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Observational Study
. 2017 Feb 7;166(3):157-163.
doi: 10.7326/M16-0551. Epub 2016 Dec 6.

Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study

Joshua M Thorpe  1 , Carolyn T Thorpe  1 , Walid F Gellad  1 , Chester B Good  1 , Joseph T Hanlon  1 , Maria K Mor  1 , John R Pleis  1 , Loren J Schleiden  1 , Courtney Harold Van Houtven  1
Affiliations
Observational Study

Dual Health Care System Use and High-Risk Prescribing in Patients With Dementia: A National Cohort Study

Joshua M Thorpe et al. Ann Intern Med. .

Abstract

Background: Recent federal policy changes attempt to expand veterans' access to providers outside the Department of Veterans Affairs (VA). Receipt of prescription medications across unconnected systems of care may increase the risk for unsafe prescribing, particularly in persons with dementia.

Objective: To investigate the association between dual health care system use and potentially unsafe medication (PUM) prescribing.

Design: Retrospective cohort study.

Setting: National VA outpatient care facilities in 2010.

Participants: 75 829 veterans with dementia who were continuously enrolled in Medicare from 2007 to 2010; 80% were VA-only users, and 20% were VA-Medicare Part D (dual) users.

Measurements: Augmented inverse propensity weighting was used to estimate the effect of dual-system versus VA-only prescribing on 4 indicators of PUM prescribing in 2010: any exposure to Healthcare Effectiveness Data and Information Set (HEDIS) high-risk medication in older adults (PUM-HEDIS), any daily exposure to prescriptions with a cumulative Anticholinergic Cognitive Burden (ACB) score of 3 or higher (PUM-ACB), any antipsychotic prescription (PUM-antipsychotic), and any PUM exposure (any-PUM). The annual number of days of each PUM exposure was also examined.

Results: Compared with VA-only users, dual users had more than double the odds of exposure to any-PUM (odds ratio [OR], 2.2 [95% CI, 2.2 to 2.3]), PUM-HEDIS (OR, 2.4 [CI, 2.2 to 2.8]), and PUM-ACB (OR, 2.1 [CI, 2.0 to 2.2]). The odds of PUM-antipsychotic exposure were also greater in dual users (OR, 1.5 [CI, 1.4 to 1.6]). Dual users had an adjusted average of 44.1 additional days of any-PUM exposure (CI, 37.2 to 45.0 days).

Limitation: Observational study design of veteran outpatients only.

Conclusion: Among veterans with dementia, rates of PUM prescribing are significantly higher among dual-system users than with VA-only users.

Primary funding source: U.S. Department of Veterans Affairs.

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Figures

Appendix Figure 1.
Appendix Figure 1.
Rule-out sensitivity analysis for any-PUM exposure. Area above the curve represents values of the levels of confounding necessary to produce the observed OR (2.2). Area below the curve represents levels of confounding that would not be sufficient on their own, after adjustment for observed confounders, to produce the observed ORs. For example, the dashed lines indicate that an unobserved confounder would need to have a relative risk of greater than 7.0 with PUM exposure and an OR of 6.0 or greater with dual use of the VA and Medicare Part D to nullify the observed adjusted OR of 2.2. ACB = Anticholinergic Cognitive Burden; any-PUM = includes exposure to PUM-HEDIS, PUM-ACB, and PUM-antipsychotic; HEDIS = Healthcare Effectiveness Data and Information Set; OR = odds ratio; PUM = potentially unsafe medication; PUM-ACB = daily exposure to drugs that have a cumulative ACB scale score of ≥3; PUM-antipsychotic = any prescription for antipsychotic medication; PUM-HEDIS = exposure to any high-risk drug based on the 2010 HEDIS list of potentially harmful drugs in older adults; VA = U.S. Department of Veterans Affairs.
Appendix Figure 2.
Appendix Figure 2.
Predicted probability of PUM exposure, by the proportion of all VA prescriptions. Error bars represent 95% CIs. ACB = Anticholinergic Cognitive Burden; Any-PUM = includes exposure to PUM-HEDIS, PUM-ACB, and PUM-antipsychotic; HEDIS = Healthcare Effectiveness Data and Information Set; PUM = potentially unsafe medication; PUM-ACB = daily exposure to drugs that have a cumulative ACB scale score of ≥3; PUM-antipsychotic = any prescription for antipsychotic medication; PUM-HEDIS = exposure to any high-risk drug based on the 2010 HEDIS list of potentially harmful drugs in older adults; VA = U.S. Department of Veterans Affairs; A. Any-PUM exposure. B. PUM-HEDIS exposure. C. PUM-ACB exposure. D. PUM-antipsychotic exposure.
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References

    1. World Health Organization. Dementia: A Public Health Priority. Geneva, Switzerland.
    1. Cooley SG, Asthana S. Dementia care for veterans: Enhancing comprehensive, coordinated services. Generations. 2011;34(42):57–63.
    1. U.S. Department of Health and Human Services. Healthy People 2020. Washington, DC: Office of Disease Prevention and Health Promotion; 2012.
    1. Callahan CM, Boustani MA, Unverzagt FW, Austrom MG, Damush TM, Perkins AJ, et al. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. JAMA. 2006;295(18):2148–57. - PubMed
    1. Bynum JP, Rabins PV, Weller W, Niefeld M, Anderson GF, Wu AW. The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. J Am Geriatr Soc. 2004;52(2):187–94. - PubMed

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