Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Anderson, Timothy S.; Jing, Bocheng; Auerbach, Andrew D.; Wray, Charlie M; Lee, Sei; Boscardin, W. John; Fung, Kathy Z.; Ngo, Sarah; Silvestrini, Molly; Steinman, Michael A.

doi:10.1001/jamainternmed.2019.3007

Cited by 62 publications

(81 citation statements)

References 36 publications

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“…One study34 of patients filling insulin following discharge observed a subsequent increased risk of death and readmissions; however, this study lacked information on patients' inpatient or outpatient glycemic control. Another study4 examining the antihypertensive intensifications at discharge found increased risks of adverse events and readmissions. Thus, additional information is needed on the long-term outcomes of intensifying diabetes medications at discharge.…”

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confidence: 99%

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

et al. 2020

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IMPORTANCE Elevated blood glucose levels are common in hospitalized older adults and may lead clinicians to intensify outpatient diabetes medications at discharge, risking potential overtreatment when patients return home. OBJECTIVE To assess how often hospitalized older adults are discharged with intensified diabetes medications and the likelihood of benefit associated with these intensifications. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study examined patients aged 65 years and older with diabetes not previously requiring insulin. The study included patients who were hospitalized in a Veterans Health Administration hospital for common medical conditions between 2011 and 2013. MAIN OUTCOMES AND MEASURES Intensification of outpatient diabetes medications, defined as receiving a new or higher-dose medication at discharge than was being taken prior to hospitalization. Mixed-effect logistic regression models were used to control for patient and hospitalization characteristics. RESULTS Of 16 178 patients (mean [SD] age, 73 [8] years; 15 895 [98%] men), 8535 (53%) had a preadmission hemoglobin A 1c (HbA 1c) level less than 7.0%, and 1044 (6%) had an HbA 1c level greater than 9.0%. Overall, 1626 patients (10%) were discharged with intensified diabetes medications including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. Nearly half of patients receiving intensifications (49% [791 of 1626]) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal HbA 1c , while 20% (329 of 1626) were classified as having potential to benefit. Both preadmission HbA 1c level and inpatient blood glucose recordings were associated with discharge with intensified diabetes medications. Among patients with a preadmission HbA 1c level less than 7.0%, the predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for patients with severely elevated inpatient blood glucose levels. CONCLUSIONS AND RELEVANCE In this study, 1 in 10 older adults with diabetes hospitalized for common medical conditions was discharged with intensified diabetes medications. Nearly half of these individuals were unlikely to benefit owing to limited life expectancy or already being at their HbA 1c goal.

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Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

et al. 2020

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“…Information includes mode, time, location (home vs clinic), content of contact, results of glucose or blood pressure self-monitoring, goals, life events, pharmacist interactions, and interventions. Intensification of therapy will be defined as the number of dosage increases of antihypertensive, hypoglycemic agent, or insulin or the addition of a new agent since the baseline visit [ 98 - 100 ]. Chart review will define the number of PCP visits and pharmacist videoconferences as well as the number of pharmacist- or physician-initiated medication changes.…”

Section: Methodsmentioning

confidence: 99%

A Pharmacist and Health Coach–Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study

Sharp¹,

Biggers²,

Perez³

et al. 2021

JMIR Res Protoc

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Background Aggressive management of blood glucose, blood pressure, and cholesterol through medication and lifestyle adherence is necessary to minimize the adverse health outcomes of type 2 diabetes. However, numerous psychosocial and environmental barriers to adherence prevent low-income, urban, and ethnic minority populations from achieving their management goals, resulting in diabetes complications. Health coaches working with clinical pharmacists represent a promising strategy for addressing common diabetes management barriers. Mobile health (mHealth) tools may further enhance their ability to support vulnerable minority populations in diabetes management. Objective The aim of this study is to evaluate the impact of an mHealth clinical pharmacist and health coach–delivered intervention on hemoglobin A1c (HbA1c, primary outcome), blood pressure, and low-density lipoprotein (secondary outcomes) in African-Americans and Latinos with poorly controlled type 2 diabetes. Methods A 2-year, randomized controlled crossover study will evaluate the effectiveness of an mHealth diabetes intervention delivered by a health coach and clinical pharmacist team compared with usual care. All patients will receive 1 year of team intervention, including lifestyle and medication support delivered in the home with videoconferencing and text messages. All patients will also receive 1 year of usual care without team intervention and no home visits. The order of the conditions received will be randomized. Our recruitment goal is 220 urban African-American or Latino adults with uncontrolled type 2 diabetes (HbA1c ≥8%) receiving care from a largely minority-serving, urban academic medical center. The intervention includes the following: health coaches supporting patients through home visits, phone calls, and text messaging and clinical pharmacists supporting patients through videoconferences facilitated by health coaches. Data collection includes physiologic (HbA1c, blood pressure, weight, and lipid profile) and survey measures (medication adherence, diabetes-related behaviors, and quality of life). Data collection during the second year of study will determine the maintenance of any physiological improvement among participants receiving the intervention during the first year. Results Participant enrollment began in March 2017. We have recruited 221 patients. Intervention delivery and data collection will continue until November 2021. The results are expected to be published by May 2022. Conclusions This is among the first trials to incorporate health coaches, clinical pharmacists, and mHealth technologies to increase access to diabetes support among urban African-Americans and Latinos to achieve therapeutic goals. International Registered Report Identifier (IRRID) DERR1-10.2196/17170

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“…During hospitalization, intensification of older adults' antihypertensive medications caused by reasons unrelated to hospitalization could occur which may increase risk for adverse clinical outcomes. Anderson et al aimed to investigate the association between antihypertensive regimen intensification at hospital discharge and clinical health outcomes after discharge 22 . The authors conducted a retrospective cohort study, using national inpatient and outpatient Veterans Health Administration (VHA) combined with clinical data and Medicare Claims data.…”

Section: Summary Of Studiesmentioning

confidence: 99%

Medication Use Quality and Safety in Older Adults: 2019 Update

Ailabouni

Marcum

Schmader

et al. 2021

J American Geriatrics Society

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Improving the quality of medication use and medication safety are important priorities for prescribers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2019. We selected highquality studies that moved the field of research forward and were not merely replication studies. The chosen articles cover domains related to aspects of suboptimal prescribing and medication safety. The first study used a nationally representative sample of Medicare beneficiaries to examine the continuation of medications with limited benefit in patients admitted for cancer and non-cancer diagnoses in hospice (domain: potentially inappropriate medications). The second study, a retrospective cohort study of older adults in Ontario, Canada, assessed the association between prescribing oral anticoagulants in an emergency department relative to not prescribing anticoagulants in the emergency department and their persistence at 6 months (domain: underuse of medications). The third study, a cluster randomized trial in Quebec, Canada, evaluated the effect of conducting electronic medication reconciliation on several outcomes including adverse drug events and medication discrepancies (domain: medication safety). Lastly, the fourth study, a retrospective study using national inpatient and outpatient Veteran Health Administration combined with clinical and Medicare Claims data, examined the effects of intensification of antihypertensive medications on older adults' likelihood for hospital readmission and other important clinical outcomes (domain: medication safety). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens.

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Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge

Cited by 62 publications

References 36 publications

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

Prevalence of Diabetes Medication Intensifications in Older Adults Discharged From US Veterans Health Administration Hospitals

A Pharmacist and Health Coach–Delivered Mobile Health Intervention for Type 2 Diabetes: Protocol for a Randomized Controlled Crossover Study

Medication Use Quality and Safety in Older Adults: 2019 Update

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