Impact of training and structured medication review on medication appropriateness and patient-related outcomes in nursing homes: results from the interventional study InTherAKT

Evaluation of the Effect of a Safe Medication Strategy on Potentially Inappropriate Medications, Polypharmacy and Anticholinergic Burden for People with Dementia: An Intervention Study

People with dementia (PWD) are at risk for medication-related harm due to their impaired cognition and frequently being prescribed many medications. This study evaluated a medication safety intervention (including pharmacist medication reconciliation and review) for PWD during an unplanned admission to hospital. This article reports the effect of the intervention on polypharmacy, potentially inappropriate medications (PIMs), and anticholinergic burden scores for PWD. A pre-post design using an intervention site and a control site was conducted in 2017-2019, in a regional area in New South Wales, Australia. Polypharmacy, PIMs, and anticholinergic burden were measured at admission, discharge, and three months after discharge. There were 628 participants including 289 at the control site and 339 at the intervention site. Polypharmacy was 95% at admission and 90% at discharge. PIMs at admission were 95-98% across timepoints and decreased significantly at discharge. The mean anticholinergic score decreased significantly between admission (2.40-3.15) and discharge (2.01-2.57). Reduced PIMs at discharge were correlated with reduced anticholinergic burden (rho = 0.48-0.55, p < 0.001). No significant differences were identified between the study and control sites for Polypharmacy, PIMs, and anticholinergic burden rates and scores. High rates of polypharmacy and PIMs in this study indicate a study population with multiple comorbidities. This intervention was feasible to implement but was limited due to difficulty recruiting participants and deaths during the study. Future multisite studies should be designed to recruit larger study samples to evaluate interventions for improving medication safety for PWD and improve outcomes for these vulnerable people.

Implementation of interprofessional quality circles on deprescribing in Swiss nursing homes: an observational study

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are still frequent among older adults in nursing homes. Deprescribing is an intervention that has been shown to be effective in reducing their use. However, the implementation of deprescribing in clinical practice has not yet been widely evaluated. The Quality Circle Deprescribing Module (QC-DeMo) intervention has been trialled through an effectiveness-implementation hybrid type 2 design. The intervention consists of a quality circle workshop session between healthcare professionals HCPs (physicians, nurses, and pharmacists) within a nursing home, in which they define a consensus to deprescribe specific PIMs classes. The aim of this study was to evaluate the implementation of the QC-DeMo intervention in nursing homes.

METHODS

This observational study focuses on the implementation part of the QC-DeMo trial. Implementation was based on the Framework for Implementation of Pharmacy Services (FISpH). Questionnaires at baseline and follow-up were used to evaluate reach, adoption, implementation effectiveness, fidelity, implementation, maintenance and the implementation strategies. Other data were collected from the QC-DeMo trial and routine data collected as part of the integrated pharmacy service where the QC-Demo trial was embedded. Implementation strategies included training of pharmacists, integration of the intervention into an existing quality circle dynamic and definition of tailored strategies to operationalise the consensus by each nursing home.

RESULTS

The QC-DeMo intervention was successfully implemented in 26 nursing homes in terms of reach, fidelity, adoption, implementation and implementation effectiveness. However, the intervention was found to be implemented with low maintenance as none of the nursing homes repeated the intervention after the trial. Implementation strategies were well received by HCPs: training was adequate according to pharmacists. Pre-existing quality circle dynamic facilitated interprofessional collaboration as involvement and support of each HCP was rated as high. HCPs recognized a specific and important role for each HCP in the deprescribing process. The most relevant tailored strategies to implement the consensus defined by each nursing home were identification of the patients by the pharmacist and a systematic review of medication's patients.

CONCLUSIONS

The implementation of a Quality Circle on Deprescribing is feasible but its maintenance in practice remains challenging. This study explores multiple implementation outcomes to better inform future implementation efforts of these types of interventions.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT03688542 ), registered on 26.09.2018.

Drug-drug interactions in nursing home residents: analysis from the COME-ON trial

BACKGROUND

as a result of the high prevalence of polypharmacy in nursing homes (NHs), nursing home residents (NHRs) are exposed to numerous drug-drug interactions (DDIs) that can lead to adverse drug effects, and increased morbidity and mortality.

OBJECTIVES

to evaluate (i) the prevalence of DDIs among NHRs and its evolution over time, and (ii) factors associated with a favourable evolution.

DESIGN

posthoc analysis of the COME-ON study, a cluster-randomised controlled trial aiming at reducing potentially inappropriate prescriptions in NHs, through the implementation of a complex intervention.

SETTING AND SUBJECTS

901 NHRs from 54 Belgian NHs.

METHODS

DDIs were identified using a validated list of 66 potentially clinically relevant DDIs in older adults. We defined a favourable evolution at 15 months as the resolution of at least one DDI present at baseline, without the introduction of any new DDI. Factors associated with a favourable evolution were analysed using multivariable logistic regression.

RESULTS

at baseline, 475 NHRs (52.7%) were exposed to at least 1 DDI and 225 NHRs (25.0%) to more than one DDI. Most common DDI was 'Concomitant use of at least three central nervous system active drugs'. At 15 months, we observed a 6.3% absolute decrease in DDI prevalence in intervention group, and a 1.0% absolute increase in control group. The intervention, older age and private NH ownership were significantly associated with a favourable DDI evolution.

CONCLUSION

a high prevalence of DDI in Belgian NHs was observed, but the COME-ON intervention was associated with a favourable evolution over time.

Nursing Home-Sensitive Hospitalizations and the Relevance of Telemedicine: A Scoping Review

The aging of society is increasing the number of hospitalizations of nursing home residents. Telemedicine might help reduce the frequency of these potentially risk-associated hospitalizations. This scoping review looked for evidence of a change in the rate of hospitalization and, if mentioned, any cost savings and/or staff acceptance of the use of telemedicine in a nursing home setting. To identify available evidence, the electronic databases PubMed, Livivo, EBSCO and JSTOR were searched (without time or regional constraints) for comparative primary research studies on this topic in peer-reviewed journals. A total of 1127 articles were retrieved and 923 titles and abstracts were screened, with 16 studies published between 2001 and 2022 being included. Telemedicine consultation reduced the hospitalization of nursing home residents in 14/16 and care costs in 8/11 articles. Staff satisfaction was mentioned positively in five studies. Most studies used telemedicine involving medical diagnostic technologies (10), (electronic) health records (9), specialists (9) and specialized nursing staff (11). Few studies had a higher level of evidence: only one randomized clinical trial was included. There is the need for high credibility studies, using guidelines on protocol and reporting, to better understand the hindering and facilitating factors of telemedicine provision in the healthcare of nursing home residents.

Determine the impact of a structured pharmacist-led medication review - a controlled intervention study to optimise medication safety for residents in long-term care facilities

Background

Medication reviews contribute to protecting long-term care (LTC) residents from drug related problems (DRPs). However, few controlled studies have examined the impact on patient-relevant outcomes so far.

Objective

We examined the impact of a one-time, pharmacist-led medication review on medication changes (primary endpoint) including discontinued medication, the number of chronic medications, hospital admissions, falls, and deaths (secondary endpoints).

Methods

A prospective, controlled intervention study was performed in three LTC facilities. In the intervention group (IG), after performing a medication review, a pharmacist gave recommendations for resolving DRPs to physicians, nurses and community pharmacists. The control group (CG) received usual care without a medication review. (i) We assessed the number of medication changes and the secondary endpoints in both groups before (t0) and after (t1, t2) the intervention. (ii) Additionally, the medication review was evaluated in the IG with regard to identified DRPs, the healthcare professional’s feedback on the forwarded pharmacist recommendations and whether DRPs were finally resolved.

Results

107 (IG) and 104 (CG) residents were enrolled. (i) More medication changes were identified in the IG than in the CG at t1 (p = 0.001). However, no significant difference was identified at t2 (p = 0.680). Mainly, medication was discontinued in those medication changes. Chronic medications increased in the CG (p = 0.005) at t2 while hospital admissions, falls, and deaths showed no differences. (ii) Overall, 1252 DRPs (median: 10; minimum-maximum: 2–39) were identified. Recommendations for 82% of relevant DRPs were forwarded to healthcare professionals, of which 61% were accepted or clarified. 22% were not accepted, 12% required further review and 6% remained without feedback. 51% of forwarded DRPs were finally resolved.

Conclusions

We found more medication changes in the IG compared to controls. Mostly, medication was discontinued. This suggests that our intervention was successful in discontinuing unnecessary medication. Other clinical outcomes such as falls, hospitalisations, and deaths were not improved due to the one-time intervention. The medication review further identified a high prevalence of DRPs in the IG, half of which were finally resolved.

Trial registration

German Clinical Trials Register, DRKS00026120 (www.drks.de, retrospectively registered 07/09/2021).

Suicidal and accidental drug poisoning mortality among older adults and working-age individuals in Spain between 2000 and 2018

BACKGROUND

Although medication poisoning in older adults is considered an increasingly important, but preventable cause of death, it has received relatively little attention. We explored recent trends and correlates of suicidal and accidental fatal drug poisonings among older and working-age individuals using nationwide data from Spain.

METHODS

We identified all 15,353 fatal drug poisonings involving decedents aged ≥15 years in Spain between 2000 and 2018 and divided them by age into older adults (≥65 years) and working-age (15-64 years) individuals. For each age group, we analyzed time trends in suicidal and accidental fatal drug poisoning rates (overall and by ICD-10 drug categories) using joinpoint regressions. To understand the specific drugs classified as "Non-psychotropic/non-specified", we used 2018 data including substance-specific ICD-10 supplementary codes. We explored relevant sociodemographic correlates of suicidal and accidental fatal poisoning rates using multivariable negative binomial regressions.

RESULTS

Between 2000 and 2018, suicidal fatal poisonings increased faster among older (from 0.19 to 0.63 per 100,000 - average annual change: 7.7%) than working-age individuals (from 0.40 to 0.72 per 100,000 - average annual change: 3.8%). Accidental fatal poisonings increased among older adults (from 0.25 to 2.67 per 100,000 - average annual change: 16.2%) but decreased among working-age counterparts (from 2.38 to 1.42 per 100,000 - average annual change: - 1.9%). Anticoagulants and cardiac-stimulants glycosides accounted for 70% of the 223 accidental fatal poisonings due to non-psychotropic/non-specified drugs registered among older adults in 2018. Roles of gender and urban dwelling in suicidal and accidental poisonings were heterogeneous across age groups.

CONCLUSION

Increases in suicidal drug poisonings were faster among older than working-age individuals. Accidental fatal poisonings increased only among older adults. Our findings that (i) sociodemographic correlates were heterogeneous across age groups and (ii) anticoagulant and cardiac-stimulant glycosides were particularly salient drivers of accidental poisonings among older adults have implications for prevention.

Healthcare Professionals' Views on the Management of Medication Complexities in the Elderly With Mental Health Disorders: A Cross-Sectional Study

BACKGROUND

Many challenges in elderly pharmacotherapy are identified, including the use of Potentially Inappropriate Medications (PIMs) which may increase the odds of adverse events, especially in elderly patients with mental health disorders (e. g., behavioral, and psychological symptoms of dementia-BPSD, schizophrenia, bipolar disorder). However, information on the knowledge and practice of healthcare professionals (HCPs) about this topic is still scarce.

METHODS

A cross-sectional study was undertaken from July-October 2019. An online questionnaire was specifically designed and validated for this study. We sought HCPs (physicians, pharmacists, and nurses) worldwide, using (a) social media, via Facebook, Twitter, and LinkedIn; and (b) email contacts of the research team (convenience sample). Either way participants were asked to share on their social media or via e-mail the questionnaires with other HCPs (snowballing sample). The survey assessed two main domains: knowledge and practice. Knowledge was evaluated by self-report (perceived knowledge by a 5-item Likert confidence scale) and using three clinical cases, scored between 0 and 30 points (each one rated from 0 to 10 points; real knowledge). Barriers in clinical practice were evaluated using a 5-item Likert scale judging practitioners' opinion.

RESULTS

A total of 165 questionnaires were collected. HCPs were mainly female (n = 114; 69.1%), with a mean age of 35.3 ± 11.3 years old. Seventy-two percent (n = 118) were pharmacists, 21.1% (n = 35) were physicians, and 7.3% (n = 12) nurses. There was a weak correlation, albeit significant, between perceived and real knowledge (r = 0.199; p = 0.001). The mean score of the clinical vignettes regarding elderly patients with dementia and bipolar disorder were 4.59 ± 4.08 and 4.86 ± 2.97 points, respectively. Most HCPs were classified as having an intermediate knowledge (n = 100; 60.6%) about medication complexities in the elderly with mental disorders. Most HCPs agreed that lack of time (81.6%; n = 138), lack of education and training on elderly pharmacotherapy (72.2%; n = 122), and lack of tools adapted to daily practice (61.8%; n = 105) were the main barriers.

CONCLUSIONS

Most of the HCPs felt confident to manage medication complexities in elder patients with mental disorders, but only a minority obtained a good score in the knowledge assessment test. The main barriers identified included structural barriers (tools unfit for practice) and process barriers (time).

Telemedication Reviews to Optimize Medication Prescription for Older People in Nursing Homes

Introduction: Older people living in nursing homes (NH) are at a higher risk of preventable drug-related adverse events because of age-related physiological changes, polypathology, and polypharmacy. NH residents are particularly exposed to potentially inappropriate medications (PIMs). Many strategies have been developed to improve the quality and the safety of drug prescription in NH, including medication reviews (MRs). Methods: In the context of the application of telemedicine, we developed and are currently implementing a novel hospital expert-based MRs through tele-expertise (or "telemedication review," telemedication reviews hereafter [TMR]) in French NH residents. The impact of these TMR on unplanned hospitalizations 3 months after implementation is assessed. TMR consider all available sociodemographic, clinical, biological, and pharmaceutical data pertaining to the patient and are performed in accordance with their health care objectives. Results: The preliminary results for the 39 TMRs performed to date (September 2021) showed that a total of 402 PIMs were detected, and all residents had at least one PIM. We also present the feasibility and the usefulness of this novel TMR for NH, illustrating these preliminary results with two concrete TMR experiences. Among the 39 TMR performed, the average acceptance rate of expert recommendations made to general practitioners (GP) working in NH was ∼33%. Discussion and Conclusions: The success of this novel TMR depends on how the proposed prescription adjustments made by the hospital expert team are subsequently integrated into health care practices. The low acceptance rate by GP highlights the need to actively involve these professionals in the process of developing TMR, with a view to encouraging them to act on proposed adjustments.

Expert-based medication reviews to reduce polypharmacy in older patients in primary care: a northern-Italian cluster-randomised controlled trial

BACKGROUND

Evidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice.

METHODS

The cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function.

RESULTS

Twenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs.

CONCLUSIONS

No conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing.

TRIAL REGISTRATION

Current Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.

Abuse/Misuse of Prescription Medications in Older Adults

The world population is aging due to increasing life expectancy. The rate of drug use increases, and inappropriate prescribing is frequently encountered with advancing age. In addition, misuse and abuse of prescription drugs is a serious problem in older adults. It is challenging to detect substance and drug abuse in older patients because it may have fewer consequences in social, legal, and occupational fields. However, there is not enough information about the screening, evaluation, diagnosis, and treatment of abuse. Therefore, the awareness of health care professionals and others involved in older patients' care should be raised about the misuse and abuse of drugs.

A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities

OBJECTIVES

To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included.

METHODS

Screening, data extraction, and quality assessment were performed independently by 2 review authors.

RESULTS

Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2).

CONCLUSIONS AND IMPLICATIONS

Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.

Ethical Tenets of PRN Medicines Management in Healthcare Settings: A Clinical Perspective

Prescription and administration of pro re nata (PRN) medications has remained a poorly discussed area of the international literature regarding ethical tenets influencing this type of medication practice. In this commentary, ethical tenets of PRN medicines management from the clinical perspective based on available international literature and published research have been discussed. Three categories were developed by the authors for summarising review findings as follows: 'benefiting the patient', 'making well-informed decision', and 'follow up assessment' as pre-intervention, through-intervention, and post-intervention aspects, respectively. PRN medicines management is mainly intertwined with the ethical tenets of beneficence, nonmaleficence, dignity, autonomy, justice, informed consent, and error disclosure. It is a dynamic process and needs close collaboration between healthcare professionals especially nurses and patients to prevent unethical practice.

Quality standards for safe medication in nursing homes: development through a multistep approach including a Delphi consensus study

OBJECTIVES

The aim of the study was to develop quality standards reflecting minimal requirements for safe medication processes in nursing homes.

DESIGN

In a first step, relevant key topics for safe medication processes were deducted from a systematic search for similar guidelines, prior work and discussions with experts. In a second step, the essential requirements for each key topic were specified and substantiated with a literature-based rationale. Subsequently, the requirements were evaluated with a piloted, two-round Delphi study.

SETTING

Nursing homes in Switzerland.

PARTICIPANTS

Interprofessional panel of 25 experts from science and practice.

PRIMARY AND SECONDARY OUTCOME MEASURES

Each requirement was rated for its relevance for a safer and resident-oriented medication on a 9-point Likert-Scale based on the RAND/UCLA method. The requirements were considered relevant if, in the second round, the median relevance rating was ≥7 and the proportion of ratings ≥7 was ≥80%.

RESULTS

Five key topics with a total of 87 requirements were elaborated and rated in the Delphi study. After the second round (response rate in both rounds 100%), 85 requirements fulfilled the predefined criteria and were therefore included in the final set of quality standards. The five key topics are: (I) 'The medication is reviewed regularly and in defined situations', (II) 'The medication is reviewed in a structured manner', (III) 'The medication is monitored in a structured manner', (IV) 'All healthcare professionals are committed to an optimal interprofessional collaboration' and (V) 'Residents are actively involved in medication process'.

CONCLUSIONS

We developed normative quality standards for a safer and resident-oriented medication in Swiss nursing homes. Altogether, 85 requirements define the medication processes and the behaviour of healthcare professionals. A rigorous implementation may support nursing homes in taking a step towards safer and resident-oriented medication.

Pharmacist-led interventions to reduce adverse drug events in older people living in residential aged care facilities: A systematic review

AIMS

We aimed to investigate the efficacy and effectiveness of pharmacist-led interventions to reduce adverse drug events (ADEs) in older people living in residential aged care facilities (RACFs).

METHODS

We systematically searched MEDLINE via PubMed, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from their inceptions to July 2020. We investigated experimental study designs that employed a control group, or quasi-experimental studies conducted in RACFs.

RESULTS

We screened 3826 records and included 23 studies. We found seven single-component and 16 multicomponent pharmacist-led interventions to reduce ADEs in older people living in RACFs. The most frequent single-component pharmacist-led intervention was medication review. Medication review and education provision to healthcare professionals were the most common components in many pharmacist-led multicomponent interventions. Thirteen studies (56%) showed no effect, whereas ten studies (43%) reported significant reductions in ADEs following pharmacist-led interventions either as a sole intervention or as a part of a multi-component intervention. Many interventions focused on reducing the incidence of falls (39%).

CONCLUSIONS

This systematic review suggests that pharmacist-led interventions have the potential to reduce the incidence of ADEs in older people living in RACFs. Medication review and educational programmes, particularly academic detailing, either as a single component or as part of multicomponent interventions were the most common approaches to reducing drug-related harm in older people living in RACFs. The lack of a positive association between interventions and ADE in many studies suggests that targeted and tailored pharmacist-led interventions are required to reduce ADEs in older people in RACFs.

Epidemiology and associated factors of polypharmacy in older patients in primary care: a northern Italian cross-sectional study

Background

A precondition for developing strategies to reduce polypharmacy and its well-known harmful consequences is to study its epidemiology and associated factors. The objective of this study was to analyse the prevalence of polypharmacy (defined as ≥8 prescribed drugs), of potentially inappropriate medications (PIMs) and major drug-drug interactions (DDIs) among community-dwelling general practice patients aged ≥75 years and to identify characteristics being associated with polypharmacy.

Methods

This cross-sectional study is derived from baseline data (patients’ demographic/biometric characteristics, diagnoses, medication-related data, cognitive/affective status, quality of life) of a northern-Italian cluster-RCT. PIMs and DDIs were assessed using the 2012 Beers criteria and the Lexi-Interact® database. Data were analysed using descriptive methods, Wilcoxon rank-sum tests, Fisher’s exact tests and Spearman correlations.

Results

Of the eligible patients aged 75+, 13.4% were on therapy with ≥8 drugs. Forty-three general practitioners and 579 patients participated in the study. Forty five point nine percent of patients were treated with ≥1 Beers-listed drugs. The most frequent PIMs were benzodiazepines/hypnotics (19.7% of patients) and NSAIDs (6.6%). Sixty seven point five percent of patients were exposed to ≥1 major DDI, 35.2% to ≥2 major DDIs. Antithrombotic/anticoagulant medications (30.4%) and antidepressants/antipsychotics (23.1%) were the most frequently interacting drugs. Polypharmacy was significantly associated with a higher number of major DDIs (Spearman’s rho 0.33, p < 0.001) and chronic conditions (Spearman’s rho 0.20, p < 0.001), higher 5-GDS scores (thus, lower affective status) (Spearman’s rho 0.12, p = 0.003) and lower EQ-5D-5L scores (thus, lower quality of life) (Spearman’s rho − 0.14, p = 0.001). Patients’ age/sex, 6-CIT scores (cognitive status), BMI or PIM use were not correlated with the number of drugs.

Conclusions

The prevalence of polypharmacy, PIMs and major DDIs was considerable. Results indicate that physicians should particularly observe their patients with multiple conditions, reduced health and affective status, independently from other patients’ characteristics. Careful attention about indication, benefit and potential risk should be paid especially to patients on therapy with specific drug classes identified as potentially inappropriate or prone to major DDIs in older persons (e.g., benzodiazepines, NSAIDs, protonic pump inhibitors, antithrombotics/anticoagulants, antidepressants/antipsychotics).

Trial registration

The cluster-RCT on which this cross-sectional analysis is based was registered with Current Controlled Trials Ltd. (ID ISRCTN: 38449870) on 2013-09-11.

The Prevalence of Selected Potential Drug-Drug Interactions of Analgesic Drugs and Possible Methods of Preventing Them: Lessons Learned From the Analysis of the Real-World National Database of 38 Million Citizens of Poland

Introduction: Drug-drug interactions may lead to poor health outcomes, as well as increased costs and utilization of healthcare services. Unfortunately, real-world data continuously prove high prevalence of potential drug-drug interactions (pDDIs) worldwide. Among identified drivers, ageing, multimorbidity and polypharmacy play a very important role. With these factors being widespread, the need for implementation of strategies minimizing the burden of pDDIs becomes an urgency. This, however, requires a better understanding of the prevalence of pDDIs and the underlying causative factors.

Aim of study: To assess the real-world prevalence of pDDIs and its characteristics in the general population of Poland, using analgesic drugs as a model, and to find out whether pDDIs are caused by prescribing coming from the very same prescribers (co-prescribing).

Methods: A retrospective analysis of the 2018 dispensation data of the National Health Fund (NHF) - the only Polish public healthcare payer organization with nationwide coverage. We searched for selected pDDIs of non-steroidal anti-inflammatory drugs (NSAIDs) with antihypertensives, other NSAIDs (double use), oral glucocorticoids, oral anticoagulants, selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), and antiplatelet drugs; as well as opioides with SSRIs, SNRIs, gabapentinoids, and benzodiazepines. A pDDI was deemed present if two drugs standing in a possible conflict were dispensed within the same calendar month.

Results: Out of 38.4 million citizens of Poland, 23.3 million were dispensed prescribed drugs reimbursed by NHF in 2018. In this cohort, we have identified 2,485,787 cases of analgesic drug pDDIs, corresponding with 6.47% of the Polish population. Out of these, the most prevalent pDDI was caused by “NSAIDs + antihypertensives” (1,583,575 cases, i.e., 4.12% of the Polish population), followed by “NSAIDs + NSAIDs” (538,640, 1.40%) and “NSAIDs + glucocorticoids” (213,504, 0.56%). The most persistent pDDIs among those studied were caused by “Opioids + Gabapentinoids” (2.19, 95%CI: 2.16–2.22 months). On average, 76.63% of all cases of pDDIs were caused by drugs prescribed by the very same prescribers.

Conclusion: Based on high-quality, nationwide data, we have found a high prevalence of analgesic drugs-related pDDIs in Poland. Over ¾ of the identified pDDIs were caused by co-prescribing, i.e., prescriptions issued by the same prescribers. The significance of the problem, illustrated with our findings on analgesic drugs-related pDDIs in Poland, deserves much more scientific and policymaker attention.

A New Care Model Reduces Polypharmacy and Potentially Inappropriate Medications in Long-Term Care

OBJECTIVES

Assess the impact of a new pharmaceutical care model on (1) polypharmacy and (2) potentially inappropriate medication (PIM) use in long-term care facilities (LTCFs).

DESIGN

Pragmatic quasi-experimental study with a control group. This multifaceted model enables pharmacists and nurses to increase their professional autonomy by enforcing laws designed to expand their scope of practice. It also involves a strategic reorganization of care, interdisciplinary training, and systematic medication reviews.

SETTING AND PARTICIPANTS

Two LTCFs exposed to the model (409 residents) were compared to 2 control LTCFs (282 residents) in Quebec, Canada. All individuals were aged 65 years or older and residing in included LTCFs.

MEASURES

Polypharmacy (≥10 medications) and PIM (2015 Beers criteria) were analyzed throughout 12 months between March 2017 and June 2018. Groups were compared before and after implementation using repeated measures mixed Poisson or logistic regression models, adjusting for potential confounding variables.

RESULTS

Over 12 months, for regular medications, polypharmacy decreased from 42% to 20% (exposed group) and from 50% to 41% (control group) [difference in differences (DID): 13%, P < .001]. Mean number of PIMs also decreased from 0.79 to 0.56 (exposed group) and from 1.08 to 0.90 (control group) (DID: 0.05, P = .002).

CONCLUSIONS AND IMPLICATIONS

Compared with usual care, this multifaceted model reduced the probability of receiving ≥10 medications and the mean number of PIMs. Greater professional autonomy, reorganization of care, training, and medication review can optimize pharmaceutical care. As the role of pharmacists is expanding in many countries, this model shows what could be achieved with increased professional autonomy of pharmacists and nurses in LTCFs.

Are medications safely used by residents in elderly care homes? - A multi-centre observational study from Sri Lanka

BACKGROUND

Most residents in elderly care homes in Sri Lanka do not receive formal, on-site, patient care services.

OBJECTIVE

To evaluate the appropriateness of prescribing, dispensing, administration, and storage practices of medication used by residents in selected elderly care homes in Colombo District, Sri Lanka.

METHODOLOGY

This was a prospective, cross-sectional, multi-center study of 100 residents with chronic, non-communicable diseases, who resided in nine selected elderly care homes in Sri Lanka. Medication histories were obtained from each resident/caregiver and the appropriateness of medications in their current prescription was reviewed using standard treatment guidelines. Prescriptions were cross-checked against respective dispensing labels to identify dispensing errors. Medication administration was directly observed on two separate occasions per resident for accuracy of administration, and matched against the relevant prescription instructions. Medication storage was also observed in terms of exposure to temperature and sunlight, the suitability of container, and adequacy of separation if using multiple medications.

RESULTS

The mean age of residents was 70±10.5 years and the majority were women (72%). A total of 168 errors out of 446 prescriptions were identified. The mean number of prescribing errors per resident was 1.68±1.23 [median, 2.00 (1.00-3.00)]. Inappropriate dosing frequencies were the highest (37.5%;63/168), followed by missing or inappropriate medications (31.5%;53/168). The mean number of dispensing errors per resident was 15.9±13.1 [median, 14.0 (6.00-22.75)] with 3.6 dispensing errors per every medication dispensed. Mean administration errors per resident was 0.95±1.5 [median, 0.00 (0.00-1.00)], with medication omissions being the predominant error (50.5%;48/95). Another lapse was incorrect storage of medications (143 storage errors), and included 83 medications not properly separated from each other (58.0%).

CONCLUSION

Multiple errors related to prescribing, dispensing, administration, and storage were identified amongst those using medication in elderly care homes. Services of a dedicated consultant pharmacist could improve the quality of medication use in elderly care homes in Sri Lanka.