Long-term trajectories of medicine use among older adults experiencing polypharmacy in Australia

Longitudinal cohort study of discrepancies between prescribed and administered polypharmacy rates: implications for National Aged Care Quality Indicator Programs

BACKGROUND

Polypharmacy is frequently used as a quality indicator for older adults in Residential Aged Care Facilities (RACFs) and is measured using a range of definitions. The impact of data source choice on polypharmacy rates and the implications for monitoring and benchmarking remain unclear. We aimed to determine polypharmacy rates (≥9 concurrent medicines) by using prescribed and administered data under various scenarios, leveraging electronic data from 30 RACFs.

METHOD

A longitudinal cohort study of 5662 residents in New South Wales, Australia. Both prescribed and administered polypharmacy rates were calculated biweekly from January 2019 to September 2022, providing 156 assessment times. 12 different polypharmacy rates were computed separately using prescribing and administration data and incorporating different combinations of items: medicines and non-medicinal products, any medicines and regular medicines across four scenarios: no, 1-week, 2-week and 4-week look-back periods. Generalised estimating equation models were employed to identify predictors of discrepancies between prescribed and administered polypharmacy.

RESULTS

Polypharmacy rates among residents ranged from 33.9% using data on administered regular medicines with no look-back period to 63.5% using prescribed medicines and non-medicinal products with a 4-week look-back period. At each assessment time, the differences between prescribed and administered polypharmacy rates were consistently more than 10.0%, 4.5%, 3.5% and 3.0%, respectively, with no, 1-week, 2-week and 4-week look-back periods. Diabetic residents faced over two times the likelihood of polypharmacy discrepancies compared with counterparts, while dementia residents consistently showed reduced likelihood across all analyses.

CONCLUSION

We found notable discrepancies between polypharmacy rates for prescribed and administered medicines. We recommend a review of the guidance for calculating and interpreting polypharmacy for national quality indicator programmes to ensure consistent measurement and meaningful reporting.

The outcomes of considering goals of care in medication reviews for older adults: a systematic review

INTRODUCTION

This is a systematic review of prescribing, clinical, patient-reported, and health utilization outcomes of goal-directed medication reviews in older adults.

METHODS

A systematic review was conducted using MEDLINE, EMBASE, SCOPUS and CINAHL databases to identify studies examining outcomes of goal-directed medication reviews in humans, with mean/median age ≥ 60 years and in English.

RESULTS

Seventeen out of 743 articles identified were included. Whilst there were inconsistent findings regarding changes in the number of medications between groups or post-intervention in one group (n = 6 studies), studies found reductions in drug-related problems (n = 2) and potential to reduce anticholinergics and sedatives (n = 2). Two out of seven studies investigating clinical outcomes found improvements, such as reduced hospital readmissions and improved depression severity. One study found 75% of patients achieved ≥ 1 goals and another found 43% of goals were achieved at six months. Four out of five studies found significant improvements in patient-reported quality of life between groups (n = 2) or post-intervention in one group (n = 2). Both studies investigating cost-effectiveness reported the intervention was cost-effective.

CONCLUSIONS

There is evidence of positive impact on medication rationalization, quality of life and cost-effectiveness, supporting goal-directed medication reviews. Larger, longitudinal studies, exploring patient-focused outcomes may provide further insights into the ongoing impact of goal-directed medication reviews.

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

INTRODUCTION

As health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged ≥ 65 years in primary care in Ireland differ between patients with public and private health cover.

METHODS

This was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011-2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged ≥ 65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex, and hospitalisations.

RESULTS

Overall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n = 26,490). The rate of prescribing in all drug classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.

CONCLUSION

Our study found a significantly larger number of medications were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medications use.

Sex-specific medication trajectories in older adults newly diagnosed with diabetes

Background

People with diabetes tend to use many medications to treat diabetes and comorbidities. Nevertheless, the evolution of polypharmacy in newly diagnosed males and females has been little studied.

Objective

The objective of this paper was to identify and describe medication trajectories in incident diabetes cases according to sex.

Methods

Data were obtained from the Quebec Integrated Chronic Disease Surveillance System. We built a population-based cohort of community-dwelling individuals aged >65 years diagnosed with diabetes in 2014 who were alive and covered with the public drug plan until March 31, 2019. Latent class models were used to identify medication trajectory groups in males and females separately.

Results

Of the 10,363 included individuals, 51.4% were males. Females were older and more likely to have more medication claims than males. Four trajectory groups were identified for males and five for females. Most trajectories showed sustained and stable number of medications over time. For each sex, only one of the trajectory groups included a mean annual number of medications lesser than five. Slight increasing trends of medication use were detected in the trajectories composed of very high users, which included older, more comorbid individuals frequently exposed to potentially inappropriate medications.

Conclusions

Most males and females with incident diabetes had a high burden of medication following the year of diagnosis and were classified in a group of sustained medication use over time. The largest increase in medication was among those who had higher level of polypharmacy of questionable quality at baseline, raising concerns about the innocuity of such medication trajectories.

Longitudinal Patterns of Postfracture Outpatient Physical Therapy and Occupational Therapy Use and Its Association With 3-Year Mortality Among Adults With Cerebral Palsy

OBJECTIVE

Fragility fractures are common among adults with cerebral palsy (CP), but clinical rehabilitation use after fracture and its effect on long-term health outcomes have not been sufficiently studied. The objectives of this study were to identify patterns of the use of physical therapy, occupational therapy, or both in the 6-month postfracture period and the association with 3-year mortality in adults with CP.

METHODS

This retrospective cohort study included adults who were ≥18 years old, had CP, and had sustained an incident fragility fracture between January 1, 2014, and December 31, 2016, as identified from a random 20% Medicare fee-for-service dataset. Six-month outpatient physical therapy or occupational therapy use patterns after fracture were identified using group-based trajectory modeling. Cox regression determined the association between physical therapy or occupational therapy use trajectory patterns and mortality from 6 months to 3 years after fracture, adjusting for confounders. Effect modification by key characteristics was tested, including age, sex, and the modified Whitney Comorbidity Index (mWCI), which is a CP-specific comorbidity index that better captures overall medical complexity.

RESULTS

Of the 2429 participants included, the majority (73.2%) were characterized as having little to no probability of physical therapy or occupational therapy use, whereas 16.0 and 10.7% were characterized as having early initiation and later initiation, respectively. Compared to the mortality rate for the little to no physical therapy or occupational therapy group, the mortality rates were 26% lower for the early physical therapy or occupational therapy initiation group (hazard ratio [HR] = 0.74; 95% CI = 0.55-1.00) and were 20% lower for the later initiation group (HR = 0.80; 95% CI = 0.57-1.12). There was effect modification by the mWCI. The mortality rate was lower when the early initiation and later initiation groups were compared to the little to no initiation group across all mWCI values examined (median and interquartile range), but the effect was stronger (ie, lower mortality rate) for lower mWCI values for both early initiation and later initiation groups.

CONCLUSION

Most adults with CP underutilize outpatient physical therapy or occupational therapy services within 6 months postfracture. Early or later initiation versus little to no physical therapy or occupational therapy use was associated with a lower HR of mortality, although the effect was stronger and statistically significant among those with less medical complexity.

IMPACT

Throughout their lives, the use of rehabilitation services in individuals with CP, including physical therapy and occupational therapy, dramatically declines despite the need for continued rehabilitation across their lifespans. This study characterized longitudinal physical therapy or occupational therapy use patterns in the 6 months following a fragility fracture among adults with CP and found that nearly 3 in 4 adults with CP had little to no physical therapy or occupational therapy use during this critical window to optimize postfracture health and function. Further, those who more regularly used physical therapy or occupational therapy services, regardless of the timing of initiation (early vs later), had significantly improved survival up to 3 years after fracture, suggesting the need for greater access to and delivery of clinical rehabilitation services.

Population- and individual-level trajectories of opioid prescription patterns among adults with cerebral palsy: a retrospective cohort study

BACKGROUND

There is little epidemiologic evidence on opioid prescription among adults with cerebral palsy (CP).

AIM

To describe the population- and individual-level opioid prescription patterns for adults with versus without CP.

METHOD

This retrospective cohort study used commercial claims (Optum's de-identified Clinformatics® Data Mart Database) from the USA from 01/01/2011-12/31/2017 from adults ≥ 18 years old with CP and matched adults without CP. For the population-level analysis, monthly estimates of opioid exposure were described for adults ≥ 18 years old with CP and matched adults without CP. For the individual-level analysis, group based trajectory modelling (GBTM) was used to identify groups of similar individual-level monthly opioid exposure patterns for adults with CP and matched adults without CP for 1-year starting from their first opioid exposure month.

RESULTS

For the population-level, adults with (n = 13,929) versus without (n = 278,538) CP had a higher prevalence of opioid exposure (~ 12%, ~ 8%) and days supplied (median, ~ 23, ~17) monthly over 7 years. For the individual-level, there were 6 trajectory groups for CP (n = 2099) and 5 for non-CP (n = 10,361). Notably, 14% of CP (comprising 4 distinct trajectory groups) and 8% (comprising 3 distinct groups) of non-CP had variably high monthly opioid volume for extended periods; exposure was higher for CP. The remaining had low/absent opioid exposure trajectories; for CP (non-CP), 55.7% (63.3%) had nearly absent exposure and 30.4% (28.9%) had consistently low exposure to opioids.

CONCLUSION

Adults with versus without CP were more likely to be exposed to opioids and for a longer duration, which may alter the risk-benefit balance of opioids.

Medication changes and potentially inappropriate prescribing in older patients with significant polypharmacy

BACKGROUND

Number of medicines and medicines appropriateness are often used as outcome measures to evaluate the effectiveness of deprescribing interventions.

AIM

The aim of this study was to evaluate changes in prescribing, potentially inappropriate prescriptions (PIP) and prescribing of low-value medicines in older people with multimorbidity and significant polypharmacy.

METHOD

This study was a retrospective secondary analysis of prescription data from a cluster randomised controlled trial involving 404 participants aged ≥ 65 years and prescribed ≥ 15 repeat medicines from 51 different general practices. For this study, repeat medications at baseline and follow-up (~ 1 year later) were assigned Anatomical Therapeutic Classification (ATC) codes. Outcomes were the most commonly prescribed and potentially inappropriately prescribed drug groups, the most frequently discontinued or initiated drug groups and the number of changes per person between baseline and follow-up.

RESULTS

There were 7051 medicines prescribed to 404 participants at baseline. There was a median of 17 medicines (IQR 15-19) at baseline and 16 (IQR 14-19) at follow-up. PIP represented 17.1% of prescriptions at baseline and 15.7% (n = 6777) at follow-up. There were reductions in the prescription of most drug groups with the largest reduction in antiplatelet prescriptions. Considering medication discontinuations, initiations and switches, there was a median of five medication changes per person (range 0-30, IQR 3-9) by follow-up. There were 95 low-value prescriptions at baseline reducing to 78 at follow-up.

CONCLUSION

The number of medication changes per person was not reflected by summarising medication count at two time points, highlighting the complexity of prescribing for patients with polypharmacy. Frequent medication changes has potentially important implications for patients in terms of adherence and medication safety.

TRIAL REGISTRY

The SPPiRE trial was registered prospectively on the ISRCTN registry (ISRCTN12752680).

Trajectories of medication use and polypharmacy among children with cerebral palsy

BACKGROUND: Children with cerebral palsy (CP) may have chronic exposure to polypharmacy to address several medical needs, but there is little research on the topic to inform surveillance methods and clinical practice. OBJECTIVE: To identify the trajectories of medication number and pediatric polypharmacy (≥2 concurrent medications) exposure over 3.5 years among children with CP. METHODS: This cohort study used commercial claims from January 1, 2015, to December 31, 2018 (4-year period). Children with CP, aged 5-18 years by January 1, 2016, and with continuous health plan enrollment for all 4 years, were included and categorized as with or without co-occurring neurological/ RESULTS: Of the 1,252 children with CP, 600 were in the CP only cohort (mean [SD]; age, 11.4 [4.1] years; 46.0% female) and 652 were in the CP + NDDs cohort (age, 11.9 [4.1] years; 41.3% female; 32.7% had ≥2 of the NDDs). For the primary GBTM, 3 trajectory groups were identified for CP only: on average, no prescribed medications (69.7% of the cohort), 1 medication/month (24.8%), and 4 medications/month (5.5%). Five trajectory groups were identified for CP + NDDs: 0 (22.4%), 1 (25.6%), 2 (25.2%), 4 (18.4%), and 6 (8.4%) prescribed medications/month. For the secondary GBTM, 3 trajectory groups were identified for CP only: 80.5% were characterized as negligible probability of polypharmacy exposure, 10.8% as low probability, and 8.7% as high probability. Five trajectory groups were identified for CP + NDDs: 37.9% as negligible probability of polypharmacy exposure, 32.8% as constantly high probability, and 29.2% as changing probability (eg, increasing/decreasing). CONCLUSIONS: Children with CP are chronically exposed to differing levels of polypharmacy. Findings can help establish polypharmacy surveillance practices. Studies need to determine if polypharmaceutical strategies are balanced to optimize health and development for children with CP. DISCLOSURES: Dr Whitney is supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund. The funding source had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital

Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions.

Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021.

Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds.

Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Polypharmacy and trajectories of health-related quality of life in older adults: an Australian cohort study

Background

Health-related quality of life (HRQoL) is an important outcome measure when considering medical treatment; however, the impact of polypharmacy on trajectories of HRQoL over time is unknown. This study aimed to investigate the association between polypharmacy status and trajectories of HRQoL in older adults.

Methods

A longitudinal cohort study of 2181 community-dwelling adults, 65 years and older, who participated in the 2013 to 2017 waves of the Household Income and Labour Dynamics in Australia (HILDA) Survey. Polypharmacy was defined as the regular use of ≥ 5 prescription medications. Polypharmacy status was categorised into no polypharmacy, in 2013 only (baseline only polypharmacy), in 2017 only (incident polypharmacy) or at both time points (persistent polypharmacy). HRQoL was assessed through the SF-36 questionnaire generating two summary scores: physical component summary (PCS) and mental component summary (MCS). Linear mixed-effects models stratified according to polypharmacy status and change in comorbidities were used to assess trajectories of HRQoL.

Results

Older adults with persistent polypharmacy had lowest scores for HRQoL measures from 2013 to 2017. After adjusting for all covariates, those with incident polypharmacy had the steepest annual decline in both the PCS and MCS: − 0.86 in PCS and − 0.76 in MCS for those with decreasing or stable comorbidities, and − 1.20 in PCS and − 0.75 in MCS for those with increasing comorbidities.

Conclusions

Polypharmacy was associated with poorer HRQoL, even after adjusting for confounders. Incident polypharmacy was found to be associated with a clinically important decline in HRQoL and this should be considered when prescribing additional medication to older adults.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03136-9.

The impact of tightened prescribing restrictions on proton pump inhibitor use in Australia: An evaluation using interrupted time series analysis

AIM

In May 2019, Australia's Pharmaceutical Benefits Scheme (PBS) tightened the prescribing restrictions for publicly subsidized high and standard strength proton-pump inhibitors (PPIs). We aimed to determine the impacts on PPI use in Australia.

METHODS

Population-based interrupted time series analysis of PBS dispensing claims for a 10% sample of PBS-eligible Australian residents from January 2017 to December 2020 and national prescription and over-the-counter sales to pharmacies from January 2017 to October 2020. We examined trends in monthly PPI dispensings, switches from higher to lower strength formulations, and volume (kg) dispensed and sold.

RESULTS

From May 2019, we observed a small, immediate decrease (-7830 [95%CI: -8818 to -6842]) in standard strength PPI dispensings/month, which rebounded to exceed pre-intervention levels by December 2020. High strength dispensings decreased until the end of the study period to less than half their pre-intervention average/month; low strength dispensings/month increased until the end of the study period to more than double their pre-intervention average/month. We observed transient increases in switches to lower strength formulations post-intervention. The kilograms of PPIs sold/month followed a similar pattern to PBS kilograms dispensed/month with the exception of standard strength formulations where PBS dispensings decreased by -74 (95%CI: -93 to -55) but total sales remained unchanged (comprising PBS and private prescriptions, and over-the-counter sales).

CONCLUSIONS

Tightened prescribing restrictions had an immediate and sustained impact on PPI use in Australia, with decreased high strength use and increased low strength use. Some patients likely switched to private market prescriptions for standard strength PPI, given the observed patterns in total volume sold/dispensed.

An Update on Medication Use in Older Adults: a Narrative Review

Purpose of Review

The global phenomenon of population aging is impacting the health and care needs of society. The use of medications by older adults is acknowledged to be the most common form of medical intervention for many acute and chronic conditions and prescribing in this population continues to increase. In this narrative review, we summarise the age-related factors that should be considered when prescribing for older adults, address some of the perennial challenges related to medicine use in older people, and highlight important emerging research in this area.

Recent Findings

A range of age-related factors should be considered when prescribing for older adults. However, the evidence base still lacks data pertaining to older adults due to their continued under-representation in clinical trials. Multimorbidity, polypharmacy, and inappropriate prescribing continue to remain prevalent among older adults, although recent research has been focused on the development and evaluation of complex interventions to address these challenges.

Summary

Further high-quality studies of interventions to improve and support medication use in older adults are needed, ensuring that older adults are well represented in such trials and consideration is given to the measurement of patient- and provider-focused outcomes.