Medication discrepancies and potentially inadequate prescriptions in elderly adults with polypharmacy in ambulatory care

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group.

Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary.

Data sources: Articles published between January 2010–March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults.

Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems.

Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no “gold standard” is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

A multifactorial intervention to lower potentially inappropriate medication use in older adults in Argentina

BACKGROUND

Adverse drug reactions are a common cause of potentially avoidable harm, particularly in older adults.

AIMS

To evaluate the feasibility and efficacy of a pilot multifactorial intervention to reduce potentially inappropriate medication (PIM) use in older adults.

METHODS

We conducted a phase 2, feasibility, open-label study in the ambulatory setting of an integrated healthcare network in Buenos Aires, Argentina. We recruited primary care physicians (PCPs) and measured PIM use in a sample of their patients (65 years or older). Educational workshops for PCPs were organized with the involvement of clinician champions. Practical deprescribing algorithms were designed based on Beers criteria. Automatic email alerts based on specific PIMs recorded in each patient's electronic health record were used as a reminder tool. PCPs were responsible for deprescribing decisions. We randomly sampled 879 patients taking PIMs from eight of the most commonly used drug classes at our institution and compared basal (6 months prior to the intervention) and final (12 months after) prevalence of PIM use using a test of proportions.

RESULTS

There was a significant reduction (p < 0.05) in all drug classes evaluated. Non-Steroidal Anti-Inflammatory Drugs (basal prevalence 5.92%; final 1.59%); benzodiazepines (10.13%; 6.94%); histamine antagonists (7.74%; 3.07%); opioids (2.16%; 1.25%); tricyclic antidepressants (8.08%; 4.10%); muscle relaxants (7.74%; 3.41%), anti-hypertensives (3.53%; 1.82%) and oxybutynin (2.96%; 1.82%). The absolute reduction in the overall prevalence was 8.5 percentage points (relative reduction of 51.4%).

CONCLUSION

This multifactorial intervention is feasible and effective in reducing the use of potentially inappropriate medication in all drug classes evaluated.

Medication Discrepancies and Regimen Complexity in Decompensated Cirrhosis: Implications for Medication Safety

Discrepancies between the medicines consumed by patients and those documented in the medical record can affect medication safety. We aimed to characterize medication discrepancies and medication regimen complexity over time in a cohort of outpatients with decompensated cirrhosis, and evaluate the impact of pharmacist-led intervention on discrepancies and patient outcomes. In a randomized-controlled trial (n = 57 intervention and n = 57 usual care participants), medication reconciliation and patient-oriented education delivered over a six-month period was associated with a 45% reduction in the incidence rate of 'high' risk discrepancies (IRR = 0.55, 95%CI = 0.31-0.96) compared to usual care. For each additional 'high' risk discrepancy at baseline, the odds of having ≥ 1 unplanned medication-related admission during a 12-month follow-up period increased by 25% (adj-OR = 1.25, 95%CI = 0.97-1.63) independently of the Child-Pugh score and a history of variceal bleeding. Among participants with complete follow-up, intervention patients were 3-fold less likely to have an unplanned medication-related admission (adj-OR = 0.27, 95%CI = 0.07-0.97) compared to usual care. There was no association between medication discrepancies and mortality. Medication regimen complexity, frequent changes to the regimen and hepatic encephalopathy were associated with discrepancies. Medication reconciliation may improve medication safety by facilitating communication between patients and clinicians about 'current' therapies and identifying potentially inappropriate medicines that may lead to harm.

Dental services use before and after inpatient admission among privately insured adults in the United States

BACKGROUND

Oral health has been connected to worse outcomes among hospitalized patients, but access to oral health care services in the hospital setting is limited. It is unknown how a hospital admission affects subsequent dental services use.

METHODS

The authors conducted a retrospective analysis of insurance claims data from a national private insurer. Patients were included if they were admitted to the hospital and had visited a dentist at least once in the year before or after admission. Total number of dental visits, as well as Code on Dental Procedures and Nomenclature codes associated with these visits in the year before and after a hospital stay, patient demographic characteristics, hospital admission diagnosis, and length of stay were recorded. Differences in dental services use before and after the hospital stay were calculated.

RESULTS

In total, 107,116 patients met inclusion criteria. There were fewer dental visits after admission (mean [standard deviation {SD}] 1.6 [1.7] than before admission (mean [SD] 1.9 [1.8]; P < .0001). Fewer procedures were recorded in the year after discharge (mean [SD] 7.0 [11.4] total Code on Dental Procedures and Nomenclature codes versus 8.5 [12.5] in the year before admission; P < .0001). The number of diagnostic and restorative services delivered was higher after admission, and the number of periodontic, endodontic, oral surgery, and prosthodontic services decreased (overall Pearson χ², P < .0001).

CONCLUSIONS

Patients are less likely to visit a dentist after a hospital stay, although impact on oral health is unknown.

PRACTICAL IMPLICATIONS

Hospitalization may contribute to already existing oral health disparities. Hospital teams and dentists should work together to enhance access to oral health care after hospital admission.

Defining clinical pharmacy and support activities indicators for hospital practice using a combined nominal and focus group technique

Background Although clinical pharmacy is a crucial part of hospital pharmacist’s day-to-day activity, its performance is not usually subject to a holistic assessment. Objective To define a set of relevant and measurable clinical pharmacy and support activities key performance indicators (cpKPI and saKPI, respectively). Setting Portuguese Hospital Pharmacies. Method After a comprehensive literature review focusing on the metrics already in use in other countries, several meetings with directors of hospital pharmacies were conducted to obtain their perspectives on hospital pharmacy practices and existing metrics. Finally, five rounds with a panel of 8 experts were performed to define the final set of KPIs, where experts were asked to score each indicator’ relevance and measurability, and encouraged to suggest new metrics. Main outcome measure The first Portuguese list of KPIs to assess pharmacists’ clinical and support activities performance and quality in hospital pharmacies. Results A total of 136 KPIs were assessed during this study, of which 57 were included in the original list and 79 were later added by the expert panel. By the end of the study, a total of 85 indicators were included in the final list, of which 40 are considered to be saKPI, 39 cpKPI and 6 neither. Conclusion A set of measurable KPIs was established to allow for benchmarking within and between Portuguese hospital Pharmacies and to elevate professional accountability and transparency. Future perspectives include the use of both cpKPIs and saKPIs on a national scale to identify the most efficient performances and areas of possible improvement.

Preoperative medication use and development of postoperative delirium and cognitive dysfunction

Postoperative delirium (POD) and postoperative (neuro‐)cognitive disorder (POCD) are frequent and serious complications after operations. We aim to investigate the association between pre‐operative polypharmacy and potentially inappropriate medications and the development of POD/POCD in elderly patients. This investigation is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini‐Mental State Examination score less than or equal to 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method (for the intensive care unit [ICU]), and a patient chart review. POCD was assessed 3 months after surgery with a neuropsychological test battery. Pre‐operative long‐term medication was evaluated in terms of polypharmacy (≥5 agents) and potentially inappropriate medication (defined by the PRISCUS and European list of potentially inappropriate medications [EU(7)‐PIM] lists), and associations with POD and POCD were analyzed using logistic regression analysis. Eight hundred thirty‐seven participants were included for analysis of POD and 562 participants for POCD. Of these, 165 patients (19.7%) fulfilled the criteria of POD and 60 (10.7%) for POCD. After adjusting for confounders, pre‐operative polypharmacy and intake of potentially inappropriate medications could not be shown to be associated with the development of POD nor POCD. We found no associations between pre‐operative polypharmacy and potentially inappropriate medications and development of POD and POCD. Future studies should focus on the evaluation of drug interactions to determine whether patients benefit from a pre‐operative adjustment.

Development of Machine Learning Models to Validate a Medication Regimen Complexity Scoring Tool for Critically Ill Patients

INTRODUCTION

The Medication Regimen Complexity -Intensive Care Unit (MRC-ICU) is the first tool for measuring medication regimen complexity in critically ill patients. This study tested machine learning (ML) models to investigate the relationship between medication regimen complexity and patient outcomes.

METHODS

This study was a single-center, retrospective observational evaluation of 130 adults admitted to the medical ICU. The MRC-ICU score was utilized to improve the inpatient model's prediction accuracy. Three models were proposed: model I, demographic data without medication data; model II, demographic data and medication regimen complexity variables; and model III: demographic data and the MRC-ICU score. A total of 6 ML classifiers was developed: k-nearest neighbor (KNN), naïve Bayes (NB), random forest, support vector machine, neural network, and logistic classifier (LC). They were developed and tested using electronic health record data to predict inpatient mortality.

RESULTS

The results demonstrated that adding medication regimen complexity variables (model II) and the MRC-ICU score (model III) improved inpatient mortality prediction.. The LC outperformed the other classifiers (KNN and NB), with an overall accuracy of 83%, sensitivity (Se) of 87%, specificity of 67%, positive predictive value of 93%, and negative predictive value of 46%. The APACHE III score and the MRC-ICU score at the 24-hour interval were the 2 most important variables.

CONCLUSION AND RELEVANCE

Inclusion of the MRC-ICU score improved the prediction of patient outcomes on the previously established APACHE III score. This novel, proof-of-concept methodology shows promise for future application of the MRC-ICU scoring tool for patient outcome predictions.

Factors, influencing medication errors in prehospital care: A retrospective observational study

To determine the frequency of medication errors in prehospital care and to investigate the influencing factors - diagnostic agreement (DA), the medical educational status, the specialty, the approval for emergency medicine of the prehospital emergency physician, the patient age and sex and the time of deployment.We retrospectively reviewed 708 patients from 2013 to 2015, treated by the prehospital emergency physicians of the emergency medical service center Bad Belzig, Germany. The medication appropriateness was determined by a systematic comparison of the administered medication in prehospital deployments with the discharge diagnosis, according to current guidelines. The influencing factors were examined by univariate analysis of medication appropriateness (MA), using the χ, the Mann-Whtiney U and the Welch tests. We calculated a cut-off value with the Youden index to predict absent MA, according to patients age. The significance level was P = .05.MA was absent in 220 of 708 patients (31.1%). In the case of present DA, MA was absent in 103 of 491 patients (20.9%). In the case of absent DA, MA was absent in 117 of 217 patients (53.9%) (P = .01). MA was absent in 82 of 227 patients (36.1%), treated by specialist and in 138 of 481 patients (28.7%), treated by resident physicians (P = .04). The calculated cut-off value to predict absent MA was 75.5 years. MA was absent in 100 of 375 patients (26.7%) of the younger patient age group (≤75.5 years), MA was absent 120 of 333 patients (36.0%) of the older patient age group (>75.5 years) (P = .01). Absent MA showed peak values (46.7%-60%) at night from 3 to 6 AM (P = .01) The other investigated factors had no influence on MA.The correctness of medication as a quality feature in prehospital care shows a necessity for improvement with a proportion of 31.1% medication errors. The correct diagnosis by the prehospital emergency physician and his rapid accumulation of experience had an impact on the correctness of medication in prehospital care. Elderly patients (75+ years) and nighttime prehospital deployments (3-6 AM) were identified as high risk for medication errors by the emergency physicians.