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Parekh 2018 Incidence of medication-related harm in older adults following hospital discharge- A systematic review.pdf

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Parekh 2018 Incidence of medication-related harm in older adults following hospital discharge- A systematic review.pdf
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  REVIEW ARTICLE Incidence of Medication-Related Harm in Older Adults AfterHospital Discharge: A Systematic Review Nikesh Parekh, MPH,* †  Khalid Ali, MD,* †  Amy Page, PhD,  ‡§  Tom Roper, BA (Hons), †  and Chakravarthi Rajkumar, PhD* †  OBJECTIVES:  To determine the incidence, severity, andpreventability of and risk factors for medication-relatedharm (MRH) in community-dwelling older adults afterhospital discharge. DESIGN:  Systematic review. SETTING:  A search of Medline, EMBASE, CINAHL, andthe Cochrane Library was undertaken without timerestrictions. PARTICIPANTS:  Older adults (average age   65) partici-pating in observational studies investigating postdischargeadverse drug reactions (ADRs) or adverse drug events(ADEs) within a defined follow-up period. MEASUREMENTS:  One author screened abstracts of allarticles to exclude obviously irrelevant articles. Twoauthors independently screened the remaining articles forinclusion. Two authors independently extracted data,including study characteristics, MRH incidence, and riskfactors; a third reviewer critically appraised and verifiedthe data. Disagreements were resolved through discussion. RESULTS:  From 584 potentially relevant articles, 8 stud-ies met our inclusion criteria: 5 North American and 3European. Most of the included studies were of moderatequality. There was a wide range in MRH incidence, from0.4% to 51.2% of participants, and 35% to 59% of MRH was preventable. MRH incidence within 30 daysafter discharge ranged from 167 to 500 events per 1,000individuals discharged (17–51% of individuals). There issubstantial methodological heterogeneity across multipledomains of the studies, including ADR and ADE defini-tions, characteristics of recruited populations, follow-upduration after discharge, and data collection. CONCLUSION:  MRH is common after hospital dischargein older adults, but methodological inconsistenciesbetween studies and a paucity of data on risk factors lim-its clear understanding of the epidemiology. There is aneed for international consensus on conducting andreporting MRH studies. Data from large, multicenter stud-ies examining a range of biopsychosocial risk factors couldprovide insight into this important area of safety.  J AmGeriatr Soc 2018. Key words: systematic review; older adults; medicationharm; hospital discharge; epidemiology C utting severe, avoidable medication-related harm(MRH) in half over the next 5 years is a WorldHealth Organization (WHO) global patient safety chal-lenge  1 . MRH is often described in terms of adverse drugreactions (ADRs; noxious, unintended reactions caused bya medicine at appropriate dosage) or adverse drug events(ADEs; which include ADRs and injuries related to medi-cine use at inappropriate dosages (medical error))  2–7 . Inthis article, ADRs and ADEs are combined and calledMRH, in accordance with recent WHO terminology 1 .Older adults (  65) are a particularly high-risk popu-lation for MRH because of polypharmacy  8 and age-related pharmacokinetic and pharmacodynamics changes. 9 Approximately 10% of hospital admissions of olderadults are attributable to MRH  10 , and the incidence of MRH is increasing in Europe and the United States  11–14 ;between 2005/06 and 2013/14, the rate of U.S. emergencydepartment visits for MRH almost doubled, from 5.2 to9.7 visits per 1,000 older adults. Excess healthcare costs inthe United States due to preventable MRH to acommunity-dwelling older adult has been estimated at$2,000. 15 Reducing MRH during transitions of care is a priorityarea in the WHO’s global challenge 16 . Patients and care-givers describe the transition period around hospital From the *Academic Department of Geriatric Medicine, Brighton andSussex Medical School, Brighton, Sussex, United Kingdom;  † Departmentof Elderly Medicine, Brighton and Sussex University Hospitals NationalHealth Service Trust, Sussex, United Kingdom;  ‡ School of Medicine andPharmacology, University of Western Australia; and the  § PharmacyDepartment, Alfred Health, Melbourne, Australia.Address correspondence to Professor C. Rajkumar, Chair in Geriatric andStroke Medicine, Brighton and Sussex Medical School, Audrey Emerton Build-ing, Eastern Road, Brighton, Sussex, UK BN2 5BE. E-mail: c.rajkumar@bsms.ac.ukDOI: 10.1111/jgs.15419  JAGS 2018 V C 2018, Copyright the Authors Journal compilation V C  2018, The American Geriatrics Society 0002-8614/18/$15.00  discharge as a unique situation that presents a high riskfor the occurrence of MRH 17–19 . During this period, con-fusion and inaccuracies in medicines management com-pound the deconditioning the occurs from hospitalization,alongside ongoing recovery from illness  20 . Medicationdiscrepancies affect up to half of older adults around hos-pital discharge, 21 and administrative difficulties withreceiving medicines and poor education regarding medica-tion use can compound this situation  22 . Coordinationbetween secondary care, primary care, patients, and care-givers after hospital discharge is commonly inadequate.Based on 4 studies from the United States and Australia, arecent systematic review found that primary care physi-cians never receive 5% to 38% of discharge summaries  23 .The quality of information communicated is also problem-atic. For instance, the same review found that 40% of dis-charge summaries did not provide diagnostic test results,75% provided no information on pending tests, 22%lacked information on discharge medications, and 58%did not communicate follow-up plans.A review of medication problems that older adultsexperienced around hospital discharge was conductedalmost a decade ago 24 . Fourteen studies of medicationproblems in community and care home settings were iden-tified, including medication discrepancies, education, non-adherence, drug interactions, and MRH. The authorscould not estimate the magnitude of the problem becauseof study heterogeneity. In the meantime, despite no sys-tematic quantification of the problem, there have beennumerous interventional studies to reduce MRH in thepostdischarge period  25,26 . In view of this, we conducted asystematic review to investigate the epidemiology of MRH, in contrast to all medication problems that may ormay not cause harm. Our aim was to determine the inci-dence, severity, preventability, and risk factors, associatedwith MRH in community-dwelling older adults afterdischarge. METHODS We followed Preferred Reporting Items for SystematicReviews and Meta-Analyses guidance (SupplementaryTable S1) in conjunction with the Joanna Briggs Institutemethodological guidance for systematic reviews of obser-vational epidemiological studies 27 . Our primary objectivewas to provide a synthesis of the epidemiological data onMRH in community-dwelling older adults after hospitaldischarge. Search strategy Two authors (NP, TR) conducted an electronic search of Medline, EMBASE, CINAHL, and the Cochrane Libraryfrom their inceptions to June 2016 without restrictions.We reran this search in June 2017 looking for any newstudies. The search strategy was designed in Medline(using the Healthcare Databases Advanced Search fromthe National Institute of Health and Care Excellence)using a combination of key words and Medical SubjectHeadings (Supplementary Table S2). We subsequentlyadapted this search strategy for EMBASE and CINAHL.Key concepts in the search strategy were adverse drugreaction, elderly, and hospital discharge. For each of theseconcepts, synonyms, related terms and controlled vocabu-lary terms were selected and combined using Boolean andproximity operators and truncation to ensure that alterna-tive forms were retrieved. In addition, reference lists of rel-evant articles were scanned to identify any articles notfound in the electronic search. We also consulted the stud-ies in a review published in 2010 on a similar theme 24 ,conducted forward citation searches on this prior reviewand on studies that we identified for inclusion, and suc-cessfully corresponded with investigators of 4 includedstudies to ensure that we did not miss any articles. Selection criteria We considered all published observational studies thatevaluated MRH (ADR or ADE) in community-dwellingolder adults (average age   65) within a defined follow-upperiod after hospital discharge. We included studies inwhich the incidence or prevalence of MRH was reportedor could be calculated. Given that our objective was toestablish the extent of MRH in the general older popula-tion discharged from the hospital, we had the followingexclusion criteria: studies investigating only rehospitalizedindividuals; studies investigating only individuals with aspecific disease or condition or harms of one particularmedicine; and studies of institutionalized individuals. Outcomes Our primary outcome of interest was incidence of MRHafter discharge. Secondary outcomes included the propor-tion of serious events, preventable events, and associatedrisk factors. Study selection One author (NP) screened titles and abstracts of identifiedarticles to exclude obviously irrelevant articles (n 5 338).Two authors (NP, AP) independently screened the remain-ing papers (n 5 215), excluding those identified as reviews,interventional studies, conference proceedings, researchletters and protocol papers, articles related to a specificmedicine or condition, and articles not investigating theposthospital discharge period. The same two authors inde-pendently reviewed full-text articles of potentially eligibletitles and abstracts and selected articles according to theinclusion criteria. A third author (KA) then reviewed thesestudies to confirm their eligibility for inclusion. Any dis-agreement was resolved through discussion. Data extraction Two reviewers (NP, AP) independently extracted dataonto a standard data collection form (Table S3), which athird reviewer (KA) verified. We extracted data fromincluded articles on study year and country; study design;discharge setting; duration of follow-up; methods used fordata collection and causality assessment; and ADE and 2 2018 JAGS  ADR incidence or prevalence, severity, and preventabilityand associated risk factors. Quality assessment Two authors (NP, AP) independently assessed the qualityof included studies using the Joanna Briggs Institute criti-cal appraisal tool for prevalence studies  27 . The 9 domainsin this tool address sampling bias (target population, sam-pling, sample size, description of participants and setting),coverage bias (coverage of identified sample), measure-ment bias (methods to identify outcome, reliability in out-come measurement, appropriate statistical analysis), andnonresponse bias (response rate). Any disagreements thatarose were resolved through discussion. A risk-of-bias fig-ure was completed for included studies using RevManVersion 5.3. Copenhagen: The Nordic Cochrane Centre,The Cochrane Collaboration, 2014. Data synthesis We report the incidence proportions of MRH stated in theincluded studies. In studies in which this was not clearlystated, we calculated the incidence proportion from theavailable data (number of persons that developed MRH/ total population at risk). If the number of events withinthe population was stated, we also calculated the incidenceof events per 1,000 discharges. We have not reported inci-dence rates (in which follow-up time is incorporated intothe denominator) because this would be misleading, giventhat the risk of MRH after hospital discharge is not con-stant over time. Data were extracted on the medicineclasses commonly implicated in MRH. If this was reportedin an alternative format (e.g., mixture of medicine classesand specific medicines themselves), we categorized themedicines using the WHO Anatomical Therapeutics Cod-ing system 28 . RESULTSStudy Selection We identified 584 individual records from our searchstrategy, out of which we read 31 articles in full becausethey were deemed relevant based on their title andabstract. From this, we excluded 24 articles because theydid not meet all the inclusion criteria, and 1 additionalstudy was identified from a reference list of an article.Therefore, 8 observational studies met our inclusion crite-ria (Figure 1). Study Characteristics Study characteristics are outlined in Tables 1 and 2. Fivestudies were conducted in North America 29–33 and 3 inEurope (Netherlands 34 , Croatia, 35 France 36 ). All identifiedstudies were cohort studies (prospective, n 5 5; retrospec-tive, n 5 2), with the exception of 1 prospective Records idenfied through databases searching(n = 794)        S     c     r     e     e     n       i     n     g       I     n     c       l     u       d     e       d        E       l       i     g       i       b       i       l       i      t     y      n     o       i      t     a     c       i       f       i      t     n     e       d       I Addional records idenfied through other source (n = 1)Records screened aer duplicates removed (n = 584)Full-text arcles assessed for eligibility(n = 31)Full-text arcles excludeddue to focus on medicaon issues other than MRH i.e. polypharmacy(n=3), inappropriate prescribing(n=3), medicaon discrepancies(n=3), paent knowledge(n=1), risk factors (n=1); averageparcipant age <65(n=6); hospital-based study (n=4); alternave analysis of included arcle (n=1); not specific to post-discharge period (n=2)Studies included for systemac synthesis(n = 8)Records excluded due to irrelevance of tle and abstract (n=338); review paper, intervenonal study, conference proceedings, research leers, protocol paper (n=79); arcle related to specific medicine or condion (n=67); study not invesgang period post-hospital discharge (n=69) Figure 1.  Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram for included studies.  JAGS 2018 3      T   a    b    l   e    1 .    C    h   a   r   a   c   t   e   r    i   s   t    i   c   s   o    f    I   n   c    l   u    d   e    d    S   t   u    d    i   e   s 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    U   n    i    t   e    d    S    t   a    t   e   s    P   r   o   s   p   e   c    t    i   v   e   c   o    h   o   r    t    O   n   e    h   o   s   p    i    t   a    l   ;   w   a   r    d   s   n   o    t   r   e   p   o   r    t   e    d    3    0    3    1    2    8    0       6     7 .    3    R   e   c   e    i   v    i   n   g    h   o   m   e   n   u   r   s    i   n   g   c   a   r   e .    E   x   c    l   u   s    i   o   n   s   :    t   e   r   m    i   n   a    l    l   y    i    l    l ,   r   e   c   e   n    t   m   y   o   c   a   r    d    i   a    l    i   n    f   a   r   c    t    i   o   n   o   r   c   e   r   e    b   r   o   v   a   s   c   u    l   a   r   a   c   c    i    d   e   n    t ,    d   e   m   e   n    t    i   a   w    i    t    h   o   u    t   c   a   r   e   g    i   v   e   r   a    t    h   o   m   e ,   n   o   n   a   m    b   u    l   a    t   o   r   y     M   e    d    i   c   a   t    i   o   n  -   r   e    l   a   t   e    d    h   a   r   m    (    M    R    H    )   w   a   s   a   s   u    b   c   a   t   e   g   o   r   y   o    f   a    d   v   e   r   s   e   e   v   e   n   t   s    i   n    1   s   t   u    d   y        2       9    a   n    d   o    f    d   r   u   g  -   r   e    l   a   t   e    d   p   r   o    b    l   e   m   s    i   n    2        3       3  ,       3       4  .    A    D    R     5    a    d   v   e   r   s   e    d   r   u   g   r   e   a   c   t    i   o   n   ;    A    D    E     5    a    d   v   e   r   s   e    d   r   u   g   e   v   e   n   t   ;    G    P     5    g   e   n   e   r   a    l   p   r   a   c   t    i   t    i   o   n   e   r . 4 2018 JAGS
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