Preventive health therapy and behavior outcomes from a brown bag medication review for older adults.

BACKGROUND: Morbidity and mortality associated with preventable diseases can be reduced with the use of preventive health services. We evaluated the uptake and retention of preventive health behaviors and management of accidental medication poisonings in older adults after a health prevention educational component was combined with a brown bag medication review. METHODS: This study used a cohort design and was conducted in six urban senior centers and three independent senior living communities in Detroit, Michigan. Participants included 85 older adults (>60 years old) taking five or more medications with 63 participants returning follow up materials. Pharmacy personnel conducted brown bag medication reviews that were combined with a preventive health education component. Information was collected on medications, vaccinations, supplement use, and accidental medication poisoning management. Participants were given written recommendations on prescription medications and preventive health therapies to improve health and medication use. An investigator developed program satisfaction survey was administered immediately after the review. An investigator-developed follow-up preventive health implementation survey was conducted at least 3 months later to assess recommendation implementation. RESULTS: Participants' mean age was 75.9 ± 8.5 years. Fifty-six older adults had 124 recommendations in preventive health in total (1-5/participant). Eleven participants had no recommendations. Sixty-three participants (74%) returned follow-up preventive health surveys. Twenty-three percent of recommendations were already implemented with 34% planned to be done in the future. Poisoning management knowledge increased for 13 participants, reporting they would call the poison control center. The program was well received, with participants reporting high satisfaction scores (4.8 ± 0.7 out of 5). CONCLUSIONS: Brown bag medication reviews can be an effective method to promote the uptake of preventive health behaviors among older adults, but additional accidental medication poisoning management education is still needed.

Drug-Related-Problem Outcomes and Program Satisfaction from a Comprehensive Brown Bag Medication Review.

OBJECTIVES: To classify and quantify drug-related problems (DRPs), determine acceptance of DRP recommendations, and assess medication review satisfaction. DESIGN: Comprehensive brown bag medication reviews. SETTING: Six senior centers and three senior high-rises. PARTICIPANTS: Individuals aged 60 and older (mean age 75.9 ± 8.5) taking five or more medications (n = 85). MEASUREMENTS: Two investigators independently classified DRPs using modified Pharmaceutical Care Network Europe classification scheme and severity of medication error and value of service scales. Two other investigators adjudicated classification differences. Satisfaction surveys were administered immediately and 3 months after review. A DRP recommendation implementation survey was completed at least 3 months after the review. RESULTS: Participants had a mean of 4.3 ± 2.8 DRPs (range 0-10). DRPs were classified as adverse reactions (30%), treatment effectiveness (28%), treatment costs (13%), information need (8%), and other (21%). Causes included drug selection (40%), wrong dosage (23%), participant problems (e.g., adherence, lack of medication knowledge, 16%), drug use process problems (12%), drug formulation (0.5%), treatment duration (0.5%), and other (7%). Interventions required drug changes (44%), prescriber input (37%), individual counseling (18%), or other (1%). DRP severities were significant (59%) or minor (35%). Participants expressed satisfaction with the program because they were able to ask questions, trusted the answers, and knew more about their medications. After 3 months, they had implemented 63% of the DRP recommendations. CONCLUSION: Older adults found the medication review helpful and implemented 63% of the DRP recommendations.

Bridging for an isolated subtherapeutic INR: an evaluation of clinical practice patterns, outcomes, and costs from an anticoagulation clinic.

No formal recommendations support bridging patients taking warfarin for a subtherapeutic international normalized ratio (INR). This study aimed to: (1) characterize practices at one anticoagulation clinic, (2) evaluate adverse events, and (3) compare cost of bridging versus withholding bridging for subtherapeutic INR. A retrospective chart review of 320 patients having 546 isolated subtherapeutic INR episodes included patients with an INR below their therapeutic range, preceded by two INRs within or above range. Bridged episodes required more frequent follow-up visits to achieve therapeutic INR (2.5 ± 1.0 vs. 2.2 ± 0.6; P = 0.097), but fewer days until the INR returned to therapeutic range (6.8 ± 5.0 vs. 18.9 ± 16.0; P < 0.0001). The strongest predictor of bridging was the magnitude the INR fell below the therapeutic range, where those with a severely-low INR were 30-fold more likely to be bridged (P < 0.0001), and moderately-low INR episodes were 6-fold more likely to be bridged compared with mildly-low INR (P < 0.0001). Those at high thromboembolic risk were more likely to be bridged than at low-risk (OR 3.39 [1.50-7.68]; P = 0.0034). Increasing age reduced the likelihood of being bridged (OR 0.97 [0.95-0.99]; P = 0.0118). Adverse events were infrequent in both the bridged and non-bridged; thrombosis (2.0 vs. 0.7%), major bleeding (2.0 vs. 1.3%), minor bleeding (4.1 vs. 3.1%) and bruising (18.4 vs. 3.6%). Incremental cost difference of bridging was significantly greater for total cost ($967.13) and its components, direct medical ($951.32), transportation ($2.73) and productivity cost ($13.08). It is unclear if bridging for an isolated subtherapeutic INR reduces thrombosis risk, but it is associated with higher costs.

Striking a balance between the risks and benefits of anticoagulation bridge therapy in patients with atrial fibrillation: clinical updates and remaining controversies.

Long-term anticoagulation with a vitamin K antagonist (VKA) or the new agent dabigatran is recommended to decrease stroke risk in patients with atrial fibrillation. When patients with atrial fibrillation undergo initiation or interruption of VKA therapy, or experience an isolated subtherapeutic international normalized ratio (INR), bridge therapy with a parenteral anticoagulant may be considered. To describe the literature for anticoagulation bridge therapy in patients with atrial fibrillation, we conducted a MEDLINE search (1966-February 2011) of the English-language literature to identify related studies. Ongoing clinical trials were identified through a search of the ClinicalTrials.gov registry. Major national and international guidelines were gathered and evaluated. Additional literature was obtained through review of relevant references of the identified articles. Bridging is not supported by guidelines or clinical trials for patients starting VKA therapy for atrial fibrillation. A subtherapeutic INR value during long-term VKA therapy may be associated with increased thromboembolic events, but the benefit of bridging has not been demonstrated. When VKA therapy is interrupted for procedures, retrospective and cohort data suggest that the decision to bridge should be based on a patient's thromboembolic and bleeding risks associated with the procedure. Typically, it is recommended to use bridge therapy in patients with atrial fibrillation at high risk for thromboembolism, but the benefit of bridging is less clear in patients at low risk. Not all procedures necessitate anticoagulation interruption. Recent trials suggest that VKAs can be continued when patients are undergoing cardiac device procedures and some types of radiofrequency ablation. Several clinical trials are ongoing that will provide more definitive guidance for perioperative anticoagulation management of patients with atrial fibrillation. Patients taking dabigatran are unlikely to require bridge therapy because of a predictable anticoagulant effect and rapid onset of action. However, evidence for optimal perioperative management of dabigatran is needed.

Transportation cost of anticoagulation clinic visits in an urban setting.

BACKGROUND: Patients being managed on warfarin make frequent or regular visits to anticoagulation monitoring appointments. International studies have evaluated transportation cost and associated time related to anticoagulation clinic visits. To our knowledge, no studies have evaluated the cost of transportation to such clinic visits in the United States. OBJECTIVE: To describe the methods of transportation and estimate the average total cost of transportation to and from an anticoagulation clinic in an urban setting. METHODS: We prospectively conducted a survey of patients treated at the Harper Anticoagulation Clinic located in Detroit, Michigan, during November 2010. The survey was given to patients while waiting at their regularly scheduled clinic appointments and included questions regarding mode of transportation, distance traveled in miles, parking payment, and time missed from work for clinic appointments. The mean distance traveled was translated into cost assuming 50 cents per mile based on 2010 estimates by the Internal Revenue Service. RESULTS: Sixty patients responded to the 11-item survey; response rates for individual items varied because participants were instructed to skip questions that did not pertain to them. Of the 47 participants responding to demographic questions, 70.2% were female, and 46.8% were older than 60 years. Transportation by private vehicle (80.0%), either driven by patients (41.7%) or someone else (38.3%), was the most common method reported. Use of private automobile translated into a cost of $11.19 per round trip. Other means of transportation identified include a ride from a medical transportation service (10.0%), bus (5.0%), walking (3.3%), and taxi (1.7%). The mean (SD) distance traveled to the clinic for all methods of transportation was 8.34 (7.7) miles. We estimated the average cost of round-trip transportation to be $10.78 weighted for all transportation modes. This is a direct nonmedical cost that is paid for by most patients out of pocket. However, 9 of 44 (20.5%) responded that their insurance plans provided at least some coverage for their rides to the anticoagulation clinic. Most participants stated that they did not take any time off work for clinic visits (88%) primarily because a large proportion of the study population was unemployed or retired. CONCLUSION: The round-trip cost of transportation to an anticoagulation clinic in an urban setting in the United States may translate into a substantial expense, ranging from weekly appointments ($560 annually) to once monthly appointments ($130 annually).