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101. Factors associated with medication regimen complexity in older people: a cross-sectional population-based study

Author

J. Simon Bell, Barbara C. Wimmer, Johan Fastbom, Kristina Johnell, Michael D. Wiese, Wimmer, Barbara Caecilia, Johnell, Kristina, Fastbom, Johan, Wiese, Michael David, and Bell, Simon J

Subjects
Male, Pediatrics, medicine.medical_specialty, medication regimen complexity, Cross-sectional study, Population, Psychological intervention, Medication Adherence, medicine, Humans, Pharmacology (medical), polypharmacy, education, Aged, Multinomial logistic regression, Aged, 80 and over, Pharmacology, Polypharmacy, education.field_of_study, business.industry, Age Factors, inappropriate prescribing, General Medicine, Odds ratio, Middle Aged, Confidence interval, Regimen, aged, Cross-Sectional Studies, population-based study, Female, business
Abstract

Purpose: There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications. Methods: This cross-sectional population-based study included 3348 people aged ≥60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications. Results: In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI >0–5.5). Similar factors were associated with both regimen complexity and number of medications. Conclusion: Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person’s number of medications to target interventions to reduce complexity. Refereed/Peer-reviewed

Published
2015

102. Factors associated with medication regimen complexity in residents of long-term care facilities

Author

M. Herson, Tina Emery, Edwin C.K. Tan, Barbara C. Wimmer, J.S. Bell, Leonie Robson, Herson, M, Bell, JS, Tan, ECK, Emery, Tina, Robson, L, and Wimmer, BC

Subjects
Polypharmacy, medicine.medical_specialty, medication regimen complexity, Activities of daily living, Geriatrics & Gerontology, business.industry, Medical record, Odds ratio, nursing homes, medicine.disease, Confidence interval, Long-term care, Regimen, aged, Internal medicine, medicine, Dementia, long-term care, Geriatrics and Gerontology, polypharmacy, Intensive care medicine, business, Gerontology
Abstract

Background Polypharmacy and multimorbidity are highly prevalent in long-term care facilities (LTCFs). However, no previous research has investigated factors associated with medication regimen complexity in older residents living in LTCFs. Objective To investigate factors associated with medication regimen complexity in LTCFs. Methods This was a cross-sectional study across six LTCFs in South Australia. Medication, clinical and diagnostic data were extracted from each residents medication and medical record. Residents’ medication regimen complexity was quantified using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression analyses were used to compute unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for variables associated with high regimen complexity. Results There were a total of 383 participants in the study. The mean age of the participants was 87.5 (standard deviation [SD]: 6.2) years. The median MRCI was 43.5 (range: 4–113). The median number of regular and as-needed medications was 13.0 (range: 1–30). Chronic pulmonary disease (OR: 5.10, 95% CI: 2.21–11.8), diabetes (OR: 3.22, 95% CI: 1.51–6.86) and congestive heart failure (OR: 3.13, 95% CI: 1.10–8.85) were associated with high regimen complexity. Independence in activities of daily living (ADLs) (OR: 0.72, 95% CI: 0.62–0.84) and diagnosed dementia (OR: 0.34, 95% CI: 0.17–0.67) were inversely associated with high regimen complexity. Conclusion LTCF residents are at-risk of high medication regimen complexity. Diabetes, congestive heart failure and chronic pulmonary diseases were associated with high regimen complexity, whereas dementia was inversely associated with high regimen complexity.

Published
2015

103. Factors associated with medication regimen complexity in older people : a cross-sectional population-based study

Author

Wimmer, Barbara Caecilia, Johnell, Kristina, Fastbom, Johan, Wiese, Michael David, Bell, J. Simon, Wimmer, Barbara Caecilia, Johnell, Kristina, Fastbom, Johan, Wiese, Michael David, and Bell, J. Simon

Abstract

There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications. This cross-sectional population-based study included 3348 people aged a parts per thousand yen60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications. In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI > 0-5.5). Similar factors were associated with both regimen complexity and number of medications. Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person's number of medications to target interventions to reduce complexity.

Published
2015
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104. Validation of a patient-level medication regimen complexity index as a possible tool to identify patients for medication therapy management intervention

Author

Anne M. Libby, Jan D. Hirsch, Patrick Hosokawa, and Kelli R. Metz

Subjects
Male, medicine.medical_specialty, medication regimen complexity, Prescription Drugs, hypertension, Medication Therapy Management, Psychological intervention, Risk management tools, Nonprescription Drugs, Pharmacists, Statistics, Nonparametric, Regular Manuscripts, Cohort Studies, Ambulatory care, Health care, Medication therapy management, Ambulatory Care, Diabetes Mellitus, Medicine, Humans, Pharmacology (medical), Medical prescription, Intensive care medicine, Aged, Retrospective Studies, Geriatrics, Aged, 80 and over, MRCI, geriatrics, diabetes, human immunodeficiency virus, business.industry, HIV, Middle Aged, Clinical pharmacy, Cross-Sectional Studies, Physical therapy, Female, MTM, business, complexity, chronic disease
Abstract

Currently in the United States, health care systems are being asked to increase the volume of patients who receive medication therapy management (MTM) services and to improve quality indicators that have a heavy emphasis on appropriate medication use. MTM services include comprehensive assessment and evaluation of a patient's complete medication therapy regimen.1 The Centers for Medicare and Medicaid Services (CMS) 2014 guidelines for MTM programs added requirements for health plan sponsors to have a dedicated MTM information page linked to their website and to actively promote available MTM services to beneficiaries in an effort to increase awareness of MTM service availability and ultimately utilization.2 A similar medication focus can be found in the recent CMS star rating system for health plans that implemented incentive quality-based payments based on number of stars earned, where some star rating criteria are related directly to medication use and could be improved through MTM programs.3 For example, star ratings are earned through direct medication targets, such as medication adherence rates (e.g., diabetes, hypertension), percentage of members receiving medications with a high risk of side effects, or other criteria that depend on appropriate medication use (e.g., percentage of patients with diabetes with controlled levels of blood sugar). A screening tool that reliably identifies patients with greater medication regimen complexity could be useful for health plans (e.g., CMS ratings) and for practicing clinicians. A literature review of measures of medication regimen complexity and associated outcomes found that medication regimen complexity is related to patient nonadherence, caregiver burden, quality of life, and medical resource utilization.4 Many different methods were used to quantify the complexity of medication regimens. The medication regimen complexity index (MRCI) was the most frequently used method. The MRCI is a tool that quantifies medication regimen complexity beyond the number of medications to include weighted scores for types of prescribed dosage forms, dosing frequency, and additional administration directions.5 The MRCI has been used to quantify medication regimen complexity in several studies.6–21 Results of MRCI studies describe medication regimen complexity for general groups of patients8,10–13,15–18 and for defined cohorts based on specific disease management (e.g., diabetes, hypertension).6,7,9,14,19–21 Two studies assessed the relationship of MRCI scores with medication adherence and found that increased MRCI scores were related to lower medication adherence levels.6,12 Earlier MRCI studies included only prescription medications for specific target diseases of interest (e.g., prescribed diabetes medications) and ignored other prescription and over-the-counter (OTC) medications for comorbidities (e.g., hypertension, pain management). In contrast, recent studies broadened the MRCI score to include all prescription and OTC medications used for all comorbidities, thus reporting a patient-level MRCI score.11,18,20,21 Patient-level MRCI scores have been shown to differentiate between high, medium, and low medical complexity as determined by other accepted measures of patient complexity, hospital readmission rates, medication count, comorbidity count, and Charlson comorbidity scores (a method of predicting mortality risk based on presence of comorbidities).11,20,21 The potential for the MRCI to be used as a tool in clinical practice and by health plans to identify patients who may benefit from subsequent interventions (e.g., comprehensive medication review) is limited by the original narrowly defined scope for the tool and the associated validation evidence. Although the MRCI was judged to be a reliable and valid tool from the original expert panel validation, the process was conducted using a single cohort of patients (chronic obstructive pulmonary disease) and only included prescription medications in the assessment of medication regimen complexity.5 Also, concordance of MRCI score ranking versus five expert clinician rankings was conducted by asking five experts from different fields (academic, research nurse, adherence expert, clinical pharmacist, and home medication review expert) to judge “the difficulty in coping with the provided regimens without taking into account any drug-, clinical-, or patient-related factors.”5 Considering the number of studies conducted since this initial validation, there appears to be a desire to use the MRCI as a risk assessment tool, along with other patient data, across disease states to identify patients for subsequent interventions.6–21 Thus, there is a need to validate the MRCI to identify patients for subsequent MTM interventions using commonly available drug- and patient-related data across multiple disease states.

Published
2014

105. Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People

Author

Elsa Dent, Barbara C. Wimmer, Kristina Johnell, J. Simon Bell, Renuka Visvanathan, Ian Chapman, Michael D. Wiese, Wimmer, Barbara C, Dent, Elsa, Bell, J Simon, Wiese, Michael D, Chapman, Ian, Johnell, Kristina, and Visvanathan, Renuka

Subjects
Geriatrics, Pediatrics, medicine.medical_specialty, Hospital readmission, medication regimen complexity, business.industry, Hazard ratio, elderly, Medication regimen, hospital readmission, Medicine, Pharmacology (medical), Prospective cohort study, business, Older people
Abstract

Background: Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization. Objective: To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period. Method: The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period. Result: Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78). Conclusion: Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient’s discharge destination is an important factor in unplanned medication-related readmissions. Refereed/Peer-reviewed

Published
2014

106. Polypharmacy and Medication Regimen Complexity as Risk Factors for Hospitalization Among Residents of Long-Term Care Facilities: A Prospective Cohort Study

Author

J. Simon Bell, Barbara C. Wimmer, Leonie Robson, Tina Emery, Jenni Ilomäki, Janet K. Sluggett, Samanta Lalic, Edwin C.K. Tan, Lalic, Samanta, Sluggett, Janet K, Ilomaki, Jenni, Wimmer, Barbara C, Tan, Edwin CK, Robson, Leonie, Emery, Tina, and Bell, J Simon

Subjects
Male, medication regimen complexity, Pediatrics, medicine.medical_specialty, Geriatrics & Gerontology, Activities of daily living, nursing homes, 030204 cardiovascular system & hematology, 03 medical and health sciences, symbols.namesake, 0302 clinical medicine, Risk Factors, medicine, Homes for the Aged, Humans, Prospective Studies, 030212 general & internal medicine, Poisson regression, polypharmacy, Prospective cohort study, General Nursing, Aged, Aged, 80 and over, Geriatrics, Polypharmacy, business.industry, Health Policy, Hazard ratio, Australia, General Medicine, Confidence interval, Hospitalization, Long-term care, Emergency medicine, symbols, long-term care, Female, Geriatrics and Gerontology, business, hospitalization
Abstract

Objectives To investigate the association between polypharmacy and medication regimen complexity with time to first hospitalization, number of hospitalizations, and number of hospital days over a 12-month period. Design A 12-month prospective cohort study. Participants and Setting A total of 383 residents of 6 Australian long-term care facilities (LTCFs). Measurements The primary exposures were polypharmacy (≥9 regular medications) and the 65-item Medication Regimen Complexity Index (MRCI). Cox proportional hazards regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between polypharmacy and MRCI with time to first hospitalization. Poisson regression was used to compute incident rate ratios (IRR) and 95% CIs for the association between polypharmacy and MRCI with number of hospitalizations and number of hospital days. Models were adjusted for age, sex, length of stay in LTCF, comorbidities, activities of daily living, and dementia severity. Results There were 0.56 (95% CI 0.49–0.65) hospitalizations per person-year and 4.52 (95% CI 4.31–4.76) hospital days per person-year. In adjusted analyses, polypharmacy was associated with time to first hospitalization (HR 1.84; 95% CI 1.21–2.79), number of hospitalizations (IRR 1.51; 95% CI 1.09–2.10), and hospital days per person-year (IRR 1.39; 95% CI 1.24–1.56). Similarly, in adjusted analyses a 10-unit increase in MRCI was associated with time to first hospitalization (HR 1.17; 95% CI 1.06–1.29), number of hospitalizations (IRR 1.15; 95% CI 1.06–1.24), and hospital days per person-year (IRR 1.19; 95% CI 1.16–1.23). Conclusions Polypharmacy and medication regimen complexity are associated with hospitalizations from LTCFs. This highlights the importance of regular medication review for residents of LTCFs and the need for further research into the risk-to-benefit ratio of prescribing in this setting.

Published
2016

107. Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People

Author

Wimmer, Barbara C., Dent, Elsa, Bell, J. Simon, Wiese, Michael D., Chapman, Ian, Johnell, Kristina, Visvanathan, Renuka, Wimmer, Barbara C., Dent, Elsa, Bell, J. Simon, Wiese, Michael D., Chapman, Ian, Johnell, Kristina, and Visvanathan, Renuka

Abstract

Background: Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization. Objective: To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a I 2-month period. Method: The prospective study comprised patients aged >= 70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period. Result: Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.2), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharnnacy (>= 9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78). Conclusion: Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhonne settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions., AuthorCount:7

Published
2014
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108. Medication regimen complexity and its impact on medication adherence and glycemic control among patients with type 2 diabetes mellitus in an Ethiopian general hospital.

Author

Ayele AA, Tegegn HG, Ayele TA, and Ayalew MB

Subjects
Blood Glucose analysis, Cross-Sectional Studies, Female, Follow-Up Studies, Glycated Hemoglobin analysis, Hospitals, General, Humans, Male, Middle Aged, Prognosis, Biomarkers analysis, Diabetes Mellitus, Type 2 drug therapy, Drug Utilization Review standards, Hypoglycemic Agents therapeutic use, Medication Adherence statistics & numerical data, Medication Therapy Management, Polypharmacy
Abstract

Background: Different studies reported that higher diabetes-specific Medication Regimen Complexity Index (MRCI) has a negative impact on glycemic control potentially by decreasing medication adherence. However, information about regimen complexity and its association with adherence and glycemic control in Ethiopian patients with diabetes is unknown., Aim: To evaluate medication regimen complexity and to assess its impact on medication adherence and glycemic control among patients with type 2 diabetes Mellitus (T2DM)., Methods: A hospital-based cross-sectional design was conducted at Debre Tabor General Hospital from 1 May 2018 to 30 June 2018. Medication regimen complexity was evaluated using the 65-item validated tool called Medication Complexity Index (MRCI). Adherence was measured using Morisky Medication Adherence Scale while patients were classified as having poor or good glycemic control based on the recent record of their fasting blood glucose. Multivariable logistic regression analysis was applied to determine the association between predictive variables and outcome variables., Results: A total of 275 patients with T2DM who meet the inclusion criteria were included in the final analysis. About 22.2% of the participants were classified as having high diabetes-specific MRCI, whereas 35.6% of the participants were classified as having high patient-level MRCI. The majority (70.5%) of the respondents were adherent to their medications, and 42.9% of the total population were categorized as having good glycemic control. According to the result of the multivariate analysis, patients with low-level and moderate-level MRCI of both diabetes-specific and patient-level MRCI were more adherent to their medication compared with patients with high MRCI. High diabetes medication regimen complexity was associated with poor glycemic control in the adjusted analyses (adjusted OR = 0.276; 95% CI = 0.100 o 0.759)., Conclusion: The prevalence of high MRCImedication regimen complexity index is high among patients with T2DM. Patients with low and moderate regimen complexity had improved adherence. High diabetes-specific medication regimen complexity was associated with poor glycemic control. Simplification of a complex medication regimen for patients with diabetes should be sought by physicians and pharmacists to improve medication adherence and subsequent improvement in glycemic control., Competing Interests: Competing interests: No, there are no competing interests for any author.

Published
2019
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109. Medication Regimen Complexity and Hospital Readmission in Older Adults With Chronic Kidney Disease.

Author

Tesfaye WH, Peterson GM, Castelino RL, McKercher C, Jose MD, Wimmer BC, and Zaidi STR

Subjects
Aged, Female, Hospitalization, Humans, Male, Retrospective Studies, Clinical Protocols standards, Patient Readmission statistics & numerical data, Renal Insufficiency, Chronic therapy
Abstract

Background: Chronic kidney disease (CKD) is characterized by high rates of hospital admissions and readmissions. However, there is a scarcity of research into medication-related factors predicting such outcomes in this patient group., Objective: To evaluate the effect of medication regimen complexity at hospital discharge on subsequent readmissions and their timing in older adults with CKD., Methods: This was a 12-month retrospective cohort study of 204 older (⩾65 years) CKD patients in an Australian tertiary care hospital. Medication regimen complexity was quantified using the 65-item medication regimen complexity index (MRCI). The outcomes were the occurrence of readmission in 30 days and time to readmission within 12 months. Logistic regression was used to identify factors predicting 30-day readmission, and a competing risks proportional subdistribution hazard model, accounting for deaths, was used for factors predicting time to readmission., Results: Overall, 50 (24%) patients, predominantly men (72%), were readmitted within 30 days of follow-up. MRCI was not significantly associated with 30-day readmission (odds ratio [OR] = 1.27; 95% CI = 0.94-1.73). The median (interquartile range) time to readmission within 12 months was 145 (31-365) days. On a multivariate analysis, a 10-unit increase in MRCI was associated with a shorter time to readmission within 12 months (subdistribution HR = 1.18; 95% CI = 1.01-1.36). Conclusion and Relevance: Medication regimen complexity was not significantly associated with 30-day readmission; however, it was associated with a significantly shorter time to 12-month readmission in older CKD patients. This finding highlights the importance of medication regimen complexity as a potential target for medical interventions to reduce readmission risks.

Published
2019
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110. Medication Regimen Complexity Measured by MRCI: A Systematic Review to Identify Health Outcomes.

Author

Alves-Conceição V, Rocha KSS, Silva FVN, Silva ROS, Silva DTD, and Lyra-Jr DP

Subjects
Clinical Protocols standards, Drug-Related Side Effects and Adverse Reactions diagnosis, Drug-Related Side Effects and Adverse Reactions epidemiology, Female, Hospitalization trends, Humans, Male, Medication Therapy Management trends, Patient Readmission trends, Treatment Outcome, Drug-Related Side Effects and Adverse Reactions prevention & control, Medication Adherence, Medication Therapy Management standards, Patient Readmission standards
Abstract

Objective: To perform a systematic review to identify health outcomes related to medication regimen complexity as measured by the Medication Regimen Complexity Index (MRCI) instrument., Data Sources: Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science were searched from January 1, 2004, until April 02, 2018, using the following search terms: outcome assessment, drug therapy, and Medication Regimen Complexity Index and their synonyms in different combinations., Study Selection and Data Extraction: Studies that used the MRCI instrument to measure medication regimen complexity and related it to clinical, humanistic, and/or economic outcomes were evaluated. Two reviewers independently carried out the analysis of the titles, abstracts, and complete texts according to the eligibility criteria, performed data extraction, and evaluated study quality., Data Synthesis: A total of 23 studies met the inclusion criteria; 18 health outcomes related to medication regimen complexity were found. The health outcomes most influenced by medication regimen complexity were hospital readmission, medication adherence, hospitalization, adverse drug events, and emergency sector visit. Only one study related medication regimen complexity with humanistic outcomes, and no study related medication regimen complexity to economic outcomes. Most of the studies were of good methodological quality. Relevance to Patient Care and Clinical Practice: Health care professionals should pay attention to medication regimen complexity of the patients because this may influence health outcomes., Conclusion: This study identified some health outcomes that may be influenced by medication regimen complexity: hospitalization, hospital readmission, and medication adherence were more prevalent, showing a significant association between MRCI increase and these health outcomes.

Published
2018
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111. Patient-level medication regimen complexity across populations with chronic disease

Author

Joseph J. Saseen, Anne M. Libby, Sunny A. Linnebur, Douglas N. Fish, Kavita V. Nair, Joseph P. Vande Griend, Sara P. Vu, Jan D. Hirsch, Patrick Hosokawa, and Kelli R. Metz

Subjects
Male, medicine.medical_specialty, medication regimen complexity, hypertension, Colorado, comorbidities, Cohort Studies, medicine, Humans, Pharmacology (medical), Dosing, Medical prescription, Intensive care medicine, Retrospective Studies, Pharmacology, Medical Audit, MRCI, diabetes, business.industry, Medical record, geriatric depression, HIV, Retrospective cohort study, Cross-Sectional Studies, Pill, Cohort, Chronic Disease, Female, business, Medication list, Cohort study
Abstract

BackgroundExpected treatment effectiveness from medications can be diminished due to suboptimal adherence. Medication nonadherence has been linked to pill burden from the quantity of medications; however, medication regimens with similar quantities of medications vary in complexity due to multiple dosage forms, frequency of dosing, and additional usage directions. Thus, a simple medication count ignores medication regimen complexity, especially as it pertains to a patient-level perspective that includes prescription and over-the-counter medications. A gap exists in the study of a patient-level medication regimen complexity metric across disease-specific populations.ObjectiveThe goal of this study was to implement the quantitative Medication Regimen Complexity Index (MRCI) at the patient level in defined populations with chronic disease (geriatric depression, HIV, diabetes mellitus, and hypertension). Patient-level medication regimen complexity included all prescribed medications and over-the-counter medications documented in the electronic medication list.MethodsUsing electronic medical records at the University of Colorado Hospital ambulatory clinics, we sampled 4 retrospective cohorts of adult patients in active care in 2011 with a qualifying medical diagnosis and prescribed disease-specific medication. Samples were randomly selected from all qualifying patients; de-identified information was coded using the MRCI.ResultsCohort-defining disease-specific prescription medications (eg, antidepressants for the depression-defined cohort) contributed

Published
2012

112. Polypharmacy and Medication Regimen Complexity as Risk Factors for Hospitalization Among Residents of Long-Term Care Facilities: A Prospective Cohort Study.

Author

Lalic S, Sluggett JK, Ilomäki J, Wimmer BC, Tan EC, Robson L, Emery T, and Bell JS

Subjects
Aged, Aged, 80 and over, Australia, Female, Humans, Male, Prospective Studies, Risk Factors, Homes for the Aged, Hospitalization, Polypharmacy
Abstract

Objectives: To investigate the association between polypharmacy and medication regimen complexity with time to first hospitalization, number of hospitalizations, and number of hospital days over a 12-month period., Design: A 12-month prospective cohort study., Participants and Setting: A total of 383 residents of 6 Australian long-term care facilities (LTCFs)., Measurements: The primary exposures were polypharmacy (≥9 regular medications) and the 65-item Medication Regimen Complexity Index (MRCI). Cox proportional hazards regression was used to compute hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between polypharmacy and MRCI with time to first hospitalization. Poisson regression was used to compute incident rate ratios (IRR) and 95% CIs for the association between polypharmacy and MRCI with number of hospitalizations and number of hospital days. Models were adjusted for age, sex, length of stay in LTCF, comorbidities, activities of daily living, and dementia severity., Results: There were 0.56 (95% CI 0.49-0.65) hospitalizations per person-year and 4.52 (95% CI 4.31-4.76) hospital days per person-year. In adjusted analyses, polypharmacy was associated with time to first hospitalization (HR 1.84; 95% CI 1.21-2.79), number of hospitalizations (IRR 1.51; 95% CI 1.09-2.10), and hospital days per person-year (IRR 1.39; 95% CI 1.24-1.56). Similarly, in adjusted analyses a 10-unit increase in MRCI was associated with time to first hospitalization (HR 1.17; 95% CI 1.06-1.29), number of hospitalizations (IRR 1.15; 95% CI 1.06-1.24), and hospital days per person-year (IRR 1.19; 95% CI 1.16-1.23)., Conclusions: Polypharmacy and medication regimen complexity are associated with hospitalizations from LTCFs. This highlights the importance of regular medication review for residents of LTCFs and the need for further research into the risk-to-benefit ratio of prescribing in this setting., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Published
2016
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113. Cross-cultural Adaptation and Validation of the Medication Regimen Complexity Index Adapted to Spanish.

Author

Saez de la Fuente J, Such Diaz A, Cañamares-Orbis I, Ramila E, Izquierdo-Garcia E, Esteban C, and Escobar-Rodríguez I

Subjects
Aged, Aged, 80 and over, Female, Humans, Male, Patient Discharge, Pharmacists, Psychometrics, Reproducibility of Results, Surveys and Questionnaires, Clinical Protocols, Cross-Cultural Comparison, Pharmaceutical Preparations administration & dosage
Abstract

Background: The most widely used validated instrument to assess the complexity of medication regimens is the Medication Regimen Complexity Index (MRCI)., Objective: This study aimed to translate, adapt, and validate a reliable version of the MRCI adapted to Spanish (MRCI-E)., Methods: The cross-cultural adaptation process consisted of an independent translation by 3 clinical pharmacists and a backtranslation by 2 native English speakers. A reliability analysis was conducted on 20 elderly randomly selected patients. Two clinical pharmacists calculated the MRCI-E from discharge treatments and 2 months later. For the validity analysis, the sample was augmented to 60 patients. Convergent validity was assessed by analyzing the correlation between the number of medications; discriminant validity was stratified by gender; and predictive validity was determined by analyzing the ability to predict readmission and mortality at 3 and 6 months., Results: The MRCI-E retained the original structure of 3 sections. The reliability analysis demonstrated an excellent internal consistency (Cronbach's α=0.83), and the intraclass correlation coefficient exceeded 0.9 in all cases. The correlation coefficient with the number of medications was 0.883 ( P<0.001). No significant differences were found when stratified by gender (3.6; 95%CI=-2.9 to 10.2; P=0.27). Patients who were readmitted at 3 months had a higher MRCI-E score (10.7; 95%CI=4.4 to 17.2; P=0.001). The differences remained significant in patients readmitted at 6 months, but differences in mortality were not detected., Conclusions: The MRCI-E retains the reliability and validity of the original index and provides a suitable tool to assess the complexity of medication regimens in Spanish.

Published
2016
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114. Do we prescribe what patients prefer? Pilot study to assess patient preferences for medication regimen characteristics

Author

Walter E. Haefeli, Diana Witticke, Hanna M. Seidling, and Hans-Dieter Klimm

Subjects
medication regimen complexity, Pediatrics, medicine.medical_specialty, business.industry, Health Policy, patient perception, Alternative medicine, Medicine (miscellaneous), Patient preference, Patient perceptions, Medication regimen, Patient Preference and Adherence, Ambulatory care, medicine, adherence, Intensive care medicine, business, Pharmacology, Toxicology and Pharmaceutics (miscellaneous), Social Sciences (miscellaneous), Original Research
Abstract

Diana Witticke,1,2 Hanna Marita Seidling,1,2 Hans-Dieter Klimm,3 Walter Emil Haefeli1,21Department of Clinical Pharmacology and Pharmacoepidemiology, 2Cooperation Unit Clinical Pharmacy, 3Department of General Practice and Health Service Research, University of Heidelberg, Heidelberg, GermanyBackground: The aim of this pilot study was to evaluate patients' self-reported attitudes towards medication-related factors known to impair adherence and to assess their prevalence in ambulatory care as an essential prerequisite to improve patient adherence.Methods: We conducted a face-to-face interview with 110 primary care patients maintained on at least one drug. For each drug, the patient was asked to specify medication-related factors of interest, ie, dosage form, dosage interval, required relationship with food intake, and the planned time of day for intake, and to rate the individual relevance of each prevalent parameter on a three-point Likert scale (discriminating between prefer, neutral, and dislike).Results: Tablets with a once-daily dosage frequency were the most preferred dosage form, with a high prevalence in the ambulatory setting. Drug intake in the morning and evening were most preferred, and drug intake at noon was least preferred, but also had a low prevalence in contrast with drug intake independent of meals that was most preferred. Interestingly, only one quarter (26.4%) of all the patients were able to indicate clear preferences or dislikes.Conclusion: When patients are asked to specify their preferences for relevant medication regimen characteristics, they clearly indicated regimens that have been associated with better adherence in earlier studies. Therefore, our results suggest that adaptation of drug regimens to individual preferences might be a promising strategy to improve adherence. Because the German health care system may differ from other systems in relevant aspects, our findings should be confirmed by evaluation of patient preferences in other health care systems. Once generalizability of the study results is shown, these findings could be a promising basis upon which to promote patient adherence right from the beginning of drug therapy.Keywords: patient perception, medication regimen complexity, adherence

Published
2012

115. Medication Regimen Complexity and Polypharmacy as Factors Associated With All-Cause Mortality in Older People: A Population-Based Cohort Study.

Author

Wimmer BC, Bell JS, Fastbom J, Wiese MD, and Johnell K

Subjects
Activities of Daily Living, Aged, Aged, 80 and over, Cohort Studies, Female, Humans, Male, Middle Aged, Proportional Hazards Models, Pharmaceutical Preparations administration & dosage, Polypharmacy
Abstract

Objectives: To investigate whether medication regimen complexity and/or polypharmacy are associated with all-cause mortality in older people., Methods: This was a population-based cohort study among community-dwelling and institutionalized people ≥60 years old (n = 3348). Medication regimen complexity was assessed using the 65-item Medication Regimen Complexity Index (MRCI) in 10-unit steps. Polypharmacy was assessed as a continuous variable (number of medications). Mortality data were obtained from the Swedish National Cause of Death Register. Cox proportional hazard models were used to compute unadjusted and adjusted hazard ratios (HRs) and 95% CIs for the association between regimen complexity and polypharmacy with all-cause mortality over a 3-year period. Subanalyses were performed stratifying by age (≤80 and>80 years), sex, and cognition (Mini-Mental State Examination [MMSE] <26 and ≥26)., Results: During follow-up, 14% of the participants (n = 470) died. After adjusting for age, sex, comorbidity, educational level, activities of daily living, MMSE, and residential setting, a higher MRCI was associated with mortality (adjusted HR = 1.12; 95% CI = 1.01-1.25). Polypharmacy was not associated with mortality (adjusted HR = 1.03; 95% CI = 0.99-1.06). When stratifying by sex, both MRCI and polypharmacy were associated with mortality in men but not in women. MRCI was associated with mortality in participants ≤80 years old and in participants with MMSE ≥26 but not in participants >80 years old or with MMSE <26., Conclusion: Regimen complexity was a better overall predictor of mortality than polypharmacy. However, regimen complexity was not predictive of mortality in women, in participants >80 years old, or in those with MMSE<26. These different associations with mortality deserve further investigation., (© The Author(s) 2015.)

Published
2016
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116. Clinical Outcomes Associated With a Collaborative Pharmacist-Endocrinologist Diabetes Intense Medical Management "Tune Up" Clinic in Complex Patients.

Author

Morello CM, Christopher ML, Ortega L, Khoan J, Rotunno T, Edelman SV, Henry RR, and Hirsch JD

Subjects
Aged, Ambulatory Care Facilities, Disease Management, Female, Glycated Hemoglobin analysis, Humans, Male, Middle Aged, Pharmacists, Physicians, Retrospective Studies, Diabetes Mellitus, Type 2 drug therapy, Patient Care Team organization & administration, Pharmaceutical Services organization & administration, Quality Assurance, Health Care
Abstract

Background: No previous studies exist examining the impact of a short-term pharmacist-endocrinologist collaborative practice model on glycemic control in complex patients., Objective: Evaluate outcomes associated with a PharmD-Endocrinologist Diabetes Intense Medical Management (DIMM) "tune up" clinic for complex patients., Methods: A retrospective cohort study of 99 patients referred to DIMM clinic versus a comparator group of 56 primary care provider (PCP) patients meeting the same criteria (adult type 2 diabetes patients, glycosylated hemoglobin [A1C] ≥ 8%, follow-up visit within 6 months) in a Veterans Affairs Medical Center. DIMM clinic used a short-term model that coupled personalized clinical care with real-time, patient-specific diabetes education during two to four 60-minute visits over 6 months. PCP patients received usual care. Primary outcome was mean A1C change after 6 months. Secondary measures included fasting blood glucose, lipids, blood pressure, weight, body mass index, and percentage of patients meeting goals., Results: Patients in each group had an average of 8 and were taking 12 to 14 medications daily. Mean A1C (%) improvement in DIMM group was significantly greater at 6 months (-2.4 [SD = 2.1] vs -0.8 [SD = 1.7]; P < 0.001), than PCP group. Percentage meeting A1C goal levels (<7%, <8%, and <9%) was significantly greater at 3 and 6 months compared with baseline in the DIMM group (P < 0.001) versus (only <8%) at 3 and 6 months compared with baseline in PCP group., Conclusions: The DIMM clinic "tune up" model demonstrates a successful collaborative practice which helped complex diabetes patients achieve glycemic control in a 6-month period., (© The Author(s) 2015.)

Published
2016
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117. Patient-Level Medication Regimen Complexity in Patients With HIV.

Author

Metz KR, Fish DN, Hosokawa PW, Hirsch JD, and Libby AM

Abstract

Background: Patients with HIV often have multiple medications besides antiretrovirals (ARV). Medication regimen complexity-formulations, dosing frequencies, and additional directions-expands pill burden by considering self-care demands. Studies show an inverse association between ARV adherence and medication complexity for ARVs only. Patient-level medication regimen complexity beyond ARV complexity is unknown., Objective: To measure and characterize Patient-level Medication Regimen Complexity Index (pMRCI) and Antiretroviral Medication Regimen Complexity Index (ARCI) for patients in 2 HIV clinics. We hypothesized that an all-medication complexity metric will exceed disease-state-defined complexity metrics; for ARVs only, the pMRCI score will be smaller than the ARCI score by capturing fewer features of regimens. Associations between complexity and adherence were not assessed., Method: Electronic records supplied a retrospective, random sample of adult patients with HIV; medication lists were used to code the pMRCI (n=200). A random subsample (n=66) was coded using ARCI for ARV regimens only., Result: Medication counts ranged from 1 to 27; pMRCI scores ranged from 2 to 67.5. ARVs contributed roughly 25% to the pMRCI; other prescriptions contributed about 66%. Dosing frequency made the largest contribution of all components (62%) to the pMRCI. For ARVs, pMRCI and ARCI scores did not differ statistically., Conclusion: Unique dosing frequencies raised complexity and may provide opportunities for intervention. Other prescriptions drove pMRCI scores, suggesting that HIV management programs should review all medications. A patient-level approach added value to understanding the role of medications in patient complexity; future work can assess association of pMRCI with adherence and patient outcomes., (© The Author(s) 2014.)

Published
2014
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118. Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People.

Author

Wimmer BC, Dent E, Bell JS, Wiese MD, Chapman I, Johnell K, and Visvanathan R

Abstract

Background: Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization., Objective: To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period., Method: The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period., Result: Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78)., Conclusion: Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions., (© The Author(s) 2014.)

Published
2014
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119. Medication regimen complexity and hospital readmission for an adverse drug event.

Author

Willson MN, Greer CL, and Weeks DL

Subjects
Adult, Aged, Case-Control Studies, Drug Utilization statistics & numerical data, Humans, Middle Aged, Patient Discharge statistics & numerical data, Drug-Related Side Effects and Adverse Reactions epidemiology, Hospitalization statistics & numerical data, Patient Readmission statistics & numerical data
Abstract

Background: Adverse drug events (ADEs) are costly, dangerous, and often preventable. Little is known about the link between medication regimen complexity and rehospitalization as a result of an ADE., Objective: The objective of this study was to compare admission and discharge medication regimen complexity in 2 cohorts: patients readmitted for an ADE within 30 days and patients not readmitted for an ADE., Methods: The study used a retrospective parallel-group case-control design. Participants from 4 urban acute care hospitals were included in the revisit cohort if they were rehospitalized within 30 days as a result of an adverse event coded as accidental poisoning. The no-revisit cohort was formed by randomly sampling patients with the same disease classification codes as the revisit group but without history of a readmission within 30 days. Complexity of medication regimens at the initial admission and discharge was quantified with the medication regimen complexity index (MRCI)., Results: The revisit group comprised 92 individuals and the no-revisit group, 228. The revisit group had a significantly higher MRCI score at admission and discharge than the no-revisit group (all P < .005). Receiver operating characteristic curves, used to determine a potential MRCI cutoff score for risk of an ADE, revealed MRCI scores of 8 or greater to optimally predict increased risk for readmission caused by an ADE., Conclusions: Complex medication regimens at hospital admission are predictive of rehospitalizations for ADEs. This finding suggests that medication regimen complexity be considered as a target for interventions to decrease the risk for readmission.

Published
2014
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