Complex Regimens Research Articles

Medication regimen complexity (MRC-ICU) for in-hospital mortality prediction in COVID-19 patients.

The medication regimen complexity-intensive care unit (MRC-ICU) score was developed prior to the existence of COVID-19. The purpose of this study was to assess if MRC-ICU could predict in-hospital mortality in patients with COVID-19. A single-center, observational study was conducted from August 2020 to January 2021. The primary outcome of this study was the area under the receiver operating characteristic (AUROC) for in-hospital mortality for the 48-hour MRC-ICU. Age, sequential organ failure assessment (SOFA), and World Health Organization (WHO) COVID-19 Severity Classification were assessed. Logistic regression was performed to predict in-hospital mortality as well as WHO Severity Classification at 7 days. A total of 149 patients were included. The median SOFA score was 8 (IQR 5-11) and median MRC-ICU score at 48 hours was 15 (IQR 7-21). The in-hospital mortality rate was 36% (n = 54). The AUROC for MRC-ICU was 0.71 (95% Confidence Interval (CI), 0.62-0.78) compared to 0.66 for age, 0.81 SOFA, and 0.72 for the WHO Severity Classification. In univariate analysis, age, SOFA, MRC-ICU, and WHO Severity Classification all demonstrated significant association with in-hospital mortality, while SOFA, MRC-ICU, and WHO Severity Classification demonstrated significant association with WHO Severity Classification at 7 days. In univariate analysis, all 4 characteristics showed significant association with mortality; however, only age and SOFA remained significant following multivariate analysis. In the first analysis of medication-related variables as a predictor of severity and in-hospital mortality in COVID-19, MRC-ICU demonstrated acceptable predictive ability as represented by AUROC; however, SOFA was the strongest predictor in both AUROC and regression analysis.

Tratamientos modificadores de la enfermedad en pacientes con esclerosis múltiple en España

Multiple sclerosis is a chronic demyelinating disease of the central nervous system and long-term disabling. Different disease-modifying treatments are available. These patients, despite being generally young, have high comorbidity and risk of polymedication due to their complex symptomatology and disability. Objective primaryTo determine the type of disease-modifying treatment in patients seen in Spanish hospital pharmacy departments. Secondary objectivesTo determine concomitant treatments, determine the prevalence of polypharmacy, identify the prevalence of interactions and analyse pharmacotherapeutic complexity. MethodObservational, cross-sectional, multicentre study. All patients with a diagnosis of multiple sclerosis and active disease-modifying treatment who were seen in outpatient clinics or day hospitals during the second week of February 2021 were included. Modifying treatment, comorbidities and concomitant treatments were collected to determine multimorbidity pattern, polypharmacy, pharmacotherapeutic complexity (Medication Regimen Complexity Index) and drug-drug interactions. Results1,407 patients from 57 centres in 15 autonomous communities were included. The most frequent form of disease presentation was the relapsing remitting form (89.3%). The most prescribed disease-modifying treatment was dimethyl fumarate (19.1%), followed by teriflunomide (14.0%). Of the parenteral disease-modifying treatments, the two most prescribed were glatiramer acetate and natalizumab with 11.1% and 10.8%. 24.7% of the patients had one comorbidity and 39.8% had at least 2 comorbidities. 13.3% belonged to at least one of the defined patterns of multimorbidity and 16.5% belonged to 2 or more patterns. The concomitant treatments prescribed were psychotropic drugs (35.5%); antiepileptic drugs (13.9%) and antihypertensive drugs and drugs for cardiovascular pathologies (12.4%). The presence of polypharmacy was 32.7% and extreme polypharmacy 8.1%. The prevalence of interactions was 14.8%. Median pharmacotherapeutic complexity was 8.0 (IQR: 3.3 -- 15.0). ConclusionsWe have described the disease-modifying treatment of patients with multiple sclerosis seen in Spanish pharmacy services and characterised concomitant treatments, the prevalence of polypharmacy, interactions, and their complexity.

Pharmacophenotype identification of intensive care unit medications using unsupervised cluster analysis of the ICURx common data model

BackgroundIdentifying patterns within ICU medication regimens may help artificial intelligence algorithms to better predict patient outcomes; however, machine learning methods incorporating medications require further development, including standardized terminology. The Common Data Model for Intensive Care Unit (ICU) Medications (CDM-ICURx) may provide important infrastructure to clinicians and researchers to support artificial intelligence analysis of medication-related outcomes and healthcare costs. Using an unsupervised cluster analysis approach in combination with this common data model, the objective of this evaluation was to identify novel patterns of medication clusters (termed ‘pharmacophenotypes’) correlated with ICU adverse events (e.g., fluid overload) and patient-centered outcomes (e.g., mortality).MethodsThis was a retrospective, observational cohort study of 991 critically ill adults. To identify pharmacophenotypes, unsupervised machine learning analysis with automated feature learning using restricted Boltzmann machine and hierarchical clustering was performed on the medication administration records of each patient during the first 24 h of their ICU stay. Hierarchical agglomerative clustering was applied to identify unique patient clusters. Distributions of medications across pharmacophenotypes were described, and differences among patient clusters were compared using signed rank tests and Fisher's exact tests, as appropriate.ResultsA total of 30,550 medication orders for the 991 patients were analyzed; five unique patient clusters and six unique pharmacophenotypes were identified. For patient outcomes, compared to patients in Clusters 1 and 3, patients in Cluster 5 had a significantly shorter duration of mechanical ventilation and ICU length of stay (p < 0.05); for medications, Cluster 5 had a higher distribution of Pharmacophenotype 1 and a smaller distribution of Pharmacophenotype 2, compared to Clusters 1 and 3. For outcomes, patients in Cluster 2, despite having the highest severity of illness and greatest medication regimen complexity, had the lowest overall mortality; for medications, Cluster 2 also had a comparably higher distribution of Pharmacophenotype 6.ConclusionThe results of this evaluation suggest that patterns among patient clusters and medication regimens may be observed using empiric methods of unsupervised machine learning in combination with a common data model. These results have potential because while phenotyping approaches have been used to classify heterogenous syndromes in critical illness to better define treatment response, the entire medication administration record has not been incorporated in those analyses. Applying knowledge of these patterns at the bedside requires further algorithm development and clinical application but may have the future potential to be leveraged in guiding medication-related decision making to improve treatment outcomes.

Assessing Pain in Older Adults: Caregivers play a key role in recognizing and documenting pain at home.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Horgas, A.L., et al. Assessing Pain in Older Adults. Am J Nurs 2022; 122 (12): 42-48.

An Evaluation of the Relationship Between Medication Regimen Complexity as Measured by the MRC-ICU to Medication Errors in Critically Ill Patients.

Purpose: The purpose of this study was to determine the relationship between medication regimen complexity-intensive care unit (MRC-ICU) score at 24 hours and medication errors identified throughout the ICU. Methods: A single-center, observational study was conducted from August to October 2021. The primary outcome was the association between MRC-ICU at 24 hours and total medication errors identified. During the prospective component, ICU pharmacists recorded medication errors identified over an 8-week period. During the retrospective component, the electronic medical record was reviewed to collect patient demographics, outcomes, and MRC-ICU score at 24 hours. The primary outcome of the relationship of MRC-ICU at 24 hours to medication errors was assessed using Pearson correlation. Results: A total of 150 patients were included. There were 2 pharmacists who recorded 634 errors during the 8-week study period. No significant relationship between MRC-ICU and medication errors was observed (r2 = .13, P = .11). Exploratory analyses of MRC-ICU relationship to major interventions and harm scores showed that MRC-ICU scores >10 had more major interventions (27 vs 14, P = .27) and higher harm scores (15 vs 7, P = .33), although these values were not statistically significant. Conclusion: Medication errors appear to occur independently of medication regimen complexity. Critical care pharmacists were responsible for mitigating a large number of medication errors.

Evaluation of the factors influencing adherence to ART in HIV/AIDS patients at Kampala International University Teaching Hospital Bushenyi District

Globally, there were an estimated 33 million people living with HIV by the end of 2007, and more than 25 million people since 1981 have died from AIDS. In 2007 there were 2.7 million new infections and 2 million HIV-related deaths. All these facts are attributed to the compromise of adherence to ART. Currently, there are an estimated 940,000 people (adults and children) living with HIV in Uganda but the adherence levels are hence posing a great challenge in the fight against the scourge. To assess factors influencing adherence to ART among HIV/AIDS clients at Kampala International University Teaching Hospital, a descriptive cross-sectional study design quantitative in nature was used to recruit 52 respondents for the study out of whom 52 questionnaires thus giving a response rate of 100%. 75% of the respondents strongly agreed that level of income may influence adherence to ART, 57% of the respondents agreed that drug hypersensitivity and side effects affect adherence to ART and 63.5% of the respondents agreed that clinic characteristics can impact adherence. The researcher concluded that client-related factors influencing adherence to ART include the client’s age, level of education, level of income, social support, co-morbidities, and patient’s belief about the effectiveness of ART. Therapy-related factors affecting adherence to ART include; polypharmacy, hypersensitivity, pill burden, and regimen complexity. Health system-related factors affecting adherence to ART include; clinic characteristics, selfmedication, lengthy wait before the next clinic visit, and the patient-provider relationship. Keywords: HIV/AIDS, ART, Adherence, Uganda, Hypersensitivity.

Multidimensional Interventions on Supporting Disease Management for Hospitalized Patients with Heart Failure: The Role of Clinical and Community Pharmacists.

existing trials on the role of clinical pharmacists in managing chronic disease patients have focused on variety of interventions, including preparing patients for the transition from hospital to home. However, little quantitative evidence is available regarding the effect of multidimensional interventions on supporting disease management for hospitalized patients with heart failure (HF). The present paper reviews the effects of inpatient, discharge and/or after-discharge interventions performed on hospitalized HF patients by multidisciplinary teams, including pharmacists. articles were identified through search engines in three electronic databases following the PRISMA Protocol. Randomized controlled trials (RCTs) or non-randomized intervention studies conducted in the period 1992-2022 were included. In all studies, baseline characteristics of patients as well as study end-points were described in relation to a control group i.e., usual care and a group of subjects that received care from a clinical and/or community pharmacist, as well as other health professionals (Intervention). Study outcomes included all-cause hospital 30-day re-admission or emergency room (ER) visits, all-cause hospitalization within >30 days after discharge, specific-cause hospitalization rates, medication adherence and mortality. The secondary outcomes included adverse events and quality of life. Quality assessment was carried out using RoB 2 Risk of Bias Tool. Publication bias across studies was determined using the funnel plot and Egger's regression test. a total of 34 protocols were included in the review, while the data from 33 trials were included in further quantitative analyses. The heterogeneity between studies was high. Pharmacist-led interventions, usually performed within interprofessional care teams, reduced the rates of 30-day all-cause hospital re-admission (odds ratio, OR = 0.78; 95% CI 0.62-0.98; p = 0.03) and all-cause hospitalization >30 days after discharge (OR = 0.73; 95% CI 0.63-0.86; p = 0.0001). Subjects hospitalized primarily due to heart failure demonstrated reduced risk of hospital admission within longer periods, i.e., from 60 to 365 days after discharge (OR = 0.64; 95% CI 0.51-0.81; p = 0.0002). The rate of all-cause hospitalization was reduced by multidimensional interventions taken by pharmacists: reviews of medicine lists and/or their reconciliation at discharge (OR = 0.63; 95% CI 0.43-0.91; p = 0.014), as well as interventions that were based mainly on patient education and counseling (OR = 0.65; 95% CI 0.49-0.88; p = 0.0047). In conclusion, given that HF patients often have complex treatment regimens and multiple comorbid conditions, our findings highlight the need for greater involvement from skilled clinical and community pharmacists in disease management.

Self-care behaviours of patients with left ventricular assist devices in Israel: changes during the COVID-19 pandemic.

Left ventricular assist devices (LVADs) support the hearts of patients with advanced heart failure. Following LVAD implantation, patients face a complex regimen of self-care behaviours including self-care maintenance, self-care monitoring and self-care management. However, during the COVID-19 pandemic, symptoms of anxiety and depression may have interfered with their self-care. Currently, little is known on how specific self-care behaviours of LVAD-implanted patients changed during the COVID-19 pandemic. We aim to describe the changes in self-care behaviours among patients with an implanted LVAD in Israel during the COVID-19 pandemic and explore the factors related to self-care behaviour change. A prospective observational cross-sectional study design. A convenience sample of 27 Israeli LVAD-implanted patients (mean age 62.4±9, 86% male, 78.6% living with a partner) completed the LVAD Self-Care Behaviour Scale (1=never to 5=always) and Hospital Anxiety and Depression Scale (0=not at all to 3=most of the time). Data were collected before and after the onset of the COVID-19 pandemic in Israel. Statistical analyses included paired t-tests, Pearson's correlations, and one-way repeated measures ANOVAs. During the COVID-19 pandemic, a significant decrease was found in patients' adherence to checking and recording their LVAD speed, flow, power and PI (Pulsatility Index) (P=0.05), checking their INR (P=0.01), and daily weighing (P<0.01). The prevalence of some behaviours (e.g. regularly exercising) increased in some patients and decreased in others. Patients living without a partner worsened their adherence to some of the self-care behaviours (e.g. taking medicines as prescribed), compared with those living with a partner (Mb =5.0±0 and Md =5.0±0, delta=0 vs. Mb =5.0±0 and Md =4.6±0.9, delta=-0.4, respectively; F=4.9, P=0.04). Women, and not men, tended to improve their adherence to the self-care behaviour such as avoiding kinking, pulling, or moving the LVAD driveline at the exit site (Mb =4.0±1.0 and Md =5.0±0, delta=1.0 vs. Mb =4.5±0.9 and Md =4.4±1.2, delta=-0.1, F=4.7, P=0.04, respectively). In total, 41% (11) patients reported neither anxiety nor depression, 11% (3) reported anxiety, 15% (4) reported depression, and 44% (12) reported both anxiety and depression. No associations between anxiety and/or depression and self-care behaviours were found. Priorities in self-care behaviours among patients with implanted LVAD changed after the onset of the COVID-19 pandemic. Factors that assisted with adherence to self-care behaviours included living with a partner and being female. The current results may guide further research on identifying behaviours that are at risk of not being maintained during a time of emergency.

Medication Regimen Complexity Index After Kidney Transplant in Fortaleza, Brazil

Bruna Cristina Cardoso Martins1, Iwyson Henrique Fernandes da Costa2, Elana Figueiredo Chaves3, Paulo Yuri Milen Firmino4, Paula Frassinetti Castelo Branco Camurça Fernandes5 and Marta Maria de França Fonteles1 Author informationArticle notesCopyright and License information 1Department of Pharmacy, Postgraduate Program in Pharmaceutical Sciences, Federal University of Ceará, Pastor Samuel Munguba Street, Fortaleza, Ceará, BRAZIL 2Federal University

475 Co-designing an intervention to support safe medicines self-management for older people living with frailty and polypharmacy

Abstract Introduction Older people face numerous challenges and safety risks when managing multiple medicines. They are required to cope with complex and changing regimens and co-ordinate input from multiple healthcare professionals. If not well managed, medicines can cause harm, and older people are more susceptible to errors. Some older people can devise and implement strategies to manage their medicines, e.g. creating checklists, ensuring timely supplies, solving problems, and seeking help (1). However, no interventions address the multiple tasks polypharmacy patients must perform to safely manage their regimens. Aim To develop an intervention to support medicines self-management for older people living with frailty and polypharmacy using experience-based co-design (EBCD) (2). Methods Following video or audio-recorded qualitative interviews with 32 older people taking 5 or more medicines, a ‘trigger film’ of patients’ medicines management experiences was produced and used during EBCD to facilitate priority setting. Separate meetings were held (1) with 16 staff (2 GPs, 4 GP practice administrators, 4 GP practice pharmacists, 1 practice lead, 2 senior nurses, 2 pharmacy technicians, 1 community pharmacist) and (2) with 13 patients and 2 family members, followed by a joint meeting with 8 older people and 9 staff where a shared set of three priorities was agreed. Two subsequent co-design workshops with 6 patients, 2 family members and 7 staff developed three candidate interventions. Workshop 1 explored key themes from the trigger film to develop solutions. Workshop 2 reviewed solutions and further developed design ideas. Intervention components were merged and those addressing patient safety challenges were retained to form the prototype intervention. Ethical approval was obtained for the interviews included in the trigger film, but not required for EBCD. EBCD meetings and workshops were conducted as quality improvement: people involved were collaborators, personal information was not captured, discussions were not recorded or analysed. Results Co-design priorities were to support patients in: day-to-day practical medicines management; understanding the wider medicines management system; communication with healthcare teams. The three solutions were: a quick-start guide to managing multiple medicines including talking about medicines and managing new routines; tips and tricks to support day-to-day management, including planning and adherence tools; a tool supporting preparation for medication reviews and asking questions about medicines. After merging intervention components and identifying those addressing medicines-self-management patient safety challenges, five areas were retained for the prototype intervention: checking what you get; keeping on top of supplies; monitoring how you take your medicines; times when problems are more likely; and how do I know if I need help? Discussion/Conclusion Through EBCD patients and staff worked together to improve people’s experiences of managing medicines and to enhance safety. The prototype intervention addresses five areas where older people with complex medicines regimens require support. The intervention requires feasibility testing and subsequent robust evaluation. Strengths and limitations: • A variety of staff roles joined the co-design, offering multiple different perspectives on medicines management • EBCD meetings and workshops were run online to avoid Covid infections. This may have excluded older people with no access to internet.

443 Selection of Outcome Measurement Instruments for a Core Outcome Set for trials aimed at improving appropriate polypharmacy in older people in primary care

Abstract Introduction Different outcome measurement instruments (OMIs) have been used to measure similar outcomes in intervention studies focusing on improving appropriate polypharmacy in older people (1). It is crucial to reach consensus on which OMIs should be used for each outcome in a core outcome set (COS) to promote synthesis of trial findings and help identify effective interventions. A polypharmacy COS was previously developed, consisting of seven outcomes, including serious adverse drug reactions (ADRs), medication appropriateness, falls, medication regimen complexity, quality of life, mortality and medication side effects (1). To date, there has been no consensus as to which OMIs should be used for these outcomes. Aim To select OMIs for the seven outcomes in the COS developed to improve appropriate polypharmacy in older people in primary care. Methods This study followed the COSMIN (Consensus-based Standards for the selection of health Measurement Instruments) initiative’s guidelines for selecting OMIs for a COS (2), which include finding existing OMIs from a systematic review, conducting a quality assessment of the OMIs, selecting one OMI for each outcome in the COS, and running a Delphi consensus survey (two rounds) on OMIs for each outcome. For the Delphi exercise, researchers focusing on care of older people or clinicians who had experience in prescribing for this population in primary care, together with public advocates for older people were invited by email to participate. Following provision of consent, a questionnaire was developed and distributed by the SoGoSurvey® platform on two occasions. The two rounds were distributed on June 21st 2022 and July 11th 2022, respectively. Each round remained open for 14 days to allow participants to take part in the study. The questionnaire comprised a list of seven OMIs along with their definitions and illustrative examples. Stakeholders were asked to choose one option (‘agree’, ‘disagree’ or ‘unsure’) for every OMI. Response rate and distribution of scores for the seven OMIs were calculated following each round. Consensus for the inclusion of an OMI in the COS was reached if 70% or more participants selected ‘agree’ and 15% or less participants selected ‘disagree’. Results One hundred and eighty-eight emails were sent to relevant stakeholders (176 researchers or clinicians, 12 public representatives) inviting them to take part in the study. Fifty-seven (30.32%) stakeholders (56 researchers and one public representative) agreed to participate. Fifty (87.72%; all participants were researchers or clinicians) completed Rounds 1 and 2 of the Delphi survey. Following Rounds 1 and 2, consensus (≥70% participants agreed) was reached for three OMIs – ‘the number of ADRs’ (98%), ‘the number of deaths’ (76%) and ‘the number of patients who fell’ (70%) – to measure the ‘serious ADRs’, ‘mortality’ and ‘falls’ outcomes, respectively. Consensus was not reached for the remaining four OMIs. Conclusion This study led to the selection of OMIs for outcomes in a COS aimed at improving appropriate polypharmacy in older people. Although this study planned to include public participants, none agreed to participate. Future work should determine the most appropriate OMIs for the other four outcomes in the COS.

Like Frying Multiple Eggs in One Pan: a Qualitative Study Exploring the Understanding of Inter-speciality Training in Cancer Care

High-quality cancer care is a key priority worldwide. Caring for people affected by cancer requires a range of specific knowledge, skills and experience to deliver the complex care regimens both within the hospital and within the community environment. In June 2022, the European Cancer Organisation along with 33 European cancer societies began working together to develop a curriculum for inter-speciality training for healthcare professionals across Europe. As part of the project, this research consisted of a qualitative survey distributed to the European Union societies via email. The aim of this paper is to disseminate the qualitative findings from healthcare professionals across Europe. Questionnaires were sent out to a convenience sample of 219 healthcare professionals and patient advocates with a response rate of 55% (n = 115). The findings identified that there were four key themes: ‘What is inter-speciality training?’, ‘Barriers and challenges’, ‘Support throughout the cancer journey’ and ‘New ways of working’. These results are part of a larger needs analysis and scoping review to inform the development of a core competency framework which will be part of an inter-speciality curriculum for specialist cancer doctors, nurses and other healthcare professionals across Europe. Healthcare professionals will be able to access education and training through the virtual learning environment and workshops and by clinical rotations to other specialties.

Clinical Utility of Osilodrostat in Cushing's Disease: Review of Currently Available Literature.

Cushing's disease (CD) is caused by endogenous hypercortisolism as a result of adrenocorticotropin (ACTH) secretion from a pituitary tumor. The condition is associated with multiple comorbidities and increased mortality. First-line therapy for CD is pituitary surgery, performed by an experienced pituitary neurosurgeon. Hypercortisolism may often persist or recur after initial surgery. Patients with persistent or recurrent CD will generally benefit from medical therapy, often administered to patients who underwent radiation therapy to the sella and are awaiting its salutary effects. There are three groups of medications directed against CD, including pituitary-targeted medications that inhibit ACTH secretion from tumorous corticotroph cells, adrenally-directed medications that inhibit adrenal steroidogenesis and a glucocorticoid receptor (GR) antagonist. The focus of this review is osilodrostat, a steroidogenesis inhibitor. Osilodrostat (LCI699) was initially developed to lower serum aldosterone levels and control hypertension. However, it was soon realized that osilodrostat also inhibits 11-beta hydroxylase (CYP11B1), leading to a reduction in serum cortisol levels. The focus of drug development then shifted from treatment of hypertension to treatment of hypercortisolism in CD. In a series of studies (LINC 1 through 4), osilodrostat was shown to be effective in normalizing 24-h urinary free cortisol (UFC) in the majority of treated patients and was approved for patients with CD who have failed surgery or are not surgical candidates. Further study is needed to examine the role of combination therapy as well as long-term outcomes of treated patients. Osilodrostat was shown to have an overall good safety profile. Most common adverse effects include nausea, headache, fatigue, arthralgias, dizziness, prolonged QTc interval, hypokalemia. In females, the drug can cause hirsutism and acne. Osilodrostat is administered twice daily, making it a good choice for patients with difficulty adhering to more complex regimens. Osilodrostat has an important, albeit adjunctive, role in the management of patients with CD.

208 Pharmacy Students Explore Use of an Electronic Medication Adherence Device

OBJECTIVES/GOALS: To examine pharmacy students’ and patients’ perspectives on use of an automatic pill dispenser (APD) and adherence device, and secondly, to identify patient characteristics impacting selection of an APD. This knowledge will assist pharmacists in making appropriate device recommendations that improve medication adherence and effectiveness. METHODS/STUDY POPULATION: One hundred fifty-three pharmacy students participated in a personal APD simulation, living the life as a person taking medication. Students then each identified an actual patient exhibiting medication nonadherence from pharmacy records at their work setting, provided them with an APD free of charge and instructed them on its use. The students later interviewed their patients and reported on their patients’ ability to use the APD, as well as their perspectives (likes and dislikes) on the features of the device. Students identified individual patient characteristics associated with successful use of the APD. This new knowledge will aid these future pharmacists in making recommendations for medication adherence devices for their patients. RESULTS/ANTICIPATED RESULTS: In general, patients perceived more difficulty with use of the 10 APD features than did students. Over half of the patients indicated that the following features were a distinct advantage in adherence: individual medication compartment size, method of loading medications, alarm, flashing light, ability to lock the dispenser, and method of retrieving the medication from the device. Patients felt that the biggest disadvantage was its bulky size and lack of portability. In spite of individual difficulties with use, the research findings showed that persons who are elderly, homebound, have memory problems, take multiple medications and/or have complex regimens are most likely to benefit from the device features and exhibit improved adherence to their prescribed medication regimen. DISCUSSION/SIGNIFICANCE: Medication adherence rates in the U.S are agreed upon to be about 50% - highly relevant to healthcare practitioners since several studies suggest a correlation between adherence and improved health outcomes. Pharmacists must be knowledgeable about non-adherence tools and consider patient characteristics when recommending an adherence aid.

Managing Older Adults' Chronic Pain: Higher-Risk Interventions.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. This new group of articles provides practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses.

Potentially Inappropriate Medications and Regimen Complexity on Readmission of Elderly Patients with Polypharmacy: A Retrospective Study

Other SectionsAbstractBodyMaterials and MethodsResultsDiscussionConclusionsConflicts of InterestTableReference

Limiting Factors in Implementing Pharmacovigilance Principles in the Elderly.

The overarching aim of pharmacovigilance is to ensure the safe and effective usage of medication across the population and optimise medicines through holistic considerations. However, within the heterogeneous elderly population, several unique factors are at play, limiting the ability of clinicians to fulfil this aim. A matured physiology influencing the response and effects of drugs, increased polypharmacy enabling drug-drug interactions, and greater consumption of concurrent herbal medicines predispose patients to harmful drug events. This increasingly multimorbid subpopulation requires complex pharmaceutical regimens encouraging inappropriate prescribing and medicine non-adherence leading to suboptimal therapy. Furthermore, restrictive practices in clinical trials commonly exclude elderly patients creating disparities from expected findings within a real-world setting. These issues create an environment where elderly patients are at a heightened risk of adverse drug events and clinicians are forced to make significant decisions from limited information. With projections showing that this demographic will continue growing in size, the true burden of these limiting factors is yet to be realised.

Attitude towards deprescribing and its association with frailty and complexity of medication regimen: A survey of older inpatients in a district health board in New Zealand

BackgroundOlder inpatients, particularly those with frailty, have increased exposure to complex medication regimens. It is not known whether frailty and complexity of medication regimens influence attitudes toward deprescribing. This study aimed to investigate (1) older inpatients’ attitudes toward deprescribing; (2) if frailty and complexity of medication regimen influence attitudes and willingness to deprescribe - a relationship that has not been investigated in previous studies.MethodsIn this cross-sectional study, older adults (≥ 65 years) recruited from general medicine and geriatric services in a New Zealand hospital completed the revised Patients’ Attitudes Towards Deprescribing (rPATD) questionnaire. Hospital frailty risk score (HFRS) was calculated using diagnostic codes and other relevant information present at the time of index hospital admission; higher scores indicate higher frailty risk. Medication regimen complexity was quantified using the medication regimen complexity index (MRCI); higher scores indicate greater complexity. Logistic regression analysis was used to identify predictors of attitudes and willingness to deprescribe.ResultsA total of 222 patients were included in the study, the median age was 83 years and 63% were female. One in two patients reported feeling they were taking too many medications, and 1 in 5 considered their medications burdensome. Almost 3 in 4 (73%) wanted to be involved in decision-making about their medications, and 4 in 5 (84%) were willing to stop one or more of their medications if their prescriber said it was possible. Patients with higher MRCI had increased self-reported medication burden (adjusted odds ratio (AOR) 2.6, 95% CI 1.29, 5.29) and were more interested in being involved in decision-making about their medications (AOR 1.8, CI 0.99, 3.42) than those with lower MRCI. Patients with moderate HFRS had lower odds of willingness to deprescribe (AOR 0.45, CI 0.22,0.92) compared to the low-risk group. Female patients had a lower desire to be involved in decision-making. The oldest old age group( > 80 years) had lower self-reported medication burden and were less likely to want to try stopping their medications.ConclusionMost older inpatients wanted to be involved in decision-making about their medications and were willing to stop one or more medications if proposed by their prescriber. Medication complexity and frailty status influence patients’ attitudes toward deprescribing and thus should be taken into consideration when making deprescribing decisions. Further research is needed to investigate the relationship between frailty and the complexity of medication regimens.

Interrupting Biases in the Experience and Management of Pain Nurses can help address challenges faced by racially and ethnically diverse patients and caregivers.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home. The articles in this new installment of the series provide practical information nurses can share with family caregivers of persons living with pain. To use this series, nurses should read the articles first, so they understand how best to help family caregivers. Then they can refer caregivers to the informational tear sheet-Information for Family Caregivers-and instructional videos, encouraging them to ask questions. For additional information, see Resources for Nurses. Cite this article as: Booker, S.Q., et al. Interrupting Biases in the Experience and Management of Pain. Am J Nurs 2022; 122(9): 48-54.

Medication Regimen Complexity Index Score at Admission as a Predictor of Inpatient Outcomes: A Machine Learning Approach

In the intensive care unit, traditional scoring systems use illness severity and/or organ failure to determine prognosis, and this usually rests on the patient's condition at admission. In spite of the importance of medication reconciliation, the usefulness of home medication histories as predictors of clinical outcomes remains unexplored. A retrospective cohort study was conducted using the medical records of 322 intensive care unit (ICU) patients. The predictors of interest included the medication regimen complexity index (MRCI) at admission, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Sequential Organ Failure Assessment (SOFA) score, or a combination thereof. Outcomes included mortality, length of stay, and the need for mechanical ventilation. Machine learning algorithms were used for outcome classification after correcting for class imbalances in the general population and across the racial continuum. The home medication model could predict all clinical outcomes accurately 70% of the time. Among Whites, it improved to 80%, whereas among non-Whites it remained at 70%. The addition of SOFA and APACHE II yielded the best models among non-Whites and Whites, respectively. SHapley Additive exPlanations (SHAP) values showed that low MRCI scores were associated with reduced mortality and LOS, yet an increased need for mechanical ventilation. Home medication histories represent a viable addition to traditional predictors of health outcomes.