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Polypharmacy Among Elderly Diabetic Polypharmacy Among Elderly Diabetic Patients in Home Health CarePatients 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)863-0846E- mail: iai2@psu.edu

FOR MORE INFO...

Contact Mrs. Eunjeong Kang e-mail: exk192@psu.edu

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ObjectivesObjectives

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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IntroductionIntroduction

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 InteractionDrug-Drug Interaction

Possible mechanisms of action of DDI:– Synergy– Antagonism– Adverse effects

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MethodologyMethodology

SubjectsDataIdentification of possible interactionInclusion criteriaStatistical analysis

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SubjectsSubjects

Elderly diabetic patients who were discharged from hospital to home health care provided by a large Mid-Atlantic home health agency.

These patients received skilled nursing visits at home through either telehomecare or through traditional home visits.

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DataData

Medication sheets for these patients were examined for possible drug-drug 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 collectionData collection

Data collection spanned 18 month period from 3/1998 through 9/1999

J F M A M J J A S O N D J F M A M J J A S O N D

1998 1999

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Drugs consideredDrugs 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 checkerDrug checkerWe 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 AnalysisStatistical Analysis

Descriptive statisticst-test comparison (comparing

participants and non-participants)Pearson correlation for correlates of

polypharmacy

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ResultsResults

Sample demographic descriptionPrevalence of comorbiditiesPolypharmacy ratesSample drug-drug interactionsCorrelates of drug-drug interactions

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Table 1. Comparisons between the study Table 1. Comparisons between the study sample and the non-participantssample and the non-participants

* p<.05 ** p<.01

  Study Sample (N=139)

Excluded Sample (N=37)

Age** 73.6 (SD=9.50) 78.0 (SD=6.76)

MaleFemale

39 (28.7%) 97 (71.3%)

9 (20.0%)27 (80.0%)

Black/non-whiteWhite, 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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Table 2. Prevalence of diabetes-related Table 2. Prevalence of diabetes-related complicationscomplications

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 Prevalence of other comorbid conditionsconditions

• 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 Comorbid complications and conditionsconditions

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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PolypharmacyPolypharmacy

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 InteractionsPossible Drug-Drug Interactions

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 Table 4. Examples of Potential Severe Drug-Drug Interactions and their Frequency in our study sampleInteractions and their Frequency in our study sample

  Example Frequency (%)

Diuretic-NSAID furosemide-aspirin, 37 (39.4)

Diuretic-Antihypertentive

Furosemide-digoxin, furosemide-amiodarone, bumetanide-digoxin

18 (19.1)

Anticoagulant-NSAID

Coumadin-aspirin 14 (14.9)

Cardiac agent-Antihypertensive

Verapamil-digoxin, atenolol-verapamil 8 (8.5)

CNS agent-CNS agent

Fluoxetine-imipramin, haloperidol-sinemet, elavil-fluoxetine

3 (3.2)

CNS agent-Analgesic Carbamazepine-tramadol, norpramin-tramadol

2 (2.1)

Other Captopril-allopurinol, vasotec-allopurinol, coumadin-tamoxifen, coumadin-ampicillin, coumadin-synthroid, coumadin-amiodarone, coumadin-cyclosporin, cyclosporin-pravachol

12 (12.8)

Total   94 (100.0)

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Table 5. Pearson correlation coefficients Table 5. Pearson correlation coefficients of factors associated with polypharmacyof 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 implicationsService implications

Need for – Medication monitoring– Prescription coordination– Case management

• Community pharmacy• Patients• Home nurse

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Policy implicationsPolicy implications

What can we do to prevent or reduce the occurrence of polypharmacy and its possible ill effects?

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Future researchFuture research

Did it really happen?To what extent?How can we prevent or reduce it?

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Thank youThank you