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Ruiz Ramos J, Alquézar-Arbé A, Juanes Borrego A, Burillo Putze G, Aguiló S, Jacob J, Fernández C, Llorens P, Quero Espinosa FDB, Gordo Remartinez S, Hernando González R, Moreno Martín M, Sánchez Aroca S, Sara Knabe A, González González R, Carrión Fernández M, Artieda Larrañaga A, Adroher Muñoz M, Hong Cho JU, Escolar Martínez Berganza MT, Gayoso Martín S, Sánchez Sindín G, Silva Penas M, Gómez y Gómez B, Arenos Sambro R, González del Castillo J, Miró Ò. Short-term prognosis of polypharmacy in elderly patients treated in emergency departments: results from the EDEN project. Ther Adv Drug Saf 2024; 15:20420986241228129. [PMID: 38323189 PMCID: PMC10846059 DOI: 10.1177/20420986241228129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 01/06/2024] [Indexed: 02/08/2024] Open
Abstract
Background Polypharmacy is a growing phenomenon among elderly individuals. However, there is little information about the frequency of polypharmacy among the elderly population treated in emergency departments (EDs) and its prognostic effect. This study aims to determine the prevalence and short-term prognostic effect of polypharmacy in elderly patients treated in EDs. Methods A retrospective analysis of the Emergency Department Elderly in Needs (EDEN) project's cohort was performed. This registry included all elderly patients who attended 52 Spanish EDs for any condition. Mild and severe polypharmacy was defined as the use of 5-9 drugs and ⩾10 drugs, respectively. The assessed outcomes were ED revisits, hospital readmissions, and mortality 30 days after discharge. Crude and adjusted logistic regression analyses, including the patient's comorbidities, were performed. Results A total of 25,557 patients were evaluated [mean age: 78 (IQR: 71-84) years]; 10,534 (41.2%) and 5678 (22.2%) patients presented with mild and severe polypharmacy, respectively. In the adjusted analysis, mild polypharmacy and severe polypharmacy were associated with an increase in ED revisits [odds ratio (OR) 1.13 (95% confidence interval (CI): 1.04-1.23) and 1.38 (95% CI: 1.24-1.51)] and hospital readmissions [OR 1.18 (95% CI: 1.04-1.35) and 1.36 (95% CI: 1.16-1.60)], respectively, compared to non-polypharmacy. Mild and severe polypharmacy were not associated with increased 30-day mortality [OR 1.05 (95% CI: 0.89-2.26) and OR 0.89 (95% CI: 0.72-1.12)], respectively. Conclusion Polypharmacy was common among the elderly treated in EDs and associated with increased risks of ED revisits and hospital readmissions ⩽30 days but not with an increased risk of 30-day mortality. Patients with polypharmacy had a higher risk of ED revisits and hospital readmissions ⩽30 days after discharge.
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Affiliation(s)
- Jesus Ruiz Ramos
- Pharmacy Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), C/San Quintin 56-58, Barcelona 08025, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Ana Juanes Borrego
- Pharmacy Department, Hospital de la Santa Creu I Sant Pau, Institut de Recerca Sant Pau (IR SANT PAU), Barcelona, Spain
| | - Guillermo Burillo Putze
- Facultad de Ciencias de la Salud, Universidad Europea de Canarias, Santa Cruz de Tenerife, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, l’Hospitalet de Llobregat, Spain
| | - Cesáreo Fernández
- Emergency Department, Hospital Clínico San Carlos, IDISSC, Universidad Complutense, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital Doctor Balmis, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain
| | | | | | | | | | - Sara Sánchez Aroca
- Emergency Department, Hospital Universitario Morales Meseguer, Murcia, Spain
| | | | | | | | | | | | | | | | - Sara Gayoso Martín
- Emergency Department, Hospital Comarcal El Escorial, San Lorenzo de El Escorial, Spain
| | | | | | | | | | | | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Cavalcante-Santos LM, Guarnieri AC, Conegundes FSDL, Giardini MH, Pereira LRL, Varallo FR. Clinical pharmacy in hospital palliative medicine: non-randomised clinical trial. BMJ Support Palliat Care 2023:spcare-2023-004620. [PMID: 38129106 DOI: 10.1136/spcare-2023-004620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To assess the impact of pharmaceutical care on hospital indicators and clinical outcomes of palliative care (PC) patients admitted to a secondary hospital. METHODS A non-randomised clinical trial was carried out in the PC ward of a secondary hospital in São Paulo, Brazil. Pharmaceutical care for all patients aged 18 and above, admitted between October 2021 and March 2022, with stays exceeding 48 hours, was provided. The interventions required were performed in collaboration with healthcare teams, patients and caregivers. Assessments occurred at admission and discharge, using PC performance scales and pharmacotherapy tools, with Research Ethics Committee approval. RESULTS Over 6 months, 120 hospitalisations were analysed, primarily involving women (58.9%), averaging 71.0 years, with neoplasm diagnoses (20.5%). A total of 170 drug-related problems were identified in 68.3% of patients. Following assessment, 361 interventions were performed, with a 78.1% acceptance rate, including medication dose adjustments, additions and discontinuations. Addressing unintentional pharmacotherapy discrepancies at admission led to reduced hospital stays (p<0.05). Pharmaceutical interventions also decreased pharmacotherapy complexity (p<0.001), inappropriate medications for the older people (p<0.001) and improved symptom management, such as pain (p<0.05). CONCLUSIONS Pharmaceutical care services integrated within the multiprofessional health team contributed to reducing drug-related problems associated with polypharmacy as well as improved the management PC symptoms in end-of-life patients, which reduced hospitalisation time.
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Affiliation(s)
- Lincoln Marques Cavalcante-Santos
- Department of Pharmaceutical Sciences, Pharmaceutical Care and Clinical Pharmacy Research Center, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Ana Carolina Guarnieri
- Department of Pharmaceutical Sciences, Pharmaceutical Care and Clinical Pharmacy Research Center, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Fernanda Silva de Lima Conegundes
- Department of Pharmaceutical Sciences, Pharmaceutical Care and Clinical Pharmacy Research Center, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | | | - Leonardo Régis Leira Pereira
- Department of Pharmaceutical Sciences, Pharmaceutical Care and Clinical Pharmacy Research Center, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
| | - Fabiana Rossi Varallo
- Department of Pharmaceutical Sciences, Pharmaceutical Care and Clinical Pharmacy Research Center, School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirao Preto, São Paulo, Brazil
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3
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Jacobs DM, Slazak E, Daly CJ, Clark C, Will S, Meaney D, Iervasi V, Irwin C, Zhu J, Prescott W, Wilding GE, Singh R. Clinical and economic effectiveness of a pharmacy and primary care collaborative transition of care program. J Am Pharm Assoc (2003) 2023; 63:1722-1730.e3. [PMID: 37611896 PMCID: PMC10900124 DOI: 10.1016/j.japh.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Primary care pharmacists are uniquely positioned to improve care quality by intervening within care transitions in the postdischarge period. However, additional evidence is required to demonstrate that pharmacist-led interventions can reduce health care utilization in a cost-effective manner. The study's objective was to evaluate the clinical and economic effectiveness of a pharmacy-led transition of care (TOC) program within a primary care setting. METHODS This cluster randomized trial was conducted between 2019 and 2021 and included three primary care practices. Eligible patients were ≥18 years of age and at high risk of readmission. The multifaceted pharmacy intervention included medication reconciliation, comprehensive medication review, and patient and provider follow-up. The primary composite endpoint included hospital readmissions and emergency department (ED) visits within 30 days of discharge. Differences in outcomes were modeled using a generalized estimated equations approach and outcomes were assumed to be distributed as a Poisson random variable. A cost-benefit analysis was embedded within the study and estimated economic outcomes from a provider group/health system perspective. Cost measures included: net benefit, benefit to cost ratio (BCR), and return on investment (ROI). RESULTS Of 300 eligible patients, 36 were in the intervention group and 264 in the control group. The intervention significantly reduced the primary composite outcome of all-cause readmissions and ED visits within 30 days (adjusted incidence rate ratio [aIRR], 0.54; 95% CI, 0.44-0.66; P < 0.001). There were significant reductions in both 30-day all-cause readmissions (aIRR, 0.64; 95% CI, 0.60-0.67; P < 0.001) and ED visits (aIRR, 0.25; 95% CI, 0.20, 0.31; P < 0.001) between groups. The net benefit of the intervention was $9,078, with a BCR of 2.11 and a ROI of 111%. Sensitivity analyses were robust to changes in economic inputs. CONCLUSION This care transition program had positive clinical and economic benefits, providing further support for the essential role pharmacists demonstrate in providing TOC services.
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Affiliation(s)
- David M. Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Erin Slazak
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Christopher J. Daly
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Collin Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | | | - Drake Meaney
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Victoria Iervasi
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Caroline Irwin
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Jingtao Zhu
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - William Prescott
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
| | - Gregory E. Wilding
- Department of Biostatistics, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
| | - Ranjit Singh
- Department of Family Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
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Mendorf S, Teschner U, Lehmann T, Prell T, Mühlhammer HM. Tailored interventions to improve adherence to medication in elderly patients with Parkinson's disease: a study protocol for a randomized controlled trial (AdhCare). Trials 2023; 24:668. [PMID: 37828583 PMCID: PMC10571350 DOI: 10.1186/s13063-023-07663-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Nonadherence to medication is a major issue in patients with chronic disorders such as Parkinson's disease (PD). Many interventions for increasing adherence have been tested, and these have shown weak-to-moderate efficiency. Although the best methods to improve adherence remain unclear, it is reasonable to use tailored interventions instead of the "one-size-fits-all" approach. METHODS A randomized, controlled, triple-blinded trial in elderly patients with PD is conducted to test the efficacy of AdhCare, a tailored intervention to enhance adherence compared with that achieved with routine care (64 participants per arm). Motor function, quality of life, and adherence measures will be assessed at baseline and at 3 and 6 months of follow-up. The type of intervention depends on the main personal reason for nonadherence (e.g., forgetting to take the medication or poor knowledge about the medication). DISCUSSION The results of this study will provide valuable information for health professionals and policymakers on the effectiveness of tailored interventions in elderly patients with PD. TRIAL REGISTRATION German Clinical Trials Register DRKS00023655. Registered on 24 February 2021. Last update on 22 March 2023.
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Affiliation(s)
- Sarah Mendorf
- Department of Neurology, Jena University Hospital, Jena, Germany.
| | - Ulrike Teschner
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Jena, Germany
| | - Tino Prell
- Department of Geriatrics, Halle University Hospital, Halle, Germany
| | - Hannah Maria Mühlhammer
- Department of Neurology, Jena University Hospital, Jena, Germany
- Department of Geriatrics, Halle University Hospital, Halle, Germany
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Abdelbary A, Kaddoura R, Balushi SA, Ahmed S, Galvez R, Ahmed A, Nashwan AJ, Alnaimi S, Al Hail M, Elbdri S. Implications of the medication regimen complexity index score on hospital readmissions in elderly patients with heart failure: a retrospective cohort study. BMC Geriatr 2023; 23:377. [PMID: 37337138 DOI: 10.1186/s12877-023-04062-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND The likelihood of elderly patients with heart failure (HF) being readmitted to the hospital is higher if they have a higher medication regimen complexity index (MRCI) compared to those with a lower MRCI. The objective of this study was to investigate whether there is a correlation between the MRCI score and the frequency of hospital readmissions (30-day, 90-day, and 1-year) among elderly patients with HF. METHODS In this single-center retrospective cohort study, MRCI scores were calculated using a well-established tool. Patients were categorized into high (≥ 15) or low (< 15) MRCI score groups. The primary outcome examined the association between MRCI scores and 30-day hospital readmission rates. Secondary outcomes included the relationships between MRCI scores and 90-day readmission, one-year readmission, and mortality rates. Multivariate logistic regression was employed to assess the 30- and 90-day readmission rates, while Kaplan-Meier analysis was utilized to plot mortality. RESULTS A total of 150 patients were included. The mean MRCI score for all patients was 33.43. 90% of patients had a high score. There was no link between a high MCRI score and a high 30-day readmission rate (OR 1.02; 95% CI 0.99-1.05; p < 0.13). A high MCRI score was associated with an initial significant increase in the 90-day readmission rate (odd ratio, 1.03; 95% CI, 1.00-1.07; p < 0.022), but not after adjusting for independent factors (odd ratio, 0.99; 95% CI, 0.95-1.03; p < 0.487). There was no significant difference between high and low MRCI scores in their one-year readmission rate. CONCLUSION The study's results indicate that there is no correlation between a higher MRCI score and the rates of hospital readmission or mortality among elderly patients with HF. Therefore, it can be concluded that the medication regimen complexity index does not appear to be a significant predictor of hospital readmission or mortality in this population.
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Affiliation(s)
- Asmaa Abdelbary
- Pharmacy Department, Community and Home Health Services, Hamad Medical Corporation, Doha, Qatar
| | - Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Sara Al Balushi
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Shiema Ahmed
- Pharmacy Department, Communicable Disease Center, Hamad Medical Corporation, Doha, Qatar
| | - Richard Galvez
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Afif Ahmed
- Corporate Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Shaikha Alnaimi
- Corporate Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Moza Al Hail
- Corporate Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
| | - Salah Elbdri
- Cardiology Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Murry LT, Keller MS, Pevnick JM, Schnipper JL, Kennelty KA, Nguyen AT, Henreid A, Wisniewski J, Amer K, Armbruster C, Conti N, Guan J, Wu S, Leang DW, Llamas-Sandoval R, Phung E, Rosen O, Rosen SL, Salandanan A, Shane R, Ko EJM, Moriarty D, Muske AM, Matta L, Fanikos J. A qualitative dual-site analysis of the pharmacist discharge care (PHARM-DC) intervention using the CFIR framework. BMC Health Serv Res 2022; 22:186. [PMID: 35151310 PMCID: PMC8840769 DOI: 10.1186/s12913-022-07583-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Older adults face several challenges when transitioning from acute hospitals to community-based care. The PHARMacist Discharge Care (PHARM-DC) intervention is a pharmacist-led Transitions of Care (TOC) program intended to reduce 30-day hospital readmissions and emergency department visits at two large hospitals. This study used the Consolidated Framework for Implementation Research (CFIR) framework to evaluate pharmacist perceptions of the PHARM-DC intervention.
Methods
Intervention pharmacists and pharmacy administrators were purposively recruited by study team members located within each participating institution. Study team members located within each institution coordinated with two study authors unaffiliated with the institutions implementing the intervention to conduct interviews and focus groups remotely via telecommunication software. Interviews were recorded and transcribed, with transcriptions imported into NVivo for qualitative analysis. Qualitative analysis was performed using an iterative process to identify “a priori” constructs based on CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of the individuals involved, and the process of implementation) and to create overarching themes as identified during coding.
Results
In total, ten semi-structured interviews and one focus group were completed across both hospitals. At Site A, six interviews were conducted with intervention pharmacists and pharmacists in administrative roles. Also at Site A, one focus group comprised of five intervention pharmacists was conducted. At Site B, interviews were conducted with four intervention pharmacists and pharmacists in administrative roles. Three overarching themes were identified: PHARM-DC and Institutional Context, Importance of PHARM-DC Adaptability, and Recommendations for PHARM-DC Improvement and Sustainability. Increasing pharmacist support for technical tasks and navigating pharmacist-patient language barriers were important to intervention implementation and delivery. Identifying cost-savings and quantifying outcomes as a result of the intervention were particularly important when considering how to sustain and expand the PHARM-DC intervention.
Conclusion
The PHARM-DC intervention can successfully be implemented at two institutions with considerable variations in TOC initiatives, resources, and staffing. Future implementation of PHARM-DC interventions should consider the themes identified, including an examination of institution-specific contextual factors such as the roles that pharmacy technicians may play in TOC interventions, the importance of intervention adaptability to account for patient needs and institutional resources, and pharmacist recommendations for intervention improvement and sustainability.
Trial registration
NCT04071951.
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7
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Mills P, MacLure K. A pilot study to identify elderly patients with cognitive impairment for clinical pharmacist polypharmacy review in General Practice. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100065. [PMID: 35480613 PMCID: PMC9031366 DOI: 10.1016/j.rcsop.2021.100065] [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: 05/31/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background Polypharmacy in elderly patients is common with potential for harm. Cognitive impairment is postulated as the biggest contributor to poor medication management with increased risk of hospital admission. There is limited information about approaches to identify high risk patients for polypharmacy review. Objective Pilot study to determine if a new patient prioritisation tool would identify appropriate patients for pharmacist polypharmacy review. Method Prioritisation tool developed to rank community-dwelling elderly patients prescribed 10 or more medications with cognitive impairment for pharmacist polypharmacy review. Tool used General Practice (GP) appointments, Emergency Department attendances, repeat medications and cognitive impairment to create a score to prioritise review invitations. Reviews were completed by GP clinical pharmacists who recorded interventions and measured outcome assessments using the adapted RiO scoring tool. Results Polypharmacy reviews completed for 34 patients from three GP practices. Demographic results were 62% female (n = 21), median 78 years [IQR 72–80], median 3 comorbidities [IQR 2–4] with most reviews conducted face-to-face (n = 29; 85%). Pharmaceutical care interventions were hospital admission possible or likely prevention for the majority of patients (85%, n = 29) which contrasts with the historical level of 33% (n = 228) patients with traditional processes. Conclusion Pilot study demonstrated that the new tool identified appropriate patients for review prioritisation as patients had complex pharmaceutical care needs.
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Affiliation(s)
- Pamela Mills
- NHS Ayrshire and Arran, United Kingdom
- Corresponding author at: Pharmacy Department, University Hospital Crosshouse, Kilmarnock, Ayrshire KA2 0BE, United Kingdom.
| | - Katie MacLure
- Independent Research Consultant, Aberdeen AB32 6RU, United Kingdom
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Pharmacists' Role in Older Adults' Medication Regimen Complexity: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168824. [PMID: 34444572 PMCID: PMC8394844 DOI: 10.3390/ijerph18168824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 11/17/2022]
Abstract
Medication regimen complexity (MRC) may influence health outcomes, such as hospitalisation, hospital readmission and medication adherence. Pharmacists have been referred to as health professionals with the opportunity to act on MRC reduction. This study aimed to investigate pharmacists' role in studies about older adults' medication regimen complexity. A literature search was performed in PubMed, Web of Science and the Cochrane Library-CENTRAL-up to October 2019. Out of 653 potentially relevant studies, 17 articles met the inclusion criteria for this review. Most studies used the 65-item medication regimen complexity index (MRCI) to assess medication complexity. Pharmacists' role was mainly confined to data collection. It seems that pharmacists' active role in older adults' medication complexity has not been studied in depth so far. However, the few existing interventional ones suggest that, after previous training, regimen simplification is feasible.
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Vaismoradi M, Jamshed S, Lorenzl S, Paal P. PRN Medicines Management for Older People with Long-Term Mental Health Disorders in Home Care. Risk Manag Healthc Policy 2021; 14:2841-2849. [PMID: 34262371 PMCID: PMC8274703 DOI: 10.2147/rmhp.s316744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/02/2021] [Indexed: 12/21/2022] Open
Abstract
Older people with long-term mental health conditions who receive care in their own home are vulnerable to the inappropriate use of medications and polypharmacy given their underlying health conditions and comorbidities. Inappropriate use of pro re nata (PRN) medications in these older people can enhance their suffering and have negative consequences for their quality of life and well-being, leading to readmission to healthcare settings and the increased cost of health care. This narrative review on published international literature aims at improving our understanding of medicines management in home care and how to improve PRN medication use among older people with long-term health conditions in their own home. Accordingly, the improvement of PRN medicines management for these older people requires the development of an individualised care plan considering ‘reduction of older people’s dependence on PRN medications’, ‘empowerment of family caregivers’, and ‘support by healthcare professionals.’ PRN medication use should be reduced through deprescription and discontinuation strategies. Also, older people and their family caregivers should be encouraged to prioritize the use of non-pharmacologic methods to relieve physical and psychological problems. Besides the empowerment of family caregivers through role development, education and training about PRN medications, and involvement in decision-making, they need support by the multidisciplinary network in terms of supervision, monitoring, and home visits.
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Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, Bodø, 8049, Norway
| | - Shazia Jamshed
- Clinical Pharmacy and Practice, Faculty of Pharmacy, University Sultan Zainal Abidin, Terengganu, 22200, Malaysia
| | - Stefan Lorenzl
- Professorship for Palliative Care, Institute of Nursing Science and -Practice, Paracelsus Medical University, Salzburg, 5020, Austria.,Department of Neurology, Klinikum Agatharied, Hausham, 83734, Germany
| | - Piret Paal
- WHO Collaborating Centre at the Institute for Nursing Science and Practice, Paracelsus Medical University, Salzburg, A-5020, Austria
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Wan CS, Reijnierse EM, Maier AB. Risk Factors of Readmissions in Geriatric Rehabilitation Patients: RESORT. Arch Phys Med Rehabil 2021; 102:1524-1532. [PMID: 33607077 DOI: 10.1016/j.apmr.2021.01.082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/16/2021] [Accepted: 01/19/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To evaluate the risk factors associated with 30- and 90-day hospital readmissions in geriatric rehabilitation inpatients. DESIGN Observational, prospective longitudinal inception cohort. SETTING Tertiary hospital in Victoria, Australia. PARTICIPANTS Geriatric rehabilitation inpatients of the REStORing Health of Acutely Unwell AdulTs (RESORT) cohort evalutated by a comprehensive geriatric assessment including potential readmission risk factors (ie, demographic, social support, lifestyle, functional performance, quality of life, morbidity, length of stay in an acute ward). Of 693 inpatients, 11 died during geriatric rehabilitation. The mean age of the remaining 682 inpatients was 82.2±7.8 years, and 56.7% were women. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Thirty- and 90-day readmissions after discharge from geriatric inpatient rehabilitation. RESULTS The 30- and 90-day unplanned all-cause readmission rates were 11.6% and 25.2%, respectively. Risk factors for 30- and 90-day readmissions were as follows: did not receive tertiary education, lower quality of life, higher Charlson Comorbidity Index and Cumulative Illness Rating Scale (CIRS) scores, and a higher number of medications used in the univariable models. Formal care was associated with increased risk for 90-day readmissions. In multivariable models, CIRS score was a significant risk factor for 30-day readmissions, whereas high fear of falling and CIRS score were significant risk factors for 90-day readmissions. CONCLUSIONS High fear of falling and CIRS score were independent risk factors for readmission in geriatric rehabilitation inpatients. These variables should be included in hospital readmission risk prediction model developments for geriatric rehabilitation inpatients.
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Affiliation(s)
- Ching S Wan
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Esmee M Reijnierse
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Andrea B Maier
- Department of Medicine and Aged Care, @AgeMelbourne, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia; Department of Human Movement Sciences, @AgeAmsterdam, Faculty of Behavioural and Movement Sciences, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands; Healthy Longevity Translational Research Program, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Centre for Healthy Longevity, @AgeSingapore, National University Health System, Singapore.
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11
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Mendorf S, Witte OW, Zipprich H, Prell T. Association Between Nonmotor Symptoms and Nonadherence to Medication in Parkinson's Disease. Front Neurol 2020; 11:551696. [PMID: 33192983 PMCID: PMC7604271 DOI: 10.3389/fneur.2020.551696] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/14/2020] [Indexed: 01/09/2023] Open
Abstract
Background: Nonadherence to medication is a common and serious issue in the treatment of patients with Parkinson's disease (PD). Among others, distinct nonmotor symptoms (NMS) were found to be associated with nonadherence in PD. Here, we aimed to confirm the association between NMS and adherence. Methods: In this observational study, the following data were collected: sociodemographic data, the German versions of the Movement Disorder Society-sponsored revision of the unified Parkinson's disease rating scale for motor function (MDS-UPDRS III), Hoehn and Yahr (H&Y) stage, levodopa equivalent daily dose (LEDD), Becks depression inventory II (BDI-II), nonmotor symptoms questionnaire (NMSQ), and the Stendal adherence to medication score (SAMS). Results: The final sample included 137 people with PD [54 (39.4%) females] with a mean age of 71.3 ± 8.2 years. According to SAMS, 10.9% of the patients were fully adherent, 73% were moderately nonadherent, and 16.1% showed clinically significant nonadherence. Nonadherence was associated with LEDD, BDI-II, education level, MDS-UPDRS III, and the NMSQ. The number of NMS was higher in nonadherent patients than in adherent patients. In the multiple stepwise regression analysis, the items 5 (constipation), 17 (anxiety), and 21 (falls) predicted nonadherence to medication. These NMSQ items also remained significant predictors for SAMS after correction for LEDD, MDS-UPDRS III, BDI-II, age, education level, gender, and disease duration. Conclusion: Our study, in principle, confirms the association between NMS burden and nonadherence in PD. However, in contrast to other clinical factors, the relevance of NMSQ in terms of nonadherence is low. More studies with larger sample sizes are necessary to explore the impact of distinct NMS on adherence.
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Affiliation(s)
- Sarah Mendorf
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Department of Neurology, Jena University Hospital, Jena, Germany.,Centre for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Hannah Zipprich
- Department of Neurology, Jena University Hospital, Jena, Germany.,Centre for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Tino Prell
- Department of Neurology, Jena University Hospital, Jena, Germany.,Centre for Healthy Ageing, Jena University Hospital, Jena, Germany
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12
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Linkens AEMJH, Milosevic V, van der Kuy PHM, Damen-Hendriks VH, Mestres Gonzalvo C, Hurkens KPGM. Medication-related hospital admissions and readmissions in older patients: an overview of literature. Int J Clin Pharm 2020; 42:1243-1251. [PMID: 32472324 PMCID: PMC7522062 DOI: 10.1007/s11096-020-01040-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 04/16/2020] [Indexed: 01/26/2023]
Abstract
Background The number of medication related hospital admissions and readmissions are increasing over the years due to the ageing population. Medication related hospital admissions and readmissions lead to decreased quality of life and high healthcare costs. Aim of the review To assess what is currently known about medication related hospital admissions, medication related hospital readmissions, their risk factors, and possible interventions which reduce medication related hospital readmissions. Method We searched PubMed for articles about the topic medication related hospital admissions and readmissions. Overall 54 studies were selected for the overview of literature. Results Between the different selected studies there was much heterogeneity in definitions for medication related admission and readmissions, in study population and the way studies were performed. Multiple risk factors are found in the studies for example: polypharmacy, comorbidities, therapy non adherence, cognitive impairment, depending living situation, high risk medications and higher age. Different interventions are studied to reduce the number of medication related readmission, some of these interventions may reduce the readmissions like the participation of a pharmacist, education programmes and transition-of-care interventions and the use of digital assistance in the form of Clinical Decision Support Systems. However the methods and the results of these interventions show heterogeneity in the different researches. Conclusion There is much heterogeneity in incidence and definitions for both medication related hospital admissions and readmissions. Some risk factors are known for medication related admissions and readmissions such as polypharmacy, older age and additional diseases. Known interventions that could possibly lead to a decrease in medication related hospital readmissions are spare being the involvement of a pharmacist, education programs and transition-care interventions the most mentioned ones although controversial results have been reported. More research is needed to gather more information on this topic.
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Affiliation(s)
- A E M J H Linkens
- Department of Internal Medicine, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - V Milosevic
- Department of Clinical Pharmacy, Pharmacology and Toxicology, Zuyderland Medical Centre, PO box 5500, 6130 MB, Sittard, The Netherlands
| | - P H M van der Kuy
- Department of Clinical Pharmacy, Erasmus Medical Centre, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - V H Damen-Hendriks
- Department of Internal Medicine, Zuyderland Medical Centre, PO box 5500, 6130 MB, Sittard, Geleen, The Netherlands
| | - C Mestres Gonzalvo
- Department of Clinical Pharmacy, Maastricht University Medical Centre, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - K P G M Hurkens
- Department of Internal Medicine, Zuyderland Medical Centre, PO box 5500, 6130 MB, Sittard, Geleen, The Netherlands
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13
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Curtain CM, Chang JY, Cousins J, Parameswaran Nair N, Bereznicki B, Bereznicki L. Medication Regimen Complexity Index Prediction of Adverse Drug Reaction-Related Hospital Admissions. Ann Pharmacother 2020; 54:996-1000. [PMID: 32349531 DOI: 10.1177/1060028020919188] [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] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The relationship between the medication regimen complexity index (MRCI) and adverse drug reaction (ADR)-related hospital admissions has not yet specifically been investigated. OBJECTIVE To evaluate the MRCI and compare with medication count for prediction of ADR-related hospital admissions in older patients. METHODS This was a retrospective analysis of a prospectively collected convenience sample of 768 unplanned medical admissions of Australians aged 65 years old and older. The sample consisted of 115 (15.0%) ADR-related unplanned hospital admissions and 653 (85.0%) non-ADR-related unplanned medical admissions. The MRCI score was calculated from the medical records and analyzed to predict ADR-related hospital admissions. RESULTS The cohort had a median age of 81 years, 5 comorbidities, and 11 medications, with a slight majority of women. The MRCI score was not significantly different in patients who had ADR-related admissions compared with other medical admissions-38.5 versus 34.0, respectively; Wilcoxon Rank Sum test W = 33 522; P = 0.067. The medication count was significantly different between the ADR-related admissions compared with other medical admissions: 12 versus 10; W = 32 508; P = 0.021. However, the medication count was not a strong predictor of ADR-related admissions; unadjusted odds ratio = 1.044; 95% CI = 1.006-1.084. CONCLUSION AND RELEVANCE The MRCI score did not discriminate between ADR-related admissions and other medical admissions despite taking time to calculate with potential for inconsistent application. Medication count is more readily applicable with marginally greater relevance in this cohort; however, both measures do not appear to be useful when used alone for clinicians to identify patients at risk of ADRs.
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Affiliation(s)
| | - Jie Yi Chang
- University of Tasmania, Hobart, Tasmania, Australia
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14
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Arain MA, Graham L, Ahmad A, Cole M. Pilot implementation of elder-friendly care practices in acute care setting: a mixed methods study. BMC Health Serv Res 2020; 20:347. [PMID: 32331521 PMCID: PMC7181575 DOI: 10.1186/s12913-020-05091-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 03/09/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Frail older patients are at risk of experiencing a decline in physical and cognitive function unrelated to the reason for admission. The Elder-Friendly Care (EFC) program was designed to improve the care, experiences, and outcomes of frail older adults. The project supported 8 Early Adoption Sites (EAS) in a large Canadian healthcare organization by providing multiple strategies, educational opportunities, and resources. The purpose of this study was to assess the usefulness of EFC educational materials and resources, staff practice changes and perceptions in pilot sites, and readiness for scale and spread. METHODS The study was conducted from May 2017 to June 2018 using a mixed-methods approach incorporating the Kirkpatrick Model of Training/Evaluation. A total of 76 Direct Care Staff participated in the staff survey, which assessed their awareness of, satisfaction with, and utilization of EFC principles, resources, and practices. Additionally, 12 interviews were conducted with staff who were directly involved in site implementation of EFC. RESULTS Most survey participants were aware (86%, n = 63) of the EFC program, and 85% (n = 41) indicated they or their site/unit had implemented EFC. Out of these 41 participants, the most common practice changes identified were: incorporating alternatives to restraint (81%, n = 33), decreased use of pharmacological restraint (78%, n = 32), and patient and family care planning (76%, n = 31). Participants that attended all 3 EFC Learning Workshops (LWs) were significantly more likely to recommend the EFC Toolkit to others (87% versus 40%; χ2 = 8.82, p < 0.01) compared to participants attending less than 3 EFC LWs. Interview participants indicated that the program was well structured and flexible as sites/units could adopt changes that suited their individual sites, needs, contexts, and challenges. CONCLUSIONS The educational materials and resources used for the EFC project are useful and appreciated by the Direct Care Staff. Further, participants perceive the EFC intervention as effective in creating positive practice change and useful in reducing hospital-related complications for older patients. Future implementation will investigate the impact of EFC on system-level outcomes in acute care.
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Affiliation(s)
- Mubashir Aslam Arain
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada.
| | - Laura Graham
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada
| | - Armghan Ahmad
- Alberta Health Services, Health Systems Evaluation and Evidence, Provincial Clinical Excellence, 10301 Southport Lane SW, Calgary, AB, T2W 1S7, Canada
| | - Mollie Cole
- Alberta Health Services, Seniors Health Strategic Clinical Networks, Calgary, AB, Canada
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15
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Sluggett JK, Hopkins RE, Chen EYH, Ilomäki J, Corlis M, Van Emden J, Hogan M, Caporale T, Ooi CE, Hilmer SN, Bell JS. Impact of Medication Regimen Simplification on Medication Administration Times and Health Outcomes in Residential Aged Care: 12 Month Follow Up of the SIMPLER Randomized Controlled Trial. J Clin Med 2020; 9:E1053. [PMID: 32276360 PMCID: PMC7231224 DOI: 10.3390/jcm9041053] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/02/2022] Open
Abstract
In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.
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Affiliation(s)
- Janet K. Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide, SA 5005, Australia
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Ria E. Hopkins
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Esa YH Chen
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Jenni Ilomäki
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Megan Corlis
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | - Jan Van Emden
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | - Michelle Hogan
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Helping Hand Aged Care, Adelaide, SA 5006, Australia;
| | | | - Choon Ean Ooi
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
| | - Sarah N. Hilmer
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Kolling Institute of Medical Research, Royal North Shore Hospital, Northern Clinical School, School of Medicine, University of Sydney, Sydney, NSW 2050, Australia
| | - J. Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia; (J.K.S.); (R.E.H.); (E.Y.C.); (J.I.); (C.E.O.)
- NHMRC Cognitive Decline Partnership Centre, Hornsby Ku-ring-gai Hospital, Sydney, NSW 2077, Australia; (M.C.); (J.V.E.); (M.H.); (S.N.H.)
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
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16
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Simplicidad del régimen de medicación y supervivencia en pacientes pluripatológicos. Med Clin (Barc) 2020; 154:248-253. [DOI: 10.1016/j.medcli.2019.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/31/2019] [Accepted: 06/06/2019] [Indexed: 11/17/2022]
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17
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Mendorf S, Witte OW, Grosskreutz J, Zipprich HM, Prell T. What Predicts Different Kinds of Nonadherent Behavior in Elderly People With Parkinson's Disease? Front Med (Lausanne) 2020; 7:103. [PMID: 32269998 PMCID: PMC7109286 DOI: 10.3389/fmed.2020.00103] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 03/09/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Detailed knowledge about nonadherence to medication could improve medical care in elderly patients. We aimed to explore patterns and reasons for nonadherence in people with Parkinson's disease (PD) aged 60 years and older. Methods: Detailed clinical data and adherence (German Stendal Adherence with Medication Score) were assessed in 230 patients with PD (without dementia). Descriptive statistics were used to study reasons for nonadherence in detail, and general linear models were used to study associations between clusters of nonadherence and clinical parameters. Results: Overall, 14.2% (n = 32) of the patients were fully adherent, 66.8% (n = 151) were moderately nonadherent, and 19.0% (n = 43) showed clinically meaningful nonadherence. In the multivariable analysis, nonadherence was associated with a lower education level, higher motor impairment in activities of daily living, higher number of medications per day, and motor complications of PD. Three clusters of nonadherence were observed: 59 (30.4%) patients reported intentional nonadherence by medication modification; in 72 (37.1%) patients, nonadherence was associated with forgetting to take medication; and 63 (32.5%) patients had poor knowledge about the prescribed medication. A lower education level was mainly associated with modification of medication and poorer knowledge about prescribed medication, but not with forgetting to take medication. Patients with motor complications, which frequently occur in those with advanced disease stages, tend to be intentionally nonadherent by modifying their prescribed medication. Increased motor problems and a higher total number of drugs per day were associated with less knowledge about the names, reasons, and dosages of their prescribed medication. Conclusions: Elderly patients with PD report many reasons for intentional and non-intentional nonadherence. Understanding the impact of clinical parameters on different patterns of nonadherence may facilitate tailoring of interventions and counseling to improve outcomes.
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Affiliation(s)
- Sarah Mendorf
- Department of Neurology, Jena University Hospital, Jena, Germany
| | - Otto W Witte
- Department of Neurology, Jena University Hospital, Jena, Germany.,Center for Healthy Ageing, Jena University Hospital, Jena, Germany
| | - Julian Grosskreutz
- Department of Neurology, Jena University Hospital, Jena, Germany.,Center for Healthy Ageing, Jena University Hospital, Jena, Germany
| | | | - Tino Prell
- Department of Neurology, Jena University Hospital, Jena, Germany.,Center for Healthy Ageing, Jena University Hospital, Jena, Germany
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18
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Slazak E, Shaver A, Clark CM, Cardinal C, Panthapattu M, Prescott WA, Will S, Jacobs DM. Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study. PHARMACY 2020; 8:pharmacy8010004. [PMID: 31947920 PMCID: PMC7151670 DOI: 10.3390/pharmacy8010004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 11/16/2022] Open
Abstract
Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.
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Affiliation(s)
- Erin Slazak
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
- Correspondence: (E.S.); (D.M.J.); Tel.: +1-716-645-2828 (E.S.); +1-716-829-2134 (D.M.J.)
| | - Amy Shaver
- Department of Epidemiology and Environment Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA;
| | - Collin M. Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | | | - Merin Panthapattu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | - William A. Prescott
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
| | - Samantha Will
- General Physicians, P.C., Buffalo, NY 14214, USA; (C.C.); (S.W.)
| | - David M. Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA; (C.M.C.); (M.P.)
- Correspondence: (E.S.); (D.M.J.); Tel.: +1-716-645-2828 (E.S.); +1-716-829-2134 (D.M.J.)
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19
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Slazak E, Shaver A, Clark CM, Cardinal C, Panthapattu M, Prescott WA, Will S, Jacobs DM. Implementation of a Pharmacist-Led Transitions of Care Program within a Primary Care Practice: A Two-Phase Pilot Study. PHARMACY 2020. [PMID: 31947920 DOI: 10.3390/pharmacy8010004.pmid:31947920;pmcid:pmc7151670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Pharmacists in primary care settings have unique opportunities to address the causes of ineffective care transitions. The objective of this study is to describe the implementation of a multifaceted pharmacist transitions of care (TOC) intervention integrated into a primary care practice and evaluate the effectiveness of the program. This was a two-phase pilot study describing the development, testing, and evaluation of the TOC program. In Phase 1, the TOC intervention was implemented in a general patient population, while Phase 2 focused the intervention on high-risk patients. The two pilot phases were compared to each other (Phase 1 vs. Phase 2) and to a historical control group of patients who received usual care prior to the intervention (Phase 1 and Phase 2 vs. control). The study included 138 patients in the intervention group (Phase 1: 101 and Phase 2: 37) and 118 controls. At baseline, controls had a significantly lower LACE index, shorter length of stay, and a lower number of medications at discharge, indicating less medical complexity. A total of 344 recommendations were provided over both phases, approximately 80% of which were accepted. In adjusted models, there were no significant differences in 30-day all-cause readmissions between Phase 2 and controls (aOR 0.78; 95% CI 0.21-2.89; p = 0.71) or Phase 1 (aOR 0.99; 95% CI 0.30-3.37; p = 0.99). This study successfully implemented a pharmacist-led TOC intervention within a primary care setting using a two-phase pilot design. More robust studies are needed in order to identify TOC interventions that reduce healthcare utilization in a cost-effective manner.
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Affiliation(s)
- Erin Slazak
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - Amy Shaver
- Department of Epidemiology and Environment Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY 14214, USA
| | - Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | | | - Merin Panthapattu
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | - William A Prescott
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
| | | | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY 14214, USA
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20
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Erickson SR, Kamdar N, Wu CH. Adverse Medication Events Related to Hospitalization in the United States: A Comparison Between Adults With Intellectual and Developmental Disabilities and Those Without. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2020; 125:37-48. [PMID: 31877264 DOI: 10.1352/1944-7558-125.1.37] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This study examined the proportion of hospitalizations associated with adverse medication events (AMEs) for adults with intellectual and developmental disabilities (IDD) and adults from the general population in the United States using the 2013 National Inpatient Sample (NIS) dataset of the Healthcare Cost and Utilization Project (HCUP). Adults with IDD had greater odds of having a hospitalization associated with an AME than the general adult population. Unadjusted odds ratios (95% CI) for hospitalization due to any medication for IDD was 2.47 (2.31-2.65). In the multivariate logistic regression model, IDD was significantly associated, with an odds ratio of 1.28 (1.19-1.38). Adults who have IDD are at greater risk of having a hospital admission due to an AME.
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Affiliation(s)
- Steven R Erickson
- Steven R. Erickson and Neil Kamdar, University of Michigan; and Chung-Hsuen Wu, Taipei Medical University, Taiwan
| | - Neil Kamdar
- Steven R. Erickson and Neil Kamdar, University of Michigan; and Chung-Hsuen Wu, Taipei Medical University, Taiwan
| | - Chung-Hsuen Wu
- Steven R. Erickson and Neil Kamdar, University of Michigan; and Chung-Hsuen Wu, Taipei Medical University, Taiwan
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21
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Considine J, Fox K, Plunkett D, Mecner M, O Reilly M, Darzins P. Factors associated with unplanned readmissions in a major Australian health service. AUST HEALTH REV 2019; 43:1-9. [PMID: 29092726 DOI: 10.1071/ah16287] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 09/28/2017] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to gain an understanding of the factors associated with unplanned hospital readmission within 28 days of acute care discharge from a major Australian health service. Methods A retrospective study of 20575 acute care discharges from 1 August to 31 December 2015 was conducted using administrative databases. Patient, index admission and readmission characteristics were evaluated for their association with unplanned readmission in ≤28 days. Results The unplanned readmission rate was 7.4% (n=1528) and 11.1% of readmitted patients were returned within 1 day. The factors associated with increased risk of unplanned readmission in ≤28 days for all patients were age ≥65 years (odds ratio (OR) 1.3), emergency index admission (OR 1.6), Charlson comorbidity index >1 (OR 1.1-1.9), the presence of chronic disease (OR 1.4) or complications (OR 1.8) during the index admission, index admission length of stay (LOS) >2 days (OR 1.4-1.8), hospital admission(s) (OR 1.7-10.86) or emergency department (ED) attendance(s) (OR 1.8-5.2) in the 6 months preceding the index admission and health service site (OR 1.2-1.6). However, the factors associated with increased risk of unplanned readmission ≤28 days changed with each patient group (adult medical, adult surgical, obstetric and paediatric). Conclusions There were specific patient and index admission characteristics associated with increased risk of unplanned readmission in ≤28 days; however, these characteristics varied between patient groups, highlighting the need for tailored interventions. What is known about the topic? Unplanned hospital readmissions within 28 days of hospital discharge are considered an indicator of quality and safety of health care. What does this paper add? The factors associated with increased risk of unplanned readmission in ≤28 days varied between patient groups, so a 'one size fits all approach' to reducing unplanned readmissions may not be effective. Older adult medical patients had the highest rate of unplanned readmissions and those with Charlson comorbidity index ≥4, an index admission LOS >2 days, left against advice and hospital admission(s) or ED attendance(s) in the 6 months preceding index admission and discharge from larger sites within the health service were at highest risk of unplanned readmission. What are the implications for practitioners? One in seven discharges resulted in an unplanned readmission in ≤28 days and one in 10 unplanned readmissions occurred within 1 day of discharge. Although some patient and hospital characteristics were associated with increased risk of unplanned readmission in ≤28 days, statistical modelling shows there are other factors affecting the risk of readmission that remain unknown and need further investigation. Future work related to preventing unplanned readmissions in ≤28 days should consider inclusion of health professional, system and social factors in risk assessments.
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Affiliation(s)
- Julie Considine
- Deakin University, Geelong: School of Nursing and Midwifery and Centre for Quality and Patient Safety, 1 Gheringhap St, Geelong, Vic. 3220, Australia
| | - Karen Fox
- Eastern Health, Box Hill, Vic. 3128, Australia. ;
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22
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Alves-Conceição V, Rocha KSS, Silva FVN, Silva RDOS, Cerqueira-Santos S, Nunes MAP, Martins-Filho PRS, da Silva DT, de Lyra DP. Are Clinical Outcomes Associated With Medication Regimen Complexity? A Systematic Review and Meta-analysis. Ann Pharmacother 2019; 54:301-313. [DOI: 10.1177/1060028019886846] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: Current evidence of the influence of the medication regimen complexity (MRC) on the patients’ clinical outcomes are not conclusive. Objective: To systematically and analytically assess the association between MRC measured by the Medication Regimen Complexity Index (MRCI) and clinical outcomes. Methods: A search was carried out in the databases Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science to identify studies evaluating the association between MRC and clinical outcomes that were published from January 1, 2004, to April 2, 2018. The search terms included outcome assessment, drug therapy, and medication regimen complexity index and their synonyms in different combinations for case-control and cohort studies that used the MRCI to measure MRC and related the MRCI with clinical outcomes. Odds ratios (ORs), hazard ratios (HRs), and mean differences (WMDs) were calculated, and heterogeneity was assessed using the I2 test. Results: A total of 12 studies met the eligibility criteria. The meta-analysis showed that MRC is associated with the following clinical outcomes: hospitalization (HR = 1.20; 95% CI = 1.14 to 1.27; I2 = 0%) in cohort studies, hospital readmissions (WMD = 7.72; 95% CI = 1.19 to 14.25; I2 = 84%) in case-control studies, and medication nonadherence (adjusted OR = 1.05; 95% CI = 1.02 to 1.07; I2 = 0%) in cohort studies. Conclusion and Relevance: This systematic review and meta-analysis gathered relevant scientific evidence and quantified the combined estimates to show the association of MRC with clinical outcomes: hospitalization, hospital readmission, and medication adherence.
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23
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Robinson R, Bhattarai M, Hudali T, Vogler C. Predictors of 30-day hospital readmission: The direct comparison of number of discharge medications to the HOSPITAL score and LACE index. Future Healthc J 2019; 6:209-214. [PMID: 31660528 DOI: 10.7861/fhj.2018-0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Effective hospital readmission risk prediction tools exist, but do not identify actionable items that could be modified to reduce the risk of readmission. Polypharmacy has attracted attention as a potentially modifiable risk factor for readmission, showing promise in a retrospective study. Polypharmacy is a very complex issue, reflecting comorbidities and healthcare resource utilisation patterns. This investigation compares the predictive ability of polypharmacy alone to the validated HOSPITAL score and LACE index readmission risk assessment tools for all adult admissions to an academic hospitalist service at a moderate sized university-affiliated hospital in the American Midwest over a 2-year period. These results indicate that the number of discharge medications alone is not a useful tool in identifying patients at high risk of hospital readmission within 30 days of discharge. Further research is needed to explore the impact of polypharmacy as a risk predictor for hospital readmission.
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Affiliation(s)
- Robert Robinson
- Southern Illinois University School of Medicine, Springfield, USA
| | - Mukul Bhattarai
- Southern Illinois University School of Medicine, Springfield, USA
| | - Tamer Hudali
- University of Alabama at Birmingham, Birmingham, USA
| | - Carrie Vogler
- Southern Illinois University Edwardsville School of Pharmacy, Edwardsville, USA and adjunct clinical assistant professor, Southern Illinois University School of Medicine, Springfield, USA
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24
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Physical Therapist Determination of Discharge Disposition in the Acute Care Setting. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2019. [DOI: 10.1097/jat.0000000000000099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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25
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Tesfaye WH, Peterson GM, Castelino RL, McKercher C, Jose M, Zaidi STR, Wimmer BC. Medication-Related Factors and Hospital Readmission in Older Adults with Chronic Kidney Disease. J Clin Med 2019; 8:jcm8030395. [PMID: 30901955 PMCID: PMC6462973 DOI: 10.3390/jcm8030395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 12/20/2022] Open
Abstract
This study aimed to examine the association between medication-related factors and risk of hospital readmission in older patients with chronic kidney disease (CKD). A retrospective analysis was conducted targeting older CKD (n = 204) patients admitted to an Australian hospital. Medication appropriateness (Medication Appropriateness Index; MAI), medication regimen complexity (number of medications and Medication Regimen Complexity Index; MRCI) and use of selected medication classes were exposure variables. Outcomes were occurrence of readmission within 30 and 90 days, and time to readmission within 90 days. Logistic and Cox hazards regression were used to identify factors associated with readmission. Overall, 50 patients (24%) were readmitted within 30 days, while 81 (40%) were readmitted within 90 days. Mean time to readmission within 90 days was 66 (SD 34) days. Medication appropriateness and regimen complexity were not independently associated with 30- or 90-day hospital readmissions in older adults with CKD, whereas use of renin‒angiotensin blockers was associated with reduced occurrence of 30-day (adjusted OR 0.39; 95% CI 0.19⁻0.79) and 90-day readmissions (adjusted OR 0.45; 95% CI 0.24⁻0.84) and longer time to readmission within 90 days (adjusted HR 0.52; 95% CI 0.33⁻0.83). This finding highlights the importance of considering the potential benefits of individual medications during medication review in older CKD patients.
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Affiliation(s)
- Wubshet H Tesfaye
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Sandy Bay, TAS 7005, Australia.
| | - Gregory M Peterson
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Sandy Bay, TAS 7005, Australia.
| | - Ronald L Castelino
- Sydney Nursing School, The University of Sydney, Sydney, NSW 2006, Australia.
| | - Charlotte McKercher
- Menzies Institute for Medical Research, University of Tasmania, Hobart 7005, Australia.
| | - Matthew Jose
- Menzies Institute for Medical Research, University of Tasmania, Hobart 7005, Australia.
- Royal Hobart Hospital, University of Tasmania, GPO Box-1061, Hobart 7000, Australia.
| | | | - Barbara C Wimmer
- Pharmacy, School of Medicine, College of Health and Medicine, University of Tasmania, Sandy Bay, TAS 7005, Australia.
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26
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Balodiya S, Kamath A. Evaluation of Hospital Discharge Prescriptions in the Elderly and Younger Adults Using the Medication Regimen Complexity Index. Curr Drug Saf 2018; 14:116-121. [PMID: 30523768 DOI: 10.2174/1574886314666181207105118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/20/2018] [Accepted: 12/03/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Advances in the clinical management of diseases have been accompanied by increasing complexity of treatment regimens. The complexity of medication regimen is of concern for patients as well as doctors as it may adversely affect patient compliance and treatment outcomes. It may result in medication errors, increased utilization of health resources owing to a reduction in treatment effectiveness, and increased risk of therapeutic failure. OBJECTIVE This study aimed to assess the complexity of medication regimen prescribed to patients on hospital discharge using the medication regimen complexity index (MRCI). METHODS A cross-sectional, descriptive study was conducted. Hospital discharge prescriptions written for patients discharged from the General Medicine wards of a tertiary care teaching hospital in South India were scored for their complexity using MRCI. The correlation of age and gender with the MRCI scores was also assessed. Patients ≥60 years of age were considered elderly. RESULTS The median MRCI score for 563 prescriptions studied was 14 (Interquartile range, 9-21). Elderly patients received a significantly more complex medication regimen compared with younger patients (p < 0.001) at the time of hospital discharge. Gender variation was seen with higher MRCI scores in females, but this was not statistically significant in the elderly group. CONCLUSION MRCI scores are significantly high in elderly patients at the time of hospital discharge. Although a strong correlation is seen between the number of medications and the MRCI score, the latter helps to distinguish regimen complexity between prescriptions with the same number of medications.
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Affiliation(s)
- Sujit Balodiya
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ashwin Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
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27
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Noh Y, Lee S, Shin S. Durability of initial antidiabetic monotherapy and subsequent treatment adjustment patterns among newly treated type 2 diabetes patients. Ther Clin Risk Manag 2018; 14:1563-1571. [PMID: 30233191 PMCID: PMC6130268 DOI: 10.2147/tcrm.s169964] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND As newly available antidiabetic drugs (ADs) are used more commonly as initial hypoglycemic choice for early stage diabetes patients, there is an urgent need to investigate how these agents may differ in treatment durability relative to metformin. This study aimed to investigate the incidence and risk of treatment adjustment among newly treated type 2 diabetes mellitus (T2DM) patients receiving an oral AD as initial monotherapy. METHODS T2DM patients registered in the National Health Insurance Program who were newly prescribed an oral AD were identified. Time to treatment addition or switch to alternative antidiabetic therapy was determined using the Kaplan-Meier survival analysis. Cox proportional hazards regression was performed to estimate the hazard ratio (HR) after adjusting for potential confounding factors. RESULTS The median time to treatment adjustment was shorter for sulfonylureas (SUs), dipeptidyl peptidase-4 (DPP-4) inhibitors, alphaglucosidase (AG) inhibitors, and thiazolidinediones (TZDs) compared to that for metformin. Initiation of therapy with SUs or DPP-4 inhibitors was associated with a significantly higher risk of both treatment addition and switching than with metformin (HR 1.49 versus 1.47 for overall treatment adjustment, respectively). In contrast, among incident users of AG inhibitors or TZDs, only the hazard of switch was substantially increased compared to metformin starters (6.19, 95% confidence interval [CI] 5.77-6.64 and 7.31, 95% CI 6.35-8.42, respectively). When addition and switch events were collectively assessed, the risk of treatment adjustment was significantly elevated in all non-metformin cohorts. CONCLUSION Our results demonstrated that the durability of metformin as an initial monotherapy was superior to that of other ADs, including newer classes of antidiabetics, and appeared to be more effective in delaying treatment adjustment in real-world clinical practice.
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Affiliation(s)
- Yoojin Noh
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Yeongtong-gu, Suwon, Republic of Korea,
| | - Sukhyang Lee
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Yeongtong-gu, Suwon, Republic of Korea,
- Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Yeongtong-gu, Suwon, Republic of Korea,
| | - Sooyoung Shin
- Department of Clinical Pharmacy, College of Pharmacy, Ajou University, Yeongtong-gu, Suwon, Republic of Korea,
- Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Yeongtong-gu, Suwon, Republic of Korea,
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28
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Lepelley M, Genty C, Lecoanet A, Allenet B, Bedouch P, Mallaret MR, Gillois P, Bosson JL. Electronic Medication Regimen Complexity Index at admission and complications during hospitalization in medical wards: a tool to improve quality of care? Int J Qual Health Care 2018; 30:32-38. [PMID: 29281061 DOI: 10.1093/intqhc/mzx168] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 11/29/2017] [Indexed: 11/12/2022] Open
Abstract
Objective Adverse events during hospitalization are a major worry considering their frequency and their burden. Many could be avoided by immediate identification of at-risk patients at admission and adapted prevention. The complexity of a patient's medication regimen immediately available at admission is a good indicator of the complexity of the patient's condition. This study aims to determine whether the electronic Medication Regimen Complexity Index (MRCI) at admission is associated with complications during hospitalization. Design We performed a multilevel logistic regression model, adjusted for age and sex. Setting Premier Perspective™ database, a clinical and financial information system from 417 US hospitals. Participants Adults hospitalized for more than 3 days in a medical ward and included in Premier's Perspective™ database for 2006. Intervention(s) Multilevel logistic regression. Main Outcome Measure Association of the MRCI and complications during hospitalization, defined as in-hospital death, hospital-acquired infection, pressure ulcers; and need for highly technical healthcare, identified as the secondary introduction of catecholamines. Results In total, 1 592 383 admissions were included. The median MRCI at admission was 13 [interquartile range: 9-19]. The higher the MRCI, the higher the adjusted odds ratio of the following: in-hospital mortality, hospital-acquired infections, pressure ulcers and the secondary introduction of catecholamines. Conclusions Our results suggested that the MRCI at admission was correlated with patient complexity, independent of age. Considering that patients with complex conditions pose a heavier workload for staff, measuring MRCI at admission could be used to allocate resources in medical wards at an institutional level. The MRCI might be a useful tool to assess the management of care.
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Affiliation(s)
- Marion Lepelley
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France
| | - Céline Genty
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France.,CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France
| | - André Lecoanet
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France
| | - Benoit Allenet
- CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France.,Pharmacy Department CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France
| | - Pierrick Bedouch
- CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France.,Pharmacy Department CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France
| | - Marie-Reine Mallaret
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France.,CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France
| | - Pierre Gillois
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France.,CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France
| | - Jean-Luc Bosson
- Public Health Department, CHU Grenoble Alpes, University of Grenoble Alpes, CS 10217, 38000 Grenoble, France.,CNRS, Public Health Department CHU Grenoble Alpes, Grenoble Institute of Engineering, University of Grenoble Alpes, TIMC-IMAG, CS 10217, 38000 Grenoble, France
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29
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Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review. Drugs Aging 2018; 35:43-60. [PMID: 29350335 DOI: 10.1007/s40266-018-0516-8] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice. OBJECTIVES The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity). METHODS A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting. RESULTS After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%). CONCLUSION The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.
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Affiliation(s)
- Nashwa Masnoon
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia.
- Department of Pharmacy, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia.
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
| | - Lisa Kalisch-Ellett
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
| | - Gillian E Caughey
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, SA, Australia
- Department of Clinical Pharmacology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, Australia
- Discipline of Pharmacology, School of Medicine, University of Adelaide, North Terrace, Adelaide, SA, Australia
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30
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Tesfaye WH, Peterson GM, Castelino RL, McKercher C, Jose MD, Wimmer BC, Zaidi STR. Medication Regimen Complexity and Hospital Readmission in Older Adults With Chronic Kidney Disease. Ann Pharmacother 2018; 53:28-34. [PMID: 30070583 DOI: 10.1177/1060028018793419] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is characterized by high rates of hospital admissions and readmissions. However, there is a scarcity of research into medication-related factors predicting such outcomes in this patient group. OBJECTIVE To evaluate the effect of medication regimen complexity at hospital discharge on subsequent readmissions and their timing in older adults with CKD. METHODS This was a 12-month retrospective cohort study of 204 older (⩾65 years) CKD patients in an Australian tertiary care hospital. Medication regimen complexity was quantified using the 65-item medication regimen complexity index (MRCI). The outcomes were the occurrence of readmission in 30 days and time to readmission within 12 months. Logistic regression was used to identify factors predicting 30-day readmission, and a competing risks proportional subdistribution hazard model, accounting for deaths, was used for factors predicting time to readmission. RESULTS Overall, 50 (24%) patients, predominantly men (72%), were readmitted within 30 days of follow-up. MRCI was not significantly associated with 30-day readmission (odds ratio [OR] = 1.27; 95% CI = 0.94-1.73). The median (interquartile range) time to readmission within 12 months was 145 (31-365) days. On a multivariate analysis, a 10-unit increase in MRCI was associated with a shorter time to readmission within 12 months (subdistribution HR = 1.18; 95% CI = 1.01-1.36). Conclusion and Relevance: Medication regimen complexity was not significantly associated with 30-day readmission; however, it was associated with a significantly shorter time to 12-month readmission in older CKD patients. This finding highlights the importance of medication regimen complexity as a potential target for medical interventions to reduce readmission risks.
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Affiliation(s)
| | | | | | | | - Matthew D Jose
- 3 Menzies Institute for Medical Research, Hobart, Tasmania, Australia
- 4 Royal Hobart Hospital, Tasmania, Australia
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31
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Alves-Conceição V, Rocha KSS, Silva FVN, Silva ROS, Silva DTD, Lyra-Jr DPD. Medication Regimen Complexity Measured by MRCI: A Systematic Review to Identify Health Outcomes. Ann Pharmacother 2018; 52:1117-1134. [DOI: 10.1177/1060028018773691] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Objective: To perform a systematic review to identify health outcomes related to medication regimen complexity as measured by the Medication Regimen Complexity Index (MRCI) instrument. Data Sources: Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science were searched from January 1, 2004, until April 02, 2018, using the following search terms: outcome assessment, drug therapy, and Medication Regimen Complexity Index and their synonyms in different combinations. Study Selection and Data Extraction: Studies that used the MRCI instrument to measure medication regimen complexity and related it to clinical, humanistic, and/or economic outcomes were evaluated. Two reviewers independently carried out the analysis of the titles, abstracts, and complete texts according to the eligibility criteria, performed data extraction, and evaluated study quality. Data Synthesis: A total of 23 studies met the inclusion criteria; 18 health outcomes related to medication regimen complexity were found. The health outcomes most influenced by medication regimen complexity were hospital readmission, medication adherence, hospitalization, adverse drug events, and emergency sector visit. Only one study related medication regimen complexity with humanistic outcomes, and no study related medication regimen complexity to economic outcomes. Most of the studies were of good methodological quality. Relevance to Patient Care and Clinical Practice: Health care professionals should pay attention to medication regimen complexity of the patients because this may influence health outcomes. Conclusion: This study identified some health outcomes that may be influenced by medication regimen complexity: hospitalization, hospital readmission, and medication adherence were more prevalent, showing a significant association between MRCI increase and these health outcomes.
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32
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Foot H, Freeman C, Hemming K, Scott I, Coombes ID, Williams ID, Connelly L, Whitty JA, Sturman N, Kirsa S, Nicholson C, Russell G, Kirkpatrick C, Cottrell N. Reducing Medical Admissions into Hospital through Optimising Medicines (REMAIN HOME) Study: protocol for a stepped-wedge, cluster-randomised trial. BMJ Open 2017; 7:e015301. [PMID: 28408545 PMCID: PMC5719661 DOI: 10.1136/bmjopen-2016-015301] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION A model of general practitioner (GP) and pharmacist collaboration in primary care may be an effective strategy to reduce medication-related problems and provide better support to patients after discharge. The aim of this study is to investigate whether a model of structured pharmacist and GP care reduces hospital readmissions in high-risk patients. METHODS AND ANALYSIS This protocol details a stepped-wedge, cluster-randomised trial that will recruit participants over 9 months with a 12-month follow-up. There will be 14 clusters each representing a different general practice medical centre. A total of 2240 participants will be recruited from hospital who attend an enrolled medical centre, take five or more long-term medicines or whose reason for admission was related to heart failure or chronic obstructive pulmonary disease.The intervention is a multifaceted service, involving a pharmacist integrated into a medical centre to assist patients after hospitalisation. Participants will meet with the practice pharmacist and their GP after discharge to review and reconcile their medicines and discuss changes made in hospital. The pharmacist will follow-up with the participant and liaise with other health professionals involved in the participant's care. The control will be usual care, which usually involves a patient self-organising a visit to their GP after hospital discharge.The primary outcome is the rate of unplanned, all-cause hospital readmissions over 12 months, which will be analysed using a mixed effects Poisson regression model with a random effect for cluster and a fixed effect to account for any temporal trend. A cost analysis will be undertaken to compare the healthcare costs associated with the intervention to those of usual care. ETHICS AND DISSEMINATION The study has received ethical approval (HREC/16/QRBW/410). The study findings will be disseminated through peer-reviewed publications, conferences and reports to key stakeholders. TRIAL REGISTRATION NUMBER ACTRN12616001627448.
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Affiliation(s)
- Holly Foot
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Christopher Freeman
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Karla Hemming
- Department of Public Health, Epidemiology and Biostatistics, University of Birmingham, Birmingham, UK
| | - Ian Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Southern School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Ian D Coombes
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Department of Pharmacy, Royal Brisbane and Women's Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Ian D Williams
- Brisbane South PHN, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Luke Connelly
- Centre for the Business and Economics of Health, University of Queensland, Brisbane, Queensland, Australia
- Poche Centre for Indigenous Health, University of Queensland, Brisbane, Queensland, Australia
| | - Jennifer A Whitty
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Faculty of Medicine and Health Sciences, University of East Anglia Norwich Medical School, Norwich, UK
| | - Nancy Sturman
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Sue Kirsa
- Department of Pharmacy, Monash Health, Clayton, Victoria, Australia
- Centre for Medicine Use and Safety, Monash University Faculty of Pharmacy and Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Caroline Nicholson
- Mater Misericordiae Health Services Brisbane Ltd, South Brisbane, Queensland, Australia
| | - Grant Russell
- School of Primary Health Care, Monash University, Notting Hill, Victoria, Australia
| | - Carl Kirkpatrick
- Centre for Medicine Use and Safety, Monash University Faculty of Pharmacy and Pharmaceutical Sciences, Parkville, Victoria, Australia
| | - Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
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Cobretti MR, Page RL, Linnebur SA, Deininger KM, Ambardekar AV, Lindenfeld J, Aquilante CL. Medication regimen complexity in ambulatory older adults with heart failure. Clin Interv Aging 2017; 12:679-686. [PMID: 28442898 PMCID: PMC5396835 DOI: 10.2147/cia.s130832] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM). PATIENTS AND METHODS Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool. RESULTS The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications. CONCLUSION Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.
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Affiliation(s)
| | - Robert L Page
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | - Sunny A Linnebur
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Aurora, CO
| | | | - Amrut V Ambardekar
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO
| | - JoAnn Lindenfeld
- Advanced Heart Failure and Cardiac Transplant Program, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
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Dorajoo SR, See V, Chan CT, Tan JZ, Tan DSY, Abdul Razak SMB, Ong TT, Koomanan N, Yap CW, Chan A. Identifying Potentially Avoidable Readmissions: A Medication-Based 15-Day Readmission Risk Stratification Algorithm. Pharmacotherapy 2017; 37:268-277. [PMID: 28052412 DOI: 10.1002/phar.1896] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Stratifying patients according to 15-day readmission risk would be useful in identifying those who may benefit from targeted interventions during and/or following hospital discharge that are designed to reduce the likelihood of readmission. METHODS A prediction model was derived via a case-control analysis of patients discharged from a tertiary hospital in Singapore using multivariate logistic regression. The model was validated in two independent external cohorts separated temporally and geographically. Model discrimination was assessed using the C-statistic, while calibration was assessed using the Hosmer-Lemeshow χ2 and the Brier score statistics. RESULTS A total of 1291 patients were included with 670, 101, and 520 patients in the derivation, temporal, and geographical validation cohorts, respectively. Age (odds ratio [OR] 1.02, 95% confidence interval [CI] 1.01-1.03, p=0.008), anemia (OR 2.08, 95% CI 1.15-8.05, p=0.015), malignancy (OR 3.37, 95% CI 1.16-9.80, p=0.026), peptic ulcer disease (OR 3.05, 95% CI 1.12-8.26, p=0.029), chronic obstructive pulmonary disease (OR 3.16, 95% CI 1.24-8.05, p=0.016), number of discharge medications (OR 1.06, 95% CI 1.01-1.12, p=0.026), discharge to nursing homes (OR 3.57, 95% CI 1.57-8.34, p=0.003), and premature discharge against medical advice (OR 5.05, 95% CI 1.20-21.23, p=0.027) were independent predictors of 15-day readmission risk. The model demonstrated reasonable discrimination on the temporal and geographical validation cohorts with a C-statistic of 0.65 and 0.64, respectively. Model miscalibration was observed in both validation cohorts. CONCLUSION A 15-day readmission risk prediction model is proposed and externally validated. The model facilitates the targeting of interventions for patients who are at high risk of an early readmission.
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Affiliation(s)
| | - Vincent See
- Department of Pharmacy, National University of Singapore, Singapore
| | - Chen Teng Chan
- Department of Pharmacy, National University of Singapore, Singapore
| | - Joyce Zhenyin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital Singapore, Singapore
| | - Doreen Su Yin Tan
- Department of Pharmacy, Khoo Teck Puat Hospital Singapore, Singapore
| | | | - Ting Ting Ong
- Department of Pharmacy, Singapore General Hospital, Singapore
| | | | - Chun Wei Yap
- Department of Pharmacy, National University of Singapore, Singapore
| | - Alexandre Chan
- Department of Pharmacy, National University of Singapore, Singapore
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Wimmer BC, Cross AJ, Jokanovic N, Wiese MD, George J, Johnell K, Diug B, Bell JS. Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review. J Am Geriatr Soc 2016; 65:747-753. [PMID: 27991653 DOI: 10.1111/jgs.14682] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVES To systematically review clinical outcomes associated with medication regimen complexity in older people. DESIGN Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library. SETTING Hospitals, home, and long-term care. PARTICIPANTS English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity. MEASUREMENTS Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool. RESULTS Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff. CONCLUSION Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.
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Affiliation(s)
- Barbara C Wimmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Amanda J Cross
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Natali Jokanovic
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael D Wiese
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Kristina Johnell
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Basia Diug
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia.,Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia.,Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Li H, Guffey W, Honeycutt L, Pasquale T, Rozario NL, Veverka A. Incorporating a Pharmacist Into the Discharge Process: A Unit-Based Transitions of Care Pilot. Hosp Pharm 2016; 51:744-751. [PMID: 27803504 DOI: 10.1310/hpj5109-744] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To evaluate the impact of a multifaceted, pharmacy-driven, unit-based transitions of care (TOC) program on all-cause 30-day readmission rates and to assess readmission rates in predefined subgroup patient populations. Methods: This prospective study included adult patients who were discharged from the pilot unit from January 5 to January 30, 2015. Patients who expired during hospitalization, left the hospital against medical advice, or transferred to another unit or nonaffiliated hospital were excluded. Possible pharmacist interventions included daily medication profile review, delivery of discharge medications to the bedside, counseling, and communication of a discharge medication list to follow-up providers. Patients had a 30-day follow-up period from the date of discharge to assess for readmission. Results: A total of 131 patients were screened and 94 patients were included. The primary outcome evaluating 30-day readmission rates occurred in 12.8% of patients in the pilot group versus 18.8% of patients in the historical control group (p = .26). None of the patients who received all possible pharmacist interventions were readmitted. Secondary outcomes assessing readmission rates in predefined subgroup populations as well as length of stay were comparable between the 2 groups. All identified medication discrepancies were resolved prior to discharge. Conclusion: Readmission rates during the pilot were numerically lower but not statistically significant when compared with historical data. Enhancement of the pharmacy-driven TOC services through allocation of additional resources is in progress. Further investigation is warranted to determine the impact of a TOC pharmacist after the service is sustained.
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Lalic S, Sluggett JK, Ilomäki J, Wimmer BC, Tan EC, Robson L, Emery T, Bell JS. Polypharmacy and Medication Regimen Complexity as Risk Factors for Hospitalization Among Residents of Long-Term Care Facilities: A Prospective Cohort Study. J Am Med Dir Assoc 2016; 17:1067.e1-1067.e6. [DOI: 10.1016/j.jamda.2016.08.019] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 12/01/2022]
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Okuyan B, Babi B, Sancar M, Ay P, Yücel E, Yücel A, Izzettin FV. Validation of the Turkish version of medication regimen complexity index among elderly patients. J Eval Clin Pract 2016; 22:732-6. [PMID: 26987572 DOI: 10.1111/jep.12526] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 02/01/2016] [Accepted: 02/01/2016] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The aim of this study was to validate the Turkish version of the 'Medication Regimen Complexity Index' (MRCI). METHODS This validation study has been conducted in prescriptions of the first 100 elderly patients who had visited the pharmacy for their prescription refill to evaluate convergent and divergent validity of the Turkish version. The reliability of the Turkish version was assessed with inter-rater and test-retest analysis after its translation and cultural adaptation. RESULTS The mean age of the 100 patients (53 women) was 74.9 years (SD = 7.58, 65-95). The scale showed high inter-rater reliability and test-retest reliability for the total and subscale scores (p < 0.05). A strong and positive correlation between the number of medications in a prescription and the total Medication Regimen Complexity Index scores (r = 0.930, p < 0.001) was determined. There were no statistically significant differences between age, gender and MRCI scores (p > 0.05). CONCLUSION These results show that the Turkish version of MRCI is a reliable and valid tool in elderly patients.
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Affiliation(s)
- Betul Okuyan
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey.
| | - Bedis Babi
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
| | - Mesut Sancar
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
| | - Pınar Ay
- Department of Public Health, Marmara University Faculty of Medicine, Istanbul, Turkey
| | - Emre Yücel
- Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, Houston, TX, USA
| | - Aylin Yücel
- Pharmaceutical Health Outcomes and Policy, College of Pharmacy, University of Houston, USA
| | - Fikret Vehbi Izzettin
- Clinical Pharmacy Department, Marmara University, Faculty of Pharmacy, Istanbul, Turkey
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Abou-Karam N, Bradford C, Lor KB, Barnett M, Ha M, Rizos A. Medication regimen complexity and readmissions after hospitalization for heart failure, acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease. SAGE Open Med 2016; 4:2050312116632426. [PMID: 26985392 PMCID: PMC4778087 DOI: 10.1177/2050312116632426] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 01/13/2016] [Indexed: 01/24/2023] Open
Abstract
Objectives: Readmission rate is increasingly being viewed as a key indicator of health system performance. Medication regimen complexity index scores may be predictive of readmissions; however, few studies have examined this potential association. The primary objective of this study was to determine whether medication regimen complexity index is associated with all-cause 30-day readmission after admission for heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Methods: This study was an institutional review board–approved, multi-center, case–control study. Patients admitted with a primary diagnosis of heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease were randomly selected for inclusion. Patients were excluded if they discharged against medical advice or expired during their index visit. Block randomization was utilized for equal representation of index diagnosis and site. Discharge medication regimen complexity index scores were compared between subjects with readmission versus those without. Medication regimen complexity index score was then used as a predictor in logistic regression modeling for readmission. Results: Seven hundred and fifty-six patients were randomly selected for inclusion, and 101 (13.4%) readmitted within 30 days. The readmission group had higher medication regimen complexity index scores than the no-readmission group (p < 0.01). However, after controlling for demographics, disease state, length of stay, site, and medication count, medication regimen complexity index was no longer a significant predictor of readmission (odds ratio 0.99, 95% confidence interval 0.97–1.01) or revisit (odds ratio 0.99, 95% confidence interval 0.98–1.02). Conclusion: There is little evidence to support the use of medication regimen complexity index in readmission prediction when other measures are available. Medication regimen complexity index may lack sufficient sensitivity to capture an effect of medication regimen complexity on all-cause readmission.
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Affiliation(s)
- Nada Abou-Karam
- Department of Pharmacy Services, Sharp Memorial Hospital, San Diego, CA, USA; Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA
| | - Chad Bradford
- Department of Pharmacy Services, Sharp Memorial Hospital, San Diego, CA, USA; Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA
| | - Kajua B Lor
- Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA
| | - Mitchell Barnett
- Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA
| | - Michelle Ha
- College of Pharmacy, Western University of Health Sciences, Pomona, CA, USA
| | - Albert Rizos
- System Pharmacy Services, Sharp Healthcare, San Diego, CA, USA
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McKean M, Pillans P, Scott IA. A medication review and deprescribing method for hospitalised older patients receiving multiple medications. Intern Med J 2016; 46:35-42. [DOI: 10.1111/imj.12906] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 09/02/2015] [Accepted: 09/03/2015] [Indexed: 12/20/2022]
Affiliation(s)
- M. McKean
- Advanced Trainee General Medicine; Ipswich Hospital; Ipswich
| | - P. Pillans
- Clinical Pharmacology, Princess Alexandra Hospital; Harlow UK
| | - I. A. Scott
- Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital
- School of Medicine; University of Queensland; Brisbane Australia
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Wimmer BC, Bell JS, Fastbom J, Wiese MD, Johnell K. Medication Regimen Complexity and Number of Medications as Factors Associated With Unplanned Hospitalizations in Older People: A Population-based Cohort Study. J Gerontol A Biol Sci Med Sci 2015; 71:831-7. [PMID: 26707381 PMCID: PMC4888392 DOI: 10.1093/gerona/glv219] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 11/07/2015] [Indexed: 11/14/2022] Open
Abstract
Background: Adverse drug events are a leading cause of hospitalization among older people. Up to half of all medication-related hospitalizations are potentially preventable. The objective of this study was to investigate and compare the association between medication regimen complexity and number of medications with unplanned hospitalizations over a 3-year period. Methods: Data were analyzed for 3,348 participants aged 60 years or older in Sweden. Regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) and number of medications was assessed as a continuous variable. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios with 95% confidence intervals (CIs) for associations between regimen complexity and number of medications with unplanned hospitalizations over a 3-year period. Receiver operating characteristics curves with corresponding areas under the curve were calculated for regimen complexity and number of medications in relation to unplanned hospitalizations. The population attributable fraction of unplanned hospitalizations was calculated for MRCI and number of medications. Results: In total, 1,125 participants (33.6%) had one or more unplanned hospitalizations. Regimen complexity (hazard ratio 1.22; 95% CI 1.14–1.34) and number of medications (hazard ratio 1.07; 95% CI 1.04–1.09) were both associated with unplanned hospitalizations and had similar sensitivity and specificity (area under the curve 0.641 for regimen complexity and area under the curve 0.644 for number of medications). The population attributable fraction was 14.08% (95% CI 9.62–18.33) for MRCI and 17.61% (95% CI 12.59–22.35) for number of medications. Conclusions: There was no evidence that using a complex tool to assess regimen complexity was better at predicting unplanned hospitalization than number of medications.
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Affiliation(s)
- Barbara Caecilia Wimmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia.
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia. Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Johan Fastbom
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Sweden
| | - Michael David Wiese
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide
| | - Kristina Johnell
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Sweden
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Wimmer BC, Bell JS, Fastbom J, Wiese MD, Johnell K. Medication Regimen Complexity and Polypharmacy as Factors Associated With All-Cause Mortality in Older People: A Population-Based Cohort Study. Ann Pharmacother 2015; 50:89-95. [PMID: 26681444 PMCID: PMC4714103 DOI: 10.1177/1060028015621071] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To investigate whether medication regimen complexity and/or polypharmacy are associated with all-cause mortality in older people. Methods: This was a population-based cohort study among community-dwelling and institutionalized people ≥60 years old (n = 3348). Medication regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) in 10-unit steps. Polypharmacy was assessed as a continuous variable (number of medications). Mortality data were obtained from the Swedish National Cause of Death Register. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% CIs for the association between regimen complexity and polypharmacy with all-cause mortality over a 3-year period. Subanalyses were performed stratifying by age (≤80 and>80 years), sex, and cognition (Mini-Mental State Examination [MMSE] <26 and ≥26). Results: During follow-up, 14% of the participants (n = 470) died. After adjusting for age, sex, comorbidity, educational level, activities of daily living, MMSE, and residential setting, a higher MRCI was associated with mortality (adjusted HR = 1.12; 95% CI = 1.01-1.25). Polypharmacy was not associated with mortality (adjusted HR = 1.03; 95% CI = 0.99-1.06). When stratifying by sex, both MRCI and polypharmacy were associated with mortality in men but not in women. MRCI was associated with mortality in participants ≤80 years old and in participants with MMSE ≥26 but not in participants >80 years old or with MMSE <26. Conclusion: Regimen complexity was a better overall predictor of mortality than polypharmacy. However, regimen complexity was not predictive of mortality in women, in participants >80 years old, or in those with MMSE<26. These different associations with mortality deserve further investigation.
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Affiliation(s)
- Barbara C Wimmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Johan Fastbom
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Michael D Wiese
- Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Kristina Johnell
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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Ferreira JM, Galato D, Melo AC. Medication regimen complexity in adults and the elderly in a primary healthcare setting: determination of high and low complexities. Pharm Pract (Granada) 2015; 13:659. [PMID: 26759621 PMCID: PMC4696124 DOI: 10.18549/pharmpract.2015.04.659] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 12/02/2015] [Indexed: 11/25/2022] Open
Abstract
Background: The complexity of a medication regimen is related to the multiple characteristics of the prescribed regimen and can negatively influence the health outcomes of patients. Objective: To propose cut-off points in the complexity of pharmacotherapy to distinguish between patients with low and high complexities seen in a primary health care (PHC) setting to enable prioritization of patient management. Methods: This is a cross-sectional study, which included 517 adult and elderly patients, analyzing different cut-off points to define the strata of low and high pharmacotherapy complexities based on percentiles of the population evaluated. Data collection began with the solicitation of prescriptions, followed by a questionnaire that was administered by an interviewer. The complexity of a medication regimen was estimated from the Medication Regimen Complexity Index (MRCI). High complexity pharmacotherapy scores were analyzed from patient profiles, the use of health services, and pharmacotherapy. The criteria for subject inclusion in the sample population were as follows: inhabitant of the area covered by the municipality, 18 years or older, and being prescribed at least one drug during the collection period. Exclusion criteria at the time of collection were the use of any medication whose prescription was not available. All medications were accessed through the Primary Healthcare Service (PHS). Results: The median total pharmacotherapy complexity score was 8.5. High MRCI scores were correlated with age, medications taken with in the Brazilian PHS, having at least one potential drug-related problem, receiving up to eight years of schooling, number of medications and polypharmacy (five or more medicines), number of medical conditions, number of medical appointments, and number of cardiovascular diseases and endocrine metabolic diseases. We suggest different complexity tracks according to age (e.g., adult or elderly) that consider the pharmacotherapy and population coverage characteristics as high complexity limits. For the elderly patients, the tracks were as follows: MRCI≥25.4, MRCI≥20.9, MRCI≥17.5, MRCI≥15.7, MRCI≥14.0, and MRCI≥13.0. For adult patients, the limits of high complexity were MRCI≥25.1; MRCI ≥ 23.8; MRCI≥21.0; MRCI≥17.0; MRCI≥16.5; and MRCI≥15.5. Conclusion: The medication regimen complexity is associated with the patient’s illness profile and problems with the use of drugs; therefore, the proposed scores can be useful in prioritizing patients for clinical care by pharmacists and other health professionals.
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Affiliation(s)
- Juliana M Ferreira
- Pharmacy Department, Federal University São João Del-Rei . Divinópolis, MG ( Brasil ).
| | - Dayani Galato
- Pharmacy Department, University of Brasilia . Brasilia ( Brazil ).
| | - Angelita C Melo
- Pharmacy Department, Federal University São João Del-Rei . Divinópolis, MG ( Brasil ).
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Garfinkel D, Ilhan B, Bahat G. Routine deprescribing of chronic medications to combat polypharmacy. Ther Adv Drug Saf 2015; 6:212-33. [PMID: 26668713 DOI: 10.1177/2042098615613984] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.
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Affiliation(s)
- Doron Garfinkel
- Home Care Hospice, Israel Cancer Association, 55 Ben Gurion Road, Bat, Yam, Israel 5932210
| | - Birkan Ilhan
- Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul Medical School, Istanbul, Turkey
| | - Gulistan Bahat
- Department of Internal Medicine, Division of Geriatrics, Istanbul University, Istanbul Medical School, Istanbul, Turkey
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Factors associated with medication regimen complexity in residents of long-term care facilities. Eur Geriatr Med 2015. [DOI: 10.1016/j.eurger.2015.10.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Craftman ÅG, Johnell K, Fastbom J, Westerbotn M, von Strauss E. Time trends in 20 years of medication use in older adults: Findings from three elderly cohorts in Stockholm, Sweden. Arch Gerontol Geriatr 2015; 63:28-35. [PMID: 26791168 DOI: 10.1016/j.archger.2015.11.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 11/15/2015] [Accepted: 11/17/2015] [Indexed: 11/28/2022]
Abstract
UNLABELLED New drugs and expanded drug indications are constantly being introduced. Welfare states strive to provide equity in drug treatment for all of its citizens and todaýs healthcare systems spend financial resources on drugs for the elderly in a higher rate than for any other age group. Drug utilization in elderly persons has an impact in health and wellbeing in older people. THE PURPOSE OF THE RESEARCH It was to describe the changes in medication use including people aged 78 years and over regardless of residence and other characteristics over 20 years. MATERIALS AND METHODS The study population consisted of 4304 participants in three population-based cross-sectional surveys conducted in the Kungsholmen area of central Stockholm, Sweden. The participant's current drug utilization was reviewed by physicians following standardized protocols. Data were statistical analyzed. Logistic regression models was used to estimate odds ratios and 95% confidence intervals for use of analgesics and psychotropic drugs in the cohorts of 2001 and 2007, controlling for age, gender, education and cognition. THE PRINCIPAL RESULTS AND MAJOR CONCLUSIONS Results shows that the prevalence of medication use and polypharmacy in older adults has increased dramatically the late 1980s to the 2000s in central Stockholm, Sweden. In particular, the use of analgesics increased significantly, while some drug groups decreased, i.e., antipsychotics. Women used more medication than men in all three cohorts. Older adults living in service buildings used the largest amount of drugs in 1987, whereas those living in institutions were the most frequent users in 2001 and 2007.
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Affiliation(s)
- Åsa Gransjön Craftman
- Sophiahemmet University, Aging Research Center (ARC), Karolinska Institutet, Box 5605, SE-114 86 Stockholm, Sweden.
| | - Kristina Johnell
- Aging Research Center (ARC), Karolinska Institutet, Gävlegatan 16, SE-113 30 Stockholm, Sweden.
| | - Johan Fastbom
- Aging Research Center (ARC), Karolinska Institutet, Gävlegatan 16, SE-113 30 Stockholm, Sweden.
| | - Margareta Westerbotn
- Department of Research, Education, Development and Innovation, Education Center, SÖS.
| | - Eva von Strauss
- Aging Research Center (ARC), Karolinska Institutet, The Swedish Red Cross University College, Teknikringen 1, SE-114 28 Stockholm, Sweden.
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Yam FK, Lew T, Eraly SA, Lin HW, Hirsch JD, Devor M. Changes in medication regimen complexity and the risk for 90-day hospital readmission and/or emergency department visits in U.S. Veterans with heart failure. Res Social Adm Pharm 2015; 12:713-21. [PMID: 26621388 DOI: 10.1016/j.sapharm.2015.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/16/2015] [Accepted: 10/16/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Heart failure (HF) hospitalization is associated with multiple medication modifications. These modifications often increase medication regimen complexity and may increase the risk of readmission and/or emergency department (ED) visit. OBJECTIVES To determine the association between changes in medication regimen complexity (MRC) during hospitalization of patients with heart failure and the risk of readmission or ED visit at 90 days. Secondary objectives include examining the association between changes in MRC and time to readmission as well as the relationship between number of medications and MRC. METHODS This was a retrospective cohort study that included U.S. Veterans hospitalized with heart failure. MRC was quantified using the medication regimen complexity index (MRCI). The change in MRCI was the difference between admission MRCI and discharge MRCI recorded during the index hospitalization. Demographic and clinical data were collected to characterize the study population. Patient data for up to one year after discharge was recorded to identify hospital readmissions and ED visits. RESULTS A total of 174 patients were included in the analysis. Sixty-two patients (36%) were readmitted or had an ED visit at 90 days from the index hospitalization. The mean change (SD) in MRCI during the index hospitalization among the cohort was 4.7 (8.3). After multivariate logistic regression analysis, each unit increase in MRCI score was associated with a 4% lower odds of readmission or ED visit at 90 days but this finding was not statistically significant (OR 0.955; 95% CI 0.911-1.001). In the cox proportional hazard model, the median time to hospital readmission or ED visit was 214 days. Each unit increase in MRCI score was associated with a modest but non-significant increase in probability of survival from readmission or ED visit (HR 0.978; 95% CI 0.955, 1.001). CONCLUSION Changes in medication regimen complexity that occur during hospitalization may also be associated with optimization of medical therapy and do not necessarily portend worse outcomes in patients with HF.
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Affiliation(s)
- Felix K Yam
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, MC 0764, La Jolla, CA 92093, USA; VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA.
| | - Tiffany Lew
- San Francisco VA Medical Center, 4150 Clement Street (119), San Francisco, CA 94121, USA
| | - Satish A Eraly
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Hsiang-Wen Lin
- China Medical University, College of Pharmacy, No. 91 Hsueh-Shih Road, Taichung 40402, Taiwan, ROC
| | - Jan D Hirsch
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, 9500 Gilman Drive, MC 0714, La Jolla, CA 92093, USA
| | - Michelle Devor
- VA San Diego Healthcare System, 3350 La Jolla Village Dr., San Diego, CA, USA; UC San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
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Picker D, Heard K, Bailey TC, Martin NR, LaRossa GN, Kollef MH. The number of discharge medications predicts thirty-day hospital readmission: a cohort study. BMC Health Serv Res 2015; 15:282. [PMID: 26202163 PMCID: PMC4512093 DOI: 10.1186/s12913-015-0950-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Accepted: 07/14/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hospital readmission occurs often and is difficult to predict. Polypharmacy has been identified as a potential risk factor for hospital readmission. However, the overall impact of the number of discharge medications on hospital readmission is still undefined. METHODS To determine whether the number of discharge medications is predictive of thirty-day readmission using a retrospective cohort study design performed at Barnes-Jewish Hospital from January 15, 2013 to May 9, 2013. The primary outcome assessed was thirty-day hospital readmission. We also assessed potential predictors of thirty-day readmission to include the number of discharge medications. RESULTS The final cohort had 5507 patients of which 1147 (20.8 %) were readmitted within thirty days of their hospital discharge date. The number of discharge medications was significantly greater for patients having a thirty-day readmission compared to those without a thirty-day readmission (7.2 ± 4.1 medications [7.0 medications (4.0 medications, 10.0 medications)] versus 6.0 ± 3.9 medications [6.0 medications (3.0 medications, 9.0 medications)]; P < 0.001). There was a statistically significant association between increasing numbers of discharge medications and the prevalence of thirty-day hospital readmission (P < 0.001). Multiple logistic regression identified more than six discharge medications to be independently associated with thirty-day readmission (OR, 1.26; 95 % CI, 1.17-1.36; P = 0.003). Other independent predictors of thirty-day readmission were: more than one emergency department visit in the previous six months, a minimum hemoglobin value less than or equal to 9 g/dL, presence of congestive heart failure, peripheral vascular disease, cirrhosis, and metastatic cancer. A risk score for thirty-day readmission derived from the logistic regression model had good predictive accuracy (AUROC = 0.661 [95 % CI, 0.643-0.679]). CONCLUSIONS The number of discharge medications is associated with the prevalence of thirty-day hospital readmission. A risk score, that includes the number of discharge medications, accurately predicts patients at risk for thirty-day readmission. Our findings suggest that relatively simple and accessible parameters can identify patients at high risk for hospital readmission potentially distinguishing such individuals for interventions to minimize readmissions.
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Affiliation(s)
- David Picker
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8052, St. Louis, MO, 63110, USA.
| | - Kevin Heard
- Center for Clinical Excellence, BJC Learning Institute (BLI), 8300 Eager Road, St. Louis, MO, 63144, USA.
| | - Thomas C Bailey
- Division of Infectious Diseases, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8051, St. Louis, MO, 63110, USA.
| | - Nathan R Martin
- Division of Hospital Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8058, St. Louis, MO, 63110, USA.
| | - Gina N LaRossa
- Division of Hospital Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8058, St. Louis, MO, 63110, USA.
| | - Marin H Kollef
- Division of Pulmonary & Critical Care Medicine, Washington University School of Medicine, 660 South Euclid Ave., Campus Box 8052, St. Louis, MO, 63110, USA.
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Wimmer BC, Johnell K, Fastbom J, Wiese MD, Bell JS. Factors associated with medication regimen complexity in older people: a cross-sectional population-based study. Eur J Clin Pharmacol 2015; 71:1099-108. [PMID: 26071278 DOI: 10.1007/s00228-015-1883-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/02/2015] [Indexed: 01/17/2023]
Abstract
PURPOSE There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications. METHODS This cross-sectional population-based study included 3348 people aged ≥ 60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications. RESULTS In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI > 0-5.5). Similar factors were associated with both regimen complexity and number of medications. CONCLUSION Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person's number of medications to target interventions to reduce complexity.
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Affiliation(s)
- Barbara Caecilia Wimmer
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia,
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Olson CH, Dierich M, Adam T, Westra BL. Optimization of decision support tool using medication regimens to assess rehospitalization risks. Appl Clin Inform 2014; 5:773-88. [PMID: 25298816 DOI: 10.4338/aci-2014-04-ra-0040] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/16/2014] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Unnecessary hospital readmissions are costly for the U.S. health care system. An automated algorithm was developed to target this problem and proven to predict elderly patients at greater risk of rehospitalization based on their medication regimens. OBJECTIVE Improve the algorithm for predicting elderly patients' risks for readmission by optimizing the sensitivity of its medication criteria. METHODS Outcome and Assessment Information Set (OASIS) and medication data were reused from a study that defined and tested an algorithm for assessing rehospitalization risks of 911 patients from 15 Medicare-certified home health care agencies. Odds Ratio analyses, literature reviews and clinical judgments were used to adjust the scoring of patients' High Risk Medication Regimens (HRMRs). Receiver Operating Characteristic (ROC) analysis evaluated whether these adjustments improved the predictive strength of the algorithm's components. RESULTS HRMR scores are composed of polypharmacy (number of drugs), potentially inappropriate medications (PIM) (drugs risky to the elderly), and Medication Regimen Complexity Index (MRCI) (complex dose forms, dose frequency, instructions or administration). Strongest ROC results for the HRMR components were Areas Under the Curve (AUC) of .68 for polypharmacy when excluding supplements; and .60 for PIM and .69 for MRCI using the original HRMR criteria. The "cut point" identifying MRCI scores as indicative of medication-related readmission risk was increased from 20 to 33. CONCLUSION The automated algorithm can predict elderly patients at risk of hospital readmissions and its underlying criteria is improved by a modification to its polypharmacy definition and MRCI cut point.
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Affiliation(s)
- C H Olson
- Biomedical Health Informatics, University of Minnesota , Minneapolis, Minnesota
| | - M Dierich
- School of Nursing, University of Minnesota , Minneapolis, Minnesota
| | - T Adam
- Pharmaceutical Care & Health Systems, University of Minnesota Minneapolis , Minnesota
| | - B L Westra
- School of Nursing, University of Minnesota , Minneapolis, Minnesota
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