Individualized medication assessment and planning: optimizing medication use in older adults in the primary care setting. Pharmacist-led medication review to identify medication-related problems in older people referred to an Aged Care Assessment Team: a randomized comparative study. Practice innovations: delivering medication therapy management services via Videoconference interviews. Prevalence of medication-related problems among patients with renal compromise in an Indian hospital. Utility of a brief screening tool for medication-related problems. Self-administered medication-risk questionnaire in an elderly population. Pharmacist Advancement of Transitions of Care to Home (PATCH) Service Outcomes of medication therapy review in a family medicine clinic. Implementation of a self-administered questionnaire to identify patients at risk for medication-related problems in a family health center. Pharmacist consultations in general practice clinics: the Pharmacists in Practice Study (PIPS). Impact of an exercise program on muscular and functional performance and plasma levels of interleukin 6 and soluble receptor tumor necrosis factor in prefrail community-dwelling older women: a randomized controlled trial. Randomized controlled trial of an intervention to improve drug appropriateness in community-dwelling polymedicated elderly people Physician patient communication failure facilitates medication errors in older polymedicated patients with multiple comorbidities. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. The Quality of Pharmacologic Care for Vulnerable Older Patients Improving depression outcomes in older adults with comorbid medical illness. Chronic care clinics: a randomized controlled trial of a new model of primary care for frail older adults. Preventing disability and managing chronic illness in frail older adults: a randomized trial of a community-based partnership with primary care. A randomized study to decrease the use of potentially inappropriate medications among community-dwelling older adults in a southeastern managed care organization. Home care program for patients at high risk of hospitalization. Cognitive impairment and self-care in heart failure Preservation of cognitive function with antihypertensive medications: a longitudinal analysis of a community-based sample of African Americans. A multimodal rehabilitation program for patients with ICU acquired weakness improves ventilator weaning and discharge home☆
STUDY OBJECTIVE To test the feasibility and effectiveness of an individualized Medication Assessment and Planning ( iMAP ) program integrated within a primary care practice on the number and prevalence of medication-related problems ( MRPs ) and acute health services utilization , defined as combined hospitalizations and emergency department visits . DESIGN Six-month , prospect i ve , observational pilot study . SETTING Community-based primary care medical practice . PATIENTS Convenience sample of 64 patients aged 65 years and older who were taking at least five medications . INTERVENTION Each patient was enrolled in the iMAP program-a collaborative , multifaceted intervention facilitated by a clinical pharmacist whereby patients receive comprehensive medication therapy management at baseline and 3 and 6 months as part of routine clinical care . MEASUREMENTS AND MAIN RESULTS MRPs were assessed and recommendations proposed using the previously published MRP classification tool ; physician acceptance of recommendations served to vali date the assessment s. There was a significant reduction in mean number of MRPs/patient ( 4.2 at baseline vs 1.0 at 6 mo , p<0.0001 ) when adjusted for number of medications , race , and pharmacist . The prevalence of MRPs at 6 months compared with baseline was also significant ( p<0.0008 ) . Acute health services utilization was assessed by medical record abstract ion . The 64 patients experienced a rate of 8.3 events/100 person-months ( 64 total events ) during the 12-month pre study period . During the 6-month study period , the same patients experienced 5.4 events/100 person-months ( 20 total events ) . Thus , we noted a reduction in acute health services utilization of 35 % . Physicians were enthusiastically supportive of iMAP . CONCLUSION iMAP has the potential to address a significant and timely issue affecting older adults and primary care practice s : the burden of managing and continuously monitoring multiple medications in medically complex older adults . A more rigorous evaluation of iMAP is warranted and planned to demonstrate sustained effectiveness and cost-benefit BACKGROUND Aged Care Assessment Teams ( ACATs ) in Australia assess the care needs of frail older people . Despite being at high risk of medication-related problems ( MRPs ) , ACAT patients do not routinely receive a comprehensive medication review . OBJECTIVES The aims of the study were to compare three methods for facilitating a pharmacist-led comprehensive medication review for people referred to an ACAT , and compare MRPs identified via ACAT usual care with those identified via pharmacist-led medication review s. METHODS A prospect i ve , r and omized , comparative study involving 80 community-dwelling patients ( median age 84 years ) referred to an ACAT in Melbourne , Australia , was conducted . Following ACAT assessment ( usual care ) , a clinical pharmacist review ed all participating patients ' ACAT files to identify potential MRPs not identified by the ACAT ( medication review method 1 ) . Patients were then r and omized into two groups . Group A received information about the Australian government-funded , general practitioner (GP)-initiated Home Medicines Review ( HMR ) programme , and a letter was sent to their GP recommending an HMR ( GPHMR ; medication review method 2 ) . Group B patients were referred directly to a clinical pharmacist associated with the ACAT for an ACAT-initiated pharmacist home medicines review ( APHMR ; medication review method 3 ) ; the pharmacist arranged a home visit , obtained a thorough medication history and conducted a comprehensive medication review . The main outcome measures were the proportion of patients who received a pharmacist home visit within 28 days ; the number of MRPs identified by ACAT usual care , pharmacist review of ACAT files , and APHMR , and their clinical risk ( assessed by a geriatrician-pharmacist panel ) ; and patients ' , GPs ' and ACAT clinicians ' opinions about pharmacist medication review . RESULTS Three hundred patients were referred to the ACAT , and 80 were recruited into the study . Thirty-six of 40 APHMR patients ( 90.0 % ) received a  pharmacist home visit within 28 days , compared with 7/40 GPHMR patients (17.5%).[p < 0.001 ] . Twenty-one MRPs were identified via ACAT usual care . Pharmacist review of ACAT files identified a further 164 potential MRPs ( median 2.0 per patient ; inter-quartile range [ IQR ] 1.0 - 3.0 ) ; however , in patients who received an APHMR , 35/82 potential MRPs ( 42.7 % ) turned out not to be actual problems , most commonly because of discrepancies between the patient 's ACAT medication list and the medications currently being used by the patient ( median 3.0 discrepancies per patient ; IQR 2.0 - 5.5 ) . APHMR identified a further 79 MRPs ( median 2.0 ; IQR 1.0 - 3.0 ) . One hundred and twenty-two MRPs were included in APHMR reports sent to patients ' GPs . Of these , 94 ( 77.0 % ) were assessed as being associated with a moderate , high or extreme risk of an adverse event . Sixty-four APHMR recommendations ( 52.5 % ) led to changes to patients ' medication regimens or medication management . Thirty-six of 39 GPs ( 92.3 % ) who provided feedback reported that pharmacist medication review s were useful . Patients ( or their carers ) also reported that pharmacist home visits were useful : median rating 4.25 out of 5 ( IQR 4.0 - 5.0 ) . Seven of 11 ACAT clinicians ( 77.8 % ) agreed that pharmacist-led medication review should be a st and ard component of ACAT assessment s. CONCLUSIONS ACAT assessment s without pharmacist involvement detected fewer MRPs than any of the evaluated pharmacist-led medication review methods . APHMR was more effective than pharmacist review of routinely collected ACAT data , and more reliable and timely than referral to the patients ' GP for a GPHMR OBJECTIVE To describe  medication therapy management  ( MTM ) services via videoconferencing . DESIGN A descriptive , cross-sectional analysis of an ongoing prospect i ve , r and omized-controlled study . SETTING A secured seven-pharmacy network connected by computers , webcams , telephones , and electronic medical records . PARTICIPANTS Patients 18 years of age or older ; taking four or more chronic medications ; and with diabetes , hypertension , hyperlipidemia , asthma/chronic obstructive pulmonary disease , multiple sclerosis , and /or Parkinson 's disease . INTERVENTIONS Chart review s and videoconferencing interviews to identify medication-related problems ( MRP ) and provide patient education and recommendations to providers . MAIN OUTCOME MEASURES Patient demographics , identified MRPs , interventions , and patient satisfaction . RESULTS During April to July 2010 , 43 patients were interviewed ( mean age 50.8 ± 11.5 years ) ; of these , 12 patients ( 27.9 % ) were older adults , mean age 69.5 ± 5.0 years . Prevalent health conditions were hypertension ( 31/43 , 72 % ) , hyperlipidemia ( 28/43 , 65 % ) , and diabetes ( 19/43 , 44 % ) . A mean number of 3.5 ± 2.3 MRP/patient was identified . Compared with charted numbers , patients significantly under-reported their health conditions ( selfreported mean number 4.0 ± 1.6 , compared with 6.9 ± 3.3 , P < 0.0001 ) and medications used ( self-reported mean number 7.7 ± 3.4 , charted number 9.4 ± 2.3 , P < 0.005 ) . Providers accepted a mean number of 2.2 ± 1.6 ( out of 2.8 ± 1.3 ) pharmacist-provided recommendations ( acceptance rate 78.6 % ) . All patients interviewed agreed or strongly agreed that the MTM interview with pharmacist and the information provided were helpful . CONCLUSION Webcam-enabled videoconferencing allows effective interactions between pharmacists and patients to identify MRP and improve access to MTM services . Provider acceptance of pharmacist-provided recommendations and patient satisfaction with videoconferencing MTM services are high WHAT IS KNOWN AND OBJECTIVE Patients suffering from renal dysfunction often have multiple medical conditions either as a cause or as a consequence of their renal disease . These patients receive an average of 10 - 12 medications daily leading to complex dosing schedules and are more likely to develop medication-related problems ( MRPs ) . The objectives of this study were to determine the nature and extent of MRPs in renally compromised patients and to explore the potential clinical significance of the MRPs . The potential for a clinical pharmacist to contribute towards resolving or preventing some of these MRPs was also explored . METHODS A prospect i ve study was conducted for a period of 9 months in the renal unit of Jagadguru Shri Shivaratheeshwara ( JSS ) Medical College Hospital , Mysore , India . Patients undergoing dialysis on outpatient basis and patients who were admitted under the care of or referred to the nephrologists for renal dysfunction from other specialties were review ed . Patterns of the MRPs were identified using an adapted Hepler and Str and criteria . The potential clinical significance of the MRPs and the contribution of the clinical pharmacist in resolving or minimizing some of the MRPs were also explored . RESULTS AND DISCUSSION Three hundred and twenty-seven MRPs were identified with 308 patients review ed .  The incidence of MRPs was found to be 1·06 ± 0·85 per patient review ed . The most common MRP identified in our study was overdose ( 19·3 % ) followed by adverse drug reactions ( 19·0 % ) . Cardiovascular agents ( 33·6 % ) followed by anti-infective agents ( 26·3 % ) were the most common therapeutic classes of medication implicated in causing MRPs . Twenty-six per cent of the MRPs identified were explored to be potentially moderate or major in clinical significance . The clinical pharmacists ' recommendations were accepted in 97 % of the cases , which result ed in a change in therapy in 83 % of the cases . WHAT IS NEW AND CONCLUSION Medication-related problems are frequent in renally compromised patients in our patient population . The high level of acceptance of clinical pharmacist 's recommendations by the nephrologists demonstrates that clinical pharmacists may help improve overall patient care in this setting BACKGROUND Medication therapy management ( MTM ) services position pharmacists to prevent , detect , and resolve medication-related problems ( MRPs . ) However , selecting patients for MTM who are most at risk for MRPs is a challenge . Using self-administered scales that are practical for use in clinical practice are one approach . OBJECTIVE The objective of this study was to estimate the psychometric properties of a brief self-administered scale as a screening tool for MRPs . METHODS This was a non-r and omized study utilizing question naires administered cross-sectionally . In Phase 1 , patients ( n = 394 ) at community pharmacies and outpatient clinics completed 78 items , provided to the study team by item authors , assessing perceived MRPs . These data were used to select items for further investigation as a brief , self-administered scale , and estimate the reliability and construct validity of the result ing instrument . In Phase 2 , a convenience sample of patients ( n = 200 ) at community pharmacies completed a nine-item , self-administered scale . After completion , they were engaged in a comprehensive medication review by their pharmacist who was blinded to question naire responses . The main outcome measure for estimating the criterion-related validity of the scale was the number of pharmacist-identified medication-related problems ( MRPs . ) Item statistics were computed as well as bivariate associations between scale scores and other variables with MRPs . A multivariate model was constructed to examine the influence of scale scores on MRPs after controlling for other significant variables . RESULTS Higher scores on the question naire were positively correlated with more pharmacist-identified MRPs ( r = 0.24 ; P = 0.001 ) and scores remained as a significant predictor ( P = 0.031 ) when controlling for other relevant variables in a multivariate regression model ( R(2 ) = 0.21 ; P < 0.001 ) . CONCLUSIONS Patient responses on the scale may have a modest role in predicting MRPs . The use of self-administered question naires such as this may supplement other available patient data in developing patient eligibility criteria for MTM , however , additional research is warranted OBJECTIVE To evaluate and vali date a 10-item self-administered question naire for use by elderly patients to identify who is at increased risk of potentially experiencing a medication-related problem ( MRP ) . METHODS Forty participants aged > /=60 years who took > /=2 prescription drugs regularly completed the question naire .  Data collection was based on patient interviews , review of pharmacy or medical records , and drug regimen review s ( DRRs ) . Outcome measures included feasibility , inter-rater reliability , test-retest reliability , internal consistency , and validity of the question naire . DRR severity scores were determined for each participant based on published guidelines for appropriate use . RESULTS The question naire was easily administered to this group of older adults . Overall inter-rater reliability was high ( r = 0.847 ) . Nine of 10 individual questions matched well between the investigator and participants ( kappa 0.4 - 0.6 for 3 questions ; > 0.6 for 6 questions ) . Test-retest reliability was significant for all 10 questions ( kappa > 0.6 ) . Internal consistency was acceptable ( alpha = 0.69 ) . DRR severity scores were correlated with question naire responses to determine validity . The number of yes answers correlated significantly with higher DRR severity scores ( p < 0.001 ) . Furthermore , 5 individual questions significantly correlated with DRR severity scores . CONCLUSIONS This study suggests that a self-administered question naire can be used in an older adult population to identify patients potentially at increased risk of MRPs . Clinicians in ambulatory care setting s with similar patient population s can use a modified form of the question naire to screen for patients who should receive a medication review Background There is a paucity of literature on a well-defined role of a pharmacist in different aspects of transition of care service ( TCS ) . Although health care institutions have specific details on the discharge process , there is a need for a sustainable TCS with a well-defined role of pharmacists . Objective To describe the impact of a pharmacist-led TCS on acute health care utilization , clinic quality indicators , and identification and resolution of medication-related problems ( MRPs ) . Methods A  pharmacist-managed TCS service , referred to as the Pharmacist Advancement of Transitions of Care to Home ( PATCH ) service , was established at an academic medical center , where high-risk patients received a postdischarge phone call from a pharmacist  followed by a face-to-face meeting with the pharmacist and the patient 's primary care provider ( PCP ) . In a prospect i ve transitions of care group ( n = 74 ) , outcomes of patients such as acute health care utilization ( an emergency department visit or an inpatient readmission , within 30 days post discharge ) , clinic quality indicators , and identification and resolution of MRPs were compared to a retrospective control group ( n = 87 ) who received the st and ard of care . Results Utilization of acute health care services was significantly lower in the prospect i ve group compared to the retrospective control group ( 23 % vs 41.4 % ; P = .013 ) . A total of 49 MRPs were discovered in patients who received the TCS . Conclusions Pharmacists play an integral role in improving the transitions of care to reduce acute health care utilization . In addition , they may improve care transitions by optimizing clinic quality indicators and by identifying and resolving MRPs OBJECTIVE To evaluate the effects of pharmacist-conducted medication therapy review ( MTR ) and intervention on the quality of care of  patients in a family medicine clinic . DESIGN Prospect i ve , observational , cohort study . SETTING Family medicine clinic in Minnesota during 2000 - 2001 . PATIENTS Patients were enrolled in a statewide nonprofit managed care organization ; selected patients were seen by a clinical pharmacist .  INTERVENTION Following MTR , medication-related problems ( MRPs ) were identified and resolved . MAIN OUTCOME MEASURES MRPs identified and resolved , improvement in clinical status , achievement of therapeutic goals , important medication use , and reduction in number of medications . RESULTS 92 patients were included in the study , with a total of 203 patient encounters .  MRPs were identified in 90 % of patients , with a total of 250 identified . Overall status of medical conditions improved in 45 % of patients , 46 % stayed the same , and 9 % declined ( P < 0.001 ) . Significant improvement in status was found for hypertension ( P = 0.007 ) , dyslipidemia ( P = 0.002 ) , and asthma ( P = 0.011 ) . Significant improvement was seen for aspirin use for myocardial infa rct ion prevention ( 50 % vs. 93 % , P = 0.031 ) and inhaled steroids for asthma ( 36 % vs. 64 % , P = 0.031 ) . The number of medications was reduced from an average of 3.92 to 3.04 ( P < 0.001 ) per patient . CONCLUSION MTR and intervention by a pharmacist positively affected quality of care in this family medicine clinic STUDY OBJECTIVE To determine if a self-administered question naire can improve the identification of patients at risk for medication-related problems ( MRPs ) compared with usual methods of referral to a pharmacist . DESIGN Prospect i ve , r and omized controlled study . SETTING Multiprofessional primary care clinic at a tertiary care teaching hospital . PATIENTS One hundred ninety-four ambulatory patients aged 18 years or older who were taking at least two drugs . MEASUREMENTS AND MAIN RESULTS Patients completed a five-item , self-administered question naire modified from a tool that was previously vali date d in another population and statistically correlated with the risk of MRPs . Of 194 patients who completed the question naire , 89 were r and omized to the control group ( referral by usual methods ) and 105 were referred according to their responses on the question naire ( intervention group ) . Primary outcomes were the rate of referral and the number of at-risk patients identified . Referral rates were higher with the question naire than with usual methods ( 20 % vs 6 % , p=0.003 ) . Of five patients referred by usual methods , one was at risk for MRPs according to question naire results . Of 84 patients in the control group who were not referred , 12 ( 14 % ) were at risk according to the question naire results ; this finding suggested that several at-risk patients who were not referred by usual methods might have benefitted from a referral for a pharmacist 's assessment . CONCLUSION This self-administered medication risk assessment question naire effectively complemented the usual practice s for identifying and referring patients at risk for MRPs BACKGROUND Medication-related problems ( MRPs ) are a concern in primary care setting s. Pharmacists based in the community or community pharmacies are able to identify , resolve and prevent MRPs ; however , the lack of a formal partnership with physicians and poor access to patients ' medical records are limitations . In Australia , delivery of pharmacist services within general practice clinics is rare . OBJECTIVES To evaluate the effectiveness of consultations by pharmacists based within primary care medical practice s. METHODS A prospect i ve , before-after intervention study was conducted at two primary health care ( general practice ) clinics in Melbourne , Australia . Participants were clinic patients who had risk-factors for MRPs ( e.g. polypharmacy ) . Patients received a  consultation with the pharmacist  in a private consulting room at the clinic or in their home . The pharmacist review ed the patient 's medication regimen and adherence , with full access to their medical record , provided patient education , and produced a report for the general practitioner . The primary outcome was the number of MRPs identified by the pharmacist , and the number that remained unresolved 6 months after the pharmacist consultation . Secondary outcomes included medication adherence , health service use , and patient satisfaction . RESULTS Eighty-two patients were recruited and 62 ( 75.6 % ) completed the study . The median number of MRPs per patient identified by the practice pharmacist was 2 ( interquartile range [ IQR ] 1 , 4 ) . Six months after review , this fell to 0 ( IQR 0 , 1 ) , P < 0.001 . The proportion of patients who were adherent to their medications improved significantly , according to both the Morisky ( 44.1 % versus 62.7 % , P = 0.023 ) and the Tool for Adherence Behaviour Screening ( TABS ) ( 35.6 % versus 57.6 % , P = 0.019 ) scales . There was no significant effect on health service use . Patients were highly satisfied with the pharmacist consultations . CONCLUSIONS Consultations undertaken by pharmacists located within primary health care clinics were effective in identifying and resolving MRPs . The consultations were well received by patients and were associated with improvements in medication adherence OBJECTIVE To examine the impact of a muscle resistance program ( MRP ) on muscular and functional performance and on interleukin 6 ( IL-6 ) and soluble tumor necrosis factor receptor-1 ( sTNFr1 ) plasma levels in prefrail community-dwelling women . DESIGN R and omized controlled trial crossover design with a postintervention and short-term follow-up . SETTING University hospital . PARTICIPANTS Prefrail community-dwelling women ( N=32 ; ≥65y ) . INTERVENTION The MRP was design ed based on the exercise at 75 % of each participant 's maximum load ( 10wk , 3 times/wk ) . MAIN OUTCOME MEASURES Plasma concentrations of IL-6 and sTNFr1 ( high-sensitivity enzyme-linked immunosorbent assay kits ) , muscle strength of the knee extensors ( isokinetic ) , and functional performance ( Timed Up & Go [ TUG ] test and 10-meter walk test [ 10MWT ] ) . RESULTS There were significant differences in functional and muscular performance between the pre-MRP , post-MRP , and 10-week follow-up period . After the MRP , both functional ( TUG , pre-MRP=11.1s vs post-MRP=10.4s , P=.00 ; 10MWT , pre-MRP=4.9s vs post-MRP , 4.4s , P=.00 ) and muscular performances ( pre-MRP=77.8 % and post-MRP=83.1 % , P=.02 ) improved . After cessation of the MRP ( follow-up period ) , sTNFr1 plasma levels increased by 21.4 % at 10-week follow-up ( post-MRP , 406.4pg/mL ; 10-week follow-up , 517.0pg/mL ; P=.03 ) . There were significant differences in sTNFr1 ( P=.01 ) . CONCLUSIONS The MRP was effective in improving functional and muscular performances , although alterations in plasma levels of IL-6 and sTNFr1 could not be identified after the MRP . Cessation of the MRP after 10 weeks result ed in increased plasma levels of sTNFr1 Background . Polypharmacy is frequent in the elderly population and is associated with potentially drug inappropriateness and drug-related problems . Objectives . To assess the effectiveness and safety of a medication evaluation programme for community-dwelling polymedicated elderly people . Design . R and omized , open-label , multicentre , parallel-arm clinical trial with 1-year follow-up . Setting . Primary care centres . Participants . Polymedicated ( ≥8 drugs ) elderly people ( ≥70 years ) . Study intervention . Pharmacist review of all medication according to the Good Palliative – Geriatric Practice algorithm and the Screening Tool of Older Person ’s Prescriptions-Screening Tool to Alert Doctors to the Right Treatment criteria and recommendations to the patient ’s physician . Control intervention . Routine clinical practice . Measurements . Recommendations and changes implemented , number of prescribed drugs , restarted drugs , primary care and emergency department consultations , hospitalizations and death . Results . About 503 ( 252 intervention and 251 control ) patients were recruited and 2709 drugs were evaluated . About 26.5 % of prescriptions were rated as potentially inappropriate and 21.5 % were changed ( 9.1 % discontinuation , 6.9 % dose adjustment , 3.2 % substitution and 2.2 % new prescription ) . About 2.62 recommendations per patient were made and at least one recommendation was made for 95.6 % of patients . The mean number of prescriptions per patient was significantly lower in the intervention group at 3- and 6-month follow-up . Discontinuations , dose adjustments and substitutions were significantly higher than in the control group at 3 , 6 and 12 months . No differences were observed in the number of emergency visits , hospitalizations and deaths . Conclusion . The study intervention was safe , reduced potentially inappropriate medication , but did not reduce emergency visits and hospitalizations in polymedicated elderly people OBJECTIVE To analyse the frequency of mistakes in communication between the physician and the patient and their incidence in errors in self-administered drugs . METHODS We undertook a descriptive , cross-sectional study based on interviews with a r and om sample of patients older than 65 years who were polymedicated ( five or more drugs ) and had multiple comorbidities . Data were analysed about the patients ' reports of what the physician said , medication mistakes by the patients and their consequences . RESULTS Responses were provided by 382 patients . A medication error in the last year was reported by 287 patients ( 75 % ) , and 16 patients ( 4 % ) reported four or more errors . Most cases concerned the dosage , a similar appearance of the medication or a lack of underst and ing of the physician 's instructions . Very severe consequences occurred in 19 cases ( 5 % ) . Multiple comorbidities ( P = 0.006 ) and a greater number of treatments ( P = 0.002 ) were associated with making mistakes . Frequent changes in prescription ( P = 0.02 ) , not considering the prescriptions of other physicians ( P = 0.01 ) , inconsistency in the messages ( P = 0.01 ) , being treated by various different physicians at the same time ( P = 0.03 ) , a feeling of not being listened to ( P < 0.001 ) or loss of trust in the physician ( P < 0.001 ) were associated with making medication mistakes . CONCLUSIONS Mistakes by polymedicated patients with multiple comorbidities represent a real risk that should be addressed by the professionals . A review should be made of the routine control questions that the physician asks the patient to identify what other drugs the patient may be taking that have been indicated by another physician OBJECTIVES To develop a self-report screening tool to identify older people in the emergency department ( ED ) of a hospital at increased risk of adverse health outcomes  , including : death , admission to a nursing home or long-term hospitalization , or a clinical ly significant decrease in functional status .  DESIGN Prospect i ve ( 6-month ) follow-up study of a cohort of ED patients aged 65 and older . SETTING The EDs of four acute-care hospitals in Montreal , Quebec , Canada . PARTICIPANTS Community-dwelling patients aged 65 and older who came to the EDs during the weekday shift over a 3-month recruitment period . Patients were excluded if they could not be interviewed either because of their medical condition or because of cognitive impairment and no other informant was available . MEASUREMENTS Measures ascertained at the ED visit included : 27 self-report screening questions on social , physical , and mental risk factors ; medical history ; use of hospital services , medications , and alcohol ; and the Older American Re sources and Services ( OARS ) activities of daily living ( ADL ) scale . At follow-up , the OARS scale was readministered by telephone , and other adverse health outcomes were ascertained . RESULTS Among 1673 patients who completed the follow-up measures , 488 ( 29.2 % ) had an adverse health outcome . Scale development and selection methods included logistic regression , receiver operating characteristic curves , and expert judgment . The proposed screening tool ( ISAR ) comprises six self-report questions on functional dependence ( premorbid and acute change ) , recent hospitalization , impaired memory and vision , and polymedication . The tool performed well in the total cohort aged 65 and older , and in sub-groups defined by disposition ( admitted or released from ED ) , language of question naire administration ( French or English ) , information source ( patient or other ) , and other characteristics . CONCLUSIONS The ISAR is a short self-report question naire that can quickly identify older patients in the ED at increased risk of several adverse health outcomes and those with current disability Context Prescription and management of medications are important issues for older adults . Contribution Among elders enrolled in two managed care organizations , most quality problems were related to failure to prescribe indicated medications ; failure to monitor medications ; and failure to provide medication along with proper documentation and education in concert with other physicians . Implication s Prescribing inappropriate medications for older adults is less of an issue than other aspects of drug therapy . Quality improvement efforts should focus on avoiding errors of omission in prescribing indicated medications , monitoring , patient education , and follow-up . The Editors Pharmacotherapy is an essential component of medical treatment for older patients , but medications are also responsible for many adverse events in this group . Ninety percent of people 65 years of age or older take at least one medication ( 1 ) . This age group , which represents only 13 % of the population , accounts for one third of all prescription drug expenditures in the United States ( 2 ) . Many older persons take multiple drugs for the treatment of several conditions , which increases the chance of adverse drug reactions , drugdrug interactions , and drugdisease interactions . The frequency of adverse drug events in elderly out patients ranges from 10 % to 35 % , depending on the setting ( 3 - 5 ) . Recognizing the magnitude of medication-related issues , panels of geriatric experts rate medication problems among the most important quality -of-care problems for older patients ( 6 - 8 ) . Reflecting the severity and frequency of adverse drug events in older patients , many investigations have focused on the appropriateness of medication prescribing to elderly persons . Implicit review mechanisms include the Medication Appropriateness Index , which consists of 10 medication characteristics ( including indication , effectiveness , and dosage ) that a trained pharmacist review er can judge as appropriate , marginally appropriate , or inappropriate . An application of the Medication Appropriateness Index to elderly veterans taking 5 or more prescription medications found that 74 % had at least 1 inappropriate aspect to their prescriptions ( 9 , 10 ) . Review s using explicit criteria usually focus on medications that should be avoided in the care of older patients . The list of medications to avoid , which was developed by Beers and colleagues on the basis of a formal consensus of geriatric experts ( 11 - 13 ) , has been applied to various groups of patients , revealing a high prevalence of inappropriate drug use ( 14 - 20 ) . In addition , explicit criteria about drugdrug interactions , treatment duration , and drug contraindications were created by Tamblyn and colleagues and applied to medications prescribed to older patients in Canada ( 21 ) . They found that more than half of older patients took at least one high-risk medication . Health policy efforts , on the other h and , have focused predominantly on finding ways to pay for the medication needed by older patients . Proposals aim to improve access to pharmacologic care but do not strive to develop mechanisms to evaluate or improve the quality of medication management for older patients . Improvement in access to medications without quality assurance may result in a mere increase in care without change in outcomes . To provide a more comprehensive evaluation of the quality of pharmacologic care for older patients , we systematic ally evaluated medication management for a sample of older patients by taking advantage of a set of explicit process of care quality indicators developed and implemented in the Assessing Care of Vulnerable Elders ( ACOVE ) project ( 22 ) . Whereas the earlier ACOVE analysis described overall quality of care and compared care quality for geriatric and medical conditions , this study focuses on pharmacologic care and identifies improvement needs in medication management . Our quality evaluation covered the continuum of pharmacologic care , from recognizing the indications for medications to choosing medication , prescribing appropriately , educating and documenting , and monitoring after prescribing . Methods The ACOVE project developed a set of explicit quality indicators  to evaluate the care provided to vulnerable older persons ( 22 - 24 ) . The system focuses on processes of care within the domains of prevention , diagnosis , treatment , and follow-up and covers the spectrum of care contained in 22 conditions that are important in the care of older patients ( 7 ) . The methods for selecting conditions and developing the quality indicators are described in detail elsewhere ( 7 , 23 ) . Methods included systematic literature review s and multiple layers of expert judgment ( 23 ) . The literature review result ed in proposal of c and i date quality indicators , which were review ed by an expert panel that rated each of the proposed quality indicators for validity and feasibility . This set was modified and approved by a clinical committee of national geriatric experts and by the American College of Physicians Task Force on Aging ( 24 ) . From the final ACOVE set of quality indicators , 43 quality indicators ( Table 1 and Appendix Table ) that pertained to pharmacologic care and had more than 5 eligible patients are included in this analysis . Table 1 .  Medication Quality Indicators , Number of Eligible Patients , and Pass Rates Patients and Data Collection We assessed care provided to older persons who were enrolled in 2 managed care organizations . Each managed care organization , one in the U.S. Northeast and the other in the Southwest , had more than 20 000 senior enrollees and contracted with a network of providers to deliver care . A r and om sample of community-dwelling persons 65 years of age or older was drawn from enrollees in each managed care organization . Eligibility criteria included continuous enrollment in the managed care organization for at least 13 months , no out-of-plan care , and no active treatment for malignant conditions ( excluding nonmelanoma skin cancer ) during the period . In addition , persons who did not speak English were excluded because our interview instruments were not available in other language s. Among the enrollees , we targeted vulnerable elders , defined as persons 65 years of age and older who are at increased risk for death or functional decline . Vulnerable elders were identified on the basis of self-report ( or proxy report ) by using a brief screening survey ( the Vulnerable Elders-13 [ VE-13 ] Survey [ 25 ] ) administered by telephone . The R AND Institutional Review Board approved the study protocol . Data were derived mainly from abstract ing medical records . For participating patients , we identified all inpatient and outpatient medical records during the 13-month period of 1 July 1998 to 31 July 1999 . These medical records were abstract ed by trained nurses with experience in quality assessment . The abstract or considered all of a patient 's medical records when assessing whether a patient was eligible for and received the indicated care processes . Information on eligibility for a quality indicator could be derived from one medical record ( such as a primary care physician starting an appropriate antidepressant ) and the care process delivered and documented from records in another setting ( such as a psychiatric consultant escalating the antidepressant dosage in response to lack of improvement ) . A senior nurse- review er assessed each completed medical record abstract , and physician overreaders review ed quality indicators that required a clinical assessment , such as whether there was follow-up to newly started long-term therapy with a medication or whether newly started therapy with a highly anticholinergic drug had acceptable alternatives . We evaluated inter-rater reliability by re- abstract ing a r and om sample of 10 % of the medical records . These records contained 698 quality indicators ; 97 % had identical eligibility and 95 % demonstrated identical eligibility and score . Details of study enrollment and data collection can be found elsewhere ( 22 ) . Because some aspects of care might not be adequately captured in the medical record ( for example , patient education about medications ) , these data were supplemented by a quality -of-care interview with study participants ( or , if necessary , their proxies ) . During the interview , patients were asked to list all of their medications . On the basis of conditions and medications reported during the interview , patients were asked about specific processes of care they had received . The interview was conducted by telephone  between August and October 2000 . To minimize recall bias , we asked about most recent care when implementing quality indicators that may include multiple events ( for example , education about newly started therapy with a medication ) . Information was obtained from medical records for 37 quality indicators and from the patient interview for 6 quality indicators .  For 4 quality indicators reported previously by using medical record data ( 22 ) , we used interview data in this analysis because subsequent evaluation revealed that interview data on information transfer quality indicators yielded higher pass rates that were aligned with a priori hypotheses and provided more conservative estimates of quality of care . Statistical Analysis A  quality indicator  was scored for a patient if he or she met the eligibility criteria to receive the specified care process . The quality indicator was passed if the care process was implemented for the patient . If the medical record indicated that the patient declined the care process , the quality indicator was considered to be passed . On the other h and , if the patient had a prespecified contraindication to the care process ( such as a patient with asthma who otherwise was eligible to receive a -blocker after a myocardial infa rct ion ) , the patient was considered ineligible for the quality indicator . Quality scores were calculated as the proportion of eligible patients who received indicated care . BACKGROUND Depression is common in older adults and often coexists with multiple chronic diseases , which may complicate its diagnosis and treatment . OBJECTIVE To determine whether or not the presence of multiple comorbid medical illnesses affects patient response to a multidisciplinary depression treatment program . DESIGN , SETTING AND PARTICIPANTS Preplanned analyses of Improving Mood-Promoting Access to Collaborative Treatment ( IMPACT ) , a r and omized controlled trial of 1801 depressed older adults ( > or = 60 years ) , which was performed at 18 primary care clinics from eight health care organizations in five states across the United States from July 1999 to August 2001 . INTERVENTION Intervention patients had access for up to 12 months to a depression care manager , supervised by a psychiatrist and a primary care expert , who offered education , care management and support of antidepressant management by the patient 's primary care physician , or provided brief psychotherapy ( Problem-Solving Treatment in Primary Care ) . MEASUREMENTS Depression , quality of life ( QOL ; scale of 0 - 10 ) and mental health component score ( MCS ) of the Short-Form 12 assessed at baseline , 3 , 6 and 12 months . RESULTS Patients suffered from an average of 3.8 chronic medical conditions . Although patients with more chronic medical conditions had higher depression severity at baseline , the number of chronic diseases did not affect the likelihood of response to the IMPACT intervention when compared to care as usual . Intervention patients experienced significantly lower depression during all follow-up time points as compared with patients in usual care independent of other comorbid illnesses ( P<.001 ) . Intervention patients were also more likely to experience substantial response ( at least a 50 % reduction in depressive symptoms ) regardless of the number of comorbidities , to experience improved MCS-12 scores at 3 and 12 months , and to experience improved QOL . CONCLUSIONS The presence of multiple comorbid medical illnesses did not affect patient response to a multidisciplinary depression treatment program . The IMPACT collaborative care model was equally effective for depressed older adults with or without comorbid medical illnesses OBJECTIVE To determine whether a new model of primary care , Chronic Care Clinics , can improve outcomes of common geriatric syndromes ( urinary incontinence , falls , depressive symptoms ,  high risk medications  ,  functional impairment ) in frail older adults . DESIGN R and omized controlled trial with 24 months of follow-up . Physician practice s were r and omized either to the Chronic Care Clinics intervention or to usual care . SETTING Nine primary care physician practice s that comprise an ambulatory clinic in a large staff-model HMO in western Washington State . PARTICIPANTS Those patients aged 65 and older in each practice with the highest risk for being hospitalized or experiencing functional decline . INTERVENTION Intervention practice s ( 5 physicians , 96 patients ) held half-day Chronic Care Clinics every 3 to 4 months . These clinics included an extended visit with the physician and nurse dedicated to planning chronic disease management ; a pharmacist visit that emphasized reduction of polypharmacy and high-risk medications ; and a patient self-management/support group . Control practice s ( 4 physicians , 73 patients ) received usual care . MEASUREMENTS Changes in self-reported urinary incontinence , frequency of falls , depressive symptoms , physical function , and satisfaction were analyzed using an intention-to-treat analysis adjusted for baseline differences , covariates , and practice -level variation . Prescriptions for high-risk medications and cost/utilization data obtained from administrative data were similarly analyzed . RESULTS After 24 months , no significant improvements in frequency of incontinence , proportion with falls , depression scores , physical function scores , or prescriptions for high risk medications were demonstrated . Costs of medical care including frequency of hospitalization , hospital days , emergency and ambulatory visits , and total costs of care were not significantly different between intervention and control groups . A higher proportion of intervention patients rated the overall quality of their medical care as excellent compared with control patients ( 40.0 % vs 25.3 % , P = .10 ) . CONCLUSIONS Although intervention patients expressed high levels of satisfaction with Chronic Care Clinics , improved outcomes for selected geriatric syndromes were not demonstrated . These findings suggest the need for developing greater system-wide support for managing geriatric syndromes in primary care and illustrate the challenges of conducting practice improvement research in a rapidly changing delivery system BACKGROUND Effective new strategies that complement primary care are needed to reduce disability risks and improve self-management of chronic illness in frail older people living in the community . OBJECTIVE To evaluate the impact of a 1-year , senior center-based chronic illness self-management and disability prevention program on health , functioning , and healthcare utilization in frail older adults . DESIGN A r and omized controlled trial . SETTING A large senior center located in a northeast Seattle suburb . The trial was conducted in collaboration with primary care providers of two large managed care organizations . PARTICIPANTS A total of 201 chronically ill older adults seniors aged 70 and older recruited through medical practice s. INTERVENTION A targeted , multi-component disability prevention and disease self-management program led by a geriatric nurse practitioner ( GNP ) . MEASUREMENTS Self-reported Physical function , physical performance tests , health care utilization , and health behaviors . RESULTS Each of 101 intervention participants met with the GNP from 1 to 8 times ( median = 3 ) during the study year . The intervention group showed less decline in function , as measured by disability days and lower scores on the Health Assessment Question naire . Other measures of function , including the SF-36 and a battery of physical performance tests , did not change with the intervention . The number of hospitalized participants increased by 69 % among the controls and decreased by 38 % in the intervention group ( P = .083 ) . The total number of inpatient hospital days during the study year was significantly less in the intervention group compared with controls ( total days = 33 vs 116 , P = .049 ) . The intervention led to significantly higher levels of physical activity and senior center participation and significant reductions in the use of psychoactive medications . CONCLUSIONS This project provides evidence that a community-based collaboration with primary care providers can improve function and reduce inpatient utilization in chronically ill older adults . Linking organized medical care with complementary community-based interventions may be a promising direction for research and practice BACKGROUND Despite progress in describing the problem of potentially inappropriate medication ( PIM ) use , there have been few prospect i ve studies demonstrating that interventions with specific medication criteria can make a difference in decreasing the use of problematic drugs in older adults . OBJECTIVE To design an intervention study to change physician behavior regarding PIM prescribing to older patients . STUDY DESIGN AND METHODS A prospect i ve r and omized block design was used during an 18-month period from January 2001 to June 2002 . The study population was primary care physicians ( n = 355 ) in the Medicare + Choice product line of a southeastern managed care organization and their patients 65 years and older . There were 170 physicians in the treatment group and 185 in the control group . Physicians were assigned to the treatment or usual-care , groups using a r and omization table , and each group included physicians who had and had not prescribed a PIM . RESULTS Approximately 71 % ( 84/118 ) of the physicians in the intervention group who prescribed a PIM completed and faxed back at least 1 potentially inappropriate medication form to the managed care organization . On 15.4 % ( 260/1692 ) of the medication forms , physicians made some change regarding PIM use . CONCLUSIONS Although many studies have addressed medication use among older adults , intervention studies aim ed at influencing physician prescribing in this population are limited . This study describes a low-cost , replicable method to contact and educate physicians on drug therapy issues in older adults OBJECTIVE To assess the efficacy of a home care program design ed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization . STUDY DESIGN R and omized controlled trial in which participants were assigned to the home care intervention ( Choices for Healthy Aging [ CHA ] ) program or usual care . METHODS The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool . Measures included satisfaction with medical care , medical service use , and costs of medical care . RESULTS The intervention group reported significantly greater satisfaction with care than usual care recipients ( t test = 2.476 ; P = .014 ) . CHA patients were less likely than usual care patients to be admitted to the hospital ( 25.6 % and 37.1 % , respectively ; P = .02 ) . There were no differences in terms of costs of care between the home care and usual care groups . CONCLUSIONS Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations . Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when design ing programs for high-risk groups Background Heart failure ( HF ) is a prevalent chronic disease in older adults that requires extensive self-care to prevent decompensation and hospitalization . Cognitive impairment may impact the ability to perform HF self-care activities . We examined the association between cognitive impairment and adherence to self-care in patients hospitalized for acute HF . Design Prospect i ve cohort study . Setting and participants A total of 577 patients ( mean age = 71 years , 44 % female ) hospitalized for HF at five medical centers in the United States and Canada . Measurements and methods Participants were interviewed for information on self-reported adherence to self-care using the European Heart Failure Self-care Behaviour Scale . We assessed cognitive impairment in three domains ( memory , processing speed , and executive function ) using st and ardized measures . Patients ’ demographic and clinical characteristics were obtained through medical record review . Multivariable linear regression was used to examine the association between cognitive impairment and self-care practice s adjusting for demographic and clinical factors . Results A total of 453 patients ( 79 % ) were impaired in at least one cognitive domain . Average adherence to self-care activities among patients with global cognitive impairment did not differ significantly from those without cognitive impairment ( 30.5 versus 29.6 ; 45-point scale ) . However , impaired memory was associated with lower self-care scores ( P = 0.006 ) in multivariable models . Conclusion Cognitive impairment is highly prevalent among older patients hospitalized for HF .  Memory impairment is associated with poorer adherence to self-care practice s. Screening for memory impairment in patients with HF may help to identify patients at risk for poor self-care who may benefit from tailored disease management programs BACKGROUND Results of previous studies of white older adults suggest that antihypertensive medications preserve cognition . We assessed the long-term effect of antihypertensive medications on cognitive function in a community sample of African American older adults . METHODS We conducted longitudinal surveys and clinical assessment of cognitive function in a r and om sample of 2212 community-dwelling African Americans 65 years and older . We identified 1900 participants without evidence of cognitive impairment at baseline , 1617 of whom had subsequent follow-up information , and 946 of whom had blood pressure measurements .  Cognitive function was measured at baseline and at 2 and 5 years by means of scores on the Community Screening Instrument for Dementia and neuropsychological and clinical assessment for dementia and cognitive impairment . Prescription and nonprescription medication use was derived from in-home inspection of medications and participant and informant reports . RESULTS Of 1900 participants , 288 ( 15.2 % ) developed incident cognitive impairment . Using logistic regression to control for the effects of age , sex , education , baseline cognitive scores , and hypertension and angina or myocardial infa rct ion , we found that antihypertensive medications reduced the odds of incident cognitive impairment by 38 % ( odds ratio , 0.62 ; 95 % confidence interval , 0.45 - 0.84 ) . Corresponding analysis using blood pressure measurements on the subset of participants was inconclusive . CONCLUSION Antihypertensive medication use is associated with preservation of cognitive function in older African American adults Purpose : To compare the effects of adding a progressive multimodal rehabilitation program to usual care ( MRP + UC ) versus UC alone on 1 ) functional mobility , strength , endurance and 2 ) ventilator weaning and discharge status of patients with ICU‐acquired weakness ( ICUAW ) receiving prolonged mechanical ventilation ( PMV ) . Methods : R and omized pilot trial of an individualized MRP + UC versus UC in middle‐aged and older ICU survivors with ICUAW receiving PMV . Outcomes compare changes in strength , mobility , weaning success and discharge home from a long‐term acute care hospital ( LTACH ) between the groups . Results : Eighteen males and 14 females ( age 60.3 ± 11.9 years ) who received PMV for ≥14 days were enrolled . Despite no significant differences between groups in the changes in h and grip , gait speed , short physical performance battery or 6‐min walk distance after treatment , the MRP + UC group had greater weaning success ( 87 % vs. 41 % , p < 0.01 ) , and more patients discharged home than UC ( 53 vs. 12 % , p = 0.05 ) . Post hoc analyses , combining patients based on successful weaning or discharge home , demonstrated significant improvements in strength , ambulation and mobility . Conclusion : The addition of an MRP that improves strength , physical function and mobility to usual physical therapy in LTACH patients with ICUAW is associated with greater weaning success and discharge home than UC alone . HighlightsA multimodal rehabilitation program for ICU survivors is feasible and well tolerated . Adding a multimodal rehabilitation program to usual care results in improved clinical outcomes .Improvements in mobility are associated with successful weaning and discharge home
This review will provide an exhaustive view of medication management models that could be effective for polymedicated , home-dwelling older adults and will allow us to analyze their impact on managing and preventing MRPs .
BACKGROUND Older adults with multiple chronic diseases commonly require complex medication regimes .
When combined with frailty , cognitive impairment , and changing pharmacological prescriptions , older adults ' polymedication regimes increase the risk of medication-related problems ( MRPs ) and hospitalization .
Effective , well-organized medication management could avoid MRPs and their clinical outcomes .
OBJECTIVE Identify medication management models and analyze their impact on managing and preventing MRPs for polymedicated , home-dwelling older adults .