The Impact of Medication-Based Risk Adjustment on the Association Between Veteran Health Outcomes and Dual Health System Use.

BACKGROUND: Veterans commonly receive care from both Veterans Health Administration (VA) and non-VA sources (i.e., dual use). A major challenge in comparing health outcomes between dual users and VA-predominant users is applying an accurate method of risk adjustment. OBJECTIVE: To determine how different comorbidity indices affect the association between patterns of dual use and health outcomes. DESIGN: Retrospective cohort. PARTICIPANTS: A total of 316,775 community-dwelling Veterans (≥65 years) with type 2 diabetes who were enrolled in VA and fee-for-service Medicare from 2008 to 2010. METHODS: We determined the associations between dual use and death or diabetes-related hospitalization in FY 2010 using multivariable models incorporating claims-based (Elixhauser) or medication-based (RxRisk-V) risk adjustment. Dual use was classified using four previously identified groups of health services users: 1) VA-predominant, 2) VA + Medicare visits and labs, 3) VA + Medicare test strips, and 4) VA + Medicare medications. KEY RESULTS: Controlling for Elixhauser comorbidities, dual-use groups 2-4 had significantly decreased odds of death or hospitalization compared to VA-predominant users. Controlling for RxRisk-V comorbidities, groups 2-4 had increased odds of death compared to VA-predominant users, but variable odds of hospitalization, with group 2 having increased odds (OR 1.06, CI 1.04-1.09), while groups 3 (OR 0.96, CI 0.94-0.99) and 4 (OR 0.93, CI 0.89-0.97) had decreased odds. CONCLUSIONS: The method of risk adjustment drastically influences the direction of effect in health outcomes among dual users of VA and Medicare. These findings underscore the need for standardized and reliable risk adjustment methods that are not susceptible to measurement differences across different health systems.

Non-tricyclic and Non-selective Serotonin Reuptake Inhibitor Antidepressants and Recurrent Falls in Frail Older Women.

OBJECTIVE: To determine the risk of recurrent falls associated with antidepressants other than tricyclics (TCAs) and selective serotonin reuptake inhibitors (SSRIs) among frail older women. METHODS: This is a secondary analysis of the Zoledronic acid in frail Elders to STrengthen bone, or ZEST, trial data treated as a longitudinal cohort in 181 frail, osteoporotic women aged ≥65 years in long-term care. The primary exposure was individual non-TCA/non-SSRI antidepressants (i.e., serotonin norepinephrine reuptake inhibitors, mirtazapine, trazodone, and bupropion) at baseline and 6 months. The main outcome was recurrent (at least two) falls within 6 months after antidepressant exposure. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were derived using a generalized estimating equations model. RESULTS: At least 15% of women experienced recurrent falls between 0-6 and 6-12 months. At baseline and 6 months, 18.2% and 6.9% had a non-TCA/non-SSRI antidepressant, respectively. Adjusting for demographics, health status, and other drugs that increase risk of falls, non-TCA/non-SSRI antidepressant exposure significantly increased the risk of recurrent falls (AOR: 2.14; 95% CI: 1.01-4.54). Fall risk further increased after removing bupropion from the non-TCA/non-SSRI antidepressant group in sensitivity analyses (AOR: 2.73; 95% CI: 1.24-6.01). CONCLUSIONS: Other antidepressant classes may not be safer than TCAs/SSRIs with respect to recurrent falls in frail older women.

Use of a medication-based risk adjustment index to predict mortality among veterans dually-enrolled in VA and medicare.

BACKGROUND: There is systemic undercoding of medical comorbidities within administrative claims in the Department of Veterans Affairs (VA). This leads to bias when applying claims-based risk adjustment indices to compare outcomes between VA and non-VA settings. Our objective was to compare the accuracy of a medication-based risk adjustment index (RxRisk-VM) to diagnostic claims-based indices for predicting mortality. METHODS: We modified the RxRisk-V index (RxRisk-VM) by incorporating VA and Medicare pharmacy and durable medical equipment claims in Veterans dually-enrolled in VA and Medicare in 2012. Using the concordance (C) statistic, we compared its accuracy in predicting 1 and 3-year all-cause mortality to the following models: demographics only, demographics plus prescription count, or demographics plus a diagnostic claims-based risk index (e.g., Charlson, Elixhauser, or Gagne). We also compared models containing demographics, RxRisk-VM, and a claims-based index. RESULTS: In our cohort of 271,184 dually-enrolled Veterans (mean age = 70.5 years, 96.1% male, 81.7% non-Hispanic white), RxRisk-VM (C = 0.773) exhibited greater accuracy in predicting 1-year mortality than demographics only (C = 0.716) or prescription counts (C = 0.744), but was less accurate than the Charlson (C = 0.794), Elixhauser (C = 0.80), or Gagne (C = 0.810) indices (all P < 0.001). Combining RxRisk-VM with claims-based indices enhanced its accuracy over each index alone (all models C ≥ 0.81). Relative model performance was similar for 3-year mortality. CONCLUSIONS: The RxRisk-VM index exhibited a high level of, but slightly less, accuracy in predicting mortality in comparison to claims-based risk indices. IMPLICATIONS: Its application may enhance the accuracy of studies examining VA and non-VA care and enable risk adjustment when diagnostic claims are not available or biased. LEVEL OF EVIDENCE: Level 3.

Assessment of Postgraduate Year 2 Pharmacy Residency Programs Within the Veterans Affairs Healthcare System.

PURPOSE: Despite the increasing importance placed on advanced training for clinical pharmacists, literature describing postgraduate year 2 (PGY2) residency opportunities is limited. The objective of this study was to describe characteristics of PGY2 programs within the Veterans Affairs (VA) healthcare system. METHODS: An online survey addressing attributes of PGY2 residency programs was electronically distributed to VA residency program directors (RPDs). RESULTS: Responses from 27 (32.9%) VA PGY2 residency programs were included, representing 11 distinct PGY2 specialties. Growth and recruitment trends were similar across programs, with most programs projecting additional expansion. Staffing requirements were uncommon, but opportunities to precept and earn teaching certificates were prevalent. RPDs had been licensed pharmacists an average of 16.9 years, and most had at least 1 advanced certification. The majority of programs had a formal residency advisory committee and required preceptors to attend regular development meetings. CONCLUSION: Although multiple postgraduate specialties were represented, the requirements and opportunities available for PGY2 pharmacy residents were similar across VA facilities. By comparing residency programs in a nationally integrated health-care system, this study may promote growth of existing PGY2 programs, facilitate the establishment of new programs, and provide a framework for prospective residents to evaluate programs of interest.

Central Nervous System Medication Burden and Serious Falls in Older Nursing Home Residents.

OBJECTIVES: To examine the association between CNS medication burden and serious falls in those with a recent fall history. DESIGN: Nested-case control study; cases matched to four controls by age, gender, and date. SETTING: US nursing homes. PARTICIPANTS: 5,556 residents age ≥65 with a recent fall history admitted to a nursing home between 1/1-9/30/2010 and followed until discharge, death, or December 31, 2010. MEASUREMENTS: Outcome was serious falls as per Medicare Part A and B ICD/CPT codes. CNS burden, from Medicare Part D data, was calculated by dividing the daily dose of each CNS agent (i.e., specific antidepressants, antiepileptic, antipsychotic, benzodiazepine and opioid receptor agonists) received during the 6 days prior to the index (outcome) date by the minimum effective geriatric daily dose and summing the results across medications. RESULTS: There were 367 cases and 1,468 matched controls. Those taking 3 + CNS standardized daily doses were more likely to have a serious fall than those not taking any CNS medications (Adjusted Odds Ratio 1.83; 95% confidence interval 1.35-2.48). There was no significant difference in fall risk for residents taking >0 to <3 CNS standardized daily doses compared to residents taking no CNS medications (Adjusted Odds Ratio 0.85; 95% CI 0.63-1.15). CONCLUSION: CNS medication burden, approximately 3 + standardized daily doses, was associated with an increased risk of serious falls in nursing home residents with recent fall. Clinicians should be vigilant for opportunities to discontinue or decrease the doses of individual CNS medications and/or consider non-pharmacological alternatives. Such interventions that reduce use of CNS medications in nursing homes could reduce fall rates but further research is needed to confirm this.

Recent Literature on Medication Errors and Adverse Drug Events in Older Adults.

Medication errors and adverse drug events are common in older adults, but locating literature addressing these issues is often challenging. The objective of this article is to summarize recent studies addressing medication errors and adverse drug events in a single location to improve accessibility for individuals working with older adults. A comprehensive literature search for studies published in 2014 was conducted, and 51 potential articles were identified. After critical review, 17 studies were selected for inclusion based on innovation; rigorous observational or experimental study designs; and use of reliable, valid measures. Four articles characterizing potentially inappropriate prescribing and interventions to optimize medication regimens were annotated and critiqued in detail. The authors hope that health policy-makers and clinicians find this information helpful in improving the quality of care for older adults.

Differences in Benzodiazepine Receptor Agonist Use in Rural and Urban Older Adults.

BACKGROUND: Older adults are especially susceptible to adverse consequences of potentially inappropriate medications (PIMs), such as benzodiazepine receptor agonists (BZDRAs), due to age-related pharmacokinetic and pharmacodynamic changes. Although some risk factors for BZDRA use in older adults have been identified, the role of rural versus urban residence is less clear. OBJECTIVE: To describe BZDRA use in rural versus urban older adults using pharmaceutical claims from Pennsylvania's Pharmaceutical Assistance Contract for the Elderly (PACE) program. METHODS: The sample consisted of older adults enrolled in Pennsylvania's Healthy Steps for Older Adults and participated in Pennsylvania's PACE program. Independent sample t tests and contingency tables were used to examine residence differences. Multivariate binary logistic modeling was performed. RESULTS: The total sample (N = 426) was 305 (71.6 %) urban-dwelling adults and 121 (28.4 %) rural-dwelling adults. Rural participants were more likely to be male, white, married, and have less than a high school education compared with urban participants (p <.01). Specifically, 25 % of rural-dwelling adults received a BZDRA compared with 15 % of urban-dwelling adults (p = 0.02). Three variables reached statistical significance for predicting BZDRA use in a multivariate model: rural residence (OR 2.58, 95 % CI 1.39-4.79), history of anxiety/depression (OR 4.20, 95 % CI 2.39-7.46), and number of medications (OR 1.11, 95 % CI 1.02-1.21). CONCLUSIONS: BZDRA prescription differences in older, rural-dwelling adults further highlights the need for geriatric and mental health specialists to provide specialized care to this population. Rural healthcare professionals may be less aware of PIMs for older adults, and initiatives to support geriatric services and provide education for existing providers may be beneficial.

Impact of Drug-Drug and Drug-Disease Interactions on Gait Speed in Community-Dwelling Older Adults.

BACKGROUND: Gait speed decline, an early marker of functional impairment, is a sensitive predictor of adverse health outcomes in older adults. The effect of potentially inappropriate medications, including drug-disease and drug-drug interactions, on gait speed decline is not well known. OBJECTIVE: The aim of this study was to determine if drug interactions impair functional status as measured by gait speed. METHODS: The sample included 2402 older adults with medication and gait speed data from the Health, Aging and Body Composition study. The independent variable was the frequency of drug-disease and/or drug-drug interactions at baseline and 3 additional years. The main outcome was a clinically meaningful gait speed decline of ≥0.1 m/s the year following drug interaction assessment. Adjusted odds ratios and 95 % confidence intervals (CIs) were calculated using multivariate generalized estimating equations for both the overall sample and a sample stratified by gait speed at time of drug interaction assessment. RESULTS: The prevalence of drug-disease and drug-drug interactions ranged from 7.6 to 9.3 and 10.5 to 12.3 %, respectively, with few participants (3.8-5.7 %) having multiple drug interactions. At least 22 % of participants had a gait speed decline of ≥0.1 m/s annually. Drug interactions were not significantly associated with gait speed decline overall or in the stratified sample of fast walkers. There was some evidence, however, that drug interactions increased the risk of gait speed decline among those participants with slower gait speeds, though p values did not reach statistical significance (adjusted odds ratio 1.22; 95 % CIs 0.96-1.56; p = 0.11). Moreover, a marginally significant dose-response relationship was seen with multiple drug interactions and gait speed decline (adjusted odds ratio 1.40; 95 % CIs 0.95-2.04; p = 0.08). CONCLUSIONS: Drug interactions may increase the likelihood of gait speed decline among older adults with evidence of preexisting debility. Future studies should focus on frail elders with less physiological reserve who may be more susceptible to the harms associated with potentially inappropriate medications.

Characteristics of Postgraduate Year 1 Pharmacy Residency Programs at Veterans Affairs Medical Centers.

PURPOSE: Although the characteristics of pharmacy postgraduate year 1 (PGY1) residency programs have been examined among large academic medical centers, there are no identified studies comparing the attributes of individual programs in the Veterans Affairs (VA) Health Administration System. The primary objective of this study was to describe and contrast characteristics of VA PGY1 residency programs. METHODS: This was a cross-sectional survey of VA pharmacy residency programs. An online survey was distributed electronically to residency program directors of VA PGY1 residencies. RESULTS: Responses from 33 (33%) PGY1 programs were available for the analysis. Programs reported growth over the previous 2 years and expected continued expansion. There was a wide variety of learning opportunities, although experiences were customizable based on residents' interests. Notably, many programs allowed residents to seek rotations at other locations if specific experiences were not available on-site. Additionally, most programs had a mandatory staffing component and required residents to present the results of residency research projects. CONCLUSION: There is a high degree of variability among individual VA facilities with regard to the requirements and opportunities available to PGY1 pharmacy residents. This assessment is able to characterize the currently established residency programs and allows for an active comparison of programs in a nationally integrated health care system.

Concordance Between Anticholinergic Burden Scales.

OBJECTIVES: To evaluate concordance of five commonly used anticholinergic scales. DESIGN: Cross-sectional secondary analysis. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee. PARTICIPANTS: Community-dwelling adults aged 70 to 79 with baseline medication data from the Health, Aging, and Body Composition Study (N = 3,055). MEASUREMENTS: Any anticholinergic use, weighted scores, and total standardized daily dosage were calculated using five anticholinergic measures (Anticholinergic Cognitive Burden (ACB) Scale, Anticholinergic Drug Scale (ADS), Anticholinergic Risk Scale (ARS), Drug Burden Index anticholinergic component (DBI-ACh), and Summated Anticholinergic Medications Scale (SAMS)). Concordance was evaluated using kappa statistics and Spearman rank correlations. RESULTS: Any anticholinergic use in rank order was 51% for the ACB, 43% for the ADS, 29% for the DBI-ACh, 23% for the ARS, and 16% for the SAMS. Kappa statistics for all pairwise use comparisons ranged from 0.33 to 0.68. Similarly, concordance as measured using weighted kappa statistics ranged from 0.54 to 0.70 for the three scales not incorporating dosage (ADS, ARS, ACB). Spearman rank correlation between the DBI-ACh and SAMS was 0.50. CONCLUSION: Only low to moderate concordance was found between the five anticholinergic scales. Future research is needed to examine how these differences in measurement affect their predictive validity with respect to clinically relevant outcomes, such as cognitive impairment.