Simplify Medication Regimens Research Articles

Reducing medication regimen complexity for older patients prior to discharge from hospital: feasibility and barriers

Older hospital inpatients are often prescribed complex multi-drug regimens; increased regimen complexity is associated with poorer medication adherence and treatment outcomes. There has been little research into methods for reducing regimen complexity. The objective of this study was to explore the feasibility of incorporating medication regimen simplification into routine clinical pharmacist care for older hospital inpatients and identify barriers to regimen simplification at a major teaching hospital. Following an educational intervention, clinical pharmacists were encouraged to minimize regimen complexity for their patients by identifying potential simplifications during routine medication regimen reviews (e.g. medication chart reviews, discharge prescription reviews) and discussing these changes with hospital doctors and patients. Pharmacists completed a data collection form for patients aged 60 years or above discharged from their wards during the study period (n = 205; mean age, 81.3 years), indicating whether they had reviewed the patient's medication regimen complexity (and if not why), whether any changes to simplify the regimen were identified, and whether changes were successfully implemented (and if not why). Pharmacists reviewed medication regimen complexity for 173/205 (84.4%) patients and identified 149 potential changes to reduce regimen complexity for 79/173 (45.7%) reviewed patients. Ninety-four (63.1%) changes were successfully implemented in 54/205 (26.3%) patients. Regimens were simplified more often for patients discharged from subacute aged care (geriatric assessment and rehabilitation) wards compared with acute general medicine wards. The most commonly cited reason for not reviewing regimen complexity and not implementing identified simplification-related changes was 'lack of time'. Non-acceptance of pharmacist recommendations by patients or doctors were other common reasons for not implementing changes. This is the first study to explore pharmacist-led medication regimen simplification and barriers to regimen simplification in the hospital setting. It demonstrates that simplification of older inpatients' regimens is feasible when training in regimen simplification is provided. The main barrier to regimen simplification appears to be lack of pharmacist time.

Strategies for Increasing Treatment Adherence in Bipolar Disorder

Although bipolar disorder cannot be cured, effective medications are available that can shorten the duration of illness episodes and reduce the rates of relapse. Unfortunately, treatment nonadherence is common among patients with bipolar disorder. Factors contributing to nonadherence vary, and nonadherence can be deliberate or accidental. Strategies to improve medication adherence include forming a strong alliance with patients, educating patients and their caregivers about the disorder and the importance of adherence, simplifying medication regimens, monitoring tolerability and proactively addressing adverse effects, and treating comorbid illnesses.

Interventions to Enhance Adherence to Medications in Patients With Heart Failure

Prognosis remains poor for patients with chronic heart failure (CHF), despite improvements in the prevention and treatment of heart failure over the last 25 years. Recent estimates indicate that the median survival after a first episode of heart failure is 2.3 years for men and 1.8 years for women.1 It is suggested that the improvements in outcomes that have been achieved can be partly explained by increases in prescribing rates of medications such as angiotensin-converting enzyme inhibitors,2 β-blockers,3 and spironolactone4 over this period.1 Although the evidence on medication efficacy for certain subgroups of patients with CHF is clear, there are also compelling data showing that many of these patients do not take their medications as prescribed by health care providers.5,6 This “nonadherence” to medication therefore remains a significant barrier to enhancing the effectiveness of existing treatments. Estimates for nonadherence to medications in CHF have varied widely.5 One of the largest studies found that only 80% of patients with a prescription for angiotensin-converting enzyme inhibitors at hospital discharge completed the prescription form 30 days after discharge, and this rate subsequently fell to 60% over 1 year.7 Full adherence, defined as filing enough prescriptions to have daily medication available for 1 year, may be as low as 10% in CHF.8 Poor adherence to medication in CHF is associated with worse outcomes in observational studies, including shorter event-free survival.9 Therefore, strategies to enhance adherence provide a potentially valuable strategy for improving survival, reducing hospitalization and managing patient symptoms in CHF. In this report, we provide an up-to-date review and analysis of those studies that have developed and evaluated medication adherence interventions in CHF. Because CHF is typically symptomatic and includes medication with actions that are discernible to the patient within hours …

Quantifying home medication regimen changes and quality of life in patients receiving nocturnal home hemodialysis

Medication regimen simplification may improve adherence in end-stage kidney disease. The effect of nocturnal home hemodialysis (NHHD) on medication burden is unknown. A retrospective pilot study of NHHD patients was conducted. Medication information was collected at baseline, NHHD start, and at 3, 6, 12, 18, and 24 months. SF-36 scores were collected at baseline, 6, 12, and 24 months. The number of medications, pill burden, and number of administrations per day were determined. Medication Regimen Complexity Index was used at each time point as a comparator. Medications for anemia, mineral and bone disorders (MBD), cardiovascular (CV) disease, infection, and vitamins were analyzed for number of medications and pill burden. Thirty-five patients were included. Patients used 10.5 ± 4.4 medications at baseline and 11.8 ± 4.7 at the end of the study (P=NS). Regarding the number of medications, anemia medications, anti-infectives, and vitamins increased; MBD and CV medications decreased by the end of the study. Total pill burden did not change over 24 months, nor did anemia pill burden. Mineral bone disorder and CV pill burden decreased, and vitamins and anti-infective pill burden increased. Daily medication administration times decreased significantly from 5.0 ± 1.5 to 3.6 ± 1.5 by 24 months. Switching to NHHD was associated with a significant increase in Medication Regimen Complexity Index at 24 months (P<0.05). SF-36 scores increased significantly once patients began on NHHD. No measure of medication regimen complexity was correlated with the SF-36 score. Medication burden changes over time after starting NHHD. It is unknown what effect NHHD has on adherence or medication costs, and warrants further study in a prospective comparative investigation.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

This study sought to identify and characterize rates of clinically questionable prescribing in New York State. As part of a quality improvement initiative, 34 national psychopharmacology experts identified a set of questionable prescribing practices recognizable from pharmacy claims data. Indicators of such practices were applied to Medicaid claims data for 217,216 beneficiaries in New York State who had an active psychotropic prescription on April 1, 2008. A total of 156,103 (72%) of these beneficiaries had one or more continuing (>90 days) prescriptions for a psychotropic. About 10% of adults were prescribed four or more psychotropics concurrently, and 13% of children and 2% of older adults were prescribed three or more concurrently. Prescribing an antipsychotic with a moderate-to-high risk of causing metabolic abnormalities approached 50% (46%) among individuals who had existing cardiometabolic conditions. Among beneficiaries prescribed second-generation antipsychotics with a moderate-to-high risk of causing metabolic abnormalities, over half (60%) had not received a metabolic screening test in the past year. Among women of reproductive age prescribed mood stabilizers, over one-quarter (30%) were prescribed a valproic acid-based formulation despite its potential for teratogenicity. Only 2% of youths under age 18 were prescribed benzodiazepines; however, about half (48%) had trials over 90 days' duration. Examination of pharmacy claims from Medicaid beneficiaries in New York State indicated that prescribing practices deemed clinically questionable by pharmacology experts are common. Aggregated pharmacy claims data can identify such practices, and reviews of these data can be a core component of efforts to improve prescribing practices.

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

Identifying Clinically Questionable Psychotropic Prescribing Practices for Medicaid Recipients in New York State

A Clinician's Guide to the Assessment and Management of Nonadherence in Glaucoma

To apply lessons learned in the treatment of systemic hypertension to the problem of nonadherence in glaucoma medical therapy. Although physicians recognize that nonadherence with glaucoma medication is a problem, most lack the skill set to identify nonadherent patients, to identify the causes of nonadherence, and to provide solutions to address nonadherence. A PubMed search was conducted using the terms "adherence" OR "compliance" AND "hypertension," with the following limitations: title, English language, humans, from 2000 through 2009. Other studies identified outside of the PubMed search were included if relevant. Studies from the systemic hypertension literature suggest that simplifying medication regimens, lowering costs, and patient education about the disease and the importance of taking medications are successful strategies for improving adherence. In addition, good family or social support, frequent physician visits, and pairing medication administration with specific activities (such as meals or brushing one's teeth) can help improve adherence. The body of literature on adherence interventions in chronic diseases such as systemic hypertension shows that although many interventions have been tested and evaluated, only some are successful. Paradigms derived from behavioral medicine and nursing offer valuable lessons on how to motivate patients to change behavior, but these activities require skill sets not traditionally taught in medical school. Just as there are myriad causes of nonadherence, the interventions most likely will need to be multifaceted and tailored to the individual patient. Proprietary or commercial disclosure may be found after the references.

Addition of antipsychotics to medication regimens during schizophrenic inpatient care

The objective of the present study was to identify schizophrenia inpatients who had their original regimen augmented with additional antipsychotics during acute inpatient care, and to clarify the factors associated with these additions. The subjects were 204 schizophrenia inpatients at 34 acute care hospitals, of whom 42 (20.6%) had further antipsychotics added to their medication regimen during hospitalization. Compared with patients who were not prescribed additional antipsychotics, the subjects were typically discharged with higher dosages of antipsychotics, principally low-potency medications. Patients who exhibited aggressive behavior, who had no physical illness, or whose psychiatrists preferred typical antipsychotics, were more likely to be prescribed additional new antipsychotics. Alternative approaches such as intensive care for aggressive patients and educational intervention with psychiatrists may prove useful in stabilizing patients without adding new antipsychotics unless absolutely necessary, and in simplifying medication regimens.

Increasing Use of Single and Combination Medical Therapy in Patients Hospitalized for Acute Myocardial Infarction in the 21st Century&lt;subtitle&gt;A Multinational Perspective&lt;/subtitle&gt;

Current practice guidelines recommend the routine use of several effective cardiac medications in hospital survivors of acute myocardial infarction (AMI). We explored a recent 5-year (2000-2005) trend in hospital use of aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, lipid-lowering agents, and combinations thereof, in 26 413 adult men and women without contraindications to any of these therapies discharged after AMI from hospitals located in 14 countries that were included in the Global Registry of Acute Coronary Events. Relatively steady increases in the use of ACE inhibitors, beta-blockers, and statin therapy were observed over time, with particularly marked increases in the use of lipid-lowering therapy (from 45% in 2000 to 85% in 2005). Aspirin use remained high (by approximately 95% of patients after AMI) during all periods examined. The percentage of hospital survivors treated with all 4 cardiac medications increased from 23% in 2000 to 58% during 2005. Advancing age (>/= 65 years), female sex, medical history of heart failure or stroke, and development of atrial fibrillation during hospitalization were associated with underuse of combination medical therapy. Relatively similar factors were associated with the underuse of combination medical therapy in patients with ST-segment elevation AMI and non-ST-segment elevation AMI. Our results suggest encouraging increases over time in the use of combination medical therapy in patients hospitalized with AMI without contraindications to these medications. Educational efforts designed to increase the use of these therapies, as well as efforts to simplify medication regimens and enhance rates of adherence, remain warranted.

Decade-long changes in the use of combination evidence–based medical therapy at discharge for patients surviving acute myocardial infarction

Current practice guidelines suggest routine use of several effective cardiac medications in hospital survivors of acute myocardial infarction (AMI). The objectives of our population-based study were to describe decade-long trends (1990-2001) in the use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, lipid-lowering agents, and combinations thereof, in patients discharged from all metropolitan Worcester (Mass) hospitals after AMI. The study sample consisted of 5965 adult men and women of all ages discharged after AMI from all greater Worcester hospitals in 7 annual periods between 1990 and 2001. Although consistent increases in the use of each of the effective cardiac medications examined were observed over time, particularly marked relative increases in the use of angiotensin-converting enzyme inhibitors (168% relative increase) and lipid-lowering agents (1086% relative increase) were noted. Use of combinations of effective cardiac medications also increased substantially over time. Between 1990 and 2001, the percentage of hospital survivors treated with > or =3 cardiac medications increased from 12.9% to 74.0%. Advancing age, female sex, history of angina, hypertension, or heart failure during hospitalization, presence of an initial non-Q wave MI, and development of atrial fibrillation during the index hospitalization were independently associated with underuse of combination medical therapy. The present results suggest considerable improvements over the last decade in the medical management of patients hospitalized with AMI. Educational efforts, however, aimed at clinicians and designed to improve use of these therapies, as well as efforts to simplify medication regimens and enhance rates of adherence, remain warranted.

Chronic Pain is a Chronic Condition, Not Just a Symptom

Presented at the Kaiser Permanente Primary Care 2005 conference, Maui, Hawaii, March 20–25, 2005, as Whitten C, Evans C. Chronic pain management in primary care. Conservative estimates indicate that 60 million Americans suffer from some type of persistent or recurrent pain sufficient to significantly affect their lives.1 The Kaiser Permanente (KP) member population includes many patients with chronic pain, and this cohort is generally characterized by a high level of utilizing medical services. Compared with other conditions addressed by the Care Management Institute (CMI), chronic pain more adversely affects quality of life, functional status, and productivity.1 Recent measurement of the KP chronic pain cohort2 by CMI showed chronic pain in 5.1% of adult KP members. This incidence can be compared with the incidence of other conditions diagnosed in the KP population: diabetes, in 7.7% of the population; depression, in 6.5%; coronary artery disease, in 3.2%; persistent asthma, in 2.0%; and heart failure, in 1.6%. According to the recent CMI Annual Population Care Management Report,3 about a third of patients with moderate to severe impairment from a chronic condition would benefit from care management, and another third would benefit from case management (Figure 1). About 50% of these impaired patients require only support for self-care. As Figure 1 shows, patients who are moderately to severely impaired by chronic pain often demonstrate poor pain control, clinically significant deconditioning and physical impairment, and often a lack of coping skills. A state of learned helplessness may develop and substantially alter a person's lifestyle. Figure 1 Illustration shows levels of care needed by patients impaired by chronic medical conditions. Percentages indicate proportion of patients with indicated level of need and are taken from the 2002 Annual Population Care Management Report3 of the Kaiser Permanente ... The population with chronic pain has a high incidence of comorbid conditions. For example, 27.7% of members with chronic pain also had documented depression during 2000, whereas 6.5% of all adult members had depression. Compared with utilization by nonafflicted KP members, utilization of resources by KP members with chronic pain is much higher. For example, this utilization2 is 3.7 times higher than the HEDIS inpatient admission benchmark is 2.7 times higher than the HEDIS emergency visit benchmark includes four times more outpatient visits produces pharmacy costs that are 3.5 times higher. Chronic pain is a chronic condition with its own pathological changes, its own set of clinical and behavioral characteristics, and its own subset of effective approaches to treatment regardless of etiology. To promote healing, we teach acutely injured patients to rest passively and to focus on their pain as a gauge of when to become more active. However, treating chronic pain in the same way you treat acute pain is a prescription for failure. Ironically, the patient with chronic pain should not focus on pain but instead should focus on adequate pain control to allow improved functioning and independence. Care plans should aim to simplify medication regimens, decrease pain-related behavior, increase patient and family coping skills, improve sleep, restore daily activities (such as household chores and social engagements), and resume vocational activity. Use of a multimodal approach has proven highly effective in both the KP Northern California Regional programs4 and the KP Northwest Region's Vohs Award-winning program.5 Help your patients with chronic pain to return to improved function and independence by following four basic principles of pain management. These principles include good communication between patient and clinician support for the active role of the patient in treatment optimal medication management use of a multimodal approach (Figure 2).6 Figure 2 Multimodal model of care for the whole patient shows modalities that should be included in a coordinated, multimodal, multidisciplinary treatment plan. Self care by the patient is central to the success of this—or any—treatment plan. However, the degree of appropriate intervention in each category varies with acuity. The KP CMI Chronic Pain Workgroup developed evidence-based guidelines, models of care, and tools for use by clinicians and members to help primary care practitioners to effectively manage chronic pain in their patients. These tools can be found online at http://cl.kp.org/pkc/national/cmi/programs/chronicpain. The earlier you identify and treat a higher-risk patient, the more likely you will be to prevent development of pathologic changes, and the better the clinical outcome will be.

Do fixed-dose combination pills or unit-of-use packaging improve adherence? A systematic review.

Adequate adherence to medication regimens is central to the successful treatment of communicable and noncommunicable disease. Fixed-dose combination pills and unit-of-use packaging are therapy-related interventions that are designed to simplify medication regimens and so potentially improve adherence. We conducted a systematic review of relevant randomized trials in order to quantify the effects of fixed-dose combination pills and unit-of-use packaging, compared with medications as usually presented, in terms of adherence to treatment and improved outcomes. Only 15 trials met the inclusion criteria; fixed-dose combination pills were investigated in three of these, while unit-of-use packaging was studied in 12 trials. The trials involved treatments for communicable diseases (n = 5), blood pressure lowering medications (n = 3), diabetic patients (n = 1), vitamin supplementation (n = 1) and management of multiple medications by the elderly (n = 5). The results of the trials suggested that there were trends towards improved adherence and/or clinical outcomes in all but three of the trials; this reached statistical significance in four out of seven trials reporting a clinically relevant or intermediate end-point, and in seven out of thirteen trials reporting medication adherence. Measures of outcome were, however, heterogeneous, and interpretation was further limited by methodological issues, particularly small sample size, short duration and loss to follow-up. Overall, the evidence suggests that fixed-dose combination pills and unit-of-use packaging are likely to improve adherence in a range of settings, but the limitations of the available evidence means that uncertainty remains about the size of these benefits.

Headache Disorders in the Elderly.

Headache prevalence declines in the elderly, but remains a common reason for patients to seek medical attention. Although primary headache types remain most frequent, secondary headaches become more likely in this age group. Accurate diagnosis is essential, and the clinician should maintain a lower threshold for ordering laboratory testing and neuroimaging. The elderly are more likely to have co-existent medical conditions, which present both therapeutic limitations and opportunities when selecting acute and preventative treatments for headache. Altered pharmacokinetics and pharmacodynamics in this age group may increase the likelihood of side effects and drug interactions. Downward dose adjustments and simplifying medication regimens are often appropriate, as is using nonpharmacologic therapies whenever possible. Due to frequent contraindications related to acute medications, preventative drug regimens and nonpharmacologic treatments assume greater prominence when treating the elderly suffering frequent/severe headaches. Medication-induced headache and analgesic rebound headache occur commonly in this age group and may initiate, aggravate, or perpetuate headache. Chronic daily headache is often due to these conditions, and recognition of these problems can allow effective intervention.

Delaying the initiation of progesterone supplementation results in decreased pregnancy rates following in vitro fertilization: a randomized, prospective study.

Objective: To compare in vitro fertilization outcome between two protocols for luteal phase progesterone supplementation: one beginning on day 3 following retrieval and the other beginning on day 6 following retrieval. Design: Prospective, randomized study. Materials/Methods: 126 consecutive patients undergoing IVF at our institution between January and July 2000 were randomized to receive one of two luteal phase progesterone supplementation protocols. All patients underwent ovarian hyperstimulation using a luteal GnRH-agonist protocol, a ‘stop’ GnRH-agonist protocol, or a GnRH agonist microdose flare protocol, depending on individual patient characteristics. Patients began using 200 mg micronized progesterone vaginally TID beginning the morning of either day 3 following oocyte retrieval or beginning on day 6 following oocyte retrieval. All patients continued progesterone supplementation daily until a negative serum pregnancy test, or, if the patient became pregnant, until 10 weeks of gestation. Clinical pregnancy and implantation rates were compared. Results: All patients undergoing randomization received an embryo transfer. There were no differences in patient age, BMI, oocytes retrieved, or number of embryos transferred between the two groups. Those patients beginning progesterone support on day 6 following retrieval had a significantly lower pregnancy rate compared to those beginning on day 3 following retrieval (44.8% vs. 61.0%, p < 0.05). This difference in pregnancy rates was greater in those patients undergoing a luteal GnRH-agonist downregulation protocol (47.5% vs. 71.4%, day 6 vs. day 3, P = 0.03). Beginning progesterone on day 6 also significantly decreased implantation rates in the GnRH-agonist group (21.0% vs. 34.0%, day 6 vs. day 3, P = 0.02). Conclusions: Pregnancy rates are significantly decreased by initiating luteal phase supplementation later than day 3 following retrieval during IVF cycles. Despite elevated progesterone levels at the time of embryo transfer, progesterone supplementation should continue to be initiated at this time. Efforts to simplify medication regimens or to decrease treatment costs by decreasing the duration of progesterone supplementation should not be undertaken.

Medication administration hassles reported by family caregivers of dependent elderly persons.

Even under the new long-term care mantra for increased home- and community-based care options, attention to and an understanding of the ways that family caregivers are managing complex care for dependent elderly persons, for example, with medication administration, have been slow to materialize. Twenty-three family caregivers completed semistructured, face-to-face interviews to capture the shared and idiosyncratic experiences of individuals responsible for all aspects of medication administration regimens for elderly, dependent family members. Data analysis consisted of content analysis of the verbatim interview transcripts. This article reports an emerging typology of caregiver medication administration hassles derived from the interviews. Based on 122 separate accounts, three categories of medication administration hassles were identified. The categories (with the percentage of all accounts represented by the category) include (i) scheduling logistics (29.5%), (ii) administration procedures (31.9%), and (iii) safety issues (38.6%). Primary care providers must continually reevaluate and simplify medication regimens for dependent elderly persons in the care of family members, and the family caregivers must be given adequate training and access to ongoing information support systems to help them perform safe and effective medication administration responsibilities.

Pharmacist Review to Simplify Medication Regimens in a VAMC Primary Care Clinic

Objective: To assess the effect of a clinical pharmacist's prospective medication review of patients receiving multiple drug therapy, using the pharmaceutical care process, as determined by the number of concurrent medications the patient is receiving before and after clinic visits. Design: Assigned groups. Setting: Outpatient primary care clinic of a tertiary healthcare Veterans Affairs (VA) medical facility. Patients: Seven hundred twenty-seven patients who had eight or more active medication orders were selected. Four hundred forty-one patients (aged 67.2 ± 10.4 y) were in the intervention group; 286 others (aged 66.6 ± 11.9 y), whose medical records were not available, were assigned to the control group and received no clinical pharmacist intervention. Intervention: Medication regimens of VA ambulatory patients with eight or more active medications were reviewed by a clinical pharmacist, and a written communication to the prescriber was attached to the medical record. Main Outcome Measures: The number of active concurrent medications before and after clinic visits was measured. Results: There was a decrease in the medications in the intervention group from an average of 12.1 ±4 to 11.5 ± 4.2 (p &lt; 0.05). The medications in the control group rose from an average of 11.8 ± 4.44 to 12.2 ± 4 (p = NS). A decrease of 0.6 prescriptions per patient was highly significant (p &lt; 0.05). During the study, 1,336 recommendations were made to practitioners. From this group, 41% of the recommendations were accepted, and 477 medications were discontinued, the quantity dispensed or dosage was reduced, or an alternative medication was prescribed. Conclusions: These data suggest that clinical pharmacist intervention in an ambulatory care setting can affect practitioner prescribing habits and significantly decrease the number of medications prescribed.