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Moras E, Zaid S, Gandhi K, Barman N, Birnbaum Y, Virani SS, Tamis-Holland J, Jneid H, Krittanawong C. Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population. Curr Atheroscler Rep 2024; 26:231-248. [PMID: 38722473 DOI: 10.1007/s11883-024-01203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. RECENT FINDINGS Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.
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Affiliation(s)
- Errol Moras
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Syed Zaid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nitin Barman
- Cardiac Catheterization Laboratory, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
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Zuleta M, San-José A, Gozalo I, Sánchez-Arcilla M, Carrizo G, Alvarado M, Pérez-Bocanegra C. Patterns of inappropriate prescribing and clinical characteristics in patients at admission to an acute care of the elderly unit. Eur J Clin Pharmacol 2024; 80:553-561. [PMID: 38265499 DOI: 10.1007/s00228-024-03627-3] [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: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024]
Abstract
PURPOSE Inappropriate prescribing (IP) is common among the elderly and is associated with adverse health outcomes. The role of different patterns of IP in clinical practice remains unclear. The aim of this study is to analyse the characteristics of different patterns of IP in hospitalized older adults. METHODS This is a prospective observational study conducted in the acute care of elderly (ACE) unit of an acute hospital in Barcelona between June and August 2021. Epidemiological and demographic data were collected, and a comprehensive geriatric assessment (CGA) was performed on admitted patients. Four patterns of inappropriate prescribing were identified: extreme polypharmacy (10 or more drugs), potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs) and anticholinergic burden. RESULTS Among 93 admitted patients (51.6% male, mean age of 82.83), the main diagnosis was heart failure (36.6%). Overprescribing patterns (extreme polypharmacy, PIMs, PPOs and anticholinergic burden) were associated with higher comorbidity, increased dependence on instrumental activities of daily living (IADL) and greater prevalence of dementia. Underprescribing (omissions) was associated with important comorbidity, residence in nursing homes, an increased risk of malnutrition, higher social risk and greater frailty. Comparing different patterns of IP, patients with high anticholinergic burden exhibited more extreme polypharmacy and PIMs. In the case of omissions, no association was identified with other IP patterns. CONCLUSIONS We found statistically significant association between patterns of inappropriate prescribing and clinical and CGA variables such as comorbidity, dependency, dementia or frailty. There is a statistically significant association between patterns of overprescribing among patients admitted to the ACE unit.
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Affiliation(s)
- Mónica Zuleta
- Geriatric Unit, Internal Medicine Department, Vall d'Hebron Hospital, 08035, Barcelona, Spain.
| | - Antonio San-José
- Geriatric Unit, Internal Medicine Department, Vall d'Hebron Hospital, 08035, Barcelona, Spain
| | - Inés Gozalo
- Pharmacy Department, Sant Rafael Hospital, Barcelona, Spain
| | | | - Gabriela Carrizo
- Geriatric Unit, Internal Medicine Department, Vall d'Hebron Hospital, 08035, Barcelona, Spain
| | - Marcelo Alvarado
- Geriatric Unit, Internal Medicine Department, Vall d'Hebron Hospital, 08035, Barcelona, Spain
| | - Carmen Pérez-Bocanegra
- Geriatric Unit, Internal Medicine Department, Vall d'Hebron Hospital, 08035, Barcelona, Spain
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Jafri SH, Hushcha P, Dorbala P, Bousquet G, Lutfy C, Mellett L, Sonis L, Blankstein R, Cannon C, Plutzky J, Polk D, Skali H. Use of Optimal Medical Therapy in Patients With Cardiovascular Disease Undergoing Cardiac Rehabilitation. Curr Probl Cardiol 2024; 49:102058. [PMID: 37640175 DOI: 10.1016/j.cpcardiol.2023.102058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 08/31/2023]
Abstract
Optimal medical therapy (OMT) in patients with coronary artery disease (CAD) and/or heart failure (HF) is underused despite the established benefits of these medications. Cardiac rehabilitation (CR) may be one place where OMT could be promoted. We sought to describe the prevalence and characteristics of OMT use in patients with CAD or HF undergoing CR. We included patients with CAD (myocardial infarction, percutaneous coronary intervention, coronary artery bypass grafting, angina) and HF enrolled in our CR program. For patients with CAD, we defined OMT to consist of aspirin or other antiplatelets, statins, and beta-blockers (BB). For patients with HF or EF ≤ 40%, OMT included BB, spironolactone, and either Angiotensin Converting Enzyme inhibitors (ACEi)/angiotensin receptor blockers or angiotensin receptor neprilysin inhibitor (ARNI). For CAD patients with normal EF, OMT also included ACEi/ARB/ARNI if they also had diabetes type 2. From January 2015 to December 2019, 828 patients were referred to CR and 743 attended. Among 612 patients (mean age: 65, 23% female) with CAD, 483 (79%) patients were on OMT. Of the 131 HF patients (mean age: 64, 21% female) enrolled in CR, only 23 (18%) met all 3 OMT criteria, whereas most patients were on only 1 (93 %) or 2 (76%) HF specific medications. Spironolactone was the least prescribed (22%) medication. Over the study period, we observed a steady increase in the use of ARNI (2015: 0% vs 2019: 27%, p < 0.01). Among the individuals, 69 patients experienced both CAD and HF, while only 7 patients were under OMT for both CAD and HF. Most patients attending CR with CAD are receiving OMT, but most patients with HF are not. Although OMT has improved over time, there remains room for improvement, particularly among patients with HF.
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Affiliation(s)
- S Hammad Jafri
- Master of Medical Sciences in Clinical Investigation, Harvard Medical School, Boston, MA; Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Pavel Hushcha
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Pranav Dorbala
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Gisele Bousquet
- Cardiac Rehabilitation Program, Brigham and Women's Hospital, Foxborough, MA
| | - Christine Lutfy
- Cardiac Rehabilitation Program, Brigham and Women's Hospital, Foxborough, MA
| | - Lauren Mellett
- Cardiac Rehabilitation Program, Brigham and Women's Hospital, Foxborough, MA
| | - Lindsay Sonis
- Cardiac Rehabilitation Program, Brigham and Women's Hospital, Foxborough, MA
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | | | - Jorge Plutzky
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Donna Polk
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Hicham Skali
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA.
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Messiha D, Petrikhovich O, Lortz J, Pinsdorf D, Hogrebe K, Knuschke R, Hering R, Schulz M, Rassaf T, Rammos C. Underutilization of guideline-recommended therapy in patients 80 years and older with peripheral artery diseases. VASA 2023; 52:379-385. [PMID: 37867477 DOI: 10.1024/0301-1526/a001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Background: Ageing is a major cardiovascular risk factor with detrimental changes that culminate in a high atherosclerotic burden. Peripheral artery disease (PAD) is a major manifestation of atherosclerosis with high mortality. Guideline-recommended treatment is essential, however implementation is inadequate. With an ageing society, age-related inequalities are important and have not been elucidated in a high-risk PAD population on a nation-wide scale. We sought to analyse outpatient treatment structures and guideline adherence in treatment of PAD patients older than 80 years. Patients and methods: The study is based on ambulatory claims data comprising 70.1 million statutorily insured patients per year in Germany from 2009 to 2018. We analysed age-related differences in prevalence, pharmacotherapy and specialized outpatient care in PAD patients. Results: Of 17,633,970 PAD patients included, 28% were older than 80 years. PAD prevalence increased between 2008 and 2018 (1.85% vs. 3.14%), with the proportion of older patients increasing by a third (24.4% vs. 31.2%). Octogenarians were undertreated regarding guideline-recommended statin pharmacotherapy compared to younger patients while antiplatelets were prescribed more often (statins 2016: 46.5% vs. 52.4%; antiplatelets 2016 30.6% vs. 29.3%; p<.05). Furthermore, octogenarians received less specialized outpatient care (angiology: 6.4% vs. 9.5%, vascular surgery: 8.1% vs. 11.8%, cardiology: 25.2% vs. 29.2%, p<.05). Conclusions: Our results demonstrate that age-related differences in pharmacotherapy and specialized outpatient care of PAD patients are evident. While overall guideline-recommended outpatient treatment is low, patients 80 years and older are less likely to receive both, leaving age-related health inequalities a challenge of our future.
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Affiliation(s)
- Daniel Messiha
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Olga Petrikhovich
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Julia Lortz
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - David Pinsdorf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Kristina Hogrebe
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Ramtin Knuschke
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Ramona Hering
- Department of Data Science and Healthcare Analyses, Central Research Institute for Ambulatory Healthcare in Germany (Zi), Berlin, Germany
| | - Mandy Schulz
- Department of Data Science and Healthcare Analyses, Central Research Institute for Ambulatory Healthcare in Germany (Zi), Berlin, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
| | - Christos Rammos
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University of Duisburg-Essen, Germany
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Hanna V, Chahine B, Al Souheil F. Under‐prescription of medications in older adults according to START criteria: A cross‐sectional study in Lebanon. Health Sci Rep 2022; 5:e759. [PMID: 35949679 PMCID: PMC9358532 DOI: 10.1002/hsr2.759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims Under‐prescription is defined as the exclusion of medications indicated for the treatment of certain conditions without any rationale for not prescribing them. The under‐prescription of medications is highly prevalent among older adults (≥65 years) receiving polypharmacy. This study aimed to assess the prevalence of the under‐prescription of medications using the Screening Tool to Alert to Right Treatment (START) criteria version 2 and to identify the predictors of having potential prescribing omissions (PPOs). Methods This cross‐sectional, face‐to‐face interview study was carried out between September 2021 and February 2022. The study comprised community‐dwelling older adults taking at least one medication on a regular basis. The study questionnaire included the patients' demographics, clinical data, and comorbidities. PPOs were identified using the START criteria. The χ2 test was used to assess the association between under‐prescription of medication and the demographic/clinical variables. Multivariable logistic regression was performed to explore factors associated with under‐prescription of medications as the dependent variable and taking all variables that showed a p < 0.05 in the bivariate analysis as independent. Results A total of 444 older adults agreed to participate in this study. The mean age of participants was 71 ± 8.6; the majority of them, 305 (68.7%), were men. Polypharmacy was present in 261 patients (58.8%) and underprescribing of medications in 260 patients (58.6%). The highest percentage of under‐prescribing of medications was reported with statins in 115 patients (44.2%) followed by aspirin in 93 (35.7%), and angiotensin‐converting enzyme inhibitors in 61 (23.4%). The results of the multivariable analysis showed that patients with underprescribed medications had higher odds of polypharmacy (odds ratio [OR]: 2.015, confidence interval [CI] 95% 1.362–2.980, p < 0.001) and higher Charlson Comorbidity Index (OR 2.807, CI 95% 1.463–5.85, p = 0.02). Conclusion The present findings highlight that PPOs are highly prevalent among community‐dwelling older adults in Lebanon. Multimorbidity and polypharmacy were the identified predictors for under‐prescription of medications in this population.
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Affiliation(s)
- Venise Hanna
- PharmD Program, School of Pharmacy Lebanese International University Beirut Lebanon
| | - Bahia Chahine
- PharmD Program, School of Pharmacy Lebanese International University Beirut Lebanon
| | - Farah Al Souheil
- PharmD Program, School of Pharmacy Lebanese International University Beirut Lebanon
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Over- and under-prescribing, and their association with functional disability in older patients at risk of further decline in Germany - a cross-sectional survey conducted as part of a randomised comparative effectiveness trial. BMC Geriatr 2022; 22:564. [PMID: 35799113 PMCID: PMC9260981 DOI: 10.1186/s12877-022-03242-w] [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: 03/01/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022] Open
Abstract
Background Older patients at risk of functional decline are frequently affected by polypharmacy. This is associated with a further loss of independence. However, a relationship between functional disability and medications, such as ‘Potentially Inappropriate Medications’ (PIMs) and ‘Potential Prescribing Omissions’ (PPOs), as itemised for (de) prescribing in practice-orientated medication lists, has yet to be established. Methods As part of a randomised comparative effectiveness trial, LoChro, we conducted a cross-sectional analysis of the association between PIMs and PPOs measured using the ‘Screening Tool of Older Persons’ Prescription Criteria / Screening Tool To Alert to Right Treatment’ (STOPP/START) Version 2, with functional disability assessed using the ‘World Health Organization Disability Assessment Schedule 2.0’ (WHODAS). Individuals aged 65 and older at risk of loss of independence were recruited from the inpatient and outpatient departments of the local university hospital. Multiple linear regression analysis was used to model the potential prediction of functional disability using the numbers of PIMs and PPOs, adjusted for confounders including multimorbidity. Results Out of 461 patients, both the number of PIMs and the number of PPOs were significantly associated with an increase in WHODAS-score (Regression coefficients B 2.7 [95% confidence interval: 1.5-3.8] and 1.5 [95% confidence interval: 0.2-2.7], respectively). In WHODAS-score prediction modelling the contribution of the number of PIMs exceeded the one of multimorbidity (standardised coefficients beta: PIM 0.20; multimorbidity 0.13; PPO 0.10), whereas no significant association between the WHODAS-score and the number of medications was seen. 73.5 % (339) of the participants presented with at least one PIM, and 95.2% (439) with at least one PPO. The most common PIMs were proton pump inhibitors and analgesic medication, with frequent PPOs being pneumococcal and influenza vaccinations, as well as osteoporosis prophylaxis. Conclusions The results indicate a relationship between inappropriate prescribing, both PIMs and PPOs, and functional disability, in older patients at risk of further decline. Long-term analysis may help clarify whether these patients benefit from interventions to reduce PIMs and PPOs.
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Wells S, Choi Y, Jackson R, Parwaiz M, Mehta S, Selak V, Harwood M, Grey C, Kerse N, Poppe K. Cardiovascular disease preventive medication dispensing for almost every New Zealander 65 years and over: a preventive treatment paradox? Age Ageing 2022; 51:6514237. [PMID: 35077560 DOI: 10.1093/ageing/afab265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/15/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. METHODS New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. RESULTS Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79-87% were dispensed BPL and 73-79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65-69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65-69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26-31% across the 65-84 year age groups, falling to 17% at 85+ years. CONCLUSION The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often.
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Müller BS, Klaaßen-Mielke R, Gonzalez-Gonzalez AI, Grandt D, Hammerschmidt R, Köberlein-Neu J, Kellermann-Mühlhoff P, Trampisch HJ, Beckmann T, Düvel L, Surmann B, Flaig B, Ihle P, Söling S, Grandt S, Dinh TS, Piotrowski A, Meyer I, Karbach U, Harder S, Perera R, Glasziou P, Pfaff H, Greiner W, Gerlach FM, Timmesfeld N, Muth C. Effectiveness of the application of an electronic medication management support system in patients with polypharmacy in general practice: a study protocol of cluster-randomised controlled trial (AdAM). BMJ Open 2021; 11:e048191. [PMID: 34588245 PMCID: PMC8479941 DOI: 10.1136/bmjopen-2020-048191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Clinically complex patients often require multiple medications. Polypharmacy is associated with inappropriate prescriptions, which may lead to negative outcomes. Few effective tools are available to help physicians optimise patient medication. This study assesses whether an electronic medication management support system (eMMa) reduces hospitalisation and mortality and improves prescription quality/safety in patients with polypharmacy. METHODS AND ANALYSIS Planned design: pragmatic, parallel cluster-randomised controlled trial; general practices as randomisation unit; patients as analysis unit. As practice recruitment was poor, we included additional data to our primary endpoint analysis for practices and quarters from October 2017 to March 2021. Since randomisation was performed in waves, final study design corresponds to a stepped-wedge design with open cohort and step-length of one quarter. SCOPE general practices, Westphalia-Lippe (Germany), caring for BARMER health fund-covered patients. POPULATION patients (≥18 years) with polypharmacy (≥5 prescriptions). SAMPLE SIZE initially, 32 patients from each of 539 practices were required for each study arm (17 200 patients/arm), but only 688 practices were randomised after 2 years of recruitment. Design change ensures that 80% power is nonetheless achieved. INTERVENTION complex intervention eMMa. FOLLOW-UP at least five quarters/cluster (practice). recruitment: practices recruited/randomised at different times; after follow-up, control group practices may access eMMa. OUTCOMES primary endpoint is all-cause mortality and hospitalisation; secondary endpoints are number of potentially inappropriate medications, cause-specific hospitalisation preceded by high-risk prescribing and medication underuse. STATISTICAL ANALYSIS primary and secondary outcomes are measured quarterly at patient level. A generalised linear mixed-effect model and repeated patient measurements are used to consider patient clusters within practices. Time and intervention group are considered fixed factors; variation between practices and patients is fitted as random effects. Intention-to-treat principle is used to analyse primary and key secondary endpoints. ETHICS AND DISSEMINATION Trial approved by Ethics Commission of North-Rhine Medical Association. Results will be disseminated through workshops, peer-reviewed publications, local and international conferences. TRIAL REGISTRATION NCT03430336. ClinicalTrials.gov (https://clinicaltrials.gov/ct2/show/NCT03430336).
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Affiliation(s)
- Beate S Müller
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Renate Klaaßen-Mielke
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
| | - Ana Isabel Gonzalez-Gonzalez
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Daniel Grandt
- Department of Internal Medicine, Clinic Saarbrücken, Saarbrücken, Germany
| | - Reinhard Hammerschmidt
- Association of Statutory Health Insurance Physicians, Region Westphalia/Lippe, Dortmund, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | | | - Hans J Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
| | | | | | - Bastian Surmann
- Department of Health Economics and Health Care Management. Faculty of Health Science, Bielefeld University, Bielefeld, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Peter Ihle
- PMV Research Group, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sara Söling
- Institute for Medical Sociology, Health Services Research and Rehabilitation Science, Department of Health Services Research, University of Cologne, Cologne, Germany
| | | | - Truc Sophia Dinh
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Alexandra Piotrowski
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Ingo Meyer
- PMV Research Group, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ute Karbach
- Department of Rehabilitation Sociology, Faculty of Rehabilitation Sciences, Technical University Dortmund, Dortmund, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice (CREBP), Bond University, Robina, Queensland, Australia
| | - Holger Pfaff
- Institute of Medical Sociology, Health Services Research and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Care Management. Faculty of Health Science, Bielefeld University, Bielefeld, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Nina Timmesfeld
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, Bochum, Germany
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Germany
- Department of General Practice and Family Medicine, Medical Faculty OWL, Bielefeld University, Bielefeld, Germany
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Underprescription of medications in older adults: causes, consequences and solutions-a narrative review. Eur Geriatr Med 2021; 12:453-462. [PMID: 33709336 DOI: 10.1007/s41999-021-00471-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it. METHODS A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies. RESULTS Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription. CONCLUSION Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.
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González-González AI, Dinh TS, Meid AD, Blom JW, van den Akker M, Elders PJM, Thiem U, Kuellenberg de Gaudry D, Snell KIE, Perera R, Swart KMA, Rudolf H, Bosch-Lenders D, Trampisch HJ, Meerpohl JJ, Flaig B, Kom G, Gerlach FM, Hafaeli WE, Glasziou PP, Muth C. Predicting negative health outcomes in older general practice patients with chronic illness: Rationale and development of the PROPERmed harmonized individual participant data database. Mech Ageing Dev 2021; 194:111436. [PMID: 33460622 DOI: 10.1016/j.mad.2021.111436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 01/07/2021] [Accepted: 01/07/2021] [Indexed: 12/11/2022]
Abstract
The prevalence of multimorbidity and polypharmacy increases significantly with age and are associated with negative health consequences. However, most current interventions to optimize medication have failed to show significant effects on patient-relevant outcomes. This may be due to ineffectiveness of interventions themselves but may also reflect other factors: insufficient sample sizes, heterogeneity of population. To address this issue, the international PROPERmed collaboration was set up to obtain/synthesize individual participant data (IPD) from five cluster-randomized trials. The trials took place in Germany and The Netherlands and aimed to optimize medication in older general practice patients with chronic illness. PROPERmed is the first database of IPD to be drawn from multiple trials in this patient population and setting. It offers the opportunity to derive prognostic models with increased statistical power for prediction of patient-relevant outcomes resulting from the interplay of multimorbidity and polypharmacy. This may help patients from this heterogeneous group to be stratified according to risk and enable clinicians to identify patients that are likely to benefit most from resource/time-intensive interventions. The aim of this manuscript is to describe the rationale behind PROPERmed collaboration, characteristics of the included studies/participants, development of the harmonized IPD database and challenges faced during this process.
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Affiliation(s)
- Ana I González-González
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.
| | - Truc S Dinh
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Jeanet W Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, 2300RC, Leiden, the Netherlands
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands; Academic Centre for General Practice, Department of Public Health and Primary Care, KU, Leuven, Belgium
| | - Petra J M Elders
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Ulrich Thiem
- Chair of Geriatrics and Gerontology, University Clinic Eppendorf, 20246, Hamburg, Germany
| | - Daniela Kuellenberg de Gaudry
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany
| | - Kym I E Snell
- Centre for Prognosis Research, School of Primary Care Research, Community and Social Care, Keele University, Staffordshire, ST5 5BG, United Kingdom
| | - Rafael Perera
- Nuffield Department of Primary Care, University of Oxford, Oxford, OX2 6GG, United Kingdom
| | - Karin M A Swart
- Department of General Practice and Elderly Care Medicine, Amsterdam University Medical Center, 1007 MB, Amsterdam, the Netherlands
| | - Henrik Rudolf
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Donna Bosch-Lenders
- School of CAPHRI, Department of Family Medicine, Maastricht University, 6211 LK, Maastricht, the Netherlands
| | - Hans-Joachim Trampisch
- Department of Medical Informatics, Biometry and Epidemiology, Ruhr University, 44780, Bochum, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, 79110, Freiburg, Germany; Cochrane Germany, Cochrane Germany Foundation, Breisacher Strasse 153, 79110, Freiburg, Germany
| | - Benno Flaig
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Ghainsom Kom
- Techniker Krankenkasse (TK), 22765, Hamburg, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany
| | - Walter E Hafaeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital Heidelberg, 69120, Heidelberg, Germany
| | - Paul P Glasziou
- Centre for Research in Evidence-Based Practice, Bond University, Robina, QLD, 4226, Australia
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, 60590, Frankfurt am Main, Germany; Department of General Practice and Family Medicine, Medical Faculty OWL, University of Bielefeld, 33615, Bielefeld, Germany
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11
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Müller BS, Uhlmann L, Ihle P, Stock C, von Buedingen F, Beyer M, Gerlach FM, Perera R, Valderas JM, Glasziou P, van den Akker M, Muth C. Development and internal validation of prognostic models to predict negative health outcomes in older patients with multimorbidity and polypharmacy in general practice. BMJ Open 2020; 10:e039747. [PMID: 33093036 PMCID: PMC7583076 DOI: 10.1136/bmjopen-2020-039747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Polypharmacy interventions are resource-intensive and should be targeted to those at risk of negative health outcomes. Our aim was to develop and internally validate prognostic models to predict health-related quality of life (HRQoL) and the combined outcome of falls, hospitalisation, institutionalisation and nursing care needs, in older patients with multimorbidity and polypharmacy in general practices. METHODS Design: two independent data sets, one comprising health insurance claims data (n=592 456), the other data from the PRIoritising MUltimedication in Multimorbidity (PRIMUM) cluster randomised controlled trial (n=502). Population: ≥60 years, ≥5 drugs, ≥3 chronic diseases, excluding dementia. Outcomes: combined outcome of falls, hospitalisation, institutionalisation and nursing care needs (after 6, 9 and 24 months) (claims data); and HRQoL (after 6 and 9 months) (trial data). Predictor variables in both data sets: age, sex, morbidity-related variables (disease count), medication-related variables (European Union-Potentially Inappropriate Medication list (EU-PIM list)) and health service utilisation. Predictor variables exclusively in trial data: additional socio-demographics, morbidity-related variables (Cumulative Illness Rating Scale, depression), Medication Appropriateness Index (MAI), lifestyle, functional status and HRQoL (EuroQol EQ-5D-3L). Analysis: mixed regression models, combined with stepwise variable selection, 10-fold cross validation and sensitivity analyses. RESULTS Most important predictors of EQ-5D-3L at 6 months in best model (Nagelkerke's R² 0.507) were depressive symptoms (-2.73 (95% CI: -3.56 to -1.91)), MAI (-0.39 (95% CI: -0.7 to -0.08)), baseline EQ-5D-3L (0.55 (95% CI: 0.47 to 0.64)). Models based on claims data and those predicting long-term outcomes based on both data sets produced low R² values. In claims data-based model with highest explanatory power (R²=0.16), previous falls/fall-related injuries, previous hospitalisations, age, number of involved physicians and disease count were most important predictor variables. CONCLUSIONS Best trial data-based model predicted HRQoL after 6 months well and included parameters of well-being not found in claims. Performance of claims data-based models and models predicting long-term outcomes was relatively weak. For generalisability, future studies should refit models by considering parameters representing well-being and functional status.
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Affiliation(s)
- Beate S Müller
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Peter Ihle
- PMV Research Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Christian Stock
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Baden-Württemberg, Germany
| | - Fiona von Buedingen
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Martin Beyer
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Ferdinand M Gerlach
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, Oxfordshire, UK
| | - Jose Maria Valderas
- APEx Collaboration for Academic Primary Care, University of Exeter Medical School, Exeter, Devon, UK
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Marjan van den Akker
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt, Frankfurt am Main, Hessen, Germany
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12
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Aidoud A, Marlet J, Angoulvant D, Debacq C, Gavazzi G, Fougère B. Influenza vaccination as a novel means of preventing coronary heart disease: Effectiveness in older adults. Vaccine 2020; 38:4944-4955. [PMID: 32536551 DOI: 10.1016/j.vaccine.2020.05.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/03/2020] [Accepted: 05/25/2020] [Indexed: 12/28/2022]
Abstract
Atherosclerosis can have various etiologies, including several newly recognized immunoinflammatory mechanisms. A growing body of evidence suggests that influenza infection is chronologically linked to acute myocardial infarction (AMI), and thus that the virus is a novel cardiovascular disease (CVD) risk factor. Morbidity and mortality rates for both influenza infection and AMI rise markedly with age. Epidemiological studies have demonstrated that influenza vaccination (IV) has a cardioprotective effect, especially in people aged 65 and over; hence, IV may be of value in the management of CVD. These observations justify efforts to better understand the underlying mechanisms and to identify therapeutic targets in older adults. In view of the above, the objective of the present study was to review the literature data on the cellular mechanisms that link IV to the prevention of atherosclerotic complications. Given the greater burden of CVD in older subjects, we also questioned the impact of aging on this association. The most widely recognized benefit of IV is the prevention of influenza infection and the latter's cardiovascular complications. In a new hypothesis, however, an influenza-independent effect is driven by vaccine immunity and modulation of the ongoing immunoinflammatory response in individuals with CVD. Although influenza infection and IV both induce a proinflammatory response, they have opposite effects on the progression of atherosclerosis - suggesting a hormetic phenomenon. Aging is characterized by chronic inflammation (sometimes referred to as "inflammaging") that progresses insidiously during the course of aging-related diseases, including CVD. It remains to be determined whether vaccination has an effect on aging-related diseases other than CVD. Although the studies of this topic had various limitations, the results highlight the potential benefits of vaccination in protecting the health of older adults, and should drive research on the molecular immunology of the response to IV and its correlation with atheroprotective processes.
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Affiliation(s)
- Amal Aidoud
- Division of Geriatric Medicine, Tours University Hospital, Tours, France.
| | - Julien Marlet
- French National Institute of Health and Medical Research INSERM U1259, University of Tours, Tours, France
| | - Denis Angoulvant
- Cardiology Unit, Trousseau Hospital, CHRU de Tours & EA4245, Loire Valley Cardiovascular Collaboration, Tours University, Tours, France
| | - Camille Debacq
- Division of Geriatric Medicine, Tours University Hospital, Tours, France
| | - Gaëtan Gavazzi
- University Clinics of Geriatrics, University Hospital of Grenoble-Alpes, GREPI EA7408 University of Grenoble Alpes, Grenoble, France
| | - Bertrand Fougère
- Division of Geriatric Medicine, Tours University Hospital, Tours, France; Éducation, éthique, santé (EA 7505), Tours University, Tours, France
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13
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Feng Z, Williams D, Ladapo JA. Differences in Cardiovascular Care Between Adults With and Without Opioid Prescriptions in the United States. J Am Heart Assoc 2020; 9:e015961. [PMID: 32458701 PMCID: PMC7429007 DOI: 10.1161/jaha.120.015961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients prescribed opioids often have chronic conditions that increase their risk of adverse cardiovascular outcomes, but little is known about the primary preventive cardiovascular care these patients receive. Methods and Results We analyzed data from the 2014 to 2016 National Ambulatory Medical Care Survey to evaluate physicians’ provision of primary preventive cardiovascular care to adults with and without opioid prescriptions. We included all visits made by adults 40 to 79 years old with at least 1 cardiovascular risk factor but no existing atherosclerotic cardiovascular disease. There were ≈32 million visits by adults who were prescribed opioids and ≈167 million visits by adults not prescribed opioids on an annual basis. The prevalence of primary preventive care was modest in patients with versus those without opioid prescriptions, respectively: (1) statins for patients with dyslipidemia (52.1% versus 46.3%); (2) statins for patients with diabetes mellitus (49.1% versus 37.9%); (3) antihypertensive agents for patients with hypertension (76.5% versus 65.8%); (4) diet/exercise counseling (40.5% versus 45.3%); and (5) smoking cessation therapy (25.3% versus 19.3%). In multivariate analyses, opioid use was associated with higher rates of statin therapy in patients with diabetes mellitus (adjusted relative risk [aRR], 1.25; 95% CI, 1.06–1.47; P=0.007) and antihypertensive medication in patients with hypertension (aRR 1.14; 95% CI, 1.06–1.22; P<0.001). Conclusions Overall adherence to guideline‐recommended primary preventive cardiovascular care during ambulatory visits was suboptimal. Findings show that patients prescribed opioids versus those without opioid prescriptions were more likely to receive statin therapy and antihypertensive agents in the setting of diabetes mellitus and hypertension, respectively. Ongoing efforts to bridge these gaps in primary prevention of cardiovascular disease remain a high priority.
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Affiliation(s)
- Zekun Feng
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Dominic Williams
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
| | - Joseph A Ladapo
- Department of Medicine David Geffen School of Medicine at UCLA Los Angeles CA
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14
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Erickson SR, Basu T, Dorsch MP, Kamdar N. Disparities in the Use of Guideline-Based Pharmacotherapy Exist for Atherosclerotic Cardiovascular Disease and Heart Failure Patients Who Have Intellectual/Developmental Disabilities in a Commercially Insured Database. Ann Pharmacother 2020; 54:958-966. [PMID: 32336108 DOI: 10.1177/1060028020916842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients who have intellectual/developmental disabilities (IDDs) develop atherosclerotic cardiovascular disease (ASCVD) or heart failure (HF) at rates similar to or higher than the general population. They also face disparities accessing and using health care services. OBJECTIVE To determine if disparities exist in the use of guideline-based pharmacotherapy (GBP) for ASCVD or HF for adults with IDD. METHODS Using the 2014 Clinformatics Data Mart Database, adults with ASCVD or HF were divided into IDD or non-IDD groups. Patients with contraindications for GBP medications were excluded. Use of GBP between IDD and non-IDD groups was examined. Subgroup analysis included comparisons between IDD groups. RESULTS For HF, 1011 patients with IDD and 236,638 non-IDD patients were identified. For ASCVD, 2190 IDD and 790,343 non-IDD patients were identified. We found that 47.9%, 35.8%, and 13.1% of IDD and 58.7%, 48.4%, and 18.9% of non-IDD patients had pharmacy claims for statins (P < 0.001), β-blockers (P < 0.001), or antiplatelet therapy (P < 0.001), respectively. For HF, 46.8% and 50.3% of IDD and 59.8% and 55.4% of non-IDD patients had pharmacy claims for β-blockers (P < 0.001) and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs; P = 0.003), respectively. In all but one multivariate regression models patients with IDD were less likely to use GBP than patients in the non-IDD group. Subgroup analysis revealed that patients who had Down syndrome had lower GBP use in 4 of the 5 measures. CONCLUSION AND RELEVANCE Disparities exist in the use of GBP for patients with IDD with ASCVD or HF. Patients who have an IDD should be examined by clinicians to ensure appropriate access to and use of GBP.
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Affiliation(s)
- Steven R Erickson
- University of Michigan, Ann Arbor, MI, USA.,Wayne State University, Detroit, MI, USA
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15
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Gutiérrez-Valencia M, Martínez-Velilla N. Frailty in the older person: Implications for pharmacists. Am J Health Syst Pharm 2019; 76:1980-1987. [PMID: 31622459 DOI: 10.1093/ajhp/zxz217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Marta Gutiérrez-Valencia
- Pharmacy Department, Navarrabiomed, Universidad Pública de Navarra, Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona Navarra, Spain
| | - Nicolás Martínez-Velilla
- Geriatric Department, Navarrabiomed, Universidad Pública de Navarra, Complejo Hospitalario de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona Navarra, Spain, Biomedical Research Networking Center of Frailty and Healthy Aging, Madrid, Spain
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16
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Boehlen FH, Freigofas J, Herzog W, Meid AD, Saum KU, Schoettker B, Brenner H, Haefeli WE, Wild B. Evidence for underuse and overuse of antidepressants in older adults: Results of a large population-based study. Int J Geriatr Psychiatry 2019; 34:539-547. [PMID: 30623499 DOI: 10.1002/gps.5047] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 11/29/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Depression is common among elderly people. However, diagnosis and adequate treatment is frequently difficult. Research on underuse and overuse of antidepressants in elderly persons is scarce. This study investigates the utilization and appropriateness of pharmacological and psychological depression treatment in a large cohort of community-dwelling adults. METHODS A subsample of 3117 participants (aged 55-85 y) of the third follow-up (2008-2010) of the large population-based German ESTHER study was included. Depression was assessed using the eight-item Patient Health Questionnaire (PHQ-8). In the course of a home visit, study doctors collected complete information on medication. Logistic regression analyses were conducted to determine the relationship of depression with both underuse and overuse of antidepressants. The analyses were then adjusted for socioeconomic variables, psychosomatic comorbidities, and motivation to seek help. RESULTS One hundred sixty-three participants (5.2%; 95% confidence interval [CI], 4.5-6.1) fulfilled the criteria for major depression. Underuse of antidepressants was present in 126 depressed participants (77.3%; 70.1-83.5). Persons who were motivated to seek help, who had an established depression diagnosis, or who were taking more than five different medications had lower odds of underuse. Anxiety was associated with higher odds for underuse. Overuse of antidepressants (prescription without clinical indication) was found in 96 cases (41.7%; 35.3-48.4) of all antidepressant prescriptions. CONCLUSIONS Depression treatment in older adults is frequently insufficient; it appears to depend on diagnosis as well as the patients' motivation to seek help. Education regarding the diagnosis of depression in the elderly as well as guidelines for appropriate treatment is needed.
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Affiliation(s)
- Friederike H Boehlen
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Julia Freigofas
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Herzog
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Kai-Uwe Saum
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Ben Schoettker
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Medical University Hospital Heidelberg, Heidelberg, Germany
| | - Beate Wild
- Department of General Internal Medicine and Psychosomatics, Medical University Hospital Heidelberg, Heidelberg, Germany
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17
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Jansen J, McKinn S, Bonner C, Muscat DM, Doust J, McCaffery K. Shared decision-making about cardiovascular disease medication in older people: a qualitative study of patient experiences in general practice. BMJ Open 2019; 9:e026342. [PMID: 30898831 PMCID: PMC6475217 DOI: 10.1136/bmjopen-2018-026342] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES To explore older people's perspectives and experiences with shared decision-making (SDM) about medication for cardiovascular disease (CVD) prevention. DESIGN, SETTING AND PARTICIPANTS Semi-structured interviews with 30 general practice patients aged 75 years and older in New South Wales, Australia, who had elevated CVD risk factors (blood pressure, cholesterol) or had received CVD-related lifestyle advice. Data were analysed by multiple researchers using Framework analysis. RESULTS Twenty eight participants out of 30 were on CVD prevention medication, half with established CVD. We outlined patient experiences using the four steps of the SDM process, identifying key barriers and challenges: Step 1. Choice awareness: taking medication for CVD prevention was generally not recognised as a decision requiring patient input; Step 2. Discuss benefits/harms options: CVD prevention poorly understood with emphasis on benefits; Step 3. Explore preferences: goals, values and preferences (eg, length of life vs quality of life, reducing disease burden vs risk reduction) varied widely but generally not discussed with the general practitioner; Step 4. Making the decision: overall preference for directive approach, but some patients wanted more active involvement. Themes were similar across primary and secondary CVD prevention, different levels of self-reported health and people on and off medication. CONCLUSIONS Results demonstrate how older participants vary widely in their health goals and preferences for treatment outcomes, suggesting that CVD prevention decisions are preference sensitive. Combined with the fact that the vast majority of participants were taking medications, and few understood the aims and potential benefits and harms of CVD prevention, it seems that older patients are not always making an informed decision. Our findings highlight potentially modifiable barriers to greater participation of older people in SDM about CVD prevention medication and prevention in general.
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Affiliation(s)
- Jesse Jansen
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Shannon McKinn
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Carissa Bonner
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
| | - Danielle Marie Muscat
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
| | - Jenny Doust
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Kirsten McCaffery
- Faculty of Medicine and Health, School of Public Health, Sydney Health Literacy Lab, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, School of Public Health, Wiser Healthcare, The University of Sydney, Sydney, New South Wales, Australia
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18
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Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc 2019; 67:1123-1127. [PMID: 30697698 DOI: 10.1111/jgs.15798] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 11/29/2022]
Abstract
Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of "inappropriate" vs "appropriate" polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.
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Affiliation(s)
- Terri R Fried
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Marcia C Mecca
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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19
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Schwartz JB, Schmader KE, Hanlon JT, Abernethy DR, Gray S, Dunbar-Jacob J, Holmes HM, Murray MD, Roberts R, Joyner M, Peterson J, Lindeman D, Tai-Seale M, Downey L, Rich MW. Pharmacotherapy in Older Adults with Cardiovascular Disease: Report from an American College of Cardiology, American Geriatrics Society, and National Institute on Aging Workshop. J Am Geriatr Soc 2018; 67:371-380. [PMID: 30536694 DOI: 10.1111/jgs.15634] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To identify the top priority areas for research to optimize pharmacotherapy in older adults with cardiovascular disease (CVD). DESIGN Consensus meeting. SETTING Multidisciplinary workshop supported by the National Institute on Aging, the American College of Cardiology, and the American Geriatrics Society, February 6-7, 2017. PARTICIPANTS Leaders in the Cardiology and Geriatrics communities, (officers in professional societies, journal editors, clinical trialists, Division chiefs), representatives from the NIA; National Heart, Lung, and Blood Institute; Food and Drug Administration; Centers for Medicare and Medicaid Services, Alliance for Academic Internal Medicine, Patient-Centered Outcomes Research Institute, Agency for Healthcare Research and Quality, pharmaceutical industry, and trainees and early career faculty with interests in geriatric cardiology. MEASUREMENTS Summary of workshop proceedings and recommendations. RESULTS To better align older adults' healthcare preferences with their care, research is needed to improve skills in patient engagement and communication. Similarly, to coordinate and meet the needs of older adults with multiple comorbidities encountering multiple healthcare providers and systems, systems and disciplines must be integrated. The lack of data from efficacy trials of CVD medications relevant to the majority of older adults creates uncertainty in determining the risks and benefits of many CVD therapies; thus, developing evidence-based guidelines for older adults with CVD is a top research priority. Polypharmacy and medication nonadherence lead to poor outcomes in older people, making research on appropriate prescribing and deprescribing to reduce polypharmacy and methods to improve adherence to beneficial therapies a priority. CONCLUSION The needs and circumstances of older adults with CVD differ from those that the current medical system has been designed to meet. Optimizing pharmacotherapy in older adults will require new data from traditional and pragmatic research to determine optimal CVD therapy, reduce polypharmacy, increase adherence, and meet person-centered goals. Better integration of the multiple systems and disciplines involved in the care of older adults will be essential to implement and disseminate best practices. J Am Geriatr Soc 67:371-380, 2019.
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Affiliation(s)
- Janice B Schwartz
- Divisions of Geriatrics and Clinical Pharmacology, Departments of Medicine and Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California
| | - Kenneth E Schmader
- Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Joseph T Hanlon
- Division of Geriatrics, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Darrell R Abernethy
- Office of Clinical Pharmacology, U.S. Food & Drug Administration, Silver Spings, Maryland
| | - Shelly Gray
- Department of Pharmacy, University of Washington, Seattle, Washington
| | | | - Holly M Holmes
- Geriatric and Palliative Medicine, Department of Medicine, McGovern Medical School, Houston, Texas
| | - Michael D Murray
- Department of Pharmacy Practice, Regenstrief Institute, Purdue University, West Lafayette, Indiana
| | - Robert Roberts
- Department of Medicine, College of Medicine, University of Arizona, Phoenix, Arizona
| | - Michael Joyner
- Departments of Anesthesiology and Perioperative Medicine and Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota
| | - Josh Peterson
- Departments of Biomedical Informatics and Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Lindeman
- CITRIS and the Banatao Institute, University of California, Berkeley, California
| | - Ming Tai-Seale
- Division of Health Policy, Department of Family Medicine and Public Health, University of California, San Diego, San Diego, California
| | - Laura Downey
- Concordance Health Solutions, West Lafayette, Indiana.,Krannert School of Management, Purdue University, West Lafayette, Indiana
| | - Michael W Rich
- Cardiovascular Division, Department of Internal Medicine, Washington University, St. Louis, Missouri
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Gutiérrez‐Valencia M, Izquierdo M, Cesari M, Casas‐Herrero Á, Inzitari M, Martínez‐Velilla N. The relationship between frailty and polypharmacy in older people: A systematic review. Br J Clin Pharmacol 2018; 84:1432-1444. [PMID: 29575094 PMCID: PMC6005607 DOI: 10.1111/bcp.13590] [Citation(s) in RCA: 229] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 03/13/2018] [Accepted: 03/18/2018] [Indexed: 12/15/2022] Open
Abstract
AIMS Frailty is a complex geriatric syndrome resulting in decreased physiological reserves. Frailty and polypharmacy are common in older adults and the focus of extensive studies, although little is known about the impact they may have on each other. This is the first systematic review analysing the available evidence on the relationship between frailty and polypharmacy in older adults. METHODS Systematic review of quantitative studies. A comprehensive literature search for publications in English or Spanish was performed on MEDLINE, CINAHL, the Cochrane Database and PsycINFO in September 2017 without applying restrictions on the date of publication. Studies reporting any relationship between frailty and polypharmacy in older adults were considered. RESULTS A total of 25 publications were included, all of them observational studies. Evaluation of Fried's frailty criteria was the most common approach, followed by the Edmonton Frail Scale and FRAIL scale. Sixteen of 18 cross-sectional analyses and five of seven longitudinal analyses demonstrated a significant association between an increased number of medications and frailty. The causal relationship is unclear and appears to be bidirectional. Our analysis of published data suggests that polypharmacy could be a major contributor to the development of frailty. CONCLUSIONS A reduction of polypharmacy could be a cautious strategy to prevent and manage frailty. Further research is needed to confirm the possible benefits of reducing polypharmacy in the development, reversion or delay of frailty.
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Affiliation(s)
- M. Gutiérrez‐Valencia
- Department of GeriatricsComplejo Hospitalario de NavarraPamplonaNavarraSpain
- IdiSNa, Navarra Institute for Health ResearchPamplonaNavarraSpain
| | - M. Izquierdo
- Health Science DepartmentPublic University of NavarraPamplonaNavarraSpain
- CIBER of Frailty and Healthy AgingMadridSpain
| | - M. Cesari
- Fondazione IRCCS Ca' Granda, Ospedale Maggiore PoliclinicoMilanItaly
- Dipartimento di Scienze Cliniche e di ComunitàUniversità di MilanoMilanItaly
| | - Á. Casas‐Herrero
- Department of GeriatricsComplejo Hospitalario de NavarraPamplonaNavarraSpain
- IdiSNa, Navarra Institute for Health ResearchPamplonaNavarraSpain
- CIBER of Frailty and Healthy AgingMadridSpain
| | - M. Inzitari
- Parc Sanitari Pere VirgiliBarcelonaCataloniaSpain
- Universitat Autònoma de BarcelonaCataloniaSpain
| | - N. Martínez‐Velilla
- Department of GeriatricsComplejo Hospitalario de NavarraPamplonaNavarraSpain
- IdiSNa, Navarra Institute for Health ResearchPamplonaNavarraSpain
- CIBER of Frailty and Healthy AgingMadridSpain
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21
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Gutiérrez-Valencia M, Izquierdo M, Lacalle-Fabo E, Marín-Epelde I, Ramón-Espinoza MF, Domene-Domene T, Casas-Herrero Á, Galbete A, Martínez-Velilla N. Relationship between frailty, polypharmacy, and underprescription in older adults living in nursing homes. Eur J Clin Pharmacol 2018; 74:961-970. [PMID: 29589065 DOI: 10.1007/s00228-018-2452-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 03/19/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Frailty, polypharmacy, and underprescription are considered a major matter of concern in nursing homes, but the possible relationships between them are not well known. The aim is to examine the possible association between medication underprescription, polypharmacy, and frailty in older people living in nursing homes. METHODS A cross-sectional analysis from a concurrent cohort study, including 110 subjects ≥ 65 years living in two nursing homes. Four frailty scales were applied; polypharmacy was defined as ≥ 5 medications and underprescription was measured with Screening Tool to Alert to Right Treatment (START) criteria. Logistic regression models were performed to assess the associations. RESULTS The mean age was 86.3 years (SD 7.3) and 71.8% were female. 73.6% of subjects took ≥ 5 chronic medications and 60.9% met one or more START criteria. The non-frail participants took more medications than the frail subjects according to the imputated frailty Fried criteria (8.1 vs 6.7, p = 0.042) and the FRAIL-NH scale (7.8 vs 6.8, p = 0.026). Multivariate analyses did not find an association between frailty and polypharmacy. Frail participants according to the Fried criteria met a higher number of START criteria (1.9 vs 1.0, p = 0.017), and had a higher prevalence of underprescription (87.5 vs 50.0%), reaching the limit of statistical significance in multivariate analysis. CONCLUSION The positive association found in previous studies between frailty and polypharmacy cannot be extrapolated to institutionalized populations. There is a trend towards higher rates of underprescription in frail subjects. Underprescription in frail older adults should be redefined and new strategies to measure it should be developed.
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Affiliation(s)
- Marta Gutiérrez-Valencia
- Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain.
- IdiSNa, Navarra Institute for Health Research, Pamplona, Navarra, Spain.
| | - Mikel Izquierdo
- Health Science Department, Public University of Navarra, Pamplona, Navarra, Spain
- CIBER of Frailty and Healthy Aging, Madrid, Spain
| | - Esther Lacalle-Fabo
- Pharmacy Department, Complejo Hospitalario de Navarra, Pamplona, Navarra, Spain
| | - Itxaso Marín-Epelde
- Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain
| | | | - Thamara Domene-Domene
- Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain
| | - Álvaro Casas-Herrero
- Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain
- IdiSNa, Navarra Institute for Health Research, Pamplona, Navarra, Spain
| | - Arkaitz Galbete
- Navarrabiomed-Departamento de Salud-UPNA, Pamplona, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
| | - Nicolás Martínez-Velilla
- Department of Geriatrics, Complejo Hospitalario de Navarra, C/Irunlarrea 3, 31008, Pamplona, Spain
- IdiSNa, Navarra Institute for Health Research, Pamplona, Navarra, Spain
- CIBER of Frailty and Healthy Aging, Madrid, Spain
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Muth C, Uhlmann L, Haefeli WE, Rochon J, van den Akker M, Perera R, Güthlin C, Beyer M, Oswald F, Valderas JM, Knottnerus JA, Gerlach FM, Harder S. Effectiveness of a complex intervention on Prioritising Multimedication in Multimorbidity (PRIMUM) in primary care: results of a pragmatic cluster randomised controlled trial. BMJ Open 2018; 8:e017740. [PMID: 29478012 PMCID: PMC5855483 DOI: 10.1136/bmjopen-2017-017740] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Investigate the effectiveness of a complex intervention aimed at improving the appropriateness of medication in older patients with multimorbidity in general practice. DESIGN Pragmatic, cluster randomised controlled trial with general practice as unit of randomisation. SETTING 72 general practices in Hesse, Germany. PARTICIPANTS 505 randomly sampled, cognitively intact patients (≥60 years, ≥3 chronic conditions under pharmacological treatment, ≥5 long-term drug prescriptions with systemic effects); 465 patients and 71 practices completed the study. INTERVENTIONS Intervention group (IG): The healthcare assistant conducted a checklist-based interview with patients on medication-related problems and reconciled their medications. Assisted by a computerised decision support system, the general practitioner optimised medication, discussed it with patients and adjusted it accordingly. The control group (CG) continued with usual care. OUTCOME MEASURES The primary outcome was a modified Medication Appropriateness Index (MAI, excluding item 10 on cost-effectiveness), assessed in blinded medication reviews and calculated as the difference between baseline and after 6 months; secondary outcomes after 6 and 9 months' follow-up: quality of life, functioning, medication adherence, and so on. RESULTS At baseline, a high proportion of patients had appropriate to mildly inappropriate prescriptions (MAI 0-5 points: n=350 patients). Randomisation revealed balanced groups (IG: 36 practices/252 patients; CG: 36/253). Intervention had no significant effect on primary outcome: mean MAI sum scores decreased by 0.3 points in IG and 0.8 points in CG, resulting in a non-significant adjusted mean difference of 0.7 (95% CI -0.2 to 1.6) points in favour of CG. Secondary outcomes showed non-significant changes (quality of life slightly improved in IG but continued to decline in CG) or remained stable (functioning, medication adherence). CONCLUSIONS The intervention had no significant effects. Many patients already received appropriate prescriptions and enjoyed good quality of life and functional status. We can therefore conclude that in our study, there was not enough scope for improvement. TRIAL REGISTRATION NUMBER ISRCTN99526053. NCT01171339; Results.
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Affiliation(s)
- Christiane Muth
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Lorenz Uhlmann
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Justine Rochon
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Marjan van den Akker
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
- Department of Public Health and Primary Care, Academic Center for General Practice, KU Leuven, Leuven, Belgium
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Corina Güthlin
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Martin Beyer
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Frank Oswald
- Interdisciplinary Ageing Research (IAW), Faculty of Educational Sciences, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Jose Maria Valderas
- APEx Collaboration for Academic Primary Care, University of Exeter Medical School, Exeter, UK
| | - J André Knottnerus
- Department of Family Medicine, School CAPHRI, Maastricht University, Maastricht, The Netherlands
| | - Ferdinand M Gerlach
- Institute of General Practice, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Sebastian Harder
- Institute for Clinical Pharmacology, Johann Wolfgang Goethe University Hospital, Frankfurt / Main, Germany
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23
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Meid AD, Haefeli WE. Refining estimates of prescription durations by using observed covariates in pharmacoepidemiologic databases: Necessary refinements to stimulate alternative approaches. Pharmacoepidemiol Drug Saf 2017; 26:1135-1137. [PMID: 28913962 DOI: 10.1002/pds.4270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 06/27/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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24
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Meid AD, Mächler S, Haefeli WE, Mikus G. Real-world complexity of atrial fibrillation treatment with oral anticoagulants: design and interpretation of pharmacoepidemiological studies. Br J Clin Pharmacol 2017; 83:2321-2324. [PMID: 28734007 DOI: 10.1111/bcp.13348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/09/2017] [Accepted: 06/13/2017] [Indexed: 01/25/2023] Open
Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Sarah Mächler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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25
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Meid AD, Heider D, Adler JB, Quinzler R, Brenner H, Günster C, König HH, Haefeli WE. Comparative evaluation of methods approximating drug prescription durations in claims data: modeling, simulation, and application to real data. Pharmacoepidemiol Drug Saf 2016; 25:1434-1442. [PMID: 27633276 DOI: 10.1002/pds.4091] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 05/18/2016] [Accepted: 08/10/2016] [Indexed: 12/15/2022]
Abstract
PURPOSE The purpose of this study was to compare the predictive accuracy of different methods suggested for approximation of drug prescription durations in claims data. METHODS We expanded a well-established modeling and simulation framework to compare approximated drug prescription durations with 'true' (i.e., simulated) durations. Real claims data of persons aged ≥65 years insured by the German nationwide 'Statutory Health Insurance Fund' AOK between 2010 and 2012 provided empiric input parameters that were completed with missing information on actual dosing patterns from an observational cohort. The distinct approximation methods were based on crude measures (one tablet a day), population-averaged measures (defined daily doses), or individually-derived measures (longitudinal coverage approximation of the applied dose, COV). As a proof-of-principle, we assessed the methods' performance to predict the well-characterized bleeding risks of anticoagulant, antiplatelet, and/or non-steroidal anti-inflammatory drugs. RESULTS When applied to modeling and simulation data sets, the closest, least biased, and thus most accurate approximation was observed using the COV approximation. In a real-data example, rather similar results to an external reference were obtained for all methods. However, some of the differences between methods were meaningful, and the most reasonable and consistent results were obtained with the COV approach. CONCLUSION Based on theoretically most accurate approximations and practically reasonable estimates, the individual COV approach was preferable over the population-averaged defined daily dose technique, although the latter might be justified in certain situations. Advantages of the COV approach are expected to be even bigger for drug therapies with particularly large dosing heterogeneity. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Andreas D Meid
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Dirk Heider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Renate Quinzler
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Herrmann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Network Aging Research, University of Heidelberg, Heidelberg, Germany
| | | | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
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26
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Wauters M, Elseviers M, Vaes B, Degryse J, Dalleur O, Vander Stichele R, Christiaens T, Azermai M. Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community-dwelling oldest old. Br J Clin Pharmacol 2016; 82:1382-1392. [PMID: 27426227 DOI: 10.1111/bcp.13055] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/09/2016] [Accepted: 06/18/2016] [Indexed: 12/15/2022] Open
Abstract
AIMS Little is known about the impact of inappropriate prescribing (IP) in community-dwelling adults, aged 80 years and older. The prevalence at baseline (November 2008September 2009) and impact of IP (misuse and underuse) after 18 months on mortality and hospitalization in a cohort of community-dwelling adults, aged 80 years and older (n = 503) was studied. METHODS Screening Tool of Older People's Prescriptions (STOPP-2, misuse) and Screening Tool to Alert to Right Treatment (START-2, underuse) criteria were cross-referenced and linked to the medication use (in Anatomical Therapeutic Chemical coding) and clinical problems. Survival analysis until death or first hospitalization was performed at 18 months after inclusion using Kaplan-Meier, with Cox regression to control for covariates. RESULTS Mean age was 84.4 (range 80-102) years. Mean number of medications prescribed was 5 (range 0-16). Polypharmacy (≥5 medications, 58%), underuse (67%) and misuse (56%) were high. Underuse and misuse coexisted in 40% and were absent in 17% of the population. A higher number of prescribed medications was correlated with more misused medications (rs = .51, P < 0.001) and underused medications (rs = .26, P < 0.001). Mortality and hospitalization rate were 8.9%, and 31.0%, respectively. After adjustment for number of medications and misused medications, there was an increased risk of mortality (HR 1.39, 95% CI 1.10, 1.76) and hospitalization (HR 1.26, 95% CI 1.10, 1.45) for every additional underused medication. Associations with misuse were less clear. CONCLUSION IP (polypharmacy, underuse and misuse) was highly prevalent in adults, aged 80 years and older. Surprisingly, underuse and not misuse had strong associations with mortality and hospitalization.
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Affiliation(s)
- Maarten Wauters
- Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent.
| | - Monique Elseviers
- Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent
| | - Bert Vaes
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels.,Department of Public and Primary Health Care, Catholic University of Leuven, Leuven
| | - Jan Degryse
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Louvain Drug Research Institute, Brussels.,Department of Public and Primary Health Care, Catholic University of Leuven, Leuven
| | - Olivia Dalleur
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université Catholique de Louvain, Brussels.,Cliniques universitaires Saint-Luc, Université catholique de Louvain, Pharmacy, Brussels, Belgium
| | - Robert Vander Stichele
- Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent
| | - Thierry Christiaens
- Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent
| | - Majda Azermai
- Clinical Pharmacology Research Unit, Ghent University, Heymans Institute of Pharmacology, Ghent
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Moriarty F, Bennett K, Cahir C, Kenny RA, Fahey T. Potentially inappropriate prescribing according to STOPP and START and adverse outcomes in community-dwelling older people: a prospective cohort study. Br J Clin Pharmacol 2016; 82:849-57. [PMID: 27136457 DOI: 10.1111/bcp.12995] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/21/2016] [Accepted: 04/28/2016] [Indexed: 02/03/2023] Open
Abstract
AIMS This study aims to determine if potentially inappropriate prescribing (PIP) is associated with increased healthcare utilization, functional decline and reduced quality of life (QoL) in a community-dwelling older cohort. METHOD This prospective cohort study included participants aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) with linked administrative pharmacy claims data who were followed up after 2 years. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START). The association with number of emergency department (ED) visits and GP visits reported over 12 months was analyzed using multivariate negative binomial regression adjusting for confounders. Marginal structural models investigated the presence of time-dependent confounding. RESULTS Of participants followed up (n = 1753), PIP was detected in 57% by STOPP and 41.8% by START, 21.7% reported an ED visit and 96.1% visited a GP (median 4, IQR 2.5-6). Those with any STOPP criterion had higher rates of ED visits (adjusted incident rate ratio (IRR) 1.30, 95% confidence interval (CI) 1.02, 1.66) and GP visits (IRR 1.15, 95%CI 1.06, 1.24). Patients with two or more START criteria had significantly more ED visits (IRR 1.45, 95%CI 1.03, 2.04) and GP visits (IRR 1.13, 95%CI 1.01, 1.27) than people with no criteria. Adjusting for time-dependent confounding did not affect the findings. CONCLUSIONS Both STOPP and START were independently associated with increased healthcare utilization and START was also related to functional decline and QoL. Optimizing prescribing to reduce PIP may provide an improvement in patient outcomes.
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Affiliation(s)
- Frank Moriarty
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
| | - Kathleen Bennett
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin
| | - Caitriona Cahir
- Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin
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28
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Meid AD, Quinzler R, Groll A, Wild B, Saum KU, Schöttker B, Heider D, König HH, Brenner H, Haefeli WE. Longitudinal evaluation of medication underuse in older outpatients and its association with quality of life. Eur J Clin Pharmacol 2016; 72:877-85. [DOI: 10.1007/s00228-016-2047-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
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Hill-Taylor B, Walsh KA, Stewart S, Hayden J, Byrne S, Sketris IS. Effectiveness of the STOPP/START (Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right Treatment) criteria: systematic review and meta-analysis of randomized controlled studies. J Clin Pharm Ther 2016; 41:158-69. [PMID: 26990017 DOI: 10.1111/jcpt.12372] [Citation(s) in RCA: 129] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 02/08/2016] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE STOPP/START are explicit screening tools that identify potentially inappropriate prescribing in older adults. Our objective was to update our 2013 systematic review that showed limited evidence of impact, using new evidence from randomized controlled trials (RCTs) assessing clinical, humanistic and economic outcomes in older adults. METHODS We performed a search of PubMed, EMBASE, CINAHL, Web of Science and grey literature for RCTs published in English since the previous review through June 2014. The Cochrane Risk of Bias Tool was used. We performed a meta-analysis on the effect of STOPP on potentially inappropriate medication (PIM) rates and a narrative synthesis on other outcomes. RESULTS AND DISCUSSION Four RCTs (n = 1925 adults) from four countries were included, reporting both acute (n = 2) and long-term care (n = 2) patients. Studies differed in implementation. Two studies were judged to have low risk, and two to have moderate-to-high risk of bias in key domains. Meta-analysis found that the STOPP criteria reduced PIM rates in all four studies, but study heterogeneity (I(2) = 86·7%) prevented the calculation of a meaningful statistical summary. We found evidence that use of the criteria reduces falls, delirium episodes, hospital length-of-stay, care visits (primary and emergency) and medication costs, but no evidence of improvements in quality of life or mortality. WHAT IS NEW AND CONCLUSION STOPP/START may be effective in improving prescribing quality, clinical, humanistic and economic outcomes. Additional research investigating these tools is needed, especially in frail elderly and community-living patients receiving primary care.
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Affiliation(s)
- B Hill-Taylor
- College of Pharmacy, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
| | - K A Walsh
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland.,Department of Epidemiology and Public Health, University College Cork, Cork, Ireland
| | - S Stewart
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - J Hayden
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - S Byrne
- Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland
| | - I S Sketris
- College of Pharmacy, Faculty of Health Professions, Dalhousie University, Halifax, NS, Canada
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30
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Meid AD, Haefeli WE. Age-Dependent Impact of Medication Underuse and Strategies for Improvement. Gerontology 2016; 62:491-9. [DOI: 10.1159/000443477] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/17/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Medication underuse is common in aging populations and, because of the growing risk for competing deaths, the benefit of preventive medicines gradually vanishes with advancing age, thus limiting their success. Objective: To estimate the optimum time of initiation of the secondary prevention of cardiovascular events, we examined the impact of appropriate pharmacotherapy for different starting ages at which it is implemented. Methods: In the competing risk framework, we obtained the population's life course from life tables, combined it with effect estimates quantifying the real-world effectiveness of secondary prevention, and compared the outcome of patients not receiving appropriate treatment (underuse) with those receiving preventive medicines that have demonstrated a reduction in the transition to serious cardiovascular events (START criteria). Starting at the age of 55 years, the population proportions of the distinct states of the framework were calculated for each year of chronological age in subgroups of appropriate treatment and underuse. These proportions were used over a follow-up period to estimate measures of treatment effectiveness and risks of underuse. Results: Despite increasing relative effectiveness with advancing age, benefits measured by patient-relevant endpoints, such as life years gained (LYG) or gained quality-adjusted life years (QALYs), markedly dropped after the starting age of 75 years, but even at an initiation age of 85 years, QALYs gained exceeded 1 year. Conclusion: Interventions targeting medication underuse may achieve considerable benefits at any stage of later life, while the benefit is probably largest if appropriate treatment is started before 75 years.
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