Statin prescribing patterns in a cohort of cancer patients with poor prognosis

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

The potential for deprescribing in a palliative oncology patient population: a cross-sectional study

OBJECTIVES

The use of preventive medication in palliative oncology patients may be inappropriate due to limited life expectancy. Deprescribing tools are available but time-consuming and not always tailored to this specific population. Our primary goal was to identify potentially inappropriate medications (PIMs) in palliative oncology patients with a life expectancy of up to 2 years using an adapted deprescribing tool. Our secondary aim was to identify patient characteristics associated with the presence of PIMs.

METHODS

Oncology patients with a life expectancy of up to 2 years were included cross-sectionally. An adapted deprescribing tool was developed to identify PIMs. Logistic regression was used to identify factors associated with having PIMs.

RESULTS

A total of 218 patients were included in this study of which 56% had at least one PIM with a population mean of 1.1 PIM per patient. Most frequently defined PIMs were antihypertensive drugs and gastric acid inhibitors. Identification of PIMs by review took an estimated 5-10 min per patient. Polypharmacy, age >65 years and inpatient/outpatient status were found to be associated with having at least one PIM.

CONCLUSIONS

Deprescribing is possible in more than half of palliative oncology patients with a life expectancy of up to 2 years. The adapted deprescribing tool used is non-time consuming and suitable for palliative oncology patients, regardless of age.

Medication Adherence in Patients With Glaucoma and Disability

Importance

People with disabilities tend to have lower medication adherence. Glaucoma medication adherence has been scantly studied for people with disability.

Objective

To determine whether disability leads to reduced glaucoma medication adherence and whether this decrease varies by type of disability.

Design, Setting, and Participants

This population-based case-control study enrolled individuals with glaucoma and without disability, who were followed up until they received disability certification. All patients in Taiwan with confirmed glaucoma in 1 or both eyes were identified using National Health Insurance claims data. All patients with glaucoma who required glaucoma medication adherence (confirmed glaucoma, suspected glaucoma, and patients with ocular hypertension) and had newly obtained disability status after December 31, 2013, were identified and matched to counterparts without disability based on age and sex. The study period was January 1, 1997, to December 31, 2017. Data were analyzed from May 2021 to August 2021.

Exposures

All patients were followed up until they obtained confirmed disability status, which was identified using the National Disability Registry in Taiwan.

Main Outcomes and Measures

Secondary adherence was measured using frequencies of glaucoma medication refills and outpatient visits at 1-year and 2-year intervals.

Results

A total of 46 468 patients with glaucoma (23 234 with disability and 23 234 without disability; 24 508 men [52.7%]; 21 960 women [47.3%] mean [SD] age, 72.5 [14.3] years) were included in the study. Overall, the frequency of glaucoma outpatient visits was higher in people with disabilities than those without disabilities both before the index dates (difference, 0.64 [95% CI, 0.57-0.72]; P < .001) and after the index dates (difference, 0.34 [95% CI, 0.27-0.41]; P < .001) when using 1-year intervals. However, when stratified by the type of disability, having limb disability, being in a vegetative state, and having dementia were associated with fewer outpatient visits and lower medication adherence (at a maximum of 17.60 [95% CI, 8.90-26.30] percentage points lower; P < .001) compared with people without disability. Adjusted regression results revealed that people with visual disability had a mean of 2.50 (95% CI, 2.34-2.67) times more glaucoma outpatient visits than their matches who were disability free (P < .001).

Conclusions and Relevance

Certain types of disability can reduce glaucoma medication adherence by up to 17.60%. Policies targeting medication adherence should consider these disability types.

Medication Adherence in Patients With Glaucoma After Cancer Diagnosis

PURPOSE

To determine the association between cancer diagnosis and medication adherence in patients with glaucoma.

DESIGN

Cohort study.

METHODS

Setting: Population-based. StudyPopulation: All patients with confirmed glaucoma in one or both eyes. All patients were aged 20 years or older. Patients who developed cancer within 2 year of a confirmed glaucoma diagnosis or who were dead within 2 year after a confirmed cancer diagnosis were excluded. Intervention orObservationProcedure(s): Individuals without cancer but with a confirmed glaucoma diagnosis were followed until they received a confirmed cancer diagnosis. They were then matched with a group of patients with confirmed glaucoma who did not develop cancer during the study period. MainOutcomeMeasure(s): Secondary adherence measured using medication possession ratio (MPR) at 1-year, 2-year, and 2-year-average intervals.

RESULTS

For both patients with cancer and their matches, MPR was the highest when measured at 1-year intervals. MPR was 0.379 (95% CI: 0.370-0.388) for the cancer group and 0.313 (95% CI: 0.308-0.319) for the cancer-free group. MPR measured using 1-year intervals decreased by 17.4% after cancer diagnosis (P < .001). MPR measured using 2-year and 2-year-average intervals decreased by 10.4% (P < .001) and 9.21% (P < .001), respectively.

CONCLUSIONS

Cancer diagnosis leads to lower medication adherence in patients with glaucoma. To improve medication adherence in patients with glaucoma who also have cancer, policies should directly target the burden associated with having cancer that tends to create barriers for medication refills, rather than targeting risk factors that are also applicable to patients with glaucoma but without cancer.

Older Medicare Beneficiaries Frequently Continue Medications with Limited Benefit Following Hospice Admission

BACKGROUND

The use of medications not relieving symptoms or maximizing quality of life should be minimized following hospice enrollment.

OBJECTIVE

To evaluate the frequency of and predictive factors for continuation of medications with limited benefit after hospice admission among those admitted for cancer- and non-cancer-related causes.

DESIGN

Cohort study using the Surveillance, Epidemiology and End Results-Medicare linked database.

PATIENTS

Medicare Part D-enrolled beneficiaries 66 years and older who were admitted to and died under hospice care between January 1, 2008, and December 31, 2013 (N = 70,035).

MAIN MEASURES

Patients were followed from hospice enrollment through death for Part D dispensing of limited benefit medications (LBMs) they had used in the 6 months prior to hospice admission, including anti-hyperlipidemics, anti-hypertensives, oral anti-diabetics, anti-platelets, anti-dementia medications, anti-osteoporotic medications, and proton pump inhibitors. The proportion of patients continuing an LBM after hospice admission was evaluated. Adjusted relative risks (RRs) were estimated for factors associated with LBM continuation.

KEY RESULTS

Overall, 29.8% and 30.5% of patients admitted to hospice for a cancer- and non-cancer-related cause, respectively, continued at least one LBM after hospice admission. Anti-dementia medications were continued most frequently (29.3%) while anti-osteoporotic medications were continued least often (14.1%). Compared to home hospice, LBM continuation was greater in hospice patients residing in skilled nursing (RR 1.25, 95% CI 1.20-1.29), non-skilled nursing (RR 1.29, 95% CI 1.25-1.32), and assisted living facilities (RR 1.28, 95% CI 1.24-1.32). Patients with hospice stays ≥ 180 days were more likely to continue at least one LBM compared to those with stays of 1 week or less (RR 13.11, 95% CI 12.25-14.02).

CONCLUSIONS

A substantial proportion of Medicare hospice beneficiaries continued to receive LBMs following hospice enrollment. Providers should evaluate the necessity of continuing non-palliative medications at the end of life through a careful, patient-centric consideration of their potential risks and benefits.

How many older adults receive drugs of questionable clinical benefit near the end of life? A cohort study

BACKGROUND

The high burden of disease-oriented drugs among older adults with limited life expectancy raises important questions about the potential futility of care.

AIM

To describe the use of drugs of questionable clinical benefit during the last 3 months of life of older adults who died from life-limiting conditions.

DESIGN

Longitudinal, retrospective cohort study of decedents. Death certificate data were linked to administrative and healthcare registries with national coverage in Sweden.

SETTING

Older adults (≥75 years) who died from conditions potentially amenable to palliative care between 1 January and 31 December 2015 in Sweden. We identified drugs of questionable clinical benefit from a set of consensus-based criteria.

RESULTS

A total of 58,415 decedents were included (mean age, 87.0 years). During their last 3 months of life, they received on average 8.9 different drugs. Overall, 32.0% of older adults continued and 14.0% initiated at least one drug of questionable clinical benefit (e.g. statins, calcium supplements, vitamin D, bisphosphonates, antidementia drugs). These proportions were highest among younger individuals (i.e. aged 75-84 years), among people who died from organ failure and among those with a large number of coexisting chronic conditions. Excluding people who died from acute and potentially unpredictable fatal events had little influence on the results.

CONCLUSION

A substantial share of older persons with life-limiting diseases receive drugs of questionable clinical benefit during their last months of life. Adequate training, guidance and resources are needed to rationalize and deprescribe drug treatments for older adults near the end of life.

Preventive drugs in the last year of life of older adults with cancer: Is there room for deprescribing?

BACKGROUND

The continuation of preventive drugs among older patients with advanced cancer has come under scrutiny because these drugs are unlikely to achieve their clinical benefit during the patients' remaining lifespan.

METHODS

A nationwide cohort study of older adults (those aged ≥65 years) with solid tumors who died between 2007 and 2013 was performed in Sweden, using routinely collected data with record linkage. The authors calculated the monthly use and cost of preventive drugs throughout the last year before the patients' death.

RESULTS

Among 151,201 older persons who died with cancer (mean age, 81.3 years [standard deviation, 8.1 years]), the average number of drugs increased from 6.9 to 10.1 over the course of the last year before death. Preventive drugs frequently were continued until the final month of life, including antihypertensives, platelet aggregation inhibitors, anticoagulants, statins, and oral antidiabetics. Median drug costs amounted to $1482 (interquartile range [IQR], $700-$2896]) per person, including $213 (IQR, $77-$490) for preventive therapies. Compared with older adults who died with lung cancer (median drug cost, $205; IQR, $61-$523), costs for preventive drugs were higher among older adults who died with pancreatic cancer (adjusted median difference, $13; 95% confidence interval, $5-$22) or gynecological cancers (adjusted median difference, $27; 95% confidence interval, $18-$36). There was no decrease noted with regard to the cost of preventive drugs throughout the last year of life.

CONCLUSIONS

Preventive drugs commonly are prescribed during the last year of life among older adults with cancer, and often are continued until the final weeks before death. Adequate deprescribing strategies are warranted to reduce the burden of drugs with limited clinical benefit near the end of life.

Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study

PURPOSE

The aims of this study were to compare the application of three geriatric medication screening tools to the Beers Criteria alone for potentially inappropriate medication quantification and to determine feasibility of a pharmacist-led polypharmacy assessment in a geriatric oncology clinic.

METHODS

Adult patients with cancer aged 65 and older underwent a comprehensive geriatric assessment. A polypharmacy assessment was completed by a pharmacist and included a review of all drug therapies. Potentially inappropriate medications were screened using the Beers Criteria, Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons' Prescriptions, and the Medication Appropriateness Index. Deprescribing occurred after discussion with the pharmacist, geriatric oncologist, patient, and caregiver.

RESULTS

Data were collected for 26 patients. The mean number of medications was 12. The Beers Criteria alone identified 38 potentially inappropriate medications compared to 119 potentially inappropriate medications with the three-tool assessment; a mean of 5 potentially inappropriate medications were identified per patient. After the application of the three-tool assessment, 73% of potentially inappropriate medications identified were deprescribed, resulting in a mean of 3 medications deprescribed per patient. Approximately two thirds of patients reported a reduction in symptoms after the deprescribing intervention. Healthcare expenditures of $4282.27 per patient were potentially avoided as a result of deprescribing.

CONCLUSIONS

Our three-tool assessment identified three times more potentially inappropriate medications than the Beers Criteria alone. Pharmacist-led deprescribing interventions are feasible and may lead to improved patient outcomes and cost savings. This three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.

Prevalence and Incidence of Statin Use and 3-Year Adherence and Discontinuation Rates Among Older Adults With Dementia

OBJECTIVE

To examine the patterns of statin use and determine the 3-year adherence and discontinuation rates among a cohort of Australians aged ≥65 years with dementia.

METHODS

The yearly prevalence and incidence of statin use were compared via Poisson regression modeling using 2007 as the reference year. People with dementia were identified according to dispensing of antidementia medications. A cohort of 589 new statin users was followed longitudinally. Adherence was estimated via the proportion of days covered (PDC). Discontinuation was defined as ≥90 days without statin coverage.

RESULTS

The annual prevalence of statin use among older Australians with dementia increased from 20.6% in 2007 to 31.7% in 2016 (aged-sex adjusted rate ratio: 1.51, 95% confidence interval: 1.35-1.69). Among the new users, the proportion adherent (PDC ≥ 0.80) decreased from 60.3% at 6 months to 31.0% at 3 years. During the 3-year follow-up, 58.7% discontinued their statin.

CONCLUSIONS

Despite increased use of statins among older Australians with dementia, adherence is low and discontinuation is high, which may point to intentional cessation.

Statin use in cancer survivors versus the general population: cohort study using primary care data from the UK clinical practice research datalink

BACKGROUND

Cancer survivors may be at increased risk of cardiovascular diseases, but little is known about whether prescribing guidelines for the primary prevention of cardiovascular disease are adequately implemented in these patients. We compared levels of statin initiation and cessation among cancer survivors compared to the general population to determine differences in uptake of pharmaceutical cardiovascular risk prevention measures in these groups.

METHODS

The study population included individuals aged ≥40 during 2005-13 within the UK Clinical Practice Research Datalink primary care database. Within this population we identified cancer survivors who were alive and under follow-up at least 1 year after diagnosis, and controls with no cancer history. Follow-up time prior to cancer diagnosis was included in the control cohort. Using logistic regression, we compared these groups with respect to uptake of statins within 1 month of a first high recorded cardiovascular risk score. Then, we used Cox modelling to compare persistence on statin therapy (time to statin cessation) between cancer survivors and controls from the main study population who had initiated on a statin.

RESULTS

Among 4202 cancer survivors and 113,035 controls with a record indicating a high cardiovascular risk score, 23.0% and 23.5% respectively initiated a statin within 1 month (adjusted odds ratio 0.98 [91.8-1.05], p = 0.626). Cancer survivors appeared more likely to discontinue statin treatment than controls (adjusted hazard ratio 1.07 [1.01-1.12], p = 0.02). This greater risk of discontinuing was only evident after the first year of therapy (p-interaction < 0.001).

INTERPRETATION

Although cardiovascular risk is thought to be higher in cancer survivors compared to the general population, cancer survivors were no more likely to receive statins, and marginally more likely to cease long-term therapy, than general population controls. There may be an opportunity to mitigate the suspected higher cardiovascular risk in the growing population of cancer survivors by improving uptake of lipid-lowering treatment and persistence on therapy.

Differences in discontinuation of statin treatment in women and men with advanced cancer disease

Background

Statins are often discontinued in patients with advanced cancer since the net effect of treatment is considered negative. However, guidelines concerning discontinuation of statin treatment are lacking. The aim of this study was to investigate any differences in time of discontinuation of statin treatment between men and women with advanced cancer disease.

Methods

Medical records from 195 deceased palliative cancer patients from a previous study cohort were reviewed. Patients treated with statins 2 years before death were identified as “statin users.” The time of discontinuation of statin therapy was identified and correlated to time of death. Only patients that had incurable cancer disease at time of statin discontinuation were included in the analysis.

Results

Fifty-four patients were identified as statin users, 29 women and 25 men. The average time span between discontinuation of statin treatment and time of death was significantly longer in women than in men, 10 months compared to 4 months (p < 0.01), with a range of 1–24 months among women and 1–12 months for men. All patients died due to their cancer disease. More men than women had a history of stroke or cardiac infarction (p = 0.02). There were no differences in age, socioeconomic factors, or survival time from study inclusion between men and women. There was no difference in self-assessed quality of life (QoL) between statin users who had discontinued statin treatment and those who are still on treatment. Men generally assessed their QoL lower than women in this study (p = 0.03).

Conclusion

Statin treatment was discontinued earlier in women than in men in patients with advanced cancer. The data suggest that statins may be discontinued earlier in men as well, since earlier discontinuation did not affect cardiovascular mortality.

Missed opportunities: unnecessary medicine use in patients with lung cancer at the end of life - an international cohort study

AIMS

The aims of the current study were: (i) to examine the prescribing of preventative medication in a cohort of people with advanced lung cancer on hospital admission and discharge across different healthcare systems; and (ii) to explore the factors that influence preventative medication prescribing at hospital discharge.

METHODS

A retrospective cohort study was conducted across two centres in the UK and the US. The prescribing of preventative medication was examined at hospital admission and discharge for patients who died of lung cancer. A zero-inflated negative binomial regression model was used to examine the association between preventative medications at discharge and patient- and hospital-based factors. The classes of preventative medication prescribed included were: vitamins and minerals, and antidiabetic, antihypertensive, antihyperlipidaemic and antiplatelet medications.

RESULTS

In the UK site (n = 125), the mean number of preventative medications prescribed was 1.9 [standard deviation (SD) 1.7) on admission, and 1.7 (SD 1.7) on discharge, and in the US site (n = 191) the mean was 2.6 (SD 2.2) on admission and 1.9 (SD 2.2) on discharge. The model found a significant association between the number of preventative drugs prescribed on admission and the number on discharge; it also found a significant association between the total number of drugs prescribed on discharge and the number of preventative medications on discharge. Other indicators related to patient and hospital factors were not significantly associated with the number of preventative medications supplied on discharge.

CONCLUSIONS

The use of preventative medication was common in lung cancer patients, despite undergoing discharge. Patient- and hospital-based factors did not influence the prescribing of preventative medication.

End-of-life prescribing of aspirin in patients with breast or colorectal cancer

OBJECTIVES

The aim of this study was to evaluate the influence of an approaching cancer death on end-of-life aspirin use, a frequently prescribed medication for cardiovascular disease prevention.

METHODS

This study was conducted using linked cancer registry and prescribing data. Breast (n=1151) and colorectal (n=1859) cancer decedents were matched to cancer survivors and the probability of either initiating aspirin, or continuing established aspirin use, was estimated in consecutive periods over the 5 years approaching a cancer-specific death (decedents) or matched index date (survivors).

RESULTS

Using the linked data sets, we identified patients who died of their cancer (decedents) between 1 January 2001 and 31 December 2009. In the 5 years prior to death, we compared (1) the probability of initiating aspirin use for the first time, and (2) the probability of continuing aspirin use. In comparison to matched cancer survivors, an approaching cancer death was not associated with a reduction in aspirin initiation by breast or colorectal cancer decedents. However, the probability of continuing established aspirin use declined considerably in the 24 months approaching death and at the time of a death was significantly lower for breast (risk difference (RD) -0.26, 95% CI -0.33 to -0.20) and colorectal (RD -0.38, 95% CI -0.46 to -0.30) cancer decedents versus matched survivors.

CONCLUSION

A significant proportion of patients discontinue their aspirin in the time approaching a breast or colorectal cancer-specific death. The safety and benefits of this are unclear and empirical data are needed to guide decisions about aspirin use in the end of life.

Perspectives of patients, close relatives, nurses, and physicians on end-of-life medication management

Objective:

Our aim was to gain insight into the perspectives of patients, close relatives, nurses, and physicians on medication management for patients with a life expectancy of less than 3 months.

Method:

We conducted an empirical multicenter study with a qualitative approach, including in-depth interviews with patients, relatives, nurses, specialists, and general practitioners (GPs). We used the constant comparative method and ATLAS.ti (v. 7.1) software for our analysis.

Results:

Saturation occurred after 18 patient cases (76 interviews). Some 5 themes covering 18 categories were identified: (1) priorities in end-of-life care, such as symptom management and maintaining hope; (2) appropriate medication use, with attention to unnecessary medication and deprescription barriers; (3) roles in decision making, including physicians in the lead, relatives' advocacy, and pharmacists as suppliers; (4) organization and communication (e.g., transparency of tasks and end-of-life conversations); and (5) prerequisites about professional competence, accessibility and quality of medical records, and financial awareness. Patients, relatives, nurses, specialists, and GPs varied in their opinions about these themes.

Significance of Results:

This study adds to our in-depth understanding of the complex practice of end-of-life medication management. It provides knowledge about the diversity of the perspectives of patients, close relatives, nurses, and physicians regarding beliefs, attitudes, knowledge, skills, behavior, work setting, the health system, and cultural factors related to the matter. Our results might help to draw an interdisciplinary end-of-life medication management guide aimed at stimulating a multidisciplinary and patient-centered pharmacotherapeutic care approach.

Choosing Wisely? Measuring the Burden of Medications in Older Adults near the End of Life: Nationwide, Longitudinal Cohort Study

BACKGROUND

The burden of medications near the end of life has recently come under scrutiny, because several studies suggested that people with life-limiting illness receive potentially futile treatments.

METHODS

We identified 511,843 older adults (>65 years) who died in Sweden between 2007 and 2013 and reconstructed their drug prescription history for each of the last 12 months of life through the Swedish Prescribed Drug Register. Decedents' characteristics at time of death were assessed through record linkage with the National Patient Register, the Social Services Register, and the Swedish Education Register.

RESULTS

Over the course of the final year before death, the proportion of individuals exposed to ≥10 different drugs rose from 30.3% to 47.2% (P <.001 for trend). Although older adults who died from cancer had the largest increase in the number of drugs (mean difference, 3.37; 95% confidence interval, 3.35 to 3.40), living in an institution was independently associated with a slower escalation (β = -0.90, 95% confidence interval, -0.92 to -0.87). During the final month before death, analgesics (60.8%), anti-throm-botic agents (53.8%), diuretics (53.1%), psycholeptics (51.2%), and β-blocking agents (41.1%) were the 5 most commonly used drug classes. Angiotensin-converting enzyme inhibitors and statins were used by, respectively, 21.4% and 15.8% of all individuals during their final month of life.

CONCLUSION

Polypharmacy increases throughout the last year of life of older adults, fueled not only by symptomatic medications but also by long-term preventive treatments of questionable benefit. Clinical guidelines are needed to support physicians in their decision to continue or discontinue medications near the end of life.

Do cancer survivors change their prescription drug use for financial reasons? Findings from a nationally representative sample in the United States

BACKGROUND

There is limited evidence from nationally representative samples about changes in prescription drug use for financial reasons among cancer survivors in the United States.

METHODS

The 2011 to 2014 National Health Interview Survey was used to identify adults who reported ever having been told they had cancer (cancer survivors; n = 8931) and individuals without a cancer history (n = 126,287). Measures of changes in prescription drug use for financial reasons included: 1) skipping medication doses, 2) taking less medicine, 3) delaying filling a prescription, 4) asking a doctor for lower cost medication, 5) buying prescription drugs from another country, and 6) using alternative therapies. Multivariable logistic regression analyses were controlled for demographic characteristics, number of comorbid conditions, interactions between cancer history and number of comorbid conditions, and health insurance coverage. Main analyses were stratified by age (nonelderly, ages 18-64 years; elderly, ages ≥65 years) and time since diagnosis (recently diagnosed, <2 years; previously diagnosed, ≥2 years).

RESULTS

Among nonelderly individuals, both recently diagnosed (31.6%) and previously diagnosed (27.9%) cancer survivors were more likely to report any change in prescription drug use for financial reasons than those without a cancer history (21.4%), with the excess percentage changes for individual measures ranging from 3.5% to 9.9% among previously diagnosed survivors and from 2.6% to 2.7% among recently diagnosed survivors (P < .01). Elderly cancer survivors and those without a cancer history had comparable rates of changes in prescription drug use for financial reasons.

CONCLUSIONS

Nonelderly cancer survivors are particularly vulnerable to changes in prescription drug use for financial reasons, suggesting that targeted efforts are needed. Cancer 2017;123:1453-1463. © 2016 American Cancer Society.

Patterns of statin initiation and continuation in patients with breast or colorectal cancer, towards end-of-life

Purpose

Cross-sectional studies show that statins, used in cardiovascular disease prevention, are often discontinued approaching death. Studies investigating associations between statin exposure and cancer outcomes, not accounting for these exposure changes, are prone to reverse causation bias. The aim of this study was to describe longitudinally the changes in statin initiation and continuation prior to death in patients with breast or colorectal cancer, thus establishing an appropriate exposure lag time.

Methods

This study was carried out using linked cancer registry and prescribing data. We identified patients who died of their cancer (cases) and cancer survivors were used as controls. The probability of initiating or continuing statin use was estimated up to 5 years prior to death (or index date). Conditional binomial models were used to estimate relative risks and risk differences for associations between approaching cancer death and statin use.

Results

Compared to controls, the probability of continued statin use in breast cancer cases was significantly lower 3 months prior to death (RR 0.86 95% CI 0.79, 0.94). Similarly, in colorectal cancer cases, the probability of continued statin use was significantly lower 3 months prior to colorectal cancer death (RR 0.77 95% CI 0.68, 0.88).

Conclusion

A significant proportion of patients will cease statin treatment in the months prior to a colorectal or breast cancer death.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-017-3576-0) contains supplementary material, which is available to authorized users.

Health-care utilization by prognosis profile in a managed care setting: using the Surveillance, Epidemiology and End Results Cancer Survival Calculator SEER*CSC

BACKGROUND

Accurate estimation of the probability of dying of cancer versus other causes is needed to inform goals of care for cancer patients. Further, prognosis may also influence health-care utilization. This paper describes health service utilization patterns of subgroups of prostate cancer and colorectal cancer (CRC) patients with different relative probabilities of dying of their cancer or other conditions.

METHODS

A retrospective cohort of cancer patients from Kaiser Permanente Colorado were divided into three groups using the predicted probabilities of dying of cancer and other causes calculated by the nomograms in the National Cancer Institute Surveillance, Epidemiology and End Results Cancer Survival Calculator. Demographic, disease-related characteristics, and health service utilization patterns were described across subgroups.

RESULTS

The cohort consisted of 2092 patients (1102 prostate cancer and 990 CRC). A new diagnosis of cancer increased utilization of cancer-related services with rates as high as 9.1/1000 person-days for prostate cancer and 36.2/1000 person-days for CRC. Little change was observed in the number of primary and other specialty care visits from prediagnosis to 1 and 2 years postdiagnosis.

CONCLUSIONS

We found that although a new diagnosis of cancer increased utilization of cancer-related services for an extended time period, the timing of cancer diagnosis did not appear to affect other types of utilization. Future research should assess the reason for the lack of impact of cancer and unrelated comorbid conditions on utilization and whether desired outcomes of care were achieved.

Changes in Medication Management After a Diagnosis of Cancer Among Medicare Beneficiaries With Diabetes

PURPOSE

A new cancer diagnosis commonly initiates a cascade of health care decisions that have potentially important consequences for management of other chronic conditions such as diabetes. We sought to determine whether a new cancer diagnosis is associated with changes in medication adherence among Medicare beneficiaries with diabetes, and whether the relationship is affected by life expectancy and generosity of drug coverage.

METHODS

The study population was drawn from a 5% random sample of Medicare beneficiaries with diabetes enrolled in Medicare Part D in 2007 and 2008. Patients had cancer newly diagnosed between January and December 2007 (n = 4,348) and were compared with a cancer-free control group (N = 28,507) assigned a pseudo-diagnosis date. Adherence (proportion of days covered [PDC]) with oral hypoglycemic agents, renin-angiotensin-aldosterone system inhibitors, and statins was tracked for 6 months before and after the diagnosis date. Multivariable regression models assessed the independent impact of a cancer diagnosis, life expectancy (proxy measure: died 7 to 12 months after index date), and coverage generosity (proxy measure: low-income subsidy recipient) on PDC, controlling for individual characteristics.

RESULTS

Relatively larger declines in medication adherence (3 to 5 percentage points; P < .001) were observed overall for patients with cancer versus controls. Short life expectancy was associated with between 8% and 11% lower PDC (P < .001) in the cancer subgroup relative to controls. Low-income subsidy status had no differential effect on changes in drug adherence.

CONCLUSION

A cancer diagnosis among patients with diabetes reduced adherence with evidence-based medications, particularly if patients' life expectancy was short.

Prescribing for comorbid disease in a palliative population: focus on the use of lipid-lowering medications

BACKGROUND

The balance of benefit versus burden of ongoing treatments for comorbid disease in palliative populations as death approaches needs careful consideration given their particular susceptibility to adverse drug effects.

AIM

To provide descriptive data regarding the medications being prescribed to patients who have a life-limiting illness at the time of referral to a palliative care service in regional Australia, with particular focus on lipid-lowering medications.

METHODS

A prospective case note review of 203 patients reporting the number of medications prescribed and, for lipid-lowering medications, the indication and level of prevention sought (primary, secondary, tertiary). Rates were compared by performance status, disease phase and comorbidity burden.

RESULTS

Mean number of regular medications prescribed was 7.2, with higher rates observed in those patients with a non-malignant primary diagnosis (rate ratio 1.28, confidence interval (CI) 1.11-1.50) or poorer performance status (rate ratio 1.37, CI 1.11-1.69) and lower rates for those in the terminal phase of disease (rate ratio 0.48, CI 0.30-0.76). Over one fifth of patients were prescribed a lipid-lowering medication, and two fifths of these prescriptions were for primary prevention of cardiovascular disease. Patients in the highest quartile of Charlson Comorbidity Index score were 4.6 (CI 2.06-10.09) times more likely to be prescribed a lipid-lowering medication than those in the lowest quartile.

CONCLUSIONS

Polypharmacy is prevalent for this group of patients, placing them at high risk of drug-drug and drug-host interactions. Prescribing may be driven by risk factors and disease guidelines rather than a rational, patient-centred approach.

Inappropriate prescribing in patients accessing specialist palliative day care services

BACKGROUND

For patients accessing specialist palliative care day services, medication is prescribed routinely to manage acute symptoms, treat long-term conditions or prevent adverse events associated with these conditions. As such, the pharmacotherapeutic burden for these patients is high and polypharmacy is common. Consequently, the risk of these patients developing drug-related toxicities through drug–drug interactions is exacerbated. Medication use in this group should, therefore, be evaluated regularly to align with achievable therapeutic outcomes considering remaining life expectancy.

OBJECTIVE

To (1) assess the prevalence of inappropriate medication use; (2) identify potential drug–drug interactions; and, (3) determine how many potential drug– drug interactions could be prevented by discontinuing inappropriate medication.

SETTING

A specialist tertiary care palliative care centre in Northern England serving a population of 330,000.

MAIN OUTCOME MEASURE

Prescribing of inappropriate medication.

METHOD

Medication histories for patients accessing a specialist palliative day care centre were established and a modified Delphi method was used to reach consensus of medication appropriateness. The Delphi method utilized a framework considering the following factors: remaining life expectancy of the patient, time until benefit of the treatment, goals of care and treatment targets. Potential drug interactions were established using drug interaction recognition software and categorised by their ability to cause harm.

RESULTS

A total number of 132 patients were assessed during the study period who were prescribed 1,532 (mean = 12/patient) medications; 238 (16 %) were considered inappropriate in the context of limited life expectancy. The most common class of medications considered inappropriate were the statins, observed in 35 (27 %) patients. A total of 267 potential drug–drug interactions were identified; 112 were clinically significant and 155 were not considered clinically significant. Discontinuation of inappropriate medication would reduce the total number of medications taken to 1,294 (mean = 10/patient) and prevent 31 clinically significant potential drug–drug interactions.

CONCLUSION

Patients accessing specialist palliative day care services take many inappropriate medications. These medications not only increase the pharmacotherapeutic burden for the patient but they also contribute to potential drug–drug interactions. These patients should have their medication reviewed in the context of life limiting illness aligned with achievable therapeutic outcomes.

Strategies to support recruitment of patients with life-limiting illness for research: the Palliative Care Research Cooperative Group

CONTEXT

The Palliative Care Research Cooperative Group (PCRC) is the first clinical trials cooperative for palliative care in the U.S.

OBJECTIVES

To describe barriers and strategies for recruitment during the inaugural PCRC clinical trial.

METHODS

The parent study was a multisite randomized controlled trial enrolling adults with life expectancy anticipated to be one to six months, randomized to discontinue statins (intervention) vs. to continue on statins (control). To study recruitment best practices, we conducted semistructured interviews with 18 site principal investigators (PIs) and clinical research coordinators (CRCs) and reviewed recruitment rates. Interviews covered three topics: 1) successful strategies for recruitment, 2) barriers to recruitment, and 3) optimal roles of the PI and CRC.

RESULTS

All eligible site PIs and CRCs completed interviews and provided data on statin protocol recruitment. The parent study completed recruitment of 381 patients. Site enrollment ranged from 1 to 109 participants, with an average of 25 enrolled per site. Five major barriers included difficulty locating eligible patients, severity of illness, family and provider protectiveness, seeking patients in multiple settings, and lack of resources for recruitment activities. Five effective recruitment strategies included systematic screening of patient lists, thoughtful messaging to make research relevant, flexible protocols to accommodate patients' needs, support from clinical champions, and the additional resources of a trials cooperative group.

CONCLUSION

The recruitment experience from the multisite PCRC yields new insights into methods for effective recruitment to palliative care clinical trials. These results will inform training materials for the PCRC and may assist other investigators in the field.

Statin discontinuation in nursing home residents with advanced dementia

OBJECTIVES

To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days.

DESIGN

Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files.

SETTING

All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida).

PARTICIPANTS

NH residents with dementia.

MEASUREMENTS

Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation.

RESULTS

Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication.

CONCLUSION

Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up.

Competing risks of cancer mortality and cardiovascular events in individuals with multimorbidity

Background

Cancer patients with cardiovascular and other comorbidities are at concurrent risk of multiple adverse outcomes. However, most treatment decisions are guided by evidence from single-outcome models, which may be misleading for multimorbid patients.

Objective

We assessed the interacting effects of cancer, cardiovascular, and other morbidity burdens on the competing outcomes of cancer mortality, serious cardiovascular events, and other-cause mortality.

Design

We analyzed a cohort of 6,500 adults with initial cancer diagnosis between 2001 and 2008, SEER 5-year survival ≥26%, and a range of cardiovascular risk factors. We estimated the cumulative incidence of cancer mortality, a serious cardiovascular event (myocardial infarction, coronary revascularization, or cardiovascular mortality), and other-cause mortality over 5 years, and identified factors associated with the competing risks of each outcome using cause-specific Cox proportional hazard models.

Results

Following cancer diagnosis, there were 996 (15.3%) cancer deaths, 328 (5.1%) serious cardiovascular events, and 542 (8.3%) deaths from other causes. In all, 4,634 (71.3%) cohort members had none of these outcomes. Although cancer prognosis had the greatest effect, cardiovascular and other morbidity also independently increased the hazard of each outcome. The effect of cancer prognosis on outcome was greatest in year 1, and the effect of other morbidity was greater in individuals with better cancer prognoses.

Conclusion

In multimorbid oncology populations, comorbidities interact to affect the competing risk of different outcomes. Quantifying these risks may provide persons with cancer plus cardiovascular and other comorbidities more accurate information for shared decision-making than risks calculated from single-outcome models. Journal of Comorbidity 2014;4:29–36

Evaluation of Prescribing Medications for Terminal Cancer Patients near Death: Essential or Futile

PURPOSE

The purpose of this study is to evaluate the prescription of essential or futile medications for terminal cancer patients during their final admission.

MATERIALS AND METHODS

We conducted a retrospective review of the medical charts of terminally ill cancer patients admitted to the Hemato-oncology Department of two teaching hospitals from March 1, 2007 to December 31, 2009. Essential medications were based on the drugs listed by the International Association for Hospice and Palliative Care, while futile medications were defined when short-term benefit to patients with respect to survival, quality of life, or symptom control was not anticipated.

RESULTS

A total of 196 patients were included. Among essential medications, strong opioids were the most frequently prescribed drugs during the last admission (62.2% fentanyl, 44.3% morphine), followed by megestrol (46.0%), and metoclopramide (37.2%); 51% of gastric protectors were prescribed with potential futility. Anti-hypertensive and antiglycemic agents were administered to those who experienced arterial blood pressure below 90 mm Hg (47.3%) or presented with a single measurement of fasting glucose below 50 mg/dL (10.7%), respectively. Statins were prescribed to 6.1% (12/196) of patients, and 75% of those prescriptions were regarded as futile.

CONCLUSION

Our data suggest that effective prescription of essential medications and withdrawal from futile medications should be actively reconciled for improvement of a patient's end-of-life care.