Association between Electronic Prescribing among Ambulatory Care Providers and Adverse Drug Event Hospitalizations in Older Adults

Purpose. This dissertation research sought to determine whether the proportion of physicians using electronic prescribing (e-prescribing) was associated with the hospitalization rate for adverse drug events (ADEs) among patients aged 65 and older in 2011. Additionally, we sought to determine whether increases in the proportion of e-prescribing physicians in a county were associated with decreases in the hospitalization rate for ADE among older adults. Methods. Two study designs were used, a cross-sectional study using 2011 data and a pre-post- study using 2008 and 2011 data. Data from the 2008 and 2011 State Inpatient Databases, the Office of the National Coordinator Health IT Dashboard, and the Area Health Resource File were gathered for six states: Arizona, Florida, Maryland, Michigan, New Jersey, and Washington. ADE hospitalization rates were calculated for adults 65 years and older. The independent variable, the rate of e-prescribing, was an ecological measure for both analyses. Multivariable linear regression examined county rates of ADE hospitalization in 2011, multivariable logistic regression examined the odds that a discharge would have been ADE associated versus other causes in 2011, and negative binomial regression was used to model the ADE hospitalization rate among older adults in 2011 based on the ADE hospitalization rate in 2008, the change in e-prescribing rates, and county characteristics. Results. Results indicated that county e-prescribing rates were not significantly associated with county ADE hospitalization rates among older adults (p=0.4705). Further, after adjusting for patient, provider, health infrastructure, and community factors, the county e-prescribing rate was not a significant factor in determining the odds of an ADE hospitalization. Change in e-prescribing rates was not significantly associated with the change in ADE hospitalization rates; no other county characteristics were found to be significant factors. Conclusion. Though the adoption of e-prescribing has continued to increase throughout the U.S., our findings indicate that population-level benefits, such as decreased ADE hospitalization among older adults, have yet to be seen. It may be too early to detect population-level changes due to low levels of implementation of health information technologies, such as e-prescribing. Researchers and policy makers must continue to monitor the population impact that the implementation of HITs is having on the health of the nation

Evaluating Risks from Antibacterial Medication Therapy

ABSTRACT EVALUATING RISKS FROM ANTIBACTERIAL MEDICATION THERAPY USING AN OBSERVATIONAL PRIMARY CARE DATABASE Sharon B. Meropol Joshua P. Metlay Virtually everyone in the U.S. is exposed to antibacterial drugs at some point in their lives. It is important to understand the benefits and risks related to these medications with nearly universal public exposure. Most information on antibacterial drug-associated adverse events comes from spontaneous reports. Without an unexposed control group, it is impossible to know the real risks for treated vs. untreated patients. We used an electronic medical record database to select a cohort of office visits for non-bacterial acute respiratory tract infections (excluding patients with pneumonia, sinusitis, or acute exacerbations of chronic bronchitis), and compared outcomes of antibacterial drug-exposed vs. -unexposed patients. By limiting our assessment to visits with acute nonspecific respiratory infections, we promoted comparability between exposed and unexposed patients. To further control for confounding by indication and practice, we explored methods to promote further comparability between exposure groups. Our rare outcome presented an additional analytic challenge. Antibacterial drug prescribing for acute nonspecific respiratory infections decreased over the study period, but, in contrast to the U.S., broad spectrum antibacterial prescribing remained low. Conditional fixed effects linear regression provided stable estimates of exposure effects on rare outcomes; results were similar to those using more traditional methods for binary outcomes. Patients with acute nonspecific respiratory infections treated with antibacterial drugs were not at increased risk of severe adverse events compared to untreated patients. Patients with acute nonspecific respiratory infections exposed to antibacterials had a small decreased risk of pneumonia hospitalizations vs. unexposed patients. This very small measurable benefit of antibacterial drug therapy for acute nonspecific respiratory infections at the patient level must be weighed against the public health risk of emerging antibacterial resistance. Our data provide valuable point estimates of risks and benefits that can be used to inform future decision analysis and guideline recommendations for patients with acute nonspecific respiratory infections. Ultimately, improved point-of-care diagnostic testing may help direct antibacterial drugs to the subset of patients most likely to derive benefit

Evaluation of a Medication Management Program for Older Adults

Background: As the prevalence of chronic disease increases among older adults in the United States, the need for medical interventions to adequately manage disease is also growing. Increased prescription drug use and care by multiple health providers among older adults are associated with potentially inappropriate prescribing, which may lead to adverse drug events. The HomeMeds Medication Assurance Program (HomeMeds program) is an in-home medication risk assessment for older adults to identify and prevent potentially inappropriate prescribing. Objective: To determine the effectiveness of the HomeMeds program by describing the attitudes about the program among the target population, identifying barriers and facilitators to the program, and evaluating the results of medication risk assessments. Methods: Qualitative data were collected through focus group sessions with members of the target population and key informant interviews with HomeMeds program staff and experts in geriatric clinical pharmacy. Quantitative data were collected using the HomeMeds program database. Results: Barriers to participation in the program were a lack of awareness about the susceptibility and severity of potentially inappropriate prescribing among older adults, trust in the health care system to accurately track medications, and fear of breach in confidentiality. Clients who took five or more medications were more likely to have an alert generated in the HomeMeds system than clients who took fewer medications. Despite this, less than 35% of alerts resulted in follow-up consultations between the partnering pharmacist and client. HomeMeds staff experienced challenges with recruiting individuals and providing clinically relevant recommendations about medications. Conclusion: The public health significance of this study is that community programs that implement medication risk assessments may not be effective in preventing potentially inappropriate prescribing in older adults. Improvements to the HomeMeds program should include pharmacist-led educational sessions to provide the information necessary to motivate participation in the program. Program champions at AgeWell residential sites should be leveraged to identify vulnerable older adults and facilitate participation. Finally, partnerships with local primary care practices should be formed to recruit clients to the program, provide comprehensive information about clients’ health history, and evaluate outcomes that result from participation

Mortality associated with the use of inappropiate drugs according Beers Criteria: a systematic review

The aims of this systematic review are to identify and analyse the scientist literature available evidence about the use of potentially inappropriate medications, according to the Beers Criteria, that is associated with mortality in the elderly people.It have been made a search of publications in most traditional electronic databases among the scientific community (Pubmed / Medline, EMBASE and Web of Science) and it have been selected publications that obey the criteria of 'observational study', 'elderly' and 'Beers Criteria' and that they had as a result the mortality of the study population .After publications selection it proceeded to dump data by two researchers independently to avoid selection bias. The methodological quality of the selected studies was assessed by the checklist Newcastle-Ottawa. The final sample of this systematic review has been made up of 17 studies published in Pubmed and Embase databases majority, 8 of which make up the meta-analysis. In descriptive synthesis has been observed that most of the studies have a level of evidence IV (94'1%) with cohortdelineation (94'1%) and non-probability sampling technique (70'6%).Data collection was prospective in 58'8% of cases, with a sample (n) greater than 1000 elderly (64'7%) and followed up for 6 to 12 months (52'9%).The meta-analysis involving 90.611 elders informed that users who take inappropriate drug according to the Beers Criteria had a higher relative risk for mortality outcome (RR = 1.11, 95% CI 1'01-1'22 P = 0'023), regardless of study stage, comorbidity presence, polypharmacy or type of inappropriate medication used

Polypharmacy and potentially inappropriate medication use in geriatric oncology.

Polypharmacy is a highly prevalent problem in older persons, and is challenging to assess and improve due to variations in definitions of the problem and the heterogeneous methods of medication review and reduction. The purpose of this review is to summarize evidence regarding the prevalence and impact of polypharmacy in geriatric oncology patients and to provide recommendations for assessment and management. Polypharmacy has somewhat variably been incorporated into geriatric assessment studies in geriatric oncology, and polypharmacy has not been consistently evaluated as a predictor of negative outcomes in patients with cancer. Once screened, interventions for polypharmacy are even more uncertain. There is a great need to create standardized interventions to improve polypharmacy in geriatrics, and particularly in geriatric oncology. The process of deprescribing is aimed at reducing medications for which real or potential harm outweighs benefit, and there are numerous methods to determine which medications are candidates for deprescribing. However, deprescribing approaches have not been evaluated in older patients with cancer. Ultimately, methods to identify polypharmacy will need to be clearly defined and validated, and interventions to improve medication use will need to be based on clearly defined and standardized methods

The Shifting Paradigm of Pain Management Among U.S. Elderly Community Dwellers

Managing pain is a demanding task among elderly people as almost one third of them are experiencing chronic pain. Opioids are commonly prescribed to relieve pain symptoms, but there were no significant benefits compared with non-opioid medications. Guidelines from government agencies have dramatically changed the practice of opioid prescriptions in the community. However, for some legitimate reasons, many elderly people still need opioid medications to manage their pain. This research explored the trends of opioid use, chronic use, and heavy use of opioids among elderly people; examined the impact of different opioid use patterns on the healthcare utilizations among elderly patients with chronic non-cancer pain; and investigated the patterns and disparities of compound opioid medications for treating elderly patients with chronic non-cancer pain. These studies used Medicare Current Beneficiary (MCBS) data from 2006 to 2019 and included people aged 65 years and older who had part D prescription drug benefits. Of 119,964 participants included in the study, there was a decline of opioid use since 2015. However, the proportion of chronic use and heavy use of opioids remained stable. Of 13,751 participants who had any form of chronic non-cancer pain, chronic opioid users were 30% more likely to be hospitalized, and 50% more likely to have emergency department visits. Finally, chronic opioid users were 30-70% more likely to use high potency opioid medications (hydrocodone or oxycodone compounds) and 40% less likely to use codeine/butalbital compounds. Our findings suggest that a significant proportion of elderly patients were still at a higher risk of opioid misuse/abuse. Given higher prevalence of comorbidities and lower opioid metabolism among elderly people, risks of opioid complications, medication interactions, and medical emergencies should be actively monitored. Health care providers should be vigilant about these risks and educate patients about the proper use of pain medications including opioids

Risk of Medical Events for Falls, Fractures, Confusion, and Delirium for Patients with Filled Prescriptions for Drugs Listed on Beers Criteria Compared to Well-Matched Controls

Using the 2013 edition of the Truven Marketscan ® Administrative Claims database, this study looks to link the expected side effects of Beers Criteria medications to logical hospital admissions. This study sets to examine hospital admissions and emergency department visits for community-dwelling elderly individuals 65 years or older specifically for falls and fracture as well as confusion and delirium admissions. These hospital admission types constitute a significant number of admissions the elderly experience due to the medication side effects which affect balance, gait, and cognition. Through the use of 2.6 million propensity-score matched patients, 1.297 million having been exposed to Beers Criteria medications and 1.297 million patients not exposed, this study was able to confirm the linkage between the expected side effects of the medication classes and their logical hospital admissions. Antipsychotics and benzodiazepines were the most frequent prescribed medications to both groups of admission and were also associated with the highest increase in risk of hospitalizations. Future research into medication specific research in regards to falls and fractures, and confusion and delirium in the elderly is warranted

JAMA

IMPORTANCEThe Patient Protection and Affordable Care Act of 2010 brought attention to adverse drug events in national patient safety efforts. Updated, detailed, nationally representative data describing adverse drug events can help focus these efforts.OBJECTIVETo describe the characteristics of emergency department (ED) visits for adverse drug events in the United States in 2013-2014 and describe changes in ED visits for adverse drug events since 2005-2006.DESIGN, SETTING, AND PARTICIPANTSActive, nationally representative, public health surveillance in 58 EDs located in the United States and participating in the National Electronic Injury Surveillance System\u2013Cooperative Adverse Drug Event Surveillance project.EXPOSURESDrugs implicated in ED visits.MAIN OUTCOMES AND MEASURESNational weighted estimates of ED visits and subsequent hospitalizations for adverse drug events.RESULTSBased on data from 42 585 cases, an estimated 4.0 (95% CI, 3.1-5.0) ED visits for adverse drug events occurred per 1000 individuals annually in 2013 and 2014 and 27.3% (95% CI, 22.2%-32.4%) of ED visits for adverse drug events resulted in hospitalization. An estimated 34.5% (95% CI, 30.3%-38.8%) of ED visits for adverse drug events occurred among adults aged 65 years or older in 2013-2014 compared with an estimated 25.6% (95% CI, 21.1%-30.0%) in 2005-2006; older adults experienced the highest hospitalization rates (43.6%; 95% CI, 36.6%-50.5%). Anticoagulants, antibiotics, and diabetes agents were implicated in an estimated 46.9% (95% CI, 44.2%-49.7%) of ED visits for adverse drug events, which included clinically significant adverse events, such as hemorrhage (anticoagulants), moderate to severe allergic reactions (antibiotics), and hypoglycemia with moderate to severe neurological effects (diabetes agents). Since 2005-2006, the proportions of ED visits for adverse drug events from anticoagulants and diabetes agents have increased, whereas the proportion from antibiotics has decreased. Among children aged 5 years or younger, antibiotics were the most common drug class implicated (56.4%; 95% CI, 51.8-61.0%). Among children and adolescents aged 6 to 19 years, antibiotics also were the most common drug class implicated (31.8%; 95% CI, 28.7%-34.9%) in ED visits for adverse drug events, followed by antipsychotics (4.5%; 95% CI, 3.3-5.6%). Among older adults (aged 6565 years), 3 drug classes (anticoagulants, diabetes agents, and opioid analgesics) were implicated in an estimated 59.9% (95% CI, 56.8%-62.9%) of ED visits for adverse drug events; 4 anticoagulants (warfarin, rivaroxaban, dabigatran, and enoxaparin) and 5 diabetes agents (insulin and 4 oral agents) were among the 15 most common drugs implicated. Medications to always avoid in older adults according to Beers criteria were implicated in 1.8% (95% CI, 1.5%-2.1%) of ED visits for adverse drug events.CONCLUSIONS AND RELEVANCEThe prevalence of emergency department visits for adverse drug events in the United States was estimated to be 4 per 1000 individuals in 2013 and 2014. The most common drug classes implicated were anticoagulants, antibiotics, diabetes agents, and opioid analgesics.CC999999/Intramural CDC HHS/United States2019-04-30T00:00:00Z27893129PMC64901786242vault:3203

Examining the association of medication complexity with health-related quality of life in older adults receiving community-based long term services and supports

While the complexity of a medication regimen is a concern for all individuals, it is of significant concern for community-dwelling older adults who often require multiple medications to treat chronic health problems. Health related quality of life (HRQoL) has been identified as a key quality outcome measure when assessing care of older adults, particularly those with long-term care needs. Although the use of multiple medications has been widely explored in the literature, there is a paucity of data regarding the combination of several medication-related factors (number of active medications, therapeutic drug class, and medication regimen complexity) and HRQoL in older adults. Wilson and Cleary\u27s health-related quality of life conceptual model was the theoretical framework used to guide this study. This secondary analysis examined the relationship among the number of active medications, the number of therapeutic drug classes, and medication regimen complexity and HRQoL in community-dwelling older adults (68% Hispanic, 75% female) who were recent recipients of home and community-based services (H&CBS). The subjects in this study (N =123) were enrolled in a large, multi-site study (N=470) (R01-AG025524, PI, M. Naylor). Medication-related data were obtained from medical charts, counted to include the active number of medications as all prescription and over the counter drugs (mean =9.3), and a therapeutic drug class tool (mean =4.9) measured the number of distinct therapeutic drug classes included in a medication regimen. Medication regimen complexity (mean = 20.6) was measured using the Medication Regimen Complexity Index (MRCI). The Medical Outcomes Study Short Form (MOS SF-12 v2) physical (PCS) and mental component scores (MCS) measured HRQoL. After controlling for age, gender, education, race, ethnicity, marital status and cognitive status, it was determined that the number of active medications (beta coefficient -.497, p=.012) was a key predictor of physical health-related quality of life, while therapeutic drug class and medication regimen complexity were not associated with either physical or mental health-related quality of life. The number of medications impacts on physical health-related quality of life but the directionality of that relationship is not clear; there were no significant effects on mental health-related-related quality of life and medication-related variables. Keywords: Older adults, active medications, therapeutic drug class, medication regimen complexity, community-based long term services and supports