Objective To determine the impact of an adherence packaging and medication synchronization program on hospital visits for older people living independently in the community. Design A retrospective pre-post study that evaluated patient outcomes over a 24-month period was conducted. Patient-specific socio-demographic, medical, and hospital visit-related data were collected for 12 months before and after patient enrollment in the adherence packaging program. Setting The study was conducted at Rx Partners LTC, LLC, a University of Pittsburgh Medical Center (UPMC) pharmacy in Pittsburgh, Pennsylvania. Participants Patients 65 years of age or older, of any gender, with UPMC Health Plan insurance coverage, who enrolled in the adherence packaging program between July 2019 and December 2019. Intervention Enrollment in the adherence packaging program included medication synchronization and packaging in prefilled medication sets delivered to the patient's home monthly. Monthly medication reconciliation and review by clinical pharmacists was an included value-added service. Results Of the 92 patients included in the analysis, 60 had hospital visits during their pre-enrollment period for a total of 146 visits, compared with 54 patients in the postenrollment period totaling 126 visits; however, the mean rate of hospital visits was not statistically significant (1.59 versus 1.37; P = 0.48). Pharmacists prevented 1.87 medication errors/patient in the postenrollment setting. Conclusion Enrollment in the program was associated with fewer hospital visits, though not statistically significant, and pharmacists had abundant opportunity to prevent medication errors and optimize regimens. Further evaluation is warranted in a larger cohort.

Transitions of care (TOC) is becoming an essential component of pharmacy practice, and requires problem solving that is difficult to learn in the classroom. My unique experience of interning in community and inpatient settings along with doing my own TOC research with geriatric patients has allowed me to see patients throughout the spectrum of health care, and how discrepancies arise as they move between settings. This manuscript will provide insight to pharmacy students about why TOC is a critical area for pharmacist involvement, and how we must be prepared to guide patients through these transitions as we become new practitioners.

Older people are particularly susceptible to acute kidney injury (AKI) for a variety of reasons. Because of this, medication changes during admission and transitions of care follow-up are often necessary to ensure the safety of these patients. The American Geriatrics Society's Beers Criteria provide guidance for select medications that are potentially inappropriate in the older adult population. However, other medications, particularly those for cardiovascular disease and diabetes that are not included in the kidney function-specific section of the Beers Criteria (Table 6), can sometimes be overlooked. This manuscript will provide insight to both pharmacists and student pharmacists on the importance of being vigilant for medications that may need dosage adjustment during episodes of AKI. As interns in the outpatient setting, pharmacy students can provide education to patients and their families in order to ensure these medications are being taken correctly and are properly restarted if their discontinuation was intended for only a short time.

OBJECTIVES: To describe and gather further details about the clinical and educational activities that were documented by the geriatric pharmacist resident during both weekly interprofessional Acute Care for the Elderly (ACE) rounds as well as bedside patient counseling. DESIGN: Retrospective chart review (quality improvement project). SETTING: Inpatient geriatric service at University of Pittsburgh Medical Center (UPMC). PATIENTS: Medical learners selected one complex patient from the geriatric service for ACE rounds each week. ACTIVITIES: The geriatric pharmacist resident provided clinical information and medication education to the interprofessional team and to the patient and/or family at their bedside. Activities were documented in a newly developed template. MAIN OUTCOME MEASURES: Patient demographics, medication categories, discrepancies and dosing changes, time-in-rounds, and team members. RESULTS: De-identified data from 18 patients (72.2% female, average age 82.5 ± 9.18 years) over a 6-month period were collected and analyzed. The geriatric pharmacist resident provided most education to the team on antibiotics, antidepressants, over-thecounters (OTCs), and prescription pain medications during ACE rounds. They provided most education to the patient/family on prescription pain medications, antidepressants, OTCs, and anticoagulants. The pharmacist resident identified 38 medication discrepancies (72.2% of patients had ≥ 1 discrepancy, range 0-7) and clinically significant drug-drug interactions in 15 patients. The pharmacist resident recommended dosing changes in 12 patients and therapeutic alternatives in 11 patients. The ACE rounds lasted on average 26.6 [± 6.42] minutes and included medicine, pharmacy, social work, nurse case management, nursing, and nutrition and rehabilitative services when necessary. CONCLUSION: The results provide insight into both the clinical and educational activities of the geriatric pharmacist resident in support of interprofessional rounds.

PurposePrior studies suggest that inpatient palliative care services can reduce rehospitalizations. However, medications commonly prescribed by palliative care providers (eg, opioids, benzodiazepines, and antipsychotics) have been independently associated with rehospitalizations. Little is known regarding the role of adverse drug reaction (ADR)-related rehospitalizations within the palliative care population. ObjectiveTo determine the prevalence and explore predictors of ADR-related 30-day rehospitalizations in an inpatient palliative care population. MethodsA retrospective cohort study that included 284 palliative care patients who were readmitted within 30-days of discharge from two academic hospitals in Western Pennsylvania. All unplanned rehospitalizations were assessed for medication causality via the Naranjo algorithm by at least two independent reviewers. ResultsThe mean (SD) age of the cohort was 61 (16) years and included 45% (n = 127) female and 81% Caucasians (n = 229). Of the 254 unplanned rehospitalizations, 11 (4%) were classified as doubtful ADRs, 224 (88%) were classified as possible ADRs, and 19 (7%) were defined as probable or definite ADR-related. Tacrolimus was associated with three probable and one definite ADR-related rehospitalization. Oncologic agents (eg, venetoclax, nivolumab, vincristine, and decitabine, carfilzomib; n = 5), anticoagulants (eg, rivaroxaban, apixaban, and warfarin; n = 4), antimicrobials (eg, cephalexin and vancomycin; n = 2), potassium chloride (n = 2), lorazepam (n = 1), and nicotine replacement (n = 1) were all associated with probable ADRs. Only the number of medication changes during the index admissions was observed as a statistically significant predictor of rehospitalizations in this population (P = .043). ConclusionsPalliative care patients often suffer from potential ADR-related rehospitalizations and the number of medication changes during the index hospital admissions is associated with future potential ADRs. Clinical pharmacists should consider these findings when developing initiatives to reduce rehospitalizations in the inpatient palliative care patient population.

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed. DESIGN: This study was a retrospective quality improvement project. SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center. PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications. INTERVENTIONS: Data were obtained through retrospective chart review. MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations. RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62). CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.

Though older adults are more sensitive to the effects of medications than their younger counterparts, they are often excluded from manufacturer-based clinical studies. Practice-based research is a practical method to identify medication-related effects in older patients. This research also highlights the role of a pharmacist in improving care in this population. A single study rarely has strong enough evidence to change geriatric practice, unless it is a large-scale, multisite, randomized controlled trial that specifically targets older adults. It is important to design studies that may be used in systematic reviews or meta-analyses that build a stronger evidence base. Recent literature has documented a gap in advanced pharmacist training pertaining to research skills. In this paper, we hope to fill some of the educational gaps related to research in older adults. We define best practices when deciding on the type of study, inclusion and exclusion criteria, design of the intervention, how outcomes are measured, and how results are reported. Well-designed studies increase the pool of available data to further document the important role that pharmacists have in optimizing care of older patients.

Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by . Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.

OBJECTIVE A survey was conducted by the pharmacy team to identify improvement areas in the delivery of care in high-risk patients at a patient-centered medical home (PCMH) at the University of Pittsburgh Medical Center (UPMC). DESIGN This survey was a quality improvement project. SETTING The survey was conducted at UPMC Senior Care, a level-three accredited PCMH. PATIENTS The survey was conducted in a sample of preidentified high-risk patients. INTERVENTIONS Pharmacy performed a survey, analyzed responses for common themes, and conducted follow-up phone calls to determine the degree of goal-achievement and efficacy of educational materials provided during the initial survey. MAIN OUTCOME MEASURE The primary goal for conducting the survey was to identify needed areas for improvement in three specific domains, namely, medication decisions, communication with providers, and goals of care. RESULTS Medication reviews were provided for 23 of 24 surveyed, leading to medication discrepancy resolution in 58%. Almost 80% of the respondents were satisfied with the team's communication. More than 85% of respondents verbalized the goals they wanted to achieve in three months. The follow-up phone calls were conducted in 20 of those initially surveyed. Only 5 patients did not meet their goals. The following improvement areas were identified: need to provide medication lists and correct medication inaccuracies, need for medication review, patient goals documentation, and patient education and the appropriate medium of education. CONCLUSION Future appointments for high-risk patients at the PCMH should include the pharmacist. The team should focus education on families/caregivers and utilize alternate patient education methods.

INTRODUCTION:Curricula must not only provide students with knowledge but also foster the development of critical thinking and reasoning skills. Several learning strategies, including problem-based learning (PBL), standardized patients, and high-fidelity human simulation, have been incorporated into courses; however, it is currently unknown which technique is the most effective.METHODS:This is a prospective, randomized, crossover study that was conducted during two 90-minute seizure disorder laboratory sessions for PharmD students in their third professional year. Students rotated between 3 different seizure disorder cases (A, B, and C), with each student experiencing 3 learning strategies including PBL, standardized patients, and high-fidelity human simulation. Evaluation of knowledge consisted of quizzes at the end of each case, and student perception and satisfaction were evaluated by an anonymous survey at the conclusion of the laboratory sessions.RESULTS:Student quiz scores from the simulation learning strategy were statistically better than those from the standardized interview and modified PBL (mPBL) strategies in cases A and B (P < 0.001). The student quiz scores for the standardized interview were also statistically better than the mPBL scores in case C (P = 0.001). When surveyed, 91% of students agreed or strongly agreed that simulation improved their knowledge, whereas only 69% and 67% of students agreed or strongly agreed that mPBL or standardized patients, respectively, improved their knowledge (P < 0.001).CONCLUSIONS:High-fidelity simulation is an effective learning strategy. When it is compared with standardized patients and mPBL strategies, students performed better on knowledge-based quizzes and had higher levels of satisfaction.

Background. Studies of drug-related hospitalizations have focused on adverse drug reactions, but few data are available on therapeutic failures (TFs) and adverse drug withdrawal events (ADWEs) leading to hospitalization among community-dwelling older adults. Thus, we sought to describe the prevalence of unplanned hospitalizations caused by TFs and ADWEs. In addition, we evaluated factors associated with these events in a nationally representative sample of older Veterans. Methods. This study included 678 randomly selected unplanned hospitalizations of older (age ≥ 65 years) Veterans between December 1, 2003, and November 9, 2006. The main outcomes were hospitalizations caused by a TF and/or an ADWE as determined by a pair of health professionals from review of medication charts and application of the Therapeutic Failure Questionnaire and/or Naranjo ADWE algorithm, respectively. Preventability (ie, medication error) of the admission was also assessed. Results. Thirty-four TFs and eight ADWEs involving 54 drugs were associated with 40 (5.9%) Veterans' hospitalizations; of these admissions, 90.0% (36/40) were rated as potentially preventable mostly due to medication nonadherence and suboptimal prescribing. The most common TFs that occurred were heart failure exacerbations (n = 8), coronary heart disease symptoms (n = 6), tachyarrhythmias (n = 3), and chronic obstructive pulmonary disease exacerbations (n = 3). Half (4/8) of the ADWEs that occurred were cardiovascular in nature. Multivariable logistic regression modeling indicated that black Veterans (adjusted odds ratio 2.92, 95% CI 1.25-6.80) were significantly more likely to experience a TF-related admission compared with white Veterans. Conclusions. TF-related unplanned hospitalizations occur more frequently than ADWE-related admissions among older Veterans. Almost all TFs and/or ADWEs are potentially preventable.

OBJECTIVE:A therapeutic failure (TF) is defined as a failure to accomplish the goals of treatment attributable to inadequate therapy, a drug-drug interaction that results in a subtherapeutic level for a drug, or medication nonadherence. The objective of this study was to evaluate the prevalence of and factors associated with TF-related hospitalizations in older adults.DESIGN:This investigation was a retrospective cohort study.SETTING:This study was conducted within a university-based hospital setting.PATIENTS:This investigation included patients with a primary care physician from the University of Pittsburgh Medical Center (UPMC) Senior Care Institute admitted to any UPMC hospital between September 1, 2011, and December 1, 2011.INTERVENTIONS:Chart abstracts of patient records were screened for a TF using a validated tool called the Therapeutic Failure Questionnaire (TFQ). Covariate data were also obtained. Descriptive statistics and bivariate analyses using Fisher's exact tests were conducted to assess the association between the covariates and the primary outcome.MAIN OUTCOME MEASURE(S):The primary outcome was the presence of a TF as measured by the TFQ. Secondary outcomes included associations between covariates and the presence of a TF.RESULTS:Of the 93 hospitalizations screened, 57 met inclusion criteria, and 18% of hospitalizations were as a result of preventable TFs. On bivariate analyses, both congestive heart failure (P = 0.03) and dependency for medication management (P = 0.04) were significantly associated with occurrence of TF.CONCLUSIONS:TFs are a potentially preventable cause of hospitalization in the elderly population and are commonly caused by omission of therapy.

Background. Medication use is a potentially reversible cause of urinary incontinence (UI). The objective of this longitudinal cohort study was to evaluate whether self-reported UI in community-dwelling older women is associated with the use of different classes of antihypertensive agents.Methods. The sample consisted of 959 black and white women aged 7281 years without baseline (Year 1) UI from the Health, Aging, and Body Composition Study. Use of any antihypertensive from 10 drug classes (ie, alpha blockers [central], alpha blockers [peripheral], angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, beta blockers, calcium channel blockers, diuretics [loop], diuretics [potassium-sparing], diuretics [thiazide], and vasodilators) was determined during Year 3 in-person interviews. The number of unique antihypertensive agents used and the standardized daily dosage were also examined. Self-reported UI, operationally defined as leaking urine at least weekly during the previous 12 months, was assessed at Year 4 visits.Results. A total of 197 women (20.5%) reported UI at Year 4. Although any antihypertensive use, number of agents used, and standardized daily dosage at Year 3 were not associated with UI at Year 4, use of one particular drug class-peripheral alpha blockers (ie, doxazosin, prazosin, and terazosin)-was associated with fourfold greater odds of UI (adjusted odds ratio = 4.47; 95% confidence interval = 1.79-11.21; p = .0014). Further, in post hoc analyses, these odds nearly doubled in those also taking loop diuretics (adjusted odds ratio = 8.81; 95% confidence interval = 1.78-43.53; p = .0076).Conclusion. In community-dwelling older women, peripheral alpha blocker use was associated with UI, and the odds nearly doubled when used with loop diuretics.

ObjectivesTo describe the prevalence of unplanned hospitalizations caused by adverse drug reactions (ADRs) in older veterans and to examine the association between this outcome and polypharmacy after controlling for comorbidities and other patient characteristics.DesignRetrospective cohort.SettingVeterans Affairs Medical Centers.ParticipantsSix hundred seventy‐eight randomly selected unplanned hospitalizations of older (aged ≥ 65) veterans between October 1, 2003, and September 30, 2006.MeasurementsNaranjo ADR algorithm, ADR preventability, and polypharmacy (0–4, 5–8, and ≥9 scheduled medications).ResultsSeventy ADRs involving 113 drugs were found in 68 (10%) hospitalizations of older veterans, of which 25 (36.8%) were preventable. Extrapolating to the population of more than 2.4 million older veterans receiving care during the study period, 8,000 hospitalizations may have been unnecessary. The most common ADRs that occurred were bradycardia (n = 6; beta‐blockers, digoxin), hypoglycemia (n = 6; sulfonylureas, insulin), falls (n = 6; antidepressants, angiotensin‐converting enzyme inhibitors), and mental status changes (n = 6; anticonvulsants, benzodiazepines). Overall, 44.8% of veterans took nine or more outpatient medications and 35.4% took five to eight. Using multivariable logistic regression and controlling for demographic, health‐status, and access‐to‐care variables, polypharmacy (≥9 and 5–8) was associated with greater risk of ADR‐related hospitalization (adjusted odds ratio (AOR) = 3.90, 95% confidence interval (CI) = 1.43–10.61 and AOR = 2.85, 95% CI = 1.03–7.85, respectively).ConclusionADRs, determined using a validated causality algorithm, are a common cause of unplanned hospitalization in older veterans, are frequently preventable, and are associated with polypharmacy.

OBJECTIVETo examine the prevalence and correlates of non-opioid and opioid analgesic use and descriptively evaluate potential undertreatment in a sample of community-dwelling elders with symptomatic knee and/or hip osteoarthritis (OA).DESIGNCross-sectional.SETTINGHealth, Aging, and Body Composition Study.PATIENTSSix hundred and fifty-two participants attending the year 6 visit (2002-03) with symptomatic knee and/or hip OA.OUTCOME MEASURESAnalgesic use was defined as taking ≥1 non-opioid and/or ≥1 opioid receptor agonist. Non-opioid and opioid doses were standardized across all agents by dividing the daily dose used by the minimum effective analgesic daily dose. Inadequate pain control was defined as severe/extreme OA pain in the past 30 days from a modified Western Ontario and McMaster Universities Osteoarthritis Index.RESULTSJust over half (51.4%) reported taking at least one non-opioid analgesic and approximately 10% was taking an opioid, most (88.5%) of whom also took a non-opioid. One in five participants (19.3%) had inadequate pain control, 39% of whom were using <1 standardized daily dose of either a non-opioid or opioid analgesic. In adjusted analyses, severe/extreme OA pain was significantly associated with both non-opioid (adjusted odds ratio [AOR] = 2.44; 95% confidence interval [95% CI] = 1.49-3.99) and opioid (AOR = 2.64; 95% CI = 1.26-5.53) use.CONCLUSIONSAlthough older adults with severe/extreme knee and/or hip OA pain are more likely to take analgesics than those with less severe pain, a sizable proportion takes less than therapeutic doses and thus may be undertreated. Further research is needed to examine barriers to optimal analgesic use.

The benefits and risks of drug therapy are different for older people. This primer explains how and why. Medications are among the most common types of therapy used by older adults. The goals of medication use in older adults are primarily focused on palliating symptoms or maintaining or preventing a decline in functional status. The health status of elders is not static, so there is a need for continual reassessment of drug therapy. This article highlights why the benefit and risk evaluation differs for older versus younger adults. We will also offer practical tips to share with elders about medications, specifically about the use of generic drugs, the proper disposal of medications, and the important questions older individuals should ask their physician or pharmacist about drugs they take. Knowledge Base About Medications in Elders It is often difficult to evaluate the benefits of drug therapy in older adults. One reason is because the elder population is underrepresented in randomized clinical trials, which serve as the basis for drug approval by the United States Food and Drug Administration (Cherubini et al., 2011). Randomized clinical trials are usually designed to compare an active drug with a placebo and are considered the gold standard for determining safety and efficacy of medication use. While differences in treatment versus placebo response can be expressed using statistical (P values) and epidemiological (relative risk) measures, what is most important is how many people need to be treated before a benefit can be seen (Yuan, Levitan, and Berlin, 2011). In older adults especially it can be difficult to determine the most beneficial treatments with the fewest risks because this patient population is often excluded from clinical drug trials. There are exceptions. For example, the Hypertension in the Very Elderly Trial (HYVET) evaluated the benefits of antihypertensive therapy versus placebo in the very old (eighty years or older) and found that blood pressure lowering was associated with a reduction in mortality in this population (Beckett et al., 2008). And, the placebo-controlled studies that led to the Food and Drug Administration (FDA) approval of memantine (Namenda) for Alzheimer's Disease enrolled subjects ranging from fifty to ninetythree years of age, with a mean of seventy-six years (Reisberg et al., 2003; Tariot et al., 2004). In general, however, pre-marketing studies seek homogeneous subjects to help reduce unexplained variations in the outcome measures of interest. Investigating a heterogeneous population (e.g., including older adults with multiple comorbid conditions and medications in the same study as younger, healthier subjects) may muddle the findings of a clinical trial and weaken the probability of detecting response to treatment versus placebo (Strom, 2006). Practically speaking, older adults are more likely to create an interruption in the trial when they cannot participate (because of acute hospitalization or spousal care needs), making them less desirable as subjects. Some practical barriers can be overcome (providing transportation to and from the study site for subjects with limited mobility or without access to a car); but designing a clinical trial to accommodate participants with varying needs can be costly, time-consuming, and require additional staff. For these reasons, even when elders are included in clinical trials, the subjects are often relatively healthy and have less comorbidity and a greater ability to tolerate treatment compared to their peers. As a result, the oldest old and frail elders have been grossly underrepresented in clinical trials, causing a lack of evidence for treatment benefits in the population most likely to require therapeutic intervention (Ferrucci et al., 2004). For instance, the benefits of statin medications in reducing the risk of heart attack and stroke have been studied in numerous clinical trials. …