Impact of medication regimen simplification on medication administration times and health outcomes in residential aged care: 12 month follow up of the SIMPLER randomized controlled trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement

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

Patterns of High-Dose and Long-Term Proton Pump Inhibitor Use: A Cross-Sectional Study in Six South Australian Residential Aged Care Services

Aim: While proton pump inhibitors (PPIs) are generally considered safe and well tolerated, frail older people who take PPIs long term may be susceptible to adverse events. This study characterized PPI use and determined factors associated with high-dose use among older adults in residential aged care services (RACSs).Methods: A cross-sectional study of 383 residents of six South Australian RACSs within the same organization was conducted. Clinical, diagnostic, and medication data were collected by study nurses. The proportions of residents who took a PPI for > 8 weeks and without documented indications were calculated. Factors associated with high-dose PPI use compared to standard/low doses were identified using age- and sex-adjusted logistic regression models.Results: 196 (51%) residents received a PPI, with 45 (23%) prescribed a high dose. Overall, 173 (88%) PPI users had documented clinical indications or received medications that can increase bleeding risk. Three-quarters of PPI users with gastroesophageal reflux disease or dyspepsia had received a PPI for > 8 weeks. High-dose PPI use was associated with increasing medication regimen complexity [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01–1.04 per one-point increase in Medication Regimen Complexity Index score] and a greater number of medications prescribed for regular use (OR 1.11; 95% CI 1.01–1.21 per additional medication).Conclusions: Half of all residents received a PPI, of whom the majority had documented clinical indications or received medications that may increase bleeding risk. There remains an opportunity to review the continuing need for treatment and consider “step-down” approaches for high-dose PPI users.</p

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

Selective prescribing of statins and the risk of mortality, hospitalizations, and falls in aged care services

Abstract not availableMaarit J. Korhonen, Jenni Ilomäki, Janet K. Sluggett, M. Alan Brookhart, Renuka Visvanathan, Tina Cooper, Leonie Robson, J. Simon Bel

Patterns of high-dose and long-term proton pump inhibitor use: a cross-sectional study in six south Australian residential aged care services

AIM:While proton pump inhibitors (PPIs) are generally considered safe and well tolerated, frail older people who take PPIs long term may be susceptible to adverse events. This study characterized PPI use and determined factors associated with high-dose use among older adults in residential aged care services (RACSs). METHODS:A cross-sectional study of 383 residents of six South Australian RACSs within the same organization was conducted. Clinical, diagnostic, and medication data were collected by study nurses. The proportions of residents who took a PPI for > 8 weeks and without documented indications were calculated. Factors associated with high-dose PPI use compared to standard/low doses were identified using age- and sex-adjusted logistic regression models. RESULTS:196 (51%) residents received a PPI, with 45 (23%) prescribed a high dose. Overall, 173 (88%) PPI users had documented clinical indications or received medications that can increase bleeding risk. Three-quarters of PPI users with gastroesophageal reflux disease or dyspepsia had received a PPI for > 8 weeks. High-dose PPI use was associated with increasing medication regimen complexity [odds ratio (OR) 1.02; 95% confidence interval (CI) 1.01-1.04 per one-point increase in Medication Regimen Complexity Index score] and a greater number of medications prescribed for regular use (OR 1.11; 95% CI 1.01-1.21 per additional medication). CONCLUSIONS:Half of all residents received a PPI, of whom the majority had documented clinical indications or received medications that may increase bleeding risk. There remains an opportunity to review the continuing need for treatment and consider "step-down" approaches for high-dose PPI users.Ivanka Hendrix, Amy T. Page, Maarit J. Korhonen, J. Simon Bell, Edwin C. K. Tan, Renuka Visvanathan ... et al

Frailty, hospitalization, and mortality in residential aged care

Background: Frailty predicts mortality in residential aged care, but the relationship with hospitalization is inconsistent. The purpose of this study was to investigate and compare whether frailty is associated with hospitalization and mortality among residents of aged care services. Methods: A prospective cohort study of 383 residents aged 65 years and older was conducted in six Australian residential aged care services. Frailty was assessed using the FRAIL-NH scale and a 66-item frailty index. Results: Overall, 125 residents were hospitalized on 192 occasions and 85 died over the 12-month follow-up. Over this period, less than 3% of the nonfrail/vulnerable residents but more than 20% of the most frail residents died at the facility without hospitalization. Using the FRAIL-NH, residents with mild/moderate frailty had higher numbers of hospitalizations (adjusted incidence rate ratio 1.57, 95% confidence interval [CI] 1.11-2.20) and hospital days (incidence rate ratio 1.48, 95% CI 1.32-1.66) than nonfrail residents. Residents who were most frail had lower numbers of hospitalizations (incidence rate ratio 0.65, 95% CI 0.42-0.99) and hospital days (incidence rate ratio 0.39, 95% CI 0.33-0.46) than nonfrail residents. Similar patterns of associations with number of hospital days were observed for the frailty index. Most frail residents had a higher risk of death than nonfrail residents (for FRAIL-NH, adjusted hazard ratio 2.96, 95% CI 1.50-5.83; for frailty index, hazard ratio 5.28, 95% CI 2.05-13.59). Conclusions: Residents with mild/moderate frailty had higher risk of hospitalization and death than nonfrail residents. Residents who were most frail had higher risk of death but lower risk of hospitalization than nonfrail residents.Olga Theou, Janet K. Sluggett, J. Simon Bell, Samanta Lalic, Tina Cooper, Leonie Robson, John E. Morley, Kenneth Rockwood and Renuka Visvanatha

Root cause analysis of fall-related hospitalisations among residents of aged care services

Background: Fall-related hospitalisations from residential aged care services (RACS) are distressing for residents and costly to the healthcare system. Strategies to limit hospitalisations include preventing injurious falls and avoiding hospital transfers when falls occur. Aims: To undertake a root cause analysis (RCA) of fall-related hospitalisations from RACS and identify opportunities for fall prevention and hospital avoidance. Methods: An aggregated RCA of 47 consecutive fall-related hospitalisations for 40 residents over a 12-month period at six South Australian RACS was undertaken. Comprehensive data were extracted from RACS records including nursing progress notes, medical records, medication charts, hospital summaries and incident reports by a nurse clinical auditor and clinical pharmacist. Root cause identification was performed by the research team. A multidisciplinary expert panel recommended strategies for falls prevention and hospital avoidance. Results: Overall, 55.3% of fall-related hospitalisations were among residents with a history of falls. Among all fall-related hospitalisations, at least one high falls risk medication was administered regularly prior to hospitalisation. Potential root causes of falling included medication initiations and dose changes. Root causes for hospital transfers included need for timely access to subsidised medical services or radiology. Strategies identified for avoiding hospitalisations included pharmacy-generated alerts when medications associated with an increased risk of falls are initiated or changed, multidisciplinary audit and feedback of falls risk medication use and access to subsidised mobile imaging services. Conclusions: This aggregate RCA identified a range of strategies to address resident and system-level factors to minimise fall-related hospitalisations.Janet K. Sluggett, Samanta Lalic, Sarah M. Hosking, Jenni Ilomӓki, Terry Shortt, Jennifer McLoughlin, Solomon Yu, Tina Cooper, Leonie Robson, Eleanor Van Dyk, Renuka Visvanathan, J. Simon Bel

Root cause analysis to identify medication and non-medication strategies to prevent infection-related hospitalizations from Australian residential aged care services

Infections are leading causes of hospitalizations from residential aged care services (RACS), which provide supported accommodation for people with care needs that can no longer be met at home. Preventing infections and early and effective management are important to avoid unnecessary hospital transfers, particularly in the Australian setting where new quality standards require RACS to minimize infection-related risks. The objective of this study was to examine root causes of infection-related hospitalizations from RACS and identify strategies to limit infections and avoid unnecessary hospitalizations. An aggregate root cause analysis (RCA) was undertaken using a structured local framework. A clinical nurse auditor and clinical pharmacist undertook a comprehensive review of 49 consecutive infection-related hospitalizations from 6 RACS. Data were collected from nursing progress notes, medical records, medication charts, hospital summaries, and incident reports using a purpose-built collection tool. The research team then utilized a structured classification system to guide the identification of root causes of hospital transfers. A multidisciplinary clinical panel assessed the root causes and formulated strategies to limit infections and hospitalizations. Overall, 59.2% of hospitalizations were for respiratory, 28.6% for urinary, and 10.2% for skin infections. Potential root causes of infections included medications that may increase infection risk and resident vaccination status. Potential contributors to hospital transfers included possible suboptimal selection of empirical antimicrobial therapy, inability of RACS staff to establish on-site intravenous access for antimicrobial administration, and the need to access subsidized medical services not provided in the RACS (e.g., radiology and pathology). Strategies identified by the panel included medication review, targeted bundles of care, additional antimicrobial stewardship initiatives, earlier identification of infection, and models of care that facilitate timely access to medical services. The RCA and clinical panel findings provide a roadmap to assist targeting services to prevent infection and limit unnecessary hospital transfers from RACS.Janet K. Sluggett, Samanta Lalic, Sarah M. Hosking, Brett Ritchie, Jennifer McLoughlin, Terry Shortt, Leonie Robson, Tina Cooper, Kelly A. Cairns, Jenni Ilomäki, Renuka Visvanathan, and J. Simon Bel

Primary and Secondary Care Related Quality Indicators for Dementia Care Among Australian Aged Care Users: National Trends, Risk Factors, and Variation

Background: Studies related to clinical quality indicators (CQIs) in dementia have focused on hospitalizations, medication management, and safety. Less attention has been paid to indicators related to primary and secondary care. Objective: To evaluate the incidence of primary and secondary care CQIs for Australians with dementia using governmentsubsidized aged care. The examined CQIs were: comprehensive medication reviews, 75+ health assessments, comprehensive geriatric assessments, chronic disease management plans, general practitioner (GP) mental health treatment plans, and psychiatrist attendances. Methods: Retrospective cohort study (2011–2016) of 255,458 individuals. National trend analyses estimated incidence rates and 95% confidence intervals (CI) using Poisson or negative binomial regression. Associations were assessed using backward stepwise multivariate Poisson or negative binomial regression model, as appropriate. Funnel plots examined geographic and permanent residential aged care (PRAC) facility variation. Results: CQI incidence increased in all CQIs but medication reviews. For the overall cohort, 75+ health assessments increased from 1.07/1000 person-days to 1.16/1000 person-days (adjusted incidence rate ratio (aIRR) = 1.03, 95%CI 1.02–1.03). Comprehensive geriatric assessments increased from 0.24 to 0.37/1000 person-days (aIRR = 1.12, 95%CI 1.10–1.14). GP mental health treatment plans increased from 0.04 to 0.07/1000 person-days (aIRR = 1.13, 95%CI 1.12–1.15). Psychiatric attendances increased from 0.09 to 0.11/1000 person-days (aIRR = 1.05, 95%CI 1.03–1.07). Being female, older, having fewer comorbidities, and living outside a major city were associated with lower likelihood of using the services. Large geographical and PRAC facility variation was observed (0–92%). Conclusion: Better use of primary and secondary care services to address needs of individuals with dementia is urgently needed.Miia Rahja, Tracy Air, Susannah Ahern, Stephanie A. Ward, Gillian E. Caughey, Janet K. Sluggett, Monica Cations, Xiaoping Lin, Kasey Wallis, Maria Crotty and Maria C. Inaci