Appropriateness Of Medication Use Research Articles

Potentially Inappropriate Medication Use and Polypharmacy Before and After Admission to Internal Medicine for Older Patients

BackgroundWith the aging of the population and the increase in chronic diseases, there is an inherent risk of polypharmacy and inappropriate medication use. This study aimed to determine the prevalence and incidence of potentially inappropriate medication use and its correlation with polypharmacy. MethodsThis was a retrospective, population-based cohort study among patients ≥ 65 years hospitalized at The National University Hospital of Iceland from 2010-2020. Data on medication usage were retrieved from the National Prescription Medicine Registry. Based on the number of medications filled in the year prior to admission and post-discharge, participants were categorized as non-polypharmacy (<5), polypharmacy (5-9), and hyper-polypharmacy (≥10). The prevalence and incidence of potentially inappropriate medication use was assessed based on the 2019 Beers criteria. Regression models were used to correlate sociodemographic, clinical, and pharmacoepidemiologic variables and the odds of new potentially inappropriate medication use. ResultsThe cohort comprised 55,859 patients (48.5% male) with a median [interquartile range] age of 80 [73-86] years. The prevalence of inappropriate medication use in the year preceding admission was 34.0%, 77.7%, and 96.4% for patients with non-polypharmacy, polypharmacy, and hyper-polypharmacy, respectively. The incidence of new potentially inappropriate medication use was 46.7% (95% confidence interval 45.6%-47.6%) among those with no potentially inappropriate medication use pre-admission. Factors associated with higher odds of new potentially inappropriate medication use after discharge were the use of multi-dose dispensing services, dementia, polypharmacy, and hyper-polypharmacy. ConclusionsAn increased emphasis is needed to review and reevaluate the appropriateness of medication use among the older population in internal medicine.

Process evaluation of implementation strategies to reduce potentially inappropriate medication prescribing in older population: A scoping review.

Several implementation strategies can reduce potentially inappropriate medication (PIM) prescribing. Although use of PIMs has declined in recent years, it remains prevalent. Various strategies exist to improve the appropriateness of medication use. However, little is known about the processes of these different implementation strategies. This scoping review aims to investigate how the process evaluation of implementation strategies for reducing PIM prescribing in the older population has been studied. We searched for process evaluations of implementation strategies for reducing PIM prescribing in PUBMED, SCOPUS and Web of Science published between January 2000 and November 2019 in English. We applied the following inclusion criteria: patients aged ≥65 years, validated PIM criteria, and implementation process evaluated. The review focuses on decision support for health care professionals. We described the findings of the process evaluations, and compared the authors' concepts of process evaluation of the included publications to those of Proctor et al.( 2010). Of 9131 publications screened, 29 met our inclusion criteria. Different process evaluation conceptualizations were identified. Most process evaluations took place in the initial stages of the process (acceptability, adoption, appropriateness, and feasibility) and sustainability and implementation costs were seldom evaluated. None of the included publications evaluated fidelity. Multifaceted interventions were the most studied implementation strategies. Medication review was more common in acceptability evaluations, multidisciplinary interventions in adoption evaluations, and computerized systems and educational interventions in feasibility evaluations. Process evaluations were studied from the health care professionals' viewpoint in most of the included publications, but the management viewpoint was missing. The conceptualization of process evaluation in the field of PIM prescribing is indeterminate. There is also a current gap in the knowledge of sustainability and implementation costs. Clarifying the conceptualization of implementation process evaluation is essential in order to effectively translate research knowledge into practice.

Appropriateness of psychotropic medication use in a cohort of adolescents with intellectual disability in Queensland, Australia.

Psychotropic medications are sometimes used off-label and inappropriately. This may cause harm to adolescents with intellectual disability. However, few studies have analysed off-label or inappropriate prescribing to this group. To examine the appropriateness of psychotropic prescribing to adolescents with intellectual disability living in the community in south-east Queensland, Australia. Off-label medication use was determined based on whether the recorded medical condition treated was approved by the Australian Therapeutic Goods Administration. Clinical appropriateness of medication use was determined based on published guidelines and clinical opinion of two authors who specialise in developmental disability medicine (J.N.T. and D.H.). We followed 429 adolescents for a median of 4.2 years. A total of 107 participants (24.9%) were prescribed psychotropic medications on at least one occasion. Of these, 88 (82.2%) were prescribed their medication off-label or inappropriately at least once. Off-label or inappropriate use were most commonly associated with challenging behaviours. Off-label or inappropriate use of psychotropic medications was common, especially for the management of challenging behaviours. Clinical decision-making accounts for individual patient factors and is made based on clinical experience as well as scientific evidence, whereas label indications are developed for regulatory purposes and, although appropriate at a population level, cannot encompass the foregoing considerations. Education for clinicians and other staff caring for people with intellectual disability, and a patient-centred approach to prescribing with involvement of families should encourage appropriate prescribing. The effect of the National Disability Insurance Scheme on the appropriateness of psychotropic medication prescribing should be investigated.

Disparities in the appropriateness of medication use: Analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) population-based cohort study.

Prior work has identified disparities in the quality and outcomes of healthcare across socioeconomic subgroups. Medication use may be subject to similar disparities. To assess the association between demographic and socioeconomic factors (gender, age, race, income, education, and rural or urban residence) and appropriateness of medication use. US adults aged ≥45 years (n=26,798) from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were included in the analyses, of which 13,623 participants aged ≥65 years (recruited 2003-2007). Potentially inappropriate medication (PIM) use in older adults and drug-drug interactions (DDIs) were identified through 2015 Beers Criteria and clinically significant drug interactions list by Ament et al., respectively as measures of medication appropriateness. Multivariable logistic regression was used to assess the association of disparity parameters with PIM use and DDIs. Interactions between race and other disparity variables were investigated. Approximately 87% of the participants aged ≥65 years used at least one drug listed in the Beers Criteria, and 3.8% of all participants used two or more drugs with DDIs. Significant gender-race interaction across prescription-only drug users revealed that white females compared with white males (OR=1.33, 95% CI 1.20-1.48) and black males compared with white males (OR=1.60, 95% CI 1.41-1.82) were more likely to receive PIM. Individuals with lower income and education also were more likely to use PIM in this sub-group. Females were less likely than males (female vs. male: OR=0.55, 95% CI 0.48-0.63) and individuals resided in small rural areas as opposed to urban areas (small rural vs. urban: OR=1.37, 95% CI 1.07-1.76) were more likely to have DDIs. Demographic and socioeconomic disparities in PIM use and DDIs exist. Future studies should seek to better understand factors contributing to the disparities in order to guide development of interventions.

Safeguarding Medication Use Through Interprofessional Collaboration: Example of Inpatient Medication Management and Use

The majority of patient safety incidents cited in the latest Taiwan Patient Safety Reporting System Annual Report were medication-related, with human factors and communication issues identified as the key underlying causes of these incidents. Focusing on inpatient settings, the complex yet multiprofessional-linked drug supply scheme currently in place in medical institutions in Taiwan is described, with the aim of facilitating the accessibility and appropriateness of medication use by detailing the responsibilities of each professional role. Institutional medication management and use comprise several sequential and interconnected stages, including formulary management and drug procurement, medication storage, physician prescribing, pharmacist dispensing, nurse administration, and efficacy-and-safety monitoring and reporting. The principal tasks and personnel duties at each stage are addressed. In summary, institutional drug distribution and control is an intricate process that involves multiple processes and a diverse array of professionals and administrative staff. It is imperative to actively engage the relevant parties, especially through in-service training, in order to understand their essential roles and responsibilities and to enable communication and collaboration among stakeholders in the drug distribution chain. Implementing the appropriate initiatives in a timely manner will help establish an effective and robust safe-medication-use system.

Prediction of ADRs and Estimation of Polypharmacy in Older Patient’s Population: Retrospective Study in Russian Gerontology Center

Background: Adverse drug reactions (ADRs) are common in the elderly and often have serious clinical and economic consequences. There have been limited studies in detecting adverse effects in patients admitting hospitals. Objective: Prediction of ADR in patients ≥ 65 years old, based on GerontoNet risk score with emphasis on polypharmacy. Methods: we studied records of 201 inpatients obtained from Medical Records Section, admitted to the Russian Gerontology Clinical Research Center (RGCRC). The GerontoNet ADR risk score was calculated for all patients. Receiver operator characteristic (ROC) curves were constructed to test the ability of the GerontoNet risk score to predict ADRs. We identified people who were 65 years old and more and placed them into one of three age groups (65–74, 75–84 and ≥ 85 year). We compared polypharmacy before admission with that during hospitalization. Results: A total of 201 patients was included in this study. The mean±SD age was 76.1±6.2 years, 74.6% were female and the median number of drugs was 8 (range 6–11). Before admission, previous exposure to ADR was observed in 46 patients (22.9%) and GerontoNet risk score (Mean± SE) was 2.54±1.4, 111 (55.2%) of patients were with 0-2 points and 90 (44.8%) patients were with ≥3 points. During hospital stay, the mean (95% CL) GerontoNet ADR risk score was 4.79 (4.51-5.08) points, range (0-9). It was higher in patients had polypharmacy, compared with those patients hadn’t polypharmacy (66.2% and 24.9% respectively).The area under the curve (ROC) was 0.887 (95% CL 0.84-0.94), the cut-off point of 4 points yielded very good sensitivity and good specificity results in these subpopulations. Before admission, polypharmacy was 36.3% in patients whereas during hospital stay was 91%. polypharmacy exposure increased during hospitalization (P ˂ 0.001), consequently GerontoNet risk scale increased. Variables participating in ADR risk include renal failure, increasing number of medications, age ≥75 years and comorbidity conditions. Patients with a high GerontoNet risk scale ≥4 predicted to be exposed to ADRs approximately four times more likely than those with low GerontoNet risk scale (0-3) (odds ratio, 15.08; 95%CI 7.3–31.15) and so during hospital stay, (odds ratio, 3.103; 95% CI, 0.984–9.785). Conclusions: Polypharmacy is common among older people; this may be partly attributed to the high prevalence of multi-morbidity reported. Adverse reaction in older people can be assessed using GerontoNet, although the GerontoNet ADR risk score improperly classified 21.9% of patients as high risk. Review of appropriateness of medication use is essential, as polypharmacy places ageing people at risk of adverse effects.

Effects of discontinuation of chronic medication in primary care: a systematic review of deprescribing trials.

Polypharmacy is becoming more prevalent and evaluation of appropriateness of medication use is increasingly important. The primary care physician often conducts the deprescribing process; however, there are several barriers to implementing this. To examine the feasibility and safety of discontinuation of medication, with a focus on studies that have been conducted in the community, that is, primary care (or general practice) and nursing homes. This systematic review included randomised controlled trials published in 2005-2017, which studied withdrawal of long-term drugs prescribed in primary care settings and compared continuing medication with discontinuing. PubMed and EMBASE searches were conducted and the extracted data included the number of patients who successfully stopped medication and the number of patients who experienced relapse of symptoms or restarted medication. A total of 27 studies reported in 26 papers were included in this review. The number of participants in the studies varied from 20 to 2471 and the mean age of participants ranged from 50.3 years to 89.2 years. The proportion of patients who successfully stopped their medication varied from 20% to 100%, and the range of reported relapse varied from 1.9% to 80%. Only a few studies have examined the success rate and safety of discontinuing medication in primary care, and these studies are very heterogeneous. Most studies show that deprescribing and cessation of long-term use seem safe; however, there is a risk of relapse of symptoms. More research is needed to advise physicians in making evidence-based decisions about deprescribing in primary care settings.

The Introduction of a Full Medication Review Process in a Local Hospital: Successes and Barriers of a Pilot Project in the Geriatric Ward.

For the majority of Belgian hospitals, a pharmacist-led full medication review process is not standard care and, therefore, challenging to introduce. With this study, we aimed to evaluate the successes and barriers of the implementation of a pharmacist-led full medication review process in the geriatric ward at a local Belgian hospital. To this end, we carried out an interventional study, performing a full medication review on older patients (≥70 years) with polypharmacy (≥5 drugs) who had an unplanned admission to the geriatric ward. The process consisted of 3 steps: (1) medication reconciliation upon admission; (2) medication review using an explicit reviewing tool (STOPP/START criteria or GheOP3S tool), followed by a discussion between the pharmacist and the geriatrician; and (3) medication reconciliation upon discharge. Ethical approval was obtained from the Ethical Commission of the Ghent University Hospital. Outcomes included objective data on the interventions (e.g., number of drug discrepancies; number of potentially inappropriate prescriptions (PIP)); as well as subjective experiences (e.g., satisfaction with service; opinion on inter-professional communication). There was a special focus on communication aspects within the introduction of this process. In total, 52 patients were included in the study, taking a median of 10 drugs (IQR 8–12). Upon admission, 122 drug discrepancies were detected. During medication review, 254 PIPs were detected and discussed, leading to an improvement in the appropriateness of medication use. The satisfaction of community pharmacists concerning additional communication and the satisfaction of the patients after counselling at discharge were positive. However, several barriers were encountered, such as the time-consuming process to gather necessary information from different sources, the non-continuity of the service due to the lack of trained personnel or the lack of safe, electronic platforms to share information. The communicative and non-communicative successes and hurdles encountered during this project need to be addressed in order to improve the full medication review process and to strengthen the role of the clinical pharmacist.

Medication appropriateness for patients with dementia approaching the end of their life.

To examine medication use among patients with dementia towards the end of their life and to evaluate the appropriateness of medication use by using a nationwide database. Using Taiwan's National Health Insurance Research Database, we identified 6532 people with dementia that died between 2008 and 2012. For each person with dementia, data of medication use in the last month of outpatient setting (vs -12th month [baseline]) and last hospitalization (vs -3rd hospitalization [baseline]) before death were retrieved for study. The medications of interest were selected according to a consensus recommendation, which included five categories defining their appropriateness (i.e. always, sometimes, rarely and never appropriate, as well as no consensus). Multivariable logistic regression was carried out to analyze the determinants for use of "never appropriate" medications. Approximately 10% of the study participants were prescribed medications categorized as "never appropriate" in the last month of life in the outpatient settings, which was significantly lower than their baseline (-12th month: 17.5%; P<0.0001). A similar pattern was identified in the last hospitalization before death. Older age was associated with a lower likelihood of being prescribed "never appropriate" medications (age 75-84: aOR 0.34 [0.29-0.41], P<0.0001; age ≥85: aOR 0.34 [0.28-0.40], P<0.0001). In contrast, patients with a history of diabetes mellitus (aOR 1.31 [1.10-1.55], P=0.0018) were associated with a higher likelihood of being prescribed "never appropriate" medications. This is the first study to sophisticatedly describe medications use, particularly according to their appropriateness for palliative care, in Asian people with dementia at the end of their life. Approximately 10% of all patients were prescribed "never appropriate" medications at the end of their life, which deserves further study to evaluate the clinical impact of the quality of care. Geriatr Gerontol Int 2017: 17 (Suppl. 1): 65-74..

Clinical medication review tool for polypharmacy: Mapping approach for pharmacotherapeutic classifications.

Polypharmacy is an extremely important problem, because it increases the risk of adverse drug reactions. The aim of the current study was to create a clinical medication review tool to detect inappropriate medication use, and assess this new method with elderly Japanese patients. The new method involves optimizing prescription drugs from indications, based on the chronic disease-anatomical therapeutic class code list. The present study investigated the prevalence of potentially inappropriate medications in 5667 Japanese patients aged ≥65 years with polypharmacy (≥5 drugs) in comparison with the Beers criteria 2012. We propose a new method called the Mapping Approach for Pharmacotherapeutic Classifications: (i) identify the chronic disease-anatomical therapeutic class code assigned to the prescription drugs; (ii) identify the chronic disease-anatomical therapeutic class code corresponding to the patient's chronic disease; (iii) compare the prescription drug and patient's chronic disease chronic disease-anatomical therapeutic class codes; and (iv) identify the appropriateness of medication use based on the comparison (appropriate use is defined as matching codes). The mean number of potentially inappropriate medications detected was significantly different between the mapping approach and Beers criteria 2012 (3.1 ± 2.6 vs 0.6 ± 0.8 drugs, respectively; P < 0.001). The Mapping Approach for Pharmacotherapeutic Classifications is highly dependent on the chronic condition. Pharmacists should confirm the chronic condition with the treating physician before reducing a patient's medications. We hope this process will further influence prescribing patterns, and decrease the inappropriate use of medications and associated adverse drug reactions in older adults. Geriatr Gerontol Int 2017; 17: 2025-2033.

Development and Validation of the Revised Patients' Attitudes Towards Deprescribing (rPATD) Questionnaire: Versions for Older Adults and Caregivers.

Knowledge of consumer (patient and caregiver) attitudes is essential for conducting medication optimization in practice. The aim of this study was to develop and validate a questionnaire to capture older adults' and caregivers' beliefs and attitudes towards deprescribing. The previously validated Patients' Attitudes Towards Deprescribing (PATD) questionnaire was expanded based on literature review, expert opinion and focus groups, and a caregivers' version was developed. The revised questionnaire was piloted and then distributed for self-completion to older adults (≥65years of age), taking at least one regular medication and caregivers of older adults. Psychometric validity and reliability were examined. Responses to questions that were identified to group into a specific factor were combined to produce a score. A total of 383 consumer questionnaires and 200 caregiver questionnaires were completed and included in analysis. Exploratory factor analysis revealed four factors in both versions of the questionnaire (with four to five questions retained in each factor). The factors relate to the perceived burden of medication taking, belief in appropriateness of medication use (harms and benefits), concerns about stopping the medication, and level of involvement/knowledge of medications. Internal consistency of all factors was acceptable with Cronbach's alpha>0.6. In both the older adults' and caregivers' versions, the burden score was inversely associated with the appropriateness score (p<0.001 both versions). Factor scores between administration times (test-retest reliability) were statistically significantly correlated (p=0.000), with gamma values ranging between 0.57 and 0.89. The revised PATD questionnaire had acceptable validity and reliability. This newly validated questionnaire may provide insight into individuals' willingness for/barriers to deprescribing, with applications in practice and research.

Does Increased Medication Use among Seniors Increase Risk of Hospitalization and Emergency Department Visits?

To examine the extent of the health risks of consuming multiple medications among the older population. Secondary data from the period 2004-2006. The study setting was the province of Ontario, Canada, and the sample consisted of individuals aged 65years or older who responded to a national health survey. We estimated a system of equations for inpatient and emergency department (ED) services to test the marginal effect of medication use on hospital services. We controlled for endogeneity in medication use with a two-stage residual inclusion approach appropriate for nonlinear models. Increased prescription drug use has the effect of increasing the likelihood of both being admitted into hospital and visiting a hospital ED. Each additional medication is associated with a 2-3 percent increase in the likelihood of hospitalization and a 3-4 percent increase in the likelihood of an ED visit, after controlling for past utilization, health status, the endogeneity of medication use, and the unobserved factors that may affect the use of both services. Multiple medications appear to increase the risk of hospitalization among seniors covered by a universal prescription drug plan. These results raise questions about the appropriateness of medication use and the need for increased oversight of current prescribing practices.

Prioritizing interventions to manage polypharmacy in Australian aged care facilities

Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality. To identify and prioritize a range of potential interventions to manage polypharmacy inRACFs from the perspectives of health care professionals, health policy and consumer representatives. Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n=19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level. Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were 'implementation of a pharmacist-led medication reconciliation service for new residents,' 'conduct facility-level audits and feedback to staff and health care professionals,' 'develop deprescribing scripts to assist clinician-resident discussion,' 'develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,' 'implement electronic medication charts and records' and 'better support Medication Advisory Committees (MACs) to address medication appropriateness.' This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.

Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study

Objectives(1) To evaluate the prevalence of polypharmacy (5–9 medicines) and excessive polypharmacy (10+ medicines) and (2) to determine associated demographic and clinical characteristics in an ageing population with intellectual disabilities...

Description of a systematic pharmaceutical care approach intended to increase the appropriateness of medication use by elderly patients.

Background & AimsThe pharmaceutical care practice represents a model of responsible pharmacist involvement in the pharmacotherapy optimization of various population groups, including the elderly, known to be at risk for drug-related problems. Romanian pharmacists could use validated pharmaceutical care experiences to confirm their role as health-care professionals.This descriptive research presents the application in two real and different environments of practice of a structured pharmaceutical care approach conceived as the basis for a medication review activity and aiming at the identification and resolution of the drug related problems in the elderlyPatients and methodsTwo patients with similar degree of disease-burden complexity, receiving care in different health-care environments (The Geriatric Ward of the Royal Victoria Hospital from the McGill University Health Centre in Montréal, Québec, Canada, in November 2010, and an urban nursing-home facility in Cluj-Napoca, Romania, in March 2011), were chosen for the analysis. One clinical pharmacist suggested solutions for the management of each of the active drug-related problems identified, using the systematic pharmaceutical care approach and specific published geriatric pharmacotherapy recommendations. The number of the drug-related problems identified and the degree of the care-team acceptance of the pharmacists’ solutions were noted for each patient.ResultsThe pharmacist found 6 active drug-related problems for the hospitalized patient (72 year-old, Chronic Disease Score 9) and 7 potential ones for the nursing-home resident (79 year-old, Chronic Disease Score 8), involving misuse, underuse and overuse of medications. Each patient had 3 geriatric syndromes at baseline. The therapy changes suggested by the pharmacist were implemented for the hospitalized patient, through collaboration with the health-care team. For the nursing home resident, the pharmacist identified the need for additional 6 medications and safety and efficacy arguments to cease 7 initial therapies, simplifying the therapeutic daily schedule (from 24 daily doses to 15).ConclusionThe pharmacist’s potential contribution to the optimization of the Romanian elderly patients’ pharmacotherapy needs further exploration, as potential drug related problems reported as characteristic for this population were easily identified. The presented structured and validated model of pharmaceutical care approach could be used to this end. Its dissemination and use could be encouraged along with the enhancement of pharmacotherapy information and care team collaboration skills.

Automated dose dispensing service for primary healthcare patients: a systematic review

BackgroundAn automated dose dispensing (ADD) service has been implemented in primary healthcare in some European countries. In this service, regularly used medicines are machine-packed into unit-dose bags for each time of administration. The aim of this study is to review the evidence for ADD’s influence on the appropriateness of medication use, medication safety, and costs in primary healthcare.MethodsA literature search was performed in April 2012 in the most relevant databases (n = 10), including the Medline, Embase, and Cochrane Library. The reference lists of the studies selected were manually searched. A study was included in the review if the study was conducted in primary healthcare or nursing home settings and medicines were dispensed in unit-dose bags.ResultsOut of 328 abstracts, seven studies met the inclusion and reporting quality criteria, but none applied a randomized controlled study design. Of the four controlled studies, one was a national register-based study. It showed that the patient group in the ADD scheme more often used three or more psychotropic drugs and anticholinergics than patients using the standard dispensing procedure, while women in the ADD group used less long-acting benzodiazepines and both genders had fewer drug-drug interactions. In another, regional controlled study, the ADD group consisted of patients with higher risk of inappropriate drug use, according to all indicators applied. The third controlled study indicated that ADD user drug treatments were more likely to remain unchanged than in patients using a standard dispensing procedure. A controlled study from Norway showed that ADD reduced discrepancies in the documentation of patient medication records. Costs were not investigated in any of the studies.ConclusionsA very limited number of controlled studies have explored ADD in primary healthcare. Consequently, the evidence for ADD’s influence on appropriateness and safety of medication use is limited and lacking in information on costs. The findings of this review suggest that patients using the ADD have more inappropriate drugs in their regimens, and that ADD may improve medication safety in terms of reducing the discrepancies in medication records. Further evidence is needed to draw sound conclusions on ADD’s outcomes.

A PHARMACIST-CONDUCTED MEDICATION REVIEW IN NURSING HOME RESIDENTS: IMPACT ON THE APPROPRIATENESS OF PRESCRIBING

Medication use in nursing homes is often suboptimal. This study investigated the impact of a pharmacist-conducted medication review on the appropriateness of prescribing for Belgian nursing home residents. We conducted a 6-month controlled, non-randomized study in two nursing homes (one intervention and one control nursing home). Sixty-nine residents completed the study in the intervention group (92 residents were included). For the control group, that were 79 residents (100 residents were included). Primary outcome was the appropriateness of prescribing, assessed by a set of validated quality indicators. At baseline, this study detected three main problems associated with the appropriateness of medication use: (i) the Medication Appropriateness Index (MAI) could be improved (continuation of no longer indicated medication was the most common problem), (ii) potential overuse was present in about half of the group, and (iii) potential underuse was present in about 30% of the sample. Despite this, our pharmacist-conducted medication review only modestly improved the appropriateness of prescribing. This may be attributed to the low implementation rate of the pharmacist recommendations.

The role of the clinical pharmacist in the management of psychotropic polypharmacy in the treatment of patients with mental retardation and development disabilities

For many individuals with mental impairments/developmental disabilities (MR/DD) that reside in supported living centers, the potential to be placed on a myriad of psychotropic medications to manage both behavioral and neuropsychiatric disturbances exists. There are distinctive obstacles that a clinical pharmacist that works in a facility providing services to individuals with MR/DD can face as it relates the prescribing of psychotropic medications. As a result of the limited data or clinical trials on the use of psychotropic medications in this particular population, problems can be encountered when multiple psychotropic medications are prescribed. Based on the practice parameters for the assessment and treatment of children, adolescents, and adults with MR/DD, or other comorbid mental disorders published by the American Academy for Child and Adolescent Psychiatry, the problems can include irrational prescribing, inappropriate medication for a given diagnosis, or questionable monitoring of adverse effects. 1 The role of the clinical pharmacist in this practice setting can consist of a continuous assessment of the clinical justification and rationale for why psychotropic polypharmacy is warranted. Polypharmacy can be defined in many different ways and may differ based on the patient population being evaluated. 2 According to Fulton and Allen (2005), polypharmacy is defined as the use of medications that are not clinically indicated; and in clinical practice it is the use of more than a certain number of drugs to treat a condition regardless of its appropriateness. 3 Within an assisted living facility, periodic reviews of drug utilization can be associated with funding for the facility so the evaluation of the appropriateness of medication use, including polypharmacy, may need to be performed on a quarterly, biannual, or yearly basis. The co-occurring use of multiple psychoactive medications in a single patient is becoming an increasingly common and current practice in clinical psychiatry which largely based more on experience rather than evidence. 6 Any patient receiving more than one medication from a specific class (e.g. two antidepressants, two antipsychotics), should have regular reassessment to confirm the necessity of the polypharmacy. In general, polypharmacy is considered to a major health issue not only in primary care setting but in other practice setting as it can lead to unnecessary expenses, wasted time, and possibly mismanagement on the part of the attending clinician if the indication for psychotropic polypharmacy is not routinely evaluated. Furthermore, patients with MR/ DD have an increased potential for drug-drug interactions , side effects of psychotropic medications such as extrapyramidal effects from antipsychotic medications and delirium from benzodiazepines, and possibly unrecognized complications.

Medication Use by Australian War Veterans in Residential Aged‐Care Facilities

ABSTRACTBackgroundThere has been concerns about the appropriateness of medication use in Australian residential aged‐care facilities. Data on overall medication use in aged‐care has been unavailable.AimTo examine medication use for Australian war veterans in residential aged‐care facilities.MethodAn observational study using the Department of Veterans' Affairs' pharmacy claims database was undertaken. Veterans resident in aged‐care facilities between April and June 2005 were included. Veterans using gastrointestinal, analgesic, psychotropic, antiinfective and cardiac drugs were assessed.ResultsAll 16 126 veterans (5% of the veteran population) identified as residing continuously in aged‐care facilities were included (average age 86 years). Those with low‐care needs (44%) were dispensed on average 9 (SD 5) different medicines, while those with high‐care needs (56%) were dispensed 8 (SD 5) different medicines. More than 50% of veterans were dispensed analgesics, predominantly paracetamol, and over 60% psychotropic drugs. In all, 35% were receiving antidepressants, proton pump inhibitors and antibacterials.ConclusionVeterans residing in aged‐care facilities are taking high levels of medications, particularly analgesics, psychotropics, antibacterials, laxatives and proton pump inhibitors, for which studies have demonstrated concerns about their appropriateness.

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

Background: The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness. Objective: The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program. Methods: A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated. Results: Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study ( P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period. Conclusions: By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.