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Suboptimal medication-related quality of care preceding hospitalisation of older patients

Gillian E Caughey, Lisa M Kalisch Ellett, Stan Goldstein and Elizabeth E Roughead
Med J Aust 2015; 203 (5): 220. || doi: 10.5694/mja14.01479

Summary

Objective: To examine the prevalence of suboptimal medication-related processes of care before the hospitalisation of older patients.

Design and setting: We conducted a retrospective cohort study using a clinical indicator set related to medication management that has been validated by an expert panel as consisting of suboptimal aspects of medication use that clinicians should be able to foresee and avoid. Australian Government Department of Veterans’ Affairs administrative claims data between 1 July 2007 and 30 June 2012 were analysed according to these clinical indicators to assess medication-related processes of care preceding hospitalisation.

Participants: Veterans with one or more hospitalisations in Australia for a condition defined by the clinical indicator set.

Main outcome measure: Prevalence of suboptimal medication-related processes of care before hospitalisation as a proportion of all hospitalisations defined by diagnoses in the clinical indicator set.

Results: During the 5-year study period, there were 164 813 hospitalisations with primary diagnoses for conditions included in the clinical indicator set, encompassing 83 430 patients. The overall proportion of hospitalisations that were preceded by suboptimal medication-related processes of care was 25.2% (41 546 hospitalisations); 34.5% of patients (28 807 patients) had at least one hospitalisation and 10.4% (8640 patients) had two or more hospitalisations preceded by suboptimal medication-related processes of care. At least one in 10 hospitalisations for chronic heart failure, ischaemic stroke, asthma, gastrointestinal ulcer or bleeding, fracture, renal failure or nephropathy, hyperglycaemia or hypoglycaemia were preceded by suboptimal medication-related processes of care.

Conclusions: This study highlights conditions for which there are evidence–practice gaps in medication management in the older population. Routine prospective monitoring of these evidence-based, validated, medication-related clinical indicators provides a means for quality improvement in the management of common chronic conditions.

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  • Gillian E Caughey1
  • Lisa M Kalisch Ellett1
  • Stan Goldstein2
  • Elizabeth E Roughead1

  • 1 University of South Australia, Adelaide, SA
  • 2 BUPA Health Foundation, Sydney, NSW


Acknowledgements: 

This research was funded by the BUPA Health Foundation. We thank the expert clinical panel and the project advisory group for their time and expertise. We thank the Department of Veteransboyuan;rsquo; Affairs for providing the administrative claims data used in this study.

Competing interests:

No relevant disclosures.

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access_time 09:38, 7 September 2015
Andrew Nolan

A retrospective clinical indicator study cannot examine the reasons apparently inappropriate medications were used. GPs are well aware of the risks of medication but in elderly patients there are many competing treatment needs. Patients' wishes to be relieved of symptoms such as pain or insomnia usually trumps any worry of the risk medication can involve. Unfortunately alternatives to drug therapy for pain and insomnia are often completely ineffective or inaccessible. To blame perceived medication-related admission on GPs alone is facile.

Competing Interests: No relevant disclosures

Dr Andrew Nolan
private practice

access_time 01:00, 12 September 2015
Girish Swaminathan

Caughey et al (1) reported the prevalence of suboptimal medication-related quality of care before hospitalisation and highlighted the need for improved medication management in primary care. Considering the clinical and economic impact of this problem, it is imperative to take measures to improve medication management.

The authors’ suggestion that suboptimal care could be identified and resolved by medication reviews (1) warrants the need to consider new models of care in primary care. Clinical pharmacists working collaboratively with doctors are shown to reduce medication related issues in hospitals (2). In the current model, medication review in primary care can be achieved through home medicines review. However, this is a referral-based system and is only available to selected patients.

It is important that we acknowledge the limitations in the current system such as time constraints for general practitioners and community pharmacists. We should focus on system redesign and not on blaming professions. It is well recognised that errors are due to faulty systems that “set people up” to fail (3).

In the UK, following success stories of clinical pharmacists in general practice, the NHS is now piloting a project to encourage this model (4). We should consider similar models in Australia where clinical pharmacists are available in general practice clinics working collaboratively with doctors. The sustainability of this approach depends on funding models such as Medicare payments for pharmacist consultation. Considering the amount we are spending in hospitals to treat preventable admissions, this new model of care may in turn prove cost effective and can achieve better clinical outcomes.

1. Caughey GE, Ellett LMK, Goldstein S, Roughead EE. Suboptimal medication-related quality of care preceding hospitalisation of older patients. Med J Aust 2015;203 (5):220.

2. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: A systematic review. Arch Intern Med 2006;166(9):955-64.

3. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system: Washington DC: National Academies Press; 1999.

4. National Health Services. Clinical pharmacists in general practice pilot England: NHS, 2015 http://www.england.nhs.uk/commissioning/primary-care-comm/gp-action-plan/cp-gp-pilot/ (accessed Sep 2015).


Competing Interests: No relevant disclosures

Mr Girish Swaminathan
Regional Health Service, NSW

access_time 06:49, 3 October 2015
Alice Victoria Gilbert

This article highlights the difficulty that our health care practitioners are facing, in particular GP’s. Their patients are ageing and clinical guidelines are mostly offering guidance for a single health condition.(1)
The expectation that guidelines should be adhered to is unrealistic. It generalises the fact that individuals may not fit the standard treatment and therefore it can be considered as suboptimal care. The article reflects this thought that patients are being mismanaged if they have not received first line therapy.
Chronic diseases in our elderly population seldom happen independently. About half of all Australians have a chronic disease. Nearly 40% of those who are aged 45 and over have two or more chronic diseases, and 80% of elderly Australians (>65), the study population, report having three or more.(2,3)
Chronic diseases require constant monitoring and tailoring of medications. Changes to medications can be a result of lack of tolerance, psychical changes such as weight loss or an additional co-morbidity and of course the most important factor, patient choice.
Reviewing prescription history, unless done at initial diagnosis of a chronic condition and in conjunction with the knowledge of other disease states, does not account for medication which has been trialled and failed or account for what guidelines would deem contraindicated.(1)
Reporting on the disease states and/or number of co-morbidities of the study group, not just the admission diagnosis, may provide clinical interpretation of this data.
The study offers insight to the prescribing patterns in disease states, however it does not account for the complexity of co-morbidities. It is important to acknowledge that there is less evidence in the form of clinical guidelines for practitioners to follow once diseases states occur simultaneously.

1. Lugtenberg M, Burgers JS, Clancy C, Westert GP, Schneider EC (2011) Current Guidelines Have Limited Applicability to Patients with Comorbid Conditions: A Systematic Analysis of Evidence-Based Guidelines. PLoS ONE 6(10): e25987. doi:10.1371/journal.pone.0025987
2.Australian Institute of Health and welfare. Chronic diseases.www.aihw.gov.au/chronic-diseases (accessed 10 Sept 2015)
3. Caughey GE, Vitry AI, Gilbert AL, Roughead EE. Prevalence of comorbidity of chronic diseases in Australia. BMC Public Health. 2008;8:221. doi:10.1186/1471-2458-8-221.

Competing Interests: No relevant disclosures

Miss Alice Victoria Gilbert
Northern Territory Department of Health

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