Cynthia L. Raehl

Assessing Medication Adherence in the Elderly Which Tools to Use in Clinical Practice

Adherence to prescribed medication regimens is difficult for all patients and particularly challenging for the elderly. Medication adherence demands a working relationship between a patient or caregiver and prescriber that values open, honest discussion about medications, i.e. the administration schedule, intended benefits, adverse effects and costs.Although nonadherence to medications may be common among the elderly, fundamental reasons leading to nonadherence vary among patients. Demographic characteristics may help to identify elderly patients who are at risk for nonadherence. Inadequate or marginal health literacy among the elderly is common and warrants assessment. The number of co-morbid conditions and presence of cognitive, vision and/or hearing impairment may predispose the elderly to nonadherence. Similarly, medications themselves may contribute to nonadherence secondary to adverse effects or costs. Especially worrisome is nonadherence to ‘less forgiving’ drugs that, when missed, may lead to an adverse event (e.g. withdrawal symptoms) or disease exacerbation.Traditional methods for assessing medication adherence are unreliable. Direct questioning at the patient interview may not provide accurate assessments, especially if closed-ended, judgmental questions are posed. Prescription refill records and pill counts often overestimate true adherence rates. However, if elders are asked to describe how they take their medicines (using the Drug Regimen Unassisted Grading Scale or MedTake test tools), adherence problems can be identified in a nonthreatening manner.Medication nonadherence should be suspected in elders who experience a decline in functional abilities. Predictors of medication nonadherence include specific disease states, such as cardiovascular diseases and depression. Technological aids to assessing medication adherence are available, but their utility is, thus far, primarily limited to a few research studies. These computerised devices, which assess adherence to oral and inhaled medications, may offer insight into difficult medication management problems. The most practical method of medication adherence assessment for most elderly patients may be through patient or caregiver interview using open-ended, nonthreatening and nonjudgmental questions.

Clinical pharmacy services, pharmacy staffing, and hospital mortality rates

Objective: To determine if hospital‐based clinical pharmacy services and pharmacy staffing continue to be associated with mortality rates.

Clinical Pharmacy Services, Hospital Pharmacy Staffing, and Medication Errors in United States Hospitals

The direct relationships and associations among clinical pharmacy services, pharmacist staffing, and medication errors in United States hospitals were evaluated. A database was constructed from the 1992 National Clinical Pharmacy Services database. Both simple and multiple regression analyses were employed to determine relationships and associations. A total of 429,827 medication errors were evaluated from 1081 hospitals (study population). Medication errors occurred in 5.22% of patients admitted to these hospitals each year. Hospitals experienced a medication error every 22.04 hours (every 19.13 admissions). These findings suggest that at minimum, 90,895 patients annually were harmed by medication errors in our nations general medical‐surgical hospitals. Factors associated with increased medication errors/occupied bed/year were drug‐use evaluation (slope = 0.0023476, p=0.006), increased staffing of hospital pharmacy administrators/occupied bed (slope = 29.1972932, p<0.001), and increased staffing of dispensing pharmacists/occupied bed (slope = 19.3784148, p<0.001). Factors associated with decreased medication errors/occupied bed/year were presence of a drug information service (slope = −0.1279301, p<0.001), pharmacist‐provided adverse drug reaction management (slope = −0.3409332, p<0.001), pharmacist‐provided drug protocol management (slope = −0.3981472, p=0.013), pharmacist participation on medical rounds (slope = −0.6974303, p<0.001), pharmacist‐provided admission histories (slope = −1.6021493, p<0.001), and increased staffing of clinical pharmacists/occupied bed (slope = −9.5483813, p<0.001). As staffing increased for clinical pharmacists/occupied bed from the 10th percentile to the 90th percentile, medication errors decreased from 700.98 ± 601.42 to 245.09 ± 197.38/hospital/year, a decrease of 286%. Specific increases or decreases in yearly medication errors associated with these clinical pharmacy services in the 1081 study hospitals were drug‐use evaluation (21,372 more medication errors), drug information services (26,738 fewer medication errors), adverse drug reaction management (44,803 fewer medication errors), drug protocol management (90,019 fewer medication errors), medical round participation (42,859 fewer medication errors), and medication admission histories (17,638 fewer medication errors). Overall, clinical pharmacy services and hospital pharmacy staffing variables were associated with medication error rates. The results of this study should help hospitals reduce the number of medication errors that occur each year.

Clinical pharmacy services and hospital mortality rates.

We evaluated the associations between clinical pharmacy services and mortality rates in 1029 United States hospitals. A data base was constructed from Medicare mortality rates from the Health Care Financing Administration and the National Clinical Pharmacy Services data base. A multivariate regression analysis, controlling for severity of illness, was employed to determine the associations. Four clinical pharmacy services were associated with lower mortality rates: clinical research (p<0.0001), drug information (p=0.043), drug admission histories (p=0.005), and participation on a cardiopulmonary resuscitation (CPR) team (p=0.039). The actual number of deaths (lower) associated with the presence of these four services were clinical research 21,125 deaths in 108 hospitals, drug information 10,463 deaths in 237 hospitals, drug admission histories 3843 deaths in 30 hospitals, and CPR team participation 5047 deaths in 282 hospitals. This is the first study to indicate that both centrally based and patient‐specific clinical pharmacy services are associated with reduced hospital mortality rates. This suggests that these services save a significant number of lives in our nations hospitals.

Health care professional staffing, hospital characteristics, and hospital mortality rates.

To evaluate associations among hospital characteristics, staffing levels of health care professionals, and mortality rates in 3763 United States hospitals, a data base was constructed from the American Hospital Associations Abridged Guide to the Health Care Field and hospital Medicare mortality rates from the Health Care Financing Administration. A multivariate regression analysis controlling for severity of illness was employed to determine the associations. Hospital characteristics associated with lower mortality were occupancy rate and private nonprofit and private for‐profit ownership. Mortality rates decreased as staffing level per occupied bed increased for medical residents, registered nurses, registered pharmacists, medical technologists, and total hospital personnel. Mortality rates increased as staffing level per occupied bed increased for hospital administrators and licensed practical‐vocational nurses. To our knowledge, this is the first study to show that pharmacists were associated with lower mortality rates.

Clinical Pharmacy Services, Pharmacy Staffing, and the Total Cost of Care in United States Hospitals

This study evaluated direct relationships and associations among clinical pharmacy services, pharmacist staffing, and total cost of care in United States hospitals. A database was constructed from the 1992 American Hospital Associations Abridged Guide to the Health Care Field and the 1992 National Clinical Pharmacy Services Database. A multiple regression analysis, controlling for severity of illness, was employed to determine the relationships and associations. The study population consisted of 1016 hospitals. Six clinical pharmacy services were associated with lower total cost of care: drug use evaluation (p=0.001), drug information (p=0.003), adverse drug reaction monitoring (p=0.008), drug protocol management (p=0.001), medical rounds participation (p=0.0001), and admission drug histories (p=0.017). Two services were associated with higher total cost of care: total parenteral nutrition (TPN) team participation (p=0.001) and clinical research (p=0.0001). Total costs of care/hospital/year were lower when any of six clinical pharmacy services were present: drug use evaluation

Clinical pharmacy services, pharmacy staffing, and adverse drug reactions in United States hospitals

1,119,810.18 (total

Interrelationships among Mortality Rates, Drug Costs, Total Cost of Care, and Length of Stay in United States Hospitals: Summary and Recommendations for Clinical Pharmacy Services and Staffing

1,005,589,541.64 for the 898 hospitals offering the service), drug information

Pharmacist-Provided Anticoagulation Management in United States Hospitals: Death Rates, Length of Stay, Medicare Charges, Bleeding Complications, and Transfusions

5,226,128.22 (total

Adverse Drug Reactions in United States Hospitals

1,212,461,747.04 for the 232 hospitals offering the service), adverse drug reporting monitoring