Comorbid diabetes and copd: impact of corticosteroid use on diabetes complications

OBJECTIVE: To identify if there is a dose-dependent risk of diabetes complications in patients treated with corticosteroids who have both diabetes and chronic obstructive pulmonary disorder (COPD). RESEARCH DESIGN AND METHODS: A retrospective study of administrative claims data from the Australian Government Department of Veterans' Affairs, from 1 July 2001 to 30 June 2008, of diabetes patients newly initiated on metformin or sulfonylurea. COPD was identified by dispensings of tiotropium or ipratropium in the 6 months preceding study entry. Total corticosteroid use (inhaled and systemic) in the 12 months after study entry was determined. The outcome was time to hospitalization for a diabetes-related complication. Competing risks and Cox proportional hazard regression analyses were conducted with adjustment for a number of covariates. RESULTS: A total of 18,226 subjects with diabetes were identified, of which 5.9% had COPD. Of those with COPD, 67.2% were dispensed corticosteroids in the 12 months from study entry. Stratification by dose of corticosteroids demonstrated a 94% increased likelihood of hospitalization for a diabetes complication for those who received a total defined daily dose (DDD) of corticosteroids≥0.83/day (subhazard ratio 1.94 [95% CI 1.14-3.28], P=0.014), by comparison with those who did not receive a corticosteroid. Lower doses of corticosteroid (<0.83 DDD/day) were not associated with an increased risk of diabetes-related hospitalization. CONCLUSIONS: In patients with diabetes and COPD, an increased risk of diabetes-related hospitalizations was only evident with use of high doses of corticosteroids. This highlights the need for constant revision of corticosteroid dose in those with diabetes and COPD, to ensure that the minimally effective dose is used, together with review of appropriate response to therapy.Gillian E. Caughey, Adrian K. Preiss, Agnes I. Vitry, Andrew L. Gilbert, Elizabeth E. Roughea

Prevalence of eye conditions, utilization of eye health care services, and ophthalmic medications after entering residential aged care in Australia

Purpose This study aims to evaluate the burden and trends of eye diseases, utilisation of eye health care services, and ophthalmic medications among older people living in residential aged care facilities in Australia. Methods A cross-sectional study was conducted using data from the Registry of Senior Australians. Individuals aged ≥65 years who entered permanent residential aged care facilities between 2008 and 2015 were included. The prevalence (95% confidence interval [CI]) of eye diseases by year, eye health care services, and ophthalmic medication use within a year of entry into the service were evaluated. Poisson regression models estimated adjusted rate of change using prevalence ratio (PR) by age, sex, state, and frailty scores. Results Of the 409,186 people studied, 43.6% (N = 178,367) had an eye condition. Of the total cohort, 32.9% (N = 134,566) had chronic eye conditions and 19.7% (N = 80,661) had an acute eye condition. Common chronic eye conditions were glaucoma (13.6%, N = 55,830), cataract (8%, (N = 32,779), blindness (4.5%, N = 18,856), and poor vision (10.3%, N = 42,245). Prevalence of any eye condition (2008: 42.7%, 95% CI = 42.2%-43.2% and 2015: 41.2%, 95% CI = 40.8-41.6%, PR = 0.99, 95% CI = 0.99-0.99, P ConclusionsThe prevalence of blindness among older Australian using residential aged care services decreased over the study period. However, the burden of eye diseases remained high between 2008 and 2015, whereas the use of eye health care services was disproportionately low. This study provides evidence of a significant need for eye health care services for older people with an eye disease in residential aged care facilities. Translational relevance Four in ten long term aged care residents in Australia had at least one eye condition over the study period, indicating potential for a high eye health care needs in aged care settings.Jyoti Khadka, Julie Ratcliffe, Gillian E. Caughey, Steve L.Wesselingh and Maria C. Inaci

National trends and policy impacts on provision of Home Medicines Reviews and Residential Medication Management Reviews in older Australians, 2009–2019

Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians.Janet K. Sluggett, Luke R. Collier, Jonathan D. Bartholomaeus, Maria C. Inacio, Steve L. Wesselingh and Gillian E. Caughe

The risk of fall-related hospitalisations at entry into permanent residential aged care

Background: Entering permanent residential aged care (PRAC) is a vulnerable time for individuals. While falls risk assessment tools exist, these have not leveraged routinely collected and integrated information from the Australian aged and health care sectors. Our study examined individual, system, medication, and health care related factors at PRAC entry that are predictors of fall-related hospitalisations and developed a risk assessment tool using integrated aged and health care data. Methods: A retrospective cohort study was conducted on N=32,316 individuals ≥65 years old who entered a PRAC facility (01/01/2009-31/12/2016). Fall-related hospitalisations within 90 or 365days were the outcomes of interest. Individual, system, medication, and health care-related factors were examined as predictors. Risk prediction models were developed using elastic nets penalised regression and Fine and Gray models. Area under the receiver operating characteristics curve (AUC) assessed model discrimination. Results: 64.2% (N =20,757) of the cohort were women and the median age was 85 years old (interquartile range 80-89). After PRAC entry, 3.7% (N =1209) had a fall-related hospitalisation within 90days and 9.8% (N =3156) within 365days. Twenty variables contributed to fall-related hospitalisation prediction within 90days and the strongest predictors included fracture history (sub-distribution hazard ratio (sHR)=1.87, 95% confdence interval (CI) 1.63-2.15), falls history (sHR=1.41, 95%CI 1.21-2.15), and dementia (sHR=1.39, 95%CI 1.22-1.57). Twenty-seven predictors of fallrelated hospitalisation within 365days were identifed, the strongest predictors included dementia (sHR=1.36, 95%CI 1.24-1.50), history of falls (sHR=1.30, 95%CI 1.20-1.42) and fractures (sHR=1.28, 95%CI 1.15-1.41). The risk prediction models had an AUC of 0.71 (95%CI 0.68-0.74) for fall-related hospitalisations within 90days and 0.64 (95%CI 0.62-0.67) for within 365days. Conclusion: Routinely collected aged and health care data, when integrated at a clear point of action such as entry into PRAC, can identify residents at risk of fall-related hospitalisations, providing an opportunity for better targeting risk mitigation strategies.Maria C. Inacio, Max Moldovan, Craig Whitehead, Janet K. Sluggett, Maria Crotty, Megan Corlis, Renuka Visvanathan, Steve Wesselingh, and Gillian E. Caughe

Provision of a comprehensive medicines review is associated with lower mortality risk for residents of aged care facilities: a retrospective cohort study

Background: no studies have examined the impact of residential medication management review (RMMR, a 24-year government subsidised comprehensive medicines review program) in Australian residential aged care facilities (RACFs) on hospitalisation or mortality. Objective: to examine associations between RMMR provision in the 6–12 months after RACF entry and the 12-month risk of hospitalisation and mortality among older Australians in RACFs. Design retrospective cohort study. Subjects: individuals aged 65–105 years taking at least one medicine, who entered an RACF in three Australian states between 1 January 2012 and 31 December 2015 and spent at least 6 months in the RACF (n = 57,719). Methods: Cox regression models estimated adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) for associations between RMMR provision and mortality. Adjusted subdistribution hazard ratios were estimated for associations between RMMR provision and next (i) emergency department (ED) presentation or unplanned hospitalisation or (ii) fall-related ED presentation or hospitalisation. Results: there were 12,603 (21.8%) individuals who received an RMMR within 6–12 months of RACF entry, of whom 22.2% (95%CI 21.4–22.9) died during follow-up, compared with 23.3% (95%CI 22.9–23.7) of unexposed individuals. RMMR provision was associated with a lower risk of death due to any cause over 12-months (aHR 0.96, 95%CI 0.91–0.99), but was not associated with ED presentations or hospitalisations for unplanned events or falls. Conclusions: provision of an RMMR in the 6–12 months after RACF entry is associated with a 4.4% lower mortality risk over 12-months but was not associated with changes in hospitalisations for unplanned events or falls.Janet K Sluggett, Gillian E Caughey, Tracy Air, Max Moldovan, Catherine Lang, Grant Martin, Stephen R Carter, Shane Jackson, Andrew C Stafford, Steve L Wesselingh, Maria C Inaci

Quality and safety in residential aged care: an evaluation of a national quality indicator programme

OnlinePublBackground: In Australia, 243 000 individuals live in approximately 2700 residential aged care facilities yearly. In 2019, a National Aged Care Mandatory Quality Indicator programme (QI programme) was implemented to monitor the quality and safety of care in facilities. Aim: To examine the validity of the QI programme indicators using explicit measure review criteria. Methods: The QI programme manual and reports were reviewed. A modified American College of Physicians Measure Review Criteria was employed to examine the QI programme’s eight indicators. Five authors rated each indicator on importance, appropriateness, clinical evidence, specifications and feasibility using a nine-point scale. A median score of 1–3 was considered to not meet criteria, 4–6 to meet some criteria and 7–9 to meet criteria. Results: All indicators, except polypharmacy, met criteria (median scores = 7–9) for importance, appropriateness and clinical evidence. Polypharmacy met some criteria for importance (median = 6, range 2–8), appropriateness (median = 5, range 2–8) and clinical evidence (median = 6, range 3–8). Pressure injury, physical restraints, significant unplanned weight loss, consecutive unplanned weight loss, falls and polypharmacy indicators met some criteria for specifications validity (all median scores = 5) and feasibility and applicability (median scores = 4 to 6). Antipsychotic use and falls resulting in major injury met some criteria for specifications (median = 6–7, range 4–8) and met criteria for feasibility and applicability (median = 7, range 4–8). Conclusions: Australia’s National QI programme is a major stride towards a culture of quality promotion, improvement and transparency. Measures’ specifications, feasibility and applicability could be improved to ensure the programme delivers on its intended purposes.Maria C. Inacio, Tesfahun C. Eshetie, Gillian E. Caughey, Craig Whitehead, Johanna Westbrook, Len Gray, Peter Hibbert, Elizabeth Beattie, Jeffrey Braithwaite, Ian D. Cameron, Maria Crotty, and Steve Wesseling

Primary, allied health, geriatric, pain and palliative healthcare service utilisation by aged care residents, 2012-2017.

OnlinePublObjectives To examine the incidence and trends in primary care, allied health, geriatric, pain and palliative care service use by permanent residential aged care (PRAC) residents and the older Australian population. Methods Repeated cross-sectional analyses on PRAC residents (N = 318,484) and the older (≥65 years) Australian population (N ~ 3.5 million). Outcomes were Medicare Benefits Schedule (MBS) subsidised primary care, allied health, geriatric, pain and palliative services between 2012-13 and 2016-17. GEE Poisson models estimated incidence rates and incidence rate ratios (IRR). Results In 2016-17, PRAC residents had a median of 13 (interquartile range [IQR] 5-19) regular general medical practitioner (GP) attendances, 3 (IQR 1-6) after-hours attendances and 5% saw a geriatrician. Highlights of utilisation changes from 2012-13 to 2016-17 include the following: GP attendances increased by 5%/year (IRR = 1.05, 95% confidence interval [CI] 1.05-1.05) for residents compared to 1%/year (IRR = 1.01, 95%CI 1.01-1.01) for the general population. GP after-hours attendances increased by 15%/year (IRR = 1.15, 95%CI 1.14-1.15) for residents and 9%/year (IRR = 1.08, 95%CI 1.07-1.20) for the general population. GP management plans increased by 12%/year (IRR = 1.12, 95%CI 1.11-1.12) for residents and 10%/year (IRR = 1.10, 95%CI 1.09-1.11) for the general population. Geriatrician consultations increased by 28%/year (IRR = 1.28, 95%CI 1.27-1.29) for residents compared to 14%/year (IRR = 1.14, 95%CI 1.14-1.15) in the general population. Conclusions The utilisation of most examined services increased in both cohorts over time. Preventive and management care, by primary care and allied health care providers, was low and likely influences the utilisation of other attendances. PRAC residents' access to pain, palliative and geriatric medicine services is low and may not address the residents' needs.Maria C. Inacio, Luke Collier, Tracy Air, Kailash Thapaliya, Maria Crotty, Helena Williams, Steve L. Wesselingh, Andrew Kellie, David Roder, Adrienne Lewis, Gillian Harvey, Janet K. Sluggett, Monica Cations, Tiffany K. Gill, Jyoti Khadka, Gillian E. Caughe

Concomitant prescribing of opioids and benzodiazepines in Australia, 2012–2017

Abstract not availableGillian E Caughey, Svetla Gadzhanova, Sepehr Shakib, Elizabeth E Roughea

Use of medicines that may exacerbate heart failure in older adults: therapeutic complexity of multimorbidity

BACKGROUND:Multimorbidity is common in older patients with heart failure (HF), complicating therapeutic management and increasing the risk of harm. OBJECTIVE:This study sought to examine the prevalence of medicines for the treatment of comorbid conditions potentially associated with harm in older people, before and after HF hospitalization. METHODS:A retrospective cohort study of older people hospitalized with a primary diagnosis of HF over a 12-month period was conducted using administrative health claims data from the Department of Veterans' Affairs (DVA) Australia. We examined the prevalence of medicines that may exacerbate or worsen HF as defined by the American Heart Association (AHA) and Australian HF clinical guidelines, in the 30 days prior and 120 days before and after discharge for HF. RESULTS:A total of 4069 older adults were hospitalized for HF during the study period; almost 60% (n = 2435) received at least one medicine associated with an increased risk of harm before hospitalization, with the majority (66.7%, n = 1623) dispensed in the 30 days prior. A small but significant reduction after hospitalization was observed, but 56% (n = 1638) received at least one of these medicines after hospitalization (p = 0.001). Over one-quarter received two or more medicines before hospitalization, and this only reduced to 22% post-hospitalization (p < 0.0001). CONCLUSIONS:Little change in the prescribing of potentially harmful medicines for HF was observed; 56% of older adults received at least one following hospitalization for HF, highlighting the therapeutic complexity of multimorbidity in HF. Use of the AHA list to facilitate identification of potentially harmful medicines, followed by prioritization of treatment goals and appropriate risk mitigation are needed to facilitate reduction in hospitalization for patients with HF with multimorbidity.Gillian E. Caughey, Sepehr Shakib, John D. Barratt, Elizabeth E. Roughea

Evaluation of Uptake of COVID-19 Temporary Allied Health Services for Residential Aged Care in Australia

Research Letter OnlinePublGillian E. Caughey, Luke Collier, Monica Cations, Steve Wesselingh, Maria C. Inaci