Subtypes of potentially inappropriate medications in older Chinese-Americans during care transitions: Cross sectional retrospective study

Background

The number of Chinese Americans is growing and nearly 20% of older Chinese-American home care patients have at least one potentially inappropriate medications (PIMs) prescribed at hospital discharge. Further examination of PIMs during care transition is warranted, especially among older Chinese-Americans.

Objectives

To describe, during care transitions from hospital to home care: (i) the subtypes of PIMs, (ii) the difference of PIM prevalence prescribed at hospital discharge as compared to home care admission, (iii) the relationship between subtypes of PIMs, and (iv) issues affecting medication reconciliation among older Chinese-Americans.

Methods

This cross-sectional, retrospective study was conducted in a large urban home care agency from June 2010 to July 2011. From data collected by in-home survey and chart abstraction, PIMs were identified using 2002 diagnosis-independent Beers criteria. The difference of PIM prevalence at hospital discharge and at home care admission was analyzed by Wilcoxon Signed Ranks test. The relationship between subtypes of PIMs was evaluated using Phi coefficient.

Participants

82 older (age 65 years and above) Chinese-American home care patients following recent hospital discharge.

Results

3.38% (22) and another 3.72% (28) of prescribed medications were identified as PIMs at hospital discharge and home care admission, respectively. There was no statistically significant difference in PIM prevalence identified at hospital discharge and at homecare admission (z = −1.732, p = .083). PIMs included: long-term use of stimulant laxatives and high-dosages of ferrous sulfate, and a significant relationship between these two PIMS (r = .224, p = .04). More than 80% (n = 65) of study participants reported low education levels and limited English proficiency.

Conclusions

Subtypes of PIMs were ordered during the post-hospital transfers, indicating the necessity to review the appropriateness of medications during this transition. Guidelines such as Beer's criteria regarding appropriateness of medications should be incorporated in medication reconciliation before adding new medications to treat the older adult's health problems. The medication management process needs to be both culturally sensitive and adapted to literacy level; validating the patients’ full understanding of their medications is paramount.     

Physician perspective on propoxyphene as a potentially inappropriate medication in Tennessee

Medicare Part D data from the Quality Improvement Organization's 9th Statement of Work drug safety indicator project under the direction of the Centers for Medicare & Medicaid Services define the potentially inappropriate medications (PIMs) list for Tennessee. These data reveal propoxyphene as the main contributor to the state's PIM rate. In Tennessee, PIM and drug-drug interaction (DDI) rates indicate propoxyphene as the most prescribed medication among elderly patients despite decades of attention for potentially adverse effects. During this project, physicians agreed that PIM rates are too high, but disagreed in approach preference, i.e., administrative limits and bans versus a proactive educational approach. Physicians were interested in participating in quality improvement by using individual pharmacy data to influence prescribing patterns. Exploring alternatives in research and survey, a potential and reachable point of intervention was found, a prescribing paradigm proposed by researchers to improve outcomes by reducing adverse effects in minimizing PIMs and DDIs.     

Inappropriate prescribing in older residents of Australian care homes

What is known and objective: The incidence of inappropriate prescribing is higher amongst the older age group than the younger population. Inappropriate prescribing potentially leads to drug‐related problems such as adverse drug reactions. We aimed to determine the prevalence of inappropriate prescribing in residents of Tasmanian (Australia) residential care homes using Beers and McLeod criteria. Methods: Patient demographics, medical conditions and medications were collected from medical records. The patients who fulfilled either Beers or McLeod criteria were identified and the characteristics of these patients were then compared. Results: Data for 2345 residents were collected between 2006 and 2007. There were 1027 (43·8%) patients prescribed at least one inappropriate medication. Beers criteria identified more patients (828 patients, 35·3%) as being prescribed inappropriate medication compared with McLeod criteria (438 patients, 18·7%). Patients taking psychotropic medication/s, more than six medications or diagnosed with five or more medical conditions were more likely to be prescribed an inappropriate medication (P < 0·001). The most frequently identified inappropriate medications included benzodiazepines, amitriptyline, oxybutynin and non‐steroidal anti‐inflammatory drugs. What is new and conclusion: Inappropriate prescribing, as defined by either Beers criteria or McLeod criteria, is relatively common in Australian nursing homes. The prevalence of inappropriate prescribing, and factors influencing it, are consistent with other countries. Both Beers and McLeod criteria are a general guide to prescribing, and do not substitute for professional judgment.     

Medication Discrepancy and Potentially Inappropriate Medication in Older Chinese-American Home-Care Patients After Hospital Discharge

BackgroundStudies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investigated potential inappropriate medications (PIMs) and medication discrepancies (MDs) among older Chinese Americans during care transitions from hospital discharge to home care.ObjectiveThe aims of this study were to examine, in older Chinese Americans, the prevalence of both PIMs and MDs; the relationship between PIMs and MDs; and the patient and hospitalization characteristics associated with them during care transitions from hospital discharge to home care.MethodsThis cross-sectional study was conducted with a sample of older Chinese Americans from a large certified nonprofit home-care agency in New York City from June 2010 to July 2011. PIMs were identified by using 2002 diagnosis-independent Beers criteria. MDs were identified by comparing the differences between hospital discharge medication order and home-care admission medication order. Prevalence of PIMs and MDs and their relationship was determined. Logistic regression examined the relationship between hospitalization and patient characteristics with PIMs and MDs.ResultsThe sample consisted of 82 older Chinese-American home-care patients. Twenty (24.3%) study participants were prescribed at least one PIM at hospital discharge. Fifty-one (67.1%) study participants experienced at least one MD. A positive correlation was found between the occurrence of PIMs and MDs (r = 0.22; P = 0.05). Number of medications was the only significant factor associated with both PIMs and MDs. In addition, older age and more hospitalization days were associated with PIMs.ConclusionsThe evident prevalence of PIMs and MDs supports the practice of evaluating the appropriateness of medications while reconciling inconsistencies in medication regimens. The number of medications was the only factor associated with both PIMs and MDs, underscoring the need to address polypharmacy as a multifaceted threat to patient health.     

Potentially Inappropriate Medication Utilization in the Emergency Department Visits by Older Adults: Analysis From a Nationally Representative Sample

Objectives: The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage. Methods: The data examined during the study were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS). This study utilized the nationally representative ED data from 2000–2006 NHAMCS surveys. Our sample included older adults (age 65 years and greater) who were treated in the ED and discharged home. Estimated frequencies of PIM‐associated ED visits were calculated. A multivariable logistic regression model was created to assess demographic, clinical, and hospital factors associated with PIM administration and to assess temporal trends. Results: Approximately 19.5 million patients, or 16.8% (95% confidence interval [CI] = 16.1% to 17.4%) of eligible ED visits, were associated with one or more PIMs. The five most common PIMs were promethazine, ketorolac, propoxyphene, meperidine, and diphenhydramine. The total number of medications prescribed or administered during the ED visit was most strongly associated with PIM use. Other covariates associated with PIM use included rural location outside of the Northeast, being seen by a staff physician only (and not by a resident or intern), presenting with an injury, and the combination of female sex and age 65–74 years. There was a small but significant decrease in the proportion of visits associated with a PIM over the study period. Conclusions: Potentially inappropriate medication administration in the ED remains common. Given rising concerns about preventable complications of medical care, this area may be of high priority for intervention. Substantial regional and hospital type (teaching versus nonteaching) variability appears to exist. ACADEMIC EMERGENCY MEDICINE 2010; 17:231–237 © 2010 by the Society for Academic Emergency Medicine     

Potentially inappropriate medication prescribing in outpatient practices: Prevalence and patient characteristics based on electronic health records

Background: Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria.Objectives: The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists.Methods: This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged ≥65 years at the time of the last office visit and had ≥2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria.Results: Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria (P < 0.001), these values were 6036 (16.2%) and 4160 (17.3%). Eight of the most common PIMs were the same at both institutions, with propoxyphene and fluoxetine (once daily) being the most prescribed. Female sex, polypharmacy (≥6 medications), and multiple primary care visits were significantly associated with PIM prescribing.Conclusions: In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.     

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.     

Potentially inappropriate medication use in elderly Japanese patients

Background: Modified Beers criteria for elderly Japanese patients were developed in 2008 by consensus among 9 experts to reflect regional clinical practice and available medications in Japan. Since then, many physicians and pharmacists have expressed interest in obtaining more information about the criteria and alternative drug choices.Objective: This study examined the incidence, health care utilization, and costs associated with potentially inappropriate medications (PIMs) in elderly patients based on the modified Beers criteria.Methods: A retrospective, observational cohort study was conducted using health insurance claims data in Japan. The study population included elderly patients aged ≥65 years who had at least 2 pharmacy claims in separate months over a 1-year period (April 2006 through March 2007). Use of the PIMs was identified using the modified criteria, and 1-year incidence rates were calculated for the total study population and for subgroups stratified by age and sex. A logistic regression model was used to examine demographic and clinical characteristics associated with PIMs. Health care utilization rates and costs were also analyzed and compared between patients with and without PIMs using generalized linear models. All models included dummy variables indicating age category, female sex, hospitalization, polypharmacy, index month, and number of Elixhauser comorbidities to adjust for potential confounders.Results: Among 6628 elderly patients, 71.2% (4721/6628) were female and 62.9% (4167/6628) were aged 65 to 74 years; 43.6% (2889/6628) were prescribed at least one PIM. The most commonly used PIMs were histamine-2 blockers (20.5% [1356/6628]), benzodiazepines (11.4% [756/6628]), and anticholinergics and antihistamines (7.9% [526/6628]). No significant differences in incidence rates were observed based on age or sex. Inpatient service use, polypharmacy, and comorbidities of peptic ulcer, depression, and cardiac arrhythmias were significant predictors of PIM use while controlling for other factors. PIM users had significantly higher hospitalization risk (1.68-fold), more outpatient visit days (1.18-fold), and higher medical costs (33% increase) than did nonusers.Conclusions: In a group of elderly Japanese patients, 43.6% used at least one PIM over a 1-year period in this study. PIM use was associated with greater health care utilization rates and costs.     

Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults

BACKGROUND: Adverse events from inappropriate medications are preventable risk factors for nursing home admissions. OBJECTIVE: We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home. METHODS: A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months. RESULTS: Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26-1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20-2.47) for inappropriate narcotics and 2.68 (99% CI 2.55-2.82) for other narcotics, compared with no narcotic use. CONCLUSION: Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.