More than one third of Medicare beneficiaries receiving home health (HH) nursing services take at least one potentially inappropriate medication (PIM), and many take more than one, a study has shown. The use of these medications significantly increases the risk for hospitalization and rehospitalization in this population.
The results suggest home health episodes represent an opportunity to reduce the use of medications that are known to be risky in older adults and, by so doing, reduce the likelihood of hospitalization.
Matthew C. Lohman, PhD, from the Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, and colleagues report their findings in an article published online August 28 in the Journal of General Internal Medicine.
The researchers conducted a cross-sectional analysis of data for Medicare beneficiaries who began receiving HH nursing services between 2013 and 2014, using data from 132 HH agencies.
The researchers used the Beers criteria, which describe medications that should generally be avoided in older adults because the adverse event risk outweighs the clinical benefit, to identify PIMs.
Of 87,780 patients in the study sample, 30,168 (34.4%) were taking at least one PIM at or within the first 3 days of the start of care. “The most common PIMs were benzodiazepines, followed by medications with analgesic, cardiovascular, and anticholinergic effects,” the authors note.
Of the full study population, 11,457 (13.1%) patients were hospitalized within the first month of starting HH care. In an adjusted analysis, patients who were taking at least one PIM had an approximately 6% greater risk (risk ratio, RR, 1.06; 95% confidence interval [CI], 1.03 – 1.10) compared with no PIM use. The risk for hospitalization increased with the number of PIMs. Compared with no PIM use, taking one PIM increased the likelihood of hospitalization within 30 days by 11% (RR, 1.11; 95% CI, 1.07 – 1.16), whereas the use of two or more PIMs increased it by 21% (RR, 1.21; 95% CI, 1.12 – 1.30).
Similar risk levels were associated with nearly all the individual PIMs except nonsteroidal anti-inflammatory drugs. “In descending order of magnitude, patients taking gastrointestinal, anti-infective, glandular, benzodiazepines, or anticholinergic medications had between 33% and 10% greater risk of hospitalization than patients not taking PIMs in those respective classes,” the authors write.
Nonsteroidal anti-inflammatory drug use was associated with a significantly reduced hospitalization risk (RR, 0.81; 95% CI, 0.75 – 0.87), and when excluded from the analysis, the risk for hospitalization associated with PIM use doubled (RR, 1.13; 95% CI, 1.09 – 1.17), the authors report.
An analysis of a subset of patients (n = 35,638) who were referred to HH from a hospital showed a rehospitalization risk associated with PIM use that was “similar in both direction and magnitude” to the hospitalization risk, the researchers state.
“Together, these findings suggest that adequate consideration and management of medications remain important elements of care for medically vulnerable older adults, and represent potential targets for efforts to reduce hospitalizations,” they write.
In addition, the increased hospitalization risk associated with PIM use in this population “highlights the shared role of hospitals and HH agencies in reducing medication-related issues,” they note. “As most PIM use originated prior to HH, our findings suggest that reducing PIM prescribing in hospitals is an important step toward reducing their prevalence in HH.”
The authors point to the critical role HH nurses can play in improving communication between hospitals, HH agencies, and other providers. “For instance, HH nurses may assist in documenting and communicating the rationale for certain medications,” they write.
The authors have disclosed no relevant financial relationships.
J Gen Intern Med. Published online August 28, 2017. Abstract
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