Publications

BACKGROUND: Hospitalized older adults are commonly discharged with changes to antihypertensive and glucose-lowering (cardiometabolic) medications. Though adverse drug events remain a leading cause of readmissions, there is little contemporary data on how medication discharge planning is communicated and how often medication errors occur post-discharge.

OBJECTIVE: To assess older adults' post-hospital medication use and ambulatory follow-up after receiving cardiometabolic medication changes during hospitalization.

DESIGN: Prospective cohort study from 11/2022 to 01/2024.

PARTICIPANTS: Adults aged 65 years or older from discharged home from an academic medical center with changes to pre-admission cardiometabolic medications.

MAIN MEASURES: Participants completed 7- and 90-day telephonic surveys on health status, medication use, and discharge planning. Self-report of medication use was compared to discharge summaries to identify medication errors (not initiating, not stopping, or taking incorrect dose). Multivariable regression models were used to identify characteristics associated with errors.

KEY RESULTS: The cohort included 151 participants (median [IQR] age 74 [70-78] years; 54% male; 17% Black, 82% White, 41% frail). Participants were admitted with a median (IQR) of 3 (2-4) cardiometabolic medications and discharged with a median (IQR) of 2 (1-4) medication changes. Of the 319 individual medications changed at discharge, 33% were further modified by 90 days. Participants reported comprehensive medication discharge planning for only 13% of medication changes. Though 93% of participants reported they understood the purpose of each of their medications at discharge, 39% had ≥ 1 medication errors at 7 days and 50% at 90 days. Use of ≥ 5 cardiometabolic medications was associated with higher rates of medication errors at 7 days (IRR 1.63; 95% CI 1.07-2.48) and 90 days (IRR 1.66; 95% CI 1.13-2.45).

CONCLUSIONS: Most hospitalized older adults discharged with cardiometabolic medication changes experienced medication errors or gaps in discharge planning. Steps to ensure all patients receive high-quality medication discharge planning are needed.

OBJECTIVES: It is unclear how long youth with opioid use disorder (OUD) should continue taking buprenorphine, and what adherence they should achieve. We identified patterns of duration/adherence and assessed associations with subsequent overdose, emergency department (ED) use, and hospitalization.

METHODS: This retrospective cohort analysis used 2014-2022 data from the Massachusetts Public Health Data Warehouse. We identified youth aged 13 to 26 years initiating buprenorphine and used group-based trajectory modeling to categorize youth into duration/adherence trajectories over 12 months. Using multivariable Cox regression, we examined associations between trajectories and time to fatal/nonfatal opioid overdose, all-cause ED use, and all-cause hospitalization during the subsequent 12-month period.

RESULTS: Among 11 649 Massachusetts youth initiating buprenorphine, most were aged 21 years or older (89.0%), male (60.3%), white non-Hispanic (85.9%), and enrolled in Medicaid (55.4%). We identified 4 patterns of medication use: (1) high adherence for 12 months (23.7%); (2) low adherence for 12 months (27.5%); (3) discontinuation in 3 to 9 months (16.4%); and (4) discontinuation in less than 3 months (32.5%). Trajectories included 580 (5.0%) and 774 (6.6%) youth switching to methadone and naltrexone, respectively. Compared with high adherence for 12 months, overdose risk was higher with low adherence for 12 months (adjusted hazard ratio [aHR], 1.46; 95% CI, 1.24-1.73), discontinuation in 3 to 9 months (aHR, 1.82; 95% CI, 1.52-2.17), and discontinuation in less than 3 months (aHR, 1.76; 95% CI 1.50-2.06). Compared with high adherence, low adherence and discontinuation in less than 3 months had higher risk of ED use, and all other trajectories had higher risk of hospitalization.

CONCLUSIONS: Medication adherence may prevent overdose, ED use, and hospitalization. Strategies to increase treatment duration/adherence likely avert harm.

BACKGROUND: Prescribing rates and adherence to evidence-based cardiometabolic medications remain suboptimal. Many strategies to improve prescribing and adherence have been developed, among which pharmacy care management (PCM) programs are among the most consistently effective. Data on PCM programs come from studies that developed interventions specifically for research purposes. Benefits of real-world PCM programs for patients with cardiometabolic conditions are incompletely understood.

OBJECTIVE: To evaluate the effect of an existing PCM program in individuals with cardiometabolic conditions, specifically, whether the program improved adherence to cardiometabolic medications and reduced all-cause and cardiometabolic-specific health care use and whether those nonadherent at baseline would benefit most.

METHODS: We conducted a retrospective cohort study using adjudicated administrative claims data from a large regional Medicare Advantage Prescription Drug health plan. A total of 27,910 beneficiaries were identified as potentially eligible for the PCM program between December 2019 and November 2021. The cohort was restricted to individuals who filled at least 2 prescriptions for a cardiometabolic condition, filled at least 1 prescription after PCM enrollment, and were continuously eligible for health plan benefits for at least 12 months before and after enrollment. Potential controls met the same criteria but did not participate in the PCM program and filled prescriptions at non-PCM pharmacies. Control and PCM patients were matched 5:1 using direct and propensity score matching. The primary outcome was all-cause hospitalization over 12 months. Secondary outcomes included cardiometabolic medication adherence and disease-specific hospitalizations. We further evaluated program effects on rates of disease-specific hospitalization in patients nonadherent vs adherent at baseline.

RESULTS: 632 PCM patients were matched to 3,160 controls. PCM program participants had significantly greater improvements in adherence to all cardiometabolic medication classes, with difference-in-difference estimates ranging from 4.7% (P = 0.028) for anticoagulants to 17.0% (P < 0.001) for beta blockers. PCM program participants had 15% less all-cause hospitalizations per 1,000 patient months (P = 0.037) and experienced significantly fewer cardiometabolic-specific admissions (-33.7%; P = 0.025) and nonsignificant reductions in noncardiometabolic admissions (-8.4%; P = 0.201). PCM patients nonadherent at baseline had a significant 39.1% reduction in cardiometabolic hospitalizations (P = 0.003), whereas adherent patients had a nonsignificant 24.7% reduction (P = 0.286).

CONCLUSIONS: Compared with well-matched controls, PCM patients with cardiometabolic disease had significantly higher rates of medication adherence and significantly lower hospitalization rates during the 12-month follow-up period. This effect was greatest in patients nonadherent at baseline. Our results provide insights into how PCM programs achieve their benefits and underscore the value of targeting the PCM program to high-risk individuals.

Clostridioides difficile infection (CDI) guidelines advise against repeat testing within 7 days. This retrospective study identified factors associated with 7-day repeat testing. Attending physicians (aOR = 0.67) and advanced practice practitioners (aOR = 0.61) ordered fewer repeat tests compared to residents. Further research is necessary to address inappropriate repeat testing.

BACKGROUND: High-risk medications such as opioids and benzodiazepines are frequently prescribed in pediatric dental care, yet their prescribing patterns and associated adverse outcomes remain poorly understood. The aim of this study was to determine the extent of such prescribing to pediatric patients and factors associated with adverse outcomes.

METHODS: MarketScan data for patients younger than 18 years with a dental visit from 2014 through 2019 were analyzed. High-risk medications included benzodiazepines, barbiturates, and opioids. Composite outcomes included hospitalization, emergency department visit, or urgent care visit within 7 days after the dental visit. Opioid-attributable outcomes included opioid-related overdose within 7 days or persistent opioid use 4 through 365 days after the visit. Generalized estimating equations assessed the association between outcomes and patient and visit characteristics.

RESULTS: Among pediatric dental visits, 0.72% (n = 269,991) involved high-risk medications, with 4.3% experiencing a composite outcome. Higher odds were observed in ages 9 through 11 years (odds ratio [OR], 1.56), male patients (OR, 1.05), patients with complex chronic conditions (OR, 2.22), and care delivered in hospital or ambulatory surgery settings (OR, 2.20). Among dental visits with opioids, 10.1% had an opioid-attributable outcome, with the highest odds in patients 4 through 5 years (OR, 1.48), female patients (OR, 1.08), patients with complex chronic conditions (OR, 1.22), and care delivered in outpatient clinics (OR, 1.43).

CONCLUSIONS: One in 10 pediatric dental visits involving opioids was associated with opioid-related overdose or persistent use, with the highest odds in young children. These results highlight the need for caution in opioid prescribing and providing guideline-based nonopioid analgesia to children.

PRACTICAL IMPLICATIONS: Promote safer, equitable pediatric dental prescribing through guideline adherence, nonopioid pain management, and provider training.

Benzodiazepines are potentially inappropriate medications for older adults, and deprescribing interventions are needed. We describe the development of a psychologist-led, mindfulness-informed cognitive-behavioural therapy (CBT) intervention to pair with pharmacist-led tapering to support benzodiazepine deprescribing in older adults. Based on previous research, we first developed an intervention conceptual model. The aim of this study was to (1) gather stakeholder feedback on previous experiences with benzodiazepine tapering and on our intervention model and proposed intervention, and (2) integrate this qualitative feedback to develop an intervention manual. We conducted (a) semistructured individual interviews with older adults (N = 8) who previously attempted to taper their benzodiazepines, and (b) a focus group with members (N = 5) from a national deprescribing patient stakeholder group. Overlapping themes emerged, including support for the mindfulness-informed CBT intervention, the importance of control over taper pace, the need for a goal- and skills-oriented intervention, the importance of normalizing side effects of the taper and building confidence to manage side effects and the utility of fostering acceptance during the taper. These findings informed the development of a final intervention manual, named Confidence-Building Strategies for Reducing Sedative Medications (CSTARS), to be tested in a single-arm pilot feasibility trial.