Hasselt, Belgium
- Heart Centre Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Marco Ambrosetti
- Cardiovascular Rehabilitation Unit, ASST Crema, Santa Marta Hospital, Rivolta D'Adda, Italy
| | - Maria Back
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Goteborg, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linkoping, Sweden
| | - Thomas Berger
- Cardiomed Linz, St.John of God Hospital Linz, Linz, Austria
| | - Mariana Cordeiro Ferreira
- Psychologist, Centro de Reabilitação Cardiovascular do Centro Universitário Hospitalar Lisboa Norte, Portugal
| | | | - Constantinos H Davos
- Cardiovascular Research Laboratory, Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | - Wolfram Doehner
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology (Virchow Klinikum), Charité Universitätsmedizin Berlin and German, Berlin, Germany
- Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Ines Frederix
- Heart Centre Hasselt, Jessa Hospital Hasselt Belgium, Hasselt University, Hasselt, Belgium
- Faculty of Medicine and Life Sciences Diepenbeek Belgium, University of Antwerp, Antwerp, Belgium
- Faculty of Medicine and Health Sciences Antwerp Belgium, Antwerp University Hospital, Edegem, Belgium
| | - Andrea Greco
- Department of Human and Social Sciences, University of Bergamo, Bergamo, Italy
| | - Donata Kurpas
- Department of Family Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Matthias Michal
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Mainz, Germany
| | - Elena Osto
- Institute of Clinical Chemistry & Department of Cardiology, Heart Center, University & University Hospital Zurich, Zurich, Switzerland
| | - Susanne S Pedersen
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | - Maria Simonenko
- Heart Transplantation Outpatient Department, Cardiopulmonary Exercise Test Research Department, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Patrizia Steca
- Department of Psychology, University of Milan-Bicocca, Milano, Italy
| | - David R Thompson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Matthias Wilhelm
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ana Abreu
- Department of Cardiology of Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Institute of Preventive Medicine and Institute of Environmental Health of the Faculty of Medicine of University of Lisbon, Centre of Cardiovascular Investigation of University of Lisbon (CCUL) and Academic Centre of Medicine of University of Lisbon (CAML), Lisbon, Portugal
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10
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Xiao Y, Smith A, Abebe E, Hannum SM, Wessell AM, Gurses AP. Understanding Hazards for Adverse Drug Events Among Older Adults After Hospital Discharge: Insights From Frontline Care Professionals. J Patient Saf 2022; 18:e1174-e1180. [PMID: 35617608 PMCID: PMC9679039 DOI: 10.1097/pts.0000000000001046] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Care transitions pose a high risk of adverse drug events (ADEs). We aimed to identify hazards to medication safety for older adults during care transitions using a systems approach. METHODS Hospital-based professionals from 4 hospitals were interviewed about ADE risks after hospital discharge among older adults. Concerns were extracted from the interview transcript, and for each concern, hazard for medication-related harms was coded and grouped by its sources according to a human factors and systems engineering model that views postdischarge ADEs as the outcome of professional and patient home work systems. RESULTS Thirty-eight professionals participated (5 hospitalists, 24 nurses, 4 clinical pharmacists, 3 pharmacy technicians, and 2 social workers). Hazards were classified into 6 groups, ranked by frequencies of hazards coded: (1) medication tasks related at home, (2) patient and caregiver related, (3) hospital work system related, (4) home resource related, (5) hospital professional-patient collaborative work related, and (6) external environment related. Medications most frequently cited when describing concerns included anticoagulants, insulins, and diuretics. Top coded hazard types were complex dosing, patient and caregiver knowledge gaps in medication management, errors in discharge medications, unaffordable cost, inadequate understanding about changes in medications, and gaps in access to care or in sharing medication information. CONCLUSIONS From the perspective of hospital-based frontline health care professionals, hazards for medication-related harms during care transitions were multifactorial and represented those introduced by the hospital work system as well as defects unrecognized and unaddressed in the home work system.
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Affiliation(s)
- Yan Xiao
- From the College of Nursing and Health Innovation, University of Texas at Arlington
| | - Aaliyah Smith
- College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas
| | - Ephrem Abebe
- Department of Pharmacy Practice, Purdue University, College of Pharmacy, West Lafayette, Indiana
| | - Susan M Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrea M Wessell
- Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Ayse P Gurses
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore, Maryland
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11
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Riester MR, Goyal P, Jiang L, Erqou S, Rudolph JL, McGeary JE, Rogus-Pulia NM, Madrigal C, Quach L, Wu WC, Zullo AR. New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:3368-3379. [PMID: 34981366 PMCID: PMC9550891 DOI: 10.1007/s11606-021-07233-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge. OBJECTIVE Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge. DESIGN Retrospective cohort. PARTICIPANTS Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF. MAIN MEASURES Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge. KEY RESULTS Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge. CONCLUSIONS Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.
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Affiliation(s)
- Melissa R Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA.
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA.
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Sebhat Erqou
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - James L Rudolph
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - John E McGeary
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI, USA
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, RI, USA
| | - Nicole M Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI, USA
| | - Caroline Madrigal
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Lien Quach
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Wen-Chih Wu
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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12
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Bajeux E, Alix L, Cornée L, Barbazan C, Mercerolle M, Howlett J, Cruveilhier V, Liné-Iehl C, Cador B, Jego P, Gicquel V, Schweyer FX, Marie V, Hamonic S, Josselin JM, Somme D, Hue B. Pharmacist-led medication reconciliation at patient discharge: a tool to reduce healthcare utilization? an observational study in patients 65 years or older. BMC Geriatr 2022; 22:576. [PMID: 35831783 PMCID: PMC9281036 DOI: 10.1186/s12877-022-03192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
Background Older patients often experience adverse drug events (ADEs) after discharge that may lead to unplanned readmission. Medication Reconciliation (MR) reduces medication errors that lead to ADEs, but results on healthcare utilization are still controversial. This study aimed to assess the effect of MR at discharge (MRd) provided to patients aged over 65 on their unplanned rehospitalization within 30 days and on both patients’ experience of discharge and their knowledge of their medication. Methods An observational multicenter prospective study was conducted in 5 hospitals in Brittany, France. Results Patients who received both MR on admission (MRa) and MRd did not have significantly fewer deaths, unplanned rehospitalizations and/or emergency visits related to ADEs (OR = 1.6 [0.7 to 3.6]) or whatever the cause (p = 0.960) 30 days after discharge than patients receiving MRa alone. However, patients receiving both MRa and MRd were more likely to feel that their discharge from the hospital was well organized (p = 0.003) and reported more frequently that their community pharmacist received information about their hospital stay (p = 0.036). Conclusions This study found no effect of MRd on healthcare utilization 30 days after discharge in patients over 65, but the process improved patients’ experiences of care continuity. Further studies are needed to better understand this positive impact on their drug care pathway in order to improve patients’ ownership of their drugs, which is still insufficient. Improving both the interview step between pharmacist and patient before discharge and the transmission of information from the hospital to primary care professionals is needed to enhance MR effectiveness. Trial registration NCT04018781 July 15, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03192-3.
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Affiliation(s)
- Emma Bajeux
- Department of Epidemiology and Public Health, Univ Rennes, Rennes University Hospital, F-35000, Rennes, France.
| | - Lilian Alix
- Department of Internal Medicine and Clinical Immunology, Univ Rennes, Rennes University Hospital, F-35000, Rennes, France
| | - Lucie Cornée
- Department of Geriatrics, St-Laurent Polyclinic, Hospitalité St-Thomas de Villeneuve, F-35000, Rennes, France
| | - Camille Barbazan
- Department of Pharmacy, Rennes University Hospital, F-35000, Rennes, France
| | - Marion Mercerolle
- Department of Pharmacy, Rennes University Hospital, F-35000, Rennes, France
| | - Jennifer Howlett
- Department of Pharmacy, Rennes University Hospital, F-35000, Rennes, France
| | | | - Charlotte Liné-Iehl
- Department of Pharmacy, Montfort/Meu Hospital, F-35160, Montfort/Meu, France
| | - Bérangère Cador
- Department of Internal Medicine and Clinical Immunology, Univ Rennes, Rennes University Hospital, F-35000, Rennes, France
| | - Patrick Jego
- Department of Internal Medicine and Clinical Immunology, Univ Rennes, Rennes University Hospital, F-35000, Rennes, France
| | - Vincent Gicquel
- Department of Pharmacy, Rennes University Hospital, F-35000, Rennes, France
| | - François-Xavier Schweyer
- Department of Human and Social Sciences, Univ Rennes, EHESP, EA7348 MOS, F-35000, Rennes, France
| | | | - Stéphanie Hamonic
- Department of Epidemiology and Public Health, Univ Rennes, Rennes University Hospital, F-35000, Rennes, France
| | | | - Dominique Somme
- Department of Geriatrics, Department of Geriatrics, Univ Rennes, EHESP, CNRS, Inserm, Arènes - UMR 6051, RSMS - U 1309 , F-35000, Rennes, France
| | - Benoit Hue
- Department of Pharmacy, Rennes University Hospital, F-35000, Rennes, France
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13
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Ambulatory Medication Safety in Primary Care: A Systematic Review. J Am Board Fam Med 2022; 35:610-628. [PMID: 35641040 PMCID: PMC9730343 DOI: 10.3122/jabfm.2022.03.210334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 12/27/2021] [Accepted: 01/10/2022] [Indexed: 11/08/2022] Open
Abstract
PURPOSE To review the literature on medication safety in primary care in the electronic health record era. METHODS Included studies measured rates and outcomes of medication safety in patients whose prescriptions were written in primary care clinics with electronic prescribing. Four investigators independently reviewed titles and analyzed abstracts with dual-reviewer review for eligibility, characteristics, and risk of bias. RESULTS Of 1464 articles identified, 56 met the inclusion criteria. Forty-three studies were noninterventional and 13 included an intervention. The majority of the studies (30) used their own definition of error. The most common outcomes were potentially inappropriate prescribing/medications (PIPs), adverse drug events (ADEs), and potential prescribing omissions (PPOs). Most of the studies only included high-risk subpopulations (39), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). There was poor correlation of PIP and PPO with documented ADEs leading to physical harm. CONCLUSIONS This literature is limited by its inconsistent and highly variable outcomes. The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. Applying algorithms to primary care medication lists significantly overestimates rate of actual harms.
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Sharara SL, Arbaje AI, Cosgrove SE, Gurses AP, Dzintars K, Ladikos N, Qasba SS, Keller SC. The Voice of the Patient: Patient Roles in Antibiotic Management at the Hospital-to-Home Transition. J Patient Saf 2022; 18:e633-e639. [PMID: 34569996 PMCID: PMC8940725 DOI: 10.1097/pts.0000000000000899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Our objective was to characterize tasks required for patient-performed antibiotic medication management (MM) at the hospital-to-home transition, as well as barriers to and strategies for patient-led antibiotic MM. Our overall goal was to understand patients' role in managing antibiotics at the hospital-to-home transition. METHODS We performed a qualitative study including semistructured interviews with health care workers and contextual inquiry with patients discharged home on oral antibiotics. The setting was one academic medical center and one community hospital. Participants included 37 health care workers and 16 patients. We coded interview transcripts and notes from contextual inquiry and developed themes. RESULTS We identified 6 themes involving barriers or strategies for antibiotic MM. We identified dissonance between participant descriptions of the ease of antibiotic MM at the hospital-to-home transition and their experience of barriers. Similarly, patients did not always recognize when they were experiencing side effects. Lack of access to follow-up care led to unnecessarily long antibiotic courses. Instructions about completing antibiotics were not routinely provided. However, patients typically did not question the need for the prescribed antibiotic. CONCLUSIONS There are many opportunities to improve patient-led antibiotic MM at the hospital-to-home transition. Mismatches between patient perceptions and patient experiences around antibiotic MM at the hospital-to-home transition provide opportunities for health system improvement.
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Affiliation(s)
- Sima L Sharara
- From the Division of Infectious Diseases, Department of Medicine
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15
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Schwarzkopf A, Schönenberg A, Prell T. Patterns and Predictors of Medication Change after Discharge from Hospital: An Observational Study in Older Adults with Neurological Disorders. J Clin Med 2022; 11:563. [PMID: 35160015 PMCID: PMC8836689 DOI: 10.3390/jcm11030563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Medication is often changed after inpatient treatment, which affects the course of the disease, health behavior and adherence. Thus, it is important to understand patterns of medication changes after discharge from hospital. METHODS Inpatients at the Department of Neurology received a comprehensive assessment during their stay, including adherence, depression, cognition, health and sociodemographic variables. A month after being discharged, patients were contacted to enquire about post-discharge medication changes. RESULTS 910 older adults aged 70 ± 8.6 years participated, of which 204 (22.4%) reported medication changes. The majority of changes were initiated by physicians (n = 112, 56.3%) and only 25 (12.6%) patients reported adjusting medication themselves. Reasons for medication changes differed between patients and doctors (p < 0.001), with side effects or missing effects cited frequently. Sociodemographic and patient-related factors did not significantly predict medication changes. CONCLUSION Patients reported less post-discharge medication changes than expected, and contrary to previous literature on nonadherence, only a fraction of those changes were performed by patients themselves. Socioeconomic and clinical parameters regarding personality, mood and cognition were poorly associated with post-discharge medication changes. Instead, individual health-related factors play a role, with patient factors only indirectly influencing physicians' decisions.
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Affiliation(s)
- Anna Schwarzkopf
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (A.S.); (T.P.)
| | - Aline Schönenberg
- Department of Geriatrics, Halle University Hospital, 06120 Halle, Germany
| | - Tino Prell
- Department of Neurology, Jena University Hospital, 07747 Jena, Germany; (A.S.); (T.P.)
- Department of Geriatrics, Halle University Hospital, 06120 Halle, Germany
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16
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Toscano Guzmán MD, Banqueri MG, Otero MJ, Fidalgo SS, Noguera IF, Guerrero MCP. Validating a Trigger Tool for Detecting Adverse Drug Events in Elderly Patients With Multimorbidity (TRIGGER-CHRON). J Patient Saf 2021; 17:e976-e982. [PMID: 30418424 DOI: 10.1097/pts.0000000000000552] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aims of the study were to evaluate the performance of an initial list developed to detect adverse drug events (ADEs) in elderly patients with multimorbidity in clinical practice, to explore the possibility of shortening the list, and to use this tool to study the incidence and characteristics of the ADEs among this population. METHODS This observational study was conducted at 12 Spanish hospitals. A random sample of five charts from each hospital was selected weekly for retrospective review for a 12-week period. We included patients aged 65 years and older with multimorbidity, hospitalized more than 48 hours. Adverse drug events were detected using a list of 51 triggers previously selected by an expert panel by means of a modified Delphi method. The number of triggers identified and ADEs detected were recorded. The severity and preventability of the ADEs were evaluated. The positive predictive value (PPV) of each trigger was calculated and used to select the most efficient triggers. RESULTS In 720 charts reviewed, 1430 positive triggers were identified that led to detect 215 ADEs in 178 patients (24.7%), of which 13% were serious. One hundred nineteen ADEs (55.3%) were preventable and mainly related to inadequate treatment monitoring and prescribing errors. Triggers with a PPV of 5% or less were eliminated, resulting in a final list of 32 triggers (TRIGGER-CHRON) with a PPV of 22.1%, which accounted for 98.9% of all ADEs detected and 98.6% of the preventable ADEs. CONCLUSIONS The shorter final validated TRIGGER-CHRON tool is an efficient list for identifying ADEs in elderly patients with multimorbidity, detecting ADEs in one-fourth of hospitalized patients in internal medicine or geriatric units.
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Affiliation(s)
| | | | - María José Otero
- ISMP-SPAIN, Complejo Asistencial Universitario de Salamanca, Salamanca
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Marques Cavalcante-Santos L, Carvalho Silvestre C, Andrade Macêdo L, Mônica Machado Pimentel D, Dias de Oliveira-Filho A, Manias E, Pereira de Lyra D. Written communication about the use of medications in medical records in a Brazilian hospital. Int J Clin Pract 2021; 75:e14990. [PMID: 34710266 DOI: 10.1111/ijcp.14990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 09/23/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Effective communication regarding the use of medications in hospital environments is a process that contributes to patient safety. Despite its importance, written communication about the medication use process in medical records remains insufficiently investigated. AIM To describe the documentation in medical records regarding the medication use process by pharmacists, physicians and nurses on admission, during the hospital stay, and at hospital discharge. METHOD A retrospective cross-sectional chart review study was carried out in medical records of patients admitted to a teaching hospital in Northeast Brazil. The study considered all patients admitted between December 2016 and February 2017, aged 18 or older and hospitalised for at least 48 hours. Clinical notes made by pharmacists, physicians and nurses were examined at three transition points of care. Data were collected using a questionnaire relating to the use of medications prior to hospital admission, changes in the prescribed medications during the hospital stay and discharge, as well as prescription non-conformities. Communication failures between the three healthcare professional groups were analysed and classified. The study was authorised by the Hospital's Board of Directors and approved by the Research Ethics Committee of the Federal University of Sergipe. RESULTS This study included 202 medical records of patients with a mean age of 51.48 (SD 6.42, range: 19-97) years. There was no record of a patient or relative interview on allergies and adverse drug reactions in 54 (26.8%) physician notes, 44 (21.9%) nursing notes, and 9 (25.0%) pharmacist notes. Moreover, 1,588 changes in prescriptions were identified during data collection, and 1,198 (75.4%) of these were unjustified. CONCLUSION Medication-related information in medical records was incomplete and inconsistent in the clinical notes of the three studied professions, especially in pharmacists' documentation. Future studies should focus on investigating the consequences of interprofessional communication in patient care.
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Affiliation(s)
- Lincoln Marques Cavalcante-Santos
- Department of Pharmaceutical Sciences, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo (USP), Ribeirão Preto, São Paulo, Brazil
| | - Carina Carvalho Silvestre
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Department of Pharmacy, Federal University of Sergipe, São Cristóvão, Brazil
- Department of Pharmacy, Life Sciences Institute, Federal University of Juiz de Fora, Minas Gerais, Brazil
| | - Luana Andrade Macêdo
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Department of Pharmacy, Federal University of Sergipe, São Cristóvão, Brazil
| | | | | | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Burwood, Victoria, Australia
| | - Divaldo Pereira de Lyra
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Department of Pharmacy, Federal University of Sergipe, São Cristóvão, Brazil
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Anderson TS, Lee AK, Jing B, Lee S, Herzig SJ, Boscardin WJ, Fung K, Rizzo A, Steinman MA. Intensification of Diabetes Medications at Hospital Discharge and Clinical Outcomes in Older Adults in the Veterans Administration Health System. JAMA Netw Open 2021; 4:e2128998. [PMID: 34673963 PMCID: PMC8531994 DOI: 10.1001/jamanetworkopen.2021.28998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
IMPORTANCE Transient elevations of blood glucose levels are common in hospitalized older adults with diabetes and may lead clinicians to discharge patients with more intensive diabetes medications than they were using before hospitalization. OBJECTIVE To investigate outcomes associated with intensification of outpatient diabetes medications at discharge. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study assessed patients 65 years and older with diabetes not taking insulin who were hospitalized in the Veterans Health Administration Health System between January 1, 2011, and September 28, 2016, for common medical conditions. Data analysis was performed from January 1, 2020, to March 31, 2021. EXPOSURE Discharge with intensified diabetes medications, defined as filling a prescription at hospital discharge for a new or higher-dose medication than was being used before hospitalization. Propensity scores were used to construct a matched cohort of patients who did and did not receive diabetes medication intensifications. MAIN OUTCOMES AND MEASURES Coprimary outcomes of severe hypoglycemia and severe hyperglycemia were assessed at 30 and 365 days using competing risk regressions. Secondary outcomes included all-cause readmissions, mortality, change in hemoglobin A1c (HbA1c) level, and persistent use of intensified medications at 1 year after discharge. RESULTS The propensity-matched cohort included 5296 older adults with diabetes (mean [SD] age, 73.7 [7.7] years; 5212 [98.4%] male; and 867 [16.4%] Black, 47 [0.9%] Hispanic, 4138 [78.1%] White), equally split between those who did and did not receive diabetes medication intensifications at hospital discharge. Within 30 days, patients who received medication intensifications had a higher risk of severe hypoglycemia (hazard ratio [HR], 2.17; 95% CI, 1.10-4.28), no difference in risk of severe hyperglycemia (HR, 1.00; 95% CI, 0.33-3.08), and a lower risk of death (HR, 0.55; 95% CI, 0.33-0.92). At 1 year, no differences were found in the risk of severe hypoglycemia events, severe hyperglycemia events, or death and no difference in change in HbA1c level was found among those who did vs did not receive intensifications (mean postdischarge HbA1c, 7.72% vs 7.70%; difference-in-differences, 0.02%; 95% CI, -0.12% to 0.16%). At 1 year, 48.0% (591 of 1231) of new oral diabetes medications and 38.5% (548 of 1423) of new insulin prescriptions filled at discharge were no longer being filled. CONCLUSIONS AND RELEVANCE In this national cohort study, among older adults hospitalized for common medical conditions, discharge with intensified diabetes medications was associated with an increased short-term risk of severe hypoglycemia events but was not associated with reduced severe hyperglycemia events or improve HbA1c control. These findings indicate that short-term hospitalization may not be an effective time to intervene in long-term diabetes management.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Alexandra K. Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Shoshana J. Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - W. John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Anael Rizzo
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Tomlinson J, Marques I, Silcock J, Fylan B, Dyson J. Supporting medicines management for older people at care transitions - a theory-based analysis of a systematic review of 24 interventions. BMC Health Serv Res 2021; 21:890. [PMID: 34461892 PMCID: PMC8404335 DOI: 10.1186/s12913-021-06890-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 08/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Older patients are at severe risk of harm from medicines following a hospital to home transition. Interventions aiming to support successful care transitions by improving medicines management have been implemented. This study aimed to explore which behavioural constructs have previously been targeted by interventions, which individual behaviour change techniques have been included, and which are yet to be trialled. METHOD This study mapped the behaviour change techniques used in 24 randomised controlled trials to the Behaviour Change Technique Taxonomy. Once elicited, techniques were further mapped to the Theoretical Domains Framework to explore which determinants of behaviour change had been targeted, and what gaps, if any existed. RESULTS Common behaviour change techniques used were: goals and planning; feedback and monitoring; social support; instruction on behaviour performance; and prompts/cues. These may be valuable when combined in a complex intervention. Interventions mostly mapped to between eight and 10 domains of the Theoretical Domains Framework. Environmental context and resources was an underrepresented domain, which should be considered within future interventions. CONCLUSION This study has identified behaviour change techniques that could be valuable when combined within a complex intervention aiming to support post-discharge medicines management for older people. Whilst many interventions mapped to eight or more determinants of behaviour change, as identified within the Theoretical Domains Framework, careful assessment of the barriers to behaviour change should be conducted prior to intervention design to ensure all appropriate domains are targeted.
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Affiliation(s)
- Justine Tomlinson
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK.
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
| | - Iuri Marques
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Jonathan Silcock
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Beth Fylan
- Medicines Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Judith Dyson
- Faculty of Health, Education and Life Sciences, Birmingham City University, Birmingham, UK
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20
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Habib B, Buckeridge D, Bustillo M, Marquez SN, Thakur M, Tran T, Weir DL, Tamblyn R. Smart About Meds (SAM): a pilot randomized controlled trial of a mobile application to improve medication adherence following hospital discharge. JAMIA Open 2021; 4:ooab050. [PMID: 34345805 PMCID: PMC8325487 DOI: 10.1093/jamiaopen/ooab050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/10/2021] [Accepted: 06/17/2021] [Indexed: 11/14/2022] Open
Abstract
Objective The objectives of this pilot study were (1) to assess the feasibility of a larger evaluation of Smart About Meds (SAM), a patient-centered medication management mobile application, and (2) to evaluate SAM’s potential to improve outcomes of interest, including adherence to medication changes made at hospital discharge and the occurrence of adverse events. Materials and Methods We conducted a pilot randomized controlled trial among patients discharged from internal medicine units of an academic health center between June 2019 and March 2020. Block randomization was used to randomize patients to intervention (received access to SAM at discharge) or control (received usual care). Patients were followed for 30 days post-discharge, during which app use was recorded. Pharmacy claims data were used to measure adherence to medication changes made at discharge, and physician billing data were used to identify emergency department visits and hospital readmissions during follow-up. Results Forty-nine patients were eligible for inclusion in the study at hospital discharge (23 intervention, 26 control). In the 30 days of post-discharge, 15 (65.2%) intervention patients used the SAM app. During this period, intervention patients adhered to a larger proportion of medication changes (83.7%) than control patients (77.8%), including newly prescribed medications (72.7% vs 61.7%) and dose changes (90.9% vs 81.8%). A smaller proportion of intervention patients (8.7%) were readmitted to hospital during follow-up than control patients (15.4%). Conclusion The high uptake of SAM among intervention patients supports the feasibility of a larger trial. Results also suggest that SAM has the potential to enhance adherence to medication changes and reduce the risk of downstream adverse events. This hypothesis needs to be tested in a larger trial. Trial registration Clinicaltrials.gov, registration number NCT04676165.
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Affiliation(s)
- Bettina Habib
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
| | - David Buckeridge
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Melissa Bustillo
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
| | | | - Manish Thakur
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
| | - Thai Tran
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada
| | - Daniala L Weir
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Robyn Tamblyn
- Clinical and Health Informatics Research Group, McGill University, Montreal, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada.,Department of Medicine, McGill University Health Center, Montreal, Canada
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21
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Grubbs C, Morris L. This is not the time to modify a HTN regimen. THE JOURNAL OF FAMILY PRACTICE 2021; 70:293-295. [PMID: 34431775 PMCID: PMC8407227 DOI: 10.12788/jfp.0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Intensifying hypertension regimens at discharge increases risk in older patients.
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22
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Gage B, Lamb J, Dahri K. Evaluation of In-Hospital Management of Inhaler Therapy for Chronic Obstructive Pulmonary Disease. Can J Hosp Pharm 2021; 74:110-116. [PMID: 33896949 PMCID: PMC8042186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND In the past decade, the number of inhaled devices approved for management of chronic obstructive pulmonary disease (COPD) has tripled. Management of at-home inhaled COPD therapy can present a problem when patients are admitted to hospital, because only a limited number of these therapies are currently included in hospital formularies and there is a lack of established interchanges. OBJECTIVES To characterize and evaluate the appropriateness of management of patients' before-admission inhaled therapy upon hospital admission. METHODS This retrospective chart review involved patients with COPD admitted to a tertiary care centre over a 1-year period (October 2017 to September 2018). Before-admission inhaled therapy was compared with inhalers ordered in hospital and at discharge. Inhaler device type, regimen, therapeutic class, and disease severity were used to assess the appropriateness of inpatient management. RESULTS The charts of 200 patients were reviewed. Of these patients, 124 (62%) were kept on the same inhaler, 43 (22%) had one or more of their inhalers discontinued, 35 (18%) had to provide their own medication, and 24 (12%) had their medication changed to a formulary equivalent. An average delay of 2.6 (standard deviation 3.2) days occurred when patients provided their own medication. Formulary substitution resulted in most patients receiving a medication from the same class (75% [18/24]); however, other aspects of therapy, such as device type (17% [4/24]), regimen (29% [7/24]) and drug combination (47% [9/19]), were not maintained. Only 55% (6/11) received an equivalent dose of inhaled corticosteroids when the medication was interchanged to a formulary inhaler. CONCLUSIONS The majority of patients' inhaled therapies continued unchanged upon admission to hospital, which suggests that despite the proliferation of new inhalers on the market, their use is still limited. For patients who did require interchange to formulary inhalers, maintenance of the same regimen, device, and combination product was rare. Provision of the medication supply by patients themselves often resulted in a delay in therapy.
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Affiliation(s)
- Brittany Gage
- is a student in the Entry-to-Practice Doctor of Pharmacy program (Class of 2021), Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Julia Lamb
- is a student in the Entry-to-Practice Doctor of Pharmacy program (Class of 2021), Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Karen Dahri
- , BSc, BScPharm, PharmD, ACPR, FCSHP, is a Pharmacotherapeutic and Research Specialist (Internal Medicine) with Vancouver General Hospital and an Assistant Professor (Partner) with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
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23
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Hannum SM, Abebe E, Xiao Y, Brown R, Peña IM, Gurses AP. Engineering care transitions: Clinician perceptions of barriers to safe medication management during transitions of patient care. APPLIED ERGONOMICS 2021; 91:103299. [PMID: 33161183 PMCID: PMC10416651 DOI: 10.1016/j.apergo.2020.103299] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/20/2020] [Accepted: 10/26/2020] [Indexed: 06/11/2023]
Abstract
Medication safety during care transitions is a significant challenge, especially for older adults prescribed multiple medications. Using a systems approach to understand barriers to and strategies for safe medication management throughout high-risk periods of hospital-to-home transition is one important step in designing effective interventions. Framing the care transition as a collaboration between healthcare and patient "work systems," we conducted semi-structured interviews with 37 clinical team members, representing 10 different professional roles involved in providing transitional care for patients. Thematic analyses identified key strategies used by clinical team members in preparing patients to self-manage medications safely in the home environment: (1) streamlining and coordinating clinical management of medication reconciliation across care settings; (2) building patient capacity and engagement in self-management of medications; and (3) redesigning the transitional process. Our research highlights the value in aligning professionals' care transition goals with patients and caregiver(s) to better prepare them to self-manage medications upon discharge.
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Affiliation(s)
- S M Hannum
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Rm. 727, Baltimore, MD, 21205, USA.
| | - E Abebe
- Purdue University,College of Pharmacy, Department of Pharmacy Practice, West Lafayette, IN, USA
| | - Y Xiao
- University of Texas at Arlington, College of Nursing and Health Innovation, Arlington, TX, USA
| | - R Brown
- UChicago Medicine, Department of Quality Process Improvement, Chicago, IL, USA
| | - I M Peña
- Johns Hopkins Bayview Medical Center, Department of Internal Medicine, Baltimore, MD, USA
| | - A P Gurses
- Johns Hopkins School of Medicine, Armstrong Institute for Patient Safety and Quality, Baltimore, MD, USA
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24
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Capiau A, Foubert K, Van der Linden L, Walgraeve K, Hias J, Spinewine A, Sennesael AL, Petrovic M, Somers A. Medication Counselling in Older Patients Prior to Hospital Discharge: A Systematic Review. Drugs Aging 2020; 37:635-655. [PMID: 32643062 DOI: 10.1007/s40266-020-00780-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Older patients are regularly exposed to multiple medication changes during a hospital stay and are more likely to experience problems understanding these changes. Medication counselling is often proposed as an important component of seamless care to ensure appropriate medication use after hospital discharge. OBJECTIVES The purpose of this systematic review was to describe the components of medication counselling in older patients (aged ≥ 65 years) prior to hospital discharge and to review the effectiveness of such counselling on reported clinical outcomes. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (PROSPERO CRD42019116036), a systematic search of MEDLINE, EMBASE and CINAHL was conducted. The QualSyst Assessment Tool was used to assess bias. The impact of medication counselling on different outcomes was described and stratified by intervention content. RESULTS Twenty-nine studies were included. Fifteen different components of medication counselling were identified. Discussing the dose and dosage of patients' medications (19/29; 65.5%), providing a paper-based medication list (19/29; 65.5%) and explaining the indications of the prescribed medications (17/29; 58.6%) were the most frequently encountered components during the counselling session. Twelve different clinical outcomes were investigated in the 29 studies. A positive effect of medication counselling on medication adherence and medication knowledge was found more frequently, compared to its impact on hard outcomes such as hospital readmissions and mortality. Yet, evidence remains inconclusive regarding clinical benefit, owing to study design heterogeneity and different intervention components. Statistically significant results were more frequently observed when counselling was provided as part of a comprehensive intervention before discharge. CONCLUSIONS Substantial heterogeneity between the included studies was found for the components of medication counselling and the reported outcomes. Study findings suggest that medication counselling should be part of multifaceted interventions, but the evidence concerning clinical outcomes remains inconclusive.
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Affiliation(s)
- Andreas Capiau
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium. .,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium.
| | - Katrien Foubert
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
| | - Lorenz Van der Linden
- Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Julie Hias
- Department of Pharmacy, University Hospitals Leuven, Leuven, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université Catholique de Louvain, Brussels, Belgium.,Department of Pharmacy, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Anne-Laure Sennesael
- Department of Pharmacy, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Mirko Petrovic
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Annemie Somers
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium.,Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ghent, Belgium
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25
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Tomlinson J, Silcock J, Smith H, Karban K, Fylan B. Post-discharge medicines management: the experiences, perceptions and roles of older people and their family carers. Health Expect 2020; 23:1603-1613. [PMID: 33063445 PMCID: PMC7752204 DOI: 10.1111/hex.13145] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 09/14/2020] [Accepted: 09/20/2020] [Indexed: 11/29/2022] Open
Abstract
Background Multiple changes are made to older patients’ medicines during hospital admission, which can sometimes cause confusion and anxiety. This results in problems with post‐discharge medicines management, for example medicines taken incorrectly, which can lead to harm, hospital readmission and reduced quality of life. Aim To explore the experiences of older patients and their family carers as they enacted post‐discharge medicines management. Design Semi‐structured interviews took place in participants’ homes, approximately two weeks after hospital discharge. Data analysis used the Framework method. Setting and participants Recruitment took place during admission to one of two large teaching hospitals in North England. Twenty‐seven participants aged 75 plus who lived with long‐term conditions and polypharmacy, and nine family carers, were interviewed. Findings Three core themes emerged: impact of the transition, safety strategies and medicines management role. Conversations between participants and health‐care professionals about medicines changes often lacked detail, which disrupted some participants’ knowledge and medicines management capabilities. Participants used multiple strategies to support post‐discharge medicines management, such as creating administration checklists, seeking advice or supporting primary care through prompts to ensure medicines were supplied on time. The level to which they engaged with these activities varied. Discussion and conclusion Participants experienced gaps in their post‐discharge medicines management, which they had to bridge through implementing their own strategies or by enlisting support from others. Areas for improvement were identified, mainly through better communication about medicines changes and wider involvement of patients and family carers in their medicines‐related care during the hospital‐to‐home transition.
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Affiliation(s)
- Justine Tomlinson
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK.,Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jonathan Silcock
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK
| | - Heather Smith
- Medicine Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Karban
- Faculty of Life Sciences, University of Bradford, Bradford, UK
| | - Beth Fylan
- Medicine Optimisation Research Group, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, UK.,Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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26
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Dow AW, Chopski B, Cyrus JW, Paletta-Hobbs LE, Qayyum R. A STEEEP Hill to Climb: A Scoping Review of Assessments of Individual Hospitalist Performance. J Hosp Med 2020; 15:599-605. [PMID: 32966195 DOI: 10.12788/jhm.3445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although ensuring high-quality care requires assessment of individual hospitalist performance, current assessment approaches lack consistency and coherence. The Institute of Medicine's STEEEP framework for quality healthcare conceptualizes quality through domains of "Safe," "Timely," "Effective," "Efficient," "Equitable," and "Patient Centered." This framework may be applicable to assessing individual hospitalists. OBJECTIVE This scoping review sought to identify studies that describe variation in individual hospitalist performance and to code this data to the domains of the STEEEP framework. METHODS Via a systematic search of peer-reviewed literature that assessed the performance of individual hospitalists in the Medline database, we identified studies that described measurement of individual hospitalist performance. Forty-two studies were included in the final review and coded into one or more domains of the STEEEP framework. RESULTS Studies in the Safe domain focused on transitions of care, both at discharge and within the hospital. Many studies were coded to more than one domain, especially Timely, Effective, and Efficient. Examples include adherence to evidence-based guidelines or Choosing Wisely recommendations. The Patient Centered domain was most frequently coded, but approaches were heterogeneous. No included studies addressed the domain Equitable. CONCLUSIONS Applying the STEEEP framework to the published literature on assessment of individual hospitalist performance revealed strengths and weaknesses. Areas of strength were assessments of transitions of care and application of consensus guidelines. Other areas, such as equity and some components of safe practice, need development. All domains would benefit from more practical approaches. These findings should stimulate future work on feasibility of multidimensional assessment approaches.
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Affiliation(s)
- Alan W Dow
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Chopski
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - John W Cyrus
- Tompkins-McCaw Library for the Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Laura E Paletta-Hobbs
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rehan Qayyum
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
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27
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From Hospital to Home: A Resident-Driven Quality Improvement Project to Overcome Discharge Prescription Barriers. Qual Manag Health Care 2020; 29:226-231. [PMID: 32991540 DOI: 10.1097/qmh.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Inability to obtain timely medications is a patient safety concern that can lead to delayed or incomplete treatment of illness. While there are many patient and system factors contributing to postdischarge medication nonadherence, availability and insurance-related barriers are preventable. PURPOSE To implement a systematic process ensuring review of discharge prescriptions to ensure availability and resolve insurance barriers before patient discharge. METHODS A prospective single-arm quality improvement intervention study to identify and address insurance-related prescription barriers using nonclinical staff. Intervention was pilot tested with sequential spread across general medicine resident teams. The primary outcome was successful obtainment of postdischarge prescriptions confirmed by phone calls to patients or their pharmacies. RESULTS From April to August 2015, 59 of 161 patients included in the improvement process (36.6%) had one or more insurance or availability-related barriers with their prescriptions, totaling 89 issues. Forty-three of the 59 patients (72.9%) responded to postdischarge phone calls, 39 of whom (39/43, 90.7%) successfully filled their prescriptions on the first pharmacy visit. CONCLUSIONS In our study, we preemptively identified that over a third of patients discharged would have encountered barriers filling their prescriptions. This interdisciplinary quality improvement project using nonclinical team members removed barriers for over 90% of our patients to ensure continuation of medical therapy without disruption and a safer postdischarge plan.
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28
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Weir DL, Motulsky A, Abrahamowicz M, Lee TC, Morgan S, Buckeridge DL, Tamblyn R. Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. Health Serv Res 2020; 55:512-523. [PMID: 32434274 PMCID: PMC7376001 DOI: 10.1111/1475-6773.13292] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 03/02/2020] [Accepted: 04/04/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the hypothesis that nonadherence to medication changes made at hospital discharge is associated with an increased risk of adverse events in the 30 days postdischarge. STUDY SETTING Patients admitted to hospitals in Montreal, Quebec, between 2014 and 2016. STUDY DESIGN Prospective cohort study. DATA COLLECTION Nonadherence to medication changes was measured by comparing medications dispensed in the community with those prescribed at hospital discharge. Patient, health system, and drug regimen-level covariates were measured using medical services and pharmacy claims data as well as data abstracted from the patient's hospital chart. Multivariable Cox models were used to determine the association between nonadherence to medication changes and the risk of adverse events. PRINCIPAL FINDINGS Among 2655 patients who met our inclusion criteria, mean age was 69.5 years (SD 14.7) and 1581 (60%) were males. Almost half of patients (n = 1161, 44%) were nonadherent to at least one medication change, and 860 (32%) were readmitted to hospital, visited the emergency department, or died in the 30 days postdischarge. Patients who were not adherent to any of their medication changes had a 35% higher risk of adverse events compared to those who were adherent to all medication changes (1.41 vs 1.27 events/100 person-days, adjusted hazard ratio: 1.35, 95% CI: 1.06-1.71). CONCLUSIONS Almost half of all patients were not adherent to some or all changes made to their medications at hospital discharge. Nonadherence to all changes was associated with an increased risk of adverse events. Interventions addressing barriers to adherence should be considered moving forward.
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Affiliation(s)
- Daniala L Weir
- Department of Epidemiology and Biostatistics, Department of Medicine,, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Aude Motulsky
- Research Center, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,Department of Management, Evaluation & Health Policy, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology and Biostatistics, Department of Medicine,, McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Todd C Lee
- Department of Epidemiology and Biostatistics, Department of Medicine,, McGill University, Montreal, Quebec, Canada.,Research Center, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Steven Morgan
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David L Buckeridge
- Department of Epidemiology and Biostatistics, Department of Medicine,, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, Department of Medicine,, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
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29
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Pharmacist-led transitions-of-care services in primary care settings: Opportunities, experiences, and challenges. J Am Pharm Assoc (2003) 2020; 60:443-449. [DOI: 10.1016/j.japh.2019.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/22/2019] [Accepted: 11/14/2019] [Indexed: 11/21/2022]
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30
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Weir DL, Lee TC, McDonald EG, Motulsky A, Abrahamowicz M, Morgan S, Buckeridge D, Tamblyn R. Both New and Chronic Potentially Inappropriate Medications Continued at Hospital Discharge Are Associated With Increased Risk of Adverse Events. J Am Geriatr Soc 2020; 68:1184-1192. [PMID: 32232988 PMCID: PMC7687123 DOI: 10.1111/jgs.16413] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/17/2019] [Accepted: 12/30/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Admission to hospital provides the opportunity to review patient medications; however, the extent to which the safety of drug regimens changes after hospitalization is unclear. OBJECTIVE To estimate the number of potentially inappropriate medications (PIMs) prescribed to patients at hospital discharge and their association with the risk of adverse events 30 days after discharge. DESIGN Prospective cohort study. SETTING Tertiary care hospitals within the McGill University Health Centre Network in Montreal, Quebec, Canada. PARTICIPANTS Patients from internal medicine, cardiac, and thoracic surgery, aged 65 years and older, admitted between October 2014 and November 2016. MEASURES Abstracted chart data were linked to provincial health databases. PIMs were identified using AGS (American Geriatrics Society) Beers Criteria®, STOPP, and Choosing Wisely statements. Multivariable logistic regression and Cox models were used to assess the association between PIMs and adverse events. RESULTS Of 2,402 included patients, 1,381 (57%) were male; median age was 76 years (interquartile range [IQR] = 70‐82 years); and eight discharge medications were prescribed (IQR = 2‐8). A total of 1,576 (66%) patients were prescribed at least one PIM at discharge; 1,176 (49%) continued a PIM from prior to admission, and 755 (31%) were prescribed at least one new PIM. In the 30 days after discharge, 218 (9%) experienced an adverse drug event (ADE) and 862 (36%) visited the emergency department (ED), were rehospitalized, or died. After adjustment, each additional new PIM and continued community PIM were respectively associated with a 21% (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 1.01‐1.45) and a 10% (OR = 1.10; 95% CI = 1.01‐1.21) increased odds of ADEs. They were also respectively associated with a 13% (hazard ratio [HR] = 1.13; 95% CI = 1.03‐1.26) and a 5% (HR = 1.05; 95% CI = 1.00‐1.10) increased risk of ED visits, rehospitalization, and death. CONCLUSIONS Two in three hospitalized patients were prescribed a PIM at discharge, and increasing numbers of PIMs were associated with an increased risk of ADEs and all‐cause adverse events. Improving hospital prescribing practices may reduce the frequency of PIMs and associated adverse events. J Am Geriatr Soc 68:1184–1192, 2020. See related editorial by Donna M. Fick in this issue.
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Affiliation(s)
- Daniala L Weir
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Todd C Lee
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Emily G McDonald
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Aude Motulsky
- Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,Department of Management, Evaluation and Health Policy, School of Public Health, Université de Montréal, Montreal, Quebec, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.,Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Steven Morgan
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Buckeridge
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Robyn Tamblyn
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.,Clinical and Health Informatics Research Group, Department of Medicine, McGill University, Montreal, Quebec, Canada
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Anderson TS, Lee S, Jing B, Fung K, Ngo S, Silvestrini M, Steinman MA. Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals. JAMA Netw Open 2020; 3:e201511. [PMID: 32207832 PMCID: PMC7093767 DOI: 10.1001/jamanetworkopen.2020.1511] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/24/2020] [Indexed: 01/08/2023] Open
Abstract
Importance Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. Objective To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. Design, Setting, and Participants This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. Main Outcomes and Measures Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. Results Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A1c (HbA1c) level less than 7.0%, and 1044 (6%) had an HbA1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA1c, while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. Conclusions and Relevance In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA1c goal.
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Affiliation(s)
- Timothy S. Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Sei Lee
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Bocheng Jing
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
| | - Michael A. Steinman
- San Francisco VA Medical Center, San Francisco, California
- Division of Geriatrics, University of California, San Francisco
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Slazak E, Shaver A, Clark CM, Cardinal C, Panthapattu M, Prescott WA, Will S, Jacobs DM. Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study. PHARMACY 2020; 8:pharmacy8010004. [PMID: 31947920 PMCID: PMC7151670 DOI: 10.3390/pharmacy8010004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 11/16/2022] Open
Abstract
Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.
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Affiliation(s)
- Erin Slazak
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
- Correspondence: (E.S.); (D.M.J.); Tel.: +1-716-645-2828 (E.S.); +1-716-829-2134 (D.M.J.)
| | - Amy Shaver
- Department of Epidemiology and Environment Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA;
| | - Collin M. Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | | | - Merin Panthapattu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | - William A. Prescott
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | - Samantha Will
- General Physicians, P.C., Buffalo, NY 14214, USA; (C.C.); (S.W.)
| | - David M. Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
- Correspondence: (E.S.); (D.M.J.); Tel.: +1-716-645-2828 (E.S.); +1-716-829-2134 (D.M.J.)
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Slazak E, Shaver A, Clark CM, Cardinal C, Panthapattu M, Prescott WA, Will S, Jacobs DM. Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study. PHARMACY 2020. [PMID: 31947920 DOI: 10.3390/pharmacy8010004.pmid:31947920;pmcid:pmc7151670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.
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Affiliation(s)
- Erin Slazak
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Amy Shaver
- Department of Epidemiology and Environment Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | | | - Merin Panthapattu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - William A Prescott
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | | | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
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Anderson TS, Jing B, Auerbach A, Wray CM, Lee S, Boscardin WJ, Fung K, Ngo S, Silvestrini M, Steinman MA. Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge. JAMA Intern Med 2019; 179:1528-1536. [PMID: 31424475 PMCID: PMC6705136 DOI: 10.1001/jamainternmed.2019.3007] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization. OBJECTIVE To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019. EXPOSURES Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge. MAIN OUTCOMES AND MEASURES The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge. RESULTS The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg). CONCLUSIONS AND RELEVANCE Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California, San Francisco.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,now with Division of General Medicine, Beth Israel Deaconess Medical Center, Brookline, Massachusetts
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Andrew Auerbach
- Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Charlie M Wray
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Hospital Medicine, University of California School of Medicine, San Francisco
| | - Sei Lee
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - W John Boscardin
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Sarah Ngo
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Molly Silvestrini
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
| | - Michael A Steinman
- San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Geriatrics, University of California, San Francisco
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35
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Tesfaye WH, Wimmer BC, Peterson GM, Castelino RL, Jose MD, McKercher C, Zaidi STR. The effect of hospitalization on potentially inappropriate medication use in older adults with chronic kidney disease. Curr Med Res Opin 2019; 35:1119-1126. [PMID: 30557066 DOI: 10.1080/03007995.2018.1560193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Potentially inappropriate medication (PIM) use is associated with increased morbidity and mortality in chronic kidney disease (CKD). However, there is a paucity of data on how hospitalization affects PIM use in older adults with CKD. Therefore, we aimed to measure the impact of hospitalization on PIM use in older CKD patients, and identify factors predicting PIM use. METHODS A retrospective cohort study was conducted in older adults (≥65 years) with CKD admitted to an Australian tertiary care hospital over a 6 month period. PIM use was measured, upon admission and at discharge, using the Medication Appropriateness Index (MAI) and Beers criteria (2015 version) for medications recommended to be avoided in older adults and under certain conditions. RESULTS The median age of the 204 patients was 83 years (interquartile range (IQR): 76-87 years) and most were men (61%). Overall, the level of PIM use (MAI) decreased from admission to discharge (median [IQR]: 6 [3-12] to 5 [2-9]; p < .01]). More than half of the participants (55%) had at least one PIM per Beers criterion on admission, which was reduced by discharge (48%; p < .01). People admitted with a higher number of medications (β 0.72, 95% CI 0.56-0.88) and lower eGFR values (β - 0.11, 95% CI -0.18 to -0.04) had higher MAI scores after adjusting for age, sex and Charlson's comorbidity index. CONCLUSIONS PIMs were commonly used in older CKD patients. Hospitalization was associated with a reduction in PIM use, but there was considerable scope for improvement in these susceptible individuals.
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Affiliation(s)
- Wubshet H Tesfaye
- a Department of Pharmacy, School of Medicine, College of Health and Medicine , University of Tasmania , Tasmania , Australia
| | - Barbara C Wimmer
- a Department of Pharmacy, School of Medicine, College of Health and Medicine , University of Tasmania , Tasmania , Australia
| | - Gregory M Peterson
- a Department of Pharmacy, School of Medicine, College of Health and Medicine , University of Tasmania , Tasmania , Australia
- b Unit for Medication Outcomes Research and Education , University of Tasmania , Tasmania , Australia
| | | | - Matthew D Jose
- a Department of Pharmacy, School of Medicine, College of Health and Medicine , University of Tasmania , Tasmania , Australia
- d Menzies Institute for Medical Research , University of Tasmania , Tasmania , Australia
- e Royal Hobart Hospital , Tasmania , Australia
| | - Charlotte McKercher
- d Menzies Institute for Medical Research , University of Tasmania , Tasmania , Australia
| | - Syed Tabish R Zaidi
- a Department of Pharmacy, School of Medicine, College of Health and Medicine , University of Tasmania , Tasmania , Australia
- f School of Healthcare , University of Leeds , Leeds , UK
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36
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Xiao Y, Abebe E, Gurses AP. Engineering a Foundation for Partnership to Improve Medication Safety during Care Transitions. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019; 24:30-36. [PMID: 30842993 DOI: 10.1177/2516043518821497] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There are major gaps and barriers for patients and caregivers after hospital discharge to achieve safe medication use. Patients and caregivers are often not ready to take on the responsibility for medication management when transitioned from inpatient care. Current approaches tend to focus on adding isolated strategies. A system thinking can enable a fundamental transformation to redesign professionals' interactions with patients and caregivers with an explicit goal to develop patients and caregivers into true partners, with targeted roles, skills, attitude, knowledge, and tool support. We must recognize the fact that medication safety during care transition and, more so, at patient homes is the property of a "work system", in which the patient and caregivers are at the center, with collaboration with health professionals. Innovative ideas are needed to engineer work system components by systematically examining professionals' interactions with patients and caregivers, such as those during hospital stays and transitions (e.g., follow-up phone calls, community pharmacist consults, and home visits). Based on human factors principles, we describe a set of recommendations on engineering partnership with patients and their caregivers at different stages of a care episode, to enable productive interactions among work systems that are distributed and are often limited in their ability to exchange information and co-align their interests.
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Affiliation(s)
- Yan Xiao
- University of Texas at Arlington College of Nursing and Health Innovation, Arlington, Texas
| | - Ephrem Abebe
- Armstrong Institute Center for Health Care Human Factors, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine
| | - Ayse P Gurses
- Armstrong Institute Center for Health Care Human Factors, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine
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Anderson TS, Wray CM, Jing B, Fung K, Ngo S, Xu E, Shi Y, Steinman MA. Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study. BMJ 2018; 362:k3503. [PMID: 30209052 PMCID: PMC6283373 DOI: 10.1136/bmj.k3503] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications. DESIGN Retrospective cohort study. SETTING US Veterans Administration Health System. PARTICIPANTS Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013. MAIN OUTCOME MEASURES Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals. RESULTS Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease). CONCLUSIONS One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.
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Affiliation(s)
- Timothy S Anderson
- Division of General Internal Medicine, University of California San Francisco, San Francisco, CA 94123, USA
| | - Charlie M Wray
- Division of Hospital Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Bocheng Jing
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kathy Fung
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Sarah Ngo
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Edison Xu
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Ying Shi
- San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
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Al-Hashar A, Al-Zakwani I, Eriksson T, Sarakbi A, Al-Zadjali B, Al Mubaihsi S, Al Za'abi M. Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use. Int J Clin Pharm 2018; 40:1154-1164. [PMID: 29754251 DOI: 10.1007/s11096-018-0650-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 05/04/2018] [Indexed: 11/27/2022]
Abstract
Background Adverse drug events from preventable medication errors can result in patient morbidity and mortality, and in cost to the healthcare system. Medication reconciliation can improve communication and reduce medication errors at transitions in care. Objective Evaluate the impact of medication reconciliation and counselling intervention delivered by a pharmacist for medical patients on clinical outcomes 30 days after discharge. Setting Sultan Qaboos University Hospital, Muscat, Oman. Methods A randomized controlled study comparing standard care with an intervention delivered by a pharmacist and comprising medication reconciliation on admission and discharge, a medication review, a bedside medication counselling, and a take-home medication list. Medication discrepancies during hospitalization were identified and reconciled. Clinical outcomes were evaluated by reviewing electronic health records and telephone interviews. Main outcome measures Rates of preventable adverse drug events as primary outcome and healthcare resource utilization as secondary outcome at 30 days post discharge. Results A total of 587 patients were recruited (56 ± 17 years, 57% female); 286 randomized to intervention; 301 in the standard care group. In intervention arm, 74 (26%) patients had at least one discrepancy on admission and 100 (35%) on discharge. Rates of preventable adverse drug events were significantly lower in intervention arm compared to standard care arm (9.1 vs. 16%, p = 0.009). No significant difference was found in healthcare resource use. Conclusion The implementation of an intervention comprising medication reconciliation and counselling by a pharmacist has significantly reduced the rate of preventable ADEs 30 days post discharge, compared to the standard care. The effect of the intervention on healthcare resource use was insignificant. Pharmacists should be included in decentralized, patient-centred roles. The findings should be interpreted in the context of the study's limitations.
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Affiliation(s)
- Amna Al-Hashar
- Department of Pharmacy, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman.
| | - Ibrahim Al-Zakwani
- Department of Pharmacy, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - Tommy Eriksson
- Department of Biomedical Sciences, Faculty of Health and Society, Malmö University, Malmö, Sweden
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
| | - Alaa Sarakbi
- Department of Pharmacy, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Badriya Al-Zadjali
- Department of Pharmacy, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Saif Al Mubaihsi
- Department of Medicine, Sultan Qaboos University Hospital, Sultan Qaboos University, Muscat, Oman
| | - Mohammed Al Za'abi
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Older Peoples' Adherence and Awareness of Changes in Drug Therapy after Discharge from Hospital. PHARMACY 2018; 6:pharmacy6020038. [PMID: 29724019 PMCID: PMC6025336 DOI: 10.3390/pharmacy6020038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 04/18/2018] [Accepted: 04/24/2018] [Indexed: 11/29/2022] Open
Abstract
Non-adherence is important to address because it might affect the effectiveness of therapy and lead to adverse effects. The objectives of this interview study were to investigate old peoples’ general adherence to drugs and their awareness of and adherence to changes in drug therapy after their hospital stay. Following ethical approval, 42 patients admitted to the medical ward were invited to participate in this study. Of these, 36 persons, with a mean age of 82.5 years, who were discharged to their home, were interviewed by telephone using the Medical Adherence Report Scale (MARS) to assess their general adherence to prescribed drugs. Questions regarding awareness and adherence to drug changes during their hospital stay were asked. Different factors related to adherence and non-adherence were investigated using the Pearson chi-square test and the independent sample t-test. The average MARS score was 23.9 ± 1.4, with 31 persons (86%) assessed as adherent to their drug therapy and 5 persons (14%) as non-adherent. Of the 36 people, 30 had at least one change in their drug therapy during their hospital stay, and 23 (77%) of these people were aware of all changes and 23 (77%) were adherent to all of the changes. No significant differences between adherence and age, gender, living situation, or number of drugs were found. This small study found that some older people who were discharged from hospital were generally non-adherent, and some were not aware of or adherent to changes made in the drug therapy during their hospital stay. This is an important problem to address with further interventions.
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40
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Polinski JM, Moore JM, Kyrychenko P, Gagnon M, Matlin OS, Fredell JW, Brennan TA, Shrank WH. An Insurer's Care Transition Program Emphasizes Medication Reconciliation, Reduces Readmissions And Costs. Health Aff (Millwood) 2018; 35:1222-9. [PMID: 27385237 DOI: 10.1377/hlthaff.2015.0648] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Adverse drug events and the challenges of clarifying and adhering to complex medication regimens are central drivers of hospital readmissions. Medication reconciliation programs can reduce the incidence of adverse drug events after discharge, but evidence regarding the impact of medication reconciliation on readmission rates and health care costs is less clear. We studied an insurer-initiated care transition program based on medication reconciliation delivered by pharmacists via home visits and telephone and explored its effects on high-risk patients. We examined whether voluntary program participation was associated with improved medication use, reduced readmissions, and savings net of program costs. Program participants had a 50 percent reduced relative risk of readmission within thirty days of discharge and an absolute risk reduction of 11.1 percent. The program saved $2 for every $1 spent. These results represent real-world evidence that insurer-initiated, pharmacist-led care transition programs, focused on but not limited to medication reconciliation, have the potential to both improve clinical outcomes and reduce total costs of care.
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Affiliation(s)
- Jennifer M Polinski
- Jennifer M. Polinski is a senior director at CVS Health in Woonsocket, Rhode Island
| | - Janice M Moore
- Janice M. Moore is a senior adviser at CVS Health in Northbrook, Illinois
| | - Pavlo Kyrychenko
- Pavlo Kyrychenko is a senior manager at CVS Health in Northbrook
| | - Michael Gagnon
- Michael Gagnon is a senior consultant at CVS Health in Cumberland, Rhode Island
| | - Olga S Matlin
- Olga S. Matlin is a senior director at CVS Health in Northbrook
| | - Joshua W Fredell
- Joshua W. Fredell is a senior director at CVS Health in Northbrook
| | - Troyen A Brennan
- Troyen A. Brennan is chief medical officer at CVS Caremark, in Woonsocket
| | - William H Shrank
- William H. Shrank is chief scientific officer and chief medical officer for health systems alliances at CVS Health in Woonsocket
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Brühwiler LD, Hersberger KE, Lutters M. Hospital discharge: What are the problems, information needs and objectives of community pharmacists? A mixed method approach. Pharm Pract (Granada) 2017; 15:1046. [PMID: 28943987 PMCID: PMC5597803 DOI: 10.18549/pharmpract.2017.03.1046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 08/22/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND After hospital discharge, community pharmacists are often the first health care professionals the discharged patient encounters. They reconcile and dispense prescribed medicines and provide pharmaceutical care. Compared to the roles of general practitioners, the pharmacists' needs to perform these tasks are not well known. OBJECTIVE This study aims to a) Identify community pharmacists' current problems and roles at hospital discharge, b) Assess their information needs, specifically the availability and usefulness of information, and c) Gain insight into pharmacists' objectives and ideas for discharge optimisation. METHODS A focus group was conducted with a sample of six community pharmacists from different Swiss regions. Based on these qualitative results, a nationwide online-questionnaire was sent to 1348 Swiss pharmacies. RESULTS The focus group participants were concerned about their extensive workload with discharge prescriptions and about gaps in therapy. They emphasised the importance of more extensive information transfer. This applied especially to medication changes, unclear prescriptions, and information about a patient's care. Participants identified treatment continuity as a main objective when it comes to discharge optimisation. There were 194 questionnaires returned (response rate 14.4%). The majority of respondents reported to fulfil their role as defined by the Joint-FIP/WHO Guideline on Good Pharmacy Practice (rather) badly. They reported many unavailable but useful information items, like therapy changes, allergies, specifications for "off-label" medication use or contact information. Information should be delivered in a structured way, but no clear preference for one particular transfer method was found. Pharmacists requested this information in order to improve treatment continuity and patient safety, and to be able to provide better pharmaceutical care services. CONCLUSION Surveyed Swiss community pharmacists rarely receive sufficient information along with discharge prescriptions, although it would be needed for medication reconciliation. According to the pharmacist's opinions, appropriate pharmaceutical care is therefore impeded.
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Affiliation(s)
- Lea D Brühwiler
- Clinical pharmacist. Clinical Pharmacy, Cantonal Hospital of Baden. Baden (Switzerland).
| | - Kurt E Hersberger
- Professor. Head of Pharmaceutical Care Research Group, University of Basel. Basel (Switzerland).
| | - Monika Lutters
- Chief of Clinical pharmacy, Cantonal Hospital of Baden. Baden (Switzerland).
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Abstract
: This article is the fifth in a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project supported evidence that family caregivers aren't being given the information they need to manage the complex care regimens of their family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's medications. Each article explains the principles nurses should consider and reinforce with caregivers and is accompanied by a video for the caregiver to watch. The fifth video can be accessed at http://links.lww.com/AJN/A79.
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Mitchell B, Chong C, Lim WK. Medication adherence 1 month after hospital discharge in medical inpatients. Intern Med J 2016; 46:185-92. [PMID: 26602319 DOI: 10.1111/imj.12965] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 09/28/2015] [Accepted: 11/06/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND The rate of medication non-adherence has been consistently reported to be between 20 and 50%. The majority of available data comes from international studies, and we hypothesised that a similar rate of adherence may be observed in Australian patients. AIMS To determine the rate of adherence to medications after discharge from acute general hospital admission and identify factors that may be associated with non-adherence. METHODS A prospective cohort study of 68 patients, comparing admission and discharge medication regimens to self-reported regimens 30-40 days after discharge from hospital. Patients were followed up via telephone call and univariate and multivariate binary logistic regression used to determine patient factors associated with non-adherence. RESULTS In all, 27 of 68 patients (39.7%) were non-adherent to one or more regular medications at follow up. Intentional and unintentional non-adherence contributed equally to non-adherence. Using multivariate analysis, presence of a carer responsible for medications was associated with significantly lower non-adherence (odds ratio (OR) 0.20 (0.05-0.83), P = 0.027) when adjusted for age, co-morbidities, chemist blister pack and total number of discharge medications. CONCLUSIONS Non-adherence to prescription medications is suboptimal and consistent with previous overseas studies. Having a carer responsible for medications is associated with significantly lower rates of non-adherence. Understanding patients' preferences and involving them in their healthcare may reduce intentional non-adherence.
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Affiliation(s)
- B Mitchell
- Department of Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - C Chong
- Department of Aged Care, Northern Hospital, Melbourne, Victoria, Australia
| | - W K Lim
- Department of Aged Care, Northern Hospital, Melbourne, Victoria, Australia
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Ehnbom EC, Raban MZ, Walter SR, Richardson K, Westbrook JI. Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries. Health Inf Manag 2016; 43:4-12. [PMID: 27009792 DOI: 10.1177/183335831404300301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.
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Affiliation(s)
- Elin C Ehnbom
- The University of New South Wales UNSW Sydney NSW 2052 Australia
| | - Magdalena Z Raban
- Australian Institute of Health Innovation The University of New South Wales, Sydney NSW
| | - Scott R Walter
- Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052
| | | | - Johanna I Westbrook
- Centre for Health Systems and Safety Research Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052
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Kisuule F, Howell EE. Hospitalists and Their Impact on Quality, Patient Safety, and Satisfaction. Obstet Gynecol Clin North Am 2016; 42:433-46. [PMID: 26333633 DOI: 10.1016/j.ogc.2015.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The forces promoting the hospitalist model arose from the need for high-value care; therefore, improving quality and cost has been part of the hospitalist formula for success. The factors driving the rapid growth of generalist and subspecialty hospitalists include nationally mandated quality and safety measures, increasing age and complexity of the hospitalized patient, reduced residency duty hours, increased economic pressures to contain costs and reduce length of stay, and also primary care physicians, and specialists, relinquishing hospital privileges to focus on outpatient practices. Hospitalists are playing key roles in patient safety and quality as either leaders or practitioners in the field.
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Affiliation(s)
- Flora Kisuule
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL West, 6th Floor, Baltimore, MD 21224, USA
| | - Eric E Howell
- Division of Hospital Medicine, Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, MFL West, 6th Floor, Baltimore, MD 21224, USA.
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Harris CM, McKenzie R, Nayak S, Kiyatkin D, Baker D, Kisuule F. Graying of the HIV epidemic: a challenge for inpatient medicine providers. J Community Hosp Intern Med Perspect 2015; 5:29428. [PMID: 26653693 PMCID: PMC4677594 DOI: 10.3402/jchimp.v5.29428] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/14/2015] [Accepted: 09/22/2015] [Indexed: 12/25/2022] Open
Abstract
Since the advent of anti-retroviral therapy, patients with HIV are living longer, and in the year 2015, over half of those infected with the virus will be older than age 50. Moreover, as the general aging population continues to grow, more elderly individuals will become newly infected with HIV. Older patients with HIV contribute to high numbers of initial and rehospitalizations, have longer lengths of hospital day stays, and are at increased risk of death compared to younger patients with HIV and those without HIV. Age-related comorbidities can be exaggerated in HIV-positive patients on and off therapy. Furthermore, signs and symptoms of HIV and AIDS may mimic features seen in the normal aging process of older adults. Internists caring for patients in inpatient settings will be expected to care for and diagnose increasing numbers of older patients with HIV. This will be critical for improving quality of patient care, reducing morbidity and mortality, and managing newly diagnosed patients earlier in the disease course while reducing spread of the virus. Internists should be central leaders in the development of targeted and non-targeted HIV screening efforts in inpatient general medicine wards.
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Affiliation(s)
- Ché Matthew Harris
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.,Divisions of Hospital Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA;
| | - Robin McKenzie
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.,Infectious Diseases, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Seema Nayak
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.,Infectious Diseases, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Dmitry Kiyatkin
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.,Divisions of Hospital Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Dorcas Baker
- Community Public Health Nursing, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Flora Kisuule
- Department of Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA.,Divisions of Hospital Medicine, Johns Hopkins School of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Oliveira-Filho AD, Morisky DE, Costa FA, Pacheco ST, Neves SF, Lyra DP. Improving post-discharge medication adherence in patients with CVD: a pilot randomized trial. Arq Bras Cardiol 2014; 103:503-12. [PMID: 25590930 PMCID: PMC4290741 DOI: 10.5935/abc.20140151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 05/29/2014] [Indexed: 11/20/2022] Open
Abstract
Background Effective interventions to improve medication adherence are usually complex and
expensive. Objective To assess the impact of a low-cost intervention designed to improve medication
adherence and clinical outcomes in post-discharge patients with CVD. Method A pilot RCT was conducted at a teaching hospital. Intervention was based on the
four-item Morisky Medication Adherence Scale (MMAS-4). The primary outcome measure
was medication adherence assessed using the eight-item MMAS at baseline, at 1
month post hospital discharge and re-assessed 1 year after hospital discharge.
Other outcomes included readmission and mortality rates. Results 61 patients were randomized to intervention (n = 30) and control (n = 31) groups.
The mean age of the patients was 61 years (SD 12.73), 52.5% were males, and 57.4%
were married or living with a partner. Mean number of prescribed medications per
patient was 4.5 (SD 3.3). Medication adherence was correlated to intervention (p =
0.04) and after 1 month, 48.4% of patients in the control group and 83.3% in the
intervention group were considered adherent. However, this difference decreased
after 1 year, when adherence was 34.8% and 60.9%, respectively. Readmission and
mortality rates were related to low adherence in both groups. Conclusion The intervention based on a validated patient self-report instrument for assessing
adherence is a potentially effective method to improve adherent behavior and can
be successfully used as a tool to guide adherence counseling in the clinical
visit. However, a larger study is required to assess the real impact of
intervention on these outcomes.
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Affiliation(s)
| | | | - Francisco A Costa
- Universidade Estadual de Ciências da Saúde de Alagoas, Maceió, AL, Brazil
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Mixon AS, Neal E, Bell S, Powers JS, Kripalani S. Care transitions: a leverage point for safe and effective medication use in older adults--a mini-review. Gerontology 2014; 61:32-40. [PMID: 25277280 PMCID: PMC4479140 DOI: 10.1159/000363765] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 05/21/2014] [Indexed: 11/19/2022] Open
Abstract
Older adults often face challenges as they transition out of the acute care hospital, especially with regard to adhering to their medications. In this narrative review, we discuss medication adherence in older adults across the continuum of care, describing reasons for nonadherence, methods to assess adherence and tools to improve adherence, with particular focus on emerging techniques and technologies. Taking steps at care transitions to assess medications and foster adherence to the medication regimen can increase the safety of older adults following hospitalization.
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Affiliation(s)
- Amanda S. Mixon
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Vanderbilt University, Nashville, Tenn., USA
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tenn., USA
| | - Erin Neal
- Department of Pharmaceutical Services, Vanderbilt University, Nashville, Tenn., USA
| | - Susan Bell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University, Nashville, Tenn., USA
- Center for Quality Aging, Vanderbilt University, Nashville, Tenn., USA
| | - James S. Powers
- Department of Veterans Affairs, Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Vanderbilt University, Nashville, Tenn., USA
- Center for Quality Aging, Vanderbilt University, Nashville, Tenn., USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University, Nashville, Tenn., USA
- Center for Quality Aging, Vanderbilt University, Nashville, Tenn., USA
- Center for Clinical Quality and Implementation Research, Vanderbilt University, Nashville, Tenn., USA
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Polypharmacy and Medication Regimen Complexity as Factors Associated with Hospital Discharge Destination Among Older People: A Prospective Cohort Study. Drugs Aging 2014; 31:623-30. [DOI: 10.1007/s40266-014-0185-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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