LTC Research Key to Medication Management

Abstract

E.G. is an 85-year-old female nursing facility resident with a history of atrial fibrillation, stroke, dementia, and hypertension and who is on chronic warfarin therapy (INR of 2.0). One evening, a covering physician receives a report that E.G. has developed a fever. He prescribes an empiric antibiotic (cephalexin, 500 mg by mouth t.i.d. for 7 days) to treat a presumed urinary tract infection. The next morning, the primary care physician, unaware of the antibiotic initiation, gets E.G.'s INR from the previous day (1.75) and increases the daily warfarin from 4 mg to 5 mg per day.One week later, the INR comes back at 13.8, and a covering physician is notified. He orders that evening's warfarin to be withheld; the next day the INR is even higher—16.1, so that day's dose is withheld as well. The following day, the patient develops congestion and shortness of breath. A chest x-ray reveals an infiltrate, and the covering physician orders Augmentin (875 mg by mouth q12 hours for 10 days). E.G. passes a tarry stool the next day and is started on omeprazole. The following morning, E.G.'s hematocrit is 25 and her INR is 11.3. On notification, her primary care physician orders vitamin K for 3 days and notes in the record that warfarin is not to be reinitiated because anticoagulation has been difficult to control for unclear reasons.I n settings such as long-term care—where patients have many comorbidities and take many medications—situations such as the one described here occur despite the best efforts of physicians, nurses, and others. They happen as part of a “prescribing cascade,” said Dr. Jerry Gurwitz, AGSF, professor at the University of Massachusetts Medical School.In a presentation at the AMDA Foundation Research Network, Dr. Gurwitz said the “prescribing cascade begins when an adverse drug reaction is misinterpreted as a new medical condition.” A drug is prescribed and an adverse effect happens that is mistaken for a new medical condition. Then a new drug is prescribed, and the patient is placed at risk of developing more adverse effects from the added medication.Dr. Gurwitz stressed that medication management in the elderly is not as simple as “less is more.” Medication used properly is “one of the best ways to improve the lives of our elderly patients,” he said. However, he added, prescribing sometimes is a habit. He quoted Dr. Marcus Reidenberg, editor emeritus of Clinical Pharmacy & Therapeutics: “I know of no way to end an office visit as satisfactorily and as efficiently as by writing a prescription.”While these prescriptions generally are helpful to patients, Dr. Gurwitz noted that medications can contribute to problems and should not be viewed as a panacea.A study from the 1940s actually offers some unique insight into how physicians and patients perceive the impact of medications. The data showed that 100% of physicians believed that antihypertensive drug therapy improved patients' quality of life. However, only about 50% of patients said the medication had a positive effect on their lives; patients' relatives actually thought the drug had a negative impact. “We need to be aware that patients often have a very different opinion of whether a drug improves their health or helps them. As health care providers, we are not good at recognizing the impact that subtle side effects or even adverse effects have on patients,” Dr. Gurwitz noted.A Systematic ApproachMany factors that influence drug effects and the risk of adverse effects in the elderly are intuitive, Dr. Gurwitz observed. Nonetheless, he noted, physicians and other clinicians must keep these factors in mind:▸ Multiple co-existing illnesses.▸ Polypharmacy-redundant effects and drug-drug interactions.▸ Adverse drug effects (nonspecific).▸ Pharmacologic changes with aging.▸ Limited knowledge base.▸ Medical errors (issues of patient safety).Dr. Gurwitz noted that a systems-based approach to medication errors is viable and should address all of these issues. “The most important causes of error are faulty systems or design. Instead of the traditional approach to dealing with medication errors—name, blame, shame, and maim—a systems approach assumes that individuals are doing their best,” he said. Such an approach should utilize proven protocols and processes that ensure effective communication, consistent knowledge and education, and a means of flagging errors and potential problems.While a computerized medication management system can be useful, Dr. Gurwitz noted that such technology isn't always flawless. He pointed to one study in which the use of computerized physician order entry (CPOE) was not found to reduce the occurrence of adverse drug effects (ADEs). He suggested that an effective CPOE system should contain specific alerts, address a broad range of ADEs, and integrate more clinical information into the clinician decision support system.More LTC ResearchThere are still many unknowns about the effects of medications in the elderly, mainly because this group has been excluded from research, Dr. Gurwitz said. “Advanced age has been a primary reason for study ineligibility, and there has been a systematic exclusion of patients over age 75.”However, he said, things are improving. Fewer studies “explicitly exclude older people.” He said elderly patients were excluded from 66% of studies between 1981 and 1990, but only 32% of studies excluded this population between 1996 and 2000. “We need more elderly patients involved in studies. The long-term care population is almost forgotten, and there are few researchers who focus on it.”Dr. Gurwitz admitted that the nursing facility is a “challenging place to do research and develop interventions,” but said it is essential such studies take place. The result will be a better understanding of how medications affect these patients and fewer medication errors in long-term care settings. E.G. is an 85-year-old female nursing facility resident with a history of atrial fibrillation, stroke, dementia, and hypertension and who is on chronic warfarin therapy (INR of 2.0). One evening, a covering physician receives a report that E.G. has developed a fever. He prescribes an empiric antibiotic (cephalexin, 500 mg by mouth t.i.d. for 7 days) to treat a presumed urinary tract infection. The next morning, the primary care physician, unaware of the antibiotic initiation, gets E.G.'s INR from the previous day (1.75) and increases the daily warfarin from 4 mg to 5 mg per day. One week later, the INR comes back at 13.8, and a covering physician is notified. He orders that evening's warfarin to be withheld; the next day the INR is even higher—16.1, so that day's dose is withheld as well. The following day, the patient develops congestion and shortness of breath. A chest x-ray reveals an infiltrate, and the covering physician orders Augmentin (875 mg by mouth q12 hours for 10 days). E.G. passes a tarry stool the next day and is started on omeprazole. The following morning, E.G.'s hematocrit is 25 and her INR is 11.3. On notification, her primary care physician orders vitamin K for 3 days and notes in the record that warfarin is not to be reinitiated because anticoagulation has been difficult to control for unclear reasons. I n settings such as long-term care—where patients have many comorbidities and take many medications—situations such as the one described here occur despite the best efforts of physicians, nurses, and others. They happen as part of a “prescribing cascade,” said Dr. Jerry Gurwitz, AGSF, professor at the University of Massachusetts Medical School. In a presentation at the AMDA Foundation Research Network, Dr. Gurwitz said the “prescribing cascade begins when an adverse drug reaction is misinterpreted as a new medical condition.” A drug is prescribed and an adverse effect happens that is mistaken for a new medical condition. Then a new drug is prescribed, and the patient is placed at risk of developing more adverse effects from the added medication. Dr. Gurwitz stressed that medication management in the elderly is not as simple as “less is more.” Medication used properly is “one of the best ways to improve the lives of our elderly patients,” he said. However, he added, prescribing sometimes is a habit. He quoted Dr. Marcus Reidenberg, editor emeritus of Clinical Pharmacy & Therapeutics: “I know of no way to end an office visit as satisfactorily and as efficiently as by writing a prescription.” While these prescriptions generally are helpful to patients, Dr. Gurwitz noted that medications can contribute to problems and should not be viewed as a panacea. A study from the 1940s actually offers some unique insight into how physicians and patients perceive the impact of medications. The data showed that 100% of physicians believed that antihypertensive drug therapy improved patients' quality of life. However, only about 50% of patients said the medication had a positive effect on their lives; patients' relatives actually thought the drug had a negative impact. “We need to be aware that patients often have a very different opinion of whether a drug improves their health or helps them. As health care providers, we are not good at recognizing the impact that subtle side effects or even adverse effects have on patients,” Dr. Gurwitz noted. A Systematic ApproachMany factors that influence drug effects and the risk of adverse effects in the elderly are intuitive, Dr. Gurwitz observed. Nonetheless, he noted, physicians and other clinicians must keep these factors in mind:▸ Multiple co-existing illnesses.▸ Polypharmacy-redundant effects and drug-drug interactions.▸ Adverse drug effects (nonspecific).▸ Pharmacologic changes with aging.▸ Limited knowledge base.▸ Medical errors (issues of patient safety).Dr. Gurwitz noted that a systems-based approach to medication errors is viable and should address all of these issues. “The most important causes of error are faulty systems or design. Instead of the traditional approach to dealing with medication errors—name, blame, shame, and maim—a systems approach assumes that individuals are doing their best,” he said. Such an approach should utilize proven protocols and processes that ensure effective communication, consistent knowledge and education, and a means of flagging errors and potential problems.While a computerized medication management system can be useful, Dr. Gurwitz noted that such technology isn't always flawless. He pointed to one study in which the use of computerized physician order entry (CPOE) was not found to reduce the occurrence of adverse drug effects (ADEs). He suggested that an effective CPOE system should contain specific alerts, address a broad range of ADEs, and integrate more clinical information into the clinician decision support system. Many factors that influence drug effects and the risk of adverse effects in the elderly are intuitive, Dr. Gurwitz observed. Nonetheless, he noted, physicians and other clinicians must keep these factors in mind: ▸ Multiple co-existing illnesses. ▸ Polypharmacy-redundant effects and drug-drug interactions. ▸ Adverse drug effects (nonspecific). ▸ Pharmacologic changes with aging. ▸ Limited knowledge base. ▸ Medical errors (issues of patient safety). Dr. Gurwitz noted that a systems-based approach to medication errors is viable and should address all of these issues. “The most important causes of error are faulty systems or design. Instead of the traditional approach to dealing with medication errors—name, blame, shame, and maim—a systems approach assumes that individuals are doing their best,” he said. Such an approach should utilize proven protocols and processes that ensure effective communication, consistent knowledge and education, and a means of flagging errors and potential problems. While a computerized medication management system can be useful, Dr. Gurwitz noted that such technology isn't always flawless. He pointed to one study in which the use of computerized physician order entry (CPOE) was not found to reduce the occurrence of adverse drug effects (ADEs). He suggested that an effective CPOE system should contain specific alerts, address a broad range of ADEs, and integrate more clinical information into the clinician decision support system. More LTC ResearchThere are still many unknowns about the effects of medications in the elderly, mainly because this group has been excluded from research, Dr. Gurwitz said. “Advanced age has been a primary reason for study ineligibility, and there has been a systematic exclusion of patients over age 75.”However, he said, things are improving. Fewer studies “explicitly exclude older people.” He said elderly patients were excluded from 66% of studies between 1981 and 1990, but only 32% of studies excluded this population between 1996 and 2000. “We need more elderly patients involved in studies. The long-term care population is almost forgotten, and there are few researchers who focus on it.”Dr. Gurwitz admitted that the nursing facility is a “challenging place to do research and develop interventions,” but said it is essential such studies take place. The result will be a better understanding of how medications affect these patients and fewer medication errors in long-term care settings. There are still many unknowns about the effects of medications in the elderly, mainly because this group has been excluded from research, Dr. Gurwitz said. “Advanced age has been a primary reason for study ineligibility, and there has been a systematic exclusion of patients over age 75.” However, he said, things are improving. Fewer studies “explicitly exclude older people.” He said elderly patients were excluded from 66% of studies between 1981 and 1990, but only 32% of studies excluded this population between 1996 and 2000. “We need more elderly patients involved in studies. The long-term care population is almost forgotten, and there are few researchers who focus on it.” Dr. Gurwitz admitted that the nursing facility is a “challenging place to do research and develop interventions,” but said it is essential such studies take place. The result will be a better understanding of how medications affect these patients and fewer medication errors in long-term care settings.