Development of High-Risk Geriatric Polypharmacy Electronic Clinical Quality Measures and a Pilot Test of EHR Nudges Based on These Measures

BACKGROUND

Inappropriate polypharmacy, prevalent among older patients, is associated with substantial harms.

OBJECTIVE

To develop measures of high-risk polypharmacy and pilot test novel electronic health record (EHR)-based nudges grounded in behavioral science to promote deprescribing.

DESIGN

We developed and validated seven measures, then conducted a three-arm pilot from February to May 2019.

PARTICIPANTS

Validation used data from 78,880 patients from a single large health system. Six physicians were pre-pilot test environment users. Sixty-nine physicians participated in the pilot.

MAIN MEASURES

Rate of high-risk polypharmacy among patients aged 65 years or older. High-risk polypharmacy was defined as being prescribed ≥5 medications and satisfying ≥1 of the following high-risk criteria: drugs that increase fall risk among patients with fall history; drug-drug interactions that increase fall risk; thiazolidinedione, NSAID, or non-dihydropyridine calcium channel blocker in heart failure; and glyburide, glimepiride, or NSAID in chronic kidney disease.

INTERVENTIONS

Physicians received EHR alerts when renewing or prescribing certain high-risk medications when criteria were met. One practice received a "commitment nudge" that offered a chance to commit to addressing high-risk polypharmacy at the next visit. One practice received a "justification nudge" that asked for a reason when high-risk polypharmacy was present. One practice received both.

KEY RESULTS

Among 55,107 patients 65 and older prescribed 5 or more medications, 6256 (7.9%) had one or more high-risk criteria. During the pilot, the mean (SD) number of nudges per physician per week was 1.7 (0.4) for commitment, 0.8 (0.5) for justification, and 1.9 (0.5) for both interventions. Physicians requested to be reminded to address high-risk polypharmacy for 236/833 (28.3%) of the commitment nudges and acknowledged 441 of 460 (95.9%) of justification nudges, providing a text response for 187 (40.7%).

CONCLUSIONS

EHR-based measures and nudges addressing high-risk polypharmacy were feasible to develop and implement, and warrant further testing.

Falls prediction using the nursing home minimum dataset

OBJECTIVE

The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States.

MATERIALS AND METHODS

The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach.

RESULTS

The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model's area under the ROC curve was 0.668 (95% confidence interval: 0.643-0.693) on the validation subsample of the merged data.

DISCUSSION

Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs.

CONCLUSION

The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization

BACKGROUND/OBJECTIVES

We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk.

DESIGN

Prospective cohort analysis.

SETTING AND PARTICIPANTS

32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations.

METHODS

We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs.

RESULTS

We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47).

CONCLUSIONS AND IMPLICATIONS

AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.

Transforming the Medication Regimen Review Process Using Telemedicine to Prevent Adverse Events

BACKGROUND/OBJECTIVES

Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay.

DESIGN

Quality improvement study using a stepped-wedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017.

SETTING

Four NHs (two urban, two suburban) in Southwestern Pennsylvania.

PARTICIPANTS

All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period.

INTERVENTION

Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine.

MEASUREMENT

Main outcome was incidence of high-risk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations.

RESULTS

Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42).

CONCLUSIONS

This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.

Nursing Home Provider Perceptions of Telemedicine for Providing Specialty Consults

BACKGROUND

Nursing homes (NHs) provide care to a complex patient population and face the ongoing challenge of meeting resident needs for specialty care. A NH telemedicine care model could improve access to remote specialty providers.

INTRODUCTION

Little is known about provider interest in telemedicine for specialty consults in the NH setting. The goal of this study was to survey a national sample of NH physicians and advanced practice providers to document their views on telemedicine for providing specialty consults in the NH.

MATERIALS AND METHODS

We surveyed physician and advanced practice providers who attended the 2016 AMDA-The Society for Post-Acute and Long-Term Care Medicine Annual Conference about their likelihood of referral to and perceptions of a telemedicine program for providing specialty consults in the NH.

RESULTS

We received surveys from 524 of the 1,274 conference attendees for a 41.1% response rate. Respondents expressed confidence in the ability of telemedicine to fill existing service gaps and provide appropriate, timelier care. Providers showed the highest level of interest in telemedicine for dermatology, geriatric psychiatry, and infectious disease. Only 13% of respondents indicated that telemedicine was available for use in one of their facilities.

DISCUSSION

There appears to be unmet demand for telemedicine in NHs for providing specialty consults to residents.

CONCLUSIONS

The responses of NH providers suggest support for the concept of telemedicine as a modality of care that can be used to offer specialty consults to NH residents.

Physician Perceptions of Consultant Pharmacist Services Associated with an Intervention for Adverse Drug Events in the Nursing Facility

OBJECTIVE

To assess the importance and performance of consultant pharmacist services delivered before and after an intervention to detect and manage adverse drug events among nursing facility residents.

DESIGN

Before and after intervention survey of physicians participating in a randomized, controlled trial.

SETTING

Four nonprofit, academically affiliated nursing facilities.

PARTICIPANTS

Attending physicians providing nursing facility care who were randomized to intervention or control groups.

INTERVENTIONS

Within the intervention arm, consultant pharmacists provided academic detailing in which trained health care professionals visit practicing physicians in their offices and present the most up-to-date clinical information. Physicians responded to alerts from a medication monitoring system, adjudicated system alerts for adverse drug events (ADEs), and provided structured recommendations about ADE management.

MAIN OUTCOME MEASURES

We compared physicians' assessments of the importance and performance of consultant pharmacist services before and after the trial intervention in the intervention and control groups.

RESULTS

In the intervention group, ratings of importance increased for all 24 survey questions, and 5 of the changes were statistically significant (P < 0.05). In the control group, ratings of importance increased for 16 questions, and none of the changes were statistically significant. In the intervention group, ratings of performance increased for all 24 questions, and 20 of the changes were statistically significant. In the control group, ratings of performance increased for 16 questions, and none of the changes was statistically significant.

CONCLUSION

A multifaceted, consultant pharmacist-led intervention comprising academic detailing, computerized decision support, and structured communication framework can improve physicians' assessment of importance and performance of consultant pharmacist services.

ABBREVIATIONS

ADE = Adverse drug event, M = Statistically significant mean, RCT = Randomized controlled trial, SBAR = Situation, Background, Discussion, Recommendation, SD = Standard deviation.

Use of Telemedicine to Enhance Pharmacist Services in the Nursing Facility

OBJECTIVE

To conduct a systematic literature review to determine what telemedicine services are provided by pharmacists and the impact of these services in the nursing facility setting.

DATA SOURCES

MEDLINE®, Scopus®, and Embase® databases.

STUDY SELECTION

The terms "telemedicine" or "telehealth" were combined by "and" with the terms "pharmacist" or "pharmacy" to identify pharmacists' use of telemedicine. Also, "telepharmacy" was added as a search term. The initial search yielded 322 results. These abstracts were reviewed by two individuals independently, for selection of articles that discussed telemedicine and involvement of a pharmacist, either as the primary user of the service or as part of an interprofessional health care team. Those abstracts discussing the pharmacist service for purpose of dispensing or product preparation were excluded.

DATA EXTRACTION

A description of pharmacists' services provided and the impact on resident care.

DATA SYNTHESIS

Only three manuscripts met inclusion criteria. One was a narrative proposition of the benefits of using telemedicine by senior care pharmacists. Two published original research studies indirectly assessed the pharmacists' use of telemedicine in the nursing facility through an anticoagulation program and an osteoporosis management service. Both services demonstrated improvement in patient care.

CONCLUSION

There is a general paucity of practice-related research to demonstrate potential benefits of pharmacists' services incorporating telemedicine. Telemedicine may be a resource-efficient approach to enhance pharmacist services in the nursing facility and improve resident care.

Clinical decision support for drug related events: Moving towards better prevention

Clinical decision support (CDS) systems with automated alerts integrated into electronic medical records demonstrate efficacy for detecting medication errors (ME) and adverse drug events (ADEs). Critically ill patients are at increased risk for ME, ADEs and serious negative outcomes related to these events. Capitalizing on CDS to detect ME and prevent adverse drug related events has the potential to improve patient outcomes. The key to an effective medication safety surveillance system incorporating CDS is advancing the signals for alerts by using trajectory analyses to predict clinical events, instead of waiting for these events to occur. Additionally, incorporating cutting-edge biomarkers into alert knowledge in an effort to identify the need to adjust medication therapy portending harm will advance the current state of CDS. CDS can be taken a step further to identify drug related physiological events, which are less commonly included in surveillance systems. Predictive models for adverse events that combine patient factors with laboratory values and biomarkers are being established and these models can be the foundation for individualized CDS alerts to prevent impending ADEs.

Preparing Nursing Home Data from Multiple Sites for Clinical Research - A Case Study Using Observational Health Data Sciences and Informatics

INTRODUCTION

A potential barrier to nursing home research is the limited availability of research quality data in electronic form. We describe a case study of converting electronic health data from five skilled nursing facilities to a research quality longitudinal dataset by means of open-source tools produced by the Observational Health Data Sciences and Informatics (OHDSI) collaborative.

METHODS

The Long-Term Care Minimum Data Set (MDS), drug dispensing, and fall incident data from five SNFs were extracted, translated, and loaded into version 4 of the OHDSI common data model. Quality assurance involved identifying errors using the Achilles data characterization tool and comparing both quality measures and drug exposures in the new database for concordance with externally available sources.

FINDINGS

Records for a total 4,519 patients (95.1%) made it into the final database. Achilles identified 10 different types of errors that were addressed in the final dataset. Drug exposures based on dispensing were generally accurate when compared with medication administration data from the pharmacy services provider. Quality measures were generally concordant between the new database and Nursing Home Compare for measures with a prevalence ≥ 10%. Fall data recorded in MDS was found to be more complete than data from fall incident reports.

CONCLUSIONS

The new dataset is ready to support observational research on topics of clinical importance in the nursing home including patient-level prediction of falls. The extraction, translation, and loading process enabled the use of OHDSI data characterization tools that improved the quality of the final dataset.

Using mobile health technology to deliver decision support for self-monitoring after lung transplantation

BACKGROUND

Lung transplant recipients (LTR) experience problems recognizing and reporting critical condition changes during their daily health self-monitoring. Pocket PATH(®), a mobile health application, was designed to provide automatic feedback messages to LTR to guide decisions for detecting and reporting critical values of health indicators.

OBJECTIVES

To examine the degree to which LTR followed decision support messages to report recorded critical values, and to explore predictors of appropriately following technology decision support by reporting critical values during the first year after transplantation.

METHODS

A cross-sectional correlational study was conducted to analyze existing data from 96 LTR who used the Pocket PATH for daily health self-monitoring. When a critical value is entered, the device automatically generated a feedback message to guide LTR about when and what to report to their transplant coordinators. Their socio-demographics and clinical characteristics were obtained before discharge. Their use of Pocket PATH for health self-monitoring during 12 months was categorized as low (≤25% of days), moderate (>25% to ≤75% of days), and high (>75% of days) use. Following technology decision support was defined by the total number of critical feedback messages appropriately handled divided by the total number of critical feedback messages generated. This variable was dichotomized by whether or not all (100%) feedback messages were appropriately followed. Binary logistic regression was used to explore predictors of appropriately following decision support.

RESULTS

Of the 96 participants, 53 had at least 1 critical feedback message generated during 12 months. Of these 53 participants, the average message response rate was 90% and 33 (62%) followed 100% decision support. LTR who moderately used Pocket PATH (n=23) were less likely to follow technology decision support than the high (odds ratio [OR]=0.11, p=0.02) and low (OR=0.04, p=0.02) use groups. The odds of following decision support were reduced in LTR whose income met basic needs (OR=0.01, p=0.01) or who had longer hospital stays (OR=0.94, p=0.004). A significant interaction was found between gender and past technology experience (OR=0.21, p=0.03), suggesting that with increased past technology experience, the odds of following decision support to report all critical values decreased in men but increased in women.

CONCLUSIONS

The majority of LTR responded appropriately to mobile technology-based decision support for reporting recorded critical values. Appropriately following technology decision support was associated with gender, income, experience with technology, length of hospital stay, and frequency of use of technology for self-monitoring. Clinicians should monitor LTR, who are at risk for poor reporting of recorded critical values, more vigilantly even when LTR are provided with mobile technology decision support.

Perceived Benefits, Barriers, and Drivers of Telemedicine From the Perspective of Skilled Nursing Facility Administrative Staff Stakeholders

Potentially avoidable hospitalizations (PAHs) of skilled nursing facility (SNF) patients are common and costly. Telemedicine represents a unique approach to manage and potentially reduce PAHs in SNFs, having been used in a variety of settings to improve coordination of care and enhance access to providers. Nonetheless, broad implementation and use of telemedicine lags in SNFs relative to other health care settings. To understand why, we surveyed SNF administrative staff attending a 1-day telemedicine summit. Participants saw the highest value of telemedicine in improving the quality of care and reducing readmissions. They identified hospital and managed care telemedicine requirements as primary drivers of adoption. The most significant barrier to adoption was the initial investment required. A joint research-policy effort to improve the evidence base around telemedicine in SNFs and introduce incentives may improve adoption and continued use of telemedicine in this setting.

Acceptance and Use of Mobile Technology for Health Self-Monitoring in Lung Transplant Recipients during the First Year Post-Transplantation

OBJECTIVES

To describe lung transplant recipients (LTRs') acceptance and use of mobile technology for health self-monitoring during the first year post-transplantation, and explore correlates of the use of technology in the 0 to 2, >2 to ≤6, >6 to ≤12, and 0 to 12 months.

METHODS

Secondary analysis of data from 96 LTR assigned to use Pocket PATH(®), a smartphone application, for daily health self-monitoring in a randomized controlled trial. Use of Pocket PATH was categorized as low, moderate, and high use. Proportional odds models for ordinal logistic regression were employed to explore correlates of use of technology.

RESULTS

LTR reported high acceptance of Pocket PATH at baseline. However, acceptance was not associated with actual use over the 12 months (p=0.45~0.96). Actual use decreased across time intervals (p<0.001). Increased self-care agency was associated with the increased odds of higher use in women (p=0.03) and those less satisfied with technology training (p=0.02) in the first 2 months. Higher use from >2 to ≤6 months was associated with greater satisfaction with technology training (OR=3.37, p=0.01) and shorter length of hospital stay (OR=0.98, p=0.02). Higher use from >6 to ≤12 months was associated with older age (OR=1.05, p=0.02), lower psychological distress (OR=0.43, p=0.02), and better physical functioning (OR=1.09, p=0.01). Higher use over 12 months was also associated with older age (OR=1.05, p=0.007), better physical functioning (OR=1.13, p=0.001), and greater satisfaction with technology training (OR=3.05, p=0.02).

CONCLUSIONS

Correlates were different for short- and long-term use of mobile technology for health self-monitoring in the first year post-transplantation. It is important to follow up with LTR with longer hospital stay, poor physical functioning, and psychological distress, providing ongoing education to improve their long-term use of technology for health self-monitoring.

Using a Clinical Surveillance System to Detect Drug-Associated Hypoglycemia in Nursing Home Residents

OBJECTIVES

To determine whether a clinical surveillance system could be used to detect drug-associated hypoglycemia events and determine their incidence in nursing home (NH) residents.

DESIGN

Retrospective cohort.

SETTING

Four NHs in western Pennsylvania.

PARTICIPANTS

Any resident of the four NHs who had a computer-generated alert detecting potential drug-associated hypoglycemia over a 6-month period were included.

MEASUREMENTS

Descriptive statistics were used to summarize all variables, including the frequency and distribution of alert type according to glucose threshold. Analyses were conducted according to numbers of alerts and residents. The medications associated with the drug-associated hypoglycemia alerts were identified, and frequency of their inclusion in alerts was calculated. Additional calculations included time to drug-associated hypoglycemic event alert from date of admission and frequency of events associated with postacute, short-stay (≤35 days) admissions.

RESULTS

Seven hundred seventy-two alerts involving 141 residents were detected. Ninety (63.8%) residents had a glucose level of 55 mg/dL or less, and 42 (29.8%) had a glucose level of 40 mg/dL or less. Insulin orders were associated with 762 (98.7%) alerts. Overall incidence of drug-associated hypoglycemia events was 9.5 per 1,000 resident-days.

CONCLUSION

Hypoglycemia can be detected using a clinical surveillance system. This evaluation found a high incidence of drug-associated hypoglycemia in a general NH population. Future studies are needed to determine the potential benefits of use of a surveillance system in real-time detection and management of hypoglycemia in NHs.

A Multicenter Evaluation of Off-Label Medication Use and Associated Adverse Drug Reactions in Adult Medical ICUs

OBJECTIVE

Prior research indicates that off-label use is common in the ICU; however, the safety of off-label use has not been assessed. The study objective was to determine the prevalence of adverse drug reactions associated with off-label use and evaluate off-label use as a risk factor for the development of adverse drug reactions in an adult ICU population.

DESIGN

Multicenter, observational study

SETTING

: Medical ICUs at three academic medical centers.

PATIENTS

Adult patients (age ≥ 18 yr old) receiving medication therapy.

INTERVENTIONS

All administered medications were evaluated for Food and Drug Administration-approved or off-label use. Patients were assessed daily for the development of an adverse drug reaction through active surveillance. Three adverse drug reaction assessment instruments were used to determine the probability of an adverse drug reaction resulting from drug therapy. Severity and harm of the adverse drug reaction were also assessed. Cox proportional hazard regression was used to identify a set of covariates that influenced the rate of adverse drug reactions.

MEASUREMENTS AND MAIN RESULTS

Overall, 1,654 patient-days (327 patients) and 16,391 medications were evaluated, with 43% of medications being used off-label. One hundred and sixteen adverse drug reactions were categorized dichotomously (Food and Drug Administration or off-label), with 56% and 44% being associated with Food and Drug Administration-approved and off-label use, respectively. The number of adverse drug reactions for medications administered and the number of harmful and severe adverse drug reactions did not differ for medications used for Food and Drug Administration-approved or off-label use (0.74% vs 0.67%; p = 0.336; 33 vs 31 events, p = 0.567; 24 vs 24 events, p = 0.276). Age, sex, number of high-risk medications, number of off-label medications, and severity of illness score were included in the Cox proportional hazard regression. It was found that the rate of adverse drug reactions increases by 8% for every one additional off-label medication (hazard ratio = 1.08; 95% CI, 1.018-1.154).

CONCLUSION

Although adverse drug reactions do not occur more frequently with off-label use, adverse drug reaction risk increases with each additional off-label medication used.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.

Risk factors for acute kidney injury in older adults with critical illness: a retrospective cohort study

BACKGROUND

Risk for acute kidney injury (AKI) in older adults has not been evaluated systematically. We sought to delineate the determinants of risk for AKI in older compared with younger adults.

STUDY DESIGN

Retrospective analysis of patients hospitalized in July 2000 to September 2008.

SETTING & PARTICIPANTS

We identified all adult patients admitted to an intensive care unit (n=45,655) in a large tertiary-care university hospital system. We excluded patients receiving dialysis or a kidney transplant prior to hospital admission and patients with baseline creatinine levels ≥ 4mg/dL, liver transplantation, indeterminate AKI status, or unknown age, leaving 39,938 patients.

PREDICTOR

We collected data for multiple susceptibilities and exposures, including age, sex, race, body mass, comorbid conditions, severity of illness, baseline kidney function, sepsis, and shock.

OUTCOMES

We defined AKI according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. We examined susceptibilities and exposures across age strata for impact on the development of AKI.

MEASUREMENTS

We calculated area under the receiver operating characteristic curve (AUC) for prediction of AKI across age groups.

RESULTS

25,230 (63.2%) patients were 55 years or older. Overall, 25,120 (62.9%) patients developed AKI (69.2% aged ≥55 years). Examples of risk factors for AKI in the oldest age category (≥75 years) were drugs (vancomycin, aminoglycosides, and nonsteroidal anti-inflammatories), history of hypertension (OR, 1.13; 95% CI, 1.02-1.25), and sepsis (OR, 2.12; 95% CI, 1.68-2.67). Fewer variables remained predictive of AKI as age increased and the model for older patients was less predictive (P<0.001). For the age categories 18 to 54, 55 to 64, 65 to 74, and 75 years or older, AUCs were 0.744 (95% CI, 0.735-0.752), 0.714 (95% CI, 0.702-0.726), 0.706 (95% CI, 0.693-0.718), and 0.673 (95% CI, 0.661-0.685), respectively.

LIMITATIONS

Analysis may not apply to non-intensive care unit patients.

CONCLUSIONS

The likelihood of developing AKI increases with age; however, the same variables are less predictive for AKI as age increases. Efforts to quantify risk for AKI may be more difficult in older adults.

AKI in low-risk versus high-risk patients in intensive care

BACKGROUND AND OBJECTIVES

AKI in critically ill patients is usually part of multiorgan failure. However, nonrenal organ failure may not always precede AKI and patients without evidence of these organ failures may not be at low risk for AKI. This study examined the risk and outcomes associated with AKI in critically ill patients with and without cardiovascular or respiratory organ failures at presentation to the intensive care unit (ICU).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A large, academic medical center database, with records from July 2000 through October 2008, was used and the authors identified a low-risk cohort as patients without cardiovascular and respiratory organ failures defined as not receiving vasopressor support or mechanical ventilation within the first 24 hours of ICU admission. AKI was defined using Kidney Disease Improving Global Outcomes criteria. The primary end points were moderate to severe AKI (stages 2-3) and risk-adjusted hospital mortality.

RESULTS

Of 40,152 critically ill patients, 44.9% received neither vasopressors nor mechanical ventilation on ICU day 1. Stages 2-3 AKI occurred less frequently in the low-risk patients versus high-risk patients within 24 hours (14.3% versus 29.1%) and within 1 week (25.7% versus 51.7%) of ICU admission. Patients developing AKI in both risk groups had higher risk of death before hospital discharge. However, the adjusted odds of hospital mortality were greater (odds ratio, 2.99; 95% confidence interval, 2.62 to 3.41) when AKI occurred in low-risk patients compared with those with respiratory or cardiovascular failures (odds ratio, 1.19; 95% confidence interval, 1.09 to 1.3); interaction P<0.001.

CONCLUSIONS

Patients admitted to ICU without respiratory or cardiovascular failure have a substantial likelihood of developing AKI. Although survival for low-risk patients is better than for high-risk patients, the relative increase in mortality associated with AKI is actually greater for low-risk patients. Strategies aimed at preventing AKI should not exclude ICU patients without cardiovascular or respiratory organ failures.

Potentially suboptimal prescribing for older veteran nursing home patients with dementia

BACKGROUND

Nursing home patients with dementia may be more likely to suffer adverse drug events from suboptimal prescribing. Previous studies have not used national samples, nor have they examined multiple types of suboptimal prescribing by dementia severity.

OBJECTIVE

To examine the prevalence of and factors associated with potentially suboptimal prescribing in older veteran nursing home patients with dementia.

METHODS

This is a retrospective descriptive study of 1303 veterans 65 years or older admitted between January 1, 2004, and June 30, 2005, with dementia for long stays (90+ days) to 133 Veterans Affairs Community Living Centers. Dementia severity was determined by the Cognitive Performance Scale and functional status dependences.

RESULTS

Overall, 70.2% with mild-moderate dementia (n = 1076) had underuse because they did not receive an acetylcholinesterase inhibitor (AChEI), and 27.2% had evidence of inappropriate use because of a drug-disease or drug-drug-disease interaction. Of the 227 with severe dementia, 36.1% had overuse by receiving an AChEI or lipid-lowering or other agents, and 25.1% had evidence of inappropriate use as a result of a drug-disease or drug-drug interaction. Multinomial logistic regression analyses among those with mild to moderate dementia identified that living in the South versus other regions was the single factor associated with all 3 types of suboptimal prescribing. In those with severe dementia, antipsychotic use was associated with all 3 suboptimal prescribing types.

CONCLUSIONS

Potentially suboptimal prescribing was common in older veteran nursing home patients with dementia. Clinicians should develop a heightened awareness of these problems. Future studies should examine associations between potentially suboptimal prescribing and health outcomes in patients with dementia.

Assessing the impact of cognitive impairment on the usability of an electronic medication delivery unit in an assisted living population

PURPOSE

To examine the relationship between cognitive status and the usability of an integrated medication delivery unit (MDU) in older adults who reside in an Assisted Living Facility (ALF).

METHODS

Subjects were recruited from a single ALF in Pittsburgh, PA. Usability testing sessions required subjects to execute tasks essential to using EMMA(®) (Electronic Medication Management Assistant), a Class II Federal Drug Administration (FDA) approved integrated MDU. Video coding allowed for quantification of usability errors observed during the testing sessions. Each subject's cognitive status was assessed using the Mini Mental State Exam (MMSE(®)) with scores <24 indicating cognitive impairment. Functional status was assessed using the Lawton Instrumental Activities of Daily Living (IADL) questionnaire, and a global assessment of subjective usability was assessed by completing the System Usability Scale (SUS). Non-parametric statistics and correlation analysis were used to determine whether significant differences existed between cognitively impaired and non-impaired subjects.

RESULTS

Nineteen subjects were recruited and completed the protocol. The subject pool was primarily white, female, 80+ and in possession of above average education. There was a significant relationship between MMSE(®) scores and the percentage of task success (z=-2.03, p=0.04). Subjects with MMSE(®) scores of 24+ (no cognitive impairment) successfully completed an average of 69.0% of tasks vs. the 34.7% performance for those in the cognitively impaired group (<24). Six of the unimpaired group also succeeded at meeting the 85% (6 out of 7 correct) threshold. No subject with cognitive impairments (<24 MMSE(®)) completed more than 5/7 (71.4%) of their tasks. Two of the impaired subjects failed all of the tasks. Three of the MMSE(®)'s subsections (Date, Location and Spell 'world' backwards) were found to be significantly related (p<0.05) to the percentage of task success. Tasks success rates were related with IADL scores (z=-3.826, p<0.0001), and SUS scores (r=0.467, p=0.0429).

CONCLUSIONS

Medication delivery units like EMMA(®) have the potential to improve medication management by combining reminder systems with telemedical monitoring and control capabilities. However, subjects judged to be "cognitively impaired" (<24 MMSE(®)) scored a significantly smaller percentage of task success than the "unimpaired" (>=24), suggesting that cognitive screening of patients prior to the use of EMMA(®) may be advisable. Further studies are needed to test the use of EMMA(®) amongst ALF residents without cognitive impairment to see if this technology can improve medication adherence.

The effectiveness of computerized drug-lab alerts: a systematic review and meta-analysis

BACKGROUND

Inadequate lab monitoring of drugs is a potential cause of ADEs (adverse drug events) which is remediable.

OBJECTIVES

To determine the effectiveness of computerized drug-lab alerts to improve medication-related outcomes.

DATA SOURCES

Citations from the Computerized Clinical Decision Support System Systematic Review (CCDSSR) and MMIT (Medications Management through Health Information Technology) databases, which had searched MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, International Pharmaceutical Abstracts from 1974 to March 27, 2013.

STUDY SELECTION

Randomized controlled trials (RCTs) of clinician-targeted computerized drug lab alerts conducted in any healthcare setting. Two reviewers performed full text review to determine study eligibility.

DATA ABSTRACTION

A single reviewer abstracted data and evaluated validity of included studies using Cochrane handbook domains.

DATA SYNTHESIS

Thirty-six studies met the inclusion criteria (25 single drug studies with 22,504 participants, 14 targeting anticoagulation; 11 multi-drug studies with 56,769 participants). ADEs were reported as an outcome in only four trials, all targeting anticoagulants. Computerized drug-lab alerts did not reduce ADEs (OR 0.89, 95% CI 0.79-1.00, p=0.05), length of hospital stay (SMD 0.00, 95%CI -0.93 to 0.93, p=0.055, 1 study), likelihood of hypoglycemia (OR 1.29, 95% CI 0.31-5.37) or likelihood of bleeding, but were associated with increased likelihood of prescribing changes (OR 1.73, 95% CI 1.21-2.47) or lab monitoring (OR 1.47, 95% confidence interval 1.12-1.94) in accordance with the alert.

CONCLUSIONS

There is no evidence that computerized drug-lab alerts are associated with important clinical benefits, but there is evidence of improvement in selected clinical surrogate outcomes (time in therapeutic range for vitamin K antagonists), and changes in process outcomes (lab monitoring and prescribing decisions).

Use and perceived benefits of mobile devices by physicians in preventing adverse drug events in the nursing home

OBJECTIVE

Although mobile devices equipped with drug reference software may help prevent adverse drug events (ADEs) in the nursing home (NH) by providing medication information at the point of care, little is known about their use and perceived benefits. The goal of this study was to conduct a survey of a nationally representative sample of NH physicians to quantify the use and perceived benefits of mobile devices in preventing ADEs in the NH setting.

DESIGN/SETTING/PARTICIPANTS

We surveyed physicians who attended the 2010 American Medical Directors Association Annual Symposium about their use of mobile devices, and beliefs about the effectiveness of drug reference software in preventing ADEs.

RESULTS

The overall net valid response rate was 70% (558/800) with 42% (236/558) using mobile devices to assist with prescribing in the NH. Physicians with 15 or fewer years of clinical experience were 67% more likely to be mobile device users, compared with those with more than 15 years of clinical experience (odds ratio = 1.68; 95% confidence interval = 1.17-2.41; P = .005). For those who used a mobile device to assist with prescribing, almost all (98%) reported performing an average of 1 or more drug look-ups per day, performed an average of 1 to 2 lookups per day for potential drug-drug interactions (DDIs), and most (88%) believed that drug reference software had helped to prevent at least 1 potential ADE in the preceding 4-week period.

CONCLUSIONS

The proportion of NH physicians who use mobile devices with drug reference software, although significant, is lower than in other clinical environments. Our results suggest that NH physicians who use mobile devices equipped with drug reference software believe they are helpful for reducing ADEs. Further research is needed to better characterize the facilitators and barriers to adoption of the technology in the NH and its precise impact on NH ADEs.

Counseling about medication-induced birth defects with clinical decision support in primary care

BACKGROUND

We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects women's behavior.

METHODS

Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse.

RESULTS

Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling.

CONCLUSIONS

Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Utility of an adverse drug event trigger tool in Veterans Affairs nursing facilities

OBJECTIVE

To determine the utility (i.e., positive predictive value [PPV] and time requirement) of an adverse drug event (ADE) trigger tool in Veterans Affairs (VA) nursing facilities and to describe the most common types of potential ADEs detected with the trigger tool.

DESIGN

Retrospective chart review.

SETTING/PATIENTS

Veterans residing in three VA nursing facilities between September 29, 2010, and October 29, 2010.

MEASUREMENT

We used the Institute for Healthcare Improvement-endorsed nursing facility ADE trigger tool, modified to enhance its clinical relevance to detect potential ADEs. Electronic medical records were screened to identify residents with one or more abnormal laboratory values specified in the trigger tool.

MAIN OUTCOME MEASURES

A potential ADE was defined as the concurrent administration of medication that could cause the abnormal laboratory value. An overall PPV, or proportion of residents with an abnormal laboratory value who had a potential ADE, and average time required to complete each trigger tool assessment, were calculated.

RESULTS

Among 321 veterans, 50.5% (n = 162) had at least one abnormal laboratory value contained in the trigger tool. Ninety-nine potential ADEs involving 146 medications were detected in 65 veterans. The overall PPV of the ADE trigger tool was 40.1% (65/162), and the average time to complete resident assessments was 8.8 (standard deviation ± 5.7) minutes. The most common potential ADEs were acute kidney injury (n = 30 residents), hypokalemia (n = 18), hypoglycemia (n = 13), and hyperkalemia (n = 10).

CONCLUSIONS

The modified nursing facility trigger tool was shown to be an effective and efficient method for detecting potential ADEs.

Features of effective computerised clinical decision support systems: meta-regression of 162 randomised trials

OBJECTIVES

To identify factors that differentiate between effective and ineffective computerised clinical decision support systems in terms of improvements in the process of care or in patient outcomes.

DESIGN

Meta-regression analysis of randomised controlled trials.

DATA SOURCES

A database of features and effects of these support systems derived from 162 randomised controlled trials identified in a recent systematic review. Trialists were contacted to confirm the accuracy of data and to help prioritise features for testing.

MAIN OUTCOME MEASURES

"Effective" systems were defined as those systems that improved primary (or 50% of secondary) reported outcomes of process of care or patient health. Simple and multiple logistic regression models were used to test characteristics for association with system effectiveness with several sensitivity analyses.

RESULTS

Systems that presented advice in electronic charting or order entry system interfaces were less likely to be effective (odds ratio 0.37, 95% confidence interval 0.17 to 0.80). Systems more likely to succeed provided advice for patients in addition to practitioners (2.77, 1.07 to 7.17), required practitioners to supply a reason for over-riding advice (11.23, 1.98 to 63.72), or were evaluated by their developers (4.35, 1.66 to 11.44). These findings were robust across different statistical methods, in internal validation, and after adjustment for other potentially important factors.

CONCLUSIONS

We identified several factors that could partially explain why some systems succeed and others fail. Presenting decision support within electronic charting or order entry systems are associated with failure compared with other ways of delivering advice. Odds of success were greater for systems that required practitioners to provide reasons when over-riding advice than for systems that did not. Odds of success were also better for systems that provided advice concurrently to patients and practitioners. Finally, most systems were evaluated by their own developers and such evaluations were more likely to show benefit than those conducted by a third party.

Home-care nurses' perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period

OBJECTIVE

To understand home-care nurses' perceptions of the post-hospitalisation information needs and communication problems of older patients, and how these factors might contribute to undesirable outcomes including poor patient reintegration into prior living environments and unplanned hospital readmissions.

DESIGN

A ranked list of information needs experienced by patients was developed by two Nominal Group Technique (NGT) sessions from the perspective of home-care nurses. The list was combined with results from previously published work to develop a web-based survey administered to home-care nurses to elicit perceptions of patients' post-hospitalisation information needs.

RESULTS

Seventeen nurses participated in the NGT sessions, producing a list of 28 challenges grouped into five themes: medications, disease/condition, non-medication care/treatment/safety, functional limitations and communication problems. The survey was sent to 220 home-care nurses, with a 54.1% (119/220) response rate. Respondents identified several frequent, high-impact information and communication needs that have received little attention in readmission literature, including information about medication regimens; the severity of their condition; the hospital discharge management process; non-medication care regimens such as wound care, use of durable medical equipment and home safety; the extent of care needed; and which providers are best suited to provide that care. Responses also identified several communication difficulties that may play a role in readmissions.

CONCLUSIONS

Information needs and communication problems identified by home-care nurses expanded upon and reinforced results from prior studies. These results might be used to develop interventions that may improve information sharing among clinicians, patients and caregivers during care transitions to ensure patient reintegration into prior living environments, potentially preventing unplanned hospital readmissions.

Home-care nurses' perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period

OBJECTIVE

To understand home-care nurses' perceptions of the post-hospitalisation information needs and communication problems of older patients, and how these factors might contribute to undesirable outcomes including poor patient reintegration into prior living environments and unplanned hospital readmissions.

DESIGN

A ranked list of information needs experienced by patients was developed by two Nominal Group Technique (NGT) sessions from the perspective of home-care nurses. The list was combined with results from previously published work to develop a web-based survey administered to home-care nurses to elicit perceptions of patients' post-hospitalisation information needs.

RESULTS

Seventeen nurses participated in the NGT sessions, producing a list of 28 challenges grouped into five themes: medications, disease/condition, non-medication care/treatment/safety, functional limitations and communication problems. The survey was sent to 220 home-care nurses, with a 54.1% (119/220) response rate. Respondents identified several frequent, high-impact information and communication needs that have received little attention in readmission literature, including information about medication regimens; the severity of their condition; the hospital discharge management process; non-medication care regimens such as wound care, use of durable medical equipment and home safety; the extent of care needed; and which providers are best suited to provide that care. Responses also identified several communication difficulties that may play a role in readmissions.

CONCLUSIONS

Information needs and communication problems identified by home-care nurses expanded upon and reinforced results from prior studies. These results might be used to develop interventions that may improve information sharing among clinicians, patients and caregivers during care transitions to ensure patient reintegration into prior living environments, potentially preventing unplanned hospital readmissions.

Impact of the raising immunizations safely and effectively (RISE) program on healthcare worker influenza immunization rates in long term care settings

INTRODUCTION AND RATIONALE

National influenza immunization rates for healthcare workers (HCW) in long-term care (LTC) remain unacceptably low. This poses a serious public health threat to residents. Prior work has suggested high staff turnover rates as a contributing factor to low immunization rates. There is a critical need to identify and deploy successful models of HCW influenza immunization programs to LTC facilities. This report describes one potential model that has been successfully initiated in a network of LTC facilities.

METHODS

All facilities served by a single regional LTC pharmacy were invited to participate in a HCW influenza immunization program. This voluntary immunization program began in 2005 and continues to the present. As part of the program, the pharmacy promoted organizational change by assuming oversight and control of HCW immunization policies and processes for all facilities. Primary and secondary outcomes are the number of facilities reaching HCW influenza immunization rates of 60% and 80%.

RESULTS

Fourteen of the 16 LTC facilities participated. Facilities were diverse and included both nursing and assisted living facilities; unionized and nonunionized facilities; and urban, suburban, and rural facilities. The pharmacy provided educational and communication materials, centralized data collection using a standardized definition for HCW immunization rates, and facility feedback. All 14 LTC facilities achieved the primary goal of 60% and nearly two thirds reached the secondary goal of 80%. Twenty percent reached the new Healthy People 2020 goal of 90%.

CONCLUSION

It is possible for LTC facilities to improve HCW immunization rates using a pharmacy based, voluntary HCW influenza immunization approach. Such an approach may help attenuate the negative influence of staff turnover on HCW immunizations. Attainment of the new Health People 2020 goals still remains a challenge and may require mandatory programs.

Clinical decision support to promote safe prescribing to women of reproductive age: a cluster-randomized trial

BACKGROUND

Potentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.

OBJECTIVE

To evaluate whether computerized clinical decision support (CDS) can increase primary care providers' (PCPs') provision of family planning services when prescribing potentially teratogenic medications.

DESIGN

Cluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.

PARTICIPANTS/INTERVENTIONS

Forty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The 'simple' CDS provided a cautionary alert; the 'multifaceted' CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.

MAIN MEASURES

We assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.

KEY RESULTS

Both CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.

CONCLUSIONS

CDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Information primary care physicians want to receive about their hospitalized patients

BACKGROUND AND OBJECTIVES

Communication between physicians caring for hospitalized patients and those patients' primary care providers (PCPs) is often suboptimal, which can lead to diminished health care quality and safety. It is unclear what hospital information PCPs would find most valuable in their patients' continuing care, as is how and when they would prefer to receive such information.

METHODS

Using the modified Delphi survey methodology, we developed a consensus list of information items PCPs want to receive about their hospitalized patients, using general internists and family physicians considered experts in primary care. Panelists rated items on a 5-point Likert scale signifying their level of agreement with the information's importance and with the information communication mode. Consensus agreement or disagreement was determined using 95% confidence intervals.

RESULTS

Twelve physicians (five family physicians, seven general internists), averaging 19.6 years of primary care experience, participated in Delphi round 1; 41.6% (37 of 89) of the items were accepted by consensus, one item was rejected (receiving daily progress notes), and the remaining 51 items were equivocal. In round 2, nine physician panelists participated (four family physicians, five general internists), and six additional items were accepted. They generally preferred notification at the patient's first hospital interaction and at discharge. No consensus was found regarding communication mode; e-mail was most favored.

CONCLUSIONS

We found broad areas of consensus regarding information PCPs wish to receive about their hospitalized patients that are generally consistent with previous surveys. Our findings also suggest that physicians are becoming more comfortable with patient-related electronic communications.

A review of the effectiveness of antidepressant medications for depressed nursing home residents

BACKGROUND

Antidepressant medications are the most common psychopharmacologic therapy used to treat depressed nursing home (NH) residents. Despite a significant increase in the rate of antidepressant prescribing over the past several decades, little is known about the effectiveness of these agents in the NH population.

OBJECTIVE

To conduct a systematic review of the literature to examine and compare the effectiveness of antidepressant medications for treating major depressive symptoms in elderly NH residents.

METHODS

The following databases were searched with searches completed prior to January 2011 and no language restriction: MEDLINE, Embase, PsycINFO, CINHAL, CENTRAL, LILACS, ClinicalTrials.gov, International Standard Randomized Controlled Trial Number Register, and the WHO International Clinical Trial Registry Platform. Additional studies were identified from citations in evidence-based guidelines and reviews as well as book chapters on geriatric depression and pharmacotherapy from several clinical references. Studies were included if they described a clinical trial that assessed the effectiveness of any currently-marketed antidepressant for adults aged 65 years or older, who resided in the NH, and were diagnosed by DSM criteria and/or standardized validated screening instruments with Major Depressive Disorder, minor depression, dysthymic disorder, or Depression in Alzheimer's disease.

RESULTS

A total of eleven studies, including four randomized and seven non-randomized open-label trials, met all inclusion and exclusion criteria. It was not feasible to conduct a meta-analysis because the studies were heterogeneous in terms of study design, operational definitions of depression, participant characteristics, pharmacologic interventions, and outcome measures. Of the four randomized trials, two had a control group and did not demonstrate a statistically-significant benefit for antidepressant pharmacotherapy over placebo. While six of the seven non-randomized studies identified a response to an antidepressant, their results must be interpreted with caution as they lacked a comparison group.

CONCLUSIONS

The limited amount of evidence from randomized and non-randomized open-label trials suggests that depressed NH residents have a modest response to antidepressant medications. Further research using rigorous study designs are needed to examine the effectiveness and safety of antidepressants in depressed NH residents, and to determine the various facility, provider, and patient factors associated with response to treatment.

Year in review: medication mishaps in the elderly

OBJECTIVE

This paper reviews articles from 2010 that examined medication mishaps (ie, medication errors and adverse drug events [ADEs]) in the elderly.

METHODS

The MEDLINE and EMBASE databases were searched for English-language articles published in 2010 using a combination of search terms including medication errors, medication adherence, medication compliance, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failures, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Five studies of note were selected for annotation and critique. From the literature search, this paper also generated a selected bibliography of manuscripts published in 2010 (excluding those previously published in the American Journal of Geriatric Pharmacotherapy or by one of the authors) that address various types of medication errors and ADEs in the elderly.

RESULTS

Three studies focused on types of medication errors. One study examined underuse (due to prescribing) as a type of medication error. This before-and-after study from the Netherlands reported that those who received comprehensive geriatric assessments had a reduction in the rate of undertreatment of chronic conditions by over one third (from 32.9% to 22.3%, P < 0.05). A second study focused on reducing medication errors due to the prescribing of potentially inappropriate medications. This quasi-experimental study found that a computerized provider order entry clinical decision support system decreased the number of potentially inappropriate medications ordered for patients ≥ 65 years of age who were hospitalized (11.56 before to 9.94 orders per day after, P < 0.001). The third medication error study was a cross-sectional phone survey of managed-care elders, which found that more blacks than whites had low antihypertensive medication adherence as per a self-reported measure (18.4% vs 12.3%, respectively; P < 0.001). Moreover, blacks used more complementary and alternative medicine (CAM) than whites for the treatment of hypertension (30.5% vs 24.7%, respectively; P = 0.005). In multivariable analyses stratified by race, blacks who used CAM were more likely than those who did not to have low antihypertensive medication adherence (prevalence rate ratio = 1.56; 95% CI, 1.14-2.15; P = 0.006). The remaining two studies addressed some form of medication-related adverse patient events. A case-control study of Medicare Advantage patients revealed for the first time that the use of skeletal muscle relaxants was associated significantly with an increased fracture risk (adjusted odds ratio = 1.40; 95% CI, 1.15-1.72; P < 0.001). This increased risk was even more pronounced with the concomitant use of benzodiazepines. Finally, a randomized controlled trial across 16 centers in France used a 1-week educational intervention about high-risk medications and ADEs directed at rehabilitation health care teams. Results indicated that the rate of ADEs in the intervention group was lower than that in the usual care group (22% vs 36%, respectively, P = 0.004).

CONCLUSION

Information from these studies may advance health professionals' understanding of medication errors and ADEs and may help guide research and clinical practices in years to come.

Prevalence of potentially preventable unplanned hospitalizations caused by therapeutic failures and adverse drug withdrawal events among older veterans

Background. Studies of drug-related hospitalizations have focused on adverse drug reactions, but few data are available on therapeutic failures (TFs) and adverse drug withdrawal events (ADWEs) leading to hospitalization among community-dwelling older adults. Thus, we sought to describe the prevalence of unplanned hospitalizations caused by TFs and ADWEs. In addition, we evaluated factors associated with these events in a nationally representative sample of older Veterans. Methods. This study included 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between December 1, 2003, and November 9, 2006. The main outcomes were hospitalizations caused by a TF and/or an ADWE as determined by a pair of health professionals from review of medication charts and application of the Therapeutic Failure Questionnaire and/or Naranjo ADWE algorithm, respectively. Preventability (ie, medication error) of the admission was also assessed. Results. Thirty-four TFs and eight ADWEs involving 54 drugs were associated with 40 (5.9%) Veterans' hospitalizations; of these admissions, 90.0% (36/40) were rated as potentially preventable mostly due to medication nonadherence and suboptimal prescribing. The most common TFs that occurred were heart failure exacerbations (n = 8), coronary heart disease symptoms (n = 6), tachyarrhythmias (n = 3), and chronic obstructive pulmonary disease exacerbations (n = 3). Half (4/8) of the ADWEs that occurred were cardiovascular in nature. Multivariable logistic regression modeling indicated that black Veterans (adjusted odds ratio 2.92, 95% CI 1.25-6.80) were significantly more likely to experience a TF-related admission compared with white Veterans. Conclusions. TF-related unplanned hospitalizations occur more frequently than ADWE-related admissions among older Veterans. Almost all TFs and/or ADWEs are potentially preventable.

Age-related changes in antidepressant pharmacokinetics and potential drug-drug interactions: a comparison of evidence-based literature and package insert information

BACKGROUND

Antidepressants are among the most commonly prescribed psychotropic agents for older patients. Little is known about the best source of pharmacotherapy information to consult about key factors necessary to safely prescribe these medications to older patients.

OBJECTIVE

The objective of this study was to synthesize and contrast information in the package insert (PI) with information found in the scientific literature about age-related changes of antidepressants in systemic clearance and potential pharmacokinetic drug-drug interactions (DDIs).

METHODS

A comprehensive search of two databases (MEDLINE and EMBASE from January 1, 1975 to September 30, 2011) with the use of a combination of search terms (antidepressants, pharmacokinetics, and drug interactions) was conducted to identify relevant English language articles. This information was independently reviewed by two researchers and synthesized into tables. These same two researchers examined the most up-to-date PIs for the 26 agents available at the time of the study to abstract quantitative information about age-related decline in systemic clearance and potential DDIs. The agreement between the two information sources was tested with κ statistics.

RESULTS

The literature reported age-related clearance changes for 13 antidepressants, whereas the PIs only had evidence about 4 antidepressants (κ < 0.4). Similarly, the literature identified 45 medications that could potentially interact with a specific antidepressant, whereas the PIs only provided evidence about 12 potential medication-antidepressant DDIs (κ < 0.4).

CONCLUSION

The evidence-based literature compared with PIs is the most complete pharmacotherapy information source about both age-related clearance changes and pharmacokinetic DDIs with antidepressants. Future rigorously designed observational studies are needed to examine the combined risk of antidepressants with age-related decline in clearance and potential DDIs on important health outcomes such as falls and fractures in older patients.

Prevalence of unplanned hospitalizations caused by adverse drug reactions in older veterans

OBJECTIVES

To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics.

DESIGN

Retrospective cohort.

SETTING

Veterans Affairs Medical Centers.

PARTICIPANTS

Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006.

MEASUREMENTS

Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications).

RESULTS

Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively).

CONCLUSION

ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.

The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials

OBJECTIVE

The US Agency for Healthcare Research and Quality funded an evidence report to address seven questions on multiple aspects of the effectiveness of medication management information technology (MMIT) and its components (prescribing, order communication, dispensing, administering, and monitoring).

MATERIALS AND METHODS

Medline and 11 other databases without language or date limitations to mid-2010. Randomized controlled trials (RCTs) assessing integrated MMIT were selected by two independent reviewers. Reviewers assessed study quality and extracted data. Senior staff checked accuracy.

RESULTS

Most of the 87 RCTs focused on clinical decision support and computerized provider order entry systems, were performed in hospitals and clinics, included primarily physicians and sometimes nurses but not other health professionals, and studied process changes related to prescribing and monitoring medication. Processes of care improved for prescribing and monitoring mostly in hospital settings, but the few studies measuring clinical outcomes showed small or no improvements. Studies were performed most frequently in the USA (n=63), Europe (n=16), and Canada (n=6).

DISCUSSION

Many studies had limited description of systems, installations, institutions, and targets of the intervention. Problems with methods and analyses were also found. Few studies addressed order communication, dispensing, or administering, non-physician prescribers or pharmacists and their MMIT tools, or patients and caregivers. Other study methods are also needed to completely understand the effects of MMIT.

CONCLUSIONS

Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.

Alcohol Misuse and Abuse Reported by Nurse Aides in Assisted Living

Alcohol misuse and abuse in Assisted Living (AL) as reported by nurse aides is examined. Data came from a secondary analysis of nurse aides included in the Pennsylvania nurse aide registry. A total of 832 nurse aides had a prior place of employment in AL. Information reported from these nurse aides include the percent of residents identified as drinking alcohol, opinions of alcohol misuse and abuse, and the prevalence of alcohol misuse and abuse. Nurse aides believe a majority (69%) of AL residents drink alcohol. Of these residents, 34% are thought to drink alcohol daily. Estimated prevalence rates show that in 19% of cases nurse aides believe alcohol consumption has influenced residents’ health and 28% are suspected to make poor choices for alcohol consumption. The findings present preliminary evidence that alcohol misuse and abuse may be a problem of importance in AL. Given the potential impact of this on the health, safety, and quality of life for elders, more attention should be focused on alcohol misuse and abuse by residents living in AL.