Transcript Polypharmacy among elderly diabetic in home health care

Polypharmacy Among Elderly Diabetic
Patients in Home Health Care
Eunjeong Kang, MPH
Ibrahim Awad Ibrahim, MD, PhD. Assistant Professor
Kathryn Dansky, PhD., Associate Professor
Department of Health Policy & Administration,
College of Health and Human Development
The Pennsylvania State University
116 Henderson Bldg., University Park, PA 16802
TEL (814)865-1472 FAX (814)863-0846
E- mail: [email protected]
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Contact Mrs. Eunjeong Kang e-mail: [email protected]
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Objectives

To assess the possibility of occurrence of
polypharmacy in a home health diabetes
elderly population.
 To identify combinations of drugs that can
possibly result in serious health
consequences.
 To examine the correlates of
polypharmacy in this population.
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Introduction

Polypharmacy has been defined as:
– Regimens with unnecessary drugs
– Use of 2 more drugs for >240 days
– Simultaneous use of 5 or more drugs

Why is it important?
– Drug-drug Interaction (DDI)
– Drug Food Interaction (DFI)
– Adverse Drug Events (ADE)

Who is at risk?
– Patients with multiple diseases, complicated
prolonged diseases, multiple providers
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Drug-Drug Interaction

Possible mechanisms of action of
DDI:
– Synergy
– Antagonism
– Adverse effects
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Methodology
Subjects
 Data
 Identification of possible interaction
 Inclusion criteria
 Statistical analysis

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Subjects
Elderly diabetic patients who were
discharged from hospital to home
health care provided by a large MidAtlantic home health agency.
 These patients received skilled
nursing visits at home through either
telehomecare or through traditional
home visits.

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Data
Medication sheets for these patients
were examined for possible drugdrug interaction
 We analyzed medication sheets for
139 patients
 There were another 37 patients for
whom medication sheets could not
be obtained.

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Data collection

Data collection spanned 18 month
period from 3/1998 through 9/1999
JF MAM JJASO ND JF MAMJJASO ND
1998
1999
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Drugs considered
 Prescription
systemic drugs for
diabetes and other conditions
– Different types of insulin were considered as
one drug and collapsed into one category.
 Drugs
not considered
– Optic and topical drugs.
– Over-the-counter medications.
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Drug checker
We used an automated
DrugChecker available through
Dr.Koop’s Website: www.drkoop.com
 This drug checker is designed and
compiled by Multum Information
Service, Inc.® who used medical
literature references to support the
results of possible DDI and enhance
their reliability.

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Statistical Analysis
Descriptive statistics
 t-test comparison (comparing
participants and non-participants)
 Pearson correlation for correlates of
polypharmacy

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Results
Sample demographic description
 Prevalence of comorbidities
 Polypharmacy rates
 Sample drug-drug interactions
 Correlates of drug-drug interactions

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Table 1. Comparisons between the study
sample and the non-participants
Study Sample
(N=139)
Excluded Sample
(N=37)
Age**
73.6 (SD=9.50)
78.0 (SD=6.76)
Male
Female
39 (28.7%)
97 (71.3%)
9 (20.0%)
27 (80.0%)
Black/non-white
White, non-hispanic
90 (67.2%)
44 (32.8%)
24 (75.0%)
6 (25.0%)
Years of Education
10.5 SD=2.8)
10.9 (SD=3.4)
Number of Co-morbidities
3.0
3.1
Diabetes Severity*
2.4
2.0
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* p<.05 ** p<.01
Table 2. Prevalence of diabetes-related
complications
Complication
Frequency (%)
Ischemic heart disease
34 (25.8)
Cerebrovascular
25 (18.9)
Congestive heart failure
24 (18.2)
Infectious
21 (15.9)
Renal
11 (8.3)
Neurological
6 (4.5)
Peripheral vascular
5 (3.8)
Amputations
5 (3.8)
Retinal
1 (0.8)
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Prevalence of other comorbid
conditions
• The most common comorbid conditions were
hypertension, rheumatic arthritis, and neurological
disorders 40.5%, 9.2%, and 6.4%, respectively.
• Other conditions were urological conditions,
wounds, respiratory diseases, and gastrointestinal
conditions.
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Comorbid complications and
conditions

137 patients (98.6%) had at least one diabetic
complication or other co-morbidities.
 The most common diabetes-related
complications were ischemic heart disease
(25.8%), cerebrovascular disease (18.9%), and
congestive heart failure (18.2%).
 hypertension was most prevalent comorbid
condition (40.5%) followed by rheumatoid
arthritis was (9.2%).
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Polypharmacy

We found that 88% of the patients
reviewed were at risk for polypharmacy
(5+ drugs simultaneously)
 The average number of medications taken
by these diabetic patients was 8.9 (SD=3.4)
[range 2 – 19]
 Patients took 6.3 oral drugs per episode of
care (mean 48 days, SD 14 days).
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Possible Drug-Drug Interactions





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38.8% of patients at risk for least one severe DDI.
92.8% of patients at risk for at least one moderate DDI
70.5% of patients at risk for at least one mild DDI.
Mild:clinically insignificant effects and neutral or even
favorable effects have been reported for these interactions.
Moderate: serious, but non-lethal and non-life-threatening
injuries have been reported
Severe: death and/or life-threatening injuries have been
reported.
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Table 4. Examples of Potential Severe Drug-Drug
Interactions and their Frequency in our study sample
Example
Frequency (%)
Diuretic-NSAID
furosemide-aspirin,
37 (39.4)
DiureticAntihypertentive
AnticoagulantNSAID
Cardiac agentAntihypertensive
CNS agent-CNS
agent
CNS agent-Analgesic
Furosemide-digoxin, furosemideamiodarone, bumetanide-digoxin
Coumadin-aspirin
18 (19.1)
Other
Captopril-allopurinol, vasotec-allopurinol,
coumadin-tamoxifen, coumadin-ampicillin,
coumadin-synthroid, coumadin-amiodarone,
coumadin-cyclosporin, cyclosporin-pravachol
Total
14 (14.9)
Verapamil-digoxin, atenolol-verapamil
8 (8.5)
Fluoxetine-imipramin, haloperidolsinemet, elavil-fluoxetine
Carbamazepine-tramadol, norpramintramadol
3 (3.2)
2 (2.1)
12 (12.8)
94 (100.0)
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Table 5. Pearson correlation coefficients
of factors associated with polypharmacy
Coefficients
p-value
Age*
-0.187
0.014
Gender (female)*
0.163
0.030
Race (white)*
0.173
0.022
Co-morbidity
0.007
0.936
Diabetes Co-morbidity
-0.084
0.308
Diabetes Severity*
0.208
0.013
* p<0.05
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Service implications

Need for
– Medication monitoring
– Prescription coordination
– Case management
• Community pharmacy
• Patients
• Home nurse
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Policy implications

What can we do to prevent or reduce
the occurrence of polypharmacy and
its possible ill effects?
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Future research
Did it really happen?
 To what extent?
 How can we prevent or reduce it?

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Thank you
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