Effect of a pharmacist-led multicomponent intervention focussing on the medication monitoring phase to prevent potential adverse drug events in nursing homes

OBJECTIVES: To determine the extent to which the use of a clinical informatics tool that implements prospective monitoring plans reduces the incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

DESIGN: Randomized cluster trial.

SETTING: Twenty-five nursing homes serviced by two long-term care pharmacies.

PARTICIPANTS: Residents living in nursing homes during 2003 (1,711 in 12 intervention; 1,491 in 13 usual care) and 2004 (1,769 in 12 intervention; 1,552 in 13 usual care).

INTERVENTION: The pharmacy automatically generated Geriatric Risk Assessment MedGuide (GRAM) reports and automated monitoring plans for falls and delirium within 24 hours of admission or as part of the normal time frame of federally mandated drug regimen review.

MEASUREMENTS: Incidence of potential delirium, falls, hospitalizations potentially due to adverse drug events, and mortality.

RESULTS: GRAM triggered monitoring plans for 491 residents. Newly admitted residents in the intervention homes experienced a lower rate of potential delirium onset than those in usual care homes (adjusted hazard ratio (HR)=0.42, 95% confidence interval (CI)=0.35–0.52), overall hospitalization (adjusted HR=0.89, 95% CI=0.72–1.09), and mortality (adjusted HR=0.88, 95% CI=0.66–1.16). In longer stay residents, the effects of the intervention were attenuated, and all estimates included unity.

CONCLUSION: Using health information technology in long-term care pharmacies to identify residents who might benefit from the implementation of prospective medication monitoring care plans when complex medication regimens carry potential risks for falls and delirium may reduce adverse effects associated with appropriate medication use.

The back 2 activity trial: education and advice versus education and advice plus a structured walking programme for chronic low back pain.:education and advice versus education and advice plus a structured walking programme for chronic low back pain

BACKGROUND: Current evidence supports the use of exercise-based treatment for chronic low back pain that encourages the patient to assume an active role in their recovery. Walking has been shown it to be an acceptable type of exercise with a low risk of injury. However, it is not known whether structured physical activity programmes are any more effective than giving advice to remain active.

METHODS/DESIGN: The proposed study will test the feasibility of using a pedometer-driven walking programme, as an adjunct to a standard education and advice session in participants with chronic low back pain. Fifty adult participants will be recruited via a number of different sources. Baseline outcome measures including self reported function; objective physical activity levels; fear-avoidance beliefs and health-related quality of life will be recorded. Eligible participants will be randomly allocated under strict, double blind conditions to one of two treatments groups. Participants in group A will receive a single education and advice session with a physiotherapist based on the content of the 'Back Book'. Participants in group B will receive the same education and advice session. In addition, they will also receive a graded pedometer-driven walking programme prescribed by the physiotherapist. Follow up outcomes will be recorded by the same researcher, who will remain blinded to group allocation, at eight weeks and six months post randomisation. A qualitative exploration of participants' perception of walking will also be examined by use of focus groups at the end of the intervention. As a feasibility study, treatment effects will be represented by point estimates and confidence intervals. The assessment of participant satisfaction will be tabulated, as will adherence levels and any recorded difficulties or adverse events experienced by the participants or therapists. This information will be used to modify the planned interventions to be used in a larger randomised controlled trial.

DISCUSSION: This paper describes the rationale and design of a study which will test the feasibility of using a structured, pedometer-driven walking programme in participants with chronic low back pain.

TRIAL REGISTRATION: [ISRCTN67030896].

Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients

Background: Previous studies have not demonstrated a consistent association between potentially inappropriate medicines (PIMs) in older patients as defined by Beers criteria and avoidable adverse drug events (ADEs). This study aimed to assess whether PIMs defined by new STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) criteria are significantly associated with ADEs in older people with acute illness.

Methods: We prospectively studied 600 consecutive patients 65 years or older who were admitted with acute illness to a university teaching hospital over a 4-month interval. Potentially inappropriate medicines were defined by both Beers and STOPP criteria. Adverse drug events were defined by World Health Organization–Uppsala Monitoring Centre criteria and verified by a local expert consensus panel, which also assessed whether ADEs were causal or contributory to current hospitalization. Hallas criteria defined ADE avoidability.Wecompared the proportions of patients taking Beers criteria PIMs
and STOPP criteria PIMs with avoidable ADEs that were causal or contributory to admission.

Results: A total of 329 ADEs were detected in 158 of 600 patients (26.3%); 219 of 329 ADEs (66.6%) were considered causal or contributory to admission. Of the 219 ADEs, 151(68.9%)considered causal or contributory to admission were avoidable or potentially avoidable. After adjusting for age, sex, comorbidity, dementia, baseline activities of daily living function, and number of medications, the likelihood of a serious avoidable ADE increased significantly when STOPP PIMs were prescribed (odds ratio, 1.847; 95% confidence interval [CI], 1.506-2.264; P.001); prescription of Beers criteria PIMs did not significantly increase ADE risk (odds ratio, 1.276; 95% CI, 0.945-1.722; P=.11).

Conclusion: STOPP criteria PIMs,unlike Beers criteria PIMs, are significantly associated with avoidable ADEs in older people that cause or contribute to urgent hospitalization.

Dialogic Evidence: Documentation of Ephemeral Events

Performance and documentation have long been characterised as oppositional practices, separated by competing voices which argue the virtues of disappearance and reproducibility. In response to this state of affairs, the recently completed Dialogic Evidence project was designed to explore the possibility (and the limits) of a productive co-existence between performance and documentation practices. In this paper I reflect on this project’s processes and outcomes, particular highlighting the potential of social web technologies as a collaborative means to archive, discuss and remember live performance.

Children’s Reasoning About the Temporal Order of Past and Future Events

Four- and five-year-olds completed two sets of tasks that involved reasoning about the temporal order in which events had occurred in the past or were to occur in the future. Four-year-olds succeeded on the tasks that involved reasoning about the order of past events but not those that involved reasoning about the order of future events, whereas 5-year-olds passed both types of tasks. Individual children who failed the past-event tasks were not particularly likely to fail the more difficult future-event tasks. However, children's performance on the reasoning tasks was predictive of their performance on a task assessing their comprehension of the terms “before” and “after.” Our results suggest that there may be a developmental change over this age range in the ability to flexibly represent and reason about the before-and-after relationships between events.

Extreme events and the morphodynamics of gravel-dominated coastal barriers: Strengthening uncertain ground

The long-term morphodynamic ordering of gravel-dominated coastal systems (GDCS), many of which serve as coastal defences in northwest Europe, is dominated by extreme events that generate barrier crest overflow. An understanding of this morphodynamic ordering is fraught with several unresolved difficulties. These are related to the twin problems of the inadequacy of pertinent morphodynamic parameterisation and of obtaining data from modern shores enabling such parameterisation. Major uncertainties concern the timing of over-crest flow in terms of return period of extreme elevation; the intensity and structure of the overflow field; antecedent beachface characteristics in response to storms; the rate of relative sea-level change; tidal stage control; and barrier resistance to forcing, itself determined by a number of unknowns including barrier form and size, sediment size and mosaics, and barrier resilience. While generalised extreme value modelling may provide a means of characterising overwashing return-period and its variability, exceptional tsunami events are outside the scope of such modelling. The characterisation of GDCS morphodynamics in terms of the forcing extreme events will necessitate integrating some or all of these parameters into a single model.

Predictions of large events on a spring-block model

We study the predictability of a theoretical model for earthquakes, using a pattern recognition algorithm similar to the CN and M8 algorithms known in seismology. The model, which is a stochastic spring-block model with both global correlation and local interaction, becomes more predictable as the strength of the global correlation or the local interaction is increased.

The spatial distribution of Holocene cryptotephras in north-west Europe since 7 ka: implications for understanding ash fall events from Icelandic eruptions

We present distribution maps for all cryptotephras (distal volcanic ash layers) younger than 7 ka that have been reported from three or more lakes or peatlands in north-west Europe. All but one of the tephras originates from Iceland; the exception has been attributed to Jan Mayen. We find strong spatial patterning in tephra occurrence at the landscape scale; most, but not all of the tephra occurrences are significantly spatially clustered, which likely reflects atmospheric and weather patterns at the time of the eruptions. Contrary to expectations based on atmospheric modelling studies, tephras appear to be at least as abundant in Ireland and northern Scotland as in Scandinavia. Rhyolitic and other felsic tephras occur in lakes and peatlands throughout the study region, but andesitic and basaltic tephras are largely restricted to lake sites in the Faroe Islands and Ireland. Explanations of some of these patterns will require further research on the effects of different methodologies for locating and characterizing cryptotephras. These new maps will help to guide future investigations in tephrochronology and volcanic hazard analysis.