Medication Therapy Management after Hospitalization in CKD: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: CKD is characterized by remarkably high hospitalization and readmission rates. Our study aim was to test a medication therapy management intervention to reduce subsequent acute care utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The CKD Medication Intervention Trial was a single-blind (investigators), randomized clinical trial conducted at Providence Health Care in Spokane, Washington. Patients with CKD stages 3-5 not treated by dialysis who were hospitalized for acute illness were recruited. The intervention was designed to improve posthospitalization care by medication therapy management. A pharmacist delivered the intervention as a single home visit within 7 days of discharge. The intervention included these fundamental elements: comprehensive medication review, medication action plan, and a personal medication list. The primary outcome was a composite of acute care utilization (hospital readmissions and emergency department and urgent care visits) for 90 days after hospitalization. RESULTS: Baseline characteristics of participants (n=141) included the following: age, 69±11 (mean±SD) years old; women, 48% (67 of 141); diabetes, 56% (79 of 141); hypertension, 83% (117 of 141); eGFR, 41±14 ml/min per 1.73 m2 (serum creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation); and urine albumin-to-creatinine ratio median, 43 mg/g (interquartile range, 8-528) creatinine. The most common primary diagnoses for hospitalization were the following: cardiovascular events, 36% (51 of 141); infections, 18% (26 of 141); and kidney diseases, 12% (17 of 141). The primary outcome occurred in 32 of 72 (44%) of the medication intervention group and 28 of 69 (41%) of those in usual care (log rank P=0.72). For only hospital readmission, the rate was 19 of 72 (26%) in the medication intervention group and 18 of 69 (26%) in the usual care group (log rank P=0.95). There was no between-group difference in achievement of guideline-based goals for use of renin-angiotensin system inhibition or for BP, hemoglobin, phosphorus, or parathyroid hormone. CONCLUSIONS: Acute care utilization after hospitalization was not reduced by a pharmacist-led medication therapy management intervention at the transition from hospital to home.

Medication Intervention for Chronic Kidney Disease Patients Transitioning from Hospital to Home: Study Design and Baseline Characteristics.

BACKGROUND: The hospital readmission rate in the population with chronic kidney disease (CKD) is high and strategies to reduce this risk are urgently needed. METHODS: The CKD-Medication Intervention Trial (CKD-MIT; www.clinicaltrials.gov; NCTO1459770) is a single-blind (investigators), randomized, clinical trial conducted at Providence Health Care in Spokane, Washington. Study participants are hospitalized patients with CKD stages 3-5 (not treated with kidney replacement therapy) and acute illness. The study intervention is a pharmacist-led, home-based, medication management intervention delivered within 7 days after hospital discharge. The primary outcome is a composite of hospital readmissions and visits to emergency departments and urgent care centers for 90 days following hospital discharge. Secondary outcomes are achievements of guideline-based targets for CKD risk factors and complications. RESULTS: Enrollment began in February 2012 and ended in May 2015. At baseline, the age of participants was 69 ± 11 years (mean ± SD), 50% (77 of 155) were women, 83% (117 of 141) had hypertension and 56% (79 of 141) had diabetes. At baseline, the estimated glomerular filtration rate was 41 ± 14 ml/min/1.73 m2 and urine albumin-to-creatinine ratio was 43 mg/g (interquartile range 8-528 mg/g). The most frequent diagnosis category for the index hospital admission was cardiovascular diseases at 34% (53 of 155), but the most common single diagnosis for admission was community-acquired acute kidney injury at 10% (16 of 155). CONCLUSION: Participants in CKD-MIT are typical of acutely ill hospitalized patients with CKD. A medication management intervention after hospital discharge is under study to reduce post-hospitalization acute care utilization and to improve CKD management.

Predicting potential postdischarge adverse drug events and 30-day unplanned hospital readmissions from medication regimen complexity.

OBJECTIVES: To determine whether medication regimen complexity (MRC) could predict likelihood for occurrence of potential adverse drug events (ADEs), unplanned 30-day hospital readmission, or 30-day emergency department use in patients transitioning from hospital to home care. METHODS: Hospital discharge medication lists and medication lists constructed during visits to patients' homes were analyzed for 213 participants. MRC was quantified with the Medication Regimen Complexity Index (MRCI). The potential for ADEs was based on medication discrepancies detected between the discharge and patient reported home medication lists. Unplanned acute care utilization in the 30 days after index hospitalization was tracked. Logistic regression analyses were used to approximate the odds for an ADE and postdischarge acute care utilization from MRCI scores. RESULTS: Home medication lists were less complex than hospital discharge medication lists. High home medication list MRCI scores increased the odds more than 4-fold for a potential ADE (P < 0.001). High discharge medication list MRCI scores increased the odds more than 5-fold for an unplanned 30-day hospital readmission (P = 0.026). High regimen complexity did not significantly elevate odds for emergency department use. CONCLUSIONS: MRC was predictive of patients' potential for ADEs and unplanned hospital readmission. MRC may be useful in identifying patients that would benefit from additional transitional care interventions. Results indicate that simplifying medication regimens may favorably impact postdischarge outcomes.

Type 2 translational research for CKD.

Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a "bench-to-bedside" paradigm (conventional type 1 translation) to research that encompasses "clinic and community" is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of high-quality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge.

Polypharmacy in older adults at home: what it is and what to do about it-implications for home healthcare and hospice, part 2.

Polypharmacy-the use of more medications than are clinically indicated-is a problem that affects many older adults. Adults aged 65 years and older make up approximately 13% of the population, but they consume nearly one third of all prescriptions dispensed. Older adults are more prone to adverse drug reactions and drug-drug interactions because of physiological changes and multiple comorbidities. It can be difficult to address the problem because there are many contributing factors, including multiple prescribers and specialists, the use of multiple pharmacies, and gaps in communication. The initial step is to avoid the problem. However, when this does not work, it must be identified and then treated by carefully changing medication regimens to improve the quality of care to patients. The home healthcare nurse has an essential role in this process, which will be reviewed in this article. Some of the barriers that may be encountered and examples of communication with providers are included.

Polypharmacy in older adults at home: what it is and what to do about it--implications for home healthcare and hospice.

Polypharmacy--the use of more medications than are clinically indicated--is a problem that affects many older adults. Adults aged 65 years and older make up approximately 13% of the population, but they consume nearly one third of all prescriptions dispensed. Older adults are more prone to adverse drug reactions and drug-drug interactions due to physiological changes and multiple comorbidities. The harmful effects that may be caused by the inappropriate use of medications include but are not limited to: side effects, drug interactions, and high drug costs. Polypharmacy may lead to a decrease in quality of life. With an increase in specialization across medicine, many patients see multiple prescribers and may fill medications at multiple pharmacies. This can contribute to the problem of polypharmacy. Periodic medication reviews and effective and constant communication between healthcare providers and patients can help to identify potentially inappropriate medications, which is essential in aiding to reduce polypharmacy.

Point-of-care screening to identify cognitive impairment in older adults.

OBJECTIVE: To explore associations between results of a rapid screening tool for cognitive impairment and individual patient characteristics in a sample of patients receiving outpatient anticoagulation therapy who were not previously diagnosed with a dementia. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: Pharmacist-managed anticoagulation clinic in Spokane, WA, from June 2006 to March 2007. PARTICIPANTS: 300 community-dwelling patients aged 60 years or older who had at least 6 months of outpatient anticoagulation therapy services. INTERVENTION: Following informed consent, demographic, medical history, medication history, anticoagulation therapy, and cognitive screening data were recorded from participant medical records, and a participant interview was performed using a standardized questionnaire and data collection form. MAIN OUTCOME MEASURES: Cognitive screening status (suggests cognitive impairment versus suggests dementia less likely) was used as an independent variable by which to compare patient demographics, medical history, medication history, and percent of out-of-range International Normalized Ratio (INR) visits. RESULTS: 55 of 300 participants (18.3%) with no previous diagnosis of a cognitive impairment were classified as "suggests cognitive impairment" based on the screening test. Presence or absence of cognitive impairment differed in those needing assistance with taking medications but was not associated with other sample characteristics, including percentage of visits with out-of-range INR value, gender, in-home care needs, age, and number of medical conditions. CONCLUSION: Screening at a convenient health care access point may lead to increased identification of community-dwelling elderly patients with unrecognized and undiagnosed cognitive impairment. Pharmacists are particularly well suited to conduct this screening because of the extended and frequent contact they have with patients in settings such as anticoagulation therapy clinics.

Review of linagliptin for the treatment of type 2 diabetes mellitus.

BACKGROUND: Linagliptin is a dipeptidyl peptidase-4 inhibitor that was approved in 2011 by the US Food and Drug Administration as a treatment adjunctive to diet and exercise for the improvement of glycemic control in adults with type 2 diabetes mellitus (T2DM). OBJECTIVE: The purpose of this article is to review the pharmacology, pharmacokinetic properties, efficacy, tolerability including drug-drug interactions, contraindications/precautions, and dosage and administration of linagliptin, and the potential role of linagliptin in the management of glycemia in adults with T2DM. METHODS: MEDLINE (1966-January 12, 2012), PubMed (1950-January 12, 2012), Science Direct (1994-January 12, 2012), Web of Science (1980-January 12, 2012), and the American Diabetes Association Scientific Abstracts (2008-2011) were searched using the term linagliptin. Articles and abstracts published in English, both original research and review articles, were identified for review. Reference lists from identified articles were also searched for additional references of interest. Manufacturers' prescribing information was additionally examined. RESULTS: Data from clinical trials of linagliptin suggest clinical efficacy in terms of reductions in hemoglobin A(1c) (A(1c)), fasting plasma glucose, and postprandial glucose when linagliptin was administered as monotherapy or in combination with other oral antidiabetic agents, with placebo-subtracted A(1c) changes ranging from -0.47% to -0.69% in placebo-controlled trials. Adverse events that occurred in ≥2% of patients treated with linagliptin and at a prevalence of ≥2-fold greater compared with placebo were nasopharyngitis, hyperlipidemia, cough, hypertriglyceridemia, and weight increase (when used in combination with a thiazolidinedione [TZD]). Although linagliptin administered as monotherapy or in combination with metformin or a TZD may convey a low risk for hypoglycemia (0%-1.2%), caution is warranted when linagliptin is administered in combination with insulin secretagogues due to an increased risk for hypoglycemic events. Dosage adjustments based on renal or hepatic function are not required. Additionally, according to the currently approved prescribing information, the efficacy of linagliptin may be limited in patients receiving concurrent inducers of the cytochrome P450 3A4 isozyme or P-glycoprotein (eg, rifampin). CONCLUSIONS: Based on the findings from the present review, patients and clinicians should be aware of the risk for hypoglycemia when linagliptin is prescribed as a treatment adjunctive to a regimen of an insulin secretagogue. An initial dose decrease in the secretagogue should be considered to prevent hypoglycemic events. Dosage adjustment of linagliptin is not required in patients with renal impairment.

Transitional care: exploring the home healthcare nurse's role in medication management.

During times of transition, the pharmaceutical care patients receive is often suboptimal and wrought with danger. Home healthcare nurses play a pivotal and important role in providing transitional care to patients by identifying and resolving medication discrepancies. Nurses must partner with pharmacists, physicians, and others involved with care transitions to decrease the likelihood of patients experiencing untoward health consequences associated with medications.-Eric A. .

Clinical review of treatment options for select nonmotor symptoms of Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is associated with a host of nonmotor symptoms, including psychosis, cognitive impairment, depression, sleep disturbance, swallowing disorders, gastrointestinal symptoms, and autonomic dysfunction. The nonmotor symptoms of PD have the potential to be more debilitating than the motor features of the disorder. OBJECTIVE: The aim of this article was to review treatment options for the nonmotor manifestations of PD, including pharmacologic and nonpharmacologic interventions. METHODS: The PubMed and MEDLINE databases were searched for articles published in English between January 1966 and April 2010, using the terms Parkinson's disease, nonmotor, psychosis, hallucination, antipsychotic, cognitive impairment, dementia, depression, sleep disturbance, sleepiness, REM (rapid eye movement) sleep behavior disorder, dysphagia, swallowing disorder, sialorrhea, gastrointestinal, constipation, autonomic dysfunction, orthostatic hypotension, gastroparesis, erectile dysfunction, sexual dysfunction, and urinary dysfunction. Articles were selected for review if they were randomized controlled trials (RCTs), meta-analyses, or evidence-based reviews of treatment of patients with PD, and/or expert opinion regarding the treatment of nonmotor symptoms of PD. RESULTS: A total of 148 articles, including RCTs, meta-analyses, and evidence-based reviews, were included in this review. The treatment of hallucinations or psychosis in PD should include a stepwise reduction in medications for motor symptoms, followed by the use of quetiapine or clozapine. Dementia may be treated with acetylcholinesterase inhibitors. Evidence is lacking concerning the optimal pharmacologic treatment for depression in PD, with expert opinions indicating selective serotonin reuptake inhibitors as the antidepressants of choice. However, the largest study to date found nortriptyline therapy to be efficacious compared with placebo, whereas paroxetine controlled release was not. A variety of sleep disturbances may plague a person with PD, and treatment must be individualized to the patient's specific sleep disturbance pattern and contributing factors. Swallowing disorders may lead to aspiration and pneumonia, and patients with dysphagia should be referred to a speech therapist for further evaluation and treatment. Orthostasis may be treated with nonpharmacologic interventions as well as pharmacologic treatments (eg, fludrocortisone, midodrine, indomethacin). Other autonomic symptoms are managed in a manner similar to that in patients without PD, although careful attention must be aimed at avoiding dopamine-blocking therapies in the treatment of gastrointestinal dysfunction and gastroparesis. CONCLUSIONS: Various pharmacologic and nonpharmacologic strategies are available for the management of the nonmotor symptoms of PD. The challenges associated with nonmotor symptoms must not be forgotten in light of the motor symptoms of PD, and treatment of nonmotor symptoms should be encouraged.

Nurse identified hospital to home medication discrepancies: implications for improving transitional care.

Care transitions are clinically dangerous times, particularly for older adults with complex health problems. This article describes the most common medication discrepancies identified by nurses during patients' (n = 101) hospital to home transition. Findings indicated that medication discrepancies were astoundingly widespread, with 94% of the participants having at least 1 discrepancy. The average number of medication discrepancies identified was 3.3 per participant. Medication discrepancies were identified in virtually all classes of medications, including those with high safety risks. Evidence-based best practices to reduce transition-related medication discrepancies are presented.

Pharmacology, efficacy and safety of liraglutide in the management of type 2 diabetes.

Liraglutide is a glucagon-like peptide-1 analog with pharmacokinetic properties suitable for once-daily administration approved by the Food and Drug Administration for the treatment of patients with type 2 diabetes. Clinical trial data from large, controlled studies demonstrate the safety and efficacy of liraglutide in terms of hemoglobin A(1c) (HbA(1c)) reduction, reductions in body weight, and the drug's low risk for hypoglycemic events when used as monotherapy. Liraglutide has been studied as monotherapy and in combination with metformin, glimepiride, and rosiglitazone for the treatment of type 2 diabetes. Additionally, comparative data with insulin glargine and exenatide therapy are available from Phase III trials. Once-daily administration may provide a therapeutic advantage for liraglutide over twice-daily exenatide, with similar improvements in HbA(1c) and body weight observed when liraglutide was compared with exenatide. The glucose-dependent mechanism of insulin release with incretin analog therapy holds potential clinical significance in the management of postprandial hyperglycemic excursions, with minimal risk of hypoglycemia when used with non-secretagogue medications. Data to date on patient-reported outcomes with liraglutide treatment are encouraging. The most common adverse events associated with liraglutide therapy are dose-dependent nausea, vomiting, and diarrhea. Diligent postmarketing surveillance to elucidate the risk of pancreatitis and medullary thyroid carcinoma in a heterogeneous population are likely warranted.

Exploring the concept of medication discrepancy within the context of patient safety to improve population health.

Medication discrepancy is a concept often used in discussions about medication safety but has neither been fully explained nor clearly defined in the literature. This article explores medication discrepancy as it relates to patient safety and population health in the management of medications. Literature review reveals 2 main aspects of discrepancies in medication management; prescribing issues and patient adherence to regimens. Further development of the concept of medication discrepancy can be beneficial to the theorist, researcher, or clinician. Conceptual clarity about the various aspects of medication discrepancy in the context of patient safety has the potential to enhance quality improvement efforts and patient outcomes to improve population health.

Effectiveness of a pharmacist-nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

PURPOSE: The effectiveness of a collaborative pharmacist-nurse intervention on resolving detected medication discrepancies as patients transitioned from hospital to home health care was evaluated. METHODS: Patients age 50 years or older who were transitioning from hospital to home health care with qualifying diagnoses were eligible for study inclusion. Patients were assigned to a control or intervention group based on the geographic location of the patients' home. For the intervention group, the study coordinator initiated consultation with the nurse case manager to facilitate discrepancy resolution. Patients in the control group received usual care after the initial home visit by the study coordinator. Rehospitalization rates and the number of planned and unplanned physician visits were analyzed. Descriptive statistics were used to characterize and contrast patients in each study group. Equivalency testing was conducted to evaluate group comparability for demographic and health status variables and the use of health care services. RESULTS: A total of 490 medication discrepancies were identified. The discrepancy resolution rates in the intervention and control groups were 67.0% and 54.6%, respectively. Assignment to the intervention group was associated with enhanced medication discrepancy resolution (r = 0.539, p = 0.001). There was a trend toward more planned and unplanned physician visits, and a trend toward a greater number of rehospitalization days. CONCLUSION: A pharmacist-nurse collaboration designed to identify and resolve medication-related discrepancies in patients transitioning from the hospital to home health care led to significant improvement in medication discrepancy resolution.

The relationship between anticholinergic medications and Mini-Cog scores in older adults receiving home health care.

OBJECTIVES: To describe anticholinergic use patterns in older adult home health recipients and examine their relationship to evidence of cognitive impairment. DESIGN: Retrospective study. SETTING: A home health care agency in Eastern Washington state. PARTICIPANTS: Potential study subjects were 174 recipients of home health services between March 1, 2006, and October 1, 2006, who were 60 years of age or older and had been screened for cognitive impairment by the Mini-Cog assessment test. A random sample of 65 out of 75 patients who scored in the impaired range on the Mini-Cog and a random sample of 65 out of 99 patients who scored in the unimpaired range were included in the study. MAIN OUTCOME MEASURE: prevalence of anticholinergic medication use. RESULTS: The majority of participants (80.0%) were using a medication with anticholinergic effects; however, more participants were using weak anticholinergics (66.1%) than potent agents (33.8%). After controlling for age, caregiver presence, and marital status, participants who scored as cognitively impaired on the Mini-Cog were less likely to be taking a medication with anticholinergic properties (odds ratio 0.34, 95% confidence interval 0.13-0.94). CONCLUSION: Although anticholinergic use was common in this older adult, home health population, the majority of participants were using medications with weak anticholinergic activity, as opposed to potent ones. Participants with cognitive impairment were less likely to be using any medication with anticholinergic properties.

Treatment of chorea associated with Huntington's disease: focus on tetrabenazine.

OBJECTIVE: Review Huntington's disease (HD) and the role of tetrabenazine (TBZ) in treating chorea associated with this disease. Discuss the pharmacology, side-effect profile, drug interactions, precautions, and contraindications of TBZ. DATA SOURCES: Literature identified within MEDLINE and PubMED. STUDY SELECTION: Two manuscripts specifically regarding the management of chorea in patients with HD were identified. Additionally, studies involving the clinical use of TBZ were reviewed. DATA SYNTHESIS: The literature identified provided information regarding the efficacy, safety, and pharmacological actions of TBZ. CONCLUSION: HD is often accompanied by chorea, and the treatment with TBZ in this patient population often results in decreased chorea. Pharmacists managing patients on TBZ need to be well versed in TBZ's potential side effects, drug interactions, and unique dosing considerations.

Rate of obesity in U.S. ambulatory patients with diabetes mellitus: a national assessment of office-based physician visits.

To examine the interface between obesity and type 2 diabetes mellitus we examined data from the 2005 U.S. National Ambulatory Medical Care Survey (NAMCS). Our findings indicate a significant proportion of U.S. ambulatory patients with DM present with obesity and greater clinical acuity than patients with DM alone.