Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications

Medication patterns and potentially inappropriate medication in patients with metastatic breast cancer: results of the BRE-BY-MED study

BACKGROUND

The treatment of metastatic breast cancer (mBC) focuses on prolonging patient survival, providing adequate symptom management, and maintaining quality of life (QoL). This includes supportive therapy to prevent or treat potential side effects and handle comorbidities. The combination of mBC therapy, supportive therapy, and treatment for comorbidities increases the risk for polypharmacy, potential drug-drug interactions (pDDI), potentially inappropriate medication (PIM), and potentially missing drugs (pMD). Therefore, the aim of this study was to assess medication patterns of mBC patients in routine care within a cohort study from South Germany.

METHODS

Between July 2022 and February 2024 individuals with advanced or mBC, aged ≥ 18 years, living in Bavaria, and who gave written informed consent, were included in the BRE-BY-MED "Breast Cancer Care in Bavaria for Patients with Metastatic Disease" cohort study (DRKS00026601). BRE-BY-MED was carried out at the University Hospital Würzburg with the primary aim of estimating the prevalence of guideline-concordant treatment. For the present analysis cross-sectional data from the baseline assessment was used. Medication was extracted from routine medical records. PIM, pDDI and pMD were assessed using established criteria. Polypharmacy was defined as ≥ 5 concomitantly prescribed drugs.

RESULTS

Ninety-three patients with a median age of 57 years (IQR = 48-64 years), were consecutively enrolled in the BRE-BY-MED study. One patient was male. At baseline, a total of 668 drugs were documented for all patients, including 131 unique substances, of which 44% were mBC therapy, 18% supportive therapy and 38% treatment for comorbidities or supplements. Patients took a median of 6 (IQR = 5-9) concomitant drugs. Polypharmacy (i.e. ≥ 5 concomitant drugs) was observed in 80.6% (n = 75) of the patients. PIM were documented in 9.7% (n = 9), pDDI in 12.9% (n = 12) and pMD in 64.5% (n = 60) of the patients.

CONCLUSION

We observed a high drug burden in mBC patients, largely due to treatment for comorbidities. These drugs might not only be associated with additional risk for side effects, pDDI, or PIM use, yet might also contribute to low medication adherence, higher medication costs and impaired QoL. Considering the burden of mBC and the predicted life expectancy, mBC patients might benefit from closer monitoring of their medication.

Potentially inappropriate medication use, polypharmacy, and falls among hospitalized patients

AIM

This matched case-control study investigated potentially inappropriate medication (PIM) use, polypharmacy, and other potential risk factors for falls among hospitalized older adults in Taiwan.

METHODS

During an 18-month study period, 131 case patients who experienced a fall during hospitalization in an acute-care hospital were identified and matched by the time of day, hospital ward, and age to controls (five for each case) who were selected through random systematic sampling. Data on demographics, medical characteristics, and all orally and intravascularly administered medications during hospitalization prior to a fall were collected. PIMs were assessed using the 2019 Beers criteria.

RESULTS

A conditional logistic regression analysis revealed that admission to the departments of internal medicine (odds ratio [OR] = 2.33; 95% confidence interval [CI] = 1.09-4.91) and neurology and rehabilitation (OR = 4.67; 95% CI = 2.08-10.5), diabetes with end-organ damage (OR = 2.07; 95% CI = 1.11-3.86), PIM use of central nervous system drugs (OR = 1.81; 95% CI = 1.15-2.86), use of colchicine (OR = 5.49; 95% CI = 1.34-22.5) and spironolactone (OR = 4.54; 95% CI = 1.31-15.8) for renal function impairment, and polypharmacy (≥5 medications; OR = 1.81; 95% CI = 1.05-3.10) significantly increased the risk of falls. By contrast, being overweight or obese (OR = 0.47; 95% CI = 0.29-0.78) was associated with a significantly lower risk of falls.

CONCLUSIONS

PIM use may increase the risk of falls in hospitalized older patients, and PIM identification and evaluation can reduce this risk. Geriatr Gerontol Int 2022; ••: ••-••.

Stability implications of repackaged medications in dose administration aids: a systematic review

BACKGROUND

Dose administration aids (DAAs) or multi-compartment compliance aids are commonly used to organise doses of medications in accordance with a patient's dosing schedule. Despite their widespread use, there is a paucity of information on the stability of repackaged medications in DAAs.

OBJECTIVES

The objectives of this work were to evaluate stability studies conducted on repackaged medicine in DAAs and to provide a summary of the latest stability data available.

METHODS

A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on studies associated with repackaged medications in DAAs and drug stability. PubMed, CINAHL, EMBASE and SCOPUS were searched from January 1998 to June 2021.

KEY FINDINGS

A total of 342 articles were retrieved and 29 articles met the inclusion criteria. Data regarding medications from the reviewed papers were reported according to stability testing and physicochemical properties. The extracted data were then compared with stability information on DAA provision available on the database in the UK. This review identified several discrepancies between this dataset and reported stability and reveals a significant shortage in the stability data of medications repackaged in DAAs.

CONCLUSION

This review highlights the need for further studies to be conducted to better understand the impact of DAA repackaging on the stability, safety and efficacy of medications. It is recommended that a database of stability information of repackaged medications via systematic stability testing studies could be established, serving as a valuable resource for pharmacists when preparing DAAs without compromising patient safety.

Medication Compliance Aids Unpackaged: A National Survey

Aims

Sixty‐four million pharmacy‐filled multicompartment medication compliance aids (MCAs) are dispensed by pharmacies in England each year. Despite the widespread use of MCAs and evidence that their use may be associated with harm there is no national consensus regarding MCA provision by acute hospital Trusts in England. The aim was to determine current practice for initiation and supply of MCAs in acute hospital Trusts in England and the potential consequences for patients and hospitals.

Methods

A 26‐item survey was distributed to all acute hospital Trusts in England. The questionnaire covered: policy, initiation, supply and review of MCAs; alternatives offered; and pharmacy staffing and capacity related to MCAs.

Results

Seventy‐two out of 138 (52%) Trusts responded to the survey: 70 Trusts responded regarding policy for MCA provision, with 60 (86%) having a policy regarding this; 33/55 (60%) that supplied MCAs on discharge supplied a different prescription length for MCA vs. non‐MCA prescriptions; 49/55 (89%) Trusts provided only 1 brand of MCA; 47/55 (85%) MCA‐supplying Trusts identified frequent difficulties with MCAs and 13/55 (24%) reported employing staff specifically to complete MCAs; and 30/35 (86%) MCA‐initiating Trusts had an assessment process for initiation, with care agency request reportedly the most common reason for initiation.

Conclusion

There is a lack of a national approach to MCA provision and initiation by acute hospital Trusts in England. This leads to significant variation in care and has the potential to put MCA users at an increased risk of medication‐related harm.

Nurse-Filled Versus Pharmacy-Filled Medication Organization Devices—Survey on Current Practices and Views of Home Care Nursing Services

Medication organization devices (MODs) are widely used among home care nursing services. However, current practices such as the responsibility for filling MODs, different MOD types used and requirements of home care nursing services are largely unknown. The study aimed at analyzing home care nursing services’ current practices regarding MOD use, investigating their requirements and determining whether different practices met these requirements. A survey was administered online to German home care nursing services in February 2021. The importance of requirements and the extent of satisfaction were measured using a five-point scale. Attitudes towards disposable, pharmacy-filled MODs were recorded as free text. In total, 690 nursing services responded (67.5% privately owned and 34.5% based in large cities), 92.2% filled MODs themselves and used predominantly reusable, rigid MODs. Pharmacies filling MODs used primarily disposable MODs. Satisfaction with current practices was generally high. Respondents filling MODs themselves were more satisfied with nurses’ medication knowledge, but less satisfied with cost effectiveness than those who had pharmacies fill MODs. Of all respondents filling MODs themselves who expressed an opinion on disposable, pharmacy-filled MODs, 50.9% were skeptical, primarily due to fear of losing flexibility. However, no difference in satisfaction with flexibility was found between respondents filling MODs themselves and those using pharmacy-filled MODs. In conclusion, employment of MODs in the professional care setting is a complex task with nursing services as key constituents. There is potential for improvement in the inter-professional collaboration between pharmacies and home care nursing services on the use of MODs. Measures for improvement have to address home care nursing services’ requirements with respect to flexibility and medication knowledge.

An Observational Cohort Study to Evaluate the Impact of a Tailored Medicines Optimisation Service on Medication Use, Accident and Emergency Department Visits, and Admissions Among Patients Identified with Medication Support Needs in Secondary Care

PURPOSE

Quantifying the impact of pharmacy interventions, such as tailored medicines optimisation, can be challenging owing to the sometimes-indirect nature of their effect on patient outcomes such A&E (Accident & Emergency) attendance, hospital admission and length of stay. This study aimed to assess the impact of the, Lewisham Integrated Medicines Optimisation Service (LIMOS) on medicines self-management, A&E attendances and hospital admissions.

PATIENTS AND METHODS

The study was conducted as a retrospective and prospective observational evaluation of patients referred to LIMOS at University Hospital Lewisham between April and September 2016. Only patients with an appropriate referral that received a LIMOS intervention within the study period were considered eligible. The main outcomes examined pre- and post-LIMOS included medicines self-management, A&E attendance, number of admissions, as well as length of stay.

RESULTS

Data were collected for a total of 193 patients. Over half (56.4%, n = 109) identified as female with a mean age of 78 years at the time of referral. The number of hospital admissions decreased significantly post-LIMOS (-0.36 ± 1.87, 95% CI -0.63-0.10). Furthermore, the mean reduction in length of stay was significant and decreased by over a week (19.58 vs 11.09 days post-LIMOS, -7.67 ± 48.57, 95% CI -14.57--0.78). There was a significant increase in A&E visits observed post-intervention (0.78 ± 1.93, 95% CI 0.50-1.06); however, the majority (63%, n =165/261) occurred over 90 days post-intervention. There was a significant reduction in the number of patients self-managing medication post-LIMOS, with the number of patients receiving additional support with their medication increasing (-0.38 ± 0.50, 95% CI -0.45--0.31). LIMOS, therefore, successfully identified patients who were unable to manage their medicines.

CONCLUSION

Specialist pharmacy interventions, which include support with medicines management, have a positive impact on admission avoidance and length of hospital stay.

Development of a structured clinical pharmacology review for specialist support for management of complex polypharmacy in primary care

AIMS

Polypharmacy is widespread and associated with medication-related harms, including adverse drug reactions, medication errors and poor treatment adherence. General practitioners and pharmacists cite limited time and training to perform effective medication reviews for patients with complex polypharmacy, yet no specialist referral mechanism exists. To develop a structured framework for specialist review of primary care patients with complex polypharmacy.

METHODS

We developed the clinical pharmacology structured review (CPSR) and stopping by indication tool (SBIT). We tested these in an age-sex stratified sample of 100 people with polypharmacy aged 65-84 years from the Clinical Practice Research Datalink, an anonymised primary care database. Simulated medication reviews based on electronic records using the CPSR and SBIT were performed. We recommended medication changes or review to optimise treatment benefits, reduce risk of harm or reduce treatment burden.

RESULTS

Recommendations were made for all patients, for almost half (4.8 ± 2.4) of existing medicines (9.8 ± 3.1), most commonly stopping a drug (1.7 ± 1.3/patient) or reviewing with the patient (1.4 ± 1.2/patient). At least 1 new medicine (0.7 ± 0.9) was recommended for 51% patients. Recommendations predominantly aimed to reduce harm (44%). There was no relationship between number of recommendations made and time since last primary care medication review. We identified a core set of clinical information and investigations (polypharmacy workup) that could inform a standard screen prior to specialist review.

CONCLUSION

The CPSR, SBIT and polypharmacy workup could form the basis of a specialist review for patients with complex polypharmacy. Further research is needed to test this approach in patients in general practice.

Quantifying and characterising multi-compartment compliance aid provision

BACKGROUND

Medication compliance aids (MCAs) to support adherence lack evidence for cost-effectiveness yet a 2001 survey in England estimated 100,000 patients receiving an MCA whilst living in their home.

OBJECTIVE

(s): To obtain a contemporary estimate of MCA provision by community pharmacies in England and describe factors influencing pharmacist decision-making regarding MCA initiation.

METHODS

A stratified random sample of two community pharmacies per county (n = 40) in England were surveyed by telephone and a more detailed postal survey sent to participants expressing an interest. Data were collected to determine magnitude of MCA provision and, professional and administrative factors influencing initiation were reported as percentage (95% confidence interval) respondents reporting a factor.

RESULTS

An estimated 273,529 MCAs are filled by community pharmacies in England with a median (IQR) of 20(10, 50) MCAs per pharmacy per month provided for patients living in their home. Practitioners' judgement of appropriateness for MCA initiation was reported by 51.3 ± 11% as the primary factor influencing decision-making relative to 16.3 ± 8% and 20 ± 8.8% reporting patient's and carer's opinion respectively. Some form of assessment tool was reported by 13 ± 7.3% respondents. Postal survey respondents (n = 31) indicated that decision-making regarding MCA initiation was often or always affected by suitability of medication for dispensing in an MCA by 58% ± 17% of respondents; 74.2% ± 15.4% and 53.3% ± 17.9% of respondents' decision-making was never or rarely affected by the risk of adverse events and reduced patient autonomy arising from an MCA respectively.

CONCLUSIONS

Provision of MCAs by pharmacies in England has more than doubled in the past decade. Beyond considering the practicalities of whether an MCA is suitable for a patient, there is limited evidence of pharmacists considering patient choice or risk of adverse events arising from sudden increased adherence prior to initiation.

Immediate or deferred adjustment of drug regimens in multidose drug dispensing systems

BACKGROUND

Multidose drug dispensing (MDD) is used to help patients take their medicines appropriately. Little is known about drug regimen changes within these MDD systems and how they are effectuated by the community pharmacist. Manual immediate adjustments of the MDD system could introduce dispensing errors. MDD guidelines therefore recommend to effectuate drug regimen changes at the start of a new MDD system.

OBJECTIVE

The aim of this study was to investigate the frequency, type, procedure followed, immediate necessity, and time taken to make MDD adjustments.

METHODS

This was a cross-sectional study in eight community pharmacies in the Netherlands. All adjustments to MDD systems were systematically documented for 3 weeks by the community pharmacist.

RESULTS

Overall, 261 MDD adjustments involving 364 drug changes were documented for 250 patients: 127 (35%) drug changes involved the addition of a new drug, 124 (34%) a change in dosage, and 95 (26%) drug discontinuation. Of the MDD adjustments, 135 (52%) were effectuated immediately: 81 (31%) by adjusting the MDD system manually, 49 (19%) by temporarily dispensing the drug separately from the MDD system, and 5 (2%) by ordering a new MDD system. Pharmacists considered that 36 (27%) of the immediate MDD adjustments could have been deferred until the next MDD system was produced. Immediate adjustment took significantly longer than deferred adjustment (p < 0.001).

CONCLUSIONS

This study shows that in patients using MDD systems, over half of the drug regimen changes are adjusted immediately. The necessity of these immediate changes should be critically evaluated.

The experiences and beliefs of older people in Scottish very sheltered housing about using multi-compartment compliance aids

Background Multi-compartment compliance aids (MCAs) are promoted as a potential solution to medicines non-adherence despite the absence of high quality evidence of effectiveness of MCA use impacting medicines adherence or any clinical outcomes. Furthermore, there is a lack of qualitative research which focuses on the perspectives of older people receiving MCAs. Objectives To describe experiences and beliefs surrounding very sheltered housing (VSH) residents’ use of MCAs with emphasis on issues of personalisation, reablement, shared decision-making, independence and support. Setting VSH in north east Scotland. Methods Qualitative, face-to-face interviews with 20 residents (≥ 65 years, using MCA > 6 months) in three VSH complexes. Interviews focused on: when and why the MCA was first introduced; who was involved in making that decision; how the MCA was used; perceptions of benefit; and any difficulties encountered. Interviews were audiorecorded, transcribed and analysed using a framework approach. Main outcome measure Experiences and beliefs surrounding use of MCAs. Results Nine themes were identified: shared decision-making; independence; knowledge and awareness of why MCA had been commenced; support in medicines taking; knowledge and awareness of medicines; competent and capable to manage medicines; social aspects of carers supporting MCA use; benefits of MCAs; and drawbacks. Conclusion Experiences and beliefs are diverse and highly individual, with themes identified aligning to key strategies and policies of the Scottish Government, and other developed countries around the world, specifically personalisation shared decision making, independence, reablement and support.

Prescription of potentially inappropriate medications among older people with intellectual disability: a register study

BACKGROUND

Older people have a greater disease burden and are more likely than younger to be prescribed medications. They are also more sensitive to adverse effects. With this in mind, a range of medications have been suggested inappropriate in this population. People with intellectual disability (ID) have a higher disease burden than the general population, putting them at even greater risk of prescription of such medications. The aim of this study was to describe prescription of potentially inappropriate medications among older people with ID in relation to prescriptions among their age peers in the general population.

METHODS

We established an administrative cohort of people with ID (ID cohort; n = 7936), using a Swedish national register. A referent cohort from the general population (gPop) was matched one-to-one by sex and year of birth. Data regarding prescription of potentially inappropriate medications were collected from the Swedish prescribed drug register for the years 2006-2012.

RESULTS

People with ID were more likely than the general population to be prescribed medications with anticholinergic effects, intermediate- or long-acting benzodiazepines, and antipsychotics at least once during the study period, and also had more number of years with prescription. Except for benzodiazepines, those in the ID cohort with at least one prescription had larger amounts prescribed than those in the gPop cohort. People in the ID cohort were less likely than the general population to be prescribed non-steroidal anti-inflammatory drugs (NSAIDs). Among those with at least one prescription of NSAIDs, those in the ID cohort had prescriptions during fewer years and in lower amounts than those in the gPop cohort.

CONCLUSIONS

Although prescription of potentially inappropriate medications overall is more common among people with ID than in the general population, the opposite pattern is found for medications for pain management. This may be a result of pain being under-recognized and under-treated in this population. Thus, there is a need for training as well as increased knowledge and awareness among care and health care professionals regarding signs of adverse effects and the need of continuous evaluation of treatment in this vulnerable group.

The behaviors and experiences of the community pharmacy team on the provision of multi-compartment compliance aids

BACKGROUND

Multi-compartment compliance aids (MCAs) are repackaging systems for solid dosage form medicines. Acknowledging the lack of evidence that MCAs improve adherence or clinical outcomes, the Royal Pharmaceutical Society has expressed concern that MCAs have 'become regarded as a panacea for medicines use'.

OBJECTIVES

To determine the behaviors and experiences of the community pharmacy team around MCA provision.

METHODS

A cross-sectional survey was conducted in 26 community pharmacies in the north east of Scotland. Survey items were grouped into: current activities in the provision of MCAs; potential influences on these activities; reports of patient experiences; and demographics. Data were analysed using descriptive and inferential statistics, and content analysis of responses to open questions. Principal component analysis (PCA) was performed on the items of potential influences on activities.

RESULTS

Data were collected from 136 community team members (median 4, range1-10 per pharmacy; 32.3% pharmacists). All were involved in some aspect of MCA provision and within the same pharmacy, several different staff positions were commonly involved in the same activity. PCA gave seven components; the lowest scores were obtained for the component of 'others expecting me to provide MCAs'. Participants agreed that GPs, patients and their families, and carers expected them to provide MCAs. Positive experiences of MCA provision were in themes of promoting patient adherence, reducing patient stress and enhancing patient monitoring. Further negative experiences were in of lack of shared patient decision making, worsening adherence and generation of medicines waste, and dealing with changing medicines. MCAs were not always considered to be the most appropriate solution.

CONCLUSION

While community pharmacy teams value MCAs, there may be issues around staff assignment to particular roles, expectations from others and reports of negative patient experiences. A systematic approach to MCA provision and monitoring involving the multidisciplinary health and social care team is warranted.

Multicompartment compliance aids in the community: the prevalence of potentially inappropriate medications

AIMS

To assess the prevalence of potentially inappropriate medications (PIMs) use in a population of community-based multicompartment compliance aid (MCA) users in north-east Scotland.

METHODS

Data for MCAs dispensed by 48 of the 50 community pharmacies in Aberdeen City between 1^st June to 31^st October 2014, together with concurrently prescribed medications, patient demographics and Carstairs index of social deprivation were recorded. Drug-specific quality indicators for PIMs from the Swedish National Board of Health and Welfare were applied and bivariate logistic regression analysis used to assess for associations with demographic variables.

RESULTS

The median age was 82 years (range 12-105 years, 59% female). A total of 1977 PIMs were identified affecting 57.8% of patients. A quarter of patients were prescribed ≥10 medications and 43% had a prescription containing at least one clinically significant drug-drug interaction (DDI). Ten drug groups accounted for 76% of all DDIs. A significant increase in the risk for at least one PIM was associated with female sex (for all indicators of PIM use), age <80 years (three or more psychotropic medicines [OR 5.88, 2.96-11.70, P < 0.001]) and lower socioeconomic status (prescription of ≥10 medications [OR: 1.43, 95% CI: 1.16-1.78], prescription of a long-acting benzodiazepine [OR: 1.84, CI: 1.14-2.98]).

CONCLUSIONS

MCA use is associated with a significant incidence of PIMs particularly affecting those younger than 80 years and those living in deprived areas. Our findings indicate the need for a more aggressive multidisciplinary approach to the review of the medications prescribed to MCA users.