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Objectives To assess the association between multiple pharmacy use and medication adherence and potential drug-drug interactions ( DDIs) in older adults. Design Cross-sectional propensity score-weighted analysis. Setting 2009 claims data. Participants A nationally representative sample of 926,956 Medicare Part D beneficiaries aged 65 and older continuously enrolled in fee-for-service Medicare and Part D that year who filled one or more prescriptions at a community retail or mail order pharmacy. Measurements Multiple pharmacy use was defined as concurrent (overlapping time periods) or sequential use (non-overlapping time periods) of ≥2 pharmacies in the year. Medication adherence was calculated using a proportion of days covered of 0.80 or greater for eight therapeutic categories (beta-blockers, renin angiotensin system antagonists, calcium channel blockers, statins, sulfonylureas, biguanides (metformin), thiazolidinediones, and dipeptidyl peptidase- IV inhibitors). Potential DDIs arising from use of certain drugs across a broad set of classes were defined as the concurrent filling of two interacting drugs. Results Overall, 38.1% of the sample used multiple pharmacies. Those using multiple pharmacies (concurrently or sequentially) consistently had higher adjusted odds of nonadherence (ranging from 1.10 to 1.31, P < .001) across all chronic medication classes assessed after controlling for sociodemographic, health status, and access to care factors than single pharmacy users. The adjusted predicted probability of exposure to a DDI was also slightly higher for those using multiple pharmacies concurrently (3.6%) than for single pharmacy users (3.2%, adjusted odds ratio ( AOR) = 1.11, 95% confidence interval ( CI) = 1.08-1.15) but lower in individuals using multiple pharmacies sequentially (2.8%, AOR = 0.85, 95% CI = 0.81-0.91). Conclusions Filling prescriptions at multiple pharmacies was associated with lower medication adherence across multiple chronic medications and a small but statistically significant greater likelihood of DDIs in concurrent pharmacy users. [ABSTRACT FROM AUTHOR]

Objectives To describe the prevalence of unplanned hospitalizations caused by adverse drug reactions ( ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics. Design Retrospective cohort. Setting Veterans Affairs Medical Centers. Participants Six hundred seventy-eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006. Measurements Naranjo ADR algorithm, ADR preventability, and polypharmacy (0-4, 5-8, and ≥9 scheduled medications). Results Seventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta-blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin-converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health-status, and access-to-care variables, polypharmacy (≥9 and 5-8) was associated with greater risk of ADR-related hospitalization (adjusted odds ratio ( AOR) = 3.90, 95% confidence interval ( CI) = 1.43-10.61 and AOR = 2.85, 95% CI = 1.03-7.85, respectively). Conclusion ADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy. [ABSTRACT FROM AUTHOR]

Objective. To examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA). Design. Cross-sectional. Setting. Health, Aging, and Body Composition Study. Patients. Six hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA. Outcome Measures. Analgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index. Results. Just over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use. Conclusions. Although older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use. [ABSTRACT FROM AUTHOR]

Objective To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. Design Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. Setting Primary care clinics within four integrated health care systems in the United States. Subjects 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. Methods Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). Results The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93–1.09; P  = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91–1.07; P  = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. Conclusions Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging. [ABSTRACT FROM AUTHOR]

Objectives To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs ( VA) facilities-exposure to high-risk medications in elderly adults ( HRME) and drug-disease interactions ( Rx- DIS)-and to identify facility characteristics associated with high-quality prescribing. Design Cross-sectional. Setting VA Healthcare System. Participants Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 ( N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx- DIS exposure). Measurements Incident use of any HRME ( iHRME) and incident Rx- DIS ( iRx- DIS) and facility-level rates and facility-level predictors of iHRME and iRx- DIS exposure, adjusting for differences in patient characteristics. Results Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio ( OR) = 0.86, 95% confidence interval ( CI) = 0.77-0.96) and iRx- DIS ( OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME ( OR = 1.54, 95% CI = 1.35-1.75) and iRx- DIS exposure ( OR = 1.22, 95% CI = 1.11-1.33). Conclusion Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To identify prevalence and risk factors for exposure to drug-disease interactions included in the Healthcare Effectiveness Data and Information Set (HEDIS) Drug-Disease Interaction (Rx-DIS) measure. DESIGN: Cross-sectional retrospective database analysis. SETTING: Outpatient clinics within the Department of Veterans Affairs (VA). PARTICIPANTS: Individuals aged 65 and older who received VA outpatient care between October 1, 2003, and September 30, 2006. MEASUREMENTS: Rx-DIS exposure based on the HEDIS measure was identified in VA patients with dementia, falls, and chronic renal failure using VA pharmacy and administrative databases. Factors associated with Rx-DIS exposure were examined, including demographic, health status, and access-to-care factors, including VA outpatient health services use and copayment status. RESULTS: Of the 305,041 older veterans who met criteria for inclusion, the 1-year prevalence of Rx-DIS exposure was 15.2%; prevalence was 20.2% for dementia, 16.2% for falls, and 8.5% for chronic renal failure. Patients with high disease burden (physical, psychiatric, number of medications) were significantly more likely to have Rx-DIS exposure, regardless of condition. Hispanics and individuals with no copayments were more likely to have Rx-DIS exposure than whites or those with required copayments. There was variation in other predictors based on the type of Rx-DIS. CONCLUSION: The prevalence of Rx-DIS was common in older VA outpatients. Future studies should examine the risk of Rx-DIS exposure on health outcomes using separate analyses for each type of Rx-DIS separately before combining all Rx-DIS into a single measure of exposure. Studies that examine the effectiveness of interventions to reduce Rx-DIS exposure will also be helpful in improving the quality of care for older adults. [ABSTRACT FROM AUTHOR]