Medication Assessments by Care Managers Reveal Potential Safety Issues in Homebound Older Adults

A pharmacy-based intervention to improve safe over-the-counter medication use in older adults

BACKGROUND

For older adults, health risks from inappropriate use of over-the-counter (OTC) medications represent a prevalent clinical and public health challenge. Focus groups with pharmacists led to the identification of a number of systems barriers to pharmacists supporting the safe selection and use of OTC medications by this population. Such feedback informed the development of the Senior Section™, a physical redesign that located a curated inventory of lower-risk OTC medications proximal to the prescription department.

OBJECTIVES

To determine whether implementation of the Senior Section resulted in improvements to the ability of pharmacy staff to engage with older adult patients to support OTC medication safety issues.

METHODS

A qualitative approach, in which pharmacy staff from 4 pharmacies within a single chain participated in a semi-structured interview, was used to evaluate the implementation of the Senior Section in their pharmacies. Interview transcripts underwent a deductive and iterative content analysis.

RESULTS

Eight pharmacists and 5 technicians were interviewed. They viewed the Senior Section as contributing to notable improvements in proximity, medication safety, convenience, and patient selection behaviors. The Senior Section's safer OTC inventory and its sectional layout, its relationship to the prescription department, and its signage served to enhance its usefulness as an OTC safety improvement intervention. Moreover, it functioned beneficially while streamlining the coordination of services with between pharmacists and technicians, and did not interfere with existing pharmacy workflows.

CONCLUSIONS

Pharmacy staff believed that the Senior Section facilitated their ability to engage with older adults to support safe OTC selection and use and thus to reduce OTC-related harms.

Safety of older people at home: An integrative literature review

AIM

The aim of this review was to examine the relevant health literature, to describe safety in the homes of older and older people's perceptions and understanding of their safety at home based on current literature.

BACKGROUND

Safety is a multifaceted, basic need of older people living at home. Many studies are hospital focused and few focus on safety at home. Research on the safety of older people at home appears to be under-researched.

METHODS

MEDLINE, CINAHL, Scopus and Web of Science databases from the earliest to August 2017 were investigated. The integrative literature review was conducted in December 2017. The full text of the remaining n = 93 papers was then screened for relevance by inclusion and exclusion criteria which reduced the number by 59 to n = 34.

RESULTS

Four dimensions of safety at home were discovered, namely physical, social, emotional and mental, and cognitive safety. Safety dimensions had both positive and negative components. Older people's main wish was to be able to live in their own home for as long as possible. Their perceptions of safety at home was categorised as active living, coping at home, managed living and the knowledge of the existence of disease.

CONCLUSIONS

The safety of older people at home is a worldwide concern. Identification of safety issues can assist in developing measures to help people stay at home for longer as they age. The management of this would need to take account of all four dimensions of safety, in ways that promote ageing at home.

IMPLICATIONS FOR PRACTICE

Learning, understanding and developing new strategies about safety affect everyone who visits the home of older people, and stakeholders have an important role to identify safety risks.

A qualitative study to understand over-the-counter medication use and decision-making among residents of senior-living communities

INTRODUCTION

OTC medications are generally considered safe and convenient to use without requiring a prescription. However, the safety of an OTC medication and the final health outcome depends in part upon consumers' perceptions, beliefs, and their decision-making about OTC medication use. This study uses a qualitative approach to explore the knowledge, beliefs, and practices associated with OTC medication use and decision-making in adults aged 65 years and older.

METHODS

A set of focus groups (N = 10) were conducted in a sample of independently living older adult residents of senior apartment buildings (N = 80) using purposeful sampling. All focus groups were recorded, transcribed verbatim, and analyzed qualitatively.

RESULTS

Most participants considered OTC medications safe and effective to use if following the drug label instructions appropriately. Brand name products were perceived as equally or more effective compared to generic products by participants. Two approaches to OTC treatment decision-making were observed: 1) a decision to treat their symptoms by themselves (self-recommended) or 2) a decision to ask and/or follow their physician's recommendation (physician-recommended). Each of these treatment approaches may lead to the other depending on the person's financial and healthcare resources, the severity of the symptoms, experiences with the medication, and relationship with the physician. Maximum and fast relief was mentioned as the most important attribute in the final OTC purchase decision, followed by the lower cost, and easy to swallow dosage forms. Aspirin and ibuprofen were the two most frequently reported OTC medications associated with adverse effects and inappropriate use.

CONCLUSIONS

Older adults, in general, feel positive about OTC medications and are satisfied with using them. Considering the self-reported malpractices and side effects associated with OTC medications, older adults should be encouraged to make safe and responsible decisions about self-medication.

Frequency and Nature of Adverse Drug Reactions Due to Non-Prescription Drugs in Children: A Retrospective Analysis from the French Pharmacovigilance Database

INTRODUCTION

Studies that evaluate the safety of non-prescription drugs in children remain scarce.

OBJECTIVES

The aim of the present study was to compare adverse drug reactions (ADRs) due to prescription versus non-prescription drugs in children.

METHODS

We conducted a retrospective analysis of ADR notifications for a pediatric population (aged <18 years) registered in the French PharmacoVigilance Database (FPVD) between January 1985 and December 2016 by the Midi-Pyrénées PharmacoVigilance Center (in the south of France). We compared ADR profiles according to drug prescription status using a Chi-squared test.

RESULTS

We included 2218 notifications concerning 3687 ADRs in the study. Non-prescription drugs were involved in 506 notifications (22.8%). Patients were younger in the non-prescription drug group (6.7 ± 5.3 vs. 8.4 ± 5.7 years in the prescription drug group). No difference by sex was found. Neurological ADRs were more frequent with prescription drugs (21.0%) than with non-prescription drugs (14.2%, p = 0.0008), whereas dermatological disorders (37.2 vs. 29.1%, respectively) and general ADRs (30.8 vs. 20.1%, respectively) were more frequent with non-prescription than with prescription drugs (p = 0.0006 and p < 0.0001, respectively). The frequency of "serious" ADRs was higher with prescription drugs than with non-prescription drugs (40.9 vs. 34.2%, p = 0.007). The non-prescription drugs most frequently implicated with serious ADRs were ibuprofen (n = 37; 4.2%), tuberculosis vaccine (n = 23; 2.6%), aspirin (n = 20, 2.3%), and paracetamol (n = 17; 1.9%). ADRs from prescription drugs involved asparaginase (n = 27; 3.1%), immunoglobulins (n = 25; 2.9%), and amoxicillin (n = 23; 2.4%).

CONCLUSIONS

Non-prescription drugs, usually considered safe, were frequently responsible for ADR notifications. The non-prescription medication most frequently involved in serious ADRs was ibuprofen.

[Drug prescriptions of patients treated in a geriatric outpatient ward of a university hospital: a descriptive cross-sectional study]

The scope of this study was to evaluate drug prescriptions for elderly patients in the geriatric outpatient ward of a hospital. A cross-sectional descriptive study was conducted in a university hospital, with the application of a questionnaire. Patients aged >60 years were interviewed about their drug prescriptions and a total of 208 patients were interviewed. The average number of drugs used per person was 3.8 and the drugs most used were for the cardiovascular system (37%). 406 potential interactions were identified in 140 patients (67.3%), and duplicate therapy was found in two prescriptions. The potentially inappropriate drug most used for the elderly was nifedipine (2.4%). Data from this study support the relevance of the issue of drug use among the elderly, thus reinforcing the importance of the evaluation of the process of the prescription of drugs for this population.

Homeopathic medical practice for anxiety and depression in primary care: the EPI3 cohort study

Background

The purpose of the study was to compare utilization of conventional psychotropic drugs among patients seeking care for anxiety and depression disorders (ADDs) from general practitioners (GPs) who strictly prescribe conventional medicines (GP-CM), regularly prescribe homeopathy in a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho).

Methods

This was one of three epidemiological cohort studies (EPI3) on general practice in France, which included GPs and their patients consulting for ADDs (scoring 9 or more in the Hospital Anxiety and Depression Scale, HADS). Information on all medication utilization was obtained by a standardised telephone interview at inclusion, 1, 3 and 12 months.

Results

Of 1562 eligible patients consulting for ADDs, 710 (45.5 %) agreed to participate. Adjusted multivariate analyses showed that GP-Ho and GP-Mx patients were less likely to use psychotropic drugs over 12 months, with Odds ratio (OR) = 0.29; 95 % confidence interval (CI): 0.19 to 0.44, and OR = 0.62; 95 % CI: 0.41 to 0.94 respectively, compared to GP-CM patients. The rate of clinical improvement (HADS <9) was marginally superior for the GP-Ho group as compared to the GP-CM group (OR = 1.70; 95 % CI: 1.00 to 2.87), but not for the GP-Mx group (OR = 1.49; 95 % CI: 0.89 to 2.50).

Conclusions

Patients with ADD, who chose to consult GPs prescribing homeopathy reported less use of psychotropic drugs, and were marginally more likely to experience clinical improvement, than patients managed with conventional care. Results may reflect differences in physicians’ management and patients’ preferences as well as statistical regression to the mean.

Utilization of psychotropic drugs by patients consulting for sleeping disorders in homeopathic and conventional primary care settings: the EPI3 cohort study

BACKGROUND

Utilization of sedative hypnotic drugs for sleeping disorders (SD) raises concerns, particularly among older people. This study compared utilization of conventional psychotropic drugs for SD among patients seeking care from general practitioners (GPs) who strictly prescribe conventional medications (GP-CM), regularly prescribe homeopathy in a mixed practice (GP-Mx), or are certified homeopathic GPs (GP-Ho).

METHODS

This was a French population-based cohort study of GPs and their patients consulting for SD, informed through the Pittsburgh sleep quality index (PSQI) questionnaire. Information on psychotropic drugs utilization was obtained from a standardized telephone interview at inclusion, one, three and 12 months.

RESULTS

346 patients consulting for SD were included. Patients in the GP-Ho group experienced more often severe SD (41.3%) than patients in the GP-CM group (24.3%). Adjusted multivariate analyses showed that patients who chose to be managed by GP-Ho were less likely to use psychotropic drugs over 12 months as opposed to the GP-CM group, with Odds ratio (OR) = 0.25; 95% confidence interval (CI): 0.14 to 0.42. Patients in the GP-Mx group also used less psychotropic drugs but the result was not statistically significant (OR = 0.67; 95% CI: 0.39-1.16). Rates of clinical improvement of the SD did not differ between groups.

CONCLUSIONS

Patients with SD who chose to consult GPs certified in homeopathy consumed less psychotropic drugs and had a similar evolution of their condition to patients treated with conventional medical management. This result may translate in a net advantage with reduction of adverse events related to psychotropic drugs.

Medicare part D and long-term care: a systematic review of quantitative and qualitative evidence

BACKGROUND

In the largest overhaul to Medicare since its creation in 1965, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 established Part D in 2006 to improve access to essential medication among disabled and older Americans. Despite previous evidence of a positive impact on the general Medicare population, Part D's overall effects on long-term care (LTC) are unknown.

OBJECTIVE

The purpose of this systematic review was to evaluate the literature regarding Part D's impact on the LTC context, specifically costs to LTC residents, providers and payers; prescription drug coverage and utilization; and clinical and administrative outcomes.

DATA SOURCES

Four electronic databases [PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Business Fulltext Elite and Science Citation Index Expanded], selected US government and non-profit websites, and bibliographies were searched for quantitative and qualitative studies characterizing Part D in the LTC context. Searches were limited to studies that may have been published between 1 January 2006 (date of Part D implementation) and 8 January 2013.

STUDY SELECTION

Systematic searches identified 1,624 publications for a three-stage (title, abstract and full-text) review. Included publications were in English language; based in the US; assessed Part D-related outcomes; and included or were directly relevant to LTC residents or settings. News articles, reviews, opinion pieces, letters or commentaries; case reports or case series; simulation or modeling studies; and summaries that did not report original data were excluded.

STUDY APPRAISAL AND SYNTHESIS METHODS

A standardized form was used to abstract study type, study design, LTC setting, sources of data, method of data collection, time periods assessed, unit of observation, outcomes and results. Methodological quality was assessed using modified criteria specific to quantitative and qualitative studies.

RESULTS

Eleven quantitative and eight qualitative studies met inclusion criteria. In the seven years since its implementation, Part D decreased out-of-pocket costs among enrolled nursing home residents and potentially increased costs borne by LTC facilities. Coverage of prescription drugs frequently used by older adults was adequate, except for certain drugs and alternative formulations of importance to LTC residents. The use of medications that raise safety concerns was decreased, but overall drug utilization may have been unaffected. Although there was uncertain impact on clinical outcomes, quantitative studies demonstrated evidence of unintended health consequences. Qualitative studies consistently revealed increased administrative burden among providers.

LIMITATIONS

Empirical evidence of Part D's LTC impact was sparse. Due to limitations in available types of data, quantitative studies were generically lacking in methodological rigor. Qualitative studies suffered from lack of clarity of reporting. As future studies use clinical Medicare data, study quality is expected to improve.

CONCLUSION

Although LTC-specific policies continue to evolve, it appears that the prescription drug benefit may require further modifications to more effectively provide for LTC residents' unique medication needs and improve their health outcomes. Adjustments may be needed for Part D to be more compatible with LTC prescription drug delivery processes.

Readmission risk factors after hospital discharge among the elderly

Hospital readmission rates among the elderly are attracting increasing attention. Readmission is costly, especially as proposed new guidelines could deny reimbursement for readmissions. Identifying key factors at discharge that can serve as prognostic indicators for readmission is an important step toward developing and targeting interventions to reduce hospital readmissions rates. Published literature has listed predominantly demographic, clinical, and health care utilization characteristics to describe the factors that put the elderly at risk. However, additional factors are proposed that include social, clinical, individual-level, environmental, and system-level factors. Multimodal interventions have been tested and some reduction in readmissions has been shown. Whether these additional factors might lead to a further reduction remains unclear. In addition to possible factors at discharge, factors identified after the patient has been discharged also must be identified and addressed. The patient safety literature characterizes factors that put the elderly at risk for adverse drug events, which function as antecedent factors for readmission and likely include the environmental and system-level factors. Synthesizing these factors from the readmission and patient safety literature provides the basis to develop a more comprehensive conceptual framework to identify research gaps aimed at reducing hospital readmissions among the elderly.