Refill adherence to oral hypoglycemic agents and glycemic control in veterans.

BACKGROUND: Although medication nonadherence may contribute to inadequate diabetes control, adherence is not routinely measured. Persistence, the continuous refill of medications, is one metric that could be integrated into clinical care if associated with glycemic control. OBJECTIVE: To characterize the association of persistence levels (non-, good, overpersistence) with hemoglobin A(1c) (A1C) over 1 year in newly medicated diabetics in the Veterans Administration. METHODS: Eligible veterans were > or =18 years and first filled a prescription for oral hypoglycemic agents (OHA) between January 1, 2000, and December 31, 2002. The date the OHA was first dispensed was defined as the baseline date. Subjects must have filled at least 1 prescription for any drug, but no diabetes medications, during the 12 months preceding the baseline date. Persistence was measured in days supply of medication over 365 days and defined as non- (<0.80), good (> or =0.8-1.10), and over- (>1.10) persistence. The main outcome measure was achieving goal A1C (< or =7.0%) after 1 year. RESULTS: A total of 56,181 veterans were included. Veterans were male (97%) and white (67%) with comorbid hypertension (58%) and hyperlipidemia (40%). Median age was 63 years, while median baseline A1C was 7.7%. Fifty-two percent of patients had good persistence; 25% were overpersistent. Good persistence was associated with achieving goal A1C (RR 1.07; 95% CI 1.06 to 1.09). The association of overpersistence with the same outcome (RR 0.95; 95% CI 0.94 to 0.97) was lower than good persistence, but higher than nonpersistence (RR 0.93; 95% CI 0.92 to 0.94). CONCLUSIONS: Good persistence was associated with glycemic control. Overpersistent patients were common and more likely than nonpersistent patients, but less likely than good persisters to attain goal A1C. Estimating these different strata of persistence may be useful in identifying patients at risk of poor glycemic control.

Improving sedative-hypnotic prescribing in older hospitalized patients: provider-perceived benefits and barriers of a computer-based reminder.

BACKGROUND: Older adults are commonly prescribed sedative-hypnotic (SH) medications when hospitalized, yet these drugs are associated with important adverse effects such as falls and delirium. OBJECTIVE: To identify provider-perceived benefits or barriers of a computer-based reminder regarding appropriate use of SH medications. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS AND SETTING: Thirty-six house staff physicians at a university hospital. MEASUREMENTS: Information was collected regarding the experiences of prescribing an SH using a computer order entry system with a reminder intervention. Clinicians were asked about their perceptions of the reminder and what they found most and least useful about it. Responses were analyzed using grounded theory methodology. RESULTS: The 36 participants (including 29 interns) had prescribed an SH medication for a hospitalized patient over age 65 years. Three themes associated with benefits of a computer reminder were identified: increasing awareness of safety, including risk of delirium, falls, and general patient safety risks; usefulness of information technology; and the value of the educational content, including geriatric pharmacology review and nonpharmacologic treatment options. Barriers included the demands of the reminder with regard to time needed to read the reminder, the role of clinician experience with regard to preserving clinical autonomy, and the information content of the reminder, including its being too basic or not relevant for a particular patient. The mean satisfaction rating for the reminder was 8.5 (+/-0.9 SD), with 10 indicating high satisfaction. CONCLUSIONS: Improving decision support systems involves an understanding of how clinicians respond to real-time strategies encouraging better prescribing.

Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review.

BACKGROUND: Older adults take multiple medications and are at high risk for adverse drug effects. OBJECTIVE: This systematic review was conducted to describe the impact of computer decision support (CDS) interventions designed to improve the quality of medication prescribing in older adults. METHODS: PubMed and EMBASE databases were searched from January 1980 through July 2007 (English-language only); studies were eligible if they described a CDS intervention intended to improve medication prescribing in adults aged > or =60 years. Studies were retained if they were observational or experimental in design and reported > or =1 process or clinical outcome measurement related to medication prescribing. In the main analysis, study characteristics and major outcome results were extracted. A combination of searches was performed using relevant medical subject headings: aged; drug therapy, computer-assisted; medication errors; medication errors/prevention and control; decision making, computer-assisted; decision support systems, clinical; and clinical pharmacy information systems. RESULTS: After review of study abstracts, 10 articles met the eligibility criteria. Of those 10 studies testing CDS interventions, 8 showed at least modest improvements (median number needed to treat, 33) in prescribing, as measured by minimizing drugs to avoid, optimizing drug dosage, or more generally improving prescribing choices in older adults (according to each study's intervention protocols). Findings for the impact of CDS interventions on clinical outcomes were mixed and were reported for only 2 studies. CONCLUSIONS: Various types of CDS interventions may be effective in improving medication prescribing in older adults, but few studies reported clinical outcomes related to changes in medication prescribing. Data from this study should help to guide refinement and testing of future CDS interventions that specifically target older adult populations that are taking multiple medications.

Assessing multiple medication use with probabilities of benefits and harms.

OBJECTIVE: A quantitative framework to assess harms and benefits of candidate medications in the context of drugs that a patient is already taking is proposed. METHOD: Probabilities of harms and benefits of a given medication are averaged to yield a utility value. The utility values of all medications under consideration are combined as a geometric mean to yield an overall measure of favorability. The grouping of medications yielding the highest favorability value is chosen. RESULTS: Five examples of choosing between widely used candidate medications demonstrate the feasibility of the proposed framework. DISCUSSION: The framework proposed provides a simple method for considering the trade-offs involved in prescribing multiple medications. It can be adapted to include additional parameters representing severity of condition, prioritization of outcomes, patient preferences, dosages, and medication interactions. Inconsistent reporting in the medical literature of data about benefits and harms of medications, dosages, and interactions constitutes its primary limitation.

Use of a computer-based reminder to improve sedative-hypnotic prescribing in older hospitalized patients.

OBJECTIVES: To develop a feasible, inexpensive, point-of-care computerized reminder to improve sedative-hypnotic prescribing in hospitalized older people. DESIGN: Pre-postintervention with a computer-based reminder. SETTING: Academic medical center. PARTICIPANTS: Hospitalized patients aged 65 and older. INTERVENTION: Computer-based reminder directing clinicians to prescribe a nonpharmacological sleep protocol, to minimize the potential for harm with diphenhydramine and diazepam use by choosing an alternative medication (trazodone or lorazepam), or both. MEASUREMENTS: Frequency of prescription of four sedative-hypnotic drugs (diphenhydramine, diazepam, lorazepam, and trazodone) during the 12 months before (n=12,356 patients) and after (n=12,153) the reminder was instituted. RESULTS: Prescribing of sedative-hypnotics decreased from 2,208 per 12,356 (18%) patients preintervention to 1,832 per 12,153 (15%) postintervention (odds ratio for the intervention=0.82, 95% confidence interval=0.76-0.87), an 18% risk reduction. Combined prescription rates for all four drugs fell consistently throughout the postintervention period. Diphenhydramine, diazepam, and lorazepam orders declined overall, with lorazepam prescriptions decreasing 39% during the intervention. Ninety-five percent of patients were successfully directed to a safer sedative-hypnotic drug or a nonpharmacological sleep protocol. CONCLUSION: Using real-time computer-based reminders could lead to improved sedative-hypnotic prescribing for older persons in acute care. This study highlights the potential to address patient safety concerns, and the quality of medication prescribing in particular, in vulnerable hospitalized patients.

Effects of statin use on muscle strength, cognition, and depressive symptoms in older adults.

OBJECTIVES: To determine the relationship between hydroxymethyl glutaryl coenzyme A reductase inhibitor (statin) use and proximal muscle strength, cognition, and depression in older adults. DESIGN: Observational cohort study. SETTING: Outpatient primary care clinics. PARTICIPANTS: Seven hundred fifty-six community-dwelling veterans aged 65 and older. MEASUREMENTS: Timed chair stands (a measure of proximal muscle strength), Trail Making Test Part B (a measure of cognition), and the Center for Epidemiologic Studies Depression Scale score were measured at baseline and 1-year follow-up. Participants were assessed for statin prescriptions (and indications for or contraindications to their use), concomitant medication use, comorbidities, and other potential confounders. RESULTS: Statin users (n=315) took a mean 6.6 medications, versus 4.6 for nonusers (n=441), and had a median duration of statin use of 727 days. Statin users were more likely to be white and had (as expected) more cardiac, cerebrovascular, and peripheral vascular disease. Based on multivariable models adjusting for pertinent covariates, statin users performed modestly better than nonusers for timed chair stands (-0.5 seconds; P=.04), Trail Making Test Part B (-7.7 seconds; P=.08), and depression scores (-0.2 points; P=.49) at follow-up. Of potentially high-risk participants (based on age, comorbidity, and number of medications), statin users also showed similar 1-year changes as nonusers, although worsened depression scores were found in those with greater comorbidity (+0.88 points; P=.10). CONCLUSION: Older, community-dwelling male participants taking maintenance statin therapy had similar outcomes to those of nonusers in tests of muscle strength, cognition, and depression, but further examination of benefits and harms in different subgroups is warranted.

Association between antihypertensive medication use and non-cardiovascular outcomes in older men.

BACKGROUND: Antihypertensive drugs are prescribed commonly in older adults for their beneficial cardiovascular and cerebrovascular effects, but few studies have assessed antihypertensive drugs' adverse effects on non-cardiovascular outcomes in routine clinical practice. OBJECTIVE: To evaluate, among older adults, the association between antihypertensive medication use and physical performance, cognition, and mood. DESIGN AND SETTING: Prospective cohort study in a Veterans Affairs primary care clinic, with patients enrolled in 2000-2001 and assessed for medication use, comorbidities, health behaviors, and other characteristics; and followed-up 1 year later. PARTICIPANTS: 544 community-dwelling hypertensive men over age 65 years. MEASUREMENTS: Timed chair stands; Trail Making Test part B; and Centers for Epidemiologic Studies Depression (CES-D) scores. RESULTS: Participants had a mean age of 74.4 +/- 5.2 years and took a mean of 2.3 +/- 1.2 antihypertensive medications at baseline. After adjustment for age, comorbidities, level of blood pressure, and other confounders, each 1-unit increase in antihypertensive medication "intensity" was associated with a 0.11-second (95% confidence interval, 0.05-0.16) increase in the time required to complete the timed chair stands. No significant relationship was found between antihypertensive medication intensity and outcomes for Trail Making B or CES-D scores. CONCLUSIONS: A higher cumulative exposure to antihypertensive medications in community-living older men was associated with adverse effects on physical performance, but not on the cognitive or depression measures available in this study. Clinicians should consider non-cardiovascular related adverse effects when treating older males taking multiple antihypertensive medications.

Views of older adults on patient participation in medication-related decision making.

BACKGROUND: Medication decision making is complex, particularly for older patients with multiple conditions for whom benefits may be uncertain and health priorities may be variable. While patient input would seem important in the face of this uncertainty and variability, little is known about older patients' views of involvement in medication decision making. OBJECTIVE: To explore the views of older adults regarding participation in medication decision making. DESIGN: Qualitative study. PARTICIPANTS: Fifty-one persons at least 65 years old who consumed at least one medication were recruited from 3 senior centers and 4 physicians' offices. APPROACH: One-on-one interviews were conducted to uncover participants' perceptions of medication-related decision making through semistructured, open-ended questions. Themes were compared according to the constant comparative method of analysis. RESULTS: The predominant theme that emerged was the variability in perceptions concerning whether it was possible or desirable for patients to participate in prescribing decisions. For some participants, involvement was limited to sharing information. Physician and system factors that were felt to facilitate or impede patient participation included communication skills, the expanding number of medications available, multiple physicians prescribing for the same patient, and a focus on treating numbers. Perceived lack of knowledge, low self-efficacy, and fear were the patient factors mentioned. Both the presence and absence of trust in the prescribing physician were seen as alternatively impeding and enhancing patient participation. Only 1 participant explicitly mentioned patient preference, a cornerstone of shared decision making. CONCLUSIONS: While evolution to greater patient involvement in medication decision making may be possible, and desirable to some older patients, findings suggest that the transition will be challenging.

A chart-based method for identification of delirium: validation compared with interviewer ratings using the confusion assessment method.

OBJECTIVES: To validate a chart-based method for identification of delirium and compare it with direct interviewer assessment using the Confusion Assessment Method (CAM). DESIGN: Prospective validation study. SETTING: Teaching hospital. PARTICIPANTS: Nine hundred nineteen older hospitalized patients. MEASUREMENTS: A chart-based instrument for identification of delirium was created and compared with the reference standard interviewer ratings, which used direct cognitive assessment to complete the CAM for delirium. Trained nurse chart abstractors were blinded to all interview data, including cognitive and CAM ratings. Factors influencing the correct identification of delirium in the chart were examined. RESULTS: Delirium was present in 115 (12.5%) patients according to the CAM. Sensitivity of the chart-based instrument was 74%, specificity was 83%, and likelihood ratio for a positive result was 4.4. Overall agreement between chart and interviewer ratings was 82%, kappa=0.41. By contrast, using International Classification of Diseases, Ninth Revision, Clinical Modification, administrative codes, the sensitivity for delirium was 3%, and specificity was 99%. Independent factors associated with incorrect chart identification of delirium were dementia, severe illness, and high baseline delirium risk. With all three factors present, the chart instrument was three times more likely to identify patients incorrectly than with none of the factors present. CONCLUSION: A chart-based instrument for delirium, which should be useful for patient safety and quality-improvement programs in older persons, was validated. Because of potential misclassification, the chart-based instrument is not recommended for individual patient care or diagnostic purposes.

The role of adherence on the effectiveness of nonpharmacologic interventions: evidence from the delirium prevention trial.

BACKGROUND: The impact of adherence on outcome for a nonpharmacologic intervention strategy has not been previously examined. OBJECTIVE: To examine the impact of level of adherence on effectiveness of the intervention strategy in a large clinical trial of nonpharmacologic interventions to prevent delirium. METHODS: The subjects included 422 consecutive patients 70 years or older admitted to the medicine service at a university hospital. The intervention protocols were targeted toward 6 delirium risk factors. The primary outcome was new-onset delirium during hospitalization. RESULTS: During 9882 patient-days, complete adherence rates for individual intervention protocols ranged from 10% for the sleep protocol to 86% for the orientation protocol. The rate of complete adherence with all protocols was 57%, and combined partial and complete adherence was 87%. Higher levels of adherence resulted in lower delirium rates, with a significant graded effect, for orientation, mobility, and therapeutic activities protocols, and for the composite adherence measure. After controlling for potential confounding variables, such as illness severity, comorbidity, baseline delirium risk, and functional status, adherence continued to demonstrate a consistently strong and significant protective effect against delirium (adjusted odds ratio, 0.69; 95% confidence interval, 0.56-0.87). Patients in the highest adherence group demonstrated an 89% reduction in delirium risk compared with patients in the lowest group. CONCLUSIONS: Adherence played an important independent role in the effectiveness of a nonpharmacologic multicomponent intervention strategy. Higher levels of adherence resulted in reduced rates of delirium in a directly graded fashion, with extremely low levels of delirium in the highest adherence group. Thus, adherence must be ensured in nonpharmacologic interventions to optimize effectiveness.

The relationship between number of medications and weight loss or impaired balance in older adults.

OBJECTIVES: To examine the relationship between cumulative medication exposure and risk of two common manifestations of adverse drug effects: weight loss and impaired balance. DESIGN: Cross-sectional and longitudinal cohort. SETTING: Urban Connecticut community. PARTICIPANTS: Eight hundred eighty-five community-dwelling residents aged 72 and older. MEASUREMENTS: Weight loss (> or =10 pounds) and balance, a composite of four balance measures. RESULTS: Participants took a mean+/-standard deviation of 2.2+/-1.9 medications (range 0-15). After adjustment for age, depressive symptoms, cognitive impairment, vision and hearing impairments, number of chronic diseases, and number of hospitalizations in the previous year, the adjusted odds ratio (OR) for weight loss was 1.48 (95% confidence interval (CI)=0.85-2.59) for those taking one to two medications, 1.96 (95% CI=1.08-3.54) for three to four medications, and 2.78 (95% CI=1.38-5.60) for five or more medications. For impaired balance, adjusted ORs were 1.44 (95% CI=0.94-2.19), 1.72 (95% CI=1.09-2.71), and 1.80 (95% CI=1.02-3.19), respectively. CONCLUSION: A greater number of medications were associated with increased risk of adverse drug outcomes, after extensive adjustment for chronic illness. Clinicians should consider the adverse effects of total drug use and not merely the benefits or risks of individual medications for specific diseases.

Delirium superimposed on dementia: a systematic review.

Delirium in a patient with preexisting dementia is a common problem that may have serious complications and poor prognostic implications. The purpose of this paper was to conduct a systematic review of the medical literature on delirium superimposed on dementia, specifically to review studies on prevalence, associated features, outcomes, and management. Areas of controversy and gaps in our knowledge of this problem are highlighted. Finally, an agenda for future research is proposed. Fourteen studies were reviewed, including seven prospective studies, three retrospective studies, two cross-sectional studies, and two clinical trials. For the review of the literature on delirium superimposed on dementia, we searched MEDLINE from January 1966 through February 2002 for research studies with primary sources of data. Selection criteria for inclusion of articles in this study were inclusion of data on subjects with delirium superimposed on dementia, inclusion of a validated operational definition/measures of dementia and delirium, actual data on persons with delirium and dementia reported in the paper, and reporting of primary data. MEDLINE was searched using the following key search terms: delirium, acute confusion, cognitive impairment, Alzheimer's disease, dementia, delirium superimposed on dementia, and elderly. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. To date, only one reported study systematically identified associated factors and interventions for delirium superimposed on dementia, but several studies examining outcomes have found that adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, rehospitalization, and increased mortality. This paper highlights the dearth of research on delirium superimposed on dementia and stresses the importance of early recognition and prevention of delirium in persons with dementia.

Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan.

Patient-centered, accountable care has garnered increased attention with the passage of the Affordable Care Act and new Medicare regulations. This case study examines a care model jointly developed by a provider and a payer that approximates an accountable care organization for a Medicare Advantage population. The collaboration between Aetna and NovaHealth, an independent physician association based in Portland, Maine, focused on shared data, financial incentives, and care management to improve health outcomes for approximately 750 Medicare Advantage members. The patient population in the pilot program had 50 percent fewer hospital days per 1,000 patients, 45 percent fewer admissions, and 56 percent fewer readmissions than statewide unmanaged Medicare populations. NovaHealth's total per member per month costs across all cost categories for its Aetna Medicare Advantage members were 16.5 percent to 33 percent lower than costs for members not in this provider organization. Clinical quality metrics for diabetes, ischemic vascular disease, annual office visits, and postdischarge follow-up for patients in the program were consistently high. The experience of developing and implementing this collaborative care model suggests that several components are key, including robust data sharing and information systems that support it, analytical support, care management and coordination, and joint strategic planning with close provider-payer collaboration.

Hypertension prevalence and prescribing trends in older US adults: 1999-2004.

To describe hypertension trends in US adults aged 65 years and older using Medicare Current Beneficiary Survey (MCBS) data, a cross-sectional, nationally representative health examination survey from MCBS files between 1999 and 2004 was investigated. Overall, 62% of beneficiaries, or an estimated 20 million US adults aged 65 years and older, were hypertensive as extrapolated from MCBS data. From 1999 to 2004, the prevalence rate of hypertension increased from 59% to 65% (P<.001). Nonwhite persons and women had a higher prevalence of hypertension than whites and men. A history of diabetes mellitus, prior myocardial infarction, coronary artery disease, or stroke was significantly associated with hypertension treatment. In addition, significant geographic variation in treatment was noted. There was a significant increase in hypertension prevalence in older Medicare beneficiaries from 1999 to 2004. Women, patients 85 years and older, and nonwhite patients were less likely to be treated with antihypertensive medications, and significant geographic variation existed in treatment.

Cumulative anticholinergic exposure is associated with poor memory and executive function in older men.

OBJECTIVES: To examine the longitudinal relationship between cumulative exposure to anticholinergic medications and memory and executive function in older men. DESIGN: Prospective cohort study. SETTING: A Department of Veterans Affairs primary care clinic. PARTICIPANTS: Five hundred forty-four community-dwelling men aged 65 and older with diagnosed hypertension. MEASUREMENTS: The outcomes were measured using the Hopkins Verbal Recall Test (HVRT) for short-term memory and the instrumental activity of daily living (IADL) scale for executive function at baseline and during follow-up. Anticholinergic medication use was ascertained using participants' primary care visit records and quantified as total anticholinergic burden using a clinician-rated anticholinergic score. RESULTS: Cumulative exposure to anticholinergic medications over the preceding 12 months was associated with poorer performance on the HVRT and IADLs. On average, a 1-unit increase in the total anticholinergic burden per 3 months was associated with a 0.32-point (95% confidence interval (CI)= 0.05-0.58) and 0.10-point (95% CI=0.04-0.17) decrease in the HVRT and IADLs, respectively, independent of other potential risk factors for cognitive impairment, including age, education, cognitive and physical function, comorbidities, and severity of hypertension. The association was attenuated but remained statistically significant with memory (0.29, 95% CI=0.01-0.56) and executive function (0.08, 95% CI=0.02-0.15) after further adjustment for concomitant non-anticholinergic medications. CONCLUSION: Cumulative anticholinergic exposure across multiple medications over 1 year may negatively affect verbal memory and executive function in older men. Prescription of drugs with anticholinergic effects in older persons deserves continued attention to avoid deleterious adverse effects.

Views of older persons with multiple morbidities on competing outcomes and clinical decision-making.

OBJECTIVES: To examine the ways in which older persons with multiple conditions think about potentially competing outcomes in order to gain insight into how processes to elicit values regarding these outcomes can be grounded in the patient's perspective. DESIGN: Qualitative study consisting of purposefully sampled focus groups. SETTING: Community. PARTICIPANTS: Persons aged 65 and older taking five or more medications. MEASUREMENTS: Participants were asked their perceptions about whether their illnesses or treatment interacted with each other, goals of their treatment, and decisions to change or stop treatment. RESULTS: Although participants were largely unaware that treatment of one condition could worsen another, many had experience with adverse medication effects as a competing outcome. Participants initially discussed their conditions in terms of disease-specific outcomes, such as achieving a target blood pressure or lipid level. In the context of decision-making, participants shifted their discussion from disease-specific to global, cross-disease health outcomes, such as survival, preservation of physical function, and relief of symptoms. Despite having some misconceptions regarding the likelihood of these outcomes, they weighed the outcomes against one another to consider what was most important to them. Their preference was for the treatment that would achieve the most desired outcome. CONCLUSION: Because of their experience with adverse medication effects, older persons with multiple morbidities can understand the concept of competing outcomes. The task of prioritizing global, cross-disease outcomes can help to clarify what is most important to seniors who are faced with complex healthcare decisions.

Systolic hypertension in older persons: how aggressive should treatment be?

Systolic hypertension (SH) is a major public health concern predominantly affecting older persons. A key message of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) is that SH is a much more important cardiovascular disease risk factor than diastolic hypertension, particularly in older persons. Consequently, aggressive control of elevations of systolic blood pressure (SBP) is recommended. Despite increasing attention, SH is on the rise: isolated elevations of SBP in a national sampling of Veteran's Administration patients have increased from 57% in 1990 to 1995 to 76% of patients in 1999. This article considers several clinically pertinent issues, including the evidence for treating older patients with elevations in SBP, treating SH in the "oldest old" (those aged >85 years), and how aggressively these patients should be treated. In addition, issues regarding clinical decision making in older patients with SH are discussed.