Trends in Use of High‐Risk Medications for Older Veterans: 2004 to 2006

Pugh, Mary Jo; Hanlon, Joseph T.; Wang, Chen Pin; Semla, Todd P.; Burk, Muriel; Amuan, Megan E.; Lowery, Ashlei W.; Good, Chester B.; Berlowitz, Dan R.

doi:10.1111/j.1532-5415.2011.03559.x

Cited by 30 publications

(36 citation statements)

References 36 publications

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“…We did not have access to care received from Medicare which leads to incomplete ascertainment of emergency care or hospital admission, unlike VA mortality data which has been found to be very accurate. 21 Individuals with HRME or Rx-DIS tend to have more chronic disease 14, 15 and therefore may be more likely to receive hospital admission or emergency care in a Medicare setting than individuals without such exposure. Because that would bias toward the null hypothesis, we believe our results are conservative.…”

Section: Discussionmentioning

confidence: 99%

“…11, 25, 26 These variables were selected for inclusion in this analysis since they were identified as being associated with HRME and Rx-DIS in our prior research. 14, 15 …”

Section: Methodsmentioning

confidence: 99%

“…9-13 We hypothesize that, because the majority of exposure represents chronic use 14, 15 , the source of these inconsistent findings may be due to survivor bias, where individuals who have adverse events discontinue the drug and those who tolerate the drug represent the vast majority of prevalent users. 16 Thus, we sought to evaluate the clinical importance of HRME and Rx-DIS measures by assessing the association between new HRME and Rx-DIS exposure and the subsequent outcomes of emergency care, hospital admission and mortality using a cohort of community-dwelling elders receiving care in the Veterans Health Administration (VA).…”

Section: Introductionmentioning

confidence: 99%

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The Quality of Quality Measures: HEDIS® Quality Measures for Medication Management in the Elderly and Outcomes Associated with New Exposure

et al. 2013

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Background Clinical validation studies of the Healthcare Effectiveness Data and Information Set (HEDIS®) measures of inappropriate prescribing in the elderly are limited. Objectives The objective of this study was to examine associations of new exposure to High Risk Medication in Elderly (HRME) and drug-disease interaction (Rx-DIS) with mortality, hospital admission, and emergency care. Methods A retrospective database study was conducted examining new use of HRME and Rx-DIS in fiscal year 2006 (Oct 2005-Sep 2006; FY06), with index date being date of first HRME/Rx-DIS exposure, or first day of FY07 if no HRME/Rx-DIS exposure. Outcomes were assessed one year after index date. The participants are veterans who were ≥65 years old in FY06and received Veterans Health Administration (VA) care in FY05-06. A history of falls/hip fracture, chronic renal failure, and/or dementia per diagnosis codes defined the Rx-DIS subsample. The variables included a number of new unique HRME drug exposures and new unique Rx-DIS drug exposure (0, 1, >1) in FY06, and outcomes (i.e., 1-year mortality, hospital admission, and emergency care) up to one year after exposure. Descriptive statistics summarized variables for the overall HRME cohort and the Rx-DIS subset. Multivariable statistical analyses using Generalized Estimating Equations (GEE) models with a logit link accounted for nesting of patients within facilities. For these latter analyses, we controlled for demographic characteristics, chronic disease states, and indicators of disease burden the previous year (e.g., number of prescriptions, emergency/hospital care). Results Among the 1,807,404 veterans who met inclusion criteria, 5.2% had new HRME exposure. Of the 256,388 in the Rx-DIS cohort, 3.6% had new Rx-DIS exposure. Multivariable analyses found that HRME was significantly associated with mortality (1: adjusted odds ratio [AOR]=1.62, 95% CI 1.56-1.68; >1: AOR=1.80; 95% CI 1.45-2.23), hospital admission (1: AOR=2.31, 95% CI 2.22-2.40; >1: AOR=3.44, 95% CI 3.06-3.87) and emergency care (1: AOR=2.59, 95% CI 2.49-2.70; >1: AOR=4.18, 95% CI 3.71-4.71). Rx-DIS exposure was significantly associated with mortality (1: AOR=1.60, 95% CI 1.51-1.71; >1: AOR=2.00; 95% CI 1.38-2.91), hospital admission for one exposure (1: AOR=1.12, 95% CI 1.03-1.27; >1: AOR=1.18; 95% CI 0.71-1.95) and emergency care for two or more exposures (1: AOR=1.06; 95% CI 0.97-1.15; >1: AOR=2.0; 95% CI 1.35-3.10. Conclusions Analyses support the link between HRME/Rx-DIS exposure and clinically significant outcomes in older Veterans. Now is the time to begin incorporating input from both patients who receive these medications and providers who prescribe to develop approaches to reduce exposure to these agents.

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Section: Discussionmentioning

confidence: 99%

“…11, 25, 26 These variables were selected for inclusion in this analysis since they were identified as being associated with HRME and Rx-DIS in our prior research. 14, 15 …”

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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The Quality of Quality Measures: HEDIS® Quality Measures for Medication Management in the Elderly and Outcomes Associated with New Exposure

et al. 2013

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“…An analysis of data from all VA outpatient clinics focusing on individuals older than 65 years old found that increased number of medications was associated with exposure to any high-risk medication (OR = 1.13 [99 % CI 1.12, 1.13]). Increased number of medications was also associated with exposure to specific high-risk medications, including antihistamines (OR = 1.12 [99 % CI 1.11, 1.12]), opioids (OR = 1.10 [99 % CI 1.09, 1.10]), psychotropics (OR = 1.12 [99 % CI 1.12, 1.13]), and skeletal muscle relaxants (OR = 1.10 [99 % CI 1.10, 1.10]) [88]. These findings are consistent with other studies [89].…”

Section: Polypharmacy and Harmsmentioning

confidence: 99%

The Next Therapeutic Challenge in HIV: Polypharmacy

et al. 2013

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With the adoption of combination antiretroviral therapy (ART), most HIV-infected individuals in care are on five or more medications and at risk of harm from polypharmacy, a risk that likely increases with number of medications, age, and physiologic frailty. Established harms of polypharmacy include decreased medication adherence and increased serious adverse drug events, including organ system injury, hospitalization, geriatric syndromes (falls, fractures, and cognitive decline) and mortality. The literature on polypharmacy among those with HIV infection is limited, and the literature on polypharmacy among non-HIV patients requires adaptation to the special issues facing those on chronic ART. First, those aging with HIV infection often initiate ART in their 3rd or 4th decade of life and are expected to remain on ART for the rest of their lives. Second, those with HIV may be at higher risk for age-associated comorbid disease, further increasing their risk of polypharmacy. Third, those with HIV may have an enhanced susceptibility to harm from polypharmacy due to decreased organ system reserve, chronic inflammation, and ongoing immune dysfunction. Finally, because ART is life-extending, nonadherence to ART is particularly concerning. After reviewing the relevant literature, we propose an adapted framework with which to address polypharmacy among those on lifelong ART and suggest areas for future work.

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“…These databases are the repositories of clinical data from more than 150 VA hospitals and 850 outpatient clinics. Details regarding this study cohort have been previously published 25,26 .…”

Section: Methodsmentioning

confidence: 99%

Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain

Makris¹,

Pugh²,

Berlowitz

et al. 2015

The American Journal of the Medical Sciences

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Background Chronic pain is common, costly, and leads to significant morbidity in older adults, yet we have limited data on medication safety. We sought to evaluate the association of incident High Risk Medication in the Elderly (HRME) with mortality, emergency department (ED) or hospital care among older adults with chronic pain. Methods A retrospective Veterans Health Administration cohort study was conducted examining older Veterans with chronic pain diagnoses and use of incident HRME (opioids, skeletal muscle relaxants, antihistamines, and psychotropics). Outcomes evaluated included all-cause mortality, ED visits, or inpatient hospital care. Descriptive statistics summarized variables for the overall cohort, the chronic pain cohort, and those with and without HRME. Separate generalized linear mixed-effect regression models were used to examine the association of incident HRME on each outcome, controlling for potential confounders. Results Among 1,807,404 Veterans who received VA care in 2005–2006, 584,066 (32.3%) had chronic pain; 45,945 Veterans with chronic pain (7.9%) had incident HRME exposure. The strongest significant associations of incident HRME were for: high-risk opioids with all-cause hospitalizations (OR 2.08, 95%CI 1.95–2.23); skeletal muscle relaxants with all-cause ED visits (OR 2.62, 95%CI 2.52–2.73) and mortality (OR 0.80, 95%CI 0.74–0.86); antihistamines with all-cause ED visits (OR 2.82 95%CI 2.72–2.95); and psychotropics with all-cause hospitalizations (OR 2.15, 95%CI 1.96–2.35). Conclusions Our data indicate that incident HRME is associated with clinically important adverse outcomes in older Veterans with chronic pain and highlight the importance of being judicious with prescribing certain classes of drugs in this vulnerable population.

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Trends in Use of High‐Risk Medications for Older Veterans: 2004 to 2006

Cited by 30 publications

References 36 publications

The Quality of Quality Measures: HEDIS® Quality Measures for Medication Management in the Elderly and Outcomes Associated with New Exposure

The Quality of Quality Measures: HEDIS® Quality Measures for Medication Management in the Elderly and Outcomes Associated with New Exposure

The Next Therapeutic Challenge in HIV: Polypharmacy

Exposure to High-Risk Medications is Associated With Worse Outcomes in Older Veterans With Chronic Pain

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