A Pilot Study Into Factors Influencing Medication Discrepancies

A Pilot Study Into Factors Influencing Medication Discrepancies Amongst Elderly Patients Post-Hospitalization Kaur, K. , Chew, P. C. , Chan, K. L. , & Png, H. H. ACTION TEAM (Aged Care Transition Team)

Purpose To identify the extent of poor medication management in the home of the elderly using the Medication Discrepancy Tool (MDT) (Smith et al, 2004)

Objectives Explore the prevalence of poor medication management amongst the elderly in the community Describe the characteristics of patients associated with poor medication management

Singapore’s Demographics Population of approximately over 5 million Chinese (76. 8%), Malays (13. 9%), Indians (7. 9%) & Others (1. 4%) Number of seniors living alone or with spouse: 1995: 9. 7% 2005: 19. 9%

(Ministry of Health, 2006)

National University Health System Jurong General Hospital Khoo Teck Puat Hospital Singapore General Hospital Tan Tock Seng Hospital Changi General Hospital

(Ministry of Health, 2009)

Local Dementia Prevalence

Background According to Pin (2009), 9 out of 10 elderly have at least 1 chronic condition, of which 43% have at least 3 chronic conditions In April 2009, the Agency for Integrated Care (AIC) funded SGH to commence the Aged Care Transition (ACTION) team

ACTION Process High-risk hospital inpatients Residential Facility e. g. community hospital, nursing homes Discharge Admission Discharge Hospital ACTION Team Care Coordinators Home with supporting services • Day rehabilitation • Home Medical, Nursing & Rehab • Social support services About 1 -month post discharge Community • Screening high risk patients • Assessment of needs • Referral & placement in ILTC services • Develop & implement care plan • Goal setting & evaluation of care plans • Follow up assessment • Optimize patient’s self-care capabilities at home • Monitoring of high risk clients • Hand-off to other services + Phone Follow-up + Home Visit

Anecdotal Scenarios Double-dosing by patients Medications stocked in inappropriate places Non-adherence – intentional or non intentional Lack of medication knowledge

49% of hospitalized patients experience at least 1 medical error following discharge, & an estimated 19% to 23% of patients suffer an adverse drug event after discharge (Moore, Wisnivesky, Williams and Mc. Ginn, 2003) Non-adherence to medications may lead to adverse drug events with subsequent need for increased hospitalization, frequent visits to ED & increased costs (Winland-Brown & Valiante, 2000; Bergman-Evans, 2006)

Adverse events occur in 3. 7% of hospitalized patients & 19% of medical patients discharged from a hospital experienced an adverse event within a month. Of which 1/3 of these adverse events were preventable because they were due to an error & the other 1/3 could have been reduced with better monitoring (Forster et al. , 2004)

Dementia patients assessed 2 weeks after discharge from hospital, 18. 4% (n=27) were 3 x more likely to take > 120% of their prescribed medications & 30. 6% (n=45) more likely to take <70% of their medication (Gray, Mahoney and Blough, 2001) In Denmark the risks for non-adherence among patients with dementia were 9 x greater than those without dementia (Barat, Andreasen & Damsgaard, 2001)

Research Design Quantitative, cross-sectional survey design study using convenience sampling Sample size of 30 participants Only those with home visitation done were included in the study

Methodology The MDT was used to identify & categorize transition-related medication problems (Smith et al. , 2004). The MDT is categorized as either: Patient associated factors System associated factors

Methodology Both inter & intra-rater reliability was tested: Inter-rater reliability was 0. 56 Intra-rater raliability was 0. 58 to 0. 69 Kappa range between 0. 4 to 0. 6 is rated as moderate agreement & 0. 6 to 0. 8 is rated as high agreement (Simon, 2008)

Ethical Consideration Approval from institution's IRB was sought Verbal consent was obtained from participants Autonomy, anonymity & confidentiality were assured Data collected for patients were kept confidential & managed within the requirements of the department

Patients screened by care coordinators Recruited by care coordinators Not recruited by care coordinators Telephone follow-up to sought permission for home visit Nil follow-up required Conduct home visit to check on patient’s condition & medication management MDT will be completed by care coordinators

Statistical Analysis SPSS version 16. 0 Descriptive statistics Crosstabs Linear regression The significance level was set at p = 0. 05

Demographic Data n = 30 Mean age – 77. 4 (+ 8)

Social Medical Conditions

MDT’s Categorization Patient Associated Factors

MDT’s Categorization System Associated Factors

Living arrangement (p=0. 045) & number of comorbidities (p=0. 014), significantly predicts number of discrepancies experienced Vision impairment (p=0. 000) & hearing impairment (p=0. 015) significantly predicts patient’s performance deficit Patient’s age (p=0. 023) & number of co-morbidities (p=0. 026) significantly predicts MDT system level inaccurate discharge instructions Results showed that there was a significant association between vision impairment & medication discrepancies, p=0. 041

33. 3% of patients in this study had cognitive impairment Findings showed that cognitive impairment is not associated with number & type of discrepancies experienced Several studies have shown that cognitive impairment affects patient’s medication consumption (Gray et al. , 2001; Barat et al. , 2001; Hutchison et al. , 2006)

Limitations Single site Small sample size Only participants under care coordinators management were included Limited to patients who had home visits done by care coordinators

Implementation Pharmacist outreach programme (POP) Care coordinators collaborates with the pharmacist to address medication discrepancies Regular home visits by care coordinators for patients identified with potential medication discrepancies

Home Visit Case Discussion

Conclusions Medication discrepancies move beyond the multiple bags of medication The adverse events that results from patients not consuming their drugs correctly can lead to an increase in emergency visits, rehospitalisation & healthcare resources Bridging the gap can pose as a challenge to healthcare providers to ensure a smooth transition from one healthcare setting to the next

References i. Barat, I. , Andreasen, F. , & Damsgaard, E. M. S. (2001). Drug therapy in the elderly: What doctors believe and patients actually do? British Journal of Clinical Pharmacology, 51(6), 615 – 622. ii. Forster, A. J. , Clark, H. D. , Menard, A. , Dupuis, N. , Chernish, R. , Chandok, N. , . . . Walraven, C. V. (2004). Adverse events among medical patients after discharge from hospital. Canadian Medical Association Journal, 170(3), 345 – 349. iii. Gray, S. L. , Mahoney, J. E. , Blough, D. K. (2001). Medication adherence in elderly patients receiving home health services following hospital discharge. The Annals of Pharmacotherapy, 35(5), 539 – 545. iv. Hutchison, L. C. , Jones, S. K. , West, D. S. , & Wei, J. Y. (2006). Assessment of medication management by community - living elderly persons with two standardized assessment tools: A Cross-Sectional Study. The American Journal of Geriatric Pharmacotherapy, 4(2), 144 – 153. v. Ministry of Health, Singapore, Intermediate and long term care in Singapore. (2006).

References vi. Ministry of Health, Singapore, Population and vital statistics. (2009). vii. Moore, C. , Wisnivesky, J. , Williams, S. , & Mc. Ginn, T. (2003). Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine, 18(8), 646 – 651. viii. Pin, N. T. (2009) Chronic disease, functional status and quality of life among the elderly in Singapore. ix. Simon, S. (2008). Stats: What is a Kappa coefficient? (Cohen’s Kappa) x. Smith, J. D. , Coleman, E. A. , & Min, S. J. (2004). A new tool for identifying discrepancies in postacute medications for community-dwelling older adults. American Journal of Geriatric Pharmacotherapy, 2(2), 141 – 147. xi. Winland-Brown, J. E. , & Valiante, J. (2000). Effectiveness of different medication management approaches on elders’ medication adherence. Outcomes Management for Nursing Practice, 4(4), 172 – 176.