Event (ADE) Prevention identified 3 high-priority, high-risk drug classes as targets for reducing the risk of drug-related injuries: anticoagulants, diabetes agents, and opioids.OBJECTIVE To determine whether a multifaceted clinical pharmacist intervention improves medication safety for patients who are discharged from the hospital and prescribed medications within 1 or more of these high-risk drug classes. DESIGN, SETTING, AND PARTICIPANTSThis randomized clinical trial was conducted at a large multidisciplinary group practice in Massachusetts and included patients 50 years or older who were discharged from the hospital and prescribed at least 1 high-risk medication. Participants were enrolled into the trial from June 2016 through September 2018. INTERVENTIONSThe pharmacist-directed intervention included an in-home assessment by a clinical pharmacist, evidence-based educational resources, communication with the primary care team, and telephone follow-up. Participants in the control group were provided educational materials via mail. MAIN OUTCOMES AND MEASURESThe study assessed 2 outcomes over a 45-day posthospital discharge period: (1) adverse drug-related incidents and (2) a subset defined as clinically important medication errors, which included preventable or ameliorable ADEs and potential ADEs (ie, medication-related errors that may not yet have caused injury to a patient, but have the potential to cause future harm if not addressed). Clinically important medication errors were the primary study outcome.RESULTS There were 361 participants (mean [SD] age, 68.7 [9.3] years; 177 women [49.0%]; 319 White [88.4%] and 8 Black individuals [2.2%]). Of these, 180 (49.9%) were randomly assigned to the intervention group and 181 (50.1%) to the control group. Among all participants, 100 (27.7%) experienced 1 or more adverse drug-related incidents, and 65 (18%) experienced 1 or more clinically important medication errors. There were 81 adverse drug-related incidents identified in the intervention group and 72 in the control group. There were 44 clinically important medication errors in the intervention group and 45 in the control group. The intervention did not significantly alter the per-patient rate of adverse drug-related incidents (unadjusted incidence rate ratio, 1.13; 95% CI, 0.83-1.56) or clinically important medication errors (unadjusted incidence rate ratio, 0.99; 95% CI, 0.65-1.49). CONCLUSIONS AND RELEVANCEIn this randomized clinical trial, there was not an observed lower rate of adverse drug-related incidents or clinically important medication errors during the posthospitalization period that was associated with a clinical pharmacist intervention. However, there were study recruitment challenges and lower than expected numbers of events among the study population.TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02781662
Objective Substantial gaps in knowledge exist surrounding the health and healthcare of older adults with multiple chronic conditions (MCCs). We sought to prioritize research topics relevant to the care of this growing population. Design Survey of experts in MCC practice, research, and/or policy. Topics were derived from white papers, funding announcements, or funded research projects relating to older adults with MCCs. Setting Survey conducted through the HCSRN-OAICs AGING Initiative, a joint endeavor of the Health Care Systems Research Network (HCSRN) and Claude D. Pepper Older Americans Independence Centers (OAICs). Participants Individuals affiliated with the HCSRN or OAICs, and national MCC experts, including individuals affiliated with funding agencies having MCC-related grant portfolios. Measurements We employed “top box” methodology, counting the number of respondents selecting the top response on a five-point Likert scale, then dividing by total number of responses to calculate a top box percentage for each of 37 topics. Results Highest ranked research topics relevant to the health and healthcare of older adults with MCCs included: health related quality of life in older adults with MCCs; development of assessment tools (e.g., to assess symptom burden, quality of life, and function, etc.); interactions between medications, disease processes, and health outcomes; disability; implementation of novel (and scalable) models of care; association of clusters of chronic conditions with clinical, financial, and social outcomes; the role of the caregiver; symptom burden; shared decision-making to enhance care planning; and tools to improve clinical decision-making. Conclusions Our findings serve to inform the development of a comprehensive research agenda to address the challenges relating to the care of this “high-need, high-cost” population, and the healthcare delivery systems responsible for serving them.
Purpose: Prescribing cascades occur when a physician prescribes a new drug to address the side-effect of another drug. Persons with Alzheimer's disease and related dementias (ADRD) are at increased risk for prescribing cascades. Our objective was to develop an approach to estimating the proportion of calcium channel blockerdiuretic (CCB-diuretic) prescribing cascades among persons with ADRD in two U.S. health plans. Methods:We identified patients aged ≥50 on January 1, 2017, dispensed a drug to treat ADRD in the 365-days prior to/on cohort entry date. Patients had medical/ pharmacy coverage for 1 year before and through cohort entry. We excluded individuals with an institutional stay encounter in the 45 days prior to cohort entry and censored patients based on: disenrollment from coverage, death, or end of data. We identified incident and prevalent CCB use in the 183-days following cohort entry, and identified subsequent incident diuretic use among incident and prevalent CCBusers within 365-days from cohort entry.Results: There were 121 538 eligible patients. Approximately 62% were female, with a mean age of 79.5 (SD ±8.6). Overall 2.1% of the cohort experienced a prevalent CCB-diuretic prescribing cascade with 1586 incident diuretic-users among 36 462 prevalent CCB-users (4.3%, 95% CI 4.1-4.6%]); and there were161 incident diureticusers among 3304 incident CCB-users (4.9%, 95% CI 4.2-5.7%) (incident CCBdiuretic cascade).
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