Increased Medication Use Research Articles

The use of a frailty index to predict adverse health outcomes (falls, fractures, hospitalization, medication use, comorbid conditions) in people with intellectual disabilities.

Frailty in older people can be seen as the increased likelihood of future negative health outcomes. Lifelong disabilities in people with intellectual disabilities (ID) may not only influence their frailty status but also the consequences. Here, we report the relation between frailty and adverse health outcomes in older people with ID (50 years and over). In a prospective population based study, frailty was measured at baseline with a frailty index in 982 older adults with ID (≥50 yr). Information on negative health outcomes (falls, fractures, hospitalization, increased medication use, and comorbid conditions) was collected at baseline and after a three-year follow-up period. Odds ratios or regression coefficients for negative health outcomes were estimated with the frailty index, adjusted for gender, age, level of ID, Down syndrome and baseline adverse health condition. The frailty index was related to an increased risk of higher medication use and several comorbid conditions, but not to falls, fractures and hospitalization. Frailty at baseline was related to negative health outcomes three years later in older people with ID, but to a lesser extent than found in the general population.

Regression from prediabetes to normal glucose regulation is associated with reduction in cardiovascular risk: results from the Diabetes Prevention Program outcomes study.

OBJECTIVERestoration of normal glucose regulation (NGR) in people with prediabetes significantly decreases the risk of future diabetes. We sought to examine whether regression to NGR is also associated with a long-term decrease in cardiovascular disease (CVD) risk.RESEARCH DESIGN AND METHODSThe Framingham (2008) score (as an estimate of the global 10-year CVD risk) and individual CVD risk factors were calculated annually for the Diabetes Prevention Program Outcomes Study years 1–10 among those patients who returned to NGR at least once during the Diabetes Prevention Program (DPP) compared with those who remained with prediabetes or those in whom diabetes developed during DPP (N = 2,775).RESULTSThe Framingham scores by glycemic exposure did not differ among the treatment groups; therefore, pooled estimates were stratified by glycemic status and were adjusted for differences in risk factors at DPP baseline and in the treatment arm. During 10 years of follow-up, the mean Framingham 10-year CVD risk scores were highest in the prediabetes group (16.2%), intermediate in the NGR group (15.5%), and 14.4% in people with diabetes (all pairwise comparisons P < 0.05), but scores decreased over time for those people with prediabetes (18.6% in year 1 vs. 15.9% in year 10, P < 0.01). The lower score in the diabetes group versus other groups, a declining score in the prediabetes group, and favorable changes in each individual risk factor in all groups were explained, in part, by higher or increasing medication use for lipids and blood pressure.CONCLUSIONSPrediabetes represents a high-risk state for CVD. Restoration of NGR and/or medical treatment of CVD risk factors can significantly reduce the estimated CVD risk in people with prediabetes.

Do stimulant medications improve educational and behavioral outcomes for children with ADHD?

We examine the effects of a policy change in the province of Quebec, Canada which greatly expanded insurance coverage for prescription medications. We show that the change was associated with a sharp increase in the use of stimulant medications commonly prescribed for ADHD in Quebec relative to the rest of Canada. We ask whether this increase in medication use was associated with improvements in emotional functioning or academic outcomes among children with ADHD. We find little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit and may have had harmful effects given the average way these drugs are used in the community.

Physical Injury, PTSD Symptoms, and Medication Use: Examination in Two Trauma Types

Physical injury is prevalent across many types of trauma experiences and can be associated with posttraumatic stress disorder (PTSD) symptoms and physical health effects, including increased medication use. Recent studies suggest that PTSD symptoms may mediate the effects of traumatic injury on health outcomes, but it is unknown whether this finding holds for survivors of different types of traumas. The current study examined cross-sectional relationships between injury, PTSD, and pain and psychiatric medication use in 2 trauma-exposed samples, female survivors of motor vehicle accidents (MVAs; n= 315) and intimate partner violence (IPV; n= 167). Data were obtained from participants at 2 trauma research clinics who underwent a comprehensive assessment of psychopathology following the stressor. Regression with bootstrapping suggested that PTSD symptoms mediate the relationship between injury severity and use of pain medications, R(2) = .11, F(2, 452)= 28.37, p< .001, and psychiatric medications, R(2) = .06, F(2, 452)= 13.18, p< .001, as hypothesized. Mediation, however, was not moderated by trauma type (ps > .05). Results confirm an association between posttraumatic psychopathology and medication usage and suggest that MVA and IPV survivors alike may benefit from assessment and treatment of emotional distress after physical injury.

The Burden of Comedication Among Patients with Inflammatory Bowel Disease

Polypharmacy is of growing concern in the chronically ill, including individuals with inflammatory bowel disease (IBD). The authors aimed to describe the prevalence and predictors of non-IBD medication use and to compare drug use among individuals with and without IBD. This cross-sectional study included members of health plans included in the Thomson Reuters MarketScan databases with continuous enrollment during 2009 and 2010. Patients with IBD were identified through diagnosis codes and IBD medication dispensings and matched to 5 individuals without IBD. The prevalences of dispensed prescriptions for analgesics (narcotics, nonnarcotics), psychiatric medications (anxiolytics/sedatives/hypnotics, antidepressants), and broad drug classes defined by the Anatomic Therapeutic Classification system were estimated. Predictors of non-IBD medication use and comparisons of drug use by IBD status were evaluated using logistic regression. The prevalence of medication use was higher among patients with IBD than matched members of the general population for nearly every drug class examined, including narcotic analgesics (48.1% versus 34.1%), nonnarcotic analgesics (12.8% versus 8.1%), anxiolytics/sedatives/hypnotics (25.8% versus 16.7%), and antidepressants (28.3% versus 19.4%). Medicaid insurance, middle age, gastrointestinal surgery, Crohn's disease, and increasing number of inpatient, and outpatient, and prescription events were significantly associated with analgesic and psychiatric medication use among patients with IBD. Psychiatric drug dispensings were more common among female IBD patients than male patients. Patients with IBD have increased medication use, particularly of analgesic and psychiatric drugs. IBD care providers should be aware of polypharmacy and its potential for drug interactions.

Neuropsychological, Physical, and Functional Mobility Measures Associated With Falls in Cognitively Impaired Older Adults

Older people with cognitive impairment have an elevated fall risk, with 60% falling annually. There is a lack of evidence for fall prevention in this population, in part due to limited understanding of risk factors. This study examined fall risk in older people with cognitive impairment with an emphasis on identifying explanatory and modifiable risk factors. One hundred and seventy-seven community-dwelling older people with mild-moderate cognitive impairment (Mini-Mental State Examination 11-23/Addenbrooke's Cognitive Examination-Revised <83) underwent neuropsychological, physical, and functional assessments. Falls were recorded prospectively for 12 months with the assistance of carers. Of the 174 participants available to follow-up, 111 (64%) fell at least once and 71 (41%) at least twice. Higher fall rates were associated with slower reaction time, impaired balance (sway on floor and foam, semitandem, near-tandem, tandem stance), and reduced functional mobility (co-ordinated stability, timed up-and-go, steps needed to turn 180°, sit-to-stand, gait velocity). Higher fall rates were also associated with increased medication use (central nervous system, total number) and poorer performances in cognitive (Addenbrooke's Cognitive Examination-Revised: visuospatial domain, cube drawing; Trail-Making Test) and psychological (Geriatric Depression Scale, Goldberg Anxiety Scale, Falls Efficacy Scale-International) tests. Multivariate analysis identified increased sway on foam, co-ordinated stability score, and depressive symptoms to be significantly and independently associated with falls while controlling for age, years of education, and Addenbrooke's Cognitive Examination-Revised score. This study identified several risk factors of falls in older people with cognitive impairment, a number of which are potentially modifiable. Future research involving targeted interventions addressing medication use, balance, mood, and functional performance may prove useful for fall prevention in this population.

Adverse Drug Reaction Labelling for Atomoxetine, Methylphenidate and Modafinil: Comparison of Product Information for Oral Formulations in Australia, Denmark and the United States

Objective Hyponatraemia is a serious adverse event commonly reported in elderly people treated with serotonergic antidepressants. The mechanism, incidence and risk factors for antidepressant induced hyponatraemia are not fully understood. Method In a retrospective chart analysis, depressed patients aged >63 years were investigated for change in serum sodium levels between two time points, separated by a median period of 45.5 days, with the first specimen taken prior to treatment. Patients were grouped into three cohorts; treated with an SSRI or SNRI (n=77), treated with an antidepressant other than an SSRI or SNRI (n=54) and not treated with an antidepressant (n=128). Results For change in sodium level between measurements and total number of patients with hyponatraemia, there was no significant difference between cohorts. However, the rate of reduction of serum sodium levels between time points was significantly greater for SSRI and SNRI treated patients (p<0.001) and patients treated with other antidepressants (p=0.03) compared to patients not treated with antidepressants. Moreover, the distribution of values of change in serum sodium was skewed towards reduced serum sodium in patients treated with SSRI or SNRIs (skew -0.43) and patients treated with other antidepressants (skew -0.09) but not for patients without antidepressants (skew 0.25). Conclusions These data suggest that antidepressant treatment is associated with hyponatraemia affecting a subgroup of individuals only. Generalised linear modelling showed that the risk of hyponatraemia increases with increased age, female gender, and particularly the antidepressant agents sertraline and escitalopram. The findings are of clinical significance as they demonstrate that hyponatraemia can occur rapidly with antidepressants, and SSRI/SNRI medications induce more rapid changes. They support the use of electrolyte monitoring early in antidepressant treatment in patients receiving antidepressants.

CV Risk Persists in RA Patients despite Increased Medication Use for Both

CV Risk Persists in RA Patients despite Increased Medication Use for Both

Oral Chemotherapy & Biotherapy: Effective Care and Support for Patients

Background: Oral anti-cancer medications are increasingly a part of standard chemotherapy regimens. Clinicians and patients alike overwhelmingly prefer oral chemotherapy to traditional intravenous chemotherapy. However, the side effect profiles of oral chemotherapy agents are often just as severe as IV chemotherapy medications that are given under the close supervision of health-care professionals. This leaves a significant ‘care gap’ for those taking oral chemotherapy as the development of evidence-based care standards has not kept pace with the increasing use of these medications. Purpose: The purpose of this study is to explore current practice to support patients taking oral chemotherapy at the BC Cancer Agency and to make specific recommendations for future practice based on current literature. Methods: An electronic literature review utilizing the databases PubMed, CINAHL, and the Cochrane Library resulted in 140 identified peer-reviewed journal articles, of which 31 were deemed relevant and retrieved. Additionally, a qualitative cross sectional survey was administered to the regional nursing and pharmacy leaders of the six (6) Regional BC Cancer Agency Centers to gain understanding of current practice. Findings: Models of care identified in the literature for patients receiving oral chemotherapy and biotherapy include: Nurse/Pharmacy led clinics, Automated Voice System Response, and Home Care Nursing. Inconsistent practice within nursing and pharmacy was identified across the Regional BC Cancer Centers. Recommendations based on findings include: Provision of patient/family centered education, increased support to patients throughout their first cycle of oral chemotherapy, and development of consistent protocols for nursing and pharmacy across the BC Cancer Agency.

PDB88 - Impact of medicare part d: Comparison of health care expenditures and utilization for medicare patients with diabetes

To compare overall and diabetes-related health care utilization and expenditures in Medicare beneficiaries with diabetes prior to and after implementation of Part D. Data were from the 2001-2010 Medical Expenditure Panel Survey. Medicare beneficiaries aged ≥65 years with self-reported diabetes were identified, excluding individuals who were Medicare-Medicaid dual eligible, had TRICARE, or other public coverage. The outcomes included overall and diabetes-related prescriptions, medical services utilization, and expenditures as well as out-of-pocket costs. These outcomes were analyzed using generalized linear model regression models with a log-link and gamma (for costs) or Poisson (utilization) distribution. All expenditures were inflated to 2010 dollars. STATA survey commands were used to account for the complex survey design. There were 21,864 eligible Medicare beneficiaries with diabetes that comprised the sample population. After adjusting for sociodemographic characteristics and health status, implementation of Part D was associated with decreased out-of-pocket expenditures for insulin (Coeff.: -0.577, p<0.05) and oral antidiabetic agents (Coeff.:-1.292, p<0.001). No statistically significant effect on total health care and prescription expenditures were found. Implementation of Part D was associated with increased number of prescriptions filled (Coeff.: 0.145, p< 0.001) without increase in emergency room visits or inpatient stays. The implementation of Medicare Part D increased medication use and reduced out-of-pocket costs for elderly diabetes patients. This reduction would allow for enhanced access to necessary medications, and thereby may have a positive impact on adherence and health outcomes.

143 TRENDS AND VARIATION IN MEDICAL MANAGEMENT OF MEN WITH BENIGN PROSTATIC HYPERPLASIA AND LOWER URINARY TRACT SYMPTOMS (1993-2010)

INTRODUCTION AND OBJECTIVES: Management options for men with benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) have evolved over the last 15 years. We used a population-based survey to describe historical trends and variation in medical management of men with BPH/LUTS in the United States. METHODS: We used the National Ambulatory Medical Care Survey (1993-2010) to evaluate outpatient office visits by men with BPH/LUTS. Visits for BPH/LUTS were based on ICD-9 diagnosis codes for BPH and/or patient self-report of LUTS. Prescriptions of interest included -blockers (AB), 5reductase inhibitors (5ARI), and anticholinergics (AC). Standardized survey weights were applied to obtain national estimates. Data from multiple years were occasionally combined to ensure statistical reliability. Linear trends over time were analyzed using 2 tests. Factors associated with AB use were evaluated with 2 tests and multivariable logistic regression. All tests were performed to the 5% level of significance. RESULTS: From 1993-2010, there were over 141 million outpatient visits for men with BPH/LUTS. Among these visits, ABs were prescribed most commonly, increasing from 6.4% of visits in 1993 to nearly 30% in 2010 (p 0.01). Use of 5ARIs increased from 3.8% of visits in 1993-1994 to 14.3% of visits in 2009-2010 (p 0.01). Use of ACs also increased, from 2.3% of visits in 1999-2000 to 8.2% of visits in 2009-2010. Use of terazosin decreased from 78% of AB prescriptions from 1993-1995 to 12% from 2008-2010 (Figure). In the modern era, tamsulosin was the most common AB prescribed, representing 61% of prescriptions from 2008-2010 (Figure). Use of AB did not vary by race, region, or insurance status (all p 0.05). Compared to primary care physicians, urologists were no more likely to prescribe ABs prior to the introduction of tamsulosin (OR 0.88, 95% CI 0.57-1.35). However, after tamsulosin was available, urologists were nearly twice as likely to prescribe ABs (OR 1.92, 95% CI 1.41-2.62). CONCLUSIONS: Over the past 15 years, there has been a steady increase in use of medications to manage men with BPH. Urologists were more likely to prescribe ABs after tamsulosin was available, suggesting that urologists may adopt novel medications more readily that primary care providers. Source of Funding: NIH T32 Clinical Training Grant.

Antipsychotic Use by Medicaid-Insured Youths: Impact of Eligibility and Psychiatric Diagnosis Across a Decade

This cross-sectional study evaluated the impact of Medicaid-eligibility category on the increased use of antipsychotic medication by Medicaid-insured youths across a decade. The authors analyzed computerized administrative claims data for 456,315 youths aged two to 17 years who were continuously enrolled in Medicaid in a mid-Atlantic state in 1997 (N=159,171) and 2006 (N=297,144). Bivariate and multivariable analyses quantified changes in antipsychotic use in relation to the youths' psychiatric diagnosis and eligibility category (Temporary Assistance for Needy Families [TANF], state Children's Health Insurance Program [SCHIP], Supplemental Security Income [SSI], and foster care). A second multivariable regression model examined changes in demographic and clinical characteristics of antipsychotic users with a psychiatric diagnosis. The prevalence of antipsychotic use increased from 1.2% in 1997 to 3.2% in 2006. The increase in odds of antipsychotic use in 2006 was greatest among youths enrolled in SCHIP (adjusted odds ratio [AOR]=5.9), followed by youths enrolled in foster care (AOR=4.1), TANF (AOR=3.6), and SSI (AOR=2.8). Among users of antipsychotics who had a psychiatric diagnosis, youths with externalizing behavior disorders and bipolar disorder had 2.4- to 3.8-fold greater odds of using antipsychotics in 2006 versus 1997 compared with youths with schizophrenia or other psychoses and pervasive developmental disorders. The proportion of youths using antipsychotics between 1997 and 2006 increased significantly more among African Americans and Hispanics than among whites. The expansion of antipsychotic use was most prominent among youths who were Medicaid eligible because of low family income (SCHIP) and reflects increased medication use for behavioral problems.

1246 – Medico-economic impact of a suicide attempt on the relatives of the suicide attempter

A suicide attempt is an major event that creates harm on both family and close relatives, that can be measured in terms of traumatic stress and medico-economic impact (costs). Each year, 3.750.000 French people are concerned by a suicide attempt of a relative (or close person). Male or female, older than 16, being a relative of a suicide attempter (i.e. living in the same house as the suicide attempter). 171 families were included (171 suicide attempters and 171 « family informants »). These subjects were compared to IRDES datas on French population (Institute of Research and Documentation on Health Economy ; sample of 20.000 subjects, representing 95% of the French families). All subjects were reassessed by phone at 3 month and 1 year. 80% of the relatives declare “being fine” at 1 year; the 20% that declare being “not so well” are important to qualify, the sooner after the suicide attempt. An explicative model trying to evaluate the risk of being “not so well” at 1 year is possible ; this model is highly represented by the psychotraumatic impact of the confrontation with the suicide attempt. On the economic plan, we can observe a great stability in healthcare contacts at 1 year (hospitalizations, GP or Specialists contacts, other kind of care contact…), contrasting with a big increase in medication use (× 2.37 in comparison with IRDES population); all the medication types being concerned, psychotropic and others. The question of a self-medication partly unconscious is raised.

Advances in pediatric asthma in 2012: Moving toward asthma prevention

Last year's "Advances in pediatric asthma: moving forward" concluded the following: "Now is also the time to utilize information recorded in electronic medical records to develop innovative disease management plans that will track asthma over time and enable timely decisions on interventions in order to maintain control that can lead to disease remission and prevention." This year's summary will focus on recent advances in pediatric asthma on modifying disease activity, preventing asthma exacerbations, managing severe asthma, and risk factors for predicting and managing early asthma, as indicated in Journal of Allergy and Clinical Immunology publications in 2012. Recent reports continue to shed light on methods to improve asthma management through steps to assess disease activity, tools to standardize outcome measures in asthma, genetic markers that predict risk for asthma and appropriate treatment, and interventions that alter the early presentation of asthma to prevent progression. We are well on our way to creating a pathway around wellness in asthma care and also to use new tools to predict the risk for asthma and take steps to not only prevent asthma exacerbations but also to prevent the early manifestations of the disease and thus prevent its evolution to severe asthma.

P189 Reduced COPD Exacerbations Associated with Aclidinium Bromide Versus Placebo: A Pooled Analysis of Phase III Data

Introduction and objectiveAclidinium bromide is a novel, long-acting, inhaled muscarinic antagonist indicated for the treatment of chronic obstructive pulmonary disease (COPD). COPD is characterised by periodic worsening of symptoms (exacerbations)...

“Tight Control” in Geriatrics: The Emperor Wears a Thong

The deep-seated faith in tight glycemic control for patients with type 2 diabetes mellitus shows signs of moderating, especially for elderly adults, but faith in the importance of a glycosylated hemoglobin goal of 7% retains a strong influence over many clinicians. This faith persists despite weak evidence from randomized controlled trials of any meaningful benefit from "tight control" in any patient group, consistent evidence of lack of benefit for many outcomes, and an almost complete lack of evidence about elderly adults or those with extensive vascular disease. Clinicians who care for these vulnerable individuals face a strong public belief in "tight control" and an orchestrated campaign to increase medication use. Although no benefit has been shown in elderly adults, some harms are clear, and others are likely.

Just Because It’s Low Cost Doesn’t Mean It’s Accessible

Just Because It’s Low Cost Doesn’t Mean It’s Accessible

Integrating asthma education and smoking cessation for parents: Financial return on investment

Caregivers who smoke and have children with asthma are an important group for intervention. Home-based interventions successfully reduce asthma morbidity, yet are costly. This study evaluated the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program, a combined asthma education and smoking cessation intervention. Participants included caregivers (n = 224) that smoked, had a child with asthma, and were enrolled in a Medicaid managed care plan. Participants received nurse-delivered asthma education and smoking counseling in three home visits. Program implementation costs were estimated, and healthcare expenses were obtained from insurance claims data 12 months pre- and 12 months post intervention. ROI was calculated for all participants, children <6 years, children 6-18 years, and children with moderate/severe persistent asthma. Total program implementation cost was $34,481. After intervention, there was increased mean annual refills of beta-agonist (0.51 pre, 1.64 post; P < 0.001), and controller medications (0.65 pre, 2.44 post; P < 0.001). Reductions were found in mean annual emergency department visits (0.33 pre, 0.14 post; P < 0.001), hospitalizations (0.23 pre, 0.08 post; P < 0.001), and outpatient visits (2.33 pre, 1.45 post, P < 0.001). The program had negative ROI (-21.8%) for the entire sample. The ROI was positive (+106.9) for children <6 years, negative (-150.3) for children 6-18, and negligible for moderate/severe persistent asthma (+6.9%). PAQS was associated with increased medication use and decreased healthcare utilization. While the overall ROI for PAQS was negative, PAQS had a positive ROI for caregivers of young children with asthma.

Trends in stroke incidence rates and stroke risk factors in Rotterdam, the Netherlands from 1990 to 2008

Stroke incidence rates have decreased in developed countries over the past 40 years, but trends vary across populations. We investigated whether age-and-sex-specific stroke incidence rates and associated risk factors as well as preventive medication use have changed in Rotterdam in the Netherlands during the last two decades. The study was part of the Rotterdam Study, a large population-based cohort study among elderly people. Participants were 10,994 men and women aged 55–94 years who were stroke-free at baseline. Trends were calculated by comparing the 1990 subcohort (n = 7516; baseline 1990–1993) with the 2000 subcohort (n = 2883; baseline 2000–2001). Poisson regression was used to calculate incidence rates and incidence rate ratios in age-and-sex-specific strata. We further compared the prevalence of stroke risk factors and preventive medication use in the two subcohorts. In the 1990 subcohort 467 strokes occurred during 45,428 person years; in the 2000 subcohort 115 strokes occurred in 18,356 person years. Comparing the subcohorts, incidence rates decreased by 34% in men, but remained unchanged in women. Blood pressure levels increased between 1990 and 2000, whereas the proportion of current cigarette smokers decreased in men, but not in women. There was a strong increase in medication use for treatment of stroke risk factors across all age categories in both sexes. Our findings suggest that in Rotterdam between 1990 and 2008 stroke incidence rates have decreased in men but not in women.

Patient characteristics associated with polypharmacy and inappropriate prescribing of medications among older adults with cancer

OBJECTIVES: To identify patient characteristics associated with polypharmacy and inappropriate medication (PIM) use among older patients with newly diagnosed cancer. DESIGN: Cross-Sectional Study. SETTING: Ambulatory oncology clinics at an academic medical center. PARTICIPANTS: 117 patients aged ≥ 65 years with newly diagnosed histologically confirmed stage I-IV cancer were enrolled between April 2008 and September 2009. MEASUREMENTS: Medication review, included patient self-report and medical records. Polypharmacy was defined as the concurrent use of ≥ five medications, (Yes/No). PIM use was defined as use of ≥ one medication included in the 2003 update of Beers Criteria, (Yes/No). RESULTS: The prevalence of polypharmacy and PIM use were 80% and 41%, respectively. Three independent correlates of medication use were identified. An increase in comorbidity count by one, ECOG-PS score by one, and PIM use by one, was associated with an increase in medication use by 0.48 (P=0.0002), 0.79 (P=0.01) and 1.22 (P=0.006), respectively. Two independent correlates of PIM use were identified. The odds of using PIMs decreased by 10% for one unit increase in Body Mass Index [Odds Ratio (OR) 0.90, 95% CI = (0.84, 0.97)], and increased by 18% for each increase in medication count by one [OR 1.18, 95% CI = (1.04, 1.34)]. CONCLUSION: There was a high prevalence of polypharmacy and PIM use in older patients with newly diagnosed cancer. Given the co-occurrence of polypharmacy with poor performance status and multi-morbidity, multi-dimensional interventions are needed in the geriatric-oncology population to improve health and cancer outcomes.