Assessing an Interprofessional Polypharmacy and Deprescribing Educational Intervention for Primary Care Post-graduate Trainees: a Quantitative and Qualitative Evaluation.

BACKGROUND: Polypharmacy and potentially inappropriate medications (PIMs) are increasingly common and associated with adverse health effects. However, post-graduate education in polypharmacy and complex medication management for older adults remain limited. OBJECTIVE: The Initiative to Minimize Pharmaceutical Risk in Older Veterans (IMPROVE) polypharmacy clinic was created to provide a platform for teaching internal medicine (IM) and nurse practitioner (NP) residents about outpatient medication management and deprescribing for older adults. We aimed to assess residents' knowledge of polypharmacy and perceptions of this interprofessional education intervention. DESIGN: A prospective cohort study with an internal comparison group. PARTICIPANTS: IM residents and NP residents; Veterans ≥ 65 years and taking ≥ 10 medications. INTERVENTION: IMPROVE consists of a pre-clinic conference, shared medical appointment, individual appointment, and interprofessional precepting model. MAIN MEASURES: We assessed residents' performance on a pre-post knowledge test, residents' qualitative assessment of the educational impact of IMPROVE, and the number and type of medications discontinued or decreased. KEY RESULTS: The IMPROVE intervention group (n = 18) had a significantly greater improvement in test scores than the control group (n = 18) (14% ± 15% versus - 1.3% ± 16%) over a period of 6 months (Wilcoxon rank sum, p = 0.019). In focus groups, residents (n = 17) reported perceived improvements in knowledge and skills, noting that the experience changed their practice in other clinical settings. In addition, residents valued the unique interprofessional experience. Veterans (n = 71) had a median of 15 medications (IQR 12-19), and a median of 2 medications (IQR 1-3) was discontinued. Vitamins, supplements, and cardiovascular medications were the most commonly discontinued medications, and cardiovascular medications were the most commonly decreased in dose or frequency. CONCLUSIONS: Overall, IMPROVE is an effective model of post-graduate primary care training in complex medication management and deprescribing that improves residents' knowledge and skills, and is perceived by residents to influence their practice outside the program.

Utility of an adverse drug event trigger tool in Veterans Affairs nursing facilities.

OBJECTIVE: To determine the utility (i.e., positive predictive value [PPV] and time requirement) of an adverse drug event (ADE) trigger tool in Veterans Affairs (VA) nursing facilities and to describe the most common types of potential ADEs detected with the trigger tool. DESIGN: Retrospective chart review. SETTING/PATIENTS: Veterans residing in three VA nursing facilities between September 29, 2010, and October 29, 2010. MEASUREMENT: We used the Institute for Healthcare Improvement-endorsed nursing facility ADE trigger tool, modified to enhance its clinical relevance to detect potential ADEs. Electronic medical records were screened to identify residents with one or more abnormal laboratory values specified in the trigger tool. MAIN OUTCOME MEASURES: A potential ADE was defined as the concurrent administration of medication that could cause the abnormal laboratory value. An overall PPV, or proportion of residents with an abnormal laboratory value who had a potential ADE, and average time required to complete each trigger tool assessment, were calculated. RESULTS: Among 321 veterans, 50.5% (n = 162) had at least one abnormal laboratory value contained in the trigger tool. Ninety-nine potential ADEs involving 146 medications were detected in 65 veterans. The overall PPV of the ADE trigger tool was 40.1% (65/162), and the average time to complete resident assessments was 8.8 (standard deviation ± 5.7) minutes. The most common potential ADEs were acute kidney injury (n = 30 residents), hypokalemia (n = 18), hypoglycemia (n = 13), and hyperkalemia (n = 10). CONCLUSIONS: The modified nursing facility trigger tool was shown to be an effective and efficient method for detecting potential ADEs.

Cognitive Impairment and Medication Complexity in Community-Living Older Adults: The Health, Aging and Body Composition Study.

BACKGROUND: Medication complexity is a large determinant of adherence. Few studies have explored the relationship between cognitive impairment and medication complexity. OBJECTIVE: To evaluate whether cognitive impairment is associated with medication complexity for prescription and over-the-counter (OTC) medications. METHODS: In this cross-sectional analysis, we studied the association between cognitive impairment and the complexity of prescription and OTC drug regimens. Baseline participants were from the Health, Aging and Body Composition study, consisting of 3075 well-functioning 70- to 79-year-old black and white men and women. Cognitive impairment was defined by having a Modified Mini-Mental State Examination score <80. The complexity of prescription and OTC (including supplements/herbals) medications was assessed using a modified version of the Medication Regimen Complexity Index (mMRCI). The mMRCI score increases with complexity of dosage forms, number of medications, pill burden, and nondaily dosing. RESULTS: The mean (SD) age was 74 (2.9) years (n = 3055; 52% female, 41% black). The median prescription mMRCI score was 6 (range 0-66). The median OTC mMRCI score was 4 (range 0-71). Adjusting for health status, demographics, and access to care, medication complexity was lower in participants with cognitive impairment for prescription (adjusted RR 0.89; 95% CI 0.80 to 0.99) and OTC medications (adjusted RR 0.76; 95% CI 0.64 to 0.93) compared to those without cognitive impairment. The number of prescription medications was not different, but the number of OTC drugs was lower for those with cognitive impairment. CONCLUSIONS: In this cohort of well-functioning older adults, those with cognitive impairment had lower prescription complexity due to less-complex dosage forms, pill burden, or daily dosing. OTC complexity was also lower, primarily due to a lower number of OTC drugs. The results of this study show that further research on medication complexity and adherence and health outcomes in cognitively impaired individuals is warranted.

Experiences with Cyclical User-Centered Design for Patient and Clinician Facing Medication Reconciliation mHealth Applications.

Accurate medication lists are essential data required to make clinically informed decisions. Obtaining a comprehensive, up-to-date medication list is difficult for clinicians. Patients have limited input into reviewing and reconciling their own medication data. Ideally, a medication list would comprise a 360-degree view of all prescribed, dispensed, purchased medications and would seamlessly connect patients and providers to medication data from multiple sources. While an ideal medication list would capture every aspect of medication management, in reality a Best-Possible Medication History (BPMH) is a more achievable goal. In an effort to realize a BPMH and to facilitate the goals of the State of Connecticut's Office of Health Strategy's Medication Reconciliation and Polypharmacy Committee (MRPC), we engaged stakeholders (patients, clinicians, advocates) in focus-groups and interviews to solicit feedback on the user interface requirements for a BPMH. Feedback was obtained via facilitated discussions that occurred in-person, via virtual meetings, and through online surveys.

Pharmacists' Experiences, Perceptions, and Knowledge of Direct-to-Consumer Prescription Coupons.

BACKGROUND: Despite widespread use of manufacturer-sponsored prescription drug coupons and pharmacy network discount cards (i.e., direct-to-consumer prescription coupons), little is known about community pharmacists' experiences, perceptions, and knowledge of coupon cards. OBJECTIVE: To identify community pharmacists' experiences, perceptions, and knowledge of prescription coupons. METHODS: An 11-item telephonic survey was conducted from August 2018 to March 2019. Eligible respondents included English-speaking pharmacists employed during the survey period in a community pharmacy physically located in Connecticut. Data were analyzed via descriptive statistics and one-way analysis of variance (ANOVA). One-way ANOVAs were conducted to test the relationship between the respondents' practice types, the average daily volume of coupons processed, and the average time needed to process each coupon. The responses were based on a 5-point Likert scale and dichotomized to enable interpretation of the results. RESULTS: There were 240 surveys completed from an eligible pool of 691 community pharmacy sites (34.7% response rate). Respondents representing 60 different businesses located across 123 of the state's 282 major ZIP codes, representing 83.5% of the state's population. Respondents overwhelmingly held positive perceptions of the ability of prescription coupons to increase patients' medication access (91.7 %) and reduce out-of-pocket costs (93.3%). However, respondents also believed patients have trouble paying for prescriptions once coupons expire (70.8%). When questioned about privacy practices, 57.5% of respondents believed that it is illegal to "sell patients' information" (i.e., with no distinction made between protected health information and any other information), while another 25.8% declined to answer, citing they did not know. Only 20.8% (n = 50) of respondents knew that community pharmacies could see lowered reimbursement from accepting network drug discount cards, and 40.4% (n = 97) knew that pharmaceutical manufacturers can cover the difference in patients' copay costs. Approximately 10% of respondents believed (incorrectly) that discounts from pharmacy network discount cards were covered via patients' prescription insurance and/or the third-party discount card vendor companies (7.9% and 3.3%, respectively). Respondents believed patients received prescription coupons most often from the internet or mail (77.1%), their prescribers (62.9%), or from their own community pharmacies (33.3%). Finally, on average, respondents processed 14.6 (SD 19.8) coupons per day and required 4.8 (SD 4.3) minutes for each claim. CONCLUSIONS: As far as we know, this is the first exploration of community pharmacists' experiences, perceptions, and knowledge of direct-to-consumer prescription coupons. Results show that, while community pharmacists overwhelmingly hold positive perceptions towards prescription coupons and drug discount cards, there is an opportunity to increase general understanding of the differences in business practices between manufacturer-sponsored prescription drug coupons and pharmacy network discount cards. Community pharmacies also spend a significant amount of time processing coupon claims. DISCLOSURES: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare no relevant conflicts of interest or financial relationships. This study was presented as a poster at the 2019 American Society of Health Systems Pharmacists Midyear Clinical Meeting during December 8-12, 2019, in Las Vegas, NV.

Home is where the heart is: living arrangements for older adults.

Beginning January 1, 2011 the first of the baby boomers will turn 65 years of age. One of the biggest challenges they will encounter is deciding where they wish to live. Faced with uncertainty regarding their health, longevity, expenses, and need for supportive services, many older adults are overwhelmed with selecting long-term care options. Today, there are a variety of living arrangements available to seniors. These range from independent living to home care or day care, congregate housing, assisted living or nursing facilities. With the number of adults 65 years of age and older projected to exceed 80 million by 2030, there also is a growing concern over the availability of these housing options. Furthermore, as the Institute of Medicine report, "Retooling for an Aging America," notes there will be an additional need for qualified professionals to care for older adults. Pharmacists are uniquely qualified and positioned to provide these services. This article describes various types of living arrangements available to the older adults and the issues associated with transitioning from one setting to another setting. Opportunities for pharmacists to consult in the emerging continuum of care marketplace also will be discussed.

The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study: study protocol for a randomized trial.

BACKGROUND: Diabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings. METHODS: The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment groups: (1) SMAs, (2) SMAs plus P2P, and (3) usual care. We will collect and analyze data over a 2.5-year implementation period at five geographically diverse Veterans Affairs (VA) health systems. The primary outcome is the relative change in hemoglobin A1c over time. Secondary outcomes are changes in systolic blood pressure, antihypertensive medication use, statin use, and insulin initiation over the study period. The unit of analysis is the individual, adjusted by the individual's SMA group (the cluster). We will use mixed methods to rigorously evaluate processes and costs of implementing these programs in each of the clinic settings. DISCUSSION: We hypothesize that patients will experience improved outcomes immediately following participation in SMAs and that augmenting SMAs with reciprocal peer support will help to maintain these gains over time. The results of this study will be among the first to examine the effects of diabetes SMAs alone and in conjunction with P2P in a range of real-life clinical settings. In addition, the study will provide important information on contextual factors associated with successful program implementation. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT02132676 . Registered on 21 August 2013.

Geriatric pharmacy training requirements: A survey of residency programs.

PURPOSE: Results of a survey assessing opportunities for geriatrics training currently available to pharmacy residents and residency directors' views on the concept of a defined slate of required geriatrics rotations are reported. METHODS: Directors of postgraduate year 1 (PGY1) pharmacy residency programs (n = 368) and postgraduate year 2 (PGY2) geriatric pharmacy residencies (n = 13) were surveyed regarding current training opportunities in geriatrics. PGY2 residency directors were invited to participate in a follow-up survey to identify high-priority areas for possible standardization of residency requirements on clinical rotations in geriatric practice settings. RESULTS: About 21% of the PGY1 residency directors who responded to the survey indicated that their program required a geriatrics rotation, and 47% reported elective geriatrics rotations. All 13 PGY2 geriatric pharmacy residencies represented in the survey offered a long-term care rotation, with 12 offering rotations in mental health and outpatient geriatrics, 11 offering a hospice/palliative care rotation, and 10 offering a rotation in inpatient geriatrics. All 11 PGY2 directors who responded to the follow-up survey supported requiring a long-term care rotation in future revisions of the ASHP accreditation standard for geriatric pharmacy residencies; 10 supported required rotations in inpatient and outpatient geriatrics, and 9 supported requiring a hospice/palliative care rotation. CONCLUSION: Geriatrics-oriented training in PGY1 pharmacy residencies is limited, with only about one in five programs requiring a geriatrics rotation. The survey results indicated broad support among PGY2 program heads for required rotations in various geriatric healthcare settings.

Restructuring care for older adults undergoing surgery: preliminary data from the Co-Management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) model of care.

Surgery is common in older adults, so geriatric and surgical providers need to develop expertise in the care of older adults undergoing surgery. The Co-management of Older Operative Patients En Route Across Treatment Environments (CO-OPERATE) program is a clinical and educational collaboration between geriatrics and several surgical specialties at Veterans Affairs Health Care Connecticut. Individuals in CO-OPERATE are co-managed during the pre-, peri-, and postoperative periods. General surgery, urology, vascular surgery, orthopedics, cardiothoracic surgery and neurosurgery all participate in the program, with geriatrics expertise provided by a geriatrician, geriatric nurse practitioner and a geriatric clinical pharmacist. In the initial 3 years, there were 211 CO-OPERATE participants; 31% were evaluated preoperatively, and 62% of the individuals seen preoperatively were seen in clinic. There was a median of three recommendations per consultation. At discharge, 56% returned to the community. Individuals seen preoperatively were more likely to return to the community (63%) than those seen after surgery (50%, P = .10). Geriatrics co-management with a variety of surgical specialties is feasible and may be associated with higher rates of discharge back to the community.

Risk versus benefit of non-vitamin K dependent anticoagulants compared to warfarin for the management of atrial fibrillation in the elderly.

The objective of this review was to compare the safety and efficacy of dabigatran, rivaroxaban and apixaban to warfarin for the management of atrial fibrillation (AF) in older adults. The prevalence and incidence of AF increase with age. Approximately 5 % of the United States population over the age of sixty-five years and 10 % over the age of seventy-nine years have AF. AF is associated with increased risk for thromboembolic events. Despite the increasing incidence and prevalence of AF in older adults and the risks of thromboembolic events, clinicians often avoid anticoagulants. Specifically with warfarin, the risk of hemorrhage may outweigh the benefit in stroke risk reduction in certain populations. Aspirin, while safer to use, is not as effective as warfarin in stroke risk reduction. Newer non-vitamin K dependent antithrombotic therapies (e.g. dabigatran, rivaroxaban, and apixaban) are redefining thromboprophylaxis of AF. Dabigatran, rivaroxaban, and apixaban are at least as effective as warfarin in stroke risk reduction. With new mechanisms of action and no need for therapeutic drug monitoring, countless new patients are potential candidates for anticoagulation. However patient adherence, lack of a reversal agent, cost, and other safety concerns remain reasons for caution and careful consideration. Furthermore, older adults exhibited greater adverse effects from these agents across the clinical trials. This review will examine the newer anticoagulants safety and efficacy with particular attention to their role in treating older adults with AF. Alternatives to warfarin therapy now exist for thromboprophylaxis of AF. Whether these agents represent advances in overall safety in older adults remains uncertain. More experience and research are needed before endorsing their widespread use as a replacement for warfarin in the geriatric population.

Progressive tremor, truncal ataxia, and acute mental status changes after use of bupropion.

An 84-year-old male with stage III chronic kidney disease and a history of multiple psychiatric and medical disorders presented to the emergency department (ED) with new onset proximal leg weakness with tremor upon standing, truncal ataxia, and myoclonic jerks of the upper extremity that had progressively worsened over three weeks. Magnetic resonance imaging and head computed tomography showed no acute change from baseline. After admission, the patient reported visual hallucinations, vertigo, and slurred speech, and displayed nocturnal agitation/delirium. These symptoms were managed with risperidone. Prior to admission, the most recent medication change was the initiation of bupropion 100 mg extended-release twice daily. Bupropion was titrated to 150 mg twice daily over the three weeks prior to the ED visit. Gradual tapering of the bupropion dose was started after admission. Symptoms of agitation, delirium, speech, and motor disturbances decreased 36 to 48 hours after bupropion dose was lowered to 75 mg daily, and risperidone was changed to quetiapine. The patient was discharged to short-term rehabilitation with return of mental status to baseline. Bupropion and quetiapine were discontinued at discharge from the rehabilitation center. Case reports exist for acute psychotic and parkinsonian symptoms after administration of bupropion and bupropion extended-release, but none exist for the combination of focal neurologic deficits and psychotic symptoms found in this patient's presentation. Limited pharmacokinetic data in the elderly and those with renal impairment suggest that this patient population may have reduced clearance of bupropion. Dose adjustment should be considered in such patients and signs of toxicity closely monitored. Adverse reactions to bupropion should be considered if a patient presents with acute neurologic or psychotic symptoms after initiation or dose modification of bupropion.

The quality of warfarin prescribing and monitoring in Veterans Affairs nursing homes.

OBJECTIVES: To describe the quality of warfarin prescribing and monitoring in Veterans Affairs (VA) nursing homes and to assess the factors associated with maintaining a therapeutic international normalized ratio (INR). DESIGN: Retrospective cohort. SETTING: Five VA nursing homes. PARTICIPANTS: All veterans who received warfarin between January 1 and June 30, 2008, at the nursing homes. MEASUREMENTS: Using medical records, the percentage of person-time spent in the target INR range, the proportion of patients with INRs in the therapeutic range on 50% or more of their person-days, and the frequency of INR monitoring were estimated. Multivariable logistic regression was used to identify factors associated with maintaining a therapeutic INR 50% or more of the time. RESULTS: Over 6 months, 160 patients received 10,380 person-days of warfarin. INRs were in the therapeutic range for 55% of the person-days, and 99% of the INR tests were repeated within 4 weeks of the previous result. On an individual level, 49% of patients had INRs in the target range for 50% or more of their person-days. Achieving this outcome was more likely in patients with prevalent warfarin use than with new use (adjusted odds ratio (AOR)=2.86, 95% confidence interval (CI)=1.06-7.72). Conversely, patients with a history of a stroke (AOR=0.38, 95% CI =0.18-0.80) were less likely to have therapeutic INRs for 50% or more of their days. CONCLUSION: Warfarin appears to be prescribed and monitored effectively in VA nursing home patients. Future studies should focus on increasing time in therapeutic range in patients with poor INR control.

Gabapentin for hot flashes in prostate cancer.

OBJECTIVE: To report a case of successful treatment of refractory hot flashes with gabapentin in a patient with prostate cancer who was receiving combination antiandrogen and gonadotropin hormone-releasing hormone (GnRH) analog therapy. CASE SUMMARY: A 70-year-old white man with a history of advancing prostate cancer experienced disabling hot flashes from combination therapy with the antiandrogen bicalutamide and the GnRH analog goserelin acetate. He failed to respond to clonidine 0.1 mg twice daily, megestrol acetate 40 mg/d, diethylstilbestrol 1 mg/d, and venlafaxine 25 mg twice daily. The patient was then treated with gabapentin 600 mg once daily, at which time he experienced near-complete resolution of his symptoms. DISCUSSION: This case supports a previous report of the marked improvement in severity and duration of hot flashes associated with antiandrogen or GnRH analog therapy in prostate cancer. The mechanism by which gabapentin reduces hot flashes is unknown. CONCLUSIONS: Hot flashes resulting from antiandrogen or GnRH analog therapy are often difficult to treat and leave many patients disabled. Gabapentin has been shown to markedly reduce the severity, frequency, and duration of these hot flashes. Controlled trials are necessary to evaluate gabapentin against other therapeutic modalities.