Enhancing Quality in Psychiatry with Psychiatrists (EQUIPP)--results from a pilot study.

OBJECTIVES: To pilot a pharmacist-led, patient centered medication management program. DESIGN: Prospective, single arm trial. SETTING: Academic geriatric psychiatry outpatient clinic. PARTICIPANTS: Outpatients at least 65 years old, proxy available if demented, and on two or more psychiatric medications. INTERVENTION: A clinical pharmacist completed a baseline medication review and made evidence-based recommendations that were implemented by the pharmacist after discussion with the physician. The pharmacist made a minimum of monthly contact for 6 months to review medications and related issues. MEASUREMENTS: The primary outcome was the change in number of medication related problems over time (3 and 6 months) as defined by a predetermined classification system. RESULTS: The mean age of the 27 patients was 75 years, 10 of whom required a proxy to participate. On average, patients had nine chronic conditions and were taking 14 medications. The mean number (SD; range) of medication related problems at baseline was 4.1 (2.2; 0-8) and at 3 and 6 months were 3.6 (2.4, 0-9) and 3.4 (2.1; 0-8), respectively. Most follow-up problems were new (80% and 89% at 3 and 6 months, respectively). CONCLUSION: Using a pharmacist to deliver a medication management program was feasible and addressed existing problems. New problems, however, developed over a short interval (3-6 months), suggesting that ongoing intervention is required.

Individualized medication assessment and planning: optimizing medication use in older adults in the primary care setting.

STUDY OBJECTIVE: To test the feasibility and effectiveness of an individualized Medication Assessment and Planning (iMAP) program integrated within a primary care practice on the number and prevalence of medication-related problems (MRPs) and acute health services utilization, defined as combined hospitalizations and emergency department visits. DESIGN: Six-month, prospective, observational pilot study. SETTING: Community-based primary care medical practice. PATIENTS: Convenience sample of 64 patients aged 65 years and older who were taking at least five medications. INTERVENTION: Each patient was enrolled in the iMAP program-a collaborative, multifaceted intervention facilitated by a clinical pharmacist whereby patients receive comprehensive medication therapy management at baseline and 3 and 6 months as part of routine clinical care. MEASUREMENTS AND MAIN RESULTS: MRPs were assessed and recommendations proposed using the previously published MRP classification tool; physician acceptance of recommendations served to validate the assessments. There was a significant reduction in mean number of MRPs/patient (4.2 at baseline vs 1.0 at 6 mo, p<0.0001) when adjusted for number of medications, race, and pharmacist. The prevalence of MRPs at 6 months compared with baseline was also significant (p<0.0008). Acute health services utilization was assessed by medical record abstraction. The 64 patients experienced a rate of 8.3 events/100 person-months (64 total events) during the 12-month prestudy period. During the 6-month study period, the same patients experienced 5.4 events/100 person-months (20 total events). Thus, we noted a reduction in acute health services utilization of 35%. Physicians were enthusiastically supportive of iMAP. CONCLUSION: iMAP has the potential to address a significant and timely issue affecting older adults and primary care practices: the burden of managing and continuously monitoring multiple medications in medically complex older adults. A more rigorous evaluation of iMAP is warranted and planned to demonstrate sustained effectiveness and cost-benefit.

Racial disparities in quality of medication use in older adults: findings from a longitudinal study.

BACKGROUND: The quality of medication use in older adults is suboptimal, with a large percentage of individuals not receiving recommended care. Most efforts to evaluate the quality of medication use target high-risk drugs, appropriate treatment of prevalent chronic disease states, or a set of predefined quality indicators of medication use rather than the patient. It is also suggested that racial differences in the quality of medication use may exist in older adults. OBJECTIVE: This study was conducted to determine the prevalence, number, and types of medication-related problems in older adults, examining the impact of race on quality medication use. METHODS: This was a prospective cohort study involving in-home interviews and medical record reviews of community-residing older adults, stratified by race, conducted 3 times over 1 year. No intervention to address medication-related problems was performed. The quality of medication use was reported as medication-related problems by clinical pharmacists. RESULTS: Of the 200 participants (100 blacks, 100 whites), mean age was 78.3 (whites) and 75.5 (blacks), and the majority of patients were female. Although whites used more medications than blacks (mean, 11.6 vs 9.7; P < 0.01), blacks had more medication-related problems per person than whites (mean, 6.3 vs 4.9; P < 0.01). All patients had at least 1 medication-related problem. Common problems at baseline, 6 months, and 12 months for both whites and blacks were undertreatment, suboptimal drug use, suboptimal dosing, nonadherence, and less costly alternative available. Blacks had significantly higher rates of nonadherence than whites (68% vs 42%; P < 0.01). Over the 12-month study, the number of medication-related problems not only persisted but increased (adjusted P = 0.0168). CONCLUSIONS: Medication-related problems were prevalent in both black and white older adults and persisted over 1 year. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in the quality of medication use in older adults and the impact of race on specific medication-related problems.

A targeted decision aid for the elderly to decide whether to undergo colorectal cancer screening: development and results of an uncontrolled trial.

BACKGROUND: Competing causes of mortality in the elderly decrease the potential net benefit from colorectal cancer screening and increase the likelihood of potential harms. Individualized decision making has been recommended, so that the elderly can decide whether or not to undergo colorectal cancer (CRC) screening. The objective is to develop and test a decision aid designed to promote individualized colorectal cancer screening decision making for adults age 75 and over. METHODS: We used formative research and cognitive testing to develop and refine the decision aid. We then tested the decision aid in an uncontrolled trial. The primary outcome was the proportion of patients who were prepared to make an individualized decision, defined a priori as having adequate knowledge (10/15 questions correct) and clear values (25 or less on values clarity subscale of decisional conflict scale). Secondary outcomes included overall score on the decisional conflict scale, and preferences for undergoing screening. RESULTS: We enrolled 46 adults in the trial. The decision aid increased the proportion of participants with adequate knowledge from 4% to 52% (p < 0.01) and the proportion prepared to make an individualized decision from 4% to 41% (p < 0.01). The proportion that preferred to undergo CRC screening decreased from 67% to 61% (p = 0. 76); 7 participants (15%) changed screening preference (5 against screening, 2 in favor of screening) CONCLUSION: In an uncontrolled trial, the elderly participants appeared better prepared to make an individualized decision about whether or not to undergo CRC screening after using the decision aid.

Racial disparities in the quality of medication use in older adults: baseline findings from a longitudinal study.

BACKGROUND: Medication-related problems are prevalent in older adults and adversely affect the quality of care. It has been suggested that racial differences exist in medication use. Most efforts to evaluate the quality of medication use target specific drugs or disease states, or a set of pre-defined quality indicators, rather than the patient. OBJECTIVE: We conducted a prospective cohort study to determine the prevalence and types of medication-related problems in older adults, examining the impact of race on quality medication use. METHODS: In-home interviews and medical record reviews of 200 (100 white, 100 black) older adults were conducted three times over 1 year. The quality of medication use was measured using a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We used logistic and negative binomial regression models to analyze the two primary endpoints of prevalence and number of medication-related problems. RESULTS: Mean age was 78.3 (whites) and 75.5 (blacks), with the majority being female. Although whites used more medications than blacks (11.6 versus 9.7; p < 0.01), blacks had more medication-related problems per person than whites (6.2 versus 4.9; p < 0.01). All patients had at least one medication-related problem; undertreatment, suboptimal drug, suboptimal dosing, and nonadherence were most prevalent. Blacks had significantly higher rates of nonadherence than whites (68% versus 42%; p < 0.01). CONCLUSION: Medication-related problems are prevalent in community-residing older adults. Blacks had more medication-related problems than whites, including higher rates of nonadherence. These findings require further study to better understand racial disparities in quality medication use.

Methodology of a pilot study to improve the quality of medication use in older adults: Enhancing Quality in Psychiatry Using Pharmacists (EQUIPP).

BACKGROUND: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increased risk because of their underlying disease and types of medications prescribed. Efforts to improve the quality of medication use often focus on select medication-related problems, select diagnoses, or predefined quality indicators; however, such an approach fails to consider the potential for multiple coexisting problems within individuals. OBJECTIVE: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. This article describes the methodology of the study and details of the intervention, and presents baseline characteristics of the study population. METHODS: English-speaking psychiatry outpatients aged > or = 65 years taking > or = 2 drugs that are active in the central nervous system were enrolled into a medication management program, in which medication management was provided by a clinical pharmacist for 6 months. Patients were evaluated at baseline, 3 months, and 6 months. Data were collected on the patients' demographic characteristics, health and medications, health literacy, functional status, symptoms of depression, health services utilization, quality of medication use, adherence, and patient satisfaction with the program. RESULTS: One hundred seventy-three older adults were assessed for inclusion; 146 were not eligible, not reachable, or not interested in participating. Twenty-seven older adults were enrolled in the study, all but one of whom completed the 3- and 6-month visits. The mean (SD) age of the 27 participants was 74.7 (8.1) years; 63% were female, 74% were white, and 70% had no cognitive impairment. CONCLUSIONS: This pilot study tested the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. Findings from this study, which will be reported at a later date, will help to refine the program and subsequent testing, with the overall goal of improving the quality of medication use and health outcomes in older adults.

The quality of medication use in older adults: methods of a longitudinal study.

BACKGROUND: The quality of medication use in older adults is a recurring problem of substantial concern. Efforts to both measure and improve the quality of medication use often define quality too narrowly and fall short of addressing the complexity of an older adult's medication regimen. OBJECTIVES: In an effort to more comprehensively define the quality of medication use in older adults, we conducted a prospective cohort study to: (1) describe the quality of medication use in community-dwelling older adults at baseline, examining differences between whites and blacks; (2) examine the effect of race on medication-related problems; and (3) assess the change in quality medication use between whites and blacks over time. This paper presents the research design and methods of this longitudinal study. METHODS: We interviewed white and black community-dwelling older adults (aged > or =60 years) 3 times over 1 year (baseline, 6, and 12 months). We oversampled blacks so that we could estimate racial differences in the quality of medication use. We collected information on the quality of medication use, relying on a clinical pharmacist's assessment of quality and the Assessing Care of Vulnerable Elders quality indicators. We also collected data on demographic characteristics, health literacy, functional status, and participant-reported drug therapy concerns. RESULTS: Four hundred thirty-five older adults were assessed for inclusion; 200 older adults (100 white, 100 black) were enrolled in the study and completed a baseline visit. Of the 200, 92% completed the 6-month visit (n = 183) and 88% completed the 12-month visit (n = 176). We present baseline demographic characteristics for the 200 older adults enrolled in the study. CONCLUSION: This longitudinal study is an initial step toward developing more comprehensive, patient-centered measures and interventions to address the quality of medication use in older adults.

Nutritional issues in long-term care.

Because long-term care residents often have chronic illnesses and complex care regimens, nutritional issues are common in these populations. Furthermore, management is complicated because some residents are terminally ill and under palliative care treatment plans that allow for dehydration and low oral intake. As a result, the medical management of nutrition is complex and challenging for medical providers caring for residents of nursing homes, assisted living facilities, and other long-term care settings. Quality nutritional practice in long-term care involves careful assessment of barriers to adequate nutrition; reduction of risk factors; attention to specialized diets, food presentation, and supplements, when appropriate; awareness of the importance of psychosocial and environmental issues; and consideration of the role of medication both as a cause and a therapeutic adjunct. Optimal practice at a facility level would involve a systematic approach to applying the best evidence-based approaches, with a focus on individualizing each resident's nutritional management.

Accounting for the sedative and analgesic effects of medication changes during patient participation in clinical research studies: measurement development and application to a sample of institutionalized geriatric patients.

BACKGROUND: To date, no system has been published that allows investigators to adjust for the overall sedative and/or analgesic effects of medications, or changes in medications, in clinical trial participants for whom medication use cannot be controlled. This is common in clinical trials of behavioral and complementary/alternative therapies, and in research involving elderly or chronically ill patients for whom ongoing medical care continues during the trial. This paper describes the development, and illustrates the use, of a method we developed to address this issue, in which we generate single continuous variables to represent the daily sedative and analgesic loads of multiple medications. METHODS: Medications for 90 study participants in a clinical trial of a nonpharmacological intervention were abstracted from medication administration records across multiple treatment periods. An expert panel of three academic clinical pharmacists and a geriatrician met to develop a system by which each study medication could be assigned a sedative and analgesic effect rating. RESULTS: The two measures, when applied to data on 90 institutionalized persons with Alzheimer's disease, resulted in variables with moderately skewed distributions that are consistent with the clinical profile of analgesia and sedation use in long-term care populations. The average study participant received 1.89 analgesic medications per day and had a daily analgesic load of 2.96; the corresponding figures for sedation were 2.07 daily medications and an average daily load of 11.41. CONCLUSIONS: A system of classifying the sedative and analgesic effects of non-study medications was created that divides drugs into categories based on the strength of their effects and assigns a rating to express overall sedative and analgesic effects. These variables may be useful in comparing patients and populations, and to control for drug effects in future studies.

Self-reported medication use in community-residing older adults: A pilot study.

BACKGROUND: Older adults (ie, those aged > or = 65 years) are at increased risk of developing drug therapy problems, which may lead to poor health outcomes and decreased quality of life. OBJECTIVE: The primary goal of this pilot study was to evaluate and report medication use and potential drug therapy problems in older adults who received Eldercare program assistance through the Orange County Department on Aging in North Carolina. METHODS: Between May and July 2002, subjects were consecutively sampled from a registry of adults aged > or = 60 years enrolled in the Eldercare program. To be eligible for the study, individuals had to be receiving the services of the Eldercare program, speak English, and reside independently in the community of Orange County. The older adults were contacted by the program director to determine interest in participating in the study. If interested, the individual was contacted by a trained pharmacy doctoral student to verify study eligibility and arrange a home visit. At the home visit, information was collected via self-report on medication use and medical history. Nonadherence, potentially inappropriate prescribing, health literacy, and functional capacity were also assessed. All home visits were conducted between May and July 2002. RESULTS: A total of 100 subjects were interviewed. The mean (SD) age of respondents was 77.5 (8.7) years; 85% were women, 66% were white, 34% black, and 70% lived alone. The mean (SD) number of prescription medications used per patient was 9.6 (4.1). Adequate health literacy, defined as a score > or = 23 (range of possible scores, 0-36) on the Short Test of Functional Health Literacy in Adults, was documented in only 35% of individuals. Twenty-five percent of the sample (25/100) had reduced functional capacity when evaluated on the Functional Activities Questionnaire, with total scores > or = 10 (range of possible scores, 10-30) indicative of reduced functional ability. Rates of nonadherence, defined as a score of 0 to 3 on the 4-item Morisky instrument, were 53%. When evaluating inappropriate prescribing based on the Beers criteria, 34% of individuals used > or = 1 potentially inappropriate medication. In bivariate analyses, there was a statistically significant relationship between race and number of medications (P < 0.002), adherence (P < 0.001), health literacy status (P < 0.001), and functional capacity (P < 0.027). No differences were noted when examining the effects of age on the same variables. CONCLUSIONS: In this study, older adults residing independently in the community were responsible for managing and taking a considerable number of medications on a daily basis. In addition, inadequate health literacy, poor adherence, and potentially inappropriate medication use were prevalent in this sample. The results also suggest that race may have played an important role in the risk of developing medication-related problems.