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D'Aiuto C, Lunghi C, Guénette L, Berbiche D, Bertrand K, Vasiliadis HM. Risk of Mortality Associated with Potentially Inappropriate Medication Use Including Opioids in Older Adults. Drug Saf 2024; 47:799-807. [PMID: 38722482 DOI: 10.1007/s40264-024-01429-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION AND OBJECTIVE As the population ages, understanding the potential risks associated with inappropriate medication use becomes increasingly important. Given the lack of studies in this area, our objective was to study the risk of mortality associated with potentially inappropriate medication use involving opioids in community-dwelling older adults. METHODS Data came from a longitudinal study on older adults aged ≥ 65 years recruited in primary care clinics between 2011 and 2013 with an average follow-up of 4.25 years. Older adults were excluded if they used an opioid or had a malignant tumor diagnosis in the year before the study survey. A nested case-control within a cohort of older adults with at least one opioid claim during follow-up was used to evaluate the risk of all-cause mortality. Four controls per case were matched on follow-up time using risk-set sampling, i.e., while still at risk of death when their matched case died. The risk of mortality was estimated using conditional logistic regression analyses. Exposure to potentially inappropriate medication use involving opioids, defined using the Beers 2019 criteria, was assessed from provincial drug claims data in the 0-90 days before death. RESULTS In a cohort of 472 community-dwelling older adults with an incident episode of opioid use, there were 40 cases matched to 160 controls. Exposure to inappropriate medication use involving opioids in the 90 days before death was associated with an increased risk of mortality (odds ratio 6.81, 95% confidence interval 1.69-27.47), after adjusting for potential confounders. CONCLUSIONS Exposure to inappropriate medication use involving opioids in the 90 days before death is associated with an increased risk of mortality in older adults. These findings can be used to encourage safer pain management strategies in older adults.
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Affiliation(s)
- Carina D'Aiuto
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), Longueuil, QC, Canada
| | - Carlotta Lunghi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Line Guénette
- Population Health and Optimal Health Practices Research Unit, CHU de Québec Research Center, Québec City, QC, Canada
- Faculty of Pharmacy, Laval University, Québec City, QC, Canada
| | - Djamal Berbiche
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), Longueuil, QC, Canada
| | - Karine Bertrand
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada
- Charles-Le Moyne Research Center (CR-CLM), Longueuil, QC, Canada
| | - Helen-Maria Vasiliadis
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, University of Sherbrooke, 150 Place Charles-Le Moyne, Longueuil, QC, J4K 0A8, Canada.
- Charles-Le Moyne Research Center (CR-CLM), Longueuil, QC, Canada.
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Vandenberg AE, Hwang U, Das S, Genes N, Nyamu S, Richardson L, Ezenkwele U, Legome E, Richardson C, Belachew A, Leong T, Kegler M, Vaughan CP. Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models. J Am Geriatr Soc 2024; 72:2184-2194. [PMID: 38259070 DOI: 10.1111/jgs.18746] [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: 07/31/2023] [Revised: 11/09/2023] [Accepted: 12/09/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.
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Affiliation(s)
- Ann E Vandenberg
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ula Hwang
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
- James J. Peters VA Medical Center GRECC, Bronx, New York, USA
| | - Shamie Das
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nicholas Genes
- Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Sylviah Nyamu
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lynne Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ugo Ezenkwele
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric Legome
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher Richardson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Belachew
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Michelle Kegler
- Department of Behavioural, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Birmingham/Atlanta VA GRECC, Atlanta, Georgia, USA
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Inglis JM, Caughey G, Thynne T, Brotherton K, Liew D, Mangoni AA, Shakib S. Association of Drug-Disease Interactions with Mortality or Readmission in Hospitalised Middle-Aged and Older Adults: A Systematic Review and Meta-Analysis. Drugs Real World Outcomes 2024:10.1007/s40801-024-00432-3. [PMID: 38852118 DOI: 10.1007/s40801-024-00432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Multimorbidity is common in hospitalised adults who are at increased risk of inappropriate prescribing including drug-disease interactions. These interactions occur when a medicine being used to treat one condition exacerbates a concurrent medical condition and may lead to adverse health outcomes. The aim of this review was to examine the association between drug-disease interactions and the risk of mortality and readmission in hospitalised middle-aged and older adults. METHODS A systematic review was conducted on drug-disease interactions in hospitalised middle-aged (45-64 years) and older adults (≥65 years). The study protocol was prospectively registered with PROSPERO (Registration Number: CRD42022341998). Drug-disease interactions were defined as a medicine being used to treat one condition with the potential to exacerbate a concurrent medical condition or that were inappropriate based on a comorbid medical condition. Both observational and interventional studies were included. The outcomes of interest were mortality and readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, Web of Science, SCOPUS and the Cochrane Library from inception to 12 July, 2022. A meta-analysis was performed to pool risk estimates using the random-effects model. RESULTS A total of 563 studies were identified and four met the inclusion criteria. All were observational studies in older adults, with no studies identified in middle-aged adults. Most of the studies were at risk of bias because of an inadequate adjustment for covariates and a lack of clarity around individuals lost to follow-up. There were various definitions of drug-disease interactions within these four studies. Two studies assessed drugs that were contraindicated based on renal function, one assessed an individual drug-disease combination, and one was based on the clinical judgement of a pharmacist. There were two studies that showed an association between drug-disease interactions and the outcomes of interest. One reported that the use of diltiazem in patients with heart failure was associated with an increased risk of readmissions. The second reported that the use of medicines contraindicated according to renal function were associated with increased risk of all-cause mortality and a composite of mortality and readmission. Three of the studies (total study population = 5705) were amenable to a meta-analysis, which showed no significant association between drug-disease interactions and readmissions (odds ratio = 1.0, 95% confidence interval 0.80-1.38). CONCLUSIONS Few studies were identified examining the risk of drug-disease interactions and mortality and readmission in hospitalised adults. Most of the identified studies were at risk of bias. There is no universal accepted definition of drug-disease interactions in the literature. Further studies are needed to develop a standardised and accepted definition of these interactions to guide further research in this area.
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Affiliation(s)
- Joshua M Inglis
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia.
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia.
| | - Gillian Caughey
- Registry of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - Tilenka Thynne
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Kate Brotherton
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Danny Liew
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of General Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Sepehr Shakib
- Adelaide Medical School, University of Adelaide, North Terrace, Adelaide, SA, 5000, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, Adelaide, SA, Australia
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Gettel CJ, Galske J, Sather AR, Haidous AK, Hwang U, Brackett AL, Venkatesh AK, Rising KL, Goldberg EM, van Oppen JD, Conroy SP, Carpenter CR. Patient-reported outcome measure use among older adults after emergency department care: A systematic review. Acad Emerg Med 2024; 31:273-287. [PMID: 38366698 DOI: 10.1111/acem.14850] [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: 09/15/2023] [Revised: 12/05/2023] [Accepted: 12/09/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Patient-reported outcome measures (PROMs) are gaining favor in clinical and research settings given their ability to capture a patient's symptom burden, functional status, and quality of life. Our objective in this systematic review was to summarize studies including PROMs assessed among older adults (age ≥ 65 years) after seeking emergency care. METHODS With the assistance of a medical librarian, we searched Ovid MEDLINE, PubMed, Embase, CINAHL, Web of Science-Core Collection, and Cochrane CENTRAL from inception through June 2023 for studies in which older adult ED patients had PROMs assessed in the post-emergency care time period. Independent reviewers performed title/abstract review, full-text screening, data extraction, study characteristic summarization, and risk-of-bias (RoB) assessments. RESULTS Our search strategy yielded 5153 studies of which 56 met study inclusion criteria. Within included studies, 304 unique PROM assessments were performed at varying time points after the ED visit, including 61 unique PROMs. The most commonly measured domain was physical function, assessed within the majority of studies (47/56; 84%), with measures including PROMs such as Katz activities of daily living (ADLs), instrumental ADLs, and the Barthel Index. PROMs were most frequently assessed at 1-3 months after an ED visit (113/304; 37%), greater than 6 months (91/304; 30%), and 4-6 months (88/304; 29%), with very few PROMs assessed within 1 month of the ED visit (12/304; 4%). Of the 16 interventional studies, two were determined to have a low RoB, four had moderate RoB, nine had high RoB, and one had insufficient information. Of the 40 observational studies, 10 were determined to be of good quality, 20 of moderate quality, and 10 of poor quality. CONCLUSIONS PROM assessments among older adults following an ED visit frequently measured physical function, with very few assessments occurring within the first 1 month after an ED visit.
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Affiliation(s)
- Cameron J Gettel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - James Galske
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Ali K Haidous
- University of Michigan-Dearborn, Dearborn, Michigan, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, New York, USA
| | - Alexandria L Brackett
- Harvey Cushing/John Hay Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
- Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Center for Connected Care, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- College of Nursing, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Elizabeth M Goldberg
- Department of Emergency Medicine, School of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - James D van Oppen
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Simon P Conroy
- Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, UK
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Lockery JE, Collyer TA, Woods RL, Orchard SG, Murray A, Nelson MR, Stocks NP, Wolfe R, Moran C, Ernst ME. Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults. J Am Geriatr Soc 2023; 71:2495-2505. [PMID: 37039393 PMCID: PMC10524300 DOI: 10.1111/jgs.18353] [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: 12/09/2022] [Revised: 02/12/2023] [Accepted: 03/05/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort. METHODS Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities. RESULTS At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability. CONCLUSIONS PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.
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Affiliation(s)
- Jessica E Lockery
- Cancer, Ageing and Vaccines Research Group, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Taya A Collyer
- Peninsula Clinical School, Monash University, Melbourne, VIC, Australia
| | - Robyn L Woods
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Suzanne G Orchard
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Anne Murray
- Hennepin Healthcare Research Institute, Hennepin Healthcare, Minnesota, U.S
- Division of Geriatrics, Department of Medicine, University of Minnesota, Minnesota, U.S
| | - Mark R Nelson
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Nigel P Stocks
- Discipline of General Practice, University of Adelaide, South Australia, Australia
| | - Rory Wolfe
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Chris Moran
- School of Public Health & Preventive Medicine, Monash University, Melbourne VIC, Australia
| | - Michael E Ernst
- Department of Pharmacy Practice and Science, College of Pharmacy and Department of Family Medicine, Carver College of Medicine, The University of Iowa, Iowa City, U.S
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Kegler MC, Rana S, Vandenberg AE, Hastings SN, Hwang U, Eucker SA, Vaughan CP. Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments. FRONTIERS IN HEALTH SERVICES 2022; 2:1053489. [PMID: 36925898 PMCID: PMC10012623 DOI: 10.3389/frhs.2022.1053489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 12/13/2022]
Abstract
Background Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Materials and methods Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Results Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Discussion Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. Conclusion This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.
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Affiliation(s)
- Michelle C. Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Shaheen Rana
- School of Medicine, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | | | - Ula Hwang
- Yale University School of Medicine, New Haven, CT, United States
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Rider AC, Dang BT, Caretta‐Weyer HA, Schertzer KA, Gisondi MA. A mixed‐methods needs assessment to identify pharmacology education objectives for emergency medicine residents. J Am Coll Emerg Physicians Open 2022; 3:e12682. [PMID: 35310405 PMCID: PMC8913520 DOI: 10.1002/emp2.12682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 12/17/2021] [Accepted: 01/27/2022] [Indexed: 11/08/2022] Open
Abstract
Objectives Medication errors represent a significant threat to patient safety. Pharmacotherapy is one of the 23 Accreditation Council of Graduate Medical Education milestones for emergency medicine, yet there is minimal understanding of what content should be prioritized during training. The study aim was to develop objectives for a patient‐safety focused pharmacology curriculum for emergency medicine residents. Methods We incorporated data from a de‐identified safety event database and survey responses of 30 faculty and clinical pharmacists at a single‐site suburban university hospital with 24‐hour emergency medicine pharmacists and an annual volume of approximately 70,000. We reviewed the database to quantify types and severity of medication errors over a 5‐year period for a total of 370 errors. Anonymous surveys included categorical items that we analyzed with descriptive statistics and short answer questions that underwent thematic analysis by 2 coders. We summarized all data sources to identify curriculum gaps. Results Common medication errors reported in our database were wrong dose (43%) and computer order entry errors (14%). Knowledge gaps were medication cost (63%), pregnancy risk information (60%), antibiotic stewardship (53%), interactions (47%), and side effects (47%). Qualitative analysis revealed the need to optimize computer order entry, understand the scope of critical medications, use references, and consult pharmacists. Integration of data suggested specific medications should be covered in curricular efforts, including antibiotics, analgesics, sedatives, and insulin. Conclusion We developed objectives of pharmacology topics to prioritize during emergency medicine training to enhance prescribing safety. This study is limited due to its small sample and single institution source of data. Future studies should investigate the impact of pharmacology curriculum on minimizing clinical errors.
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Affiliation(s)
- Ashley C. Rider
- Department of Emergency Medicine Stanford University Palo Alto California USA
| | | | | | | | - Michael A. Gisondi
- Department of Emergency Medicine Stanford University Palo Alto California USA
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Kooda K, Canterbury E, Bellolio F. Impact of Pharmacist-Led Antimicrobial Stewardship on Appropriate Antibiotic Prescribing in the Emergency Department: A Systematic Review and Meta-Analysis. Ann Emerg Med 2022; 79:374-387. [PMID: 35039180 DOI: 10.1016/j.annemergmed.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 12/25/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to evaluate the impact of pharmacist presence or pharmacist-led antimicrobial stewardship interventions on appropriate prescribing of antibiotics in the emergency department (ED). METHODS Systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were conducted. Studies describing the role of pharmacists and their association with antimicrobial stewardship in the ED were included. The comparator for pharmacist intervention was hours without a pharmacist present, preprotocol implementation, and nonpharmacist culture follow-up. RESULTS In total, 24 studies (9,984 patients) were included in the qualitative synthesis, and 22 studies (5,791 patients) had data for the primary outcome and were included for the quantitative assessment (meta-analysis). Appropriate prescribing of antibiotics was more likely with pharmacist intervention (22 studies; odds ratio [OR], 3.47; 95% confidence interval [CI] 2.39 to 5.03), particularly among patients with pneumonia (5 studies; OR, 3.74; 95% CI 2.14 to 6.54) or urinary tract infection (4 studies; OR, 1.76; 95% CI 1.24 to 2.50). Time to culture review was similar with or without pharmacist intervention. Time to appropriate antibiotic was shorter with pharmacist intervention (mean difference, 18.9 hours; 95% CI 11.9 to 25.9; P<.001). Repeat ED visit for the same complaint was not significant (10 studies; OR, 0.65; 95% CI 0.39 to 1.10). CONCLUSION Pharmacist presence and pharmacist-led antimicrobial stewardship interventions appear to be effective for the appropriate prescribing of antibiotics in adult patients presenting to EDs with a variety of infectious syndromes.
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Nightingale G, Scopelliti EM, Casten R, Woloshin M, Xiao S, Kelley M, Chang AM, Hollander JE, Leiby BE, Peterson AM, Pizzi LT, Rising KL, White N, Rovner B. Polypharmacy and Potentially Inappropriate Medication Use in Older Blacks with Diabetes Mellitus Presenting to the Emergency Department. J Aging Health 2021; 34:499-507. [PMID: 34517775 DOI: 10.1177/08982643211045546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: Medication-related problems in older Blacks with diabetes mellitus (DM) are not well established. Objectives: To describe the frequency of medication-related problems in older Blacks with DM presenting to the emergency department (ED). Methods: The study was a cross-sectional analysis of baseline data from a randomized controlled trial evaluating Blacks aged ≥60 years of age presenting to the ED. Polypharmacy, potentially inappropriate medication (PIM) use, and anticholinergic score were evaluated. Results: Of 168 patients (median age = 68, range 60-92), most (n = 164, 98%) were taking ≥5 medications, and 67 (39.9%) were taking a PIM. A majority (n = 124, 74%) were taking a medication with an anticholinergic score ≥1. Number of medications was correlated with number of PIMs (r = .22, p = .004) and anticholinergic score (r = .50, p < .001). Conclusion: Polypharmacy and PIM use was common in older Blacks with DM.
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Affiliation(s)
- Ginah Nightingale
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Emily M Scopelliti
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Robin Casten
- Department of Psychiatry and Human Behavior, Sidney Kimmel Medical College, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Monica Woloshin
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Shu Xiao
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Megan Kelley
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Anna Marie Chang
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Judd E Hollander
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Benjamin E Leiby
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Andrew M Peterson
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Laura T Pizzi
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Kristin L Rising
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Neva White
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
| | - Barry Rovner
- Department of Pharmacy Practice, Jefferson College of Pharmacy, 114062Thomas Jefferson University, Philadelphia, PA, USA
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10
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Manias E, Kabir MZ, Maier AB. Inappropriate medications and physical function: a systematic review. Ther Adv Drug Saf 2021; 12:20420986211030371. [PMID: 34349978 PMCID: PMC8287273 DOI: 10.1177/20420986211030371] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 06/17/2021] [Indexed: 01/10/2023] Open
Abstract
Background and aims: Inappropriate medication prescription is highly prevalent in older adults and is associated with adverse health outcomes. The aim of this study was to examine the associations between potentially inappropriate medications (PIMS) and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: A systematic search was completed using the following databases: MEDLINE, CINAHL, PsycINFO, EMBASE and COCHRANE. Results were extracted from the included studies. Results: In total, 55 studies reported on 2,767,594 participants with a mean age of 77.1 years (63.5% women). Study designs comprised 26 retrospective cohort studies, 21 prospective cohort studies and 8 cross-sectional studies. Inappropriate medications in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), impaired activities of daily living (ADL; 8 out of 10 studies) and impaired instrumental ADL (IADL) score (4 out of 6 studies). Five out of seven studies also showed that PIMs were associated with poorer physical performance comprising the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many medication classes were implicated as PIMs in falls, fractures and impairment in physical performance including antipsychotic, sedative, anti-anxiety, anticholinergic, antidiabetic, opioid and antihypertensive medications. For patients not receiving musculoskeletal medications, such as calcium, vitamin D and bisphosphonates, older adults were found to be at risk of a hospital admission for a fall or fracture. Conclusion: Inappropriate medication prescriptions are associated with impaired physical function across longitudinal and cross-sectional studies in older adults situated in diverse settings. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions. Plain language summary Inappropriate medications and physical function Background and aims: The use of inappropriate medications is very common in older adults and is associated with harmful health problems. The aim was to examine associations between potentially inappropriate medications and potential prescribing omissions with physical function in older adults situated in diverse environments. Methods: Library databases were examined for possible studies to include and a systematic search was completed. Relevant information was obtained from the included studies. Results: In total, 55 studies reported on 2,767,594 participants who were an average age of 77.1 years and about 6 out of 10 were women. A variety of different study designs were used. Inappropriate medication prescriptions in community and hospital settings were significantly associated with higher risk of falls (21 out of 30 studies), higher risk of fractures (7 out of 9 studies), problems with activities of daily living (ADL), such as eating, bathing, dressing, grooming, walking and toileting (8 out of 10 studies) and problems with instrumental ADL such as managing medications, house cleaning and shopping (4 out of 6 studies). Five out of seven studies also showed that inappropriate medications were associated with poorer physical performance involving the Timed Up and Go test, walking speed, grip strength, time to functional recovery, functional independence and scale of functioning. Many types of medication classes were shown to be associated with a risk of falls, fractures and problems with physical performance. Omitted medications were also associated with falls and fractures. Conclusion: Inappropriate medication prescriptions are associated with problems relating to physical function. It is important to support older people to reduce their use of inappropriate medications and prevent prescribing omissions.
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Affiliation(s)
- Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, 221 Burwood Highway, Burwood, VIC 3125, Australia
| | - Md Zunayed Kabir
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Andrea B Maier
- Department of Medicine and Aged Care, @ Age Melbourne, The Royal Melbourne Hospital, The University of Melbourne, VIC, Australia
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11
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Bakey KH, Nguyen CTN. Impact of a Pharmacist Intervention in the Emergency Department on the Appropriateness of Direct Oral Anticoagulants Prescribed in Venous Thromboembolism Patients. J Pharm Pract 2021; 35:599-605. [PMID: 33736522 DOI: 10.1177/08971900211000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is now widely accepted to manage low risk acute venous thromboembolism (VTE) in the outpatient setting with direct oral anticoagulants (DOACs). Although DOACs are straightforward to dose, they are high risk medications and not immune to medication errors. There is limited evidence that pharmacists' intervention has an impact on DOAC discharge medication errors in the ED. OBJECTIVE To determine if pharmacist involvement reduced the rate of DOAC discharge medication errors in low risk VTE patients. METHODS This retrospective cohort study evaluated a clinical pharmacy service implemented prior to the study. Included patients were evaluated in 2 groups: the cohort with pharmacist involvement and the cohort without pharmacist involvement. The primary outcome was the rate of anticoagulation medication errors. RESULTS A total of 58 patients were evaluated. Of these patients, 14 had a pharmacist directly involved with their care in the ED while 44 patients did not. The rate of medication errors was lower when a pharmacist was involved, 7.1% (n = 1), compared to when a pharmacist was not involved, 36.4% (n = 16), (p = 0.046). All patients in the pharmacist involvement group received anticoagulation counseling prior to discharge compared to only 56.8% of patients in the non-pharmacist involvement group (p = 0.002). CONCLUSION Our protocol for pharmacist involvement at the time of VTE diagnosis during an ED admission showed a reduced rate of anticoagulation medication errors when a pharmacist was involved. This benefit could potentially translate into improved outcomes such as readmission rates, patient safety outcomes, and hospitalizations.
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Affiliation(s)
- Kristen H Bakey
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, FL, USA.,University of Florida College of Pharmacy, Gainesville, FL, USA
| | - Cam-Tu N Nguyen
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, FL, USA.,University of Florida College of Pharmacy, Gainesville, FL, USA
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12
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Burkett E, Carpenter CR, Hullick C, Arendts G, Ouslander JG. It's time: Delivering optimal emergency care of residents of aged care facilities in the era of COVID-19. Emerg Med Australas 2020; 33:131-137. [PMID: 33131219 DOI: 10.1111/1742-6723.13683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ellen Burkett
- Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Healthcare Improvement Unit, Clinical Excellence Queensland, Brisbane, Queensland, Australia
| | | | - Carolyn Hullick
- Belmont Hospital, Belmont, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Emergency Department, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Joseph G Ouslander
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida, USA
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13
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Vandenberg AE, Kegler M, Hastings SN, Hwang U, Wu D, Stevens MB, Clevenger C, Eucker S, Genes N, Huang W, Ikpe-Ekpo E, Nassisi D, Previll L, Rodriguez S, Sanon M, Schlientz D, Vigliotti D, Vaughan CP. Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system. Int J Qual Health Care 2020; 32:470-476. [PMID: 32671390 DOI: 10.1093/intqhc/mzaa077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVES To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up. DESIGN Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package. SETTING Three academic emergency departments that each implemented EQUIPPED over three successive years. PARTICIPANTS Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects. INTERVENTION(S) EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge. MAIN OUTCOME MEASURE(S) Implementation process components assembled through successive implementation. RESULTS Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model. CONCLUSIONS Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.
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Affiliation(s)
| | - Michelle Kegler
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | | | - Ula Hwang
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Daniel Wu
- Emory University School of Medicine, Atlanta, GA 30322, USA
| | | | | | - Stephanie Eucker
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Nick Genes
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Wennie Huang
- Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Denise Nassisi
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Laura Previll
- Duke University School of Medicine, Durham, NC 27710, USA
| | - Sandra Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Martine Sanon
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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14
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Towiwat P, Phungoen P, Tantrawiwat K, Laohakul P, Aiewruengsurat D, Thanadetsuntorn C, Ruchakorn N, Sangsawangchot P, Buttham B. Quality of gout care in the emergency departments: a multicentre study. BMC Emerg Med 2020; 20:27. [PMID: 32312248 PMCID: PMC7171834 DOI: 10.1186/s12873-020-00319-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 03/19/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND To report on prevalence of gout flare in emergency departments and to report the quality of gout care in emergency departments and causes of admission at emergency departments. METHODS A retrospective chart review of visits that had a primary diagnosis in gout by the International Classification of Diseases, the tenth revision, at emergency departments from 6 universities in Thailand over a 5 year period from 1 January 2012 to 31 December 2016. RESULTS Six hundred thirty-two visits were included to the study. Prevalence of gout flare in emergency departments was 0.04. Only 29.3% of the visits had arthrocentesis. 628/632 (99.4%) and 519/585 (88.7%) of the visits were prescribed medications in emergency departments and had home medications, respectively. Although all visits that were prescribed colchicine in emergency departments received adequate doses of colchicine, it was also found that more than 2.4 mg/day of colchicine was prescribed (3/394, 0.8%) for home medications. In addition, 183/343 (53.4%) of the visits with normal renal function were prescribed non-steroidal anti-inflammatory drugs (NSAIDs). However, prescribed NSAIDs in abnormal renal function (42/343, 12.2%) was also found. The interruption of dosing, including increase, decrease, addition or discontinuance of urate lowing therapy in a gout flare period was 42/632 (6.6%). The most common cause of admission was acute gouty arthritis (31/47, 66.0%). CONCLUSIONS Quality of gout care in the emergency departments was not good. Inappropriate management of gout flare in emergency departments was demonstrated in our study, particularly with regard to investigations and pharmacological management. Gaps between clinicians and guidelines, the knowledge of clinicians, and overcrowding in emergency departments were hypothesized in the results.
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Affiliation(s)
- Patapong Towiwat
- Department of Internal Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, 65000 Thailand
| | - Pariwat Phungoen
- Department of Emergency Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Kitti Tantrawiwat
- Department of Surgery, Faculty of Medicine, Naresuan University, Phitsanulok, Thailand
| | - Pavita Laohakul
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Duangkamol Aiewruengsurat
- Allergy and Rheumatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand
| | - Chokchai Thanadetsuntorn
- Division of Allergy Immunology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nopparat Ruchakorn
- Department of Internal Medicine, Faculty of Medicine, Srinakharinthawirot University, Bangkok, Thailand
| | - Passagorn Sangsawangchot
- Department of Internal Medicine, Faculty of Medicine, Srinakharinthawirot University, Bangkok, Thailand
| | - Bodin Buttham
- Department of Internal Medicine, Faculty of Medicine, Naresuan University, Phitsanulok, 65000 Thailand
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15
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Chahine EB, Durham SH, Mediwala KN, Chastain DB, Gauthier TP, Hill BK, Jones BM, Kisgen JJ, Marx AH, Stover KR, Worley MV, Bland CM, Bookstaver PB. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2018. Open Forum Infect Dis 2019; 6:ofz450. [PMID: 31700942 PMCID: PMC6825802 DOI: 10.1093/ofid/ofz450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/06/2019] [Indexed: 02/06/2023] Open
Abstract
With an increasing number of antimicrobial stewardship-related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related peer-reviewed literature that detailed an actionable intervention for 2018. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the actionable intervention used by antimicrobial stewardship programs to provide key stewardship literature for teaching and training as well as to identify potential intervention opportunities within one's institution.
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Affiliation(s)
- Elias B Chahine
- Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy, West Palm Beach, Florida, USA
| | - Spencer H Durham
- Auburn University Harrison School of Pharmacy, Auburn, Alabama, USA
| | | | | | | | - Brandon K Hill
- University of Virginia Health System, Charlottesville, Virginia, USA
| | - Bruce M Jones
- St. Joseph’s/Candler Health System, Savannah, Georgia, USA
| | - Jamie J Kisgen
- Sarasota Memorial Health Care System, Sarasota, Florida, USA
| | - Ashley H Marx
- UNC Medical Center, Chapel Hill, North Carolina, USA
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, Mississippi, USA
| | - Marylee V Worley
- Nova Southeastern University College of Pharmacy, Fort Lauderdale, Florida, USA
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16
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Pouliot J, Hahn M, Sharpe B. Impact of Initiating Clinical Pharmacy Services in a Non-Academic Community Medical Center Emergency Department Setting. JOURNAL OF CONTEMPORARY PHARMACY PRACTICE 2019. [DOI: 10.37901/jcphp17-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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17
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Xing XX, Zhu C, Liang HY, Wang K, Chu YQ, Zhao LB, Jiang DC, Wang YQ, Yan SY. Associations Between Potentially Inappropriate Medications and Adverse Health Outcomes in the Elderly: A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 53:1005-1019. [PMID: 31129978 DOI: 10.1177/1060028019853069] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Adverse drug outcomes in the elderly have led to the development of lists of potentially inappropriate medications (PIMs), such as the Beers criteria, and these PIMs have been studied widely; however, it is still unclear whether PIM use is predictive of adverse outcomes in older people. Objective: To qualitatively examine the associations between exposure to PIMs from the general Beers criteria and the Screening Tool of Older Persons' Prescriptions list and adverse outcomes, such as adverse drug reactions (ADRs)/adverse drug events (ADEs), hospitalization, and mortality. Methods: Specified databases were searched from inception to February 1, 2018. Two reviewers independently selected studies that met the inclusion criteria, assessed study quality, and extracted data. Data were pooled using Stata 12.0. The outcomes were ADRs/ADEs, hospitalization, and mortality. Results: A total of 33 studies met the inclusion criteria. The combined analysis revealed a statistically significant association between ADRs/hospitalizations and PIMs (odds ratio [OR] = 1.44, 95% CI = 1.33-1.56; OR = 1.27, 95% CI = 1.20-1.35), but no statistically significant association was found between mortality and PIMs (OR = 1.04; 95% CI = 0.75-1.45). It is interesting to note that the results changed when different continents/criteria were used for the analysis. Compared with the elderly individuals exposed to 1 PIM, the risk of adverse health outcomes was much higher for those who took ≥2 PIMs. Conclusion and Relevance: We recommend that clinicians avoid prescribing PIMs for older adults whenever feasible. In addition, the observed associations should be generalized to other countries with different PIM criteria with caution.
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Affiliation(s)
- Xiao Xuan Xing
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
| | - Chen Zhu
- 3 Zhejiang University, Hangzhou, P R China
| | - Hua Yu Liang
- 4 The Seventh Medical Center of PLA General Hospital, Beijing, P R China
| | - Ke Wang
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
| | - Yan Qi Chu
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
| | - Li Bo Zhao
- 5 Capital Medical University, Beijing, P R China
| | - De Chun Jiang
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
| | - Yu Qin Wang
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
| | - Su Ying Yan
- 1 Xuanwu Hospital of Capital Medical University, Beijing, P R China.,2 National Clinical Research Center for Geriatric Disorders, Beijing, P R China
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18
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Moss JM, Bryan WE, Wilkerson LM, King HA, Jackson GL, Owenby RK, Van Houtven CH, Stevens MB, Powers J, Vaughan CP, Hung WW, Hwang U, Markland AD, Sloane R, Knaack W, Hastings SN. An Interdisciplinary Academic Detailing Approach to Decrease Inappropriate Medication Prescribing by Physician Residents for Older Veterans Treated in the Emergency Department. J Pharm Pract 2019; 32:167-174. [PMID: 29277130 PMCID: PMC6533068 DOI: 10.1177/0897190017747424] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the impact of an academic detailing intervention delivered as part of a quality improvement project by a physician-pharmacist pair on (1) self-reported confidence in prescribing for older adults and (2) rates of potentially inappropriate medications (PIMs) prescribed to older adults by physician residents in a Veteran Affairs emergency department (ED). METHODS This quality improvement project at a single site utilized a questionnaire that assessed knowledge of Beers Criteria, self-perceived barriers to appropriate prescribing in older adults, and self-rated confidence in ability to prescribe in older adults which was administered to physician residents before and after academic detailing delivered during their emergency medicine rotation. PIM rates in the resident cohort who received the academic detailing were compared to residents who did not receive the intervention. RESULTS Sixty-three residents received the intervention between February 2013 and December 2014. At baseline, approximately 50% of the residents surveyed reported never hearing about nor using the Beers Criteria. A significantly greater proportion of residents agreed or strongly agreed in their abilities to identify drug-disease interactions and to prescribe the appropriate medication for the older adult after receiving the intervention. The resident cohort who received the educational intervention was less likely to prescribe a PIM when compared to the untrained resident cohort with a rate ratio of 0.73 ( P < .0001). CONCLUSION Academic detailing led by a physician-pharmacist pair resulted in improved confidence in physician residents' ability to prescribe safely in an older adult ED population and was associated with a statistically significant decrease in PIM rates.
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Affiliation(s)
- Jason M. Moss
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Campbell University College of Pharmacy and Health Sciences, Buies Creek, NC, USA
| | - William E. Bryan
- Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Loren M. Wilkerson
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Heather A. King
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - George L. Jackson
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Ryan K. Owenby
- Pharmacy Service, Veterans Affairs Health Care System, Durham, NC, USA
| | - Courtney H. Van Houtven
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Melissa B. Stevens
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA
- Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - James Powers
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Nashville, TN, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Camille P. Vaughan
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Atlanta/Decatur, GA, USA
- Emory University School of Medicine, Atlanta/Decatur, GA, USA
| | - William W. Hung
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | - Ula Hwang
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Bronx, NY, USA
- Icahn School of Medicine at Mount Sinai, Bronx, NY, USA
| | | | - Richard Sloane
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Department of Duke Aging Center, Duke University Medical Center, Durham, NC, USA
| | - William Knaack
- Division of General Internal Medicine, Veterans Affairs Health Care System, Durham, NC, USA
| | - Susan Nicole Hastings
- Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center, Durham, NC, USA
- Center for Health Services Research in Primary Care, Veterans Affairs Health Care System, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
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19
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Schepel L, Lehtonen L, Airaksinen M, Ojala R, Ahonen J, Lapatto-Reiniluoto O. Medication reconciliation and review for older emergency patients requires improvement in Finland. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2019; 30:19-31. [PMID: 30103352 PMCID: PMC6294607 DOI: 10.3233/jrs-180030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: 10–30% of hospital stays by older patients are drug-related. The admission phase is important for identifying drug-related problems, but taking an incorrect medication history often leads to medication errors. OBJECTIVES: To enhance medication history recording and identify drug-related problems (DRPs) of older patients admitted to emergency departments (EDs). METHODS: DRPs were identified by pharmacists-led medication reconciliation and review procedures in two EDs in Finland; Helsinki University Hospital (HUS), and Kuopio University Hospital (KUH). One-hundred-and-fifty patients aged ≥65-years, living at home and using ≥6 medicines were studied. RESULTS: 100% of patients (N = 75) in HUS and 99% in KUH (N = 75), had discrepancies in their admission-medication chart recorded by the nurse or physician. Associations between admission-diagnosis and drug-related problems were found in 12 patients (16%) in HUS and 22 patients (29%) in KUH. Of these, high-alert medications (e.g. antithrombotics, cytostatics, opioids) were linked to eight patients (11%) in HUS and six patients (8%) in KUH. Other acute DRPs were identified in 19 patients (25%) in HUS and 54 patients (72%) in KUH. Furthermore, 67 patients (89%) in HUS and all patients in KUH had non-acute DRPs. CONCLUSIONS: Medication reconciliation and review at admission of older ED patients requires improvement in Finland.
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Affiliation(s)
- Lotta Schepel
- HUS Pharmacy, Hospital Pharmacy of Helsinki University Hospital (HUS), Finland.,Specialization Programme of Hospital and Health Centre Pharmacy, Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
| | - Lasse Lehtonen
- Helsinki University Hospital and University of Helsinki, Finland
| | - Marja Airaksinen
- Specialization Programme of Hospital and Health Centre Pharmacy, Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland.,Clinical Pharmacy Group, Faculty of Pharmacy, University of Helsinki, Finland
| | - Raimo Ojala
- KUH Pharmacy, Hospital Pharmacy of Kuopio University Hospital, Finland
| | - Jouni Ahonen
- KUH Pharmacy, Hospital Pharmacy of Kuopio University Hospital, Finland
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20
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Heider D, Matschinger H, Meid AD, Quinzler R, Adler JB, Günster C, Haefeli WE, König HH. The impact of potentially inappropriate medication on the development of health care costs and its moderation by the number of prescribed substances. Results of a retrospective matched cohort study. PLoS One 2018; 13:e0198004. [PMID: 30063697 PMCID: PMC6067698 DOI: 10.1371/journal.pone.0198004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/12/2018] [Indexed: 11/30/2022] Open
Abstract
Background In the growing population of the elderly, drug-related problems are considered an important health care safety issue. One aspect of this is the prescription of potentially inappropriate medication (PIM) which is considered to increase health care costs. Objective Using data from the Health Economics of Potentially Inappropriate Medication (HEPIME) study, we aimed to analyze how the number of prescribed substances moderates the association of PIM use as defined by the German PRISCUS list and health care costs applying a longitudinal perspective. Methods An initial number of 6,849,622 insurants aged 65+ of a large German health insurance company were included in a retrospective matched cohort study. Based on longitudinal claims data from the four separate quarters of a 12-month pre-period, 3,860,842 individuals with no exposure to PIM in 2011 were matched to 508,212 exposed individuals. Exposure effects of PIM use on health care costs and the number of prescribed substances were measured based on longitudinal claims data from the four separate quarters of the 12-month post-period. Results After successful balancing for the development of numerous matching variables during the four quarters of the pre-period, exposed individuals consumed 2.1 additional prescribed substances and had higher total health care costs of 1,237 € when compared to non-exposed individuals in the 1st quarter of the post-period. Controlling for the number of prescribed substances, the difference in total health care costs between both study groups was 401 €. The average effect of one additionally prescribed substance (other than PIM) on total health care costs was increased by an amount of 137 € for those being exposed to a PIM. In quarters 2–4 of the post-period, the differences between both study groups tended to decrease sequentially. Conclusions PIM use has an increasing effect on the development of health care costs. This cost-increasing effect of PIM use is moderated by the number of prescribed substances.
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Affiliation(s)
- Dirk Heider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Herbert Matschinger
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas D. Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Renate Quinzler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | | | | | - Walter E. Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Kulwicki BD, Brandt KL, Wolf LM, Weise AJ, Dumkow LE. Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections. Am J Emerg Med 2018; 37:839-844. [PMID: 30097272 DOI: 10.1016/j.ajem.2018.07.052] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community-acquired pneumonia (CAP) and intra-abdominal infections (CA-IAI). METHODS A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA-IAI. The primary outcome of this study was to compare guideline-concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early-ASP vs. established-ASP. RESULTS 320 patients were included in the study (EMP n = 185, no-EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline-concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA-IAI subgroups (62% vs. 44%, p = 0.025). Total guideline-concordant prescribing significantly increased between the early-ASP and established-ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early-ASP: 68.3% vs. 45.8%, p = 0.005; established-ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline-concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). CONCLUSION The presence of an EMP significantly improved guideline-concordant empiric antibiotic prescribing for CAP and CA-IAI in both an early and established ASP. Inpatient orders were more likely to be guideline-concordant if appropriate therapy was ordered in the ED.
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Affiliation(s)
| | - Kasey L Brandt
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA
| | - Lauren M Wolf
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA
| | - Andrew J Weise
- Grand Rapids Emergency Medical Group, Grand Rapids, MI, USA
| | - Lisa E Dumkow
- Pharmaceutical Services, Mercy Health Saint Mary's, Grand Rapids, MI, USA.
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22
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Kim M, Mitchell SH, Gatewood M, Bennett KA, Sutton PR, Crawford CA, Bentov I, Damodarasamy M, Kaplan SJ, Reed MJ. Older adults and high-risk medication administration in the emergency department. Drug Healthc Patient Saf 2017; 9:105-112. [PMID: 29184448 PMCID: PMC5685141 DOI: 10.2147/dhps.s143341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Older adults are susceptible to adverse effects from opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and benzodiazepines (BZDs). We investigated factors associated with the administration of elevated doses of these medications of interest to older adults (≥65 years old) in the emergency department (ED). PATIENTS AND METHODS ED records were queried for the administration of medications of interest to older adults at two academic medical center EDs over a 6-month period. Frequency of recommended versus elevated ("High doses" were defined as doses that ranged between 1.5 and 3 times higher than the recommended starting doses; "very high doses" were defined as higher than high doses) starting doses of medications, as determined by geriatric pharmacy/medicine guidelines and expert consensus, was compared by age groups (65-69, 70-74, 75-79, 80-84, and ≥85 years), gender, and hospital. RESULTS There were 17896 visits representing 11374 unique patients >65 years of age (55.3% men, 44.7% women). A total of 3394 doses of medications of interest including 1678 high doses and 684 very high doses were administered to 1364 different patients. Administration of elevated doses of medications was more common than that of recommended doses. Focusing on opioids and BZDs, the 65-69-year age group was much more likely to receive very high doses (1481 and 412 doses, respectively) than the ≥85-year age groups (relative risk [RR] 5.52, 95% CI 2.56-11.90), mainly reflecting elevated opioid dosing (RR 8.28, 95% CI 3.69-18.57). Men were more likely than women to receive very high doses (RR 1.47, 95% CI 1.26-1.72), primarily due to BZDs (RR 2.12, 95% CI 2.07-2.16). CONCLUSION Administration of elevated doses of opioids and BZDs in the older population occurs frequently in the ED, especially to the 65-69-year age group and men. Further attention to potentially unsafe dosing of high-risk medications to older adults in the ED is warranted.
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Affiliation(s)
- Mitchell Kim
- Department of Emergency Medicine, University of Washington
| | | | | | - Katherine A Bennett
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Paul R Sutton
- Division of General Internal Medicine, Department of Medicine, University of Washington
| | | | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington
| | - Mamatha Damodarasamy
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
| | - Stephen J Kaplan
- Section of General, Thoracic and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington
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23
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Rodríguez Del Río E, Perdigones J, Fuentes Ferrer M, González Del Castillo J, González Armengol J, Borrego Hernando MI, Arias Fernández ML, Martín-Sánchez FJ. [Impact of medium-term outcomes of inappropriate prescribing in older patients discharged from a short stay unit]. Aten Primaria 2017; 50:467-476. [PMID: 29079010 PMCID: PMC6837115 DOI: 10.1016/j.aprim.2017.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 02/21/2017] [Accepted: 03/28/2017] [Indexed: 11/29/2022] Open
Abstract
Objetivo Estudiar la asociación entre prescripciones potencialmente inapropiadas (PPI) y eventos adversos a los 30 y 180 días tras el alta de una unidad de corta estancia (UCE). Material y método Estudio analítico observacional de cohortes retrospectivo que incluyó pacientes ≥ 75 años al alta de una UCE. Se utilizó la versión 2 de los criterios STOPP-START. La variable resultado fue la presencia de algún evento adverso a 30 y 180 días. Resultados Se incluyeron 179 pacientes con una media de 84 (DE: 5) años. La presencia de ≥ 1PPI al alta no se asoció con la aparición de algún evento adverso a los 30 ni a los 180 días de manera global. La presencia de ≥ 1PPI al alta de fármacos del proceso cardiovascular tuvo mayor riesgo de presentar algún evento adverso a los 30 días del alta (OR ajustada 2,1; IC 95%: 1,0-3,2; p = 0,045), los fármacos del proceso «neuropsiquiátrico y riesgo de caídas» se relacionaron con deterioro funcional a los 30 días del alta (OR ajustada 6,3; IC 95%: 1,7-22,5; p = 0,005), y la omisión de fármacos del sistema cardiovascular se asoció con el reingreso a los 180 días (OR ajustada 3,6; IC 95%: 1,5-8,3, p = 0,003). Conclusiones La presencia de eventos adversos de pacientes ancianos dados de alta de una UCE podría relacionarse con PPI detectadas por algunos criterios STOPP-START, y concretamente con los fármacos de los procesos cardiovasculares, neuropsiquiátrico y relacionado con las caídas.
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Affiliation(s)
- Elena Rodríguez Del Río
- Servicio de Farmacia, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - Javier Perdigones
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Manuel Fuentes Ferrer
- Servicio de Medicina Preventiva, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Juan González Del Castillo
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Juan González Armengol
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - M Isabel Borrego Hernando
- Servicio de Farmacia, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - M Lourdes Arias Fernández
- Servicio de Farmacia, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Francisco Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
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24
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Vandenberg AE, Vaughan CP, Stevens M, Hastings SN, Powers J, Markland A, Hwang U, Hung W, Echt KV. Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use. Int J Qual Health Care 2017; 29:117-123. [PMID: 27852639 DOI: 10.1093/intqhc/mzw129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 10/12/2016] [Indexed: 11/14/2022] Open
Abstract
Quality problem or issue Clinical decision support (CDS) may improve prescribing for older adults in the Emergency Department (ED) if adopted by providers. Initial assessment Existing prescribing order entry processes were mapped at an initial Veterans Administration Medical Center site, demonstrating cognitive burden, effort and safety concerns. Choice of solution Geriatric order sets incorporating 2012 Beers guidelines and including geriatric prescribing advice and prepopulated order options were developed. Implementation Geriatric order sets were implemented at two sites as part of the multicomponent 'Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department' quality improvement initiative. Evaluation Facilitators and barriers to order sets use at the two sites were evaluated. Phone interviews were conducted with two provider groups (n = 20), those 'EQUiPPED' with the interventions (n = 10, 5 at each site) and Comparison providers who were only exposed to order sets through a clickable option on the ED order menu within the patient's medical record (n = 10, 5 at each site). All providers were asked about order set 'use' and 'usefulness'. Users (n = 11) were asked about 'usability'. Lessons learned Order set adopters described 'usefulness' in terms of 'safety' and 'efficiency', whereas order set consultants and order set non-users described 'usefulness' in terms of 'information' or 'training'. Provider 'autonomy', 'comfort' level with existing tools, and 'learning curve' were stated as barriers to use. Conclusions Quantifying efficiency advantages and communicating safety benefit over preexisting practices and tools may improve adoption of CDS in ED and in other settings of care.
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Affiliation(s)
- Ann E Vandenberg
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Camille P Vaughan
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Melissa Stevens
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
| | - Susan N Hastings
- Durham VA GRECC and HSR&D Center, Durham VA Medical Centre, 508 Fulton St, Durham, NC 27705, USA.,Center for the Study of Aging and Department of Medicine, Duke University Medical Center 3710, Durham, NC 27710, USA
| | - James Powers
- Tennessee Valley VA GRECC, Tennessee Valley Healthcare System, 1310 24th Avenue S, Nashville, TN 37212-2637, USA.,Division of Geriatrics, Department of Medicine, Vanderbilt University School of Medicine, 7159 Vanderbilt Medical Center East, Nashville, TN 37232, USA
| | - Alayne Markland
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294, USA
| | - Ula Hwang
- James J Peters VA Medical Center GRECC, 130 West Kingsbridge Road, GRECC, 4A-17, Bronx, NY 10468, USA.,Departments of Emergency Medicine and Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA
| | - William Hung
- James J Peters VA Medical Center GRECC, 130 West Kingsbridge Road, GRECC, 4A-17, Bronx, NY 10468, USA.,Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, 1428 Madison Avenue, New York, NY 10029, USA
| | - Katharina V Echt
- Birmingham/Atlanta VA GRECC, Atlanta VA Medical Center, 1670 Clairmont Rd, Decatur, GA 30033, USA.,Birmingham/Atlanta VA GRECC, Birmingham VA Medical Center, 700 S. 19th St, Birmingham, AL 35233, USA.,Department of Medicine, Emory University, 201 Dowman Drive, Atlanta, GA 30322, USA
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Prevalence and predictors of potentially inappropriate prescribing of central nervous system and psychotropic drugs among elderly patients: A national population study in Korea. Arch Gerontol Geriatr 2017; 74:1-8. [PMID: 28917110 DOI: 10.1016/j.archger.2017.08.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 08/30/2017] [Accepted: 08/30/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To investigate the prevalence of potentially inappropriate prescribing (PIP) of central nervous system and psychotropic (CNS-PS) drugs to the Korean elderly population, and to identify PIP-associated factors. METHODS Ambulatory care visits were identified from the 2013 National Aged Patient Sample (HIRA-APS-2013) data, composed of 20% random samples of all enrollees in the universal health security program aged ≥65 years. The CNS-PS section of Screening Tool of Older Person's potentially inappropriate Prescriptions (STOPP) criteria version 2 was used to identify PIP at these visits. RESULTS A total of 24,427,069 prescription claims records and 1,122,080 patients were included in the study; 10.73% of the claims and 53.64% of the patients satisfied at least one STOPP criterion in the prescription of CNS-PS drugs. The highest prevalence of PIP was observed for the criteria of "first-generation antihistamines" (FGAH), followed by tricyclic antidepressants (TCA) in patients with prostatism and TCA in patients with dementia. The generalized estimating equation logistic regression analysis showed that the PIP of FGAH was significantly associated with polypharmacy (5-9 drugs: odds ratio (OR) 4.965, 95% confidence interval (CI) 4.936-4.994; ≥10 drugs: OR 5.704, 95% CI 5.604-5.807), less severe health conditions (Charlson Comorbidity Index (CCI)=2: OR 0.852, 95% CI 0.842-0.862; CCI=1: OR 0.975, 95% CI 0.964-0.986), prescriptions from clinics (OR>1.0), and outpatient care by general practitioners (OR>1.0). CONCLUSIONS Appropriate interventions to reduce PIP should be made, especially for the criteria that indicate a high PIP prevalence. Targeted strategies are necessary to modify the risk factors of PIP identified from this study.
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Nothelle SK, Sharma R, Oakes AH, Jackson M, Segal JB. Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review. J Am Med Dir Assoc 2017; 18:806.e1-806.e17. [PMID: 28764876 DOI: 10.1016/j.jamda.2017.06.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/03/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized. METHODS We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data. RESULTS Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians. CONCLUSIONS Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.
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Affiliation(s)
- Stephanie K Nothelle
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Ritu Sharma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Allison H Oakes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Johns Hopkins University Center for Health Services and Outcomes Research, Baltimore, MD
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Abstract
Hospital Pharmacy welcomes contributions to this column, in which articles originally published in pharmacy department newsletters are reprinted. Material is selected because of its educational value or because it typifies the type of information that is interesting to pharmacy newsletter readers. If you wish to have your newsletter material considered for publication in this column, mail a copy and a computer disk containing the document to Jennifer Allen, Journal Editor, Facts and Comparisons, 111 Westport Plaza, Suite 300, St. Louis, Mo 63147.
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Affiliation(s)
- Conchetta White Fulton
- Division of Clinical and Administrative Sciences, Xavier University of Louisiana College of Pharmacy, New Orleans (formerly Pharmacy Practice Resident at St. Claire Medical Center, Morehead, Kentucky)
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28
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A Systematic Review of the Impact of Potentially Inappropriate Medication on Health Care Utilization and Costs Among Older Adults. Med Care 2017; 54:950-64. [PMID: 27367864 DOI: 10.1097/mlr.0000000000000587] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Potentially inappropriate medications (PIMs) are defined as those medicines having a greater potential risk than benefit for older adults. In this systematic literature review, we evaluate the current evidence on health care service use and health care costs associated with PIMs among older adults. METHODS A literature search was conducted in August 2015 without publication date restrictions using the databases PubMed and Scopus. Selected articles included in the review of articles were: (1) observational cohort or case-control, or intervention studies; (2) investigating PIM use among older adults aged 65 years or older with outcomes on health care utilization (eg, hospitalization) or health care costs; and (3) use of some published criteria for assessing PIMs. RESULTS Of 825 abstracts screened, in total 51 articles proceeded to full-text review. Of those full-text articles, 39 articles were included in this review. Most of the articles found that PIMs had a statistically significant effect on health care service use, especially on hospitalization, among older adults. The findings of impact on length of stay or readmissions were inconclusive. Five studies found statistically significant higher medical or total health care costs for PIM users compared those who did not use any PIMs. CONCLUSIONS PIMs can, in addition to health and quality of life problems, also lead to greater health care service use and, thus, higher health care costs. However, the heterogeneity of the study settings makes the interpretation of the results difficult. Further studies, especially on economic issues with country-specific criteria, are needed.
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Stevens M, Hastings SN, Markland AD, Hwang U, Hung W, Vandenberg AE, Bryan W, Cross D, Powers J, McGwin G, Fattouh N, Ho W, Clevenger C, Vaughan CP. Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (
EQU
i
PPED
). J Am Geriatr Soc 2017; 65:1609-1614. [DOI: 10.1111/jgs.14890] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Melissa Stevens
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | - Susan N. Hastings
- Durham VA GRECC and HSR&D Durham North Carolina
- Duke University Durham North Carolina
| | - Alayne D. Markland
- Birmingham/Atlanta VA GRECC Birmingham Alabama
- University of Alabama at Birmingham Birmingham Alabama
| | - Ula Hwang
- Bronx VA GRECC Bronx New York
- Mount Sinai Hospital New York New York
| | - William Hung
- Bronx VA GRECC Bronx New York
- Mount Sinai Hospital New York New York
| | - Ann E. Vandenberg
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | | | | | - James Powers
- Tennessee Valley VA GRECC Nashville Tennessee
- Vanderbilt University Nashville Tennessee
| | - Gerald McGwin
- Birmingham/Atlanta VA GRECC Birmingham Alabama
- University of Alabama at Birmingham Birmingham Alabama
| | - Noor Fattouh
- James J. Peters VA Medical Center Bronx New York
| | - William Ho
- James J. Peters VA Medical Center Bronx New York
| | - Carolyn Clevenger
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
| | - Camille P. Vaughan
- Birmingham/Atlanta VA GRECC Atlanta Georgia
- Emory University Atlanta Georgia
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30
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Muhlack DC, Hoppe LK, Weberpals J, Brenner H, Schöttker B. The Association of Potentially Inappropriate Medication at Older Age With Cardiovascular Events and Overall Mortality: A Systematic Review and Meta-Analysis of Cohort Studies. J Am Med Dir Assoc 2017; 18:211-220. [PMID: 28131719 DOI: 10.1016/j.jamda.2016.11.025] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this systematic review was to identify, evaluate, and meta-analyze cohort studies reporting the association of potentially inappropriate medication (PIM) intake with mortality and cardiovascular events. DESIGN A systematic review and meta-analysis of prospective and retrospective cohort studies were conducted. Study appraisal included a thorough risk of bias assessment. Data synthesis followed a random-effects model. DATA SOURCES The included studies were retrieved from the databases MEDLINE and ISI Web of Knowledge. Additionally, the authors checked the references of the included studies for further relevant literature. ELIGIBILITY CRITERIA FOR SELECTING STUDIES For inclusion in a study, the population needed to be older than 60 years of age and not restricted to having one specific disease. The outcome had to address all-cause mortality or cardiovascular events. Studies that examined polypharmacy or specific drugs were excluded. RESULTS At first, 13 studies were included in a meta-analysis. The association of PIM with overall mortality was not statistically significant (risk ratio; 95% confidence interval, 1.13; 0.95-1.35). However, the majority of studies showed a high risk of specific forms of bias. These biases can be excluded by applying a new user design. It ascertains that adverse events occurring early in therapy are recorded. After restricting the meta-analysis to three studies with a new user design, the association of PIM use and mortality was statistically significant (risk ratio; 95% confidence interval, 1.59; 1.45-1.75). Only one study focused on cardiovascular events and found no statistically significant association. However, the study was not conducted with a new user design. CONCLUSION In studies with adequate methods (new user design), PIM use, defined by Beers criteria or the HEDIS-DAE list, was associated with a 1.6-fold increased mortality in older adults. Physicians should therefore avoid prescribing PIM for older adults whenever feasible. Further new user design studies are required for cardiovascular outcomes and to compare the predictive value of different PIM criteria for mortality.
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Affiliation(s)
- Dana Clarissa Muhlack
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Liesa Katharina Hoppe
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Janick Weberpals
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | - Ben Schöttker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany; Network Aging Research, University of Heidelberg, Heidelberg, Germany; Institute of Health Care and Social Sciences, FOM University, Essen, Germany.
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Al Odhayani A, Tourkmani A, Alshehri M, Alqahtani H, Mishriky A. Potentially inappropriate medications prescribed for elderly patients through family physicians. Saudi J Biol Sci 2017; 24:200-207. [PMID: 28053591 PMCID: PMC5198987 DOI: 10.1016/j.sjbs.2016.05.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 04/27/2016] [Accepted: 05/01/2016] [Indexed: 11/20/2022] Open
Abstract
The elderly population is increasing throughout the globe, resulting in higher healthcare costs. Potential inappropriate medication (PIM) prescriptions are a major health problem affecting the elderly persons. Due to limited studies in PIM use in primary care and home healthcare in Saudi Arabia, we aim to examine the extent of PIM prescription for and use by elderly patients. This study was carried out with 798 elderly patients, arbitrarily selected from Prince Sultan Medical Military City through the patient register. The mean age of the patients were in the range of 75.2 ± 5.5; 37.8% were males and 62.2% were females. The elderly patients are affected majorly with diabetes (73.9%), hypertension (83.2%) and lipid abnormalities (73.8%). The maximum patients involved in this study were affected with lower hemoglobin levels i.e. 99.2%. Renal impairment was found in 64% and iron supplements were the most commonly used in 23.1%, followed by analgesics and opioids (17%). The 52.5% of participants were using one or more PIMs. Kidney was the only functions and had influence on prescribed decisions. This study indicates PIM is a concern in elderly patients attending clinics and home residents and commonly prescribed ones are atypical antipsychotics, iron overdose, benzodiazepines and opioids. Prescription of drug-drug interactions, cascades and inappropriate drug doses results in preventable adverse effects.
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Affiliation(s)
- Abdulaziz Al Odhayani
- Family and Community Medicine Department, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Burkett E, Martin-Khan MG, Scott J, Samanta M, Gray LC. Trends and predicted trends in presentations of older people to Australian emergency departments: effects of demand growth, population aging and climate change. AUST HEALTH REV 2017; 41:246-253. [DOI: 10.1071/ah15165] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 05/23/2016] [Indexed: 11/23/2022]
Abstract
Objectives
The aim of the present study was to describe trends in and age and gender distributions of presentations of older people to Australian emergency departments (EDs) from July 2006 to June 2011, and to develop ED utilisation projections to 2050.
Methods
A retrospective analysis of data collected in the National Non-admitted Patient Emergency Department Care Database was undertaken to assess trends in ED presentations. Three standard Australian Bureau of Statistics population growth models, with and without adjustment for current trends in ED presentation growth and effects of climate change, were examined with projections of ED presentations across three age groups (0–64, 65–84 and ≥85 years) to 2050.
Results
From 2006–07 to 2010–11, ED presentations increased by 12.63%, whereas the Australian population over this time increased by only 7.26%. Rates of presentation per head of population were greatest among those aged ≥85 years. Projections of ED presentations to 2050 revealed that overall ED presentations are forecast to increase markedly, with the rate of increase being most marked for older people.
Conclusion
Growth in Australian ED presentations from 2006–07 to 2010–11 was greater than that expected from population growth alone. The predicted changes in demand for ED care will only be able to be optimally managed if Australian health policy, ED funding instruments and ED models of care are adjusted to take into account the specific care and resource needs of older people.
What is known about the topic?
Rapid population aging is anticipated over coming decades. International studies and specific local-level Australian studies have demonstrated significant growth in ED presentations. There have been no prior national-level Australian studies of ED presentation trends by age group.
What does this paper add?
The present study examined national ED presentation trends from July 2006 to June 2011, with specific emphasis on trends in presentation by age group. ED presentation growth was found to exceed population growth in all age groups. The rate of ED presentations per head of population was highest among those aged ≥85 years. ED utilisation projections to 2050, using standard Australian Bureau of Statistics population modelling, with and without adjustment for current ED growth, were developed. The projections demonstrated linear growth in ED presentation for those aged 0–84 years, with growth in ED presentations of the ≥85 year age group demonstrating marked acceleration after 2030.
What are the implications for practitioners?
Growth in ED presentations exceeding population growth suggests that current models of acute health care delivery require review to ensure that optimal care is delivered in the most fiscally efficient manner. Trends in presentation of older people emphasise the imperative for ED workforce planning and education in care of this complex patient cohort, and the requirement to review funding models to incentivise investment in ED avoidance and substitutive care models targeting older people.
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Abstract
Abdominal pain in the elderly can be a challenging and difficult condition to diagnose and treat. The geriatric population has significant comorbidities and often takes polypharmacy that can mask symptoms. The presentation of common conditions can be different than that in the younger population, often lacking the traditional indicators of disease, making it of pivotal importance for the clinician to consider a wide differential during their workup. It is also important to consider extra-abdominal abnormality that may manifest as abdominal pain.
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Affiliation(s)
- Amy Leuthauser
- Department of Emergency Medicine, Bay of Plenty District Health Board, Tauranga Hospital, Cameron Road, Private bag 12024, Tauranga 3142, New Zealand.
| | - Benjamin McVane
- Department of Emergency Medicine, Icahn School of Medicine, Mount Sinai Hospital, 1 gustav levy place, New York, NY 10028, USA
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Chen CC, Cheng SH. Potentially Inappropriate Medication and Health Care Outcomes: An Instrumental Variable Approach. Health Serv Res 2015; 51:1670-91. [PMID: 26601656 DOI: 10.1111/1475-6773.12417] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach. DATA SOURCES/STUDY SETTING Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010. STUDY DESIGN We employed a panel study design to examine the relationship between PIM and hospitalization. We applied both the naive generalized estimating equation (GEE) model, which controlled for the observed patient and hospital characteristics, and the two-stage residual inclusion (2SRI) GEE model, which further accounted for the unobserved confounding factors. The PIM prescription rate of the physician most frequently visited by each patient was used as the IV. PRINCIPAL FINDINGS The naive GEE models indicated that patient PIM use was associated with a higher likelihood of hospitalization (odds ratio [OR], 1.399; 95 percent confidence interval [CI], 1.363-1.435). Using the physician PIM prescribing rate as an IV, we identified a stronger significant association between PIM and hospitalization (OR, 1.990; 95 percent CI, 1.647-2.403). CONCLUSIONS PIM use is associated with increased hospitalization in elderly individuals. Adjusting for unobserved confounders is needed to obtain unbiased estimates of the relationship between PIM and health care outcomes.
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Affiliation(s)
- Chi-Chen Chen
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Shou-Hsia Cheng
- Department of Public Health, College of Medicine, Fu Jen Catholic University, Taiwan
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Rosen T, Connors S, Clark S, Halpern A, Stern ME, DeWald J, Lachs MS, Flomenbaum N. Assessment and Management of Delirium in Older Adults in the Emergency Department: Literature Review to Inform Development of a Novel Clinical Protocol. Adv Emerg Nurs J 2015; 37:183-96; quiz E3. [PMID: 26218485 PMCID: PMC4633298 DOI: 10.1097/tme.0000000000000066] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Delirium occurs frequently in older patients in the emergency department (ED), is underrecognized, and has potentially serious consequences. Despite its seriousness, delirium is frequently missed by emergency providers, and patients with unrecognized delirium are often discharged from the ED. Even when it is appropriately recognized, managing delirium in older adults poses a significant challenge for ED providers. Geriatric delirium is typically caused by the interaction of multiple factors, including several that are commonly missed: pain, urinary retention, constipation, dehydration, and polypharmacy. Appropriate management includes nonpharmacological management with medication intervention reserved for emergencies. We have developed a new, comprehensive, evidence-based protocol for diagnosis/recognition, management, and disposition of geriatric delirium patients in the ED with a focus on identifying and treating commonly missed contributing causes.
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Affiliation(s)
- Tony Rosen
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Scott Connors
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Sunday Clark
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Alexis Halpern
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Michael E. Stern
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Jennifer DeWald
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Mark S. Lachs
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
| | - Neal Flomenbaum
- Division of Emergency Medicine, Weill Cornell Medical College, 525 East 68 Street, Box 39, New York, NY 10065
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Stevens MB, Hastings SN, Powers J, Vandenberg AE, Echt KV, Bryan WE, Peggs K, Markland AD, Hwang U, Hung WW, Schmidt AJ, McGwin G, Ikpe-Ekpo E, Clevenger C, Johnson TM, Vaughan CP. Enhancing the Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department (EQUiPPED): Preliminary Results from Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department, a Novel. J Am Geriatr Soc 2015; 63:1025-9. [DOI: 10.1111/jgs.13404] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Melissa B. Stevens
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | - Susan Nicole Hastings
- Department of Veterans Affairs Geriatric Research, Education, and Clinical Center; Durham North Carolina
- Health Services Research and Development Center; Durham North Carolina
- Durham Veterans Affairs Medical Center; Durham North Carolina
- Department of Medicine; Duke University; Durham North Carolina
| | - James Powers
- Department of Veterans Affairs Geriatric Research, Education, and Clinical Center; Nashville Tennessee
- Tennessee Valley Veterans Affairs Health System; Nashville Tennessee
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | | | - Katharina V. Echt
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | | | - Kiffany Peggs
- Tennessee Valley Veterans Affairs Health System; Nashville Tennessee
- Department of Medicine; Vanderbilt University; Nashville Tennessee
| | - Alayne D. Markland
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Department of Medicine; University of Alabama at Birmingham; Birmingham Alabama
| | - Ula Hwang
- Department of Veterans Affairs, Geriatric Research, Education, and Clinical Center; Bronx New York
- Department of Emergency Medicine; Icahn School of Medicine at Mount Sinai; New York New York
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | - William W. Hung
- Department of Veterans Affairs, Geriatric Research, Education, and Clinical Center; Bronx New York
- Department of Geriatrics and Palliative Medicine; Icahn School of Medicine at Mount Sinai; New York New York
| | | | - Gerald McGwin
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Department of Epidemiology; University of Alabama at Birmingham; Birmingham Alabama
| | - Edidiong Ikpe-Ekpo
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Emergency Medicine; Emory University; Atlanta Georgia
| | - Carolyn Clevenger
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- School of Nursing; Emory University; Atlanta Georgia
| | - Theodore M. Johnson
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
| | - Camille P. Vaughan
- Department of Veterans Affairs Birmingham; Birmingham, Alabama/Atlanta Geriatric Research, Education, and Clinical Center; Atlanta Georgia
- Atlanta Veterans Affairs Medical Center; Atlanta Georgia
- Department of Medicine; Emory University; Atlanta Georgia
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Welch SA, Graudins LV. Scope of Pharmacy Services to the Emergency Department. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2007.tb00653.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Santos APAL, Silva DT, Alves-Conceição V, Antoniolli AR, Lyra DP. Conceptualizing and measuring potentially inappropriate drug therapy. J Clin Pharm Ther 2015; 40:167-76. [PMID: 25682702 DOI: 10.1111/jcpt.12246] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice. METHODS A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT. RESULTS AND DISCUSSION From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1 = 0·479) and substantial for abstracts (κ2 = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature. WHAT IS NEW AND CONCLUSION This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.
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Affiliation(s)
- A P A L Santos
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Pharmacy College, Federal University of Sergipe, São Cristóvão, Brazil
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39
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A systematic review of prescribing criteria to evaluate appropriateness of medications in frail older people. ACTA ACUST UNITED AC 2014. [DOI: 10.1017/s0959259814000161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
SummaryThis study systematically reviews the published literature regarding inappropriate prescribing in frail individuals aged at least 65 years. Twenty-five of 466 identified studies met the inclusion criteria. All papers measured some surrogate indicators of frailty, such as performance-based tests, cognitive function and functional dependency. Beers criteria were used in 20 studies (74%) to evaluate inappropriate medication use and 36% (9/25) studies used more than one criterion. The prevalence of inappropriate medications ranged widely from 11 to 92%. Only a few studies reported the relationship between potentially inappropriate medication use and surrogate measures of frailty. These diverse findings indicate the need for a standardized measure for assessing appropriateness of medication in frail older individuals. Prescribing tools should address both medication and patient-related factors such as life expectancy and functional status to minimize inappropriate prescribing in frail individuals.
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40
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Kerr GS, Richards JS, Nunziato CA, Patterson OV, DuVall SL, Aujero M, Maron D, Amdur R. Measuring physician adherence with gout quality indicators: a role for natural language processing. Arthritis Care Res (Hoboken) 2014; 67:273-9. [PMID: 25047509 DOI: 10.1002/acr.22406] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 07/15/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate physician adherence with gout quality indicators (QIs) for medication use and monitoring, and behavioral modification (BM). METHODS Gout patients were assessed for the QIs as follows: QI 1: initial allopurinol dosage <300 mg/day for patients with chronic kidney disease (CKD); QI 2: uric acid within 6 months of allopurinol start; and QI 3: complete blood count and creatinine phosphokinase within 6 months of colchicine initiation. Natural language processing (NLP) was used to analyze clinical narrative data from electronic medical records (EMRs) of overweight (body mass index ≥28 kg/m(2) ) gout patients for BM counseling on gout-specific dietary restrictions, weight loss, and alcohol consumption (QI 4). Additional data included sociodemographics, comorbidities, and number of rheumatology and primary care visits. QI compliance versus noncompliance was compared using chi-square analyses and independent-groups t-test. RESULTS In 2,280 gout patients, compliance with QI was as follows: QI 1: 92.1%, QI 2: 44.8%, and QI 3: 7.7%. Patients compliant with QI 2 had more rheumatology visits at 3.5 versus 2.6 visits (P < 0.001), while those compliant with QI 3 had more CKD (P < 0.01). Of 1,576 eligible patients, BM counseling for weight loss occurred in 1,008 patients (64.0%), low purine diet in 390 (24.8%), alcohol abstention in 137 (8.7%), and all 3 elements in 51 patients (3.2%). Regular rheumatology clinic visits correlated with frequent advice on weight loss and gout-specific diet (P < 0.0001). CONCLUSION Rheumatology clinic attendance was associated with greater QI compliance. NLP proved a valuable tool for measuring BM as documented in the clinical narrative of EMRs.
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Affiliation(s)
- Gail S Kerr
- Veterans Affairs Medical Center, Georgetown University, and Howard University, Washington, DC
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Weant KA, Bailey AM, Baker SN. Strategies for reducing medication errors in the emergency department. Open Access Emerg Med 2014; 6:45-55. [PMID: 27147879 PMCID: PMC4753984 DOI: 10.2147/oaem.s64174] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Medication errors are an all-too-common occurrence in emergency departments across the nation. This is largely secondary to a multitude of factors that create an almost ideal environment for medication errors to thrive. To limit and mitigate these errors, it is necessary to have a thorough knowledge of the medication-use process in the emergency department and develop strategies targeted at each individual step. Some of these strategies include medication-error analysis, computerized provider-order entry systems, automated dispensing cabinets, bar-coding systems, medication reconciliation, standardizing medication-use processes, education, and emergency-medicine clinical pharmacists. Special consideration also needs to be given to the development of strategies for the pediatric population, as they can be at an elevated risk of harm. Regardless of the strategies implemented, the prevention of medication errors begins and ends with the development of a culture that promotes the reporting of medication errors, and a systematic, nonpunitive approach to their elimination.
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Affiliation(s)
- Kyle A Weant
- North Carolina Public Health Preparedness and Response, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Abby M Bailey
- University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - Stephanie N Baker
- University of Kentucky HealthCare, Department of Pharmacy Services, Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY, USA
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Zeraatchi A, Talebian MT, Nejati A, Dashti-Khavidaki S. Frequency and types of the medication errors in an academic emergency department in Iran: The emergent need for clinical pharmacy services in emergency departments. J Res Pharm Pract 2014; 2:118-22. [PMID: 24991618 PMCID: PMC4076918 DOI: 10.4103/2279-042x.122384] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: Emergency departments (EDs) are characterized by simultaneous care of multiple patients with various medical conditions. Due to a large number of patients with complex diseases, speed and complexity of medication use, working in under-staffing and crowded environment, medication errors are commonly perpetrated by emergency care providers. This study was designed to evaluate the incidence of medication errors among patients attending to an ED in a teaching hospital in Iran. Methods: In this cross-sectional study, a total of 500 patients attending to ED were randomly assessed for incidence and types of medication errors. Some factors related to medication errors such as working shift, weekdays and schedule of the educational program of trainee were also evaluated. Findings: Nearly, 22% of patients experienced at least one medication error. The rate of medication errors were 0.41 errors per patient and 0.16 errors per ordered medication. The frequency of medication errors was higher in men, middle age patients, first weekdays, night-time work schedules and the first semester of educational year of new junior emergency medicine residents. More than 60% of errors were prescription errors by physicians and the remaining were transcription or administration errors by nurses. More than 35% of the prescribing errors happened during the selection of drug dose and frequency. The most common medication errors by nurses during the administration were omission error (16.2%) followed by unauthorized drug (6.4%). Most of the medication errors happened for anticoagulants and thrombolytics (41.2%) followed by antimicrobial agents (37.7%) and insulin (7.4%). Conclusion: In this study, at least one-fifth of the patients attending to ED experienced medication errors resulting from multiple factors. More common prescription errors happened during ordering drug dose and frequency. More common administration errors included dug omission or unauthorized drug.
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Affiliation(s)
- Alireza Zeraatchi
- Department of Emergency Medicine, Tehran University of Medical Science, Tehran, Iran
| | | | - Amir Nejati
- Department of Emergency Medicine, Tehran University of Medical Science, Tehran, Iran
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Dumkow LE, Kenney RM, MacDonald NC, Carreno JJ, Malhotra MK, Davis SL. Impact of a Multidisciplinary Culture Follow-up Program of Antimicrobial Therapy in the Emergency Department. Infect Dis Ther 2014; 3:45-53. [PMID: 25134811 PMCID: PMC4108117 DOI: 10.1007/s40121-014-0026-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction Antimicrobial prescribing in the emergency department is predominantly empiric, with final microbiology results either unavailable or reported after most patients are discharged home. Systematic follow-up processes are needed to ensure appropriate antimicrobial therapy at this transition of care. The objective of this study was to assess the impact of a culture follow-up (CFU) program on the frequency of emergency department (ED) revisits within 72 h and hospital admissions within 30 days compared to the historical standard of care (SOC). Additionally, infection characteristics and antimicrobial therapy were compared. Methods A single group, pre-test post-test quasi-experimental study was conducted comparing a retrospective SOC group to a prospective CFU group. CFU was implemented using computerized decision-support software and a multidisciplinary team of pharmacists and emergency physician staff. Results Over the four-month intervention period the CFU group evaluated 197 cultures and modified antimicrobial therapy in 25.5%. The rate of combined ED revisits within 72 h and hospital admissions within 30 days was 16.9% in the SOC group and 10.2% in the CFU group (p = 0.079). When evaluating the uninsured population alone, revisits to the ED within 72 h were reduced from 15.3% in the SOC group to 2.4% in the CFU group (p = 0.044). Conclusion Implementation of a multidisciplinary CFU program was associated with a reduction in ED revisits within 72 h and hospital admissions within 30 days. One-fourth of patients required post-discharge intervention, representing a large need for antimicrobial stewardship expansion to ED practice models. Electronic supplementary material The online version of this article (doi:10.1007/s40121-014-0026-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa E. Dumkow
- Mercy Health St. Mary’s, Grand Rapids, MI USA
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | - Rachel M. Kenney
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
| | | | - Joseph J. Carreno
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
- Albany College of Pharmacy and Health Sciences, Albany, NY USA
| | - Manu K. Malhotra
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Susan L. Davis
- Department of Pharmacy Services, Henry Ford Hospital, Detroit, MI USA
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University and Henry Ford Hospital, 259 Mack Ave, Detroit, MI 48201 USA
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Shade MY, Berger AM, Chaperon C. Potentially inappropriate medications in community-dwelling older adults. Res Gerontol Nurs 2014; 7:178-92. [PMID: 24530281 DOI: 10.3928/19404921-20140210-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 12/13/2013] [Indexed: 11/20/2022]
Abstract
Potentially inappropriate medication (PIM) use is a significant worldwide public health problem. Community-dwelling older adults are susceptible to the negative outcomes associated with the use of PIMs. A database search (January 1991-June 2013) produced 19 prospective correlational and 10 intervention studies. The current state of the science reveals that conceptual clarity is lacking regarding the use of PIMs. The prevalence of PIM use is well documented in an abundance of descriptive studies. However, researchers have not examined an intervention's effects on health outcomes in community-dwelling older adults. Although independent older adults can acquire PIMs outside of a provider, current interventions aim to change the behavior of the prescribing physician and pharmacist. Nurses need to collaborate with other disciplines in PIM use research. Priority needs are to design interventions that reduce the use of PIMs and negative health outcomes.
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45
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Kuo CF, Grainge MJ, Mallen C, Zhang W, Doherty M. Rising burden of gout in the UK but continuing suboptimal management: a nationwide population study. Ann Rheum Dis 2014; 74:661-7. [PMID: 24431399 PMCID: PMC4392307 DOI: 10.1136/annrheumdis-2013-204463] [Citation(s) in RCA: 415] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To describe trends in the epidemiology of gout and patterns of urate-lowering treatment (ULT) in the UK general population from 1997 to 2012. METHODS We used the Clinical Practice Research Datalink to estimate the prevalence and incidence of gout for each calendar year from 1997 to 2012. We also investigated the pattern of gout management for both prevalent and incident gout patients. RESULTS In 2012, the prevalence of gout was 2.49% (95% CI 2.48% to 2.51%) and the incidence was 1.77 (95% CI 1.73 to 1.81) per 1000 person-years. Prevalence and incidence both were significantly higher in 2012 than in 1997, with a 63.9% increase in prevalence and 29.6% increase in incidence over this period. Regions with highest prevalence and incidence were the North East and Wales. Among prevalent gout patients in 2012, only 48.48% (95% CI 48.08% to 48.89%) were being consulted specifically for gout or treated with ULT and of these 37.63% (95% CI 37.28% to 38.99%) received ULT. In addition, only 18.6% (95% CI 17.6% to 19.6%) of incident gout patients received ULT within 6 months and 27.3% (95% CI 26.1% to 28.5%) within 12 months of diagnosis. The management of prevalent and incident gout patients remained essentially the same during the study period, although the percentage of adherent patients improved from 28.28% (95% CI 27.33% to 29.26%) in 1997 to 39.66% (95% CI 39.11% to 40.22%) in 2012. CONCLUSIONS In recent years, both the prevalence and incidence of gout have increased significantly in the UK. Suboptimal use of ULT has not changed between 1997 and 2012. Patient adherence has improved during the study period, but it remains poor.
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Affiliation(s)
- Chang-Fu Kuo
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Matthew J Grainge
- Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
| | - Christian Mallen
- Arthritis Research UK Primary Care Centre, Keele University, Keele, UK
| | - Weiya Zhang
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Nottingham, UK
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Martin-Khan M, Burkett E, Schnitker L, Jones RN, Gray LC. Methodology for developing quality indicators for the care of older people in the Emergency Department. BMC Emerg Med 2013; 13:23. [PMID: 24314126 PMCID: PMC4029470 DOI: 10.1186/1471-227x-13-23] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 10/31/2013] [Indexed: 01/01/2023] Open
Abstract
Background Compared with younger people, older people have a higher risk of adverse health outcomes when presenting to emergency departments. As the population ages, older people will make up an increasing proportion of the emergency department population. Therefore it is timely that consideration be given to the quality of care received by older persons in emergency departments, and to consideration of those older people with special needs. Particular attention will be focused on important groups of older people, such as patients with cognitive impairment, residents of long term care and patients with palliative care needs. This project will develop a suite of quality indicators focused on the care of older persons in the emergency department. Methods/design Following input from an expert panel, an initial set of structural, process, and outcome indicators will be developed based on thorough systematic search in the scientific literature. All initial indicators will be tested in eight emergency departments for their validity and feasibility. Results of the data from the field studies will be presented to the expert panel at a second meeting. A suite of Quality Indicators for the older emergency department population will be finalised following a formal voting process. Discussion The predicted burgeoning in the number of older persons presenting to emergency departments combined with the recognised quality deficiencies in emergency department care delivery to this population, highlight the need for a quality framework for the care of older persons in emergency departments. Additionally, high quality of care is associated with improved survival & health outcomes of elderly patients. The development of well-selected, validated and economical quality indicators will allow appropriate targeting of resources (financial, education or quality management) to improve quality in areas with maximum potential for improvement.
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Affiliation(s)
- Melinda Martin-Khan
- Centre for Research in Geriatric Medicine, Level 2, Building 33, Princess Alexandra Hospital, The University of Queensland, Ipswich Road, Woolloongabba QLD 4102, Australia.
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Abstract
SummaryPrescribing for older people is often complex and challenging. With age, people almost invariably develop diseases leading to the prescription of drugs and the risk of multiple prescribing increases, especially if there is strict adherence to single disease guidelines. There remains a paucity of evidence from clinical trials as to the efficacy of many drugs in patients aged over 80 years due to the gross under-representation of older people in clinical trials. Older people are also at increased risk of adverse drug events, which are an important cause of morbidity and mortality. A significant percentage of these are both predictable and potentially avoidable.In this updated review the concept of appropriate prescribing in older people is explored, including the importance of individualized care and shared decision-making. The available tools to enhance prescribing practice are examined, including those aimed at reducing inappropriate prescriptions and under prescribing. The limitations of existing tools are discussed and areas with particular promise and scope for advancement are highlighted, including the development of integrated IT systems and software engines to aid clinicians in appropriate prescribing.
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Using pharmacists to optimize patient outcomes and costs in the ED. Am J Emerg Med 2013; 32:673-7. [PMID: 24703064 DOI: 10.1016/j.ajem.2013.11.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 11/16/2013] [Accepted: 11/17/2013] [Indexed: 11/20/2022] Open
Abstract
Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.
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Gray LC, Peel NM, Costa AP, Burkett E, Dey AB, Jonsson PV, Lakhan P, Ljunggren G, Sjostrand F, Swoboda W, Wellens NIH, Hirdes J. Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study. Ann Emerg Med 2013; 62:467-474. [PMID: 23809229 DOI: 10.1016/j.annemergmed.2013.05.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 05/07/2013] [Accepted: 05/14/2013] [Indexed: 11/17/2022]
Abstract
STUDY OBJECTIVE We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations. METHODS This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses. RESULTS A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations. CONCLUSION Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs.
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Affiliation(s)
- Leonard C Gray
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia
| | - Nancye M Peel
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia.
| | - Andrew P Costa
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada; Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ellen Burkett
- Princess Alexandra Hospital Emergency Department, Brisbane, Queensland, Australia
| | - Aparajit B Dey
- Department of Geriatric Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Palmi V Jonsson
- Department of Geriatrics, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavic, Iceland
| | - Prabha Lakhan
- Centre for Research in Geriatric Medicine, the University of Queensland, Brisbane, Queensland, Australia
| | - Gunnar Ljunggren
- Public Healthcare Services Committee Administration, Stockholm County Council, Stockholm, Sweden; Medical Management Centre, Department of Learning, Informatics, Management and Ethics, Stockholm, Sweden; Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Sjostrand
- Karolinska Institutet, Stockholm, Sweden; Department of Clinical Science and Education, Södersjukhuset and Section of Emergency Medicine, Södersjukhuset AB, Stockholm, Sweden
| | - Walter Swoboda
- Institute for Biomedicine of Aging, University of Erlangen Nuremberg, Klinikum Nuremberg, Germany
| | - Nathalie I H Wellens
- Department of Public Health, Centre for Health Services and Nursing Research, KU Leuven, Belgium
| | - John Hirdes
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada
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Hsiao FY, Hsieh PH, Gau CS. Ten-year trend in prescriptions of z-hypnotics among the elderly: A nationwide, cross-sectional study in Taiwan. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.jcgg.2012.12.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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