Healthcare system intervention for safer use of medicines in elderly patients in primary care—a qualitative study of the participants’ perceptions of self-assessment, peer review, feedback and agreement for change

The elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants' perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care

GP's Adherence to Guidelines for Cardiovascular Disease among Elderly: A Quality Development Study

Background. Evidence-based guidelines should in most cases be followed also in the treatment of elderly. Older people are often suboptimally treated with the recommended drugs. Objectives. To describe how well general practitioners adhere to current guidelines in the treatment of elderly with cardiovascular disease and evaluate local education as a tool for improvement. Method. Data was collected from the medical records of patients aged ≥65, who visited a primary health care center in Sweden 2006 and had one or more of the following diagnoses: hypertension, ischemic heart disease, heart failure, chronic atrial fibrillation, or prior stroke. Local education was organized and included feed-back to the patient's doctor and discussion about regional guidelines. Repeated measurements were performed in 2008. Results and Conclusion. The adherence to guidelines was low. Approximately one-third of the patients with hypertension reached target blood pressure, stroke patients more often. More patients with heart failure were treated with angiotensin converting enzyme inhibitor than in other European countries, but still only 60%. Half of the patients with chronic atrial fibrillation were treated with Warfarin, although more than two-thirds had a CHADS2 score indicating the need. Educational efforts appeared to increase the adherence and hence should be encouraged

Cost-utility analysis of case management for frail older people: effects of a randomised controlled trial

Background To evaluate the effects of a case management intervention for frail older people (aged 65+ years) by cost and utility. Materials and methods One hundred and fifty-three frail older people living at home were randomly assigned to either an intervention (n = 80) or a control group (n = 73). The 1-year intervention was carried out by nurses and physiotherapists working as case managers, who undertook home visits at least once a month. Differences in costs and quality-adjusted life years (QALYs) based on the health-related quality-of-life instruments EQ-5D and EQ-VAS, and also the incremental cost-effectiveness ratio were investigated. All analyses used the intention-to-treat principle. Results There were no significant differences between the intervention group and control group for total cost, EQ-5D-based QALY or EQ-VAS-based QALY for the 1-year study. Incremental cost-effectiveness ratio was not conducted because no significant differences were found for either EQ-5D- or EQ-VAS-based QALY, or costs. However, the intervention group had significantly lower levels of informal care and help with instrumental activities of daily living both as costs (€3,927 vs. €6,550, p = 0.037) and provided hours (200 vs. 333 hours per year, p = 0.037). Conclusions The intervention was cost neutral and does not seem to have affected health-related quality of life for the 1-year study, which may be because the follow-up period was too short. The intervention seems to have reduced hours and cost of informal care and help required with instrumental activities of daily living. This suggests that the intervention provides relief to informal caregivers

Prevalence and predictors of healthcare utilization among older people (60+): Focusing on ADL dependency and risk of depression.

The aim of this study was to investigate healthcare utilization patterns over a six-year period among older people (60+), classified as dependent/independent in Activities of Daily Living (ADL) and/or at/not at risk of depression and to identify healthcare utilization predictors. A sample (n=1402) comprising ten age cohorts aged between 60 and 96 years was drawn from the Swedish National study on Aging and Care (SNAC). Baseline data were collected between 2001 and 2003. Number and length of hospital stays were collected for six years after baseline year. Group differences and mean changes over time were investigated. Healthcare utilization predictors were explored using multiple linear regression analysis. The results revealed that 21-24% had at least one hospital stay in the six years after baseline, 29-37% among ADL dependent subjects and 24-33% among those at risk of depression. There was a significant increase of hospital stays in all groups over time. ADL-dependent subjects and those at risk of depression had significant more hospital stays, except for those at/not at risk of depression in years 2, 4 and 5. The healthcare utilization predictors 5-6 years after baseline were mainly age, previous healthcare utilization and various symptoms and, in 1-2 and 3-4 years after baseline, age, various diagnostic groups and various physical variables. Thus healthcare utilization patterns seem to be similar for the different groups, but it is difficult to find universal predictors. This suggests that different variables should be considered, including both ADL and psychosocial variables, when trying to identify future healthcare users

"It is meaningful; I feel that I can make a difference" -A qualitative study about GPs' experiences of work at nursing homes in Sweden

Background: Swedish nursing homes (NH) have limited capacity. As a result elderly people living in NH represent the part of the elderly population in most need of care. In Sweden a General Practitioner (GP) is usually responsible for the medical care of all subjects living in a NH. The residents in NH seldom have adequate pharmacological treatment according to diagnosis and often have polypharmacy and/or inappropriate medical treatment regarding concerns of declining renal function. What prevents optimal care for the elderly is multifaceted, but there is limited research on how GPs experience their work with the elderly in NH in Sweden. This study aims to illuminate the GPs' work with the elderly in NH to provide input on how the care can be improved, as well as to identify potential obstacles for good quality of care. Methods: This qualitative study is based on individual semi-structured interviews with 12 GPs and a follow-up focus group discussion with six of the interviewed GPs. The interviews were analysed with systematic text condensation, with the process leading to identify categories and themes. Thereafter, the themes were discussed among six of the participating GPs in a focus group interview. Results: Two main themes were identified: concern for the patient and sustainable working conditions. The principal focus for the GPs was to contribute to the best possible quality of life for the patients. The GPs described discordance between the demand from staff for medications and the patients' actual need of care. GPs found their work with NH enjoyable. Even though the patients at the NH often suffered from multiple illnesses, which could lead to difficult decisions being made, the doctors felt confident in their role by having a holistic view of the patient in tandem with reliable support from the nurse at the NH. Conclusion: Working with NH patients was considered important and meaningful, with the GPs striving for the patient's well-being with special consideration to the continuum of ageing. A continuous and well-functioning relationship between the GP and the nurse was crucial for the patients' well-being

The assessment of renal function in relation to the use of drugs in elderly in nursing homes; a cohort study

Background Renal function decreases with age. Dosage adjustment according to renal function is   indicated for many drugs, in order to avoid adverse reactions of medications and/or   aggravation of renal impairment. There are several ways to assess renal function in   the elderly, but no way is ideal. The aim of the study was to explore renal function   in elderly subjects in nursing homes and the use of pharmaceuticals that may be harmful   to patients with renal impairment. Methods 243 elderly subjects living in nursing homes were included. S-creatinine and s-cystatin   c were analysed. Renal function was estimated using Cockcroft-Gault formula, Modification   of Diet in Renal Disease (MDRD) and cystatin C-estimated glomerular filtration rate   (GFR). Concomitant medication was registered and four groups of renal risk drugs were   identified: metformin, nonsteroidal anti-inflammatory drugs (NSAID), angiotensin-converting   enzyme -inhibitors/angiotensin receptor blockers and digoxin. Descriptive statistics   and the Kappa test for concordance were used. Results Reduced renal function (cystatin C-estimated GFR < 60 ml/min) was seen in 53%. Normal   s-creatinine was seen in 41% of those with renal impairment. Renal risk drugs were   rather rarely prescribed, with exception for ACE-inhibitors. Poor concordance was   seen between the GFR estimates as concluded by other studies. Conclusions The physician has to be observant on renal function when prescribing medications to   the elderly patient and not only rely on s-creatinine level. GFR has to be estimated   before prescribing renal risk drugs, but using different estimates may give divergence   in the results

What if something happens tonight? A qualitative study of primary care physicians’ perspectives on an alternative to hospital admittance

Background Due to demographic changes, hospital emergency departments in many countries are overcrowded. Internationally, several primary healthcare models have been introduced as alternatives to hospitalisation. In Norway, municipal acute wards (MAWs) have been implemented as primary care wards that provide observation and medical treatment for 24 h. The intention is to replace hospitalisation for patients who require acute admission but not specialist healthcare services. The aim of this study was to explore primary care physicians’ (PCPs’) perspectives on admission to a MAW as an alternative to hospitalisation. Methods The study had a qualitative design, including interviews with 21 PCPs in a county in southeastern Norway. Data were analysed with a thematic approach. Results The PCPs described uncertainty when referring patients to the MAW because of the fewer diagnostic opportunities there than in the hospital. Admission of patients to the MAW was assumed to be unsafe for both PCPs, MAW nurses and physicians. The PCPs assumed that medical competence was lower at the MAW than in the hospital, which led to scepticism about whether their tentative diagnoses would be reconsidered if needed and whether a deterioration of the patients’ condition would be detected. When referring patients to a MAW, the PCPs experienced disagreements with MAW personnel about the suitability of the patient. The PCPs emphasised the importance of patients’ and relatives’ participation in decisions about the level of treatment. Nevertheless, such participation was not always possible, especially when patients’ wishes conflicted with what PCPs considered professionally sound. Conclusions The PCPs reported concerns regarding the use of MAWs as an alternative to hospitalisation. These concerns were related to fewer diagnostic opportunities, lower medical expertise throughout the day, uncertainty about the selection of patients and challenges with user participation. Consequently, these concerns had an impact on how the PCPs utilised MAW services.publishedVersio

Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden.

BACKGROUND: Antipsychotics form a class of drugs that should be used with caution among elderly people because of a high risk of adverse events. Despite the risks and modest effects, their use is estimated to be high, especially in nursing homes. OBJECTIVE: The aim was to explore the effects of medication reviews on antipsychotic drug use for elderly primary care patients and describe the extent of, and reasons for, the prescription of antipsychotics. METHODS: In this cross-sectional study in primary care in Skåne, Sweden, patients aged ≥75 years living in nursing homes or in their own homes with home care were included. The effects of medication reviews were documented, as were the use of antipsychotics and the differences in characteristics between patients receiving or not receiving antipsychotics. RESULTS: A total of 1683 patients aged 87.6 (±5.7) years were included in the analysis. Medication reviews reduced the use of antipsychotics by 23% (p < 0.001) in this study. Of the 206 patients using antipsychotics, 43% (n = 93) had an approved indication, while for 15% (n = 32) the indication was not given. Antipsychotic drug use was more common with increasing number of drugs (p = 0.001), and in nursing home residents (p < 0.01). It was also more frequent in patients with cognitive impairment, depressive symptoms or sleeping problems. CONCLUSION: The use of antipsychotic drugs is high in elderly patients in nursing homes. They are often given for indications that are not officially approved or are poorly documented. Medication reviews appear to offer one useful strategy for reducing excessive use of these drugs

The effect of medication reconciliation in elderly patients at hospital discharge.

Objective To assess the impact of medication reconciliation interventions on medication error rates when elderly patients are discharged from hospital to community care or nursing homes.Setting Elderly patients (>65 years) living in nursing homes or in their own homes with care provided by the community nursing system. Method All medical records containing information on drug treatment were collected from hospital departments, the community care service and GPs. We then identified if there were any changes in the transfer of information i.e. if the drugs were not the same as before the transfer. Two different persons independently evaluated all information about the patients' drugs to identify medication errors for three different time periods. During all three periods structured discharge information was used. In period 2, electronic medication lists were introduced and in period 3 we introduced specific routines and support by a clinical pharmacist to ensure prescription in the specific medication dispensing system (ApoDos). Asymptotic Linear by-Linear Association Test was used to compare number of medication errors in period 1, 2 and 3 respectively. Main outcome measure Number of medication errors per patient. Results A total of 123 patients were evaluated at discharge. For the 109 patients using the ApoDos system, there were significant differences in the number of medication errors between period 1 and 3 (P = 0.048), period 2 and 3 (P = 0.037 but not between period 1 and 2 (P = 0.41). The mean numbers of errors were 1.5, 1.1 and 0.5 for period 1, 2 and 3 respectively. The 14 patients not using the ApoDos system had on average 0.4 errors per patient. Among the 58 patients with medication errors, 34 were evaluated as having low clinical risk, 22 moderate, and 2 high clinical risk. Conclusion Medication errors are still common when elderly patients are transferred from hospital to community/primary care. The main risk factor seems to be the specific medication dispensing system (ApoDos) or rather the process on how to use it. When this system was supported by clinical pharmacists, the error rate dropped to the same level as for patients without ApoDos

Longitudinal age-and cohort trends in body mass index in Sweden - a 24-year follow-up study

Background: The aim of this longitudinal study was to analyze whether mean Body Mass Index (BMI), assessed at four occasions, changed within different age groups and birth cohorts over time, i.e., between 1980/81 and 2004/05, after adjustment for possible confounders. Methods: A sample of 2728 men and 2770 women aged 16-71 years at study start were randomly drawn from the Swedish Total Population Register and followed from 1980/81 to 2004/05. The same sample was assessed on four occasions during the 24-year study period (i.e., every eighth year). The outcome variable, BMI, was based on self-reported height and weight. A mixed model, with random intercept and random slope, was used to estimate annual changes in BMI within the different age groups and birth cohorts. Results: Mean BMI increased from 24.1 to 25.5 for men and from 23.1 to 24.3 for women during the 24-year study period. The annual change by age group was highest in the ages of 32-39, 40-47 and 48-55 years among men, and in the ages of 24-31, 32-39, and 40-47 years among women. The highest annual changes were found in the youngest birth cohorts for both men and women, i.e., those born 1958-65, 1966-73, and 1974-81. For each birth cohort, the annual change in BMI increased compared to the previous, i.e., older, birth cohort. In addition, age-by-cohort interaction tests revealed that the increase in BMI by increasing age was higher in the younger birth cohorts (1966-1989) than in the older ones. Conclusions: Public health policies should target those age groups and birth cohorts with the highest increases in BMI. For example, younger birth cohorts had higher annual increases in BMI than older birth cohorts, which means that younger cohorts increased their BMI more than older ones during the study period