Denys T. Lau

Unexplained Variation Across US Nursing Homes in Antipsychotic Prescribing Rates

BACKGROUND Serious safety concerns related to the use of antipsychotics have not decreased the prescribing of these agents to nursing home (NH) residents. We assessed the extent to which resident clinical characteristics and institutional prescribing practice were associated with antipsychotic prescribing. METHODS Antipsychotic prescribing was assessed for a nationwide, cross-sectional population of 16 586 newly admitted NH residents in 2006. We computed facility-level antipsychotic rates based on the previous years (2005) prescribing patterns. Poisson regressions with generalized estimating equations were used to identify the likelihood of resident-level antipsychotic medication use in 2006, given 2005 facility-level prescribing pattern and NH resident indication for antipsychotic therapy (psychosis, dementia, and behavioral disturbance). RESULTS More than 29% (n = 4818) of study residents received at least 1 antipsychotic medication in 2006. Of the antipsychotic medication users, 32% (n = 1545) had no identified clinical indication for this therapy. Residents entering NHs with the highest facility-level antipsychotic rates were 1.37 times more likely to receive antipsychotics relative to those entering the lowest prescribing rate NHs, after adjusting for potential clinical indications (risk ratio [RR], 1.37; 95% confidence interval [CI], 1.24-1.51). The elevated risk associated with facility-level prescribing rates was apparent for only NH residents with dementia but no psychosis (RR, 1.40; 95% CI, 1.23-1.59) and residents without dementia or psychosis (RR, 1.54; 95% CI, 1.24-1.91). CONCLUSIONS The NH antipsychotic prescribing rate was independently associated with the use of antipsychotics in NH residents. Future research is needed to determine why such a prescribing culture exists and whether it could result in adverse health consequences.

Polypharmacy and potentially inappropriate medication use among community-dwelling elders with dementia.

This cross-sectional study examines the association between total prescription medication use and potentially inappropriate medication use (PIRx) among community-dwelling elderly patients with and without dementia. Data (September 2005 to September 2007) were from the National Institute on Aging-funded National Alzheimers Coordinating Center Uniform Data Set. The study analyzed the Uniform Data Set initial visits of 4518 community-dwelling subjects aged 65 years and above with and without dementia (2665 and 1853, respectively). PIRx was defined using a partial list of the 2003 Beers criteria. Generalized linear mixed models were applied to estimate the association between PIRx and polypharmacy. In both groups (with and without dementia), subjects who received PIRx on average took more medications than those taking no PIRx. As the total number of medications used increased, the odds of having PIRx also increased, controlling for dementia diagnosis and other subject characteristics. Our key findings were consistent after considering 2 definitions of PIRx (with or without oral estrogens) and accounting for missing data. In summary, the total number of medications used is associated with PIRx among Alzheimers Disease Centers community-dwelling elderly patients with and without dementia, with polypharmacy increasing the risk of PIRx. Ensuring appropriate medication use in this population is clinically important because of the significant risks for institutionalization.

The Relationship Between Living Arrangement and Preventive Care Use Among Community-Dwelling Elderly Persons

OBJECTIVES We sought to examine the relationship between living arrangements and obtaining preventive care among the elderly population. METHODS We obtained data on 13,038 community-dwelling elderly persons from the 2002 to 2005 Medical Expenditure Panel Survey and used multivariate logistic regression models to estimate the likelihood of preventive care use among elderly persons in 4 living arrangements: living alone (38%), living with ones spouse only (52%), living with ones spouse and with ones adult offspring (5%), and living with ones adult offspring only (5%). Preventive care services included influenza vaccination, physical and dental checkup, and screenings for hypertension, cholesterol, and colorectal cancer. RESULTS After we controlled for age, gender, race, education, income, health insurance, comorbidities, self-reported health, physical function status, and residence location, we found that elderly persons living with a spouse only were more likely than were those living alone to obtain all preventive care services, except for hypertension screening. However, those living with their adult offspring were not more likely to obtain recommended preventive care compared with those living alone. These results did not change when the employment status and functional status of adult offspring were considered. CONCLUSIONS Interventions to improve preventive care use should target not only those elderly persons who live alone but also those living with adult offspring.

Narcotic drug use among patients with lower back pain in employer health plans: a retrospective analysis of risk factors and health care services.

OBJECTIVE This study examines the risk factors of narcotic drug use, medical and pharmacy claim costs, and health services use among lower back pain (LBP) patients who use narcotic medications. METHODS This retrospective study used administrative claims data between September 2002 and March 2004 from 3 employer health plans that collectively contained records of 165,569 employees 18 to 64 years of age. Multivariate regression analyses were performed to examine risk factors and health care services use consequences of narcotic drug use in patients with LBP. RESULTS The study sample included 13,760 patients with LBP due to mechanical causes. Nearly 60% were female and the average age was 47 years. Almost half of the patients with LBP (45%) used narcotic drugs. Narcotic-using patients with LBP had significantly higher rates of comorbid conditions than patients with LBP not using narcotic drugs; hypertension (23% vs 13%), arthritis (14% vs 4%), depression (10% vs 5%), anxiety (6% vs 3%), and cancer (2% vs 1%) (P<0.001). Patients with LBP with 2 identified psychological comorbid conditions, depression and anxiety, on average used more narcotic medications. Patients with LBP who had surgery were significantly more likely to use narcotic drugs within 1 week of procedure than those patients without surgery (P<0.001). In contrast, patients with LBP who had chiropractic services for LBP were less likely to take narcotic drugs within 7 days after services compared to those without chiropractic services (P<0.001). Furthermore, controlling for health conditions, patients with LBP who took narcotic medications were significantly more likely than patients not taking narcotics to have an emergency room visit within 30 days after the initial narcotic drug prescription dates (P<0.001). Narcotic-using patients with LBP accounted for 62% of health care costs among all patients with LBP. The average monthly health care cost for a narcotic-using LBP patient was

Older patients' perceptions of medication importance and worth: an exploratory pilot study.

1222, compared to

Functional decline associated with polypharmacy and potentially inappropriate medications in community-dwelling older adults with dementia

430 for a LBP patient not using narcotic drugs (P<0.001). CONCLUSIONS The subjects with LBP who used narcotic medications were more likely to have additional coexisting health conditions and used more health care services than nonusing patients with LBP (P<0.001). Unadjusted health care services costs, including pharmacy claims costs, were significantly higher in patients with LBP using narcotic drugs than in nonusing patients with LBP (P<0.001).

Cholinesterase Inhibitor and N-Methyl-D-Aspartic Acid Receptor Antagonist Use in Older Adults with End-Stage Dementia: A Survey of Hospice Medical Directors

AbstractBackground: Cost-related medication non-adherence may be influenced by patients’ perceived importance of their medications. Objectives: This exploratory pilot study addresses three related but distinct questions: Do patients perceive different levels of importance among their medications? What factors influence perceptions of medication importance? Is perceived importance associated with perceived worth of medications, and does expense impact on that association? Methods: Study participants included individuals aged ≥60 years who were taking three or more prescription drugs. Semi-structured, in-person interviews were conducted to measure how patients rated their medications in terms of importance, expense and worth. Factors that influenced medication importance were identified using qualitative analysis. Ordinal logistic regression analyses were employed to examine the association between perceived importance and perceived worth of medications, and the impact of expense on that association. Results: For 143 prescription drugs reported by 20 participants, the weighted mean rating of medication importance was 8.2 (SD 1.04) on a scale from 0 (not important at all) to 10 (most important). Patients considered 38% of these medications to be expensive. The weighted mean rating of worth was 8.4 (SD 1.46) on a scale from 0 (not worth it at all) to 10 (most worth). Three major factors influenced medication importance: drug-related (characteristics, indications, effects and alternatives); patient-related (knowledge, attitudes and health); and external (the media, healthcare and family caregivers, and peers). Regression analyses showed an association between perceived importance and perceived worth for inexpensive medications (odds ratio [OR] 2.23; p = 0.002) and an even greater association between perceived importance and perceived worth for expensive medications (OR 4.29; p < 0.001). Discussion: This study provides preliminary evidence that elderly patients perceive different levels of importance for their medications based on factors beyond clinical efficacy. Their perception of importance influences how they perceive their medications’ worth, especially for medications of high costs. Understanding how patients perceive medication importance may help in the development of interventions to reduce cost-related non-adherence.

Urinary Incontinence and Self-Reported Health Among the U.S. Medicare Managed Care Beneficiaries

This study provides empirical evidence on whether polypharmacy and potentially inappropriate prescription medications (PIRx, as defined by the 2003 Beers criteria) increase the likelihood of functional decline among community-dwelling older adults with dementia. Data were from the National Alzheimer’s Coordinating Center, Uniform Data Set (9/2005-9/2009). Study sample included 1994 community-dwelling participants aged ≥65 with dementia at baseline. Results showed that participants having ≥5 medications were more likely to have functional decline than participants having <5 medications. However, the increased likelihood was only apparent in participants who did not have PIRx. Instead of magnifying the associated risk as hypothesized, PIRx appeared to have a protective effect albeit marginally statistically significant. Therefore, increased medication burden may be associated with functional decline in community-dwelling older adults with dementia who are not prescribed with PIRx. More research is needed to understand which classes of medications have the most deleterious effect on this population.

Community and Individual Race/Ethnicity and Home Health Care Use among Elderly Persons in the United States

BACKGROUND Cholinesterase inhibitors and N-methyl-D-aspartic acid (NMDA) receptor antagonists are Food and Drug Administration (FDA) approved for the treatment of moderate to severe Alzheimers disease. As dementia progresses to the end stage and patients become hospice-eligible, clinicians consider whether or not to continue these therapies without the benefit of scientific evidence. We sought to describe hospice medical directors practice patterns and experiences in the use and discontinuation of cholinesterase inhibitors and NMDA receptor antagonists in hospice patients that meet the Medicare hospice criteria for dementia. STUDY DESIGN Mail survey of hospice medical directors from a random sample from the National Hospice and Palliative Care Organization. RESULTS Of the 413 eligible participants, 152 completed surveys were returned, yielding a response rate of 37%. Of the respondents, 75% and 33% reported that at least 20% of their patients were taking a cholinesterase inhibitor or memantine, respectively, at the time of hospice admission. The majority of respondents do not consider these therapies effective in persons with end-stage dementia, however, a subset believe that these medications improved patient outcomes including stabilization of cognition (22%), decrease in challenging behaviors (28%), and maintenance of patient function (22%) as well as caregiver outcomes namely reduced caregiver burden (20%) and improved caregiver quality of life (20%). While 80% of respondents recommended discontinuing these therapies to families at the time of hospice enrollment, 72% of respondents reported that families experienced difficulty stopping these therapies. A subset of respondents observed accelerated cognitive (30%) and functional decline (26%) or emergence of challenging behaviors (32%) with medication discontinuation. CONCLUSIONS The findings from this survey indicate that cholinesterase inhibitors and/or NMDA receptor antagonists are prescribed for a subset of patients with advanced dementia and that a proportion of hospice medical directors report clinical benefit from the ongoing use of these agents. In addition, physician preferences for discontinuing these therapies are frequently at odds with the wishes of family members. Prospective studies are needed to evaluate the clinical impact of the discontinuation of these therapies on patient and caregiver outcomes.

Medicare Part D and Quality of Prescription Medication Use in Older Adults

Objectives: To examine the prevalence and management of urinary incontinence (UI) and their impact on self-reported health in the U.S. Medicare managed care beneficiaries. Methods: Data were from the 2003 Medicare Health Outcomes Survey Cohort VI Baseline. Only beneficiaries aged 65 years or older and who self-completed the telephone interview were included. Results: About 37% of the study sample (N = 82,196) reported having accidental urine leakage (the UI group). A total of 75% of the UI group indicated UIs being a problem and 41% of them had spoken with a doctor about it. Of these, 50% had received treatment. The findings indicate the UI group generally had significantly worse SF-36 Survey Scale scores than the non-UI group with and without adjusting other covariates. Discussion: UI is prevalent but undertreated as it adversely affects many health domains in this population. This study highlights the need for early detection, proper education, and access to effective treatment options for UI in the elderly.