Preventable adverse drug events (ADEs) represent a significant public health challenge for the older adult population, since they are associated with higher medical expenditures and more hospitalizations and emergency department (ED) visits. This study examines whether a novel medication risk prediction tool, the MedWise Risk Score™ (MRS), is associated with ADEs and other pertinent outcomes in participants of the Programs of All-Inclusive Care for the Elderly (PACE). Unlike other risk predictors, this tool produces actionable information that pharmacists can easily use to reduce ADE risk. This was a retrospective cross-sectional study that analyzed administrative medical claims data of 1965 PACE participants in 2018. To detect ADEs, we identified all claims that had ADE-related International Classification of Diseases and Health Related Problems, 10th revision (ICD-10) codes. Using logistic and linear regression models, we examined the association between the MRS and a variety of outcomes, including the number of PACE participants with an ADE, total medical expenditures, ED visits, hospitalizations, and hospital length of stay. We found significant associations for every outcome. Specifically, every point increase in the MRS corresponded to an 8.6% increase in the odds of having one or more ADEs per year (OR = 1.086, 95% CI: 1.060, 1.113), $1037 USD in additional annual medical spending (adjusted R2 of 0.739; p < 0.001), 3.2 additional ED visits per 100 participants per year (adjusted R2 of 0.568; p < 0.001), and 2.1 additional hospitalizations per 100 participants per year (adjusted R2 of 0.804; p < 0.001). Therefore, the MRS can risk stratify PACE participants and predict a host of important and relevant outcomes pertaining to medication-related morbidity.
Treatment of behavioral and psychological symptoms of dementia (BPSD) and comorbidities often necessitates the concomitant use of antipsychotics and non-antipsychotic drugs, thereby potentiating the risk for drug–drug interactions (DDIs). The primary objective of our study was to identify potentially clinically relevant cytochrome P450 (CYP)-mediated DDIs involving antipsychotics among participants enrolled in the Program of All-Inclusive Care for the Elderly (PACE) with BPSD. Additionally, we wanted to determine the prevalence of antipsychotic use in this population. The study included 10,001 PACE participants. The practice setting used a proprietary clinical decision support system (CDSS) to analyze simultaneous multidrug interactions. A retrospective analysis of pharmacy claims data was conducted to identify DDIs involving antipsychotics prescribed for BPSD, using snapshots of medication profiles paired with the CDSS. Of the participants who met inclusion criteria, 1190 (11.9%) were prescribed an antipsychotic; of those, 1071 (90.0%) were prescribed an atypical antipsychotic. Aripiprazole commonly caused (being a perpetrator drug 94.6% of the time) potential DDIs with antidepressants (e.g., duloxetine, venlafaxine, mirtazapine), opioids (e.g., hydrocodone, oxycodone, tramadol) and metoprolol via the CYP2D6 isoform. Risperidone commonly caused (85.7%) potential DDIs with donepezil, lamotrigine and trazodone via the CYP3A4 isoform. Quetiapine exclusively suffered (100%) from potential DDIs with amlodipine, buspirone, omeprazole or topiramate via the CYP3A4 isoform. Antipsychotics are commonly prescribed to PACE participants for BPSD treatment and they may interact with other drugs used to treat comorbidities. A thorough review of concomitant medications will help mitigate the likelihood of potentially dangerous CYP-mediated DDIs involving antipsychotics.
Background Given associations with serious cognitive and physical adverse effects (e.g., dementia, falls), strong anticholinergics, like urinary antimuscarinics (UAMs), should be avoided in older adults. This feasibility study aimed to (1) evaluate the implementation rate of pharmacists' recommendations intended to de‐escalate UAMs, (2) quantify the change in overall anticholinergic dosing exposure from these recommendations, and (3) investigate factors that predict recommendation implementation. Methods This was a retrospective, observational, before‐and‐after study. Pharmacists (n = 18) devised strategies to de‐escalate UAMs in 187 participants (mean age 72.4 ± 9.4; 77.0% female; mean number of medications 12.9 ± 4.6) of 35 Programs of All‐Inclusive Care for the Elderly (PACE). PACE prescribers (non‐physicians and physicians) determined whether to implement recommendations. Implementation was defined as a change in the prescription records consistent with the pharmacist's recommendation at 2‐, 4‐, 6‐, and 9‐months post‐recommendation. Anticholinergic dosing exposure was measured at each time point using standardized daily doses (SDD). Multivariable logistic regression was used to identify factors that predicted recommendation implementation. Results Across 9 months, recommendations were implemented in 118 out of 187 participants, yielding a 63.1% implementation rate. Of these, 77.1% (n = 91/118) implemented by month 2. Implementers' mean overall anticholinergic SDD decreased 65.4% from baseline (baseline: 2.6 [95% CI: 2.2, 3.0] to month 9: 0.9 [95% CI: 0.6,1.2], p < 0.001) whereas non‐implementers demonstrated no significant change (p = 0.52). Taking <10 baseline medications (OR 2.75; 95% CI: 1.09, 7.61); baseline UAM SDD ≥2 (OR 2.20; 95% CI: 1.11, 4.44); uncomplicated recommendations (OR 3.38; 95% CI: 1.67–7.03); and baseline calcium channel blocker use (OR 2.19; 95% CI: 1.09, 4.52) predicted implementation. Conclusion Our high implementation rate indicates that pharmacists' recommendations to de‐escalate UAMs as a way to reduce overall anticholinergic exposure is feasible in medically complex, community‐dwelling older adults. Future research should investigate whether these recommendations benefit cognitive (e.g., delirium, dementia) and/or physical functioning (e.g., falls).
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