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Paulamäki J, Jyrkkä J, Hyttinen V, Huhtala H, Jämsen E. Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study. Res Social Adm Pharm 2023; 19:1372-1379. [PMID: 37355437 DOI: 10.1016/j.sapharm.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/06/2023] [Accepted: 06/17/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Certain medications should be used with caution in older persons, which challenges rational prescribing. Potentially inappropriate medications (PIMs) are defined as medicines whose potential risk of harm typically outweighs the clinical benefits in geriatric population. Earlier studies have found regional differences in PIM use, but the factors underlying this phenomenon are unclear. OBJECTIVE To compare prescription PIM prevalence among Finnish hospital districts and determine which population characteristics and factors related to social and health care are associated with regional variation. METHODS This nationwide register study was based on the Prescription Centre data on all people aged ≥75 years in 2017-2019. Hospital district (n = 20) characteristics were drawn from the Finnish Institute for Health and Welfare's, Finnish Medical Association's, and Finnish Medicines Agency's publicly open data. PIMs were defined according to the Finnish Meds75+ database. A linear mixed-effect model was used to analyze potential associations of regional characteristics with PIM prevalence. RESULTS Prevalence of PIMs varied between 16.4% and 24.8% across regions. The highest prevalence was observed in the southern regions, while the lowest prevalence was on the west coast. Hospital district characteristics associated with higher PIM prevalence were higher share of population living alone, with excessive polypharmacy, or assessed using the Resident Assessment Instrument, shortage of general practitioners in municipal health centers, and low share of home care personnel. Waiting time in health care or share of population with morbidities were not associated with PIM use. Of the total variance in PIM prevalence, 86% was explained by group-level factors related to hospital districts. The regional variables explained 75% of this hospital-district-level variation. CONCLUSIONS PIM prevalence varied significantly across hospital districts. Findings suggest that higher PIM prevalence may be related to challenges in the continuity of care rather than differences in health care accessibility or share of the population with morbidities.
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Affiliation(s)
- Jasmin Paulamäki
- Faculty of Medicine and Health Technology, Clinical Medicine, Tampere University, FI-33014, Tampere University, Finland; Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Johanna Jyrkkä
- Development and Information Services, Finnish Medicines Agency Fimea, P.O. Box 55, FI-00034, FIMEA, Finland.
| | - Virva Hyttinen
- Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211, Kuopio, Finland.
| | - Heini Huhtala
- Faculty of Social Sciences, Health Sciences, Tampere University, FI-33014, Tampere University, Finland.
| | - Esa Jämsen
- Faculty of Medicine (Clinicum), University of Helsinki, P.O. Box 63, FI-00014, University of Helsinki, Finland; Department of Geriatrics, Helsinki University Hospital, P.O. Box 340, FI-00029, Helsinki, HUS, Finland.
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Antibiotic Prescribing in Outpatient Settings: Rural Patients Are More Likely to Receive Fluoroquinolones and Longer Antibiotic Courses. Antibiotics (Basel) 2023; 12:antibiotics12020224. [PMID: 36830137 PMCID: PMC9952143 DOI: 10.3390/antibiotics12020224] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023] Open
Abstract
Suboptimal antibiotic prescribing may be more common in patients living in rural versus urban areas due to various factors such as decreased access to care and diagnostic testing equipment. Prior work demonstrated a rural health disparity of overprescribing antibiotics and longer durations of antibiotic therapy in the United States; however, large-scale evaluations are limited. We evaluated the association of rural residence with suboptimal outpatient antibiotic use in the national Veterans Affairs (VA) system. Outpatient antibiotic dispensing was assessed for the veterans diagnosed with an upper respiratory tract infection (URI), pneumonia (PNA), urinary tract infection (UTI), or skin and soft tissue infection (SSTI) in 2010-2020. Rural-urban status was determined using rural-urban commuting area codes. Suboptimal antibiotic use was defined as (1) outpatient fluoroquinolone dispensing and (2) longer antibiotic courses (>ten days). Geographic variation in suboptimal antibiotic use was mapped. Time trends in suboptimal antibiotic use were assessed with Joinpoint regression. While controlling for confounding, the association of rurality and suboptimal antibiotic use was assessed with generalized linear mixed models with a binary distribution and logit link, accounting for clustering by region and year. Of the 1,405,642 veterans diagnosed with a URI, PNA, UTI, or SSTI and dispensed an outpatient antibiotic, 22.8% were rural-residing. In 2010-2020, in the rural- and urban-residing veterans, the proportion of dispensed fluoroquinolones declined by 9.9% and 10.6% per year, respectively. The rural-residing veterans were more likely to be prescribed fluoroquinolones (19.0% vs. 17.5%; adjusted odds ratio (aOR), 1.03; 95% confidence interval (CI), 1.02-1.04) and longer antibiotic courses (53.8% vs. 48.5%; aOR, 1.19, 95% CI, 1.18-1.20) than the urban-residing veterans. Among a large national cohort of veterans diagnosed with URIs, PNA, UTIs, and SSTIs, fluoroquinolone use and longer antibiotic courses were disproportionally more common among rural- as compared to urban-residing veterans. Outpatient antibiotic prescribing must be improved, particularly for rural-residing patients. There are many possible solutions, of which antibiotic stewardship interventions are but one.
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Danek R, Blackburn J, Greene M, Mazurenko O, Menachemi N. Measuring rurality in health services research: a scoping review. BMC Health Serv Res 2022; 22:1340. [PMID: 36369057 PMCID: PMC9652888 DOI: 10.1186/s12913-022-08678-9] [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: 03/23/2022] [Accepted: 09/28/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study is a scoping review of the different methods used to measure rurality in the health services research (HSR) literature. Methods We identified peer-reviewed empirical studies from 2010–2020 from seven leading HSR journals, including the Journal of Rural Health, that used any definition to measure rurality as a part of their analysis. From each study, we identified the geographic unit (e.g., county, zip code) and definition (e.g., Rural Urban Continuum Codes, Rural Urban Commuting Areas) used to classify categories of rurality. We analyzed whether geographic units and definitions used to classify rurality differed by focus area of studies, including costs, quality, and access to care. Lastly, we examined the number of rural categories used by authors to assess rural areas. Findings In 103 included studies, five different geographic units and 11 definitions were used to measure rurality. The most common geographic units used to measure rurality were county (n = 59, 57%), which was used most frequently in studies examining cost (n = 12, 75%) and access (n = 33, 57.9%). Rural Urban Commuting Area codes were the most common definition used to measure rurality for studies examining access (n = 13, 22.8%) and quality (n = 10, 44%). The majority of included studies made rural versus urban comparisons (n = 82, 80%) as opposed to focusing on rural populations only (n = 21, 20%). Among studies that compared rural and urban populations, most studies used only one category to identify rural locations (n = 49 of 82 studies, 60%). Conclusion Geographic units and definitions to determine rurality were used inconsistently within and across studies with an HSR focus. This finding may affect how health disparities by rural location are determined and thus how resources and federal funds are allocated. Future research should focus on developing a standardized system to determine under what circumstances researchers should use different geographic units and methods to determine rurality by HSR focus area. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08678-9.
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Galimberti F, Olmastroni E, Casula M, Merlo I, Franchi M, Catapano AL, Orlando V, Menditto E, Tragni E, EDU.RE.DRUG Group OBO. Evaluation of Factors Associated With Appropriate Drug Prescription and Effectiveness of Informative and Educational Interventions—The EDU.RE.DRUG Project. Front Pharmacol 2022; 13:832169. [PMID: 35548361 PMCID: PMC9081494 DOI: 10.3389/fphar.2022.832169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background: EDU.RE.DRUG study is a prospective, multicentre, open-label, parallel-arm, controlled, pragmatic trial directed to general practitioners (GPs) and their patients. Methods: The study data were retrieved from health-related administrative databases of four local health units (LHUs) of Lombardy and four LHUs in Campania. According to the LHUs, the GPs/patients were assigned to (A) intervention on both GPs (feedback reports about appropriate prescribing among their patients and online courses) and patients (flyers and posters on proper drug use), (B) intervention on GPs, (C) intervention on patients, and (D) no intervention (control arm). A set of appropriate prescribing indicators (potential drug–drug interactions [pDDIs], potential and unnecessary therapeutic duplicates [pTDs], and inappropriate prescriptions in the elderly [ERD-list]) were measured at baseline and after the intervention phase. The effectiveness of the intervention was evaluated estimating the absolute difference in percentages of selected indicators carrying out linear random-intercept mixed-effect models. Results: A cohort of 3,586 GPs (2,567 in intervention groups and 1,019 in the control group) was evaluated. In Campania, the mean pre-intervention percentage of patients with at least one pDDI was always greater than 20% and always lower than 15% in Lombardy. The pre–post difference was quite heterogeneous among the LHUs, ranging from 1.9 to −1.4 percentage points. The mean pre-intervention percentage of patients with pTDs ranged from 0.59 to 2.1%, with slightly higher values characterizing Campania LHUs. The magnitude of the pre–post difference was very low, ranging from −0.11 to 0.20. In Campania, the mean pre-intervention percentage of patients with at least one ERD criterium was considerably higher than in Lombardy (approximately 30% in Lombardy and 50% in Campania). The pre–post difference was again quite heterogeneous. The results from the models accounting for GP geographical belonging suggested that none of the interventions resulted in a statistically significant effect, for all the three indicators considered. Conclusion: The proposed strategy was shown to be not effective in influencing the voluntary changes in GP prescription performance. However, the use of a set of explicit indicators proved to be useful in quantifying the inappropriateness. Further efforts are needed to find more efficient strategies and design more tailored interventions.
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Affiliation(s)
| | - Elena Olmastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Manuela Casula
- IRCCS MultiMedica, Sesto S. Giovanni, Italy
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
- *Correspondence: Manuela Casula,
| | - Ivan Merlo
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
- Laboratory of Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Matteo Franchi
- National Centre for Healthcare Research and Pharmacoepidemiology, Milan, Italy
- Laboratory of Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Alberico Luigi Catapano
- IRCCS MultiMedica, Sesto S. Giovanni, Italy
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
| | - Valentina Orlando
- CIRFF, Center of Pharmacoeconomics, Federico II University of Naples, Naples, Italy
- Department of Pharmacy, Federico II University of Naples, Naples, Italy
| | - Enrica Menditto
- CIRFF, Center of Pharmacoeconomics, Federico II University of Naples, Naples, Italy
- Department of Pharmacy, Federico II University of Naples, Naples, Italy
| | - Elena Tragni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences, University of Milan, Milan, Italy
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Xu Z, Liang X, Zhu Y, Lu Y, Ye Y, Fang L, Qian Y. Factors associated with potentially inappropriate prescriptions and barriers to medicines optimisation among older adults in primary care settings: a systematic review. Fam Med Community Health 2021; 9:e001325. [PMID: 34794961 PMCID: PMC8603289 DOI: 10.1136/fmch-2021-001325] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify factors that likely contribute to potentially inappropriate prescriptions (PIPs) among older adults in primary care settings, as well as barriers to medicines optimisation and recommended potential solutions. DESIGN Systematic review. ELIGIBILITY CRITERIA Quantitative studies that analysed the factors associated with PIPs among older adults (≥65 years) in primary care settings, and qualitative studies that explored perceived barriers and potential solutions to medicines optimisation for this population. INFORMATION SOURCES PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, CNKI and Wanfang. RESULTS Of the 13 167 studies identified, 50 were included (14 qualitative, 34 cross-sectional and 2 cohort). Nearly all quantitative studies examined patient-related non-clinical factors (eg, age) and clinical factors (eg, number of medications) and nine studies examined prescriber-related factors (eg, physician age). A greater number of medications were identified as positively associated with PIPs in 25 quantitative studies, and a higher number of comorbidities, physical comorbidities and psychiatric comorbidities were identified as patient-related clinical risk factors for PIPs. However, other factors showed inconsistent associations with the PIPs. Barriers to medicines optimisation emerged within four analytical themes: prescriber related (eg, inadequate knowledge, concerns of adverse consequences, clinical inertia, lack of communication), patient related (eg, limited understanding, patient non-adherence, drug dependency), environment related (eg, lack of integrated care, insufficient investment, time constraints) and technology related (eg, complexity of implementation and inapplicable guidance). Recommended potential solutions were based on each theme of the barriers identified accordingly (eg, prescriber-related factors: incorporating training courses into continuing medical education). CONCLUSIONS Older adults with more drugs prescribed and comorbidities may have a greater risk of receiving PIPs in the primary care setting, but it remains unclear whether other factors are related. Barriers to medicines optimisation among primary care older adults comprise multiple factors, and evidence-based and targeted interventions are needed to address these difficulties. PROSPERO REGISTRATION NUMBER CRD42020216258.
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Affiliation(s)
- Zhijie Xu
- Department of General Practice, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xujian Liang
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yue Zhu
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yiting Lu
- Zhongdai Community Healthcare Center, Huzhou, China
| | - Yuanqu Ye
- Baili Community Healthcare Center, The People's Hospital of Longhua, Shenzhen, China
| | - Lizheng Fang
- Department of General Practice, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yi Qian
- School of Public Health, Hangzhou Normal University, Hangzhou, Zhejiang, China
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Li Y, Delcher C, Reisfield GM, Wei YJ, Brown JD, Winterstein AG. Utilization Patterns of Skeletal Muscle Relaxants Among Commercially Insured Adults in the United States from 2006 to 2018. PAIN MEDICINE 2021; 22:2153-2161. [PMID: 33690860 DOI: 10.1093/pm/pnab088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 12/31/2020] [Accepted: 03/02/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To examine the prevalence and duration of skeletal muscle relaxant (SMR) treatment among commercially insured adults in the United States. METHODS We used the MarketScan Research Database to identify a cohort of adults 18 to 64 years who had ≥2-year continuous enrollment between 2005 and 2018. We estimated the prevalence of SMR treatment using a repeated cross-sectional design and derived treatment duration using the Kaplan-Meier method. Analyses were stratified by age group, sex, geographic region, individual SMR agent, and musculoskeletal disorder. RESULTS 48.7 million individuals were included. Treatment prevalence ranged from 61.5 to 68.3 per 1,000. About one-third of users did not have a preceding musculoskeletal disorder diagnosis. Cyclobenzaprine was the dominant agent accounting for >50% of prescriptions. The considerable growth in the use of baclofen, tizanidine, and methocarbamol paralleled with a decline in carisoprodol and metaxalone use. The prevalence was highest in the South while lowest in the Northeast. The median treatment duration was 14 days with 4.0%, 1.9%, and 1.0% of individuals using SMRs for more than 90, 180, and 365 days, respectively. Compared with cyclobenzaprine, patients initiating baclofen, tizanidine, and carisoprodol had longer treatment duration. CONCLUSIONS SMRs are widely used in the United States. Their use slightly increased in recent years, but trends varied among individual agents, patient groups, and geographic regions. Despite limited evidence to support efficacy, a sizable number of U.S. adults used SMRs for long-term and off-label conditions. Further study is needed to understand determinants of treatment as well as outcomes associated with such use.
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Affiliation(s)
- Yan Li
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
| | - Chris Delcher
- Institute for Pharmaceutical Outcomes & Policy, Department of Pharmacy Practice & Science, College of Pharmacy, University of Kentucky, Lexington, KY
| | - Gary M Reisfield
- Department of Psychiatry, College of Medicine, University of Florida, Gainesville, FL
| | - Yu-Jung Wei
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL
| | - Joshua D Brown
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL
| | - Almut G Winterstein
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL.,Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, FL.,Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL, USA
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McCullough MB, Zogas A, Gillespie C, Kleinberg F, Reisman JI, Ndiwane N, Tran MH, Ourth HL, Morreale AP, Miller DR. Introducing clinical pharmacy specialists into interprofessional primary care teams: Assessing pharmacists' team integration and access to care for rural patients. Medicine (Baltimore) 2021; 100:e26689. [PMID: 34559093 PMCID: PMC8462613 DOI: 10.1097/md.0000000000026689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 06/17/2021] [Indexed: 01/05/2023] Open
Abstract
Clinical pharmacy specialists (CPS) were deployed nationally to improve care access and relieve provider burden in primary care.The aim of this study was to assess CPS integration in primary care and the Clinical Pharmacy Specialist Rural Veteran Access (CRVA) initiative's effectiveness in improving access.Concurrent embedded mixed-methods evaluation of participating CRVA CPS and their clinical team members (primary care providers, others).Health care providers on primary care teams in Veterans Health Administration (VHA).Perceived CPS integration in comprehensive medication management assessed using the MUPM and semi-structured interviews, and access measured with patient encounter data.There were 496,323 medical encounters with CPS in primary care over a 3-year period. One hundred twenty-four CPS and 1177 other clinical team members responded to a self-administered web-based questionnaire, with semi-structured interviews completed by 22 CPS and clinicians. Survey results indicated that all clinical provider groups rank CPS as making major contributions to CMM. CPS ranked themselves as contributing more to CMM than did their physician team members. CPS reported higher job satisfaction, less burn out, and better role fit; but CPS gave lower scores for communication and decision making as clinic organizational attributes. Themes in provider interviews focused on value of CPS in teams, relieving provider burden, facilitators to integration, and team communication issues.This evaluation indicates good integration of CPS on primary care teams as perceived by other team members despite some communication and role clarification challenges. CPS may play an important role in improving access to primary care.
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Affiliation(s)
- Megan B. McCullough
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- University of Massachusetts, Lowell, Zuckerberg School of Health Sciences, Department of Public Health, Lowell, MA
| | - Anna Zogas
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Chris Gillespie
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Felicia Kleinberg
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Joel I. Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Ndindam Ndiwane
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Michael H. Tran
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Heather L. Ourth
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Anthony P. Morreale
- Pharmacy Benefits Management Services, Veterans Health Administration Central Office, Department of Veterans Affairs, Washington, DC
| | - Donald R. Miller
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- University of Massachusetts, Lowell, Center for Population Health, Department of Biomedical and Nutritional Sciences, Lowell, MA
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Bensley KMK, Kerr WC, Barnett SB, Mulia N. Postmortem screening of opioids, benzodiazepines, and alcohol among rural and urban suicide decedents. J Rural Health 2021; 38:77-86. [PMID: 33817837 DOI: 10.1111/jrh.12574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE Fatal suicides involving opioids are increasingly common, particularly in rural areas. As co-use of opioids with other substances contributes significantly to mortality risk, we examined whether positive screens for opioids with other substances is more prevalent among rural versus urban suicide deaths, as this could have implications for public health strategies to reduce overdose suicides. METHODS Data from all states reporting opioid-related overdose suicides in the National Violent Death Reporting System from 2012 to 2015 were used. Relative risk ratios were obtained using multinomial logistic regression, comparing opioid-only to (1) opioid and alcohol, (2) opioid and benzodiazepines, and (3) opioid, alcohol, and benzodiazepines suicides across rurality. Models were fit using robust standard errors and fixed effects for year of death, adjusting for individual, county, and state-level covariates. FINDINGS There were 3,781 opioid-overdose suicide decedents (42% female) tested for all 3 substances during the study period. Unadjusted prevalence of positive screens in decedents varied across rurality (P = .022). Urban decedents were more likely to test positive for opioids alone, while rural decedents were more to likely test positive for opioids and benzodiazepines. CONCLUSIONS Rural suicides are associated with increased opioid and benzodiazepine positive screens. These findings suggest the need for rural-focused interventions to support appropriate co-prescribing, better health education for providers about risks associated with drug mixing, and more linkages with mental health services.
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Affiliation(s)
- Kara Marie Kubiak Bensley
- School of Public Health, University of California, Berkeley, California, USA.,Alcohol Research Group, Public Health Institute, Emeryville, California, USA
| | - William C Kerr
- Alcohol Research Group, Public Health Institute, Emeryville, California, USA
| | - Sarah Beth Barnett
- School of Public Health, University of California, Berkeley, California, USA.,Alcohol Research Group, Public Health Institute, Emeryville, California, USA
| | - Nina Mulia
- Alcohol Research Group, Public Health Institute, Emeryville, California, USA
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Bories M, Bouzillé G, Cuggia M, Le Corre P. Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study. Pharmaceutics 2021; 13:pharmaceutics13020266. [PMID: 33669162 PMCID: PMC7919637 DOI: 10.3390/pharmaceutics13020266] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 01/18/2023] Open
Abstract
Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.
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Affiliation(s)
- Mathilde Bories
- Pôle Pharmacie, Service Hospitalo-Universitaire de Pharmacie, CHU de Rennes, 35033 Rennes, France;
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, F-35000 Rennes, France; (G.B.); (M.C.)
- Laboratoire de Biopharmacie et Pharmacie Clinique, Faculté de Pharmacie, Université de Rennes 1, 35043 Rennes, France
| | - Guillaume Bouzillé
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, F-35000 Rennes, France; (G.B.); (M.C.)
| | - Marc Cuggia
- Univ Rennes, CHU Rennes, INSERM, LTSI-UMR 1099, F-35000 Rennes, France; (G.B.); (M.C.)
| | - Pascal Le Corre
- Pôle Pharmacie, Service Hospitalo-Universitaire de Pharmacie, CHU de Rennes, 35033 Rennes, France;
- Laboratoire de Biopharmacie et Pharmacie Clinique, Faculté de Pharmacie, Université de Rennes 1, 35043 Rennes, France
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail)-UMR_S 1085, F-35000 Rennes, France
- Correspondence:
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Saastamoinen L, Verho J. Regional variation in potentially inappropriate medicine use in older adults. - A national register-based cross-sectional study on economic, health system-related and patient-related characteristics. Res Social Adm Pharm 2020; 17:1223-1227. [PMID: 33071213 DOI: 10.1016/j.sapharm.2020.08.018] [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] [Received: 03/10/2020] [Revised: 08/19/2020] [Accepted: 08/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Potentially inappropriate medicines (PIM), i.e. medicines in which the potential harms may outweigh the benefits, use may be associated with e.g. hospitalization, outpatient visits and health care costs. As regional institutions are often responsible for financing pharmaceuticals, understanding the regional variation of PIM use could help to tackle the associated problems and costs. OBJECTIVE To explore regional variation in PIM use among older adults and the association with regional health-system related, patient-related and economic characteristics and the frequency of PIM use. METHODS This is a nation-wide study based on the Finnish Prescription Register. PIM use was defined according to the Finnish Meds75+ database and regional characteristics derived from national statistics. RESULTS Variation at the hospital district level was large, with the largest difference between the most and least PIM prescribing being 45.2%. The factors associated with high PIM prescribing were a higher share of women and a higher number of private doctor visits per inhabitant in a municipality. The factor associated to lower PIM prescribing was a higher share of Swedish-speaking population. The studied factors explained 23% of the municipal-level variation in PIM. CONCLUSIONS Large regional differences may lead to regional inequality in prescribing and in the distribution of pharmaceutical costs. As only a small share of the variation was explained by economic, health system-related and patient-related factors, the key reasons may lie in unobserved prescribing practices.
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Affiliation(s)
- Leena Saastamoinen
- Research Unit, The Social Insurance Institution of Finland, PO Box 450, 00056, Kela, Helsinki, Finland.
| | - Jouko Verho
- VATT Institute for Economic Research, Arkadiankatu 7, Helsinki, 00100, Finland.
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11
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Chinthammit C, Bhattacharjee S, Axon DR, Slack M, Bentley JP, Warholak TL, Wilson DL, Lo-Ciganic WH. Geographic Variation in the Prevalence of High-Risk Medication Use Among Medicare Part D Beneficiaries by Hospital Referral Region. J Manag Care Spec Pharm 2020; 26:1309-1316. [PMID: 32996396 PMCID: PMC10391208 DOI: 10.18553/jmcp.2020.26.10.1309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Understanding geographic patterns of high-risk medication (HRM) prescribed and dispensed among older adults may help the Centers for Medicare & Medicaid Services and their partners develop and tailor prevention strategies. OBJECTIVE To compare the geographic variation in the prevalence of HRM use among Medicare Part D beneficiaries from 2011 to 2013, for Medicare Advantage Prescription Drug (MA-PD) plans and stand-alone Prescription Drug Plans (PDPs). METHODS This retrospective study used the data of a 5% national Medicare sample (2011-2013). Beneficiaries were included in the study if they were aged ≥ 65 years, continuously enrolled in MA-PDs or PDPs (~1.3 million each year), and had ≥ 2 prescriptions for the same HRM (e.g., amitriptyline) prescribed and dispensed during the year based on the Pharmacy Quality Alliance's (PQA) quality measures for HRM use. Multivariable logistic regression was used to estimate adjusted annual HRM use rates (i.e., adjusted predictions, average marginal predictions, or model-adjusted risk) across 306 Dartmouth Atlas of Health Care hospital referral regions (HRRs), controlling for sociodemographic, health-status, and access-to-care factors. RESULTS Among eligible beneficiaries each year (1,161,076 in 2011, 1,237,653 in 2012, and 1,402,861 in 2013), nearly 40% were enrolled in MA-PD plans, whereas the remaining 60% were in PDP plans. The adjusted prevalence of HRM use significantly decreased among Medicare beneficiaries enrolled in MA-PD (13.1%-8.4%, P < 0.001) and PDP (16.2%-12.2%, P < 0.001) plans from 2011 to 2013. For MA-PD and PDP beneficiaries, HRM users were more likely to be (all P < 0.001) the following: female (MA-PD: 70.4% vs. 59.9%; PDP: 72.8% vs. 62.5%); White (MA-PD: 84.6% vs. 81.4%; PDP: 86.6% vs. 85.3%); with low-income subsidy or dual eligibility for Medicaid (MA-PD: 22.3% vs. 16.6%; PDP: 29.2% vs. 23.3%); and disabled (MA-PD: 15.6% vs. 8.7%; PDP: 15.4% vs. 8.5%) compared with non-HRM users in 2013. In 2013, significant geographic variation existed, with the ratios of 75th-25th percentiles of HRM use rates across HRRs as 1.42 for MA-PDs and 1.31 for PDPs. For MA-PDs, the top 5 HRRs with the highest HRM use rates in 2013 were Casper, WY (20.4%), Waco, TX (16.7%), Lubbock, TX (15.7%), Santa Barbara, CA (15.2%), and Temple, TX (15.1%); for PDPs, they were Lawton, OK (18.8%), Alexandria, LA (18.8%), Lake Charles, LA (18.6%), Oklahoma City, OK (18.0%), and Slidell, LA (18.0%). CONCLUSIONS Substantial geographic variation exists in the prevalence of HRM use among older adults in Medicare, regardless of prescription drug plan. Areas with high prevalence of HRM use may benefit from targeted interventions (e.g., medication therapy management monitoring or alternative medication substitutions) to prevent potential adverse consequences. DISCLOSURES No outside funding supported this study. The authors have nothing to disclose. This study was presented as a poster at the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) Asia Pacific Meeting; September 8-11, 2018; Tokyo, Japan.
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Affiliation(s)
- Chanadda Chinthammit
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Arizona, Tucson, and Eli Lilly & Company, Indianapolis, Indiana
| | - Sandipan Bhattacharjee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| | - David R. Axon
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| | - Marion Slack
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| | - John P. Bentley
- Department of Pharmacy Administration, School of Pharmacy, University of Mississippi, University, Gainesville
| | - Terri L. Warholak
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson
| | - Debbie L. Wilson
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, and Center for Drug Evaluation and Safety, College of Pharmacy, University of Florida, Gainesville
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12
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Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease. Coron Artery Dis 2020; 31:733-738. [PMID: 32404592 DOI: 10.1097/mca.0000000000000907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA. METHODS The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup. RESULTS Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53-0.89] and West (OR 0.53; 95% CI 0.41-0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast. CONCLUSIONS In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted.
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13
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Gillmeyer KR, Rinne ST, Glickman ME, Lee KM, Shao Q, Qian SX, Klings ES, Maron BA, Hanlon JT, Miller DR, Wiener RS. Factors Associated With Potentially Inappropriate Phosphodiesterase-5 Inhibitor Use for Pulmonary Hypertension in the United States, 2006 to 2015. Circ Cardiovasc Qual Outcomes 2020; 13:e005993. [PMID: 32393128 DOI: 10.1161/circoutcomes.119.005993] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Use of phosphodiesterase-5 inhibitors (PDE5i) for groups 2 and 3 pulmonary hypertension (PH) is rising nationally, despite guidelines recommending against this low-value practice. Although receiving care across healthcare systems is encouraged to increase veterans' access to specialists critical for PH management, receiving care in 2 systems may increase risk of guideline-discordant prescribing. We sought to identify factors associated with prescribing of PDE5i for group 2/3 PH, particularly, to test the hypothesis that veterans prescribed PDE5i for PH in the community (through Medicare) will have increased risk of subsequently receiving potentially inappropriate treatment in Veterans Health Administration (VA). METHODS AND RESULTS We constructed a retrospective cohort of 34 775 Medicare-eligible veterans with group 2/3 PH by linking national patient-level data from VA and Medicare from 2006 to 2015. We calculated adjusted odds ratios (ORs) of receiving daily PDE5i treatment for PH in VA using multivariable models with facility-specific random effects. In this cohort, 1556 veterans received VA prescriptions for PDE5i treatment for group 2/3 PH. Supporting our primary hypothesis, the variable most strongly associated with PDE5i treatment in VA for group 2/3 PH was prior treatment through Medicare (OR, 6.5 [95% CI, 4.9-8.7]). Other variables strongly associated with increased likelihood of VA treatment included more severe disease as indicated by recent right heart failure (OR, 3.3 [95% CI, 2.8-3.9]) or respiratory failure (OR, 3.7 [95% CI, 3.1-4.4]) and prior right heart catheterization (OR, 3.8 [95% CI, 3.4-4.3]). CONCLUSIONS Our data suggest a missed opportunity to reassess treatment appropriateness when pulmonary hypertension patients seek prescriptions from VA-a relevant finding given policies promoting shared care across VA and community settings. Interventions are needed to reinforce awareness that pulmonary vasodilators are unlikely to benefit group 2/3 pulmonary hypertension patients and may cause harm.
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Affiliation(s)
- Kari R Gillmeyer
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Seppo T Rinne
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Mark E Glickman
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Statistics, Harvard University, Cambridge, MA (M.E.G.)
| | - Kyung Min Lee
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Qing Shao
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Shirley X Qian
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Elizabeth S Klings
- Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
| | - Bradley A Maron
- Department of Cardiology, Veterans Affairs Boston Healthcare System, MA (B.A.M.)
| | - Joseph T Hanlon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.A.M.).,Center for Health Equity Research and Promotion (J.T.H.), Veterans Affairs Pittsburgh Healthcare System, PA
| | - Donald R Miller
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.)
| | - Renda Soylemez Wiener
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Veterans Hospital, Bedford, MA (K.R.G., S.T.R., M.E.G., K.M.L., Q.S., S.X.Q., D.R.M., R.S.W.).,Department of Medicine, Pulmonary Center, Boston University School of Medicine, MA (K.R.G., S.T.R., E.S.K., R.S.W.)
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14
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Fahlén Bergh C, Toivanen S, Johnell K, Calissendorff J, Skov J, Falhammar H, Nathanson D, Lindh JD, Mannheimer B. Factors of importance for discontinuation of thiazides associated with hyponatremia in Sweden: A population-based register study. Pharmacoepidemiol Drug Saf 2020; 29:77-83. [PMID: 31730289 DOI: 10.1002/pds.4922] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 08/08/2019] [Accepted: 10/20/2019] [Indexed: 12/31/2022]
Abstract
PURPOSE In a patient with clinically significant hyponatremia without other clear causes, thiazide treatment should be replaced with another drug. Data describing to which extent this is being done are scarce. The aim of this study was to investigate sociodemographic and socioeconomic factors that may be of importance for the withdrawal of thiazide diuretics in patients hospitalized due to hyponatremia. METHODS The study population was sampled from a case-control study investigating individuals hospitalized with a main diagnosis of hyponatremia. For every case, four matched controls were included. In the present study, cases (n = 5204) and controls (n = 7425) that had been dispensed a thiazide diuretic prior to index date were identified and followed onward regarding further dispensations. To investigate the influence of socioeconomic and sociodemographic factors, multiple logistic regression was used. RESULTS The crude prevalence of thiazide withdrawal for cases and controls was 71.9% and 10.8%, respectively. Thiazide diuretics were more often withdrawn in medium-sized towns (adjusted OR, 1.52; 95% CI, 1.21-1.90) and rural areas (aOR, 1.81; 95% CI, 1.40-2.34) compared with metropolitan areas and less so among divorced (aOR, 0.72; 95% CI, 0.53-0.97). However, education, employment status, income, age, country of birth, and gender did not influence withdrawal of thiazides among patients with hyponatremia. CONCLUSIONS Thiazide diuretics were discontinued in almost three out of four patients hospitalized due to hyponatremia. Educational, income, gender, and most other sociodemographic and socioeconomic factors were not associated with withdrawal of thiazides.
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Affiliation(s)
- Cecilia Fahlén Bergh
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Section of Diabetes and Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Susanna Toivanen
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - David Nathanson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Section of Diabetes and Endocrinology, Department of Internal Medicine, Södersjukhuset, Stockholm, Sweden
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15
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Li G, Andrews HF, Chihuri S, Lang BH, Leu CS, Merle DP, Gordon A, Mielenz TJ, Strogatz D, Eby DW, Betz ME, DiGuiseppi C, Jones VC, Molnar LJ, Hill LL. Prevalence of Potentially Inappropriate Medication use in older drivers. BMC Geriatr 2019; 19:260. [PMID: 31601189 PMCID: PMC6785868 DOI: 10.1186/s12877-019-1287-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 09/20/2019] [Indexed: 01/03/2023] Open
Abstract
Background Potentially Inappropriate Medication (PIM) use has been studied in a variety of older adult populations across the world. We sought to examine the prevalence and correlates of PIM use in older drivers. Methods We applied the American Geriatrics Society 2015 Beers Criteria to baseline data collected from the “brown-bag” review of medications for participants of the Longitudinal Research on Aging Drivers (LongROAD) study to examine the prevalence and correlates of PIM use in a geographically diverse, community-dwelling sample of older drivers (n = 2949). Proportions of participants who used one or more PIMs according to the American Geriatrics Society 2015 Beers Criteria, and estimated odds ratios (ORs) and 95% confidence intervals (CIs) of PIM use associated with participant characteristics were calculated. Results Overall, 18.5% of the older drivers studied used one or more PIM. The most commonly used therapeutic category of PIM was benzodiazepines (accounting for 16.6% of the total PIMs identified), followed by nonbenzodiazepine hypnotics (15.2%), antidepressants (15.2%), and first-generation antihistamines (10.5%). Compared to older drivers on four or fewer medications, the adjusted ORs of PIM use were 2.43 (95% CI 1.68–3.51) for those on 5–7 medications, 4.19 (95% CI 2.95–5.93) for those on 8–11 medications, and 8.01 (95% CI 5.71–11.23) for those on ≥12 medications. Older drivers who were female, white, or living in urban areas were at significantly heightened risk of PIM use. Conclusion About one in five older drivers uses PIMs. Commonly used PIMs are medications known to impair driving ability and increase crash risk. Implementation of evidence-based interventions to reduce PIM use in older drivers may confer both health and safety benefits. Trial registration Not applicable.
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Affiliation(s)
- Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA. .,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA. .,Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY, 10032, USA.
| | - Howard F Andrews
- Department of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Stanford Chihuri
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY, 10032, USA
| | - Barbara H Lang
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY, 10032, USA
| | - Cheng Shiun Leu
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, NY, USA
| | - David P Merle
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Abigail Gordon
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Thelma J Mielenz
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.,Center for Injury Epidemiology and Prevention, Columbia University Irving Medical Center, 622 West 168th St, PH5-505, New York, NY, 10032, USA
| | | | - David W Eby
- University of Michigan Transportation Research Institute, Ann Arbor, MI, USA.,The Center for Advancing Transportation Leadership and Safety (ATLAS Center), Ann Arbor, MI, USA
| | - Marian E Betz
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carolyn DiGuiseppi
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Vanya C Jones
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa J Molnar
- University of Michigan Transportation Research Institute, Ann Arbor, MI, USA.,The Center for Advancing Transportation Leadership and Safety (ATLAS Center), Ann Arbor, MI, USA
| | - Linda L Hill
- Department of Family and Preventive Medicine, University of California San Diego, La Jolla, CA, USA
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16
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Nothelle SK, Sharma R, Oakes A, Jackson M, Segal JB. Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 27:408-423. [PMID: 30964225 PMCID: PMC7938818 DOI: 10.1111/ijpp.12541] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 03/12/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States. METHODS PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently. KEY FINDINGS Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States. CONCLUSIONS Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.
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Affiliation(s)
- Stephanie K Nothelle
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ritu Sharma
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Allison Oakes
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Madeline Jackson
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jodi B Segal
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Health Services and Outcomes Research, Johns Hopkins University, Baltimore, MD, USA
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17
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Vandenberg AE, Echt KV, Kemp L, McGwin G, Perkins MM, Mirk AK. Academic Detailing with Provider Audit and Feedback Improve Prescribing Quality for Older Veterans. J Am Geriatr Soc 2019. [PMID: 29532466 DOI: 10.1111/jgs.15247] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Suboptimal prescribing persists as a driver of poor quality care of older veterans and is associated with risk of hospitalization and emergency department visits. We adapted a successful medication management model, Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE), from an urban geriatric specialty clinic to rural community-based clinics that deliver primary care. The goals were to promote prescribing quality and safety for older adults, including reduced prescribing of potentially inappropriate medications (PIMs). We augmented the original model, which involved a pharmacist-led, one-on-one medication review with high-risk older veterans, to provide rural primary care providers (PCPs) and pharmacists with educational outreach through academic detailing and tools to support safe geriatric prescribing practices, as well as individual audit and feedback on prescribing practice and confidential peer benchmarking. Twenty PCPs and 4 pharmacists at 4 rural Georgia community-based outpatient clinics participated. More than 7,000 older veterans were seen in more than 20,000 PCP encounters during the 14-month intervention period. Implementation of the IMPROVE intervention reduced PIM prescribing incidence from 9.6 new medications per 100 encounters during baseline to 8.7 after the intervention (P = .009). IMPROVE reduced PIM prevalence (proportion of encounters involving veterans who were taking at least 1 PIM) from 22.6% to 16.7% (P < .001). These approaches were effective in reducing PIMs prescribed to older veterans in a rural setting and constitute a feasible model for disseminating geriatric best practices to the primary care setting.
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Affiliation(s)
- Ann E Vandenberg
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Katharina V Echt
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Lawanda Kemp
- Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Gerald McGwin
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia
| | - Molly M Perkins
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Anna K Mirk
- Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, Decatur, Georgia.,Division of General Medicine and Geriatrics, School of Medicine, Emory University, Atlanta, Georgia.,Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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18
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Lund BC, Ohl ME, Hadlandsmyth K, Mosher HJ. Regional and Rural–Urban Variation in Opioid Prescribing in the Veterans Health Administration. Mil Med 2019; 184:894-900. [DOI: 10.1093/milmed/usz104] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/13/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Opioid prescribing is heterogenous across the US, where 3- to 5-fold variation has been observed across states or other geographical units. Residents of rural areas appear to be at greater risk for opioid misuse, mortality, and high-risk prescribing. The Veterans Health Administration (VHA) provides a unique setting for examining regional and rural–urban differences in opioid prescribing, as a complement and contrast to extant literature. The objective of this study was to characterize regional variation in opioid prescribing across Veterans Health Administration (VHA) and examine differences between rural and urban veterans.
Materials and Methods
Following IRB approval, this retrospective observational study used national administrative VHA data from 2016 to assess regional variation and rural–urban differences in schedule II opioid prescribing. The primary measure of opioid prescribing volume was morphine milligram equivalents (MME) dispensed per capita. Secondary measures included incidence, prevalence of any use, and prevalence of long-term use.
Results
Among 4,928,195 patients, national VHA per capita opioid utilization in 2016 was 1,038 MME. Utilization was lowest in the Northeast (894 MME), highest in the West (1,368 MME), and higher among rural (1,306 MME) than urban (988 MME) residents (p < 0.001). Most of the difference between rural and urban veterans (318 MME) was attributable to differences in long-term opioid use (312 MME), with similar rates of short-term use.
Conclusion
There is substantial regional and rural–urban variation in opioid prescribing in VHA. Rural veterans receive over 30% more opioids than their urban counterparts. Further research is needed to identify and address underlying causes of these differences, which could include access barriers for non-pharmacologic treatments for chronic pain.
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Affiliation(s)
- Brian C Lund
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Katherine Hadlandsmyth
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Hilary J Mosher
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Healthcare System, Iowa City, IA
- Veterans Rural Health Resource Center, Iowa City VA Healthcare System, Iowa City, IA
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
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19
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Dismuke-Greer CE, Gebregziabher M, Ritchwood T, Pugh MJ, Walker RJ, Uchendu US, Egede LE. Geographic Disparities in Mortality Risk Within a Racially Diverse Sample of U.S. Veterans with Traumatic Brain Injury. Health Equity 2018; 2:304-312. [PMID: 30374469 PMCID: PMC6203888 DOI: 10.1089/heq.2018.0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Traumatic brain injury (TBI) is a signature injury among the U.S. veterans. Hispanic U.S. veterans diagnosed with TBI have been found to have higher risk-adjusted mortality. This study examined the adjusted association of geographic location with all-cause mortality in 114,593 veterans diagnosed with TBI between January 1, 2000 and December 31, 2010, and followed through December 31, 2014. Methods: National Veterans Health Administration (VHA) databases containing administrative data including International Classification of Diseases, 9th Revision (ICD-9) codes, sociodemographic characteristics, and survival were linked. TBI was identified based on ICD-9 codes. Cox proportional hazards regression methods were used to examine the association of time from first TBI ICD-9 code to death with geographic location, after adjustment for TBI severity, race/ethnicity, other sociodemographic characteristics, military factors, and Elixhauser comorbidities. Results: Relative to urban mainland veterans with a median survival of 76.4 months, veterans living in the U.S. territories had a median survival of 69.1 months, whereas rural mainland veterans had a median survival of 77.1 months, and highly rural mainland veterans had a mean survival of 77.6 months. The final model adjusted for race/ethnicity, TBI severity, sociodemographic, military, and comorbidity covariates showed that residing in the U.S. territories was associated with a higher risk of death (hazard ratios=1.24; 95% confidence interval 1.15-1.34) relative to residing on the U.S. mainland. The race/ethnicity disparity previously found for the U.S. veterans diagnosed with TBI seems to be accounted for by living in the U.S. territories. Conclusion: The study shows that among veterans with TBI, mortality rates were higher in those who reside in the U.S. territories, even after adjustment. Previous documented higher mortality among Hispanic veterans seems to be explained by residing in the U.S. territories. The VA has a mission of ensuring equitable treatment of all veterans, and should investigate targeted policies and interventions to improve the survival of the U.S. territory veterans diagnosed with TBI.
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Affiliation(s)
- Clara E Dismuke-Greer
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Division of Internal Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mulugeta Gebregziabher
- Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina.,Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Tiarney Ritchwood
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Mary Jo Pugh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah.,IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Uche S Uchendu
- Chief Officer for Health Equity, US Department of Veterans Affairs, Washington, DC.,Principal, Health Management Associates, Washington, DC
| | - Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Center for Advancing Population Science (CAPS), Medical College of Wisconsin, Milwaukee, Wisconsin
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20
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Joling KJ, van Eenoo L, Vetrano DL, Smaardijk VR, Declercq A, Onder G, van Hout HPJ, van der Roest HG. Quality indicators for community care for older people: A systematic review. PLoS One 2018; 13:e0190298. [PMID: 29315325 PMCID: PMC5760020 DOI: 10.1371/journal.pone.0190298] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022] Open
Abstract
Background Health care systems that succeed in preventing long term care and hospital admissions of frail older people may substantially save on their public spending. The key might be found in high-quality care in the community. Quality Indicators (QIs) of a sufficient methodological level are a prerequisite to monitor, compare, and improve care quality. This systematic review identified existing QIs for community care for older people and assessed their methodological quality. Methods Relevant studies were identified by searches in electronic reference databases and selected by two reviewers independently. Eligible publications described the development or application of QIs to assess the quality of community care for older people. Information about the QIs, the study sample, and specific setting was extracted. The methodological quality of the QI sets was assessed with the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. A score of 50% or higher on a domain was considered to indicate high methodological quality. Results Searches resulted in 25 included articles, describing 17 QI sets with 567 QIs. Most indicators referred to care processes (80%) and measured clinical issues (63%), mainly about follow-up, monitoring, examinations and treatment. About two-third of the QIs focussed on specific disease groups. The methodological quality of the indicator sets varied considerably. The highest overall level was achieved on the domain ‘Additional evidence, formulation and usage’ (51%), followed by ‘Scientific evidence’ (39%) and ‘Stakeholder involvement’ (28%). Conclusion A substantial number of QIs is available to assess the quality of community care for older people. However, generic QIs, measuring care outcomes and non-clinical aspects are relatively scarce and most QI sets do not meet standards of high methodological quality. This study can support policy makers and clinicians to navigate through a large number of QIs and select QIs for their purposes. PROSPERO Registration: 2014:CRD42014007199
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Affiliation(s)
- Karlijn J. Joling
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
- * E-mail:
| | | | - Davide L. Vetrano
- Department of Geriatrics, Centro Medicina dell’Invecchiamento, Universita`Cattolica Sacro Cuore, Rome, Italy
- Aging Research Center, Karolinska Institutet, Stockholm, Sweden
- Stockholm University, Stockholm, Sweden
| | - Veerle R. Smaardijk
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Anja Declercq
- LUCAS, KU Leuven, University of Leuven, Leuven, Belgium
| | - Graziano Onder
- Department of Geriatrics, Centro Medicina dell’Invecchiamento, Universita`Cattolica Sacro Cuore, Rome, Italy
| | - Hein P. J. van Hout
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - Henriëtte G. van der Roest
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
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21
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Perdew C, Erickson K, Litke J. Innovative models for providing clinical pharmacy services to remote locations using clinical video telehealth. Am J Health Syst Pharm 2017; 74:1093-1098. [DOI: 10.2146/ajhp160625] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Cassie Perdew
- VISN 20 V-IMPACT Hub, Boise VA Medical Center, Boise, ID
| | - Katie Erickson
- VISN 20 V-IMPACT Hub, Boise VA Medical Center, Boise, ID
| | - Jessica Litke
- VISN 20 V-IMPACT Hub, Boise VA Medical Center, Boise, ID
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22
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Beuscart JB, Genin M, Dupont C, Verloop D, Duhamel A, Defebvre MM, Puisieux F. Potentially inappropriate medication prescribing is associated with socioeconomic factors: a spatial analysis in the French Nord-Pas-de-Calais Region. Age Ageing 2017; 46:607-613. [PMID: 28064169 DOI: 10.1093/ageing/afw245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Indexed: 11/12/2022] Open
Abstract
Background potentially inappropriate medication (PIM) prescribing is common in older people and leads to adverse events and hospital admissions. Objective to determine whether prevalence of PIM prescribing varies according to healthcare supply and socioeconomic status. Methods all prescriptions dispensed at community pharmacies for patients aged 75 and older between 1 January and 31 March 2012 were retrieved from French Health Insurance Information System of the Nord-Pas-de-Calais Region for patients affiliated to the Social Security scheme. PIM was defined according to the French list of Laroche. The geographic distribution of PIM prescribing in this area was analysed using spatial scan statistics. Results overall, 65.6% (n = 207,979) of people aged 75 years and over living in the Nord-Pas-de-Calais Region were included. Among them, 32.6% (n = 67,863) received at least one PIM. The spatial analysis identified 16 and 10 clusters of municipalities with a high and a low prevalence of PIM prescribing, respectively. Municipalities with a low prevalence of PIM were characterised by a high socioeconomic status whereas those with a high prevalence of PIM were mainly characterised by a low socioeconomic status, such as a high unemployment rate and low household incomes. Markers of healthcare supply were weakly associated with high or low prevalence clusters. Conclusion significant geographic variation in PIM prescribing was observed in the study territory and was mainly associated with socioeconomic factors.
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Affiliation(s)
- Jean-Baptiste Beuscart
- Univ. Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
- CHU Lille, Geriatric Department, F-59000 Lille, France
| | - Michael Genin
- Univ. Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
| | - Corrine Dupont
- Agence Régionale de Santé Nord-Pas-de-Calais, Lille, France
| | - David Verloop
- Agence Régionale de Santé Nord-Pas-de-Calais, Lille, France
| | - Alain Duhamel
- Univ. Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, F-59000 Lille, France
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23
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A Comparison of Nurse Practitioners, Physician Assistants, and Primary Care Physicians’ Patterns of Practice and Quality of Care in Health Centers. Med Care 2017; 55:615-622. [DOI: 10.1097/mlr.0000000000000689] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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24
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Hyttinen V, Taipale H, Tanskanen A, Tiihonen J, Tolppanen AM, Hartikainen S, Valtonen H. Risk Factors for Initiation of Potentially Inappropriate Medications in Community-Dwelling Older Adults with and without Alzheimer’s Disease. Drugs Aging 2016; 34:67-77. [DOI: 10.1007/s40266-016-0415-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Mattos MK, Sereika SM, Naples JG, Albert SM. Differences in Benzodiazepine Receptor Agonist Use in Rural and Urban Older Adults. Drugs Real World Outcomes 2016; 3:289-296. [PMID: 27747828 PMCID: PMC5042936 DOI: 10.1007/s40801-016-0080-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Older adults are especially susceptible to adverse consequences of potentially inappropriate medications (PIMs), such as benzodiazepine receptor agonists (BZDRAs), due to age-related pharmacokinetic and pharmacodynamic changes. Although some risk factors for BZDRA use in older adults have been identified, the role of rural versus urban residence is less clear. OBJECTIVE To describe BZDRA use in rural versus urban older adults using pharmaceutical claims from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program. METHODS The sample consisted of older adults enrolled in Pennsylvania's Healthy Steps for Older Adults and participated in Pennsylvania's PACE program. Independent sample t tests and contingency tables were used to examine residence differences. Multivariate binary logistic modeling was performed. RESULTS The total sample (N = 426) was 305 (71.6 %) urban-dwelling adults and 121 (28.4 %) rural-dwelling adults. Rural participants were more likely to be male, white, married, and have less than a high school education compared with urban participants (p <.01). Specifically, 25 % of rural-dwelling adults received a BZDRA compared with 15 % of urban-dwelling adults (p = 0.02). Three variables reached statistical significance for predicting BZDRA use in a multivariate model: rural residence (OR 2.58, 95 % CI 1.39-4.79), history of anxiety/depression (OR 4.20, 95 % CI 2.39-7.46), and number of medications (OR 1.11, 95 % CI 1.02-1.21). CONCLUSIONS BZDRA prescription differences in older, rural-dwelling adults further highlights the need for geriatric and mental health specialists to provide specialized care to this population. Rural healthcare professionals may be less aware of PIMs for older adults, and initiatives to support geriatric services and provide education for existing providers may be beneficial.
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Affiliation(s)
- Meghan K Mattos
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA.
| | - Susan M Sereika
- Department of Health and Community Systems, University of Pittsburgh School of Nursing, 415 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA
- Departments of Health and Community Systems, Epidemiology, and Biostatistics, University of Pittsburgh School of Nursing, Graduate School of Public Health, and Clinical Translational Science Institute, 360 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA
| | - Jennifer G Naples
- Division of Geriatric Medicine, University of Pittsburgh School of Medicine, 3471 Fifth Avenue, Kaufmann Building, Suite 500, Pittsburgh, PA, 15213, USA
| | - Steven M Albert
- Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, 208 Parran Hall, Pittsburgh, PA, 15261, USA
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26
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Nam YS, Han JS, Kim JY, Bae WK, Lee K. Prescription of potentially inappropriate medication in Korean older adults based on 2012 Beers Criteria: a cross-sectional population based study. BMC Geriatr 2016; 16:118. [PMID: 27255674 PMCID: PMC4890525 DOI: 10.1186/s12877-016-0285-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 05/19/2016] [Indexed: 11/10/2022] Open
Abstract
Background A high number of elderly people with multiple comorbidities are exposed to the risk of polypharmacy and prescription of potentially inappropriate medication (PIM). The purpose of this study was to determine the prevalence and patterns of PIM prescription in Korean older adults according to the 2012 Beers Criteria. Methods A retrospective study was conducted using data from the Korean Health Insurance Review and Assessment (KHIRA) database of outpatient prescription claims collected from January 1, 2009 to December 31, 2011. A total of 523,811 elderly subjects aged 65 years and older were included in the study, and several covariates related to the prescription of PIMs were obtained from the KHIRA database. These covariates were analyzed using Student’s t test and the chi-square test; furthermore, multivariate logistic regression analysis was used to evaluate the risk factors associated with the prescription of PIMs. Results A total of 80.96 % subjects were prescribed at least one PIM independent of their diagnosis or condition according to the 2012 Beers Criteria. The most commonly prescribed medication class was first-generation antihistamines with anticholinergic properties (52.33 %). Pain medications (43.04 %) and benzodiazepines (42.53 %) were next in line. When considering subjects’ diagnoses or conditions, subjects diagnosed with central nervous system conditions were most often prescribed PIMs. Female sex, severity of comorbidities, and polypharmacy were significant risk factors for PIM prescriptions. Conclusions This study confirmed that PIM prescription is common among elderly Koreans. A clinical decision support system should be developed to decrease the prevalence of PIM prescriptions. Electronic supplementary material The online version of this article (doi:10.1186/s12877-016-0285-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- You-Seon Nam
- Department of Family Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jong Soo Han
- Health Promotion Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Ju Young Kim
- Department of Family Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
| | - Woo Kyung Bae
- Health Promotion Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Kiheon Lee
- Department of Family Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
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27
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Haastrup PF, Rasmussen S, Hansen JM, Christensen RD, Søndergaard J, Jarbøl DE. General practice variation when initiating long-term prescribing of proton pump inhibitors: a nationwide cohort study. BMC FAMILY PRACTICE 2016; 17:57. [PMID: 27233634 PMCID: PMC4884377 DOI: 10.1186/s12875-016-0460-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 05/20/2016] [Indexed: 12/11/2022]
Abstract
Background Suggestions of overprescribing of proton pump inhibitors (PPIs) for long-term treatment in primary care have been raised. This study aims to analyse associations between general practice characteristics and initiating long-term treatment with PPIs. Methods A nationwide register-based cohort study of patients over 18 years redeeming first-time prescription for PPI issued by a general practitioner in Denmark in 2011. Patients redeeming more than 60 defined daily doses (DDDs) of PPI within six months were defined first-time long-term users. Detailed information on diagnoses, concomitant drug use and sociodemography of the cohort was extracted. Practice characteristics such as age and gender of the general practitioner (GP), number of GPs, number of patients per GP, geographical location and training practice status were linked to each PPI user. Logistic regression analysis was used to determine associations between practice characteristics and initiating long-term prescribing of PPIs. Results We identified 90 556 first-time users of PPI. A total of 30 963 (34.2 %) met criteria for long-term use at six months follow-up. GPs over 65 years had significantly higher odds of long-term prescribing (OR 1.32, CI 1.16-1.50), when compared to younger GPs (<45 years). Furthermore, female GPs were significantly less likely to prescribe long-term treatment with PPIs (OR 0.87, CI 0.81-0.93) compared to male GPs. Conclusions Practice characteristics such as GP age and gender could explain some of the observed variation in prescribing patterns for PPIs. This variation may indicate a potential for enhancing rational prescribing of PPIs.
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Affiliation(s)
- P F Haastrup
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - S Rasmussen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - J M Hansen
- Department of Medical Gastroenterology, Odense University Hospital, Odense, Denmark
| | - R D Christensen
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - J Søndergaard
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - D E Jarbøl
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark
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28
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Radomski TR, Good CB, Thorpe CT, Zhao X, Marcum ZA, Glassman PA, Lowe J, Mor MK, Fine MJ, Gellad WF. Variation in Formulary Management Practices Within the Department of Veterans Affairs Health Care System. J Manag Care Spec Pharm 2015; 22:114-20. [PMID: 27015250 PMCID: PMC7024562 DOI: 10.18553/jmcp.2016.14251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND All Department of Veterans Affairs Medical Centers (VAMCs) operate under a single national drug formulary, yet substantial variation in prescribing and spending exists across facilities. Local management of the national formulary may differ across VAMCs and may be one cause of this variation. OBJECTIVE To characterize variation in the management of nonformulary medication requests and pharmacy and therapeutics (P&T) committee member perceptions of the formulary environment at VAMCs nationwide. METHODS We performed an online survey of the chief of pharmacy and an additional staff pharmacist and physician on the P&T committee at all VAMCs. Respondents were asked questions regarding criteria for use for nonformulary medications, specific procedures for ordering nonformulary medications in general and specific lipid-lowering and diabetes agents, the appeals process, and the formulary environment at their VAMCs. We compared responses across facilities and between chiefs of pharmacy, pharmacists, and physicians. RESULTS A total of 212 chief pharmacists (n = 80), staff pharmacists (n = 78), and physicians (n = 54) responded, for an overall response rate of 49%. In total, 107/143 (75%) different VAMCs were represented. The majority of VAMCs reported adhering to national criteria for use, with 38 (36%) being very adherent and 69 (65%) being mostly adherent. There was substantial variation between VAMCs regarding how nonformulary drugs were ordered, evaluated, and appealed. The nonformulary lipid-lowering drugs ezetimibe, rosuvastatin, and atorvastatin were viewable to providers in the order entry screen at 67 (63%), 67 (63%), and 64 (60%) VAMCs, respectively. The nonformulary diabetes medication pioglitazone was only viewable at 58 (55%) VAMCs. In the remaining VAMCs, providers could not order these nonformulary drugs through the normal order-entry process. For questions about the formulary environment, physician respondent perceptions differed from those of staff pharmacists and chief pharmacists. Compared with pharmacy chiefs and staff pharmacists, physicians were less likely to agree that providers at their VAMC prescribed too many nonformulary medications (47% and 44% vs. 12%, P < 0.001), more likely to agree that providers must jump through too many hoops to prescribe nonformulary medication (5% and 3% vs. 25%, P < 0.001), and more likely to agree that providers make an effort to convert new patients from nonformulary to formulary lipid-lowering (65% and 73% vs. 94%, P <0.02) and diabetic medications (49% and 50% vs. 88%, P < 0.001). CONCLUSIONS Although the Department of Veterans Affairs (VA) operates under a single national formulary, we found significant differences among VAMCs regarding their management of nonformulary medication requests. We also found differences among formulary leaders regarding their perception of the environment in which their VAMC's formulary is managed. These findings have important implications not just for VA, but for any organization that develops, implements, and manages drug formularies across multiple facilities.
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Affiliation(s)
- Thomas R Radomski
- 1 Clinical Instructor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Clinical Research Fellow, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Chester B Good
- 2 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine; Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy; Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Carolyn T Thorpe
- 3 Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, and Assistant Professor, Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- 4 Statistician, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Zachary A Marcum
- 5 Assistant Professor, Division of Geriatric Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Peter A Glassman
- 6 Staff Physician, VA Greater Los Angeles Healthcare System; Professor of Clinical Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles; and Chair, Medical Advisory Panel, and Co-director, VA Center for Medication Safety, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - John Lowe
- 7 Associate Chief Consultant, Pharmacy Compliance and Efficiency, Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Maria K Mor
- 8 Director, Biostatistics and Informatics Core, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and Research Assistant Professor, Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Fine
- 9 Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Director, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- 10 Associate Professor, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, and Core Investigator, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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29
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Lund BC, Carrel M, Gellad WF, Chrischilles EA, Kaboli PJ. Incidence- Versus Prevalence-Based Measures of Inappropriate Prescribing in the Veterans Health Administration. J Am Geriatr Soc 2015. [PMID: 26200069 DOI: 10.1111/jgs.13560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe variations in potentially inappropriate prescribing (PIP) and characterize the extent to which switching to an incidence-based indicator would affect health system quality rankings. DESIGN Observational study. SETTING Veterans Health Administration in 2011. PARTICIPANTS Older adults receiving outpatient primary care. MEASUREMENTS PIP was defined according to the National Committee for Quality Assurance High-Risk Medications in the Elderly list. Ranks were separately assigned for prevalent and incident PIP at the regional, network, and healthcare system levels. RESULTS National PIP prevalence was 12.3% (167,766/1,360,251), and incidence was 5.8% (78,604/1,360,251). PIP prevalence ranged from 3.5% to 33.1% across healthcare systems (interquartile range (IQR) = 9.2-15.5%). PIP incidence ranged from 1.2% to 14.9% (IQR = 4.1-7.2%). Rank order in PIP prevalence and incidence was correlated (Spearman correlation; ρ = 0.934, P < .001), although substantial changes in ranks were seen for some healthcare systems, with seven of 139 (5.0%) systems shifting more than 30 rank positions and 21 (15.1%) systems shifting 16 to 30 positions. CONCLUSION Prevalence- and incidence-based indicators of prescribing quality were strongly correlated. Transitioning to incidence-based indicators would not produce an initial disruption in quality rankings for most healthcare systems and might yield more-salient measures for tracking healthcare quality.
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Affiliation(s)
- Brian C Lund
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Margaret Carrel
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Geographical and Sustainability Sciences, College of Medicine, University of Iowa, Iowa City, Iowa
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Peter J Kaboli
- Division of General Internal Medicine, College of Medicine, University of Iowa, Iowa City, Iowa
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30
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Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012. J Gen Intern Med 2015; 30:597-604. [PMID: 25519224 PMCID: PMC4395612 DOI: 10.1007/s11606-014-3143-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/10/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids. OBJECTIVE We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012. DESIGN Observational cohort study using Veterans Health Administration (VHA) administrative databases. PARTICIPANTS All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year. MAIN MEASURES Prevalent and incident opioid receipt during each year of the study period. KEY RESULTS The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame. CONCLUSIONS Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.
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Patterson BJ, Kaboli PJ, Tubbs T, Alexander B, Lund BC. Rural access to clinical pharmacy services. J Am Pharm Assoc (2003) 2015; 54:518-25. [PMID: 25216881 DOI: 10.1331/japha.2014.13248] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To examine the impact of rural residence and primary care site on use of clinical pharmacy services (CPS) and to describe the use of clinical telepharmacy within the Veterans Health Administration (VHA) health care system. METHODS Using 2011 national VHA data, the frequency of patients with CPS encounters was compared across patient residence (urban or rural) and principal site of primary care (medical center, urban clinic, or rural clinic). The likelihood of CPS utilization was estimated with random effects logistic regression. Individual service types (e.g., anticoagulation clinics) and delivery modes (e.g., telehealth) were also examined. RESULTS Of 3,040,635 patients, 711,348 (23.4%) received CPS. Service use varied by patient residence (urban: 24.9%; rural: 19.7%) and principal site of primary care (medical center: 25.9%; urban clinic: 22.5%; rural clinic: 17.6%). However, in adjusted analyses, urban-rural differences were explained primarily by primary care site and less so by patient residence. Similar findings were observed for individual CPS types. Telehealth encounters were common, accounting for nearly one-half of patients receiving CPS. Video telehealth was infrequent (<0.2%), but more common among patients of rural clinics than those receiving CPS at medical centers (odds ratio [OR] = 9.7; 95% CI 9.0-10.5). CONCLUSION We identified a potential disparity between rural and urban patients' access to CPS, which was largely explained by greater reliance on community clinics for primary care than on medical centers. Future research is needed to determine if this disparity will be alleviated by emerging organizational changes, including expanding telehealth capacity and integrating pharmacists into primary care teams, and whether lessons learned at VHA translate to other settings.
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Lund BC, Schroeder MC, Middendorff G, Brooks JM. Effect of hospitalization on inappropriate prescribing in elderly Medicare beneficiaries. J Am Geriatr Soc 2015; 63:699-707. [PMID: 25855518 DOI: 10.1111/jgs.13318] [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] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To determine whether acute hospitalization is associated with a change in potentially inappropriate medication (PIM) use and whether use varies across geographic region. DESIGN Observational. SETTING Continental United States. PARTICIPANTS Medicare beneficiaries aged 65 and older hospitalized for acute myocardial infarction (AMI) during 2007-08. MEASUREMENTS Potentially inappropriate medication use was defined according to the High-Risk Medications in Elderly Adults quality indicator from the Healthcare Effectiveness Data and Information Set. Prevalence of outpatient PIM use was determined at admission and discharge and then used to identify medications discontinued during hospitalization and incident medications started during this period. RESULTS Of 124,051 older adults hospitalized for AMI, 9,607 (7.7%) were outpatient PIM users at admission, which increased to 8.6% at discharge (P < .001). Admission PIM rates varied according to geographic region, as did the effect of hospitalization. Admission PIM use was lowest in the northeast and remained unchanged during hospitalization (5.1-5.1%, P = .95). In contrast, admission PIM use was highest in the south and increased significantly during hospitalization (9.9-11.4%, P < .001). PIM use also increased from the long-term perspective, with 6-month period prevalence rates of 22.6% before admission and 24.6% after discharge (P < .001). CONCLUSION Despite intervention studies demonstrating up to 80% reduction in PIM use during acute hospitalization, a significant increase in PIM use was observed in a naturalistic setting in Medicare beneficiaries with AMI. Further research is needed to develop an approach to minimizing PIM use in the inpatient setting that is cost-effective and suitable for widespread implementation.
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Affiliation(s)
- Brian C Lund
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa; Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
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Steinman MA, Miao Y, Boscardin WJ, Komaiko KDR, Schwartz JB. Prescribing quality in older veterans: a multifocal approach. J Gen Intern Med 2014; 29:1379-86. [PMID: 25002159 PMCID: PMC4175643 DOI: 10.1007/s11606-014-2924-8] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 03/31/2014] [Accepted: 05/27/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults. DESIGN AND PARTICIPANTS Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans Affairs (VA) pharmacies in 2007. MAIN MEASURES Using VA pharmacy data linked with encounter, laboratory and other data, we assessed five types of prescribing problems. KEY RESULTS Among 462,405 patients age 65 and older, mean age was 75 years, 98 % were male, and patients were prescribed a median of five medications. Half of patients (50 %) had one or more prescribing problems, including 12 % taking one or more medications at an inappropriately high dose, 30 % with drug-drug interactions, 3 % with drug-disease interactions, and 26 % taking one or more Beers criteria drugs. In addition, 16 % were taking a high-risk drug (warfarin, insulin, and/or digoxin). On multivariable analysis, age was not strongly associated with four of the five types of prescribing issues assessed (relative risk < 1.3 across age groups), and comorbid burden conferred substantially increased risk only for drug-disease interactions and use of high-risk drugs. In contrast, the number of drugs used was consistently the strongest predictor of prescribing problems. Patients in the highest quartile of medication use had 6.6-fold to12.5-fold greater risk of each type of prescribing problem compared to patients in the lowest quartile (P < 0.001 for each). CONCLUSIONS The number of medications used is by far the strongest risk factor for each of five types of prescribing problems. Efforts to improve prescribing should especially target patients taking multiple medications.
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Affiliation(s)
- Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, 4150 Clement St, VA Box 181G, San Francisco, CA, 94141, USA,
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O'Shea MP, Teeling M, Bennett K. Regional variation in medication-taking behaviour of new users of oral anti-hyperglycaemic therapy in Ireland. Ir J Med Sci 2014; 184:403-10. [PMID: 24859371 DOI: 10.1007/s11845-014-1132-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/28/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few studies have investigated regional variation in medication-taking behaviour. The purpose of this study was to investigate whether there are regional differences in non-persistence and non-adherence to oral anti-hyperglycaemic agents in patients initiating therapy and examine if any association exists between different types of comorbidity in terms of medication-taking behaviour. METHODS The Irish Health Services Executive (HSE) pharmacy claims database was used to identify new users of metformin or sulphonylureas, aged ≥25 years, initiating therapy between June 2009 and December 2010. Non-persistence and non-adherence were examined up to 12 months post-initiation. Comorbidity was assessed using modified RxRisk and RxRisk-V indices, and classified as either concordant and/or discordant with diabetes. Adjusted hazard ratios (HRs) and 95% confidence intervals (95% CIs) for non-persistence were determined in relation to both HSE region and comorbidity type using Cox proportional hazards model, adjusting for age, sex and initial OAH prescribed. Logistic regression analysis, adjusting for these covariates, was used to determine the adjusted odds ratios (ORs) and 95% CIs for non-adherence for both HSE region and comorbidity type. RESULTS Results showed little overall difference between regions. The largest reduction for both non-persistence (HR 0.86, 95% CI 0.80, 0.94) and non-adherence (OR 0.83, 95% CI 0.74, 0.93) was observed in the south. Any comorbidity was associated with a reduced risk of non-persistence and non-adherence. CONCLUSIONS Interventions to optimise medication-taking in patients with T2DM should be implemented nationally to improve the overall level of adherence and persistence, especially in patients with no comorbidity.
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Affiliation(s)
- M P O'Shea
- Department of Pharmacology and Therapeutics, Trinity Centre for Health Science, St James's Hospital, Dublin 8, Ireland,
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Hung WW, Rossi M, Thielke S, Caprio T, Barczi S, Kramer BJ, Kochersberger G, Boockvar KS, Brody A, Howe JL. A multisite geriatric education program for rural providers in the Veteran Health Care System (GRECC-Connect). GERONTOLOGY & GERIATRICS EDUCATION 2014; 35:23-40. [PMID: 24397348 DOI: 10.1080/02701960.2013.870902] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.
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Affiliation(s)
- William W Hung
- a Department of Geriatrics and Palliative Medicine , Mount Sinai School of Medicine , New York , New York , USA
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Holmes HM, Luo R, Kuo YF, Baillargeon J, Goodwin JS. Association of potentially inappropriate medication use with patient and prescriber characteristics in Medicare Part D. Pharmacoepidemiol Drug Saf 2013; 22:728-34. [PMID: 23494811 DOI: 10.1002/pds.3431] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 01/23/2013] [Accepted: 02/11/2013] [Indexed: 01/10/2023]
Abstract
PURPOSE The use of potentially inappropriate medications (PIMs) in older people is associated with increased risk of adverse drug events and hospitalization. This study aimed to determine the contribution of primary prescribers to variation in PIM use. METHODS This was a retrospective cohort study using 2008 Medicare Part D event files and claims data for a 100% sample of Texas beneficiaries. PIM use was defined as receiving any of 48 medications on the Beers 2003 list of PIMs. Patient characteristics associated with PIM use were determined using a multivariable model. A multilevel model for the odds of PIM use was constructed to evaluate the amount of variation in PIM use at the level of primary care prescriber, controlling for patient characteristics. RESULTS Of 677,580 patients receiving prescriptions through Part D in 2008, 31.9% received a PIM. Sex, ethnicity, low-income subsidy eligibility, and hospitalization in 2007 were associated with PIM use. The strongest associations with higher PIM use were increasing number of prescribers and increasing number of medications. The odds ratio for PIM use was 1.50 (95%CI 1.47-1.53) for ≥4 prescribers versus only 1 prescriber. In the multilevel model, the adjusted average percent of patients prescribed a PIM ranged from 17.5% for the lowest decile to 28.9% for the highest decile of prescribers. CONCLUSIONS PIM use was prevalent in Part D beneficiaries and varied among individual primary care prescribers. The association of PIM use with increasing numbers of prescribers suggests the need to reduce fragmentation of care to reduce inappropriate prescribing.
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Affiliation(s)
- Holly M Holmes
- Department of General Internal Medicine, UT MD Anderson Cancer Center, Houston, TX, USA.
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