Asthma medication use among U.S. adults 18 and older

BackgroundAsthma is a chronic lung disease that currently affects an estimated 25 million Americans. One way to control the disease is by regular use of preventive asthma medications and controlled use of acute medications. However, little is known about adults with asthma and factors associated with their medication use.ObjectiveTo identify factors associated with asthma medication use among U.S. adults aged 18 and older.MethodsData were obtained from the 2006 to 2010 Medical Expenditure Panel Survey (MEPS). Medication use outcome variables include: a) daily use of a preventive asthma medication (yes/no) and b) overuse (3+) of acute inhalers in last 3 months (yes/no). The Andersen Behavioral Model of Health Care was used to guide the selection of independent variables. The independent variables were categorized as predisposing, enabling and medical need factors. Logistic regression models were used to examine the relationship between asthma medication use in adults with asthma. Point estimates were weighted to the U.S. non-institutionalized population, and standard errors were adjusted to account for the complex survey design.ResultsCompared to Whites, minority adults 18 and older were less likely to use preventive asthma medication daily (Hispanic-OR: 0.72, CI: 0.54–0.96; African American-OR: 0.62, CI: 0.51–0.75 respectively). Similarly, Hispanic adults age 18 and older were at a significantly higher likelihood of overusing rescue medications compared to Whites (OR: 1.47, CI: 1.03–2.11). Non-metropolitan adults age 18 and older were more likely to overuse acute asthma medications than those from Metropolitan Statistical Area (OR: 1.57, CI: 1.15–2.16). Compared to older adults age 65 and over, late mid-life 50–64 year old adults were less likely to use a daily preventive asthma medication (OR: 0.67, CI: 0.54–0.83).ConclusionsRace, rurality and age were important factors associated with poor asthma medication use in U.S. adults. Although this is a first step toward identifying factors that may influence the use of asthma medications, future studies are needed to develop and implement interventions to overcome issues to improve asthma care.     

Medication nonadherence and subsequent risk of hospitalisation and mortality among older adults

BACKGROUND: Despite a higher risk for medication nonadherence among older adults residing in the community, few prospective studies have investigated the health outcomes associated with nonadherence in this population or the possible variations in risk in urban versus rural residents. OBJECTIVES: The primary objective of this study was to examine, in a prospective manner, the risk for hospitalisation (including an emergency department visit) and/or mortality associated with medication nonadherence in older, at-risk adults residing in the community. A secondary objective was to examine differences in the prevalence, determinants and consequences of medication nonadherence between rural and urban home care clients. METHODS: Data were derived from a 1-year prospective study of home care clients aged > or =65 years (n = 319) randomly selected from urban and rural settings in southern Alberta, Canada. Trained nurses conducted in-home assessments including a comprehensive medication review, self-report measures of adherence and the Minimum Data Set for Home Care (MDS-HC) tool. Hospitalisation and mortality data during 12-month follow-up were obtained via linkages with regional administrative and vital statistics databases. RESULTS: Nonadherent clients showed an increased but nonsignificant risk for an adverse health outcome (hospitalisation, emergency department visit or death) during follow-up (hazard ratio [adjusted for relevant covariates] = 1.24, 95% CI 0.93, 1.65). Subgroup analyses suggested this risk may be higher for unintentional nonadherence (unadjusted hazard ratio = 1.55, 95% CI 0.97, 2.48). The prevalence of nonadherence was similar among rural (38.2%) and urban (38.9%) clients and was associated with the presence of vision problems, a history of smoking, depressive symptoms, a high drug regimen complexity score, residence in a private home (vs assisted-living setting) and absence of assistance with medication administration. In both settings, approximately 20% of clients received one or more inappropriate medications. CONCLUSIONS: Although not associated with rural/urban residence, medication nonadherence was common in our study population, particularly among those with depressive symptoms and complex medication regimens. The absence of a significant association between overall medication nonadherence and health outcomes may reflect study limitations and/or the need to differentiate among types of nonadherent behaviours.     

Instruments for evaluating medication use and prescribing in older adults

ObjectiveTo describe primarily implicit instruments for assessing medication use in older adults.Data sourcesLiterature was identified via PubMed (1966–2014) and Google Scholar using the following search terms: geriatric/medication use, implicit criteria, inappropriate medication use, inappropriate prescribing, older adults/medication use, and polypharmacy. Reference citations from identified publications were also reviewed.Study selectionAll articles in English identified from data sources were evaluated. Instruments applicable to pharmacy and multiple medication classes were included. We excluded instruments developed for a single medication or medication class, for a single condition or disease state, as primarily an academic instrument, using primarily explicit criteria, for use primarily by health care practitioners other than pharmacists, or for regulatory purposes.Data synthesisSeven instruments were reviewed by evaluating characteristics, components of prescribing and medication use addressed, and settings in which they have been evaluated and validated. Screening Medications in the Older Drug User (SMOG) is a six-question instrument developed specifically for community pharmacists. The Medication Appropriateness Index (MAI); Assess, Review, Minimize, Optimize, Reassess (ARMOR) tool; and Tool to Improve Medications in the Elderly via Review (TIMER) are more comprehensive instruments, but they require clinical judgment and are time intensive. Assessing Care of Vulnerable Elders-3 (ACOVE-3) and the Good Palliative–Geriatric Practice Algorithm (GPGPA) are useful in determining need for medication continuation in older adults who are closer to the end of life. The Assessment of Underutilization (AOU) is an implicit tool to guide medication initiation.ConclusionEach instrument is unique in design, which may be beneficial in some pharmacy practice settings and present barriers in others. The use of multiple instruments may be necessary to optimize therapy in this vulnerable patient population.     

Impact on medication use and adherence of Australian pharmacists' diabetes care services.

OBJECTIVE: To assess the effect of a specialized service implemented in community pharmacies for patients with type 2 diabetes on medication use and medication-related problems. DESIGN: Parallel group, multisite, control versus intervention, repeated measures design, with three different regions in New South Wales, Australia, used as intervention regions, then matched with control regions as much as possible. INTERVENTION: After initial training, pharmacists followed a clinical protocol for more than 9 months, with patient contact approximately monthly. Each patient received an adherence assessment at the beginning and end of the study, adherence support, and a medication review as part of the intervention. MAIN OUTCOME MEASURES: Risk of nonadherence using Brief Medication Questionnaire (BMQ) scores and changes to medication regimen. RESULTS: Compared with 82 control patients, 106 intervention patients with similar demographic and clinical characteristics had significantly improved self-reported nonadherence as reflected in total BMQ scores after 9 months. The mean (+/-SD) number of medications prescribed at follow-up in intervention participants decreased significantly, from 8.2+/-3.0 to 7.7+/-2.7. No reduction was observed among the control patients (7.6+/-2.4 and 7.3+/-2.4). The overall prevalence of changes to the regimen was also significantly higher in the intervention group (51%) compared with controls (40%). CONCLUSION: Community pharmacists trained in medication review and using protocols in collaboration with providers improved adherence in patients with type 2 diabetes, reduced problems patients had in accessing their medications, and recommended medication regimen changes that improved outcomes.     

Usability and feasibility of consumer-facing technology to reduce unsafe medication use by older adults

BackgroundMobile health technology can improve medication safety for older adults, for instance, by educating patients about the risks associated with anticholinergic medication use.ObjectiveThis study's objective was to test the usability and feasibility of Brain Buddy, a consumer-facing mobile health technology designed to inform and empower older adults to consider the risks and benefits of anticholinergics.MethodsTwenty-three primary care patients aged ≥60 years and using anticholinergic medications participated in summative, task-based usability testing of Brain Buddy. Self-report usability was assessed by the System Usability Scale and performance-based usability data were collected for each task through observation. A subset of 17 participants contributed data on feasibility, assessed by self-reported attitudes (feeling informed) and behaviors (speaking to a physician), with confirmation following a physician visit.ResultsOverall usability was acceptable or better, with 100% of participants completing each Brain Buddy task and a mean System Usability Scale score of 78.8, corresponding to “Good” to “Excellent” usability. Observed usability issues included higher rates of errors, hesitations, and need for assistance on three tasks, particularly those requiring data entry. Among participants contributing to feasibility data, 100% felt better informed after using Brain Buddy and 94% planned to speak to their physician about their anticholinergic related risk. On follow-up, 82% reported having spoken to their physician, a rate independently confirmed by physicians.ConclusionConsumer-facing technology can be a low-cost, scalable intervention to improve older adults’ medication safety, by informing and empowering patients. User-centered design and evaluation with demographically heterogeneous clinical samples uncovers correctable usability issues and confirms the value of interventions targeting consumers as agents in shared decision making and behavior change.     

Assessment of medication management ability in middle-aged and older adults with bipolar disorder

Medication nonadherence is a key clinical concern in bipolar disorder (BD) across the life span. Cognitive deficits in older adults with BD may hinder medication management ability, which, in turn, may lead to nonadherence. Using an innovative performance-based measure of medication management ability, the Medication Management Ability Assessment (MMAA), we compared performance of 29 middle-aged older community-dwelling outpatients with BD who were clinically stable (mean age, 61 years; SD, 11 years; range, 45-86 years) with those of 59 normal control subjects (NCs) and 219 outpatients with schizophrenia. The MMAA is a role-play task that simulates a medication regimen likely to be encountered by older adults. Within the BD group, we examined the relationships of MMAA scores to demographic, psychiatric symptoms severity, and the Mattis Dementia Rating Scale (DRS) scores. The BD group made 2.8 times the errors on the MMAA than NCs (BD group, 6.2; SD, 5.5 vs NCs, 2.2; SD, 2.5) and did not significantly differ from the Schizophrenia group in errors on the MMAA. Errors in the BD group were more likely to be taking in too few medications as taking in too many. Within the BD group, a significant correlation was seen between MMAA scores and the DRS Total score, but not with age, education, Brief Psychiatric Rating Scale, Hamilton Depression Rating Scale, number of psychiatric medications, or medical conditions. Among DRS subscales, the Memory Subscale correlated most strongly with MMAA errors. This small cross-sectional study suggests that deficits in medication management ability may be present in later-life BD. Neurocognitive deficits may be important in understanding problems with unintentional nonadherence.     

Pharmacy-led interventions to improve medication adherence among adults with diabetes: A systematic review and meta-analysis

BackgroundControl of blood glucose and a reduced risk of complications are important treatment goals in diabetes. Medication non-adherence can influence the outcome of diabetes. Involvement of a pharmacist in diabetes care might help patients to achieve better treatment outcomes. Existing literature reviews have focused on a limited number of interventions and outcome measures, and have involved different healthcare professionals. None of the previous reviews have used a standardized effect size to compare the effects of different pharmacist-led interventions and different outcome measures.ObjectiveTo review pharmacist-led interventions to improve medication adherence in patients with diabetes and to assess the effectiveness of these interventions on medication adherence.MethodsSix databases were systematically searched between March and September 2017 for randomized controlled trials: PubMed, Cochrane library, EMBASE, CINAHL, JSTOR, and Web of Science. The outcome measures used were: medication adherence, HbA1c, fasting plasma glucose (FPG), post-prandial blood glucose (PPG), or random blood glucose (RBG). Cohen's d, a standardized effect size, enabled a comparison of studies with different outcome measures. The Cochrane risk of bias tool was used to assess the quality of the studies.ResultsFifty-nine studies were included in this review. Pharmacist-led interventions enhanced outcomes in patients with diabetes (standardized mean difference (SMD) ?0.68; 95% CI -0.79, ?0.58; p < 0.001). Sub-group analysis by intervention strategy, the type of intervention and outcome measures produced similar results. Further analysis showed that education, printed/digital material, training/group discussion, were more effective than other interventions.ConclusionThis finding supports the role of the pharmacist in diabetes care to enhance medication adherence.     

A Theory of Planned Behavior informed factorial survey of New York community pharmacists to determine their intentions to monitor antihypertensive medication adherence among older adults

BackgroundOlder adults with uncontrolled hypertension can benefit from pharmacist-led interventions as they regularly access community pharmacies. However, several barriers to adherence interventions in a community pharmacy setting exist, and few studies have evaluated the feasibility of medication adherence monitoring within the community pharmacy workflow in the United States.ObjectivesTo undertake a factorial survey to determine medication adherence monitoring attitudes of pharmacists and the factors that facilitate or impede adherence counseling by pharmacists within a U.S. community pharmacy setting for antihypertensives in older adults.MethodsThe study was a Theory of Planned Behavior informed factorial survey of New York community pharmacists. The survey had (1) a factorial vignette, to determine how pharmacists make real-life decisions in response to complex situations; (2) questionnaires on medication monitoring attitudes, behavioral beliefs, normative beliefs, and perceived behavioral control regarding medication adherence monitoring, and (3) respondent and workplace characteristics. In response to vignettes, the adherence monitoring tasks were (1) examining patients dispensing records to assess adherence, (2) asking patients about their adherence behavior, and (3) exploring patient beliefs about their antihypertensives.ResultsFrom the 350 completed responses, more than the vignette characteristics, it was the pharmacist characteristics that explained the major variance in the 3 medication monitoring tasks. The respondents demonstrated modestly positive attitudes to medication monitoring, were less positive about their external perception of medication monitoring, and reported difficulty to perform the medication monitoring tasks. In factorial vignette analysis, these attitudes and beliefs significantly impacted adherence monitoring tasks as did situational factors such as time pressures, medication beliefs of patients, the relationship developed with patients, and staffing in the pharmacy, and respondent factors such as pharmacy type and location.ConclusionFuture community pharmacist-led adherence interventions should be designed to address pharmacist attitudes and beliefs and certain workplace characteristics to enable successful implementation.     

Alcohol use and psychosocial well-being among older adults.

OBJECTIVE: The objective of this study was to examine the relationships of three dimensions of alcohol consumption (frequency of drinking, usual total weekly consumption and quantity per occasion) with social and leisure status, stress and psychological well-being among people ages 65 and older. METHOD: Nurse interviewers completed in-house surveys with 826 older persons (65% women) in one community (67% response rate of the census sample). RESULTS: Overall, relationships tended to be modest or nil. Those relationships between negative functioning and heavier alcohol use that did emerge tended to be associated with higher quantity drinking (i.e., drinks per drinking day) and to some extent volume, but not with frequency of drinking. Of the psychosocial variables, poorer psychological well-being, especially depression, was most highly correlated with heavier drinking. These results were the same controlling for sex, age, education, health and use of depressant medications. CONCLUSIONS: Higher quantity and volume of alcohol use among older people show a modest positive association with poorer psychological well-being, independent of other potentially confounding variables such as sex, age, health or use of depressant medications. Frequency of drinking, however, was not related to psychosocial status.