Prescribing patterns and predictors of high-level polypharmacy in the elderly population: A prospective surveillance study from two teaching hospitals in India

Background: Polypharmacy has been reported to increase the risks for inappropriate prescribing, adverse drug reactions, geriatric syndromes, and morbidity and mortality in elderly populations in the United States and Europe. Data on prescribing patterns and polypharmacy in the elderly population in India are limited.Objectives: The aims of this study were to assess prescribing patterns and to determine the predictors of high-level polypharmacy in the elderly population in 2 tertiary care hospitals in India.Methods: This prospective surveillance study used medical records from patients aged 60 to 95 years admitted to the medicine wards of the 2 tertiary care hospitals between January 2008 and June 2009. Data on medication prescribing from admission through discharge were reviewed. Diseases were coded using the World Health Organization (WHO) International Classification of Diseases, 10th Revision, and medications were coded using the WHO Anatomical, Therapeutic, and Chemical classification. Concordance of prescribing with the indications in the product labeling as listed in the American Hospital Formulary Services Drug Information 2007 was determined. The prevalences of polypharmacy (5–9 medications) and high-level polypharmacy (≥10 medications) were determined. Bivariate analysis and multivariate logistic regression analysis were used to determine the influential predictors of high-level polypharmacy during hospital stays.Results: Data from 814 patients were included (493 [60.6%] men, 321 [39.4%] women; median age, 66 years [range, 60–95 years]). Systemic antibacterials were the most commonly prescribed therapeutic class of medications (574 [70.5%]), and pantoprazole was the most commonly prescribed medication (498 [61.2%]). The majority (7/10 [70.0%]) of the most commonly prescribed medications were prescribed as indicated. Medications prescribed “off-label” included pantoprazole (432/498 [86.7%]), ceftriaxone (212/259 [81.9%]), and atorvastatin (109/237 [46.0%]). Polypharmacy and high-level polypharmacy were prescribed in 366 (45.0%) and 370 (45.5%) patients, respectively. On multivariate logistic regression analysis, multiple (≥3) diagnoses (odds ratio [OR] = 1.55; 95% CI, 1.16–2.08; P = 0.003), angina pectoris (OR = 2.58; 95% CI, 1.50–4.37; P < 0.001), and a length of stay ≥10 days (10–<15 days, OR = 3.14; 95% CI, 2.09–4.71; P < 0.001; and ≥15 days, OR = 5.74; 95% CI, 2.43–13.51; P < 0.001) were found to be predictors of high-level polypharmacy during hospital stays.Conclusions: The campaign for rational drug use in hospitalized elderly patients in India should promote pantoprazole, ceftriaxone, and atorvastatin prescribing in concordance with their indications. Interventions to reduce the high-level polypharmacy in the elderly during their stays in tertiary care hospitals in India should focus on patients with ≥3 diagnoses, angina pectoris, and/or ≥10 days of hospital stay.     

Osteoporosis pharmacotherapy and counseling services in US ambulatory care clinics: Opportunities for multidisciplinary interventions

Objective: This study was conducted to assess rates and predictors of osteoporosis management with medication or nonmedication therapy, and to compare rates of medication and nonmedication therapy in office-based and hospital-based ambulatory care settings in the United States.Methods: This cross-sectional study included data on all ambulatory office visits made by patients aged ≥60 years in 2000-2005 in 2 national survey databases representing US ambulatory clinics. Visits with and without a record of anti-osteoporosis medication were identified, and bivariate and multivariate analyses were performed to determine predictive factors for receipt of medication or nonmedication therapy for the prevention and treatment of osteoporosis.Results: During 2000-2005, visits by patients with a diagnosis of osteoporosis or fragility fracture represented <2% of all visits in office- and hospital-based ambulatory care settings. Medication therapy for osteoporosis was documented in 53.2% of these visits, and nonmedication therapy was documented in 31.5%. The most frequently prescribed drug class was bisphosphonates (36.0%), followed by calcium and vitamin D supplementation (23.9%). The most commonly used nonmedication therapies were exercise (16.7%) and diet/nutrition counseling (19.4%). Rates of medication therapy did not differ significantly by ambulatory care setting. However, visits to hospital-based clinics were significantly less likely than visits to office-based clinics to involve nonmedication therapy (adjusted odds ratio [OR] = 0.6; 95% CI, 0.5-0.9; P = 0.004). Compared with visits by women, visits by men were significantly less likely to involve medication therapy (adjusted OR = 0.6; 95% CI, 0.4–0.9; P = 0.013), nonmedication therapy (adjusted OR = 0.3; 95% CI, 0.2–0.6; P < 0.001), or any therapy (adjusted OR = 0.4; 95% CI, 0.3–0.6; P<0.001). Patients aged ≥80 years were significantly less likely to receive nonmedication therapy than were those aged 60 to 69 years (adjusted OR = 0.6; 95% CI, 0.4–0.9; P = 0.023). Visits by patients with public insurance were significantly less likely to involve medication therapy than visits by patients with other sources of payment (adjusted OR = 0.7; 95% CI, 0.5–1.0; P = 0.040). No difference in the prevalence of any type of therapy was observed in relation to race.Conclusions: Based on the prevalence of medication and nonmedication therapies, levels of osteoporosis care did not differ by ambulatory care setting. However, patterns of care varied by certain visit characteristics, including insurance type, age, and sex.     

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies

Background: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital).Objective: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences.Methods: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences.Results: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had ≥1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17–29); 19% (95% CI, 11–31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01–1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13–643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40–7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had ≥1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37–51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7–18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences.Conclusions: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.     

Determinants of antidepressant medication prescribing in elderly residents of aged care homes in Australia: A retrospective study

Background: Depression is underrecognized and poorly treated among older people living in aged care homes worldwide. Depression has been associated with higher rates of recurrence, disability, and death in older people.Objectives: The primary objective of this study was to assess the determinants of antidepressant medication prescribing among older people living in aged care homes in Australia. A further objective was to investigate the anti-depressant medications in common use, doses of antidepressants, and concurrent pharmacotherapy among people receiving antidepressants.Methods: A random sample of 500 deidentified medication review reports was extracted from a database containing >165,000 Residential Medication Management Review reports. Residents' demographic and clinical characteristics, medical diagnoses, and prescribed medications were systematically extracted from these reports. Logistic regression models were used to determine factors associated with the prescribing of any antidepressant, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and “other” antidepressants (eg, mianserin, mirtazapine, venlafaxine).Results: The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five percent were female. The prevalence of antidepressant prescribing among these aged care home residents was 33.0%. SSRIs were more commonly prescribed than TCAs, monoamine oxidase inhibitors, and other antidepressants. Antidepressants were more likely to be prescribed in people treated for dementia with mood disorder (odds ratio [OR] = 9.70; 95% CI, 5.26–17.88), depression (OR = 13.28; 95% CI, 6.44–27.36), and Parkinson's disease (OR = 3.56; 95% CI, 1.37–9.23). SSRI prescribing was associated with dementia with mood disorder (OR = 5.85; 95% CI, 3.19–10.72) and depression (OR = 6.44; 95% CI, 3.38–12.26). TCA prescribing was associated with depression (OR = 2.95; 95% CI, 1.18–7.35) and concurrent benzodiazepine use (OR = 2.43; 95% CI, 1.03–5.72). Other antidepressant prescribing was associated with dementia with mood disorder (OR = 6.53; 95% CI, 3.15–13.50) and depression (OR = 5.00; 95% CI, 2.23–11.19).Conclusions: There was preferential prescribing of SSRI antidepressants among these older aged care home residents with depression. Cognitive impairment alone was not significantly associated with antidepressant prescribing; however, these aged care home residents with dementia and mood disorders had an increased likelihood of being treated with antidepressants. The prescribing of TCAs was significantly associated with concurrent benzodiazepine use.     

Antipsychotic use at adult ambulatory care visits by patients with mental health disorders in the United States, 1996-2003: national estimates and associated factors

OBJECTIVES: This retrospective analysis was conducted to derive national estimates of typical, atypical, and combination (typical-atypical) antipsychotic use and to examine factors associated with their use at adult (age >-18 years) ambulatory care visits by patients with mental health disorders in the United States. METHODS: Data on adult visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a mental health disorder were extracted from the office-based National Ambulatory Medical Care Survey and the outpatient facilitybased National Hospital Ambulatory Medical Care Survey from 1996 through 2003. The visits were categorized according to whether use of a typical, atypical, or combination antipsychotic was mentioned (either prescribed, supplied, administered, ordered, or continued at the visits). Total weighted visit estimates, weighted visit percentages, and 95% CIs were calculated across the 3 types of visit groups. Bivariate analysis was performed on the association between selected characteristics and the 3 visit groups. Multivariate logistic regression was performed on factors associated with atypical versus typical antipsychotic use. RESULTS: During the 8-year period, there were an estimated 47.7 million adult ambulatory care visits involving a mental health disorder and mention of an antipsychotic (weighted percent: 0.83%; 95% CI, 0.73-0.93). From 1996/1997 to 2002/2003, visits involving atypical and combination antipsychotics increased by 195% and 149%, respectively, and visits involving typical antipsychotics decreased by 71%. Men, blacks, and those with public insurance made more visits in which combination antipsychotics rather than typical or atypical antipsychotics were mentioned. Relative to typical or combination antipsychotic visits, more atypical antipsychotic visits involved antide-pressants (weighted percent: 61.23% atypical, 37.29% typical, and 38.32% combination). Fewer atypical antipsychotic visits compared with typical or combination antipsychotic visits involved psychotic disorders (weighted percent: 32.94%, 51.23%, and 69.93%, respectively) and medications for extrapyramidal symptoms (weighted percent: 6.69%, 29.95%, and 36.64%). In multivariate analyses controlling for sex, race, diagnosis of schizophrenia, region, diagnosis of anxiety, and recent years, atypical versus typical antipsychotic use was significantly less likely at visits by those aged 41 to 64 years compared with those aged 18 to 40 years (adjusted odds ratio [OR] = 0.63; 95% CI, 0.47-0.84; P = 0.002); significantly less likely at visits by those with public compared with private insurance (Medicare OR = 0.59 [95% CI, 0.40-0.88], P = 0.010; Medicaid OR = 0.44 [95% CI, 0.28-0.69], P < 0.001); and significantly more likely at visits associated with depression compared with those not associated with depression (OR = 1.92; 95% CI, 1.26-2.93; P = 0.003) and those associated with bipolar disorder compared with those not associated with bipolar disorder (OR = 2.10; 95% CI, 1.32-3.36; P = 0.002). CONCLUSIONS: This retrospective analysis found more atypical than typical or combination antipsychotic use at US ambulatory care visits by adults with mental health disorders other than schizophrenia or psychoses in the period studied. Atypical versus typical antipsychotic use was significantly less likely at visits by adults aged 41 to 64 years and those with public insurance, but significantly more likely at visits by those with depression or bipolar disorder.     

Opioid prescriptions by U.S. primary care physicians from 1992 to 2001.

Little is known about primary care physicians' (PCPs) prescribing of opioids. We describe trends and factors associated with opioid prescribing during PCP visits over the past decade. Using the National Ambulatory Medical Care Survey, we found an opioid prescribed in 2,206 (5%) PCP visits from 1992 to 2001. The prevalence of visits where an opioid was prescribed increased from a low of 41 per 1000 visits in 1992-1993 to a peak of 63 per 1000 in 1998-1999 (P < .0001 for trend) and then stabilized (59 per 1000 in 2000-2001). Several factors increased the odds of receiving an opioid: having Medicaid (odds ratio [OR] 2.09 [95% confidence interval (CI) 1.82-2.40]) or Medicare (OR 2.00 [95% CI 1.68-2.39]); having a visit between 15 and 35 minutes (OR 1.16 [95% CI 1.05-1.27]); and receiving an NSAID (OR 2.27 [95% CI 2.04-2.53]). Patients of hispanic (OR .67 [95% CI .56-.81]) or other race/ethnicity (OR .68 [95% CI .52-.90]), patients in health maintenance organizations (OR .74 [95% CI .66-.84]), and those living in the northeast (OR .60 [95% CI .51-.69]) or midwest (OR .75 [95% CI .66-.85]) had lower odds of receiving an opioid. Substantial variation exists in opioid prescribing by PCPs. Now that pain management standards are advocated, understanding the dynamics of opioid prescribing is necessary. PERSPECTIVE: This study describes a decade-long increase in opioid prescribing by U.S. primary care physicians and identifies important geographic-, racial/ethnic-, and insurance-related differences in who receives these medications. Several underlying factors, including regulatory and legal pressures, attitudes and knowledge of opioids, and publicized opioid-related events, may contribute to these differences.     

Polypharmacy in nursing home residents in the United States: Results of the 2004 National Nursing Home Survey

Background: Despite the need for and benefits of medications, polypharmacy (defined here as concurrent use of ≥9 medications) in nursing home residents is a concern. As the number of medications taken increases, so does the risk for adverse events. Monitoring polypharmacy in this population is important and can improve the quality of nursing home care.Objectives: The aims of this article were to estimate the use of polypharmacy in residents of nursing homes in the United States, to examine the associations between select resident and facility characteristics and polypharmacy, and to determine the leading therapeutic subclasses included in the polypharmacy received by these nursing home residents.Methods: This was a retrospective, cross-sectional study of a nationally representative sample of US nursing home residents in 2004; the outcome was use of polypharmacy. The 2004 National Nursing Home Survey was used to collect medication data and other resident and facility information. Resident characteristics included age, sex, race, primary payment source, number of comorbidities, number of activities of daily living (ADLs) for which the resident required assistance, and length of stay (LOS) since admission. Facility characteristics included ownership and size (number of beds).Results: Of 13,507 nursing home residents who received care, 13,403 had valid responses for all 9 independent variables in the analyses. The prevalence of polypharmacy among nursing home residents in 2004 was ~40%. A multiple regression model controlling for resident and facility factors revealed that the odds of receiving polypharmacy were higher for residents who were female (odds ratio [OR] = 1.10; 95% CI, 1.00–1.20), were white, had Medicaid as a primary payer, had >3 comorbidities (OR = 1.57–5.18; 95% CI, 1.36–6.15), needed assistance with <4 ADLs, had an LOS since admission of 3 to <6 months (OR = 1.25; 95% CI, 1.04–1.50), and received care in a small, not- for-profit facility (data not shown for reference levels [OR = 1.00]). The most frequently reported medications for residents who received polypharmacy included gastrointestinal agents (laxatives, 47.5%; agents for acid/peptic disorders, 43.3%), drugs that affect the central nervous system (antidepressants, 46.3%; antipsychotics or antimanics, 25.9%), and pain relievers (nonnarcotic analgesics, 43.6%; antipyretics, 41.2%; antiarthritics, 31.2%).Conclusions: Despite awareness of polypharmacy and its potential consequences in older patients, results of our analysis suggest that polypharmacy remains widespread in US nursing homes. Although complex medication regimens are often necessary for nursing home residents, monitoring polypharmacy and its consequences may improve the quality of nursing home care and reduce unnecessary health care spending related to adverse events.     

Comorbidities,Age, and Polypharmacy Limit the Use by US Older Adults with Nocturia of the Only FDA-approved Drugs for the Symptom

PurposeThe goal of this study was to determine if the US adult population with nocturia (waking from sleep at night to void) can easily take medications (desmopressin acetate) approved by the US Food and Drug Administration for nocturia. The study examined: (1) the prevalence of comorbid conditions, laboratory abnormalities, and concomitant medications that increase risk of desmopressin use; and (2) whether these factors are associated with age or nocturia frequency.MethodsUsing a cross-sectional analysis of four US National Health and Nutrition Examination Survey (NHANES) waves (2005–2012), a total of 4111 participants aged ≥50 years who reported ≥2 nightly episodes of nocturia were identified. The main outcome was frequency of contraindications and drug interactions as described in US Food and Drug Administration–approved prescribing information. These prescribing concerns were matched to examination findings, medical conditions, concomitant medications, and laboratory results of NHANES participants. The associations between prescribing concerns and nocturia severity and age groups were examined.FindingsThe mean participant age was 65.7 years (95% CI, 65.3–66.1), and 45.5% were male. Desmopressin prescribing concerns were present in 80.5% (95% CI, 78.0–82.9) of those ≥50 years of age with nocturia; 50.0% (95% CI, 47.0–53.0) had contraindications, and 41.6% (95% CI, 39.3–44.0) took a concomitant drug that could increase risk of low serum sodium. Desmopressin contraindications were higher with older age (P < 0.001) and present in 73.2% (95% CI, 69.3–77.1) of those ≥80 years of age.ImplicationsUsing NHANES data, this study showed that older US adults with nocturia have a high prevalence of medical conditions, concomitant medications, and baseline laboratory abnormalities that likely increase the risk of potentially severe adverse side effects from desmopressin use. A medication designed and approved for a clinical symptom that is most common in older adults could not be taken by most of the older adults with the symptom.     

Characteristics of Family Physicians Delivering Home Visits: A Canadian Retrospective Cohort Study

ContextHome visits have become increasingly uncommon although evidence suggests they improve healthcare quality and reduce overall expenditures. This study identifies the primary care physicians delivering home visits at patients’ end of life in Ontario, Canada, describes characteristics of primary care physicians delivering end-of-life home visits, and explores associations with delivery.ObjectivesIdentify the primary care physicians delivering home visits at patients' end of life in Ontario, Canada, describe characteristics of primary care physicians delivering end-of-life home visits, and explore associations with delivery.MethodsA retrospective cohort design using population-level health administrative data housed at ICES. The cohort was composed of primary care physicians in Ontario, Canada between April 1, 2014 and March 31, 2019, who were registered in the College of Physicians and Surgeons of Ontario database dataset on or after January 1, 1990 and as of March 31, 2016.ResultsA total of 9884 physicians were identified, of which 2568 (25.7%) delivered at least one end-of-life home visit. Physician characteristics showing increased odds ratio (OR) of home visit delivery were older age (OR 1.01 [95% Confidence Interval (CI): 1.00–1.02]) international training (OR 1.28 [95% CI:1.04–1.59]), previous home visit experience (OR 1.02 [95% CI: 1.01–1.02]), capitation models of remuneration; namely enhanced fee-for-service models (OR 1.5 [95%CI: 1.17–2.00]) and mainly capitation model (OR 1.4 [95% CI:1.11–1.79]), and population size of practice location with highest odds in small rural or remote areas (<9000 residents) (OR 1.38 [95%CI: 1.02–1.88]) and large metropolitan areas (OR 1.84 [95%CI: 1.46–2.57]).ConclusionThis research confirms previous evidence and identifies novel primary care physicians’ characteristics associated with home visit practice patterns. Furthermore, it highlights characteristics amenable to policy or system-level changes (e.g., remuneration model, training, and experience) that could increase the provision of home visits which may greatly improve the dying experience of Canadians.     

Factors influencing the use of potentially inappropriate medication in older patients in Slovakia

Background: Although increasing attention has been given to the evaluation of use of potentially inappropriate medication in the older European Union (EU) member countries, information on this topic from Central and Eastern Europe is scarce. Objectives: The aims of the present study were: to identify risk factors enhancing the probability of use of potentially inappropriate medication in hospitalized older patients under the conditions of the Slovak healthcare system and to compare our results with previously published European studies. Methods: The evaluation was performed in 600 patients aged ≥65 years, hospitalized in a general hospital between 1 December 2003 and 31 March 2005. To identify the use of potentially inappropriate medication, the Beers 2003 criteria were applied. Particular socio‐demographic and clinical characteristics, as well as comorbid medical conditions were evaluated among possible factors enhancing the probability of use of potentially inappropriate medication. Results: At least one potentially inappropriate medication was prescribed to 126 (21%) of 600 patients. Multivariate analysis identified polypharmacy [odds ratio (OR) 2·38; 95% confidence interval (CI): 1·50–3·79], depression (OR 2·03; 95% CI: 1·08–3·82), immobilization (OR 1·87; 95% CI: 1·16–3·00) and heart failure (OR 1·73; 95% CI: 1·13–2·64) as factors associated with an increased risk of use of inappropriate medication. In contrast, patients aged ≥75 years had a lower risk of being prescribed potentially inappropriate medication (OR 0·58; 95% CI: 0·39–0·88). Conclusions: Polypharmacy, immobilization, heart failure and depression were documented as predictors of use of potentially inappropriate medication. In depressive patients, drugs other than antidepressants contributed to the extensive use of potentially inappropriate medication. The observed prevalence of use of potentially inappropriate medication in older hospitalized Slovak patients was lower than the prevalence previously documented in Poland and the Czech Republic, but higher than in Croatia and Turkey. The identified risk factors were consistent with previous findings from other parts of Europe.     

Risk factors for bleeding during anticoagulation of atrial fibrillation in older and younger patients in clinical practice

Background: The prevalence of atrial fibrillation increases with age, affecting ∼5% of people aged >65 years and almost 10% of people aged >80 years.Objective: The goal of this study was to identify risk factors for bleeding during warfarin treatment of nonvalvular atrial fibrillation (NNVAF) in older patients (those aged ≥75 years) compared with younger patients (those aged <75 years) in clinical practice.Methods: All patients with NVAF newly started on warfarin at an anticoagulation clinic in a large university hospital were included in this prospective observational study. Patient details were recorded at their first visit; details of any bleeding events were recorded via telephone interview every 4 to 6 weeks for a minimum of 10 months. Patients were divided into 2 groups (ie, those ≥75 years old and those <75 years old). Logistic regression analysis was used to identify risk factors for bleeding.Results: A total of 402 patients were included in the study. Group I comprised 203 patients <75 years old (mean [SD] age, 64.33 [8.33] years) and group II comprised 199 patients ≥75 years old (mean [SD] age, 80.44 [3.99] years). Follow-up ranged from 1 to 31 months (mean [SD], 19 [8.11] months). For major bleeding, number of medications was a significant risk factor in older patients (odds ratio [OR], 3.0; 95% CI, 1.2–7.8 [P = 0.02 ]) and range of the international normalized ratio (INR) was a significant risk factor in both groups. For every unit increase in the range of INR, the odds of major bleeding increased by 0.6 (OR, 1.6; 95% CI, 1.2–2.4 [P = 0.03 ]) in younger patients and by 0.4 (OR, 1.4; 95% CI, 1.07–1.99 [P = 0.04 ])in older patients. For minor bleeding, history of hypertension was the only significant risk factor in older patients (OR, 3.3; 95% CI, 1.3–8.1 [P = 0.01 ]), while history of ischemic heart disease was the only risk factor in younger patients (OR, 1.9; 95% CI, 1.1–5.4 [P = 0.04 ]).Conclusions: Bleeding pattern was similar in both age groups regarding severity, onset, anatomic site of bleeding, and INR values during the bleeding event. Risk factors for episodes of major bleeding, which are more of a clinical concern, are potentially modifiable. They include quality of anticoagulation control in both groups and number of medications in the older age group.     

Concerns and beliefs about medicines and inappropriate medications: An internet-based survey on risk factors for self-reported adverse drug events among older adults

Background: Adverse drug events (ADEs), which can be especially problematic in older adults, often can be prevented by detecting potential risk factors. Sociopsychological factors such as concerns and beliefs about medicines (patients' anxieties about the harmful effects of prescribed medications) may also be risk factors related to self-reported ADEs, even when considering clinical variables such as receiving an inappropriate medication.Objectives: This study was designed to quantify the use of inappropriate medications among older adult outpatients and to determine whether an association exists between the use of inappropriate medications, concerns and beliefs about medicines, and self-reported ADEs.Methods: This cross-sectional, Internet-based survey of Medicare beneficiaries was conducted in 2007. Harris Interactive®, a New York-based marketing research firm, invited participants from their online panel who were ≥65 years of age, residents of the United States, and enrolled in the Medicare health plan to participate in the survey. The updated Beers criteria and a modified version of the Assessing Care of Vulnerable Elders quality indicators were used to determine the appropriateness of medications. Respondents' concerns about their medicines were assessed using items from a validated scale such as “Having to take medicines worries me” and “I sometimes worry about the long-term effects of my medicines.” To establish self-reported ADEs, respondents were asked, “Did you see a doctor about any side effects, unwanted reactions, or other problems from medicines you were taking in the past year?”Results: Of the 1024 panelists who responded to the survey, 874 provided all of the information required for analysis. The respondents who were included in the analyses ranged in age from 65 to 94 years; 56.6% were female, 94.4% were white, and 20.3% self-reported an ADE. The frequency of patients receiving either an inappropriate medication or a medication that failed a quality indicator was 45.8%. Stronger concerns and beliefs about medicines (odds ratio [OR] = 1.57; 95% CI, 1.02–2.39; P = 0.04) and having more symptoms (OR = 2.26; 95% CI, 1.22–4.22; P = 0.01) were significantly related to self-reporting of ADEs, whereas receiving an inappropriate medication (OR = 1.03; 95% CI, 0.65–1.64) and the number of medications received (OR = 1.28; 95% CI, 0.52–3.13) were not.Conclusions: Stronger concerns and beliefs about medicines and having more symptoms were significantly related to self-reporting of ADEs. Receiving an inappropriate medication and the number of medicines received were not significantly related.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system