Dementia and Risk of Adverse Warfarin-Related Events in the Nursing Home Setting
ABSTRACT Little attention has been focused on the safety of medications administered to treat non illnesses in nursing home residents with dementia. It is unclear whether this population is at increased risk of adverse drug events.
To test the hypotheses that in nursing home residents with dementia prescribed warfarin have less time in therapeutic range and a higher incidence of nonpreventable and preventable adverse warfarin events compared to nursing home residents without dementia after controlling for facility and patient characteristics.
A prospective cohort embedded in a clinical trial of nursing home residents prescribed warfarin in 26 nursing homes in Connecticut was observed for up to 12 months. The primary outcome measures included adverse warfarin events (AWEs) (injuries resulting from warfarin use), potential AWEs (INR [international normalized ratio] >4.5 and management error), and AWE preventability based on physician reviews of medical record abstractions. Potential confounders included nursing home structural characteristics (eg, number of beds and for-profit status), nursing staff time, and nursing home regulatory deficiencies (pharmacy, administrative, quality of care, and all other deficiencies). Multivariable Poisson regression analysis was used to determine the independent association of dementia with potential and preventable AWEs using generalized estimating equations to account for clustering within nursing homes.
Residents with dementia had no difference in the number of INR monitoring tests or percentage of days in the therapeutic range, but did have an increased risk of AWEs (adjusted incidence rate ratio [IRR], 1.47; 95% confidence interval [CI], 1.20-1.82), and preventable or potential AWEs (adjusted IRR, 1.36; 95% CI, 1.06-1.76) after adjustment for patient characteristics, nursing home quality, and case mix. Greater nursing staff time was protective for preventable and potential AWEs (adjusted IRR, 0.66; 95% CI, 0.48-0.90) but not for nonpreventable AWEs.
A diagnosis of dementia was associated with increased risk of nonpreventable and preventable or potential AWEs. Greater nursing staff time was associated with lower risk of preventable AWEs. These findings have implications for quality-of-care reporting and patient safety.
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ABSTRACT: In 2013, the forum gesundheitsziele.de selected "reduction of alcohol consumption" and "patient safety" as new health targets. Besides the two selected targets, three other topics were considered: health at work, health during pregnancy and childbirth, and health and migration. This paper describes the selection process, which followed several criteria: mortality, morbidity, prevalence, burden of disease, economic impact, potential for improvement, equity in health, empowerment of and priorities of health problems in the population. The analysis particularly focused on the assessment of the feasibility and the readiness of stakeholders to participate in the development and implementation of health targets.Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitsschutz 09/2013; 56(9):1329-34. DOI:10.1007/s00103-013-1805-3 · 1.01 Impact Factor
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ABSTRACT: Importance Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients’ goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.Objectives To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.Design, Setting, and Participants Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.Main Outcomes and Measures Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.Results Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.Conclusions and Relevance Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.JAMA Internal Medicine 09/2014; 174(11). DOI:10.1001/jamainternmed.2014.4103 · 13.25 Impact Factor