Medications Use and Patient Outcomes at Two Indianapolis Area Skilled Nursing Facilities: a Retrospective Chart Review

Background: Residential health care has changed over time. Skilled nursing facilities (SNF) as an alternative to standard long-term care are understudied. Objective: To describe current prescribing patterns of medication use in two Indianapolis SNFs. Method: Chart review to examine associations between medication use and outcomes such as weight changes, falls and re-hospitalization. Discharged patients had to be residents for at least 14 days. Results: 35 charts were reviewed. 17 (48.6%) patients were male, 22 (62.9%) were Caucasian, 15 (42.9%) had Medicaid, 6 subjects (17%) visited the emergency department, 5 (14.3%) visited the hospital during their stay at the selected facilities, 14 (40%) suffered falls, 23 (65.7%) took antidepressants, 15 (42.9%) received antibiotics and 4 (11.4%) had high anticholinergic burden. Duration of stay ranged from 14-362 days (median 41), age ranged from 40-95 (median 75), number of diagnoses 4-23, mean 12 (±4.105), weight change from loss of 52# to gain of 35.7# (median -5.6), Beer’s violations 0-3, mean 0.46 (±0.761) for patients aged ≥65 and the maximum scheduled medications at one time 3-24, mean 9.26 (±4.273). Of the 15 (42.9%) patients that received antibiotics there were 24 instances of use, 19 (79.2%) of those fit the facilities criteria for appropriate use of antibiotics. Conclusion: There are few associations between exposures: use of antibiotics or antidepressants, anticholinergic burden, or deviations from Beer’s criteria. This may be due to small sample size or be an indication of careful prescribing at these facilities

Knowledge, Attitudes, Behaviors, and Beliefs about Chronic Kidney Disease in Indiana’s Minority Communities: A Community-Based Survey

The purpose of this report is to detail the findings of the study ‘Knowledge, Attitudes, Behaviors, And Beliefs about Chronic Kidney Disease in Indiana Minority Communities,’ undertaken as a collaboration between Indiana Minority Health Coalition, Inc. (IMHC) and the Butler University College of Pharmacy and Health Sciences (BUCOPHS). The purpose of the study was to understand knowledge of and beliefs about Chronic Kidney Disease (CKD) among racial/ethnic minorities in Indiana, to learn how these populations would like to receive information about CKD, to understand the factors associated with higher levels of CKD awareness, to estimate the proportion of people with risk factors who have been screened for CKD, and to determine the characteristics associated with people who have been screened. CKD, the ninth leading cause of death in the United States, is a major public health issue in Indiana. Just over 1 in 5 deaths in Indiana are due to kidney disease, a figure higher than the 14% national average. CKD is especially problematic for racial/ethnic minorities, who are more likely to get the disease, and at earlier ages. They also progress more quickly to End Stage Renal Disease (ESRD), the final stage of CKD, treatable only by lifelong dialysis or kidney transplant. Treatment comes with high costs in terms of public and private money as well as patients’ suffering. Nearly one quarter of the US Medicare budget ($24 billion) is spent caring for people with ESRD. Early detection and treatment of CKD are essential to stopping disease progression, which is irreversible. Most people with CKD are undiagnosed and undertreated, leading to complications and progression of the disease. Diabetes, hypertension, and family history of kidney disease are the most significant CKD risk factors, and it is recommended that adults with any of these should be screened. Very little is known about knowledge, attitudes, behaviors and beliefs regarding CKD in Indiana’s racial/ethnic minority communities. Because of this, a collaborative, community-based survey project was undertaken by IMHC and the BUCOPHS. Information on socio-demographics (including self-identified race/ethnicity); health status; healthcare access and utilization; CKD screening, knowledge and attitudes toward health,CKD and screening; and preferences for receiving health information were included. The survey was translated in several languages (Spanish, Burmese, Hakka Chin, and Falam Chin) and the translations were verified by native-speaking community members. IMHC engaged 15 community partners in 22 Indiana counties to administer the surveys. Community partners were oriented to the project and trained in survey administration, and surveys were conducted between November 2012 and February 2013. Surveys from 1,465 eligible respondents were received and scanned into a data base. Survey results were analyzed collaboratively by BUCOPHS and IMHC. Respondents represented four major racial/ethnic groups: African Americans (59%), Hispanic/Latinos (22%), American Indians/Alaskan Natives (11%), and Asian/Pacific Islanders (8%). Forty-four percent were male, and ages ranged from 18 to 92 years (average= 40 years), 20% were born outside of the United States, and 85% spoke English as their primary language. Most (84%) were in good, very good, or excellent health, and the most commonly reported health conditions were high blood pressure (36%), diabetes or arthritis (both 16%), and asthma or obesity (both 14%). Most (70%) had health insurance and a regular healthcare provider (61%), but 25% reported that they were not able to see a provider in the prior year because of cost. Being older, having higher self-rated health, being employed, higher educational attainment, having health insurance, being Hispanic/Latino, and reporting high blood pressure, diabetes, or kidney disease were all associated with more knowledge and awareness of CKD, while being Burmese and not being able to see a provider because of cost were related to less knowledge and awareness. Just over one quarter (29%) of those reporting at least one risk factor had been screened. Increased knowledge and attitude toward kidney disease, having high blood pressure or kidney disease, and having a regular healthcare provider were associated with having been screened among those with risk factors. Respondents preferred to get information in the form of brochures (66%), the internet (57%) or on television (37%); from a doctor (87%), nurse (40%), or family member (37%); at a doctor’s office or clinic (76%), or hospital or health fair (both 58%). This study’s most critical finding is that only a small minority (28.7%) of those requiring screening actually report that they had been screened for kidney disease. The findings, however, indicate many opportunities to improve knowledge and behaviors among the state’s extremely vulnerable racial/ethnic populations; indeed, they demonstrate that increasing knowledge is an important factor in encouraging at-risk people to undergo screening. It is apparent that all minority populations need, and wish to receive, information on CKD, and that access to screening should be increased. Adoption of provisions of the Affordable Care Act in the next few years, with its emphasis on prevention and establishment of medical homes, may help in promoting screening. It is apparent that communities need to provide education on the causes and consequences of kidney disease, as well as the importance of prevention and screening for those at risk for CKD. Communities should encourage people to establish and maintain medical homes, relationships with primary care providers who can manage their health conditions and help patients navigate through the healthcare system. Communities need to engage healthcare providers in CKD education. Community-appropriate educational materials, especially brochures and possibly DVDs, need to be developed. It is critical that information be easily understood by those with low education, as they are particularly vulnerable to CKD risk. Education about kidney function and disease is required for adults of all ages. Although respondents may not be representative of all racial/ethnic minority residents of Indiana and information was obtained directly from respondents rather than medical records (and thus subject to memory lapses and misunderstanding), this study lays the foundations to improve kidney health in Indiana’s health-vulnerable racial/ethnic minority communities

Administrators’ Perceptions of Medication Management in Assisted Living Facilities: Results from focus groups

Objective: Assisted living (AL) residents are vulnerable to adverse events as a result of using numerous medications and frequently need assistance in administering medications. Very little is known, however, about the ways in which medications are managed within this level of care. Design: AL administrators from the metropolitan Baltimore, Maryland area were invited to participate in focus groups to explore issues involved in medication management. Setting and Participants: Four administrators from smaller (15 beds or fewer) and six larger (more than 15 beds) certified AL facilities serving primarily older residents participated. Administrators must have served in their position at least six months. Results: Administrators described interactions with residents, physicians, and pharmacists as well as the issues of state regulations and their enforcement. We uncovered themes concerning the challenges faced in negotiating competing needs of residents, providers, and regulatory bodies. Conclusions: Administrators often feel torn between competing requirements of their position, and they experience some degree of conflict in allowing residents to retain autonomy in the face of demands of family, providers, and regulators. Small-facility administrators especially report being in a position to allow them to monitor residents\u27 medication reactions and needs. Large-facility administrators sometimes find their actions hampered by decisions made at higher (ownership) levels. Administrators want AL facilities to remain at an intermediate level of care, with less stringent regulations than for those for nursing facilities, but would also like more consistency in enforcement of regulations. Qualitative assessment of medication-related issues in AL can help to guide policy in this area

We Can Do More Than Just Sell the Test: Pharmacist Perspectives About Over-the-Counter Rapid HIV Tests

Pharmacist attitudes about the over-the-counter (OTC) sale of HIV rapid tests in pharmacies were explored through interviews conducted among 17 licensed community pharmacists in a Midwestern, moderate HIV incidence state between May and September 2012. Participants recognized that OTC rapid HIV tests would increase the number of people aware of their HIV status. Concerns included linkage to care and results consultation for those who test HIV-positive. Point of sale was identified as an opportunity for consultation about the test and to establish a relationship for future discussion about results and linkage to care. Pharmacists could provide initial test consultation or information, and consultation about the test results in order to provide post diagnosis support and facilitate linkage to care

Herbal Product Use Among Anticoagulation Patients

Warfarin interacts with many conventional drug products and herbal products,1-3 Given the incompleteness of information on drug-herbal product interactions and the potential for health care practitioners to be unaware of their patients\u27 utilization of herbal products, we surveyed the use of such products among patients receiving warfarin through an anticoagulation clinic. Patients at the University of Maryland Medical System Anticoagulation Clinic were asked to complete an anonymous written questionnaire during their regularly scheduled appointments over one month

Alternative and complementary health practices (ACHP) among older urban African Americans

Slides from presentation at: The 135th APHA Annual Meeting & Exposition (November 3-7, 2007) of APH

Concepts of Health in Older Urban African American Women with Chronic Health Conditions: A Focus Group Study

The purpose of this report is to relate the findings of the study ‘Concepts of Health in Older Urban African American Women with Chronic Health Conditions.’ This investigation, undertaken at the request of the Indiana Minority Health Coalition, Inc. (IMHC) is collaboration between IMHC, Butler University College of Pharmacy and Health Sciences, and the community partner, the Black Nurses Association of Indianapolis, Inc. (BNA). The purpose of the study is to gain an understanding of the ways older African American women from medically underserved areas of Indianapolis characterize the various parts of the concept of health; how they understand and interpret the determinants of health status; and to understand how they assess health. Researchers decided to hold focus groups of African American women from Indianapolis ages 50 years and older who had at least one diagnosis of a chronic illness. The Principal Investigator created a moderator’s guide for the focus group. All research partners met to review and redesign the guide to make sure that it was appropriate and would be effective in stimulating discussion to address the three specific aims. The groups, one of currently employed women, two of residents of senior/disabled housing, one group of members of a community church, and one mixed-recruitment group, were held in community settings. Participants received $25.00 gift cards for their involvement. Major findings are that women view ‘health’ as a concept that includes many elements: physical health, mental/emotional health, ability to function through day-to-day activities, and spiritual health. These components work together to produce a state of wholeness or well-being. ‘Health’ is determined through interplay between influences that operate on many levels: the personal, the interpersonal, and the immediate and social/political environment. Specific determinates include health behaviors, state of mind, stress, relationship with God, and the aging process. Women speak at length about their relationship with institutions of healthcare. They express problems in communicating with their healthcare providers, feeling that they are not treated as unique individuals, and they often express distrust of providers. Participants assess their own health through paying attention to their own physical symptoms, their state of mind, and their energy level. Medications are named as determinants of health and markers of health status. Women assess health of their families and friends through observation, intuition, and communication. These women act as facilitators of health status and behaviors for their family members and others in the community. Women are well aware of the importance of positive health behaviors, especially diet and exercise, and they feel strong senses of control over their health. As these women envision ‘health’ as involving many concepts and levels, interventions need to address issues beyond the physical, involving women actively through relationships within communities. Public health professionals need to work with these women in a respectful and collaborative manner. Issues that need further exploration are interplay between mental and physical health through the aging process, patient-provider communication, and women’s understanding of medications in maintaining and improving health

Association of Antipsychotic Use With Hospital Events and Mortality Among Medicare Beneficiaries Residing in Long-Term Care Facilities

Objective—Antipsychotic (AP) utilization has grown significantly in long-term care (LTC) settings. Although a growing literature associates AP use with higher mortality in elderly with dementia, the association of APs with hospital events is unclear. The authors examine prevalence and trends in AP use by Medicare beneficiaries residing in LTC and the association of APs and other drug use variables with hospital events and mortality. Design—Retrospective analysis using sequential multivariate Cox proportional hazards models. Setting—Medicare Current Beneficiary Survey linked to Institutional Drug Administration and Minimum Data Set files. Participants—A total of 2,363 LTC Medicare beneficiaries, 1999–2002. Measurements—Trends in LTC AP use overall and by type and duplicative use; association of AP utilization and two outcomes: hospital events and all-cause mortality. Results—AP use rose markedly from 1999 to 2002 (26.4%–35.9%), predominantly due to increased use of atypical agents. After controlling for sociodemographic and clinical factors, AP use is not related to hospital events (hazard ratio [HR] = 0.98, 95% confidence interval [CI] = 0.82–1.63 p = 0.7951). AP use is associated with reduced mortality in unadjusted and intermediate models, but loss of significance in the final model (HR = 0.83, 95% CI = 0.69–1.00, p = 0.0537) suggests that disease and drug burden factors may confound the AP-mortality relationship. Conclusion—This study provides no evidence of increased hospital events or mortality in LTC residents who use AP medications. Findings contribute to a growing body of evidence that APs, particularly atypical agents, may be associated with reduced mortality in LTC residents

Racial and ethnic disparities in treatment of dementia among Medicare beneficiaries

Objectives—Numerous studies have documented disparities in health care utilization between non-Hispanic White and minority elders. We investigated differences in anti-dementia medication use between non-Hispanic White and minority community-dwelling Medicare beneficiaries with dementia. Methods—Using multivariate analysis with generalized estimating equations, we estimated prevalence ratios (PRs) for anti-dementia medication use by race/ethnicity for 1,120 beneficiaries with dementia from years 2001 through 2003 of the Medicare Current Beneficiary Survey. Results—After adjusting for demographics, socioeconomics, health care access and utilization, comorbidities, and service year, we found that anti-dementia medication use was approximately 30% higher among non-Hispanic Whites compared to other racial/ethnic groups (PR = 0.73, 95% confidence interval [CI] = 0.59, 0.91). As for individual racial/ethnic groups, prevalence disparities remained significant for non-Hispanic Blacks (PR = 0.75, 95% CI = 0.57, 0.99) and non-Hispanic others (PR = 0.50, 95% CI = 0.26, 0.96) but were attenuated for Hispanics (PR = 0.84, 95% CI = 0.59, 1.20). Discussion—Results provide evidence that racial/ethnic disparities in utilization of drugs used to treat dementia exist and are not accounted for by differences in demographic, economic, health status, or health utilization factors. Findings provide a foundation for further research that should use larger numbers of minority patients and consider dementia type and severity, access to specialty dementia care, and cultural factors