Relationship of in-hospital medication modifications of elderly patients to postdischarge medications, adherence, and mortality

Impact of changes in antihypertensive medication on treatment intensity at hospital discharge and 30 days afterwards

Introduction

Little is known about the cumulative effect of changes in antihypertensive medications on treatment intensity. This study analyzed how changes in antihypertensive medications affect the intensity of antihypertensive treatment at hospital discharge and 30 days afterwards.

Methods

A prospective observational study of 299 hospitalized adult medical patients with antihypertensive therapy was conducted. The effect of medication changes on treatment intensity was evaluated by the Total Antihypertensive Therapeutic Intensity Score (TIS).

Results

At discharge, antihypertensive medications were changed in 62% of patients (184/299), resulting in a very small median reduction in TIS of -0.16. Treatment intensity was reduced more with increasing number of antihypertensive medications at admission, whereas it increased with elevated inpatient systolic blood pressure. Thirty days after discharge, antihypertensive medications were changed in 37% of patients (88/239) resulting in a median change in TIS of -0.02. Among them, 90% (79/88) had already undergone a change at discharge. The change in treatment intensity after discharge was inversely correlated with a change at discharge.

Discussion

Changes in antihypertensive medication frequently occurred at discharge but had a minimal impact on the intensity of antihypertensive treatment. However, these adjustments exposed patients to further medication changes after discharge, evidencing the need for treatment reassessment in the first month post-discharge.

Tailored interventions to improve adherence to medication in elderly patients with Parkinson's disease: a study protocol for a randomized controlled trial (AdhCare)

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.

New Antipsychotic Prescribing Continued into Skilled Nursing Facilities Following a Heart Failure Hospitalization: a Retrospective Cohort Study

BACKGROUND

Multimorbidity and polypharmacy are common among individuals hospitalized for heart failure (HF). Initiating high-risk medications such as antipsychotics may increase the risk of poor clinical outcomes, especially if these medications are continued unnecessarily into skilled nursing facilities (SNFs) after hospital discharge.

OBJECTIVE

Examine how often older adults hospitalized with HF were initiated on antipsychotics and characteristics associated with antipsychotic continuation into SNFs after hospital discharge.

DESIGN

Retrospective cohort.

PARTICIPANTS

Veterans without prior outpatient antipsychotic use, who were hospitalized with HF between October 1, 2010, and September 30, 2015, and were subsequently discharged to a SNF.

MAIN MEASURES

Demographics, clinical conditions, prior healthcare utilization, and antipsychotic use data were ascertained from Veterans Administration records, Minimum Data Set assessments, and Medicare claims. The outcome of interest was continuation of antipsychotics into SNFs after hospital discharge.

KEY RESULTS

Among 18,008 Veterans, antipsychotics were newly prescribed for 1931 (10.7%) Veterans during the index hospitalization. Among new antipsychotic users, 415 (21.5%) continued antipsychotics in skilled nursing facilities after discharge. Dementia (adjusted OR (aOR) 1.48, 95% CI 1.11-1.98), psychosis (aOR 1.62, 95% CI 1.11-2.38), proportion of inpatient days with antipsychotic use (aOR 1.08, 95% CI 1.07-1.09, per 10% increase), inpatient use of only typical (aOR 0.47, 95% CI 0.30-0.72) or parenteral antipsychotics (aOR 0.39, 95% CI 0.20-0.78), and the day of hospital admission that antipsychotics were started (day 0-4 aOR 0.36, 95% CI 0.23-0.56; day 5-7 aOR 0.54, 95% CI 0.35-0.84 (reference: day > 7 of hospital admission)) were significant predictors of continuing antipsychotics into SNFs after hospital discharge.

CONCLUSIONS

Antipsychotics are initiated fairly often during HF admissions and are commonly continued into SNFs after discharge. Hospital providers should review antipsychotic indications and doses throughout admission and communicate a clear plan to SNFs if antipsychotics are continued after discharge.

Treatment of Hypertension Among Non-Cardiac Hospitalized Patients

PURPOSE OF REVIEW

This review provides a contemporary perspective and approach for the treatment of hypertension (HTN) among patients hospitalized for non-cardiac reasons.

RECENT FINDINGS

Elevated blood pressure (BP) is a common dilemma encountered by physicians, but guidelines are lacking to assist providers in managing hospitalized patients with elevated BP. Inpatient HTN is common, and management remains challenging given the paucity of data and misperceptions among training and practicing physicians. The outcomes associated with intensifying BP treatment during hospitalization can be harmful, with little to no long-term benefits. Data also suggests that medication intensification at discharge is not associated with improved outpatient BP control. Routine inpatient HTN control in the absence of end-organ damage has not shown to be helpful and may have deleterious effects. Since routine use of intravenous antihypertensives in hospitalized non-cardiac patients has been shown to prolong inpatient stay without benefits, their routine use should be avoided for inpatient HTN control. Future large-scale trials measuring clinical outcomes during prolonged follow-up may help to identify specific circumstances where inpatient HTN control may be beneficial.

Medication Compliance Aids Unpackaged: A National Survey

Aims

Sixty‐four million pharmacy‐filled multicompartment medication compliance aids (MCAs) are dispensed by pharmacies in England each year. Despite the widespread use of MCAs and evidence that their use may be associated with harm there is no national consensus regarding MCA provision by acute hospital Trusts in England. The aim was to determine current practice for initiation and supply of MCAs in acute hospital Trusts in England and the potential consequences for patients and hospitals.

Methods

A 26‐item survey was distributed to all acute hospital Trusts in England. The questionnaire covered: policy, initiation, supply and review of MCAs; alternatives offered; and pharmacy staffing and capacity related to MCAs.

Results

Seventy‐two out of 138 (52%) Trusts responded to the survey: 70 Trusts responded regarding policy for MCA provision, with 60 (86%) having a policy regarding this; 33/55 (60%) that supplied MCAs on discharge supplied a different prescription length for MCA vs. non‐MCA prescriptions; 49/55 (89%) Trusts provided only 1 brand of MCA; 47/55 (85%) MCA‐supplying Trusts identified frequent difficulties with MCAs and 13/55 (24%) reported employing staff specifically to complete MCAs; and 30/35 (86%) MCA‐initiating Trusts had an assessment process for initiation, with care agency request reportedly the most common reason for initiation.

Conclusion

There is a lack of a national approach to MCA provision and initiation by acute hospital Trusts in England. This leads to significant variation in care and has the potential to put MCA users at an increased risk of medication‐related harm.

[Continuity of medication management after hospitalization in geriatric subacute rehabilitation care]

After one year of practice, a medication reconciliation process in geriatric aftercare was evaluated. The objective of the activity was to identify treatment changes (TC). 302 patients benefited from approach, 82.2% of changes was voluntary at hospitalization discharge and 100% of patients benefited from at least one change at hospitalization discharge. What are the consequences of so many changes and what are the measures to limit these consequences?

Medication Counselling in Older Patients Prior to Hospital Discharge: A Systematic Review

BACKGROUND

Older patients are regularly exposed to multiple medication changes during a hospital stay and are more likely to experience problems understanding these changes. Medication counselling is often proposed as an important component of seamless care to ensure appropriate medication use after hospital discharge.

OBJECTIVES

The purpose of this systematic review was to describe the components of medication counselling in older patients (aged ≥ 65 years) prior to hospital discharge and to review the effectiveness of such counselling on reported clinical outcomes.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (PROSPERO CRD42019116036), a systematic search of MEDLINE, EMBASE and CINAHL was conducted. The QualSyst Assessment Tool was used to assess bias. The impact of medication counselling on different outcomes was described and stratified by intervention content.

RESULTS

Twenty-nine studies were included. Fifteen different components of medication counselling were identified. Discussing the dose and dosage of patients' medications (19/29; 65.5%), providing a paper-based medication list (19/29; 65.5%) and explaining the indications of the prescribed medications (17/29; 58.6%) were the most frequently encountered components during the counselling session. Twelve different clinical outcomes were investigated in the 29 studies. A positive effect of medication counselling on medication adherence and medication knowledge was found more frequently, compared to its impact on hard outcomes such as hospital readmissions and mortality. Yet, evidence remains inconclusive regarding clinical benefit, owing to study design heterogeneity and different intervention components. Statistically significant results were more frequently observed when counselling was provided as part of a comprehensive intervention before discharge.

CONCLUSIONS

Substantial heterogeneity between the included studies was found for the components of medication counselling and the reported outcomes. Study findings suggest that medication counselling should be part of multifaceted interventions, but the evidence concerning clinical outcomes remains inconclusive.

Changes in Treatment of Very Elderly Patients Six Weeks after Discharge from Geriatrics Department

We assessed the prescriptions of patients hospitalized in a geriatric unit and subsequently discharged. This prospective and observational study was conducted over a two-month period in the geriatrics department (acute and rehabilitation units) of a university hospital. Patients discharged from this department were included over a two-month period. Prescriptions were analyzed at admission and discharge from the geriatrics department (DGD), and six weeks after DGD. We included 209 patients, 63% female, aged 86.8 years. The mean number of medications prescribed was significantly higher at DGD than at admission (7.8 vs. 7.1, p = 0.003). During hospitalization, 1217 prescriptions were changed (average 5.8 medications/patient): 52.8% were initiations, 39.3% were discontinuations, and 7.9% were dose adjustments. A total of 156 of the 209 patients initially enrolled completed the study. Among these patients, 81 (51.9%) had the same prescriptions six weeks after DGD. In univariate analysis, medications were changed more frequently in patients with cognitive impairment (p = 0.04) and in patients for whom the hospital report did not indicate in-hospital modifications (p = 0.007). Multivariate analysis found that six weeks after DGD, there were significantly more drug changes for patients for whom there were changes in prescription during hospitalization (p < 0.001). A total of 169 medications were changed (mean number of medications changed per patient: 1.1): 52.7% discontinuations, 34.3% initiations, and 13% dosage modifications. The drug regimens were often changed during hospitalization in the geriatrics department, and a majority of these changes were maintained six weeks after DGD. Improvements in patient adherence and hospital-general practitioner communication are necessary to promote continuity of care and to optimize patient supervision after hospital discharge.

Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days

OBJECTIVE

To evaluate the hypothesis that nonadherence to medication changes made at hospital discharge is associated with an increased risk of adverse events in the 30 days postdischarge.

STUDY SETTING

Patients admitted to hospitals in Montreal, Quebec, between 2014 and 2016.

STUDY DESIGN

Prospective cohort study.

DATA COLLECTION

Nonadherence to medication changes was measured by comparing medications dispensed in the community with those prescribed at hospital discharge. Patient, health system, and drug regimen-level covariates were measured using medical services and pharmacy claims data as well as data abstracted from the patient's hospital chart. Multivariable Cox models were used to determine the association between nonadherence to medication changes and the risk of adverse events.

PRINCIPAL FINDINGS

Among 2655 patients who met our inclusion criteria, mean age was 69.5 years (SD 14.7) and 1581 (60%) were males. Almost half of patients (n = 1161, 44%) were nonadherent to at least one medication change, and 860 (32%) were readmitted to hospital, visited the emergency department, or died in the 30 days postdischarge. Patients who were not adherent to any of their medication changes had a 35% higher risk of adverse events compared to those who were adherent to all medication changes (1.41 vs 1.27 events/100 person-days, adjusted hazard ratio: 1.35, 95% CI: 1.06-1.71).

CONCLUSIONS

Almost half of all patients were not adherent to some or all changes made to their medications at hospital discharge. Nonadherence to all changes was associated with an increased risk of adverse events. Interventions addressing barriers to adherence should be considered moving forward.

Exploring the association of the discharge medicines review with patient hospital readmissions through national routine data linkage in Wales: a retrospective cohort study

OBJECTIVE

To evaluate the association of the discharge medicines review (DMR) community pharmacy service with hospital readmissions through linking National Health Service data sets.

DESIGN

Retrospective cohort study.

SETTING

All hospitals and 703 community pharmacies across Wales.

PARTICIPANTS

Inpatients meeting the referral criteria for a community pharmacy DMR.

INTERVENTIONS

Information related to the patient's medication and hospital stay is provided to the community pharmacists on discharge from hospital, who undertake a two-part service involving medicines reconciliation and a medicine use review. To investigate the association of this DMR service with hospital readmission, a data linking process was undertaken across six national databases.

PRIMARY OUTCOME

Rate of hospital readmission within 90 days for patients with and without a DMR part 1 started.

SECONDARY OUTCOME

Strength of association of age decile, sex, deprivation decile, diagnostic grouping and DMR type (started or not started) with reduction in readmission within 90 days.

RESULTS

1923 patients were referred for a DMR over a 13-month period (February 2017-April 2018). Provision of DMR was found to be the most significant attributing factor to reducing likelihood of 90-day readmission using χ² testing and classification methods. Cox regression survival analysis demonstrated that those receiving the intervention had a lower hospital readmission rate at 40 days (p<0.000, HR: 0.59739, CI 0.5043 to 0.7076).

CONCLUSIONS

DMR after a hospital discharge is associated with a reduction in risk of hospital readmission within 40 days. Linking data across disparate national data records is feasible but requires a complex processual architecture. There is a significant value for integrated informatics to improve continuity and coherency of care, and also to facilitate service optimisation, evaluation and evidenced-based practice.

Hospital referral of older patients to community pharmacy: outcome measures in a feasibility study

Background Post-discharge medication use reviews in English community pharmacy aim to improve medicine support to recently discharged patients. However, there is little evidence of their impact on patient outcomes. Objective Identify potential outcome measures to investigate the impact of a hospital to community pharmacy referral service for older patients that utilises post-discharge medication reviews. Method Pharmacists at a district general hospital identified in-patients aged over 65 years who could benefit from a medication use review. Participants were randomised to receive referral for review, or standard discharge care. Participants were followed up at 4 weeks and 6 months via the hospital's patient administration system and by postal questionnaire, regarding readmissions, medication adherence, health related quality of life and enablement. Results Fifty-nine participants were recruited. There were no statistically significant differences in outcomes between intervention and control groups. However there were trends towards shorter length of stay on readmission and improved self-reported physical health for intervention group participants. There were no preventable medication related readmissions involving participants who had received a post-discharge medication use review as part of the study. Conclusion This feasibility study could be scaled up to a full pilot study, followed by an adequately powered randomised controlled trial, in order to further investigate the effects of medication use review referral post-discharge.

Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

IMPORTANCE

Transient elevations of blood pressure (BP) are common in hospitalized older adults and frequently lead practitioners to prescribe more intensive antihypertensive regimens at hospital discharge than the patients were using before hospitalization.

OBJECTIVE

To investigate the association between intensification of antihypertensive regimens at hospital discharge and clinical outcomes after discharge.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, patients 65 years and older with hypertension who were hospitalized in Veterans Health Administration national health system facilities from January 1, 2011, to December 31, 2013, for common noncardiac conditions were studied. Data analysis was performed from October 1, 2018, to March 10, 2019.

EXPOSURES

Discharge with antihypertensive intensification, defined as receiving a prescription at hospital discharge for a new or higher-dose antihypertensive than was being used before hospitalization. Propensity scores were used to construct a matched-pairs cohort of patients who did and did not receive antihypertensive intensifications at hospital discharge.

MAIN OUTCOMES AND MEASURES

The primary outcomes of hospital readmission, serious adverse events, and cardiovascular events were assessed by competing risk analysis. The secondary outcome was the change in systolic BP within 1 year of hospital discharge.

RESULTS

The propensity-matched cohort included 4056 hospitalized older adults with hypertension (mean [SD] age, 77 [8] years; 3961 men [97.7%]), equally split between those who did vs did not receive antihypertensive intensifications at hospital discharge. Groups were well matched on all baseline covariates (all standardized mean differences <0.1). Within 30 days, patients receiving intensifications had a higher risk of readmission (hazard ratio [HR], 1.23; 95% CI, 1.07-1.42; number needed to harm [NNH], 27; 95% CI, 16-76) and serious adverse events (HR, 1.41; 95% CI, 1.06-1.88; NNH, 63; 95% CI, 34-370). At 1 year, no differences were found in cardiovascular events (HR, 1.18; 95% CI, 0.99-1.40) or change in systolic BP among those who did vs did not receive intensifications (mean BP, 134.7 vs 134.4; difference-in-differences estimate, 0.6 mm Hg; 95% CI, -2.4 to 3.7 mm Hg).

CONCLUSIONS AND RELEVANCE

Among older adults hospitalized for noncardiac conditions, prescription of intensified antihypertensives at discharge was not associated with reduced cardiac events or improved BP control within 1 year but was associated with an increased risk of readmission and serious adverse events within 30 days.

Implementation and spread of a simple and effective way to improve the accuracy of medicines reconciliation on discharge: a hospital-based quality improvement project and success story

Background

Changes are often made to medications at times of transitions in care. Inadequate reconciliation during admission, transfer and discharge causes medication errors and increases risks of patient harm. Despite well-established multidisciplinary medicines reconciliation (MR) processes at hospital admission, our MR process at discharge; however, was poor. The main errors included failure to recommence withheld medicines and lack of documentation explaining changes made to medications on discharge. Our objective was to develop an intervention that supports prescribers to follow a simple standardised MR process at discharge to reduce these errors.

Methods

Working closely as a multidisciplinary team, we used improvement methodologies to design and test a process that reliably directs prescribers in surgery to use the inpatient prescribing chart as well as the MR on admission form as sources to create accurate discharge prescriptions. The project was segmented into testing, implementation, spread and sustainability.

Results

The tested intervention helped the accuracy of discharge prescriptions steadily and quickly improve from 45% to 96% in the pilot ward. Following the successful implementation and sustainability in two separate pilot wards, the intervention was spread to the remaining eight wards producing a similar improvement.

Conclusions

To improve patient safety, it is crucial to ensure that information about medicines is effectively communicated when care is transferred between teams. Although this can be challenging, we've shown that it can be done effectively and reliably if this responsibility is equally shared by healthcare professionals from all disciplines while being supported by safe systems that make it easy to do the right thing. Successfully implementing a standardised multidisciplinary MR process at discharge can also reduce the reliance on pharmacists therefore freeing them to undertake other clinical roles.

Adherence to medication in neurogeriatric patients: an observational cross-sectional study

Background

Poor adherence is a major issue and is associated with increased morbidity, mortality, and immense costs for the healthcare system. Due to demographic changes, the burden of neurological diseases is increasing with a crucial exacerbation of the problem of nonadherence. However, comprehensive data on geriatric patients with neurological disorders do not exist to date. In this cross-sectional observational study we aim to identify disease-specific adherence-modulating factors in neurogeriatric patients.

Methods

Patients 60 years or older with neurological disorders will receive an assessment of adherence (Stendal Adherence with Medication Score) and a comprehensive geriatric assessment during their stay in the Department of Neurology or Geriatrics at the Jena University Hospital (baseline data). In addition disease specific data will be derived from medical records. After one and twelve months a telephone interview will be conducted to evaluate if and why changes of medication occurred (follow up data).

Discussion

This study aims to explore disease-specific patterns of nonadherence in elderly patients with neurological disorders and characteristics of information transfer between a specialized center, practicing neurologists, general practitioners, and the patients and their caregivers. This comprehensive data may help to develop and apply complex and disease-specific interventions to enhance adherence.

Trial registration

German Clinical Trials Register DRKS00016774. Registered 19.02.2019.

Critical Periods for Increased Mortality After Discharge From Inpatient Mental Health Units: Opportunities for Prevention

OBJECTIVE

Studies of patients in the U.S. Department of Veterans Affairs (VA) health system and elsewhere have documented elevated mortality from suicide during a critical period within 30 to 90 days after discharge from inpatient mental health units. To support program planning, VA evaluated whether the elevated mortality during this critical period was specific to suicide or whether there were similar increases in other causes of death.

METHODS

Indicators of age, gender, inpatient diagnoses, and suicide attempts and ideation from VA records were combined with indicators of vital status and cause of death from the National Death Index. Analyses compared all-cause and cause-specific mortality in the first 30 and 90 days postdischarge with mortality in days 91 to 365 after discharge for the 106,430 VA patients discharged from inpatient mental health units in 2013-2014.

RESULTS

Elevated mortality during the first 30 and first 90 days after discharge was not specific to suicide. Higher rates of all-cause mortality were noted, including elevated mortality due to external causes other than suicide among young and middle-aged patients (ages 18-64) during the first 30 days and among older patients (≥65) during the first 90 days. An increase in natural-cause mortality among older patients was attributable to greater mortality among those with dementia diagnoses.

CONCLUSIONS

Elevated rates of nonsuicide external-cause mortality in the critical period within 30 to 90 days after discharge from inpatient mental health care suggest important opportunities for prevention. Greater mortality among patients with dementia or related neurodegenerative diseases raises questions regarding current strategies for managing behavioral symptoms and transitions to end-of-life care.

Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study

OBJECTIVES

To assess how often older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment, and to identify markers of appropriateness for these intensifications.

DESIGN

Retrospective cohort study.

SETTING

US Veterans Administration Health System.

PARTICIPANTS

Patients aged 65 years or over with hypertension admitted to hospital with non-cardiac conditions between 2011 and 2013.

MAIN OUTCOME MEASURES

Intensification of antihypertensive treatment, defined as receiving a new or higher dose antihypertensive agent at discharge compared with drugs used before admission. Hierarchical logistic regression analyses were used to control for characteristics of patients and hospitals.

RESULTS

Among 14 915 older adults (median age 76, interquartile range 69-84), 9636 (65%) had well controlled outpatient blood pressure before hospital admission. Overall, 2074 (14%) patients were discharged with intensified antihypertensive treatment, more than half of whom (1082) had well controlled blood pressure before admission. After adjustment for potential confounders, elevated inpatient blood pressure was strongly associated with being discharged on intensified antihypertensive regimens. Among patients with previously well controlled outpatient blood pressure, 8% (95% confidence interval 7% to 9%) of patients without elevated inpatient blood pressure, 24% (21% to 26%) of patients with moderately elevated inpatient blood pressure, and 40% (34% to 46%) of patients with severely elevated inpatient blood pressure were discharged with intensified antihypertensive regimens. No differences were seen in rates of intensification among patients least likely to benefit from tight blood pressure control (limited life expectancy, dementia, or metastatic malignancy), nor in those most likely to benefit (history of myocardial infarction, cerebrovascular disease, or renal disease).

CONCLUSIONS

One in seven older adults admitted to hospital for common non-cardiac conditions were discharged with intensified antihypertensive treatment. More than half of intensifications occurred in patients with previously well controlled outpatient blood pressure. More attention is needed to reduce potentially harmful overtreatment of blood pressure as older adults transition from hospital to home.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Refer-to-pharmacy: a qualitative study exploring the implementation of an electronic transfer of care initiative to improve medicines optimisation following hospital discharge

Background

Transition between care settings is a time of high risk for preventable medication errors. Poor communication about medication changes on discharge from hospital can result in adverse drug events and medicines-related readmissions. Refer-to-Pharmacy is a novel electronic referral system that allows hospital pharmacy staff to refer patients from their bedside to their community pharmacist for post-hospital discharge medication support. The aim of this study was to examine factors that promoted or inhibited the implementation of Refer-to-Pharmacy in hospital and community settings.

Methods

Twenty six interviews with hospital pharmacists (n = 11), hospital technicians (n = 10), and community pharmacists (n = 5) using Normalisation Process Theory (NPT) as the underpinning conceptual framework for data collection and analysis.

Results

Using NPT to understand the implementation of the technology revealed that the participants unanimously agreed that the scheme was potentially beneficial for patients and was more efficient than previous systems (coherence). Leadership and initiation of the scheme was more achievable in the contained hospital environment, while initiation was slower to progress in the community pharmacy settings (cognitive participation). Hospital pharmacists and technicians worked flexibly together to deliver the scheme, and community pharmacists reported better communication with General Practitioners (GPs) about changes to patients’ medication (collective action). However, participants reported being unaware of how the scheme impacted patients, meaning they were unable to evaluate the effectiveness of scheme (reflexive monitoring).

Conclusion

The Refer-to-Pharmacy scheme was perceived by participants as having important benefits for patients, reduced the possibility for human error, and was more efficient than previous ways of working. However, initiation of the scheme was more achievable in the single site of the hospital in comparison to disparate community pharmacy organisations. Community and hospital pharmacists and organisational leaders will need to work individually and collectively if Refer-to-Pharmacy is to become more widely embedded across health settings.

Impact of hospitalization in an acute geriatric unit on polypharmacy and potentially inappropriate prescriptions: A retrospective study

AIM

Polypharmacy is a highly prevalent geriatric syndrome, and hospitalizations can worsen it. The aim of the present study was to analyze the influence of hospitalization on polypharmacy and indicators of quality of prescribing, and their possible association with health outcomes.

METHODS

A retrospective study of 200 patients discharged from an acute geriatric unit was carried out. Indicators of quality of prescription were registered at admission and discharge: polypharmacy defined as ≥5 medications, hyperpolypharmacy (≥10), potentially inappropriate prescribing by Beers and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, potentially prescribing omissions by Screening Tool to Alert doctors to the Right Treatment (START) criteria, drug interactions and anticholinergic burden measured with the Anticholinergic Risk Scale. Mortality, emergency room visits and hospital admissions occurring during 6 months after discharge were also registered.

RESULTS

The total number of drugs increased at discharge (9.1 vs 10.1, P < 0.001), without increasing chronic medications (8.5 vs 8.3, P = 0.699). No significant variations were observed in the prevalence of polypharmacy (86.5% vs 82.2%), potentially inappropriate prescribing (68.5% vs 71.5%), potential prescribing omissions (58% vs 58%) or drug interactions (82.5% vs 83.5%). Patients with anticholinergic drugs tended to increase, not reaching statistical significance (39.5% vs 44.5%; P = 0.064). Polypharmacy was associated with emergency room visits (OR 2.62, 95% CI 1.07-6.40; P = 0.034), and hyperpolypharmacy with hospitalizations (OR 2.49, 95% CI 1.25-4.93; P = 0.009).

CONCLUSIONS

After hospitalization in an acute geriatric unit, the prevalence of polypharmacy, potentially inappropriate prescribing, potential prescribing omissions, interactions or anticholinergic drugs is still very high. Polypharmacy is a risk factor for hospitalization and emergency room visits. Measuring indicators of quality of prescription might be useful to design interventions to optimize pharmacotherapy and improve health outcomes in elderly acute patients. Geriatr Gerontol Int 2017; 17: 2354-2361.

How does hospitalization affect continuity of drug therapy: an exploratory study

INTRODUCTION

Transitions between different levels of health care, such as hospital admission and discharge, pose a significant threat to the quality and continuity of medication therapy. This study aims to explore the role of hospitalization on medication changes as patients are transferred from and back to ambulatory care.

METHODS

Secondary analysis of claims data from Swiss residents with basic health insurance at the Helsana Group was performed. We evaluated medication invoices of patients who were hospitalized in a Swiss private hospital group in the year 2013. Medication changes were defined as discontinuation, new prescription, or change in the Anatomical Therapeutic Chemical (ATC) Classification System level 4, which is equivalent to a change in the chemical/therapeutic/pharmacological subgroup. Multiple Poisson regression analysis was applied to evaluate whether medication change was predicted by socioeconomic or clinical patient characteristics or by a system factor (physician dispensing of medication allowed in canton of residence).

RESULTS

We investigated a total of 10,123 hospitalized patients, among whom a mean number of 3.85 (median 3.00) changes were identified. Change most frequently affected antihypertensives, analgesics, and antirheumatics. If patients were enrolled in a managed care plan, they were less likely to undergo changes. If a patient resided in a canton, in which physicians were allowed to dispense medication directly, the patient was more likely to experience change.

CONCLUSION

There is considerable change in medication when patients shift between ambulatory and inpatient health care levels. This interruption of medication continuity is in part desirable as it responds to clinical needs. However, we hypothesize that there is also a significant proportion of change due to unwarranted factors such as financial incentives for change of products.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

OBJECTIVES

Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.

SETTING

An acute 400-bedded teaching hospital in London, UK.

PARTICIPANTS

The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.

INTERVENTIONS

Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.

RESULTS

Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.

CONCLUSIONS

New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Incidence and Effects of Polypharmacy on Clinical Outcome among Patients Aged 80+: A Five-Year Follow-Up Study

OBJECTIVES

Polypharmacy is a problem of growing interest in geriatrics with the increase in drug consumption in recent years, is defined according to the WHO criteria as the, ''concurrent use of five or more different prescription medication". We investigated the clinical characteristics of polypharmacy and identified the effects of polypharmacy on clinical outcome among patients aged 80+ admitted to Chinese PLA general hospital.

METHODS

Older men aged ≥80 years (n = 1562) were included in this study. The included participants attended a structured clinical examination and an interview carried out by a geriatrician and trained nurses. A follow-up survey in 2014 was carried out on survivors in the same way as in 2009. The clinical outcome measured were adverse drug reactions, falls, frailty, disability, cognitive impairment, mortality. The association between polypharmacy and clinical outcome was assessed by logistic regression.

RESULTS

The mean (range) age of the included participants was 85.2 (80-104) years. Medication exposure was reported by 100% of the population. Mean number of medications reported in this population was 9.56±5.68. The prevalence of polypharmacy (≥6 medications) in the present study was 70%. At the time of the follow-up survey, an increase in the number of taken medicines had occurred among half of the survivors. The risk of different outcomes in relation to number of medications rises significantly, the odds ratios were 1.21 (95% confidence interval [CI]1.17-1.28) for adverse drug reactions, 1.18 (95% CI 1.10-1.26) for falls, 1.16 (95% CI 1.09-1.24) for disability, and 1.19 (95% CI 1.12-1.23) for mortality. There was no association between increasing number of medications and cognitive impairment.

CONCLUSIONS

Our study demonstrates that polypharmacy is very common in the very old patients, and observed that number of medications was a factor associated with difference clinical outcome independently of the age, type of medications prescribed and accompanied comorbidities.

A systematic review of the role of community pharmacies in improving the transition from secondary to primary care

AIM

We set out to determine the potential contribution of community pharmacists to improve the transfer of care of patients from secondary to primary care settings.

METHOD

We systematically reviewed the literature on interventions that involved community pharmacy post-discharge. We considered all relevant studies, including both randomized and non-randomized controlled trials, irrespective of patient population. Our primary outcome was any impact on patient and medication outcomes, while the secondary outcome was to identify intervention characteristics that influenced all reported outcomes.

RESULTS

We retrieved 14 studies that met our inclusion criteria. There were four studies reporting outcomes relating to the identification and rectification of medication errors that were significantly improved with community pharmacy involvement. Other patient outcomes such as medication adherence and clinical control were not unanimously positively or negatively influenced via the inclusion of community pharmacy in a transfer of care post-discharge intervention. Some inconsistencies in implementation and process evaluation of interventions were found across the reviewed studies. This limited the accuracy with which true impact could be considered.

CONCLUSIONS

There is evidence that interventions including a community pharmacist can improve drug related problems after discharge. However, impact on other outcomes is not consistent. Further studies are required which include process evaluations to describe fully the context of the intervention so as to determine better any influencing factors. Also applying more stringent controls and closer adherence to protocols in both intervention and control groups would allow clearer correlations to be made between the intervention and the outcomes.

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

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.

Discrepancies on Medication Plans detected in German Community Pharmacies

RATIONALE, AIMS AND OBJECTIVES

A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients.

METHODS

Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication.

RESULTS

Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives.

CONCLUSION

Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.

Comorbidity burden assessment in older people admitted to a Portuguese University Hospital

PURPOSE

To determine the most valuable comorbidity index to apply in a clinical context and its prospective association with 1-year mortality and 3-month readmission. The authors also intend to gauge the evolution of older patients' admission profile over 13 years, in the same clinical setting.

SUBJECTS/MATERIALS AND METHODS

The authors analyzed data from 100 consecutive patients admitted in 2012. The Charlson Comorbidity Index (CCI), the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and the Medication-Based Disease Burden Index (MDBI) were used to evaluate comorbidity. Length of stay, number of diagnoses and of medications, readmission and mortality were assessed. A p value <0.05 was considered significant.

RESULTS

Mean age was 80.6 years, mean length of stay was 8.8 days, and mean number of diagnosis per patient was 7.9. Mean values of score were of 3.6 for the CCI, 11.3 for the CIRS-G and 0.552 for the MDBI. Three-month readmission and 1-year mortality rates related to higher CCI and CIRS-G scores. No association was found between MDBI and the outcomes evaluated. One-year mortality reached 24 % and 3-month readmission was of 43 %. Comparing the two samples, mean age increased in 2.1 years and the number of diagnosis by 2.2. Length of stay decreased 2 days.

DISCUSSION AND CONCLUSION

CCI was easier to use but the CIRS-G was better at evaluating comorbidity. MDBI did not seem to be a trustworthy tool. Despite an older population with high comorbidity, length of stay decreased over 13 years. However, readmission was high. Introduction of geriatric care standards is required to improve health outcomes for older patients.

The benefits and harms of deprescribing

Deprescribing is the process of trial withdrawal of inappropriate medications. Currently, the strongest evidence for benefit of deprescribing is from cohort and observational studies of withdrawal of specific medication classes that have shown better patient outcomes, mainly through resolution of adverse drug reactions. Additional potential benefits of deprescribing include reduced financial costs and improved adherence with other medications. The harms of ceasing medication use include adverse drug withdrawal reactions, pharmacokinetic and pharmacodynamic changes and return of the medical condition. These can be minimised with proper planning (ie, tapering), monitoring after withdrawal, and reinitiation of the medication if the condition returns. More evidence is needed regarding negative, non-reversible effects of ceasing use of certain classes of medication, such as acetylcholinesterase inhibitors. Cessation of use has not been studied for many medication classes, and large-scale randomised controlled trials of systematic deprescribing are required before the true benefits and harms can be known.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing.

OBJECTIVES

This review sought to determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

In November 2013, for this first update, a range of literature databases including MEDLINE and EMBASE were searched, and handsearching of reference lists was performed. Search terms included 'polypharmacy', 'medication appropriateness' and 'inappropriate prescribing'.

SELECTION CRITERIA

A range of study designs were eligible. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people 65 years of age and older in which a validated measure of appropriateness was used (e.g. Beers criteria, Medication Appropriateness Index (MAI)).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. Study-specific estimates were pooled, and a random-effects model was used to yield summary estimates of effect and 95% confidence intervals (CIs). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall quality of evidence for each pooled outcome.

MAIN RESULTS

Two studies were added to this review to bring the total number of included studies to 12. One intervention consisted of computerised decision support; 11 complex, multi-faceted pharmaceutical approaches to interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals, such as prescribers and pharmacists. Appropriateness of prescribing was measured using validated tools, including the MAI score post intervention (eight studies), Beers criteria (four studies), STOPP criteria (two studies) and START criteria (one study). Interventions included in this review resulted in a reduction in inappropriate medication usage. Based on the GRADE approach, the overall quality of evidence for all pooled outcomes ranged from very low to low. A greater reduction in MAI scores between baseline and follow-up was seen in the intervention group when compared with the control group (four studies; mean difference -6.78, 95% CI -12.34 to -1.22). Postintervention pooled data showed a lower summated MAI score (five studies; mean difference -3.88, 95% CI -5.40 to -2.35) and fewer Beers drugs per participant (two studies; mean difference -0.1, 95% CI -0.28 to 0.09) in the intervention group compared with the control group. Evidence of the effects of interventions on hospital admissions (five studies) and of medication-related problems (six studies) was conflicting.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as pharmaceutical care, resulted in clinically significant improvement; however, they appear beneficial in terms of reducing inappropriate prescribing.

Prevalence and predictors of polypharmacy among Korean elderly

OBJECTIVE

Polypharmacy is widespread in the elderly because of their multiple chronic health problems. The objective of this study was to investigate the prevalence and predictors associated with polypharmacy in a nationally representative sample of Korean elderly individuals.

METHODS

We used the Korea Health Insurance Review and Assessment Service - National Patient Sample (HIRA-NPS) data from 2010 and 2011. We used information on 319,185 elderly patients (aged 65 years or older) between January 1, 2010 and December 31, 2011 from the HIRA-NPS database. We defined 'polypharmacy' as the concurrent use of 6 medications or more per person, 'major polypharmacy' as 11 medications or more, and 'excessive polypharmacy' as 21 medications or more. The frequency and proportion (%) and their 95% confidence intervals were presented according to the polypharmacy definition. Polypharmacy was visualized by the Quantum Geographic Information Systems (QGIS) program to describe regional differences in patterns of drug use. Multivariate ordinal logistic regression was performed to estimate odds ratios (ORs) and their 95% confidence intervals (CI) to investigate the risk factors for polypharmacy.

RESULTS

Of the Korean elderly studied, 86.4% had polypharmacy, 44.9% had major polypharmacy and 3.0% had excessive polypharmacy. Polypharmacy was found to be primarily concentrated in the Southwest region of the country. Significant associations between polypharmacy and the lower-income Medical Aid population (OR = 1.52, 95% CI 1.47, 1.56) compared with National Health Insurance patients was observed.

CONCLUSIONS

Nationwide efforts are needed for managing polypharmacy among Korean elderly patients. In particular, a national campaign and education to promote appropriate use of medicines for the Medical Aid population is needed.

The influence of comprehensive geriatric assessment on drug therapy in elderly patients

BACKGROUND

Comprehensive geriatric assessment of hospitalised patients implies optimising patients' medical treatment, and good coordination between hospital and general practice is essential for the quality of the drug treatment. Only a few studies have investigated the continuation of patients' medication from primary care to hospital and back again to primary care.

OBJECTIVES

To describe changes of drug therapy during hospital stay in a geriatric ward and the following acceptance of these changes in primary cares after discharge.

METHODS

An observational register study following 1,550 geriatric patients' pharmacological treatment longitudinally across hospital stay, by linkage of a primary care prescription database and hospital medical records. The medication regimens for the individual patients were compared at three cross sections: primary care before hospitalisation, during hospital stay and primary care after hospitalisation, analysed according to drug therapy, co-morbidity, functionality and outpatient follow-up.

RESULTS

Patients were using an average of 8.2 drugs before hospital admission, of which an average of 0.9 drugs per patient was discontinued or switched during hospitalisation. An average of 1.7 new drugs per patient was initiated by the hospital physicians. After discharge, 63.9 % of the changes initiated by hospital physicians were continued in primary care. Of new drugs initiated in hospital 42.7 % were accepted in primary care.

CONCLUSIONS

A relatively small proportion of drugs was switched or discontinued and the average number of drugs increased during hospital stay. Of these changes, two thirds were accepted in primary care after discharge and less than half of newly initiated drugs were continued in primary.

Development of a standardized knowledge base to generate individualized medication plans automatically with drug administration recommendations

AIMS

We aimed to develop a generic knowledge base with drug administration recommendations which allows the generation of a dynamic and comprehensive medication plan and to evaluate its comprehensibility and potential benefit in a qualitative pilot study with patients and physicians.

METHODS

Based on a literature search and previously published medication plans, a prototype was developed and iteratively refined through qualitative evaluation (interviews with patients and focus group discussions with physicians). To develop the recommendations for safe administration of specific drugs we screened the summary of product characteristics (SmPC) of different exemplary brands, allocated the generated advice to groups with brands potentially requiring the same advice, and reviewed these allocations regarding applicability and appropriateness of the recommendations.

RESULTS

For the recommendations, 411 SmPCs of 140 different active ingredients including all available galenic formulations, routes of administrations except infusions, and administration devices were screened. Finally, 515 distinct administration recommendations were included in the database. In 926 different generic groups, 29,879 allocations of brands to general advice, food advice, indications, step-by-step instructions, or combinations thereof were made. Thereby, 27,216 of the preselected allocations (91.1%) were confirmed as appropriate. In total, one third of the German drug market was labelled with information.

CONCLUSIONS

Generic grouping of brands according to their active ingredient and other drug characteristics and allocation of standardized administration recommendations is feasible for a large drug market and can be integrated in a medication plan.

Medication information seeking behavior of patients who use multiple medicines: how does it affect adherence?

OBJECTIVE

This article explores medication information seeking behavior (MISB). We aimed to develop a scale for measuring MISB and use it to explore the relationships between MISB, adherence and factors, which drive information seeking.

METHODS

Patients (N=910) using multiple medicines completed questionnaires. Exploratory and confirmatory factor analyses were performed. Correlations and multivariate analyses were used to investigate the relationships between variables.

RESULTS

Respondents sought medication information mainly from health professionals and written medicines information. The medication information seeking behavior scale (MISB) had acceptable reliability and validity. Information seeking was most intense among respondents who had recent changes in their medicine regimen and worries about their medicines. Those who sought medication information from autonomous sources were more likely to be non-adherent than those who never did (OR=2.00 [1.48, 2.70]). Seeking information from health professionals had no influence on adherence.

CONCLUSION

Health practitioners should carefully attend to patients' questions about medicines information. When patients mention that they are worried about their medicines and have sought medication information from television, magazines, brochures or family and friends, this could be a sign that they tend towards non-adherent behavior.

PRACTICE IMPLICATIONS

The MISB scale could be used to learn more about patients' use of medication information.

The willingness of informal caregivers to assist their care-recipient to use Home Medicines Review

Objectives

Informal caregivers experience daily hassles – a form of persistent stress, as a consequence of caregiving. This study aimed to develop and test a new theoretical model of health information‐seeking behaviour, the Knowledge Hassles Information Seeking Model (KHISM). KHISM hypothesized that the knowledge hassles of caregivers – daily stressors experienced while dealing with tasks which require knowledge about the safety and effectiveness of the care‐recipients' medicines – would influence caregivers' willingness to assist their care‐recipient to use an Australian medication management service, Home Medicines Review (HMR).

Methods

A cross‐sectional postal survey was conducted among 2350 members of Carers (NSW, Australia). Respondents were included in the study if they were involved in medication‐related tasks for their care‐recipient and were not paid as caregivers. Also, their care‐recipient needed to be taking more than five medicines daily or more than 12 doses daily and had not yet experienced HMR. Structural equation modelling was used to test the model.

Results

A total of 324 useable surveys were returned yielding a response rate of 14%. Respondents were quite willing to assist their care‐recipient to use HMR (willingness). The model predicted 51% of the variation in willingness. Knowledge hassles increased positive outcome expectancy (β = 0.40, P < 0.05) and indirectly increased willingness.

Conclusions

The more caregivers experience hassles with medication knowledge, the more they perceive HMR to be a helpful information source and the more willing they are to use it. Targeted marketing centred on HMR as an information source may increase caregivers' demand for HMR. Further exploration of the phenomenon of knowledge hassles is warranted.

Transitions of care in patients receiving oral anticoagulants: general principles, procedures, and impact of new oral anticoagulants

BACKGROUND

Most patients requiring anticoagulation therapy while hospitalized will continue this therapy as outpatients. This transition can be associated with gaps in care related to anticoagulation therapy that increase the risk of adverse events, rehospitalizations, and death. Warfarin, the most commonly used oral anticoagulant, presents distinct management challenges, including drug-food and drug-drug interactions, a narrow therapeutic window, and the requirements for periodic blood monitoring and dose adjustments, particularly during the hospital discharge process.

PURPOSE

This review explores clinical challenges and potential solutions surrounding anticoagulation therapy with warfarin during transitions of care, as well as discusses newer anticoagulants that are approved or are in late stages of development for the prevention of thromboembolic events.

CONCLUSIONS

Diligence, careful planning, and close communication between patients and healthcare providers during and after discharge are required to ensure that patients remain adequately and safely anticoagulated with warfarin in the outpatient setting. New oral anticoagulants may offer the possibility of safer and simpler care for patients requiring anticoagulation.

CLINICAL IMPLICATIONS

We summarize the latest guidelines and recommendations for safe hospital discharge and apply them to the specific case of discharging a warfarin-treated patient. In addition, we discuss the new oral anticoagulants and their potential to offer more efficacious and easier-to-manage anticoagulation.

Inpatient palliative care and patient pain: pre- and post-outcomes

CONTEXT

Hospitalized patients with serious illness often receive inadequate pain and symptom management at the end of life.

OBJECTIVES

To test the effectiveness of an interdisciplinary inpatient palliative care (IPC) consultation program in the management of pain among seriously ill patients during hospitalization, and to examine IPC patient pain outcomes 10 days following hospital discharge.

METHODS

A two-year pre-post study was conducted at a nonprofit health maintenance organization medical center in Los Angeles County. Hospital patients (n = 484) aged 65 years and older with life-threatening, complex, chronic conditions received comprehensive assessment, pain and symptom relief, care planning, counseling, and other supportive services from an IPC team. Measures included self-reported pain at baseline, two and 24 hours following IPC intervention, discharge, and 10 days post-discharge.

RESULTS

Mean pain was significantly different between baseline (1.56 ± 2.79) and two hours (0.91 ± 1.59; P < 0.001), 24 hours (0.77 ± 1.58; P < 0.001), and hospital discharge (0.40 ± 1.09; P < 0.001). Mean pain 10 days after discharge (2.04 ± 2.79; P < 0.001) was significantly higher than mean pain at discharge. Number of chronic conditions, probability of mortality, and discharge to hospice care significantly predicted increased pain following discharge.

CONCLUSION

To the authors' knowledge, this is the first study to follow IPC patient pain after hospital discharge. Findings support IPC teams' effectiveness in managing pain during hospitalization but suggest a lack of continuity in pain management following discharge. Research exploring IPC patient post-discharge transition experiences will likely improve understanding of post-discharge pain outcomes.