Reducing cost by reducing polypharmacy: the polypharmacy outcomes project

Polypharmacy among adults receiving outpatient care at Kitgum General Hospital, Northern Uganda

BACKGROUND

Polypharmacy is a major safety concern, associated with adverse outcomes, higher health services utilization, and healthcare costs. However, there is limited data on polypharmacy in the outpatient settings in semi-urban primary care settings. We assessed the prevalence and factors associated with polypharmacy among adults receiving outpatient care at Kitgum General Hospital, Uganda.

METHODS

We conducted a facility-based, cross-sectional study among adults receiving outpatient care at Kitgum General Hospital between October and December 2023. Polypharmacy was defined as the concurrent use of five or more medicines. Data was collected using a structured tool. A multivariable logistic regression analysis was performed to assess the factors associated with polypharmacy.

RESULTS

A total of 422 participants, with a mean age of 43.0 ± 18.3 years were enrolled. More than a third of the participants (35.3%, n = 149) had chronic medical conditions. Overall, 43.4% (n = 183) (95% CI: 38.7-48.2) of the participants had polypharmacy. The majority were on antibiotics (91.8%, n = 168) and analgesics (77.6%, n = 142). In total, 145 (34.4%) reported use of over-the-counter drugs and 60 (14.2) used herbal medicines. Having a chronic illness (Adjusted Odds Ratio (aOR): 5.93, 95% CI: 3.10-11.34, p < 0.001), and use of over-the-counter drugs (aOR: 16.7; 95% CI: 8.87-31.42, p = 0.009) were associated with higher odds of polypharmacy. Herbal medicine use was associated with 64% lower odds of polypharmacy (aOR: 0.36; 95% CI: 0.17-0.77, p < 0.001).

CONCLUSION

Polypharmacy was observed in almost 2 in every 5 adults receiving outpatient care in Kitgum General Hospital. Chronic illness and use of over the counter medicines increased the odds of polypharmacy among adult outpatients. Priority should be put in place to mitigate polypharmacy among outpatients in Northern Uganda and similar low resource settings.

Predilection for Perplexion: Preoperative microstructural damage is linked to postoperative delirium

Postoperative delirium is the most common postsurgical complication in older adults and is associated with an increased risk of long-term cognitive decline and Alzheimer's disease (AD) and related dementias (ADRD). However, the neurological basis of this increased risk-whether postoperative delirium unmasks latent preoperative pathology or leads to AD-relevant pathology after perioperative brain injury-remains unclear. Recent advancements in neuroimaging techniques now enable the detection of subtle brain features or damage that may underlie clinical symptoms. Among these, Neurite Orientation Dispersion and Density Imaging (NODDI) can help identify microstructural brain damage, even in the absence of visible macro-anatomical abnormalities. To investigate potential brain microstructural abnormalities associated with postoperative delirium and cognitive function, we analyzed pre- and post-operative diffusion MRI data from 111 patients aged ≥60 years who underwent non-cardiac/non-intracranial surgery. Specifically, we investigated preoperative variation in diffusion metrics within the posterior cingulate cortex (PCC), a region in which prior work has identified glucose metabolism alterations in the delirious brain, and a key region in the early accumulation of amyloid beta (Aβ) in preclinical AD. We also examined the relationship of preoperative PCC NODDI abnormalities with preoperative cognitive function. Compared to patients who did not develop postoperative delirium (n=99), we found increased free water (FISO) and neurite density index (NDI) and decreased orientation dispersion index (ODI) in the dorsal PCC before surgery among those who later developed postoperative delirium (n=12). These FISO differences before surgery remained present at six weeks postoperatively, while these NDI and ODI differences did not. Preoperative dorsal PCC NDI and ODI values were also positively associated with preoperative attention/concentration performance, independent of age, education level, and global brain atrophy. Yet, these diffusion metrics were not correlated with cerebrospinal fluid Aβ positivity or levels. These results suggest that preoperative latent brain abnormalities within the dorsal PCC may underlie susceptibility to postoperative delirium, independent of AD-related (i.e., Aβ) neuropathology. Furthermore, these preoperative microstructural differences in the dorsal PCC were linked to preoperative deficits in attention/concentration, a core feature of postoperative delirium. Our findings highlight microstructural vulnerability within the PCC, a key region of the default mode network, as a neuroanatomic locus that can help explain the link between preoperative attention/concentration deficits and increased postoperative delirium risk among vulnerable older surgical patients.

Principles of the Orthogeriatric Model of Care: A Primer

It is well known that over the last few decades, there has been significant growth of the aging population worldwide and especially in Europe, with an increase of more than two years per decade since the 1960's. Currently, in Europe, people aged over 65 years old represent 20% of the population, creating many new and complex challenges for national healthcare systems. In many countries, geriatric medicine is an established medical specialty, integrated into the primary and secondary care of the older population. In some countries, such as Portugal, specialist training in geriatric medicine is not available, even though the life-expectancy in Portugal is currently 81 years due to a decrease in fertility and mortality, and people aged over 60 currently represent nearly a third of the population. There is strong evidence in the medical literature that a fracture following a fall, and especially a neck of femur fracture, is one of the most serious events that can happen in an older person's lifetime. These fractures have been associated with increased morbidity, loss of independence, a high rate of institutionalization, and mortality. Rates of mortality after a year from femoral fractures have been proven to be three to four times higher than the expected in the general population, ranging between 15% to 36%. This emphasizes the importance of developing well-organized care pathways for these patients, which combine specialized geriatric care (also known as orthogeriatric care). This narrative review will focus on the core principles of orthogeriatric care and how medical professionals, including those who are not specialized in geriatric care, can effectively use them.

Association of polypharmacy with cognitive impairment in older trauma patients: a cross-sectional study

INTRODUCTION

Few if any studies have been conducted to date on the association between polypharmacy and cognitive impairment among older trauma patients. Therefore, we investigated whether polypharmacy is associated with cognitive impairment in trauma patients aged ≥70 years.

METHODS

This is a cross-sectional study of patients aged ≥70 years hospitalised due to a trauma-related injury. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score ≤24 points. Medications were coded according to the Anatomical Therapeutic Chemical classification. Three exposures were examined: polypharmacy (≥5 medications), excessive polypharmacy (≥10 medications), and number of medications. Separate logistic regression models adjusted for age, sex, body mass index (BMI), education, smoking, independent living, frailty, multimorbidity, depression, and type of trauma were used to test the association between the three exposures and cognitive impairment.

RESULTS

A total of 198 patients were included (mean age 80.2; 64.7% women and 35.4% men), of which 148 (74.8%) had polypharmacy and 63 (31.8%) had excessive polypharmacy. The prevalence of cognitive impairment was 34.3% overall, 37.2% in the polypharmacy group and 50.8% in the excessive polypharmacy group. More than 80% of participants were taking at least one analgesic. Overall, polypharmacy was not statistically significantly associated with cognitive impairment (odds ratio (OR) 1.20 [95% confidence interval (CI) 0.46 to 3.11]). However, patients in the excessive polypharmacy group were more than two times more likely to have cognitive impairment (OR 2.88 [95% CI 1.31 to 6.37]) even after adjustments for relevant confounders. Similarly, the number of medications was associated with greater odds of cognitive impairment (OR 1.15 [95% CI 1.04 to 1.28]) after adjustments for the same relevant confounders.

CONCLUSION

Cognitive impairment is common among older trauma patients, particularly among those in the excessive polypharmacy group. Polypharmacy was not associated with cognitive impairment. Excessive polypharmacy and number of medications, on the other hand, were associated with greater odds of cognitive impairment in older trauma patients.

In patients with chronic heart failure which polypharmacy pheno-groups are associated with adverse health outcomes? (Polypharmacy pheno-groups and heart failure outcomes)

BACKGROUND

Patients with heart failure are living longer with the inevitable morbidity of rising medication counts. It remains uncertain what fraction of this ensuing polypharmacy exactly predicts adverse clinical outcomes.

METHODS

This prospective study examined records of patients admitted to a Weill Cornell-affiliated tertiary medical institution with a confirmed diagnosis of heart failure between January 2018 to January 2022. Each patient's medications for the past four months were tallied, and a definitional threshold of ≤4, ≥5, ≥10 medications was established. The primary outcome was all-cause mortality within the study period.

RESULTS

Out of a total of 7354 patients included in the study, 70 % were males with a median age of 59 years IQR (48-71). The median (IQR) age-adjusted Charlson Comorbidity Index (CCI) was 21-5. A total of 1475 (20 %) participants died within the study period. Patient cohorts with excessive polypharmacy (≥9 medications) had the highest probability of survival up to 1.6 years compared to those with lower medication thresholds (≤4); the mortality rate decreased by 18 % for patients with excessive polypharmacy [HR = 0.82, 95 % CI: 0.71-0.94]). Conversely, patients with non-heart failure-related polypharmacy had increased risks of ICU admissions (aOR = 1.78, 95 % CI: 1.13-2.70).

CONCLUSION

In an examination of a database of patients with chronic heart failure, major non-heart failure-related polypharmacy was associated with increased risks in intensive care admissions. Excessive polypharmacy was associated with increased rates of survival.

Optimizing clinical outcomes in polypharmacy through poly-de-prescribing: a longitudinal study

Objectives

To evaluate polypharmacy in older people to determine whether the number of medications de-prescribed correlates with the extent of improvement in quality of life (QoL) and clinical outcomes.

Design

A prospective longitudinal cohort study of polypharmacy in people living in a community in Israel.

Setting

Participants aged 65 years or older who took at least six prescription drugs followed up for at least 3 years (range 3-10 years) after poly-de-prescription (PDP) recommendations.

Interventions

PDP recommended at first home visit using the Garfinkel algorithm. Annual follow-up and end-of-study questionnaires used to assess clinical outcomes, QoL, and satisfaction from de-prescribing. All medications taken, complications, hospitalizations, and mortality recorded. In total, 307 participants met the inclusion criteria; 25 incomplete end-of-study questionnaires meant 282 participants for subjective analysis. Participants divided into two subgroups: (i) those who discontinued more than 50% of the drugs (PDP group) or (ii) those who discontinued less than 50% of the drugs (non-responders, NR).

Main outcome measures

Objective: 3-year survival rate and hospitalizations. Subjective: general satisfaction from de-prescribing; change in functional, mental, and cognitive status; improved sleep quality, appetite, and continence; and decreased pain.

Results

Mean age: 83 years (range 65-99 years). Mean number of drugs at baseline visit: 9.8 (range 6-20); 6.7 ± 2.0 de-prescribed in the PDP group (n = 146) and 2.2 ± 2.1 in the NR group (n = 161) (p < 0.001).No statistical difference between the groups in the 3-year survival rate and hospitalizations, but a significant improvement in functional and cognitive status and, in general, satisfaction from the intervention in the PDP group compared to the NR group. Improvement usually evident within the first 3 months and persists for several years.

Conclusion

Poly-de-prescribing in the older population has beneficial effects on several clinical outcomes with no detrimental effect on the rate of hospitalization and survival. The extent of improvement correlates with the extent of de-prescribing. Applying the Garfinkel algorithm globally may improve QoL in millions of patients, a clinical and economic win-win situation.

Polypharmacy and associated factors in South Korean elderly patients with dementia: An analysis using National Health Insurance claims data

BACKGROUND

Dementia is accompanied by several symptoms, including cognitive function decline, as well as behavioral and psychological symptoms. Elderly patients with dementia often experience polypharmacy, the concurrent use of multiple medications, due to chronic comorbidities. However, research on polypharmacy in patients with dementia is limited. This study aimed to characterize polypharmacy and associated factors among elderly patients with dementia in South Korea, and compare the characteristics of patients with and without dementia patients.

METHODS

From the National Health Insurance Service (NHIS)-Senior cohort database, we extracted data on patients aged≥60 years who received outpatient treatment in 2019. Polypharmacy was defined as the concurrent use of five or more different oral medications for ≥90 days; excessive polypharmacy referred to the concurrent use of ten or more different oral medications for ≥90 days. We compared the prevalence of polypharmacy between patients with and without and identified the associated factors using a logistic regression model.

RESULTS

About 70.3% and 23.7% of patients with dementia exhibited polypharmacy and excessive polypharmacy, respectively. After adjusting for conditions such as age and Charlson's comorbidity index, the likelihood of polypharmacy and excessive polypharmacy significantly increased over time after the diagnosis of dementia. Additionally, under the same conditions, Medical Aid beneficiaries with dementia were more likely to experience polypharmacy and excessive polypharmacy compared to patients with dementia covered by National Health Insurance (NHI).

CONCLUSION

This study reports the latest evidence on the status and risk factors of polypharmacy in elderly patients with dementia. We proposed that careful monitoring and management are required for patients at high risk for polypharmacy.

Investigating the Impact of Polypharmacy and Anticholinergic Medication Burden on Objective Cognitive Performance in Adults With Multiple Sclerosis

BACKGROUND

Polypharmacy, or the use of 5 or more daily medications, is common in adults with multiple sclerosis (MS), and is often due to various physical, cognitive, and emotional symptoms. However, research regarding the association between polypharmacy and cognitive outcomes in MS is sparse. Furthermore, individuals with MS often use medications with anticholinergic properties, which are commonly associated with cognitive impairment and other central nervous system adverse effects. Currently, the utility of scales measuring anticholinergic burden in MS is unknown. This study aims to investigate the relationship between polypharmacy, anticholinergic burden, and objective cognitive performance in MS.

METHODS

We recruited 90 individuals with MS during routine visits at an MS specialty clinic in Kansas City. Participants completed a brief, virtual cognitive assessment and answered questions about their health. Participants provided their medication lists from which we determined polypharmacy and scores on several anticholinergic burden scales. Statistical analyses included Spearman correlations and linear regression models.

RESULTS

Approximately 44% of the individuals surveyed met the criteria for polypharmacy. The number of daily medications was negatively correlated with cognitive performance (rs = -0.45, P < .001). Further, the Drug Burden Index accounted for additional variance in cognitive performance beyond that explained by age, education, MS disease duration, and comorbidities [ΔR2 = .12, F(5, 84) = 7.84, P < .001.].

CONCLUSIONS

Clinicians should consider the possible negative consequences of polypharmacy when addressing cognitive concerns in MS. Anticholinergic burden scales may be valuable in this regard. Future investigations could explore behavioral and pharmacological interventions aimed at reducing polypharmacy in MS.

The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand

OBJECTIVES

Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort.

METHODS

Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications.

RESULTS

Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs.

CONCLUSIONS

With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.

Assessment of Hemoglobin A1c Management and Prescription Cost Due to Polypharmacy Among Patients With Diabetes in Iran Based on the STEPS Iran 2016 Survey and a Prescription Database: A Multi-level, Cross-sectional National Study

BACKGROUND

Diabetes frequently results in the need for multiple medication therapies, known as 'Polypharmacy'. This situation can incur significant costs and increase the likelihood of medication errors. This study evaluated the prescriptions of patients with diabetes regarding polypharmacy to assess its effect on the control of hemoglobin A1c (HbA1c) levels and prescription costs.

METHODS

A cross-sectional national study was conducted based on data from linking the Iranians Health Insurance Service prescriptions in 2015 and 2016 with the STEPS 2016 survey in Iran. The association of the individual and sociodemographic factors, as well as polypharmacy, as independent variables, with control of HbA1c levels and the cost of the prescriptions were assessed among diabetic patients using logistic and linear regression, respectively.

RESULTS

Among 205 patients using anti-diabetic medications, 47.8% experienced polypharmacy. The HbA1c of 74 patients (36.1%) was equal to or less than 7, indicating controlled diabetes. HbA1c control showed no significant association with gender. However, prescription costs were notably lower in females (β=0.559 [0.324‒0.964], P=0.036). No significant correlation was found between the area of residence and prescription costs, but HbA1c was significantly more controlled in urban areas (OR=2.667 [1.132‒6.282], P=0.025). Prescription costs were significantly lower in patients without polypharmacy (β=0.211, [0.106‒0.423], P<0.001), though there was no significant association between polypharmacy and HbA1c levels.

CONCLUSION

Our results demonstrated that diabetics with polypharmacy paid significantly more for their prescriptions without experiencing a positive effect on the control of HbA1c levels.

CYP2D6 Substrate Dispensing Among Patients Dispensed Mirabegron: An Administrative Claims Analysis

BACKGROUND

Overactive bladder (OAB) is characterized by the presence of bothersome urinary symptoms. Pharmacologic treatment options for OAB include anticholinergics and β3-adrenergic agonists. Use of β3-adrenergic agonists may result in similar treatment efficacy with a decreased side effect profile compared with anticholinergics because high anticholinergic burden is associated with cardiovascular and neurologic side effects. However, the β3-adrenergic agonist mirabegron, one of two approved drugs within this class, is a moderate cytochrome P450 (CYP) 2D6 inhibitor, and coadministration of drugs that are CYP2D6 substrates with mirabegron may lead to adverse drug effects.

OBJECTIVE

The aim of this study was to quantify how often CYP2D6 substrates were dispensed in patients receiving mirabegron among adults of any age and among those ≥ 65 years of age.

METHODS

In this retrospective descriptive analysis, a deidentified administrative claims database in the United States, IQVIA PharMetrics® Plus, was used to identify dispensing claims for CYP2D6 substrates and mirabegron from November 2012 to September 2019. Prevalence of CYP2D6 substrate dispensing was assessed in patients dispensed mirabegron among all adults ≥ 18 years old and additionally among a cohort of those ≥ 65 years old. Patient baseline profiles at the time of mirabegron and CYP2D6 substrate codispensing and at the time of mirabegron dispensing were compared. CYP2D6 substrates were categorized as those with the potential for increased risk of QT prolongation, with anticholinergic properties, with narrow therapeutic index (NTI), contraindicated or having a black box warning when used with CYP2D6 inhibitors, or used for depression or other psychiatric disease. Dispensing data and patient profiles were summarized descriptively.

RESULTS

Overall, 68.5% of adults ≥ 18 years old dispensed mirabegron had overlapping dispensings for one or more CYP2D6 substrate; 60.6% and 53.6% had overlapping dispensings for CYP2D6 substrates with anticholinergic properties or risk of QT prolongation, respectively. CYP2D6 substrates with NTI, contraindicated with CYP2D6 inhibitors, or for psychiatric use were codispensed in 17.7%, 16.6%, and 38.0% of adult mirabegron users, respectively. Mirabegron users receiving one or more concurrent CYP2D6 substrate were more likely to be older, have more comorbidities and baseline polypharmacy, and have increased healthcare resource utilization compared with those without concurrent CYP2D6 substrates. Commonly codispensed CYP2D6 substrates included hydrocodone, oxycodone, tramadol, metoprolol, and tamsulosin. Findings were similar for patients in the older cohort (≥ 65 years old), with 72.1% receiving overlapping CYP2D6 substrates.

CONCLUSIONS

Codispensing of CYP2D6 substrates, especially those with anticholinergic properties or risk of QT prolongation, was common among adults and older adults receiving mirabegron. Results highlight the need for improved awareness of CYP2D6 substrate prescribing among patients receiving pharmacologic treatment for OAB that inhibits the CYP2D6 pathway.

A pharmacist-led medication review service with a deprescribing focus guided by implementation science

Background: Little research addressed deprescribing-focused medication optimization interventions while utilizing implementation science. This study aimed to develop a pharmacist-led medication review service with a deprescribing focus in a care facility serving patients of low income receiving medications for free in Lebanon followed by an assessment of the recommendations' acceptance by prescribing physicians. As a secondary aim, the study evaluates the impact of this intervention on satisfaction compared to satisfaction associated with receiving routine care. Methods: The Consolidated Framework for Implementation Research (CFIR) was used to address implementation barriers and facilitators by mapping its constructs to the intervention implementation determinants at the study site. After filling medications and receiving routine pharmacy service at the facility, patients 65 years or older and taking 5 or more medications, were assigned into two groups. Both groups of patients received the intervention. Patient satisfaction was assessed right after receiving the intervention (intervention group) or just before the intervention (control group). The intervention consisted of an assessment of patient medication profiles before addressing recommendations with attending physicians at the facility. Patient satisfaction with the service was assessed using a validated translated version of the Medication Management Patient Satisfaction Survey (MMPSS). Descriptive statistics provided data on drug-related problems, the nature and the number of recommendations as well as physicians' responses to recommendations. Independent sample t-tests were used to assess the intervention's impact on patient satisfaction. Results: Of 157 patients meeting the inclusion criteria, 143 patients were enrolled: 72 in the control group and 71 in the experimental group. Of 143 patients, 83% presented drug-related problems (DRPs). Further, 66% of the screened DRPs met the STOPP/START criteria (77%, and 23% respectively). The intervention pharmacist provided 221 recommendations to physicians, of which 52% were to discontinue one or more medications. Patients in the intervention group showed significantly higher satisfaction compared to the ones in the control group (p < 0.001, effect size = 1.75). Of those recommendations, 30% were accepted by the physicians. Conclusion: Patients showed significantly higher satisfaction with the intervention they received compared to routine care. Future work should assess how specific CFIR constructs contribute to the outcomes of deprescribing-focused interventions.

Ten-Year Prospective Follow-Up of Institutionalized Patients With Diabetes in a Long-Term Care Home

Clinical practice recommendations advise individualizing diabetes treatment for elderly people, especially those living in long-term care facilities. Elderly patients face one of two main risks: either excessive treatment leading to hypoglycemia or insufficient treatment leading to progression of complications and excess mortality. This article describes a 10-year prospective observational study of people with diabetes in a long-term care home to determine the effect of routine glucose monitoring and monthly evaluation by a diabetes specialist with a goal of improving A1C. Its findings suggest that minimal glucose monitoring and monthly medical follow-up can optimize patient outcomes and help to maintain quality of life without over-medicalization of older people with diabetes in institutional settings.

Deprescribing Opportunities for Hospitalized Patients With End-Stage Kidney Disease on Hemodialysis: A Secondary Analysis of the MedSafer Cluster Randomized Controlled Trial

Background

End-stage kidney disease patients on dialysis have a substantial risk of polypharmacy due their propensity for comorbidity and contact with the health care system. MedSafer is an electronic decision support tool that integrates patient comorbidity and medication lists to generate personalized deprescribing reports focused on identifying potentially inappropriate medications (PIMs).

Objective

To conduct a secondary analysis of patients on regular hemodialysis included in the MedSafer randomized controlled trial to investigate the patterns of polypharmacy and evaluate the efficacy of the MedSafer deprescribing algorithms.

Design

Secondary analysis of a cluster randomized clinical trial.

Setting

Medical units in 11 acute care hospitals in Canada.

Patients

The MedSafer trial enrolled 5698 participants with an expected prognosis of >3 months, age 65 years and older, and on 5 or more daily home medications; 140 participants were receiving chronic hemodialysis.

Measurements

The primary outcome of the trial was 30-day adverse drug events (ADEs) post-hospital discharge, and a key secondary outcome was deprescribing.

Methods

Control patients received usual care (medication reconciliation), whereas clinicians caring for intervention patients received a MedSafer report that highlighted individualized opportunities for deprescribing.

Results

There were 70 patients in each of the control and intervention arms. The median number of home medications was 14 (compared with a median of 10 medications in the general trial population). The most frequent medications observed that were potentially inappropriate were proton pump inhibitors (potentially inappropriate in 55/76 users; 72.4%), diabetes medications in patients with a HBA1C <7.5% (36/65 users; 55.4%), docusate (27/27 users; 100%), gabapentinoids (27/36 users; 75%), and combination antiplatelet/anticoagulants (22/97 users; 22.7%). The proportion of PIMs deprescribed was higher during the intervention phase (28.8% vs 19.3%; absolute increase 9.4% [95% confidence interval 1.3%-17.6%]) compared with the control phase. There was no observed difference in ADEs at 30-day post-discharge between the control and the intervention groups. The most common ADE (n = 3) was gastrointestinal bleeding attributed to antiplatelet agents.

Limitations

This was a post hoc exploratory analysis, the original trial did not stratify by hemodialysis status, and the small sample size precludes drawing any definitive conclusions.

Conclusion

MedSafer facilitates deprescribing in hospitalized patients on hemodialysis. Larger-scale implementation of decision support software for deprescribing in dialysis and long-term follow-up are likely required to demonstrate an impact on ADEs.

Preoperative Polypharmacy in Geriatric Patients is Associated with Increased 90-Day All-Cause Hospital Readmission After Surgery for Adult Spinal Deformity Patients

OBJECTIVE

To investigate the effect of preoperative polypharmacy (PP) on 90-day all-cause readmission rate in older adults undergoing corrective surgery for ASD.

METHODS

Older adults with a diagnosis of ASD undergoing spinal surgery at a quaternary medical center from January 2016 to March 2019 were enrolled in this study. Patients were dichotomized into two groups stratified by the number of preoperative prescription medications; with PP defined as 5 or more prescription medications. The primary outcome measure was 90-day all-cause readmission rate. Secondary outcomes included postoperative changes in health-related quality of life measures.

RESULTS

Among 161 patients (mean [SD], 69.59[8.79] years), 97 patients were included in PP cohort and 64 in non-polypharmacy (non-PP) cohort. Both groups were balanced at baseline. The duration of hospital (5.82[1.93] vs. 6.50[4.00] days), mean number of fusion levels, and duration of surgery was statistically similar between both groups (p>0.05). There was no difference in the proportion of patients discharged directly home (31.25% vs. 40.42%, p=0.36). 90-day all-cause readmission rate was 3-fold higher in the PP cohort compared with the non-PP cohort. After adjusting for preoperative patient optimization, ASA grade, surgical invasiveness, smoking, depression and baseline functional disability, older adults with PP had a 9.79 increased odds of 90-day all-cause hospital readmission (p=0.04). Change in HRQOL measures were similar between both groups.

CONCLUSION

This study's findings indicate that despite preoperative optimization, older adults exposed to polypharmacy are at a significantly increased risk of hospital readmission within 90-days of surgery.

Cost-Effectiveness of Antihypertensive Deprescribing in Primary Care: a Markov Modelling Study Using Data From the OPTiMISE Trial

BACKGROUND

Deprescribing of antihypertensive medications for older patients with normal blood pressure is recommended by some clinical guidelines, where the potential harms of treatment may outweigh the benefits. This study aimed to assess the cost-effectiveness of this approach.

METHODS

A Markov patient-level simulation was undertaken to model the effect of withdrawing one antihypertensive compared with usual care, over a life-time horizon. Model population characteristics were estimated using data from the OPTiMISE antihypertensive deprescribing trial, and the effects of blood pressure changes on outcomes were derived from the literature. Health-related quality of life was modeled in Quality-Adjusted Life Years (QALYs) and presented as costs per QALY gained.

RESULTS

In the base-case analysis, medication reduction resulted in lower costs than usual care (mean difference £185), but also lower QALYs (mean difference 0.062) per patient over a life-time horizon. Usual care was cost-effective at £2975 per QALY gained (more costly, but more effective). Medication reduction resulted more heart failure and stroke/TIA events but fewer adverse events. Medication reduction may be the preferred strategy at a willingness-to-pay of £20 000/QALY, where the baseline absolute risk of serious drug-related adverse events was ≥7.7% a year (compared with 1.7% in the base-case).

CONCLUSIONS

Although there was uncertainty around many of the assumptions underpinning this model, these findings suggest that antihypertensive medication reduction should not be attempted in many older patients with controlled systolic blood pressure. For populations at high risk of adverse effects, deprescribing may be beneficial, but a targeted approach would be required in routine practice.

Polypharmacotherapy in Psychiatry: Global Insights from a Rapid Online Survey of Psychiatrists

In recent years, an increase in the problem of polypharmacotherapy in psychiatric patients has been observed, including the widespread problem of groups of people taking new psychoactive substances. One reason for this problem may be the poor knowledge of pharmacological interactions in psychiatry. The aim of this study was to explore the opinions and knowledge of psychiatrists from around the world on various aspects related to polypharmacotherapy. A total of 1335 psychiatrists from six continents were included in the study. The respondents’ opinion on the problem of hepatotoxicity in psychiatry was also examined. The greatest discrepancy among psychiatrists from different continents in the answers given concerned the definition of polypharmacotherapy (p < 0.001) and the approach to hepatotoxicity (p < 0.001). It is noteworthy that only about 20% of the psychiatrists surveyed (p < 0.001) believe that polypharmacotherapy is associated with a higher rate of patients’ hospitalisations. The most commonly used type of polypharmacy by psychiatrists was antidepressants and antipsychotics. Most of them also stated that polypharmacy was associated with reduced patient compliance with the doctor’s recommendations related to taking medications due to the increased complexity of the therapy. The continent that diversified the analysed questions to the greatest extent was Africa. Future educational activities for trainee psychiatrists should include more discussion of polypharmacotherapy in psychiatry.

Inappropriateness of Proton Pump Inhibitors After Hospital Discharge Is Associated with Thirty-Day Hospital Readmission

BACKGROUND AND AIMS

Concerns have been raised about the adverse effects of proton pump inhibitors (PPIs). Rather than PPIs themselves causing harm, we hypothesized that PPIs prescribed without appropriate indications would be associated with adverse outcomes compared to appropriately indicated PPIs.

METHODS

Adult patients initiated on a new PPI during a hospitalization at our institution from 2014 to 2018 were analyzed. The primary outcome was all-cause 30-day readmission rate. The primary exposure was long-term appropriateness of PPI determined by the presence of prespecified diagnostic codes and discharge medications. Logistic regression modeling was used to estimate the odds of 30-day readmission in patients discharged on inappropriate compared to appropriate new PPIs.

RESULTS

Of 84,236 patients admitted to our institution, 7745 (9.2%) were discharged on a new PPI, of which 5136 (66.3%) lacked an appropriately documented indication. Inappropriate PPIs were associated with 30-day hospital readmission after adjusting for other factors (adjusted odds ratio 1.30, 95% confidence interval 1.10-1.53). The excess risk associated with lack of appropriate documentation for PPIs in these patients was 44 readmissions per 1000 hospitalizations (95% confidence interval 21-67).

CONCLUSIONS

Discharge on inappropriate PPIs was associated with 30-day hospital readmission compared to appropriate PPIs. The harm associated with inappropriate PPIs is not likely due to direct effects of PPIs because all patients in the study received PPIs. Rather, patients who receive inappropriate PPIs may have additional patient-specific factors that place them at increased risk for hospital readmission.

The Costs and Healthcare Resource Utilization Associated with Anticholinergic Burden in Long-Stay Nursing Home Residents with Overactive Bladder in the US

BACKGROUND

Overactive bladder (OAB) is a prevalent condition commonly treated with anticholinergic medications. The extent to which anticholinergic burden is associated with costs and healthcare resource use (HCRU) in the long-stay nursing home (LSNH) setting is currently unknown.

OBJECTIVES

This research evaluated the impact of anticholinergic burden on HCRU and related costs among LSNH residents with OAB.

METHODS

This was a cohort study based on 2013-2015 Minimum Data Set-linked Medicare claims data involving LSNH residents aged ≥ 65 years with OAB and having Parts A, B and D coverage 6 months pre- and ≥ 12 months post-nursing home admission date (index date). Cumulative anticholinergic burden was determined using the Anticholinergic Cognitive Burden scale and defined daily dose. Direct medical costs related to HCRU were examined. HCRU included inpatient, outpatient, emergency room (ER), and physician office visits. Costs and HCRU associated with levels of anticholinergic burden were evaluated using generalized linear models.

RESULTS

A total of 123,308 LSNH residents with OAB were included in this study. Most residents (87.2%) had some level (12.8%, none; 18.0%, low; 41.9%, moderate; and 27.3%, high) of cumulative anticholinergic burden. Results indicate that all types of resource utilization were higher among those with any level of anticholinergic burden than those with no burden. The outpatient, ER, and physician costs tended to be higher with increasing anticholinergic burden.

CONCLUSIONS

Costs and HCRU patterns reflected increasing trends with anticholinergic burden. Targeted efforts towards reducing anticholinergic burden among LSNH residents with OAB may result in decreases in costs and HCRU.

Anticonvulsant Primary and Secondary Prophylaxis for Acute Ischemic Stroke Patients: A Decision Analysis

Background and Purpose

We examined the impact of 3 anticonvulsant prophylaxis strategies on quality-adjusted life-years (QALYs) among patients with an incident acute ischemic stroke.

Methods

We created a decision tree to evaluate 3 strategies: (1) long-term primary prophylaxis; (2) short-term secondary prophylaxis after an early seizure with lifetime prophylaxis if persistent or late seizures (LSs) developed; and (3) long-term secondary prophylaxis if either early, late, or persistent seizures developed. The outcome was quality-adjusted life expectancy (QALY). We created 4 base cases to simulate common clinical scenarios: (1) female patient aged 40 years with a 2% or 11% lifetime risk of an LS and a 33% lifetime risk of an adverse drug reaction (ADR); (2) male patient aged 65 years with a 6% or 29% LS risk and 60% ADR risk; (3) male patient aged 50 years with an 18% or 65% LS risk and 33% ADR risk; and (4) female patient aged 80 years with a 29% or 83% LS risk and 80% ADR risk. In sensitivity analyses, we altered the parameters and assumptions.

Results

Across all 4 base cases, primary prophylaxis yielded the fewest QALYs when compared with secondary prophylaxis. For example, under scenario 1, strategies 2 and 3 resulted in 7.17 QALYs each, but strategy 1 yielded only 6.91 QALYs. Under scenario 4, strategies 2 and 3 yielded 2.85 QALYs compared with 1.40 QALYs for strategy 1. Under scenarios in which patients had higher ADR risks, strategy 2 led to the most QALYs.

Conclusions

Short-term therapy with continued anticonvulsant prophylaxis only after postischemic stroke seizures arise dominates lifetime primary prophylaxis in all scenarios examined. Our findings reinforce the necessity of close follow-up and discontinuation of anticonvulsant seizure prophylaxis started during acute ischemic stroke hospitalization.

Economic Burden of Treatment-Resistant Depression among Adults with Chronic Non-Cancer Pain Conditions and Major Depressive Disorder in the US

OBJECTIVE

Major depressive disorder (MDD) and chronic non-cancer pain conditions (CNPC) often co-occur and exacerbate one another. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on direct total and MDD-related healthcare resource utilization (HRU) and costs among commercially insured patients with CNPC and MDD in the US.

METHODS

The retrospective longitudinal cohort study employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007 to June 2017). Costs (2018 US$) and HRU were compared between patients with and without TRD over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD.

RESULTS

Of the 21,180 adults with CNPC and MDD, 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs (US$21,015_TRD vs US$14,712_{No TRD}) and MDD-related costs (US$1201_TRD vs US$471_{No TRD}) compared with non-TRD patients (all p < 0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had a significantly higher number of inpatient (incidence rate ratio [IRR] 1.30, 95% CI 1.14-1.47) and emergency room visits (IRR 1.21, 95% CI 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient-level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups.

CONCLUSION

TRD poses a substantial direct economic burden for adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.

Polypharmacy in Multiple Sclerosis: Current Knowledge and Future Directions

Polypharmacy, or the daily use of five or more medications, is well documented in older adults and linked to negative outcomes such as medication errors, adverse drug reactions, and increased healthcare utilization. Like older adults, people with multiple sclerosis (PwMS) are susceptible to polypharmacy, owing to the variety of treatments used to address individual multiple sclerosis (MS) symptoms and other comorbidities. Between 15-65% of PwMS meet criteria for polypharmacy; in this population, polypharmacy is associated with increased reports of fatigue, subjective cognitive impairment, and reduced quality of life. Despite evidence of adverse outcomes, polypharmacy among PwMS remains a neglected area of research. This article examines the current literature regarding polypharmacy in MS, as well as implications for clinical practice and directions for future research.

Overactive Bladder Prescribing Considerations: The Role of Polypharmacy, Anticholinergic Burden, and CYP2D6 Drug‒Drug Interactions

Overactive bladder (OAB) is a common disorder in the general population, and the prevalence increases with age. Adults with OAB typically have a greater number of comorbid conditions, such as hypertension, depression, and dementia, compared with adults without OAB. Subsequent to an increased number of comorbidities, adults with OAB take a greater number of concomitant medications, which may increase the risk of potentially harmful drug‒drug interactions. There are two important considerations for many of the medications approved for the treatment of OAB in the USA: anticholinergic burden and potential for drug‒drug interactions, notably related to cytochrome P450 (CYP) 2D6, which is responsible for the metabolism of approximately 25% of all drugs. A substantial number of drugs used for the treatment of OAB and comorbid conditions (e.g., cardiovascular and neurologic disorders) are CYP2D6 substrates or inhibitors. Furthermore, a substantial number of drugs with CYP2D6 properties also have strong anticholinergic properties. Here, we review polypharmacy associated with OAB and its common comorbidities, identify drugs with reported anticholinergic properties, and provide an overview of clinically relevant drug‒drug interactions in the treatment of OAB as they relate to CYP2D6 metabolism. This review aims to provide clinicians with essential information necessary for making treatment decisions when managing OAB.

Prevalence and Factors Associated with Cumulative Anticholinergic Burden Among Older Long-Stay Nursing Home Residents with Overactive Bladder

BACKGROUND

Overactive bladder (OAB), the primary cause of urinary incontinence in nursing homes, is commonly treated with anticholinergic medications; however, the elderly population is vulnerable to the adverse effects associated with anticholinergic burden. Given the relatively high prevalence of OAB among nursing home residents, it is important to understand the magnitude of anticholinergic burden in this population.

OBJECTIVES

The objectives of this study were to (1) examine the prevalence of cumulative anticholinergic burden among long-stay nursing home (LSNH) residents with OAB; and (2) identify the factors associated with varying levels of cumulative anticholinergic burden.

METHODS

This was a retrospective, cohort study using Minimum Data Set-linked Medicare claims data. Anticholinergic burden was determined based on the Anticholinergic Cognitive Burden scale and patient-specific dosing using defined daily dose. The Andersen Behavioral Model framework was used to identify the predisposing, enabling, and need factors associated with levels of anticholinergic burden. Multivariable logistic regression models were developed to determine the factors associated with levels of anticholinergic burden.

RESULTS

A total of 123,308 LSNH residents with OAB were identified; 87.2% had some degree of anticholinergic burden and 27.3% had high cumulative burden. Multiple factors were associated with higher levels of burden, including younger age, female sex, and non-Hispanic White ethnicity (predisposing factors); dual eligibility, Southern geographic region, and rural residence (enabling factors); and a number of comorbidities and concomitant medications (need factors).

CONCLUSIONS

This study revealed a high level of anticholinergic burden among LSNH residents. Multiple factors were associated with a high level of burden. There is a need to optimize the use of anticholinergics due to their significant safety concerns in the LSNH setting.

Opioid prescribing and risk of drug-opioid interactions in older discharged patients with polypharmacy in Australia

Background Opioids are commonly prescribed to managing chronic pain in older persons. However, these patients are often at risk of drug-opioid interactions due to polypharmacy. Objectives To identify the prevalence of opioid prescribing and drug-opioid interactions in poly-medicated older patients and factors associated with opioid prescribing. Setting Patients were included if they were admitted to the Royal Adelaide Hospital between September 2015 and August 2016, aged ≥ 75 years and took ≥ 5 medications at discharge. Methods After ethics approval, data of were retrospectively collected from case notes. The Charlson Comorbidity Index and Drug Burden Index were determined and opioids were classified as strong or weak. The association between opioid use and concurrent medications was computed using logistic regression and the results presented as odds ratios (OR) and 95% confidence intervals (95% CI), adjusted for age, sex, Charlson Comorbidity Index, number of prescribed medications and modified-Drug Burden Index. Main outcome measure Association between concurrent medications and opioid prescribing. Results 15,000 geriatric admissions were identified, of which 1192 were included. A total of 283 (23.7%) patients were prescribed opioids, with oxycodone accounting for 56% of these prescriptions. Opioid users were prescribed more medications (11.2 vs. 9.0, P < 0.001) and had higher Drug Burden Index (1.2 vs. 0.14, P < 0.001) compared to non-users. Opioid use was associated with concurrent prescription of antiepileptics (OR = 1.7, 95% CI 1.1-2.6), and negatively associated with Charlson Comorbidity Index (OR = 0.9, 95% CI 0.8-0.98) and concurrent use of antipsychotics (OR = 0.5, 95% CI 0.3-0.9) and beta blocking agents (OR = 0.4, 95% CI 0.3-0.6). Conclusions Strong opioids were prescribed more often than weak opioids and opioid users presented with characteristics and concurrent medications which increased the risk of opioid related adverse drug effects.

The impact of telemental health use on healthcare costs among commercially insured adults with mental health conditions

OBJECTIVE

To determine the impact of telemental health (TMH) use on total healthcare costs and mental health (MH)-related costs paid by a third party among adults with mental health conditions (MHC).

METHOD

This study employed a pre-post design with a non-equivalent control group. The cohort comprised adults with MHCs identified using diagnosis codes from de-identified claims data of the Optum Clinformatics DataMart (2010 January 01 to 2017 June 30). We identified mental health (MH) service users and TMH users (N = 348) based on procedure codes. Non-users (N = 238,595) were defined as those who only used in-person MH services. A Difference-in-Differences (DID) analysis was performed within a multivariable two-part model (TPM) framework to examine the impact of TMH use on adjusted standardized costs (2018 US $) of all healthcare services and MH services. Patient-level and state-level factors were adjusted in TPM.

RESULTS

TMH use was associated with significantly higher MH-related costs [Marginal effect = $461.3, 95% confidence interval: $142.4-$780.2] and an excess of $370 increase in MH-related costs at follow-up as compared to baseline. However, TMH use was not associated with an increase in total third-party healthcare costs nor with changes in total costs from baseline to follow-up.

CONCLUSIONS

Despite having a higher likelihood of MH services use and MH-related costs, TMH users did not have higher total costs as compared to adults using only in-person MH services. Our findings suggest that TMH can increase access to MH care without increasing total healthcare costs among adults with MHC. Future studies exploring whether TMH use can lead to cost-savings over a longer period are warranted.

Effectiveness for introducing nurse practitioners in six long-term care facilities in Québec, Canada: A cost-savings analysis

BACKGROUND

Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new.

PURPOSE

To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs).

METHODS

A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated.

FINDINGS

The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4.

DISCUSSION

This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care.

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.

Safety and effectiveness of tofogliflozin in elderly Japanese patients with type 2 diabetes mellitus: A subanalysis of a post-marketing study (J-STEP/EL Study)

AIMS/INTRODUCTION

This subanalysis aimed to assess the safety and effectiveness of tofogliflozin by using data from the Japanese Study of Tofogliflozin with Type 2 Diabetes Mellitus Patients in an Observational Study of the Elderly to categorize elderly Japanese patients with type 2 diabetes mellitus by the number of concomitant oral antidiabetic drugs (OADs) and insulin use at baseline.

MATERIALS AND METHODS

Japanese Study of Tofogliflozin with Type 2 Diabetes Mellitus Patients in an Observational Study of the Elderly is a 1-year prospective, observational and multicenter post-marketing study that enrolled all patients with type 2 diabetes mellitus aged ≥65 years who started tofogliflozin during the first 3 months after its launch in May 2014 in Japan.

RESULTS

The safety and effectiveness analysis sets included 1,497 and 1,422 patients, respectively. Overall, 18.10 and 2.20% of the patients experienced adverse drug reactions (ADRs) and serious ADRs, respectively. ADRs of special interest in the total, 0 OAD, one OAD, two OADs, three or more OADs and insulin groups occurred in 12.22, 10.04, 12.35, 13.32, 11.27 and 14.91% of patients, respectively. Volume depletion-related events were the most frequently observed ADRs of special interest. Hypoglycemia occurred in 1.07% of patients. Overall, glycated hemoglobin and bodyweight were significantly decreased, but the estimated glomerular filtration rate was not significantly changed.

CONCLUSIONS

Our finding suggests that tofogliflozin could be safely and effectively used in elderly Japanese patients with type 2 diabetes mellitus, irrespective of the number of OADs and the use of insulin.

Patients’ and Caregivers’ Attitudes Toward Deprescribing in Singapore

Background

Knowledge of decision-making preference of patients and caregivers is needed to facilitate deprescribing. This study aimed to assess the perspectives of caregivers and older adults towards deprescribing in an Asian population. Secondary objectives were to identify and compare characteristics associated with these attitudes and beliefs.

Method

A cross-sectional survey of two groups of participants was conducted using the Revised Patients’ Attitudes Towards Deprescribing questionnaire. Descriptive results were reported for participants’ characteristics and questionnaire responses from four factors (belief in medication inappropriateness, medication burden, concerns about stopping, and involvement) and two global questions. Correlation between participant characteristics and their responses was analyzed.

Results

A total of 1,057 (615 older adults; 442 caregivers) participants were recruited from 10 institutions in Singapore. In which 511 (83.0%) older adults and 385 (87.1%) caregivers reported that they would be willing to stop one or more of their medications if their doctor said it was possible, especially among older adults recruited from acute-care hospitals (85.3%) compared with older adults in community pharmacies (73.6%). Individuals who take more than five medications and those with higher education were correlated with greater agreement in inappropriateness and involvement, respectively.

Conclusions

Clinicians should consider discussing deprescribing with older adults and caregivers in their regular clinical practice, especially when polypharmacy is present. Further research is needed into how to engage older adults and caregivers in shared decision making based on their attitudes toward deprescribing.

Self-reported medication in community-dwelling older adults in Germany: results from the Berlin Initiative Study

Background

Older adults have the highest drug utilization due to multimorbidity. Although the number of people over age 70 is expected to double within the next decades, population-based data on their medication patterns are scarce especially in combination with polypharmacy and potentially inappropriate medication (PIM). Our objective was to analyse the frequency of polypharmacy, pattern of prescription (PD) and over-the-counter (OTC) drug usage, and PIMs according to age and gender in a population-based cohort of very old adults in Germany.

Methods

Cross-sectional baseline data of the Berlin Initiative Study, a prospective cohort study of community-dwelling adults aged ≥70 years with a standardized interview including demographics, lifestyle variables, co-morbidities, and medication assessment were analysed. Medication data were coded using the Anatomical Therapeutic Chemical (ATC) classification. Age- and sex-standardized descriptive analysis of polypharmacy (≥5 drugs, PD and OTC vs. PD only and regular and on demand drugs vs regular only), medication frequency and distribution, including PIMs, was performed by age (</≥80) and gender.

Results

Of 2069 participants with an average age of 79.5 years, 97% (95%CI [96%;98%]) took at least one drug and on average 6.2 drugs (SD = 3.5) with about 40 to 66% fulfilling the criteria of polypharmacy depending on the definition. Regarding drug type more female participants took a combination of PD and OTC (male: 68%, 95%CI [65%;72%]); female: 78%, 95%CI [76%;80%]). Most frequently used were drugs for cardiovascular diseases (85%, 95%CI [83%;86%]). Medication frequency increased among participants aged ≥80 years, especially for cardiovascular drugs, antithrombotics, psychoanaleptics and dietary supplements. Among the top ten prescription drugs were mainly cardiovascular drugs including lipid-lowering agents (simvastatin), beta-blockers (metoprolol, bisoprolol) and ACE inhibitors (ramipril). The most common OTC drug was acetylsalicylic acid (35%; 95%CI [33%;37%])). Dose-independent PIM were identified for 15% of the participants.

Conclusions

Polypharmacy was excessive in older adults, with not only PD but also OTC drugs contributing to the high point prevalence. The medication patterns reflected the treatment of chronic diseases in this age group. There was even an increase in medication frequency between below and above 80 years especially for drugs of cardiovascular diseases, antithrombotic medication, psychoanaleptics, and dietary supplements.

Frailty and Comprehensive Geriatric Assessment

Frailty is defined as a reduced physiologic reserve vulnerable to external stressors. For older individuals, frailty plays a decisive role in increasing adverse health outcomes in most clinical situations. Many tools or criteria have been introduced to define frailty in recent years, and the definition of frailty has gradually converged into several consensuses. Frail older adults often have multi-domain risk factors in terms of physical, psychological, and social health. Comprehensive geriatric assessment (CGA) is the process of identifying and quantifying frailty by examining various risky domains and body functions, which is the basis for geriatric medicine and research. CGA provides physicians with information on the reversible area of frailty and the leading cause of deterioration in frail older adults. Therefore frailty assessment based on understanding CGA and its relationship with frailty, can help establish treatment strategies and intervention in frail older adults. This review article summarizes the recent consensus and evidence of frailty and CGA.

Multimorbidity, polypharmacy and primary prevention in community-dwelling adults in Quebec: a cross-sectional study

BACKGROUND

Polypharmacy carries the risk of adverse events, especially in people with multimorbidity.

OBJECTIVE

To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention.

METHODS

Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease.

RESULTS

Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention.

CONCLUSION

There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety.

Polypharmacy: a healthcare conundrum with a pharmacogenetic solution

The use of multiple medications is growing at an alarming rate with some reports documenting an average of 12-22 prescriptions being used by individuals ≥50 years of age. The indirect consequences of polypharmacy include exacerbation of drug-drug interactions, adverse drug reactions, increased likelihood of prescribing cascades, chronic dependence, and hospitalizations - all of which have significant health and economic burden. While many practical solutions for reducing polypharmacy have been proposed, they have been met with limited efficacy. This highlights the need for a new systematic approach for fine-tuning dispensing of medications. Pharmacogenetic testing provides an empirical and scientifically rigorous approach for guiding appropriate selection of medicines, with the potential to reduce unnecessary polypharmacy while improving clinical outcomes. The goal of this review article is to provide healthcare providers with an understanding of polypharmacy, its adverse effects on the healthcare system and highlight how pharmacogenetic information can be used to avoid polypharmacy in patients.

Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited.

OBJECTIVE

The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention.

DESIGN

A prospective cohort study with an internal comparison group.

PARTICIPANTS

IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications.

INTERVENTION

IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model.

MAIN MEASURES

We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased.

KEY RESULTS

The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency.

CONCLUSIONS

Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

Reducing inappropriate prescribing for older adults with advanced frailty: A review based on a survey of practice in four countries

The management of medications in persons with frailty presents challenges. There is evidence of inappropriate prescribing and a lack of consensus among healthcare professionals on the judicious use of medications, particularly for patients with more severe frailty. This study reviews the evidence on the use of commonly prescribed pharmacological treatments in advanced frailty based on a questionnaire of prescribing practices and attitudes of healthcare professionals at different stages in their careers, in different countries. A convenience sample of those attending hospital grand rounds in Ireland, Canada and Australia/New Zealand (ANZ) were surveyed on the management of 18 medications in advanced frailty using a clinical vignette (man with severe dementia, Clinical Frailty Scale 7/9). Choices were to continue or discontinue (stop now or later) medications. In total, 298 respondents from Ireland (n = 124), Canada (n = 110), and ANZ (n = 64) completed the questionnaire, response rate 97%, including 81 consultants, 40 non-consultant hospital doctors, 134 general practitioners and 43 others (nurses, pharmacists, and medical students). Most felt that statins (88%), bisphosphonates (77%) and cholinesterase inhibitors (76%) should be discontinued. Thyroid replacement (88%), laxatives (83%) and paracetamol (81%) were most often continued. Respondents with experience in geriatric, palliative and dementia care were significantly more likely to discontinue medications. Age, gender and experience working in nursing homes did not contribute to the decision. Reflecting the current literature, there was no clear consensus on inappropriate prescribing, although respondents preferentially discontinued medications for secondary prevention. Experience significantly predicted the number and type discontinued, suggesting that education is important in reducing inappropriate prescribing for people in advanced states of frailty.

Frailty in Hematologic Malignancy

PURPOSE OF REVIEW

Older adults with hematologic malignancy are a growing demographic. Estimating risk of chemotherapy toxicity based on age alone is an unreliable estimate of quality of life, functional capacity, or risk of treatment complications.

RECENT FINDINGS

Dedicated geriatric assessment tools can aid the clinician in identifying geriatric syndromes such as frailty, resulting in improved prognostication to decrease morbidity and mortality. Frailty is not synonymous with individual performance status and is dynamic. Establishing the patient goals, values, and preferences is central to the consideration of malignant hematology decision process. Careful considerations of available data on the patient's prognosis based on estimated life expectancy, geriatric assessment data, and age-specific cancer mortality, with and without treatment, can reconcile the risks and benefits. Assessments of frailty can aid the clinical feasibility and burden of the treatment to the patient and family in the context of each patient's unique needs.

Conceptualizing multiple drug use in patients with comorbidity and multimorbidity: proposal for standard definitions beyond the term polypharmacy

With older and aging populations, patients experience multiple chronic diseases at the same time. Individual chronic disease guidelines often recommend pharmacological therapies as a key intervention, resulting in patients being prescribed multiple regular medications for their different diseases. Although the term "polypharmacy" has been applied to the use of multiple medications, there is no consistent definition, and this term is now being used all inclusively. To improve both scientific rigor and optimal patient care, it is crucial that a standard terminology is used, which reclassifies the term "polypharmacy" into distinct phenotypes relating to the index chronic disease, additional conditions to the index (comorbidity), or the experience of multiple chronic conditions at the same time (multimorbidity). Using three exemplar index conditions; heart failure, type 2 diabetes, and breast cancer, we propose the reclassification of the term "polypharmacy" into three distinct phenotypes. First, index drug or multi-index drug therapy, where each index condition creates multiple drug use for that condition; second, codrug therapy, where addition of other comorbid conditions increases the multiple drug use and may influence the management of the index disease and third, multidrug therapy, where adult population with multimorbidity may be on many drugs. This article reviews guidelines for the individual exemplars to develop the basis for the new terms and then develops the pharmacoepidemiology of multiple drug use further by reviewing the evidence on the relationship between the phenotypic classification and important outcomes. The importance of standardizing "polypharmacy" terminology for the scientific agenda and clinical practice is that it relates to an index condition or disease safety outcomes including drug interactions, adverse side effects in hospital admissions, and related "polypill" concept.

Interventions to improve the appropriate use of polypharmacy for older people

BACKGROUND

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

OBJECTIVES

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient's outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

AUTHORS' CONCLUSIONS

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients' prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

A case study of polypharmacy management in nine European countries: Implications for change management and implementation

Background

Multimorbidity and its associated polypharmacy contribute to an increase in adverse drug events, hospitalizations, and healthcare spending. This study aimed to address: what exists regarding polypharmacy management in the European Union (EU); why programs were, or were not, developed; and, how identified initiatives were developed, implemented, and sustained.

Methods

Change management principles (Kotter) and normalization process theory (NPT) informed data collection and analysis. Nine case studies were conducted in eight EU countries: Germany (Lower Saxony), Greece, Italy (Campania), Poland, Portugal, Spain (Catalonia), Sweden (Uppsala), and the United Kingdom (Northern Ireland and Scotland). The workflow included a review of country/region specific polypharmacy policies, key informant interviews with stakeholders involved in policy development and implementation and, focus groups of clinicians and managers. Data were analyzed using thematic analysis of individual cases and framework analysis across cases.

Results

Polypharmacy initiatives were identified in five regions (Catalonia, Lower Saxony, Northern Ireland, Scotland, and Uppsala) and included all care settings. There was agreement, even in cases without initiatives, that polypharmacy is a significant issue to address. Common themes regarding the development and implementation of polypharmacy management initiatives were: locally adapted solutions, organizational culture supporting innovation and teamwork, adequate workforce training, multidisciplinary teams, changes in workflow, redefinition of roles and responsibilities of professionals, policies and legislation supporting the initiative, and data management and information and communication systems to assist development and implementation. Depending on the setting, these were considered either facilitators or barriers to implementation.

Conclusion

Within the studied EU countries, polypharmacy management was not widely addressed. These results highlight the importance of change management and theory-based implementation strategies, and provide examples of polypharmacy management initiatives that can assist managers and policymakers in developing new programs or scaling up existing ones, particularly in places currently lacking such initiatives.

Prevalence and determinants of polypharmacy in Switzerland: data from the CoLaus study

Background

Polypharmacy is a frequent condition, but its prevalence and determinants in the Swiss mid-aged population are unknown. We aimed to evaluate the prevalence and determinants of polypharmacy in a large Swiss mid-aged population-based sample.

Methods

Data from 4938 participants of the CoLaus study (53% women, age range 40–81 years) were collected between 2009 and 2012. Polypharmacy was defined by the regular use of five or more drugs.

Results

Polypharmacy was reported by 580 participants [11.8%, 95% confidence interval (10.9; 12.6)]. Participants on polypharmacy were significantly older (mean ± standard deviation: 66.0 ± 9.1 vs. 56.6 ± 10.1 years), more frequently obese (35.9% vs. 14.7%), of lower education (66.6% vs. 50.7%) and former smokers (46.7% vs. 36.4%) than participants not on polypharmacy. These findings were confirmed by multivariate analysis: odds ratio and (95% confidence interval) for age groups 50–64 and 65–81 relative to 40–49 years: 2.90 (2.04; 4.12) and 10.3 (7.26; 14.5), respectively, p for trend < 0.001; for low relative to high education: 1.56 (1.17; 2.07); for overweight and obese relative to normal weight participants: 2.09 (1.65; 2.66) and 4.38 (3.39; 5.66), respectively, p for trend < 0.001; for former and current relative to never smokers: 1.42 (1.14, 1.75) and 1.63 (1.25, 2.12), respectively, p for trend < 0.001.

Conclusion

One out of nine participants of our sample is on polypharmacy. Increasing age, body mass index, smoking and lower education independently increase the likelihood of being on polypharmacy.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2793-z) contains supplementary material, which is available to authorized users.

Contribution of Pharmacogenetic Testing to Modeled Medication Change Recommendations in a Long-Term Care Population with Polypharmacy

BACKGROUND

Among long-term care facility residents, polypharmacy is common, and often appropriate, given the need to treat multiple, complex, chronic conditions. Polypharmacy has, however, been associated with increased healthcare costs, adverse drug events, and drug interactions. The current study evaluates the potential medication cost savings of adding personalized pharmacogenetic information to traditional medication management strategies.

METHODS

One hundred and twelve long-term care residents completed pharmacogenetic testing for targeted variants in the following genes: CYP1A2, CYP2C9, CYP2C19, CYP2D6, CYP3A4/CYP3A5, HTR2A, HTR2C, SLC6A4, SLC6A2 COMT, OPRM1, SLCO1B1, VKORC1 and MTHFR. Following reporting of the IDgenetix Polypharmacy® test results, an internal medication management assessment was performed by a licensed clinical pharmacist to identify potential opportunities for regimen optimization through medication changes or discontinuations. The medication cost differences before and after the pharmacogenetic-guided review were assessed.

RESULTS

Medication review following pharmacogenetic result reporting identified 54 patients (48.2%) with a total of 132 drug change recommendations (45 reductions; 87 replacements) and an average of 2.4 proposed medication changes (range 1-6) per patient. Medication cost savings related to the identified reduction and replacement opportunities exceeded the cost of testing and are estimated to be US$ 1300 (year 2016 cost) per patient annually assuming full implementation.

CONCLUSION

Compared with traditional medication review, pharmacogenetic testing resulted in a 38% increase in the number of patients with current medication change opportunities and also offered valuable genetic information that could be referenced to personalize future prescribing decisions for all patients.

Polypharmacy and potentially inappropriate prescriptions identified by Beers and STOPP criteria in co-morbid older patients at hospital discharge

RATIONALE, AIMS AND OBJECTIVES

The objective of this study was to evaluate the prevalence of potentially inappropriate prescriptions (PIP) and the association with polypharmacy (more than six drugs prescribed) in co-morbid older patients in a critical moment of care transition such as hospital discharge by means of two explicit criteria (Beers 2012 and STOPP 2008).

METHOD

Cross-sectional study carried out in an older patients' population (≥65 years old) discharged from a university hospital in Spain. We recorded patients' information regarding demographics, diagnosis, drugs prescribed and associated pathological conditions and calculated the Charlson co-morbidity index. Data were obtained from the electronic medical records of hospital discharge. Beers (2012) and STOPP criteria (2008) were applied for PIP detection. The strength of association between polypharmacy and the presence of PIP was assessed by calculating the crude and adjusted odds ratio and its 95% confidence interval.

RESULTS

From 1004 patients of a 15% random sample, just 624 that fulfilled the inclusion criteria were included in the study. The number of prescribed drugs was a risk factor for PIP according to both criteria, even after adjusting for confounding variables. PIP frequency was higher in patients who received more than 12 medications (Beers: 34.8%, STOPP: 54.4%). Each additional medication increased the risk of PIP by 14 or 15% (Beers or STOPP).

CONCLUSIONS

Our results suggest that the strategies used for PIP reduction in co-morbid older patients should focus on the management of polypharmacy. Medication review at hospital discharge is highly recommended for patients taking more than six drugs.

Polypharmacy in the Aging Patient: A Review of Glycemic Control in Older Adults With Type 2 Diabetes

IMPORTANCE

There is substantial uncertainty about optimal glycemic control in older adults with type 2 diabetes mellitus.

OBSERVATIONS

Four large randomized clinical trials (RCTs), ranging in size from 1791 to 11,440 patients, provide the majority of the evidence used to guide diabetes therapy. Most RCTs of intensive vs standard glycemic control excluded adults older than 80 years, used surrogate end points to evaluate microvascular outcomes and provided limited data on which subgroups are most likely to benefit or be harmed by specific therapies. Available data from randomized clinical trials suggest that intensive glycemic control does not reduce major macrovascular events in older adults for at least 10 years. Furthermore, intensive glycemic control does not lead to improved patient-centered microvascular outcomes for at least 8 years. Data from randomized clinical trials consistently suggest that intensive glycemic control immediately increases the risk of severe hypoglycemia 1.5- to 3-fold. Based on these data and observational studies, for the majority of adults older than 65 years, the harms associated with a hemoglobin A1c (HbA1c) target lower than 7.5% or higher than 9% are likely to outweigh the benefits. However, the optimal target depends on patient factors, medications used to reach the target, life expectancy, and patient preferences about treatment. If only medications with low treatment burden and hypoglycemia risk (such as metformin) are required, a lower HbA1c target may be appropriate. If patients strongly prefer to avoid injections or frequent fingerstick monitoring, a higher HbA1c target that obviates the need for insulin may be appropriate.

CONCLUSIONS AND RELEVANCE

High-quality evidence about glycemic treatment in older adults is lacking. Optimal decisions need to be made collaboratively with patients, incorporating the likelihood of benefits and harms and patient preferences about treatment and treatment burden. For the majority of older adults, an HbA1c target between 7.5% and 9% will maximize benefits and minimize harms.

Effects of a geriatric intervention aiming to improve quality care in nursing homes on benzodiazepine use and discontinuation

BACKGROUND

Benzodiazepines and "Z drugs" are often prescribed in residents of nursing homes (NH) despite their well-known deleterious effects. We aimed to investigate if a general intervention on quality of care led to discontinuation of benzodiazepine, and to examine which NH-related factors were associated in change of benzodiazepines use.

METHODS

IQUARE is a quasi-experimental study, investigating the impact of an intervention based on a geriatric education with NH staff on several quality indicators of care (including appropriate prescriptions). All participating NH received an initial and 18-month audit regarding drug prescriptions and other quality of care variables. The analysis included 3973 residents, 2151 subjects (mean age: 84.6 ± 8.5 years; 74.3% women) in the control group and 1822 (mean age: 85.5 ± 8.1 years; 77.4% women) in the intervention group. Outcomes at 18 months were benzodiazepines use, long-acting benzodiazepines use, new-use of benzodiazepines, and discontinuation. The effect of the intervention was investigated using mixed-effect logistic regression models, including NH variables and residents' health status as confounders.

RESULTS

Higher reductions in benzodiazepine use (-2.8% vs. -1.5%) and long-acting benzodiazepine (-3.7% vs. -3.5%) were observed in intervention group, but not statistically significant. None of the structural and organisational NH-related variables predicted either discontinuation or new-use of benzodiazepines; hospitalisations and initial use of meprobamate increased the likelihood of becoming a new-user of benzodiazepines. Multivariate analysis suggested that living in a particular NH could affect benzodiazepines discontinuation.

CONCLUSIONS

A general intervention designed to improve overall NH quality indicators did not succeed in reducing benzodiazepines use. External factors interfered with the intervention. Further studies are needed to examine which NH-related aspects could impact benzodiazepines discontinuation.