Background-Antipsychotic medications are commonly prescribed to nursing home residents despite th... more Background-Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Administration(VA) nursing homes (i.e., Community Living Centers(CLCs)), we assessed the prevalence and risk factors for their use in older residents of VA CLCs. Methods-This cross-sectional study included 3,692 Veterans ≥age 65 who were admitted between January 2004-June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (e.g., schizophrenia, dementia with psychosis). We used multivariable logistic regression with
American Journal of Geriatric Pharmacotherapy, Jun 1, 2010
Background-Appropriate medication prescribing for nursing home residents remains a challenge. Obj... more Background-Appropriate medication prescribing for nursing home residents remains a challenge. Objective-The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. Methods-The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. Results-Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.
Pharmacotherapy frequently is used for the treatment of medical problems in older veteran communi... more Pharmacotherapy frequently is used for the treatment of medical problems in older veteran community living center (CLC) patients. Unfortunately, many of these drug therapies carry significant risks, including adverse drug reactions (ADRs). To our knowledge the only published study of ADRs in older VA CLC patients found that, over a 6-month period, 95 of 175 residents (54%) experienced an ADR.1 Prescribing errors, especially of primarily renally cleared oral medications (such as digoxin, glyburide, and spirononolactone), are commonly the cause of ADRs. A study by Papaioannou and colleagues (of 456 patients at 4 long-term care facilities in Canada) found that prescribing problems were common for 20 primarily renally cleared medications.2 However, in a non-VA nursing home study, it was shown that computerized alerts at the time of electronic prescribing can improve dosing of primarily renally cleared medications.3 To address the problem of inappropriate prescribing of these medications at the VA Pittsburgh Healthcare System (VAPHS) in Pennsylvania, health professional faculty members from the VAPHS Geriatric Research Education and Clinical Center (GRECC) and the VAPHS Center for Health Equity Research and Promotion implemented a 3-step approach. This approach involved compiling an agreed-upon list of medications and dosing recommendations for primarily renally cleared oral medications, determining the frequency of potentially inappropriate prescribing of these medications, and designing a quality improvement program geared toward improving the prescribing of these medications. Here, in greater detail, we describe each of the 3 steps of our approach. Developing a list of primarily renally cleared oral medications with dosing recommendations for various degrees of renal impairment is difficult, mainly due to the conflicting recommendations that currently are available in reference materials and the medical literature. A recent study-reporting on the concordance between 4 different
Journal of the American Medical Informatics Association, Jul 11, 2022
Objective The purpose of the study was to develop and validate a model to predict the risk of exp... more Objective The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States. Materials and Methods The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach. Results The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model’s area under the ROC curve was 0.668 (95% confidence interval: 0.643–0.693) on the validation subsample of the merged data. Discussion Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs. Conclusion The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.
Journal of the American Geriatrics Society, Nov 24, 2020
BACKGROUND/OBJECTIVES: Federally-mandated consultant pharmacist-conducted retrospective medicatio... more BACKGROUND/OBJECTIVES: Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay. DESIGN: Quality improvement study using a steppedwedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017. SETTING: Four NHs (two urban, two suburban) in Southwestern Pennsylvania. PARTICIPANTS: All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period. INTERVENTION: Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine. MEASUREMENT: Main outcome was incidence of highrisk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations. RESULTS: Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42). CONCLUSIONS: This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.
Journal of the American Medical Directors Association, Oct 1, 2014
Objective-Although acute kidney injury (AKI) is well-studied in the acute care setting, investiga... more Objective-Although acute kidney injury (AKI) is well-studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function or End-Stage kidney disease) criteria in NH residents.
Objective-To examine racial differences in medication use by older long-stay Veterans Affairs Nur... more Objective-To examine racial differences in medication use by older long-stay Veterans Affairs Nursing Home Care Unit (NHCU) patients.
Journal of the American Geriatrics Society, May 1, 2008
OBJECTIVES-To develop a consensus list of agreed upon laboratory, pharmacy, and Minimum Data Set ... more OBJECTIVES-To develop a consensus list of agreed upon laboratory, pharmacy, and Minimum Data Set signals that can be used by a computer system in the nursing home to detect potential adverse drug reactions (ADRs). Literature search for potential ADR signals, followed by an Internetbased, two-round, modified Delphi survey of experts in geriatrics. PARTICIPANTS-Panel of 13 physicians, 10 pharmacists, and 13 advanced practitioners. MEASUREMENTS-Mean score and 95% confidence interval (CI) for each of 80 signals rated on a 5-point Likert scale (5=strong agreement with likelihood of indicating potential ADRs). Consensus agreement indicated by a lower-limit 95% CI of ≥4.0.
Objective-To assess the importance and performance of consultant pharmacist (CP) services deliver... more Objective-To assess the importance and performance of consultant pharmacist (CP) services delivered before and after an intervention to detect and manage adverse drug events among nursing home (NH) residents. Design-Before and after intervention survey of physicians participating in a randomized controlled trial (RCT). Setting-Four non-profit, academically-affiliated NHs. Participants-Attending physicians providing NH care who were randomized to intervention or control groups. Interventions-Within the intervention arm, CPs provided academic detailing to physicians, responded to alerts from a medication monitoring system, adjudicated system alerts for adverse drug events (ADEs), and provided structured recommendations about ADE management. Main Outcome Measures-We compared physicians' assessments of the importance and performance of CP services before and after the trial intervention in the intervention and control groups. Results-In the intervention group, ratings of importance increased for all 24 survey questions, and 5 of the changes were statistically significant (p<.05). In the control group, ratings of importance increased for 16 questions, and none of the changes were statistically significant. In the intervention group, ratings of performance increased for all 24 questions, and 20 of the changes were statistically significant. In the control group, ratings of performance increased for 16 questions, and none of the changes were statistically significant. Conclusion-A multifaceted, CP-led intervention comprised of academic detailing, computerized decision support, and structured communication framework, can improve physicians' assessment of importance and performance of CP services.
OBJECTIVE-To conduct a systematic literature review to determine what telemedicine services are p... more OBJECTIVE-To conduct a systematic literature review to determine what telemedicine services are provided by pharmacists and the impact of these services in the nursing facility setting. DATA SOURCES-MEDLINE ® , Scopus ® , and Embase ® databases. STUDY SELECTION-The terms "telemedicine" or "telehealth" were combined by "and" with the terms "pharmacist" or "pharmacy" to identify pharmacists' use of telemedicine. Also, "telepharmacy" was added as a search term. The initial search yielded 322 results. These abstracts were reviewed by two individuals independently, for selection of articles that discussed telemedicine and involvement of a pharmacist, either as the primary user of the service or as part of an interprofessional health care team. Those abstracts discussing the pharmacist service for purpose of dispensing or product preparation were excluded. DATA EXTRACTION-A description of pharmacists' services provided and the impact on resident care. DATA SYNTHESIS-Only three manuscripts met inclusion criteria. One was a narrative proposition of the benefits of using telemedicine by senior care pharmacists. Two published original research studies indirectly assessed the pharmacists' use of telemedicine in the nursing facility through an anticoagulation program and an osteoporosis management service. Both services demonstrated improvement in patient care. CONCLUSION-There is a general paucity of practice-related research to demonstrate potential benefits of pharmacists' services incorporating telemedicine. Telemedicine may be a resourceefficient approach to enhance pharmacist services in the nursing facility and improve resident care.
American Journal of Geriatric Pharmacotherapy, Jun 1, 2009
Objective-The aim of this work was to examine the association between organizational characterist... more Objective-The aim of this work was to examine the association between organizational characteristics, market characteristics, and changes in antipsychotic medication use in US nursing homes over time. Methods-This was a longitudinal study comparing antipsychotic use in US nursing homes from 1996 through 2006 using Medicare and Medicaid data (the Online Survey Certification And Reporting system) and US Department of Health and Human Resources Health Resources and Services Administration data (the Area Resource File). The 3 outcomes of interest were increasing, decreasing, or stable use of antipsychotic medications. The primary independent variables were organizational characteristics (e.g., for-profit status, chain membership) and market characteristics (e.g., Medicaid reimbursement, levels of competition). Results-Antipsychotic use increased from 16.4% in 1996 to 25.9% in 2006 (P < 0.05). A multinomial generalized estimating equations model, controlling for facility, staffing, and resident factors, suggested that increased antipsychotic use was associated with for-profit facilities (adjusted odds ratio [AOR], 1.58; 95% CI, 1.51-1.65; P ≤ 0.001). Decreased antipsychotic use was associated with chain membership (AOR, 0.82; 95% CI, 0.79-0.85; P ≤ 0.001), higher levels of
Journal of the American Medical Directors Association, Jun 1, 2010
Background-Few studies have examined factors associated with antidepressant prescribing in older ... more Background-Few studies have examined factors associated with antidepressant prescribing in older nursing home residents. Objective-The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort. Settings-Settings were 12,556 US nursing homes in 1996 and 2006. Data Sources-Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF). Results-Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95%
Journal of the American Geriatrics Society, Oct 1, 2015
Author Contributions: S.M.H. and C.M.C. led the development of the study concept and design; part... more Author Contributions: S.M.H. and C.M.C. led the development of the study concept and design; participated in acquisition, analysis, and interpretation of the data; and led manuscript preparation. C.M.C constructed the intervention. S.P. performed the statistical analysis. S.L.K. and Z.M. were involved with implementation and review of data integrity, and manuscript development. All the listed authors made substantial contributions to the study design, performance, and/or analysis and contributed to and/or reviewed and revised the final manuscript. S.M.H. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Drug related events in the intensive care unit are associated with higher medical costs and dire ... more Drug related events in the intensive care unit are associated with higher medical costs and dire patient outcomes. Clinical decision support (CDS) systems are the most important component to aid in adverse drug event (ADE) surveillance and improve in medication safety. Institutions are increasing the use of CDS systems for event detection and CDS systems that combine patient factors with laboratory values, drug information and biomarkers are key to effective ADE prevention.
American Journal of Geriatric Pharmacotherapy, Feb 1, 2010
Objective-This paper reviews recent articles examining medication misadventures that can be defin... more Objective-This paper reviews recent articles examining medication misadventures that can be defined as medication errors and adverse drug events in the elderly. Methods-MEDLINE and International Pharmaceutical Abstracts were searched for articles published in English in 2009 using a combination of the terms medication errors, medication adherence, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failure, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Those studies that described unique approaches to evaluating medication misadventures in the elderly were included in the review. Results-The search identified 5 unique studies relating to medication misadventures in the elderly. A cross-sectional study found that a new 8-item paper-and-pencil adherence survey-the Morisky Medication Adherence Scale-was significantly associated with antihypertensive drug pharmacy refill adherence (P < 0.05). A cross-sectional study of medication discrepancies that occurred during transition from the hospital to a nursing home found discrepancies in almost 75% of patients. A randomized controlled trial of a computer-generated decision support intervention to reduce potentially inappropriate prescribing in an emergency department found that the intervention was associated with a significant reduction in prescriptions for such medications (P = 0.02). One study found that patients who were taking digoxin and had been hospitalized during the previous 2 months were at significantly increased risk for additional hospitalizations due to digoxin toxicity. A survey study of Medicare beneficiaries found that use of multiple types of inappropriate medications was a risk factor for self-reported adverse drug events, independent of the number of medications taken.
Objective-Prior research indicates off-label use is common in the intensive care unit (ICU); howe... more Objective-Prior research indicates off-label use is common in the intensive care unit (ICU); however the safety of off-label use has not been assessed. The study objective was to determine the incidence of adverse drug reactions (ADRs) associated with off-label use and evaluate off-label use as a risk factor for the development of ADRs in an adult ICU population. Interventions-All administered medications were evaluated for Food and Drug Administration (FDA) approved or off-label use. Patients were assessed daily for the development of an ADR through active surveillance. Three ADR assessment instruments were used to determine the probability of an ADR resulting from drug therapy. Severity and harm of the ADR were also
Background-Antipsychotic medications are commonly prescribed to nursing home residents despite th... more Background-Antipsychotic medications are commonly prescribed to nursing home residents despite their well-established adverse event profiles. Because little is known about their use in Veterans Administration(VA) nursing homes (i.e., Community Living Centers(CLCs)), we assessed the prevalence and risk factors for their use in older residents of VA CLCs. Methods-This cross-sectional study included 3,692 Veterans ≥age 65 who were admitted between January 2004-June 2005 to one of 133 VA CLCs and had a stay of ≥90 days. We used VA Pharmacy Benefits Management data to examine antipsychotic use and VA Medical SAS datasets and the Minimum Data Set to identify evidence-based indications for antipsychotic use (e.g., schizophrenia, dementia with psychosis). We used multivariable logistic regression with
American Journal of Geriatric Pharmacotherapy, Jun 1, 2010
Background-Appropriate medication prescribing for nursing home residents remains a challenge. Obj... more Background-Appropriate medication prescribing for nursing home residents remains a challenge. Objective-The purpose of this study was to conduct a narrative review of the published literature describing randomized controlled trials that used interventions to improve suboptimal prescribing in nursing homes. Methods-The PubMed, International Pharmaceutical Abstracts, and EMBASE databases were searched for articles published in the English language between January 1975 and December 2009, using the terms drug utilization, pharmaceutical services, aged, long-term care, nursing homes, prescribing, geriatrics, and randomized controlled trial. A manual search of the reference lists of identified articles and the authors' files, book chapters, and recent review articles was also conducted. Abstracts and posters from meetings were not included in the search. Studies were included if they: (1) had a randomized controlled design; (2) had a process measure outcome for quality of prescribing or a distal outcome measure for medication-related adverse patient events; and (3) involved nursing home residents. Results-Eighteen studies met the inclusion criteria for this review. Seven of those studies described educational approaches using various interventions (eg, outreach visits) and measured suboptimal prescribing in different manners (eg, adherence to guidelines). Two studies described computerized decision-support systems to measure the intervention's impact on adverse drug events (ADEs) and appropriate drug orders. Five studies described clinical pharmacist activities, most commonly involving a medication review, and used various measures of suboptimal prescribing, including a measure of medication appropriateness and the total number of medications prescribed. Two studies each described multidisciplinary and multifaceted approaches that included heterogeneous interventions and measures of prescribing. Most (15/18; 83.
Pharmacotherapy frequently is used for the treatment of medical problems in older veteran communi... more Pharmacotherapy frequently is used for the treatment of medical problems in older veteran community living center (CLC) patients. Unfortunately, many of these drug therapies carry significant risks, including adverse drug reactions (ADRs). To our knowledge the only published study of ADRs in older VA CLC patients found that, over a 6-month period, 95 of 175 residents (54%) experienced an ADR.1 Prescribing errors, especially of primarily renally cleared oral medications (such as digoxin, glyburide, and spirononolactone), are commonly the cause of ADRs. A study by Papaioannou and colleagues (of 456 patients at 4 long-term care facilities in Canada) found that prescribing problems were common for 20 primarily renally cleared medications.2 However, in a non-VA nursing home study, it was shown that computerized alerts at the time of electronic prescribing can improve dosing of primarily renally cleared medications.3 To address the problem of inappropriate prescribing of these medications at the VA Pittsburgh Healthcare System (VAPHS) in Pennsylvania, health professional faculty members from the VAPHS Geriatric Research Education and Clinical Center (GRECC) and the VAPHS Center for Health Equity Research and Promotion implemented a 3-step approach. This approach involved compiling an agreed-upon list of medications and dosing recommendations for primarily renally cleared oral medications, determining the frequency of potentially inappropriate prescribing of these medications, and designing a quality improvement program geared toward improving the prescribing of these medications. Here, in greater detail, we describe each of the 3 steps of our approach. Developing a list of primarily renally cleared oral medications with dosing recommendations for various degrees of renal impairment is difficult, mainly due to the conflicting recommendations that currently are available in reference materials and the medical literature. A recent study-reporting on the concordance between 4 different
Journal of the American Medical Informatics Association, Jul 11, 2022
Objective The purpose of the study was to develop and validate a model to predict the risk of exp... more Objective The purpose of the study was to develop and validate a model to predict the risk of experiencing a fall for nursing home residents utilizing data that are electronically available at the more than 15 000 facilities in the United States. Materials and Methods The fall prediction model was built and tested using 2 extracts of data (2011 through 2013 and 2016 through 2018) from the Long-term Care Minimum Dataset (MDS) combined with drug data from 5 skilled nursing facilities. The model was created using a hybrid Classification and Regression Tree (CART)-logistic approach. Results The combined dataset consisted of 3985 residents with mean age of 77 years and 64% female. The model’s area under the ROC curve was 0.668 (95% confidence interval: 0.643–0.693) on the validation subsample of the merged data. Discussion Inspection of the model showed that antidepressant medications have a significant protective association where the resident has a fall history prior to admission, requires assistance to balance while walking, and some functional range of motion impairment in the lower body; even if the patient exhibits behavioral issues, unstable behaviors, and/or are exposed to multiple psychotropic drugs. Conclusion The novel hybrid CART-logit algorithm is an advance over the 22 fall risk assessment tools previously evaluated in the nursing home setting because it has a better performance characteristic for the fall prediction window of ≤90 days and it is the only model designed to use features that are easily obtainable at nearly every facility in the United States.
Journal of the American Geriatrics Society, Nov 24, 2020
BACKGROUND/OBJECTIVES: Federally-mandated consultant pharmacist-conducted retrospective medicatio... more BACKGROUND/OBJECTIVES: Federally-mandated consultant pharmacist-conducted retrospective medication regimen reviews (MRRs) are designed to improve medication safety in nursing homes (NH). However, MRRs are potentially ineffective. A new model of care that improves access to and efficiency of consultant pharmacists is needed. The objective of this study was to determine the impact of pharmacist-led telemedicine services on reducing high-risk medication adverse drug events (ADEs) for NH residents using medication reconciliation and prospective MRR on admission plus ongoing clinical decision support alerts throughout the residents' stay. DESIGN: Quality improvement study using a steppedwedge design comparing the novel service to usual care in a one-year evaluation from November 2016 to October 2017. SETTING: Four NHs (two urban, two suburban) in Southwestern Pennsylvania. PARTICIPANTS: All residents in the four NHs were screened. There were 2,127 residents admitted having 652 alerts in the active period. INTERVENTION: Upon admission, pharmacists conducted medication reconciliation and prospective MRR for residents and also used telemedicine for communication with cognitively-intact residents. Post-admission, pharmacists received clinical decision support alerts to conduct targeted concurrent MRRs and telemedicine. MEASUREMENT: Main outcome was incidence of highrisk medication, alert-specific ADEs. Secondary outcomes included all-cause hospitalization, 30-day readmission rates, and consultant pharmacists' recommendations. RESULTS: Consultant pharmacists provided 769 recommendations. The intervention group had a 92% lower incidence of alert-specific ADEs than usual care (9 vs 31; 0.14 vs 0.61/1,000-resident-days; adjusted incident rate ratio (AIRR) = 0.08 (95% confidence interval (CI) = 0.01-0.40]; P = .002). All-cause hospitalization was similar between groups (149 vs 138; 2.33 vs 2.70/1,000-resident-days; AIRR = 1.06 (95% CI = 0.72-1.58); P = .75), as were 30-day readmissions (110 vs 102; 1.72 vs 2.00/1,000-resident-days; AIRR = 1.21 (95% CI = 0.76-1.93); P = .42). CONCLUSIONS: This is the first evaluation of the impact of pharmacist-led patient-centered telemedicine services to manage high-risk medications during transitional care and throughout the resident's NH stay, supporting a new model of patient care.
Journal of the American Medical Directors Association, Oct 1, 2014
Objective-Although acute kidney injury (AKI) is well-studied in the acute care setting, investiga... more Objective-Although acute kidney injury (AKI) is well-studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function or End-Stage kidney disease) criteria in NH residents.
Objective-To examine racial differences in medication use by older long-stay Veterans Affairs Nur... more Objective-To examine racial differences in medication use by older long-stay Veterans Affairs Nursing Home Care Unit (NHCU) patients.
Journal of the American Geriatrics Society, May 1, 2008
OBJECTIVES-To develop a consensus list of agreed upon laboratory, pharmacy, and Minimum Data Set ... more OBJECTIVES-To develop a consensus list of agreed upon laboratory, pharmacy, and Minimum Data Set signals that can be used by a computer system in the nursing home to detect potential adverse drug reactions (ADRs). Literature search for potential ADR signals, followed by an Internetbased, two-round, modified Delphi survey of experts in geriatrics. PARTICIPANTS-Panel of 13 physicians, 10 pharmacists, and 13 advanced practitioners. MEASUREMENTS-Mean score and 95% confidence interval (CI) for each of 80 signals rated on a 5-point Likert scale (5=strong agreement with likelihood of indicating potential ADRs). Consensus agreement indicated by a lower-limit 95% CI of ≥4.0.
Objective-To assess the importance and performance of consultant pharmacist (CP) services deliver... more Objective-To assess the importance and performance of consultant pharmacist (CP) services delivered before and after an intervention to detect and manage adverse drug events among nursing home (NH) residents. Design-Before and after intervention survey of physicians participating in a randomized controlled trial (RCT). Setting-Four non-profit, academically-affiliated NHs. Participants-Attending physicians providing NH care who were randomized to intervention or control groups. Interventions-Within the intervention arm, CPs provided academic detailing to physicians, responded to alerts from a medication monitoring system, adjudicated system alerts for adverse drug events (ADEs), and provided structured recommendations about ADE management. Main Outcome Measures-We compared physicians' assessments of the importance and performance of CP services before and after the trial intervention in the intervention and control groups. Results-In the intervention group, ratings of importance increased for all 24 survey questions, and 5 of the changes were statistically significant (p<.05). In the control group, ratings of importance increased for 16 questions, and none of the changes were statistically significant. In the intervention group, ratings of performance increased for all 24 questions, and 20 of the changes were statistically significant. In the control group, ratings of performance increased for 16 questions, and none of the changes were statistically significant. Conclusion-A multifaceted, CP-led intervention comprised of academic detailing, computerized decision support, and structured communication framework, can improve physicians' assessment of importance and performance of CP services.
OBJECTIVE-To conduct a systematic literature review to determine what telemedicine services are p... more OBJECTIVE-To conduct a systematic literature review to determine what telemedicine services are provided by pharmacists and the impact of these services in the nursing facility setting. DATA SOURCES-MEDLINE ® , Scopus ® , and Embase ® databases. STUDY SELECTION-The terms "telemedicine" or "telehealth" were combined by "and" with the terms "pharmacist" or "pharmacy" to identify pharmacists' use of telemedicine. Also, "telepharmacy" was added as a search term. The initial search yielded 322 results. These abstracts were reviewed by two individuals independently, for selection of articles that discussed telemedicine and involvement of a pharmacist, either as the primary user of the service or as part of an interprofessional health care team. Those abstracts discussing the pharmacist service for purpose of dispensing or product preparation were excluded. DATA EXTRACTION-A description of pharmacists' services provided and the impact on resident care. DATA SYNTHESIS-Only three manuscripts met inclusion criteria. One was a narrative proposition of the benefits of using telemedicine by senior care pharmacists. Two published original research studies indirectly assessed the pharmacists' use of telemedicine in the nursing facility through an anticoagulation program and an osteoporosis management service. Both services demonstrated improvement in patient care. CONCLUSION-There is a general paucity of practice-related research to demonstrate potential benefits of pharmacists' services incorporating telemedicine. Telemedicine may be a resourceefficient approach to enhance pharmacist services in the nursing facility and improve resident care.
American Journal of Geriatric Pharmacotherapy, Jun 1, 2009
Objective-The aim of this work was to examine the association between organizational characterist... more Objective-The aim of this work was to examine the association between organizational characteristics, market characteristics, and changes in antipsychotic medication use in US nursing homes over time. Methods-This was a longitudinal study comparing antipsychotic use in US nursing homes from 1996 through 2006 using Medicare and Medicaid data (the Online Survey Certification And Reporting system) and US Department of Health and Human Resources Health Resources and Services Administration data (the Area Resource File). The 3 outcomes of interest were increasing, decreasing, or stable use of antipsychotic medications. The primary independent variables were organizational characteristics (e.g., for-profit status, chain membership) and market characteristics (e.g., Medicaid reimbursement, levels of competition). Results-Antipsychotic use increased from 16.4% in 1996 to 25.9% in 2006 (P < 0.05). A multinomial generalized estimating equations model, controlling for facility, staffing, and resident factors, suggested that increased antipsychotic use was associated with for-profit facilities (adjusted odds ratio [AOR], 1.58; 95% CI, 1.51-1.65; P ≤ 0.001). Decreased antipsychotic use was associated with chain membership (AOR, 0.82; 95% CI, 0.79-0.85; P ≤ 0.001), higher levels of
Journal of the American Medical Directors Association, Jun 1, 2010
Background-Few studies have examined factors associated with antidepressant prescribing in older ... more Background-Few studies have examined factors associated with antidepressant prescribing in older nursing home residents. Objective-The primary objective was to describe the change in antidepressant prescribing for nursing home residents between 1996 and 2006. An additional objective was to examine the association between any change in antidepressant prescribing and staffing patterns or coprescribing of other psychotropic medications in the same cohort. Settings-Settings were 12,556 US nursing homes in 1996 and 2006. Data Sources-Online Survey Certification and Reporting (OSCAR) data and the Area Resource File (ARF). Results-Antidepressant prescribing significantly increased (P < .05) from 21.9% in 1996 to 47.5% in 2006. After controlling for resident, organizational, and market factors, increased antidepressant prescribing was associated with more time spent by physician extenders (adjusted odds ratio [AOR] 2.21; 95% confidence interval [CI] 1.96-2.51), registered nurses (AOR 1.06, 95% CI 1.02-1.10), or nurse aides (AOR 1.08; 95%CI 1.04-1.12) in a facility, as well as the coprescribing of sedative/hypnotics (AOR 1.12; 95% CI 1.08-1.16). Factors found to be protective of increasing antidepressant prescribing (ie, decrease antidepressant prescribing) included having medical directors and physicians spend more time in the facility (AOR 0.60; 95%
Journal of the American Geriatrics Society, Oct 1, 2015
Author Contributions: S.M.H. and C.M.C. led the development of the study concept and design; part... more Author Contributions: S.M.H. and C.M.C. led the development of the study concept and design; participated in acquisition, analysis, and interpretation of the data; and led manuscript preparation. C.M.C constructed the intervention. S.P. performed the statistical analysis. S.L.K. and Z.M. were involved with implementation and review of data integrity, and manuscript development. All the listed authors made substantial contributions to the study design, performance, and/or analysis and contributed to and/or reviewed and revised the final manuscript. S.M.H. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Drug related events in the intensive care unit are associated with higher medical costs and dire ... more Drug related events in the intensive care unit are associated with higher medical costs and dire patient outcomes. Clinical decision support (CDS) systems are the most important component to aid in adverse drug event (ADE) surveillance and improve in medication safety. Institutions are increasing the use of CDS systems for event detection and CDS systems that combine patient factors with laboratory values, drug information and biomarkers are key to effective ADE prevention.
American Journal of Geriatric Pharmacotherapy, Feb 1, 2010
Objective-This paper reviews recent articles examining medication misadventures that can be defin... more Objective-This paper reviews recent articles examining medication misadventures that can be defined as medication errors and adverse drug events in the elderly. Methods-MEDLINE and International Pharmaceutical Abstracts were searched for articles published in English in 2009 using a combination of the terms medication errors, medication adherence, suboptimal prescribing, monitoring, adverse drug events, adverse drug withdrawal events, therapeutic failure, and aged. A manual search of the reference lists of the identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional publications. Those studies that described unique approaches to evaluating medication misadventures in the elderly were included in the review. Results-The search identified 5 unique studies relating to medication misadventures in the elderly. A cross-sectional study found that a new 8-item paper-and-pencil adherence survey-the Morisky Medication Adherence Scale-was significantly associated with antihypertensive drug pharmacy refill adherence (P < 0.05). A cross-sectional study of medication discrepancies that occurred during transition from the hospital to a nursing home found discrepancies in almost 75% of patients. A randomized controlled trial of a computer-generated decision support intervention to reduce potentially inappropriate prescribing in an emergency department found that the intervention was associated with a significant reduction in prescriptions for such medications (P = 0.02). One study found that patients who were taking digoxin and had been hospitalized during the previous 2 months were at significantly increased risk for additional hospitalizations due to digoxin toxicity. A survey study of Medicare beneficiaries found that use of multiple types of inappropriate medications was a risk factor for self-reported adverse drug events, independent of the number of medications taken.
Objective-Prior research indicates off-label use is common in the intensive care unit (ICU); howe... more Objective-Prior research indicates off-label use is common in the intensive care unit (ICU); however the safety of off-label use has not been assessed. The study objective was to determine the incidence of adverse drug reactions (ADRs) associated with off-label use and evaluate off-label use as a risk factor for the development of ADRs in an adult ICU population. Interventions-All administered medications were evaluated for Food and Drug Administration (FDA) approved or off-label use. Patients were assessed daily for the development of an ADR through active surveillance. Three ADR assessment instruments were used to determine the probability of an ADR resulting from drug therapy. Severity and harm of the ADR were also
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Papers by Steven Handler