Diss. (sammanfattning) Uppsala : Uppsala universitet, 2009. / Härtill 4 uppsatser.

Antipsychotic medications are effective in the treatment of psychotic disorders. Monotherapy (MT) with antipsychotics is consistently recommended as the treatment of choice by several guidelines yet antipsychotic polypharmacy (APP) is widespread in clinical practice. The objectives of this study were to evaluate the incidence of APP, identify predictors of APP, and compare adherence, health resource utilization, and costs between patients on MT and APP using prescription and medication claims from Texas Medicaid (2006 to 2011). Patients newly initiated on antipsychotics were followed for 12 months and categorized into the APP (exposure to two or more antipsychotics for a defined time interval) and MT (no evidence of APP during the study period) groups. This sample of patients was used to evaluate incidence and predictors of APP and compare medication adherence and persistence between the MT and APP groups using multiple, logistic, and Cox proportional hazards regressions. Patients in the MT and APP groups were then matched based on their duration of exposure to antipsychotics and all-cause healthcare utilization and costs were compared using logistic and generalized linear models regression (negative binomial, Poisson, and gamma). Regression analyses for patients matched on duration of antipsychotic exposure accounted for the correlation between matched pairs. The incidence of APP was 5.4%. Several demographic, clinical, physician, and prior utilization characteristics were associated with APP. Medication adherence and persistence were better in the APP group. Length of hospital stay and medical, drug, and total costs were higher for the APP group. Sensitivity analyses were conducted for psychiatric-related costs and varied overlap and gap periods. The results for most of the sensitivity analyses were similar to the base case. Patients prescribed APP had higher medical, drug and total costs and also higher healthcare utilization i.e. increased drug costs were not offset by decreased medical costs. Long-term APP raises concern as state Medicaid agencies are allocating their limited resources to this expensive treatment which has very scarce data supporting its use. More effectiveness research on APP is needed to help provide prescription guidance to clinicians for patients who do not respond well to treatment with a single antipsychotic. / text

Class of 2014 Abstract / Specific Aims: To create and implement an educational presentation on polypharmacy using interactive strategies. Secondly, to assess the effectiveness of the interventional presentation by evaluating its helpfulness in improving polypharmacy awareness among older adults as measured by a retrospective pre-post participant survey. Methods: Residents of select independent senior living facilities in Tucson, Arizona were invited to attend an interactive, educational program entitled "What is Polypharmacy?" presented by fourth-year Doctor of Pharmacy students. This program consisted of a 30-minute PowerPoint presentation, which included various interactive learning approaches, followed by a 10-minute question and answer period. An anonymous retrospective pre-post survey was distributed to the participants after the presentation to evaluate the effectiveness and helpfulness of the program, as determined by the participants’ ratings on Likert-type scales and willingness to confidently engage in medication self-management. Main Results: Of the 73 participants from the six independent living facilities, 55 surveys were collected from the residents and 54 surveys were included in the data analysis. The retrospective pre-post data analysis found that familiarity with the definition of polypharmacy increased (p<0.001), understanding of the risks of polypharmacy increased (p<0.001), and the willingness to manage one’s own medications increased (p=0.045). Overall, 95.9% of the participants found this educational program to be helpful, and 95.8% of the participants would recommend this program to a friend. Conclusion: The interactive, educational program about polypharmacy, created and presented by pharmacy students, was helpful and effective in increasing polypharmacy awareness among older adults residing in independent senior living facilities.

As medical researchers test the feasibility of deprescribing programs to reduce medication burden associated with polypharmacy, limited scholarly consideration has been given to the perspectives of the older adults largely targeted by these programs. This dissertation makes central the voices of older adults experiencing polypharmacy and/or deprescribing. Presented as a collection of three articles, this work explores the perspectives of older adults on their use of medication in the context of both polypharmacy and deprescribing. Data were collected using in-depth semi-structured qualitative interviews with older adults concurrently using 5+ prescription medications. The first article draws on Habermas’ writing on the contribution of communicative action in negotiating trust within complex social relationships. This analysis highlights the social nature of medication work and challenges to communicative action within personal and professional health systems. The second article applies embodiment theory to understand the way older adults’ construct unique forms of expertise regarding their health, resulting from a lifetime of experiences living as and in their bodies. The last article uses social constructionist theories on systems of classification to show the way dichotomies in medical classifications are often paradoxical. This article offers insight into the work older adults do to optimize their use of medicines in the context of these paradoxes. This study, in its entirety, indicates a need for collective efforts to identify and address the problems of polypharmacy while facilitating appropriate polypharmacy for older adults with complex multiple co-morbidities. Doing so encourages a reframing of polypharmacy as a complex phenomenon about which clinical judgments are made through an ongoing collaboration with the patient and family. / Thesis / Doctor of Philosophy (PhD)

Thesis ((M. A. (Pharm.)) -- University of Limpopo, 2019 / Introduction: Polypharmacy is highly prevalent within the population of patients with diabetes mellitus (DM), with patients being prescribed with four or more medications with mainly preventative medications for cardiovascular complications. The increase in the prevalence of polypharmacy has a major impact on the drug expenditures. Meanwhile, the management of DM is expensive, and the cost affects individuals, families, society, health care providers, and national productivity. The largest component of financial cost is accounted for by medicines. Furthermore, with DM being the second cause of mortality rates in South Africa there is a need for cost of illness studies in order to develop intervention programs to ameliorate or prevent this lifestyle disease Objectives: To identify the medications the patient was taking that were considered as polypharmacy in the management of type 2 diabetes mellitus (T2DM), to calculate and analyse the costs of the medications and to quantify the financial burden of polypharmacy in T2DM patients. Method: This research was a quantitative study, providing the numeric description of the economic cost of polypharmacy. The financial burden of polypharmacy was retrospectively measured using descriptive statistics. The study was conducted using T2DM patient files (n=115) from the outpatient section of the pharmacy as well as from the records department whereby all DM patients’ files were retrieved by aid of a DM register from outpatient department (OPD). The data sheet enabled recording of information that was divided into three sections namely the demographic information, the diagnosis profile, as well as the medications. The cost of drugs was retrieved from the pharmacy purchase invoices for the years 2016 and 2017 as well as Department of Health medicines registry for the retail prices. Data was analysed using statistical Package for Social Sciences (SPSS) version 25 for descriptive analysis and Microsoft Excel TM was used for calculation and quantification of the financial burden. The independent t test was used in Microsoft ExcelTM for statistical significance of differences. Results: The distribution of the population by gender revealed that 68% of females were on polypharmacy as compared to 32% of males. The results also showed that majority of participants accounting 71% of the population were falling within the age xi group of 51-70 years, meanwhile the least number of participants accounting 1% of the population were between the age group of 30-40 years. The total cost of the treatment regimen for the two years of the study period was found to be R179303.50 in hospital (Mean=R35860.80, SD=R58945.15, n=115) and the possible cost of polypharmacy was found to be R1517379.00 in retail (Mean=R303475.76, SD=480115.84, n=115). The difference was statistically significant t (16) = 2.11, p=0.04 (1 tail) at 95% confidence interval. This means that the average cost per patient per year is R1558.18 and R129.93 per month in hospitals but R6597.30 per year and R549.78 per month in retail for the management of T2 DM patients who are on polypharmacy. These numbers are 4 times higher than patients who are on monotherapy. Conclusion: Polypharmacy imposes a high financial burden on the management of T2DM for the government and for patients in cases where medications like insulin which is the most costly component of five out of nine detected regimens are unavailable in hospitals and they therefore have to buy at retail pharmacies. The appreciation and understanding of these costs in real terms by health professionals and decision makers, can add value to processes of budget allocations to pharmaceutical services. Recommendations: Doctors and pharmacists should work together to optimize the quality of care for patients with T2DM but also consider the cost aspect when prescribing and dispensing treatment regimen for a patient. The patient’s prescriptions must be thoroughly reviewed and rationalised according to recent progress of the patient. Non-pharmacological management of T2DM is the mainstay of therapy and prevention so pharmacist and doctors needs to emphasize more on those rather than dispensing a lot of medications to patients that can manage to control their condition with no medications prescribed. Lastly, preventative programs for T2DM needs to be prioritized. / CHIETA and HWSETA

The focus of this research study is glycemic control in the presence of multiple morbidities and polypharmacy in homebound individuals with Type 2 diabetes aged 65 years and older. The research method is a quantitative retrospective cohort study of discharged patients of a nonprofit community-based home health agency from January 1, 2010, to December 31, 2011, using OASIS data. Glycemic control is assessed using the hA1C laboratory test following the recommendation of the American Diabetes Association. The study documents a moderate significant association between glycemic control, polypharmacy and comorbid conditions, indicating that homebound individuals with Type 2 diabetes aged 65 years and older are less likely to have optimal glycemic control in the presence of multiple morbidities and polypharmacy. There continues to be a need for scientific research in this population cohort; and the dose-response association between antidiabetic therapy interventions designed to lower blood glucose levels in the presence of chronic disease and polypharmacy.

Class of 2007 Abstract / Objectives: A prescription claims database from COPE Behavioral Services in Tucson, Arizona was used to retrospectively assess the differences between patients receiving <4 and those receiving > 4 psychotropic medications over a 12-month period in adult patients with schizophrenia. Methods: Medication groups (i.e., < 4 versus > 4 concomitant psychotropic agents) were compared for differences in gender, age, duplication of antipsychotic therapy, adherence rates, court order treatment status, psychiatric hospitalization rates and length of stay, cost of services provided, and concomitant psychotropic medications. Results: A total of 506 adult patients with schizophrenia (F=214 and M=292) met the inclusion criteria for receiving psychotropic medications during the 12-month study. Of those, 388 patients (76.7%) were found to have an average of < 4 medications, while 118 patients (23.3%) were found to have > 4 medications. Duplication of antipsychotic therapy was more common in the > 4 group (29.7%) compared to the < 4 group (3.1%), p < 0.001. Psychotropic adherence rates were significantly higher in the > 4 group based on month’s supply of prescriptions. Demographic differences between groups included: increased age, more women, fewer court order status, and higher cost of care in the > 4 compared to the < 4 medication group. No differences in hospitalizations, length of stay, and hospital costs were found between groups. Conclusions: Our findings suggest that patients with schizophrenia with increased rates of polypharmacy have higher adherence rates, more duplication of antipsychotics, and a higher cost of care (i.e., case management, laboratory, other services, total prescription costs) compared to patients receiving < 4 psychotropic medications.

Ageing and diabetes are two major healthcare concerns that used to be regarded as problems of the Western world but are now of increasing concern in developing nations. Treating elderly patients with diabetes poses issues for clinicians due to often complex, preexisting drug regimes. Research targeted at the development of novel drugs that have multiple effects on diabetes could go some way towards reducing polypharmacy in these patients. Here I present evidence that the oral Jak1/3 inhibitor, baricitinib, has effects on multiple aspects of diabetes. Baricitinib has been suggested to be a strong anti-inflammatory given the role Jak plays in transducing cytokine signals to elicit immune cell activation and maturation. Baricitinib was found to reduce urinary albumin to creatinine ratio and mesangial expansion in mice on an experimental high-fat diet with a diabetic metabolic profile when compared with naïve, non-diabetic mice. This reduction in renal impairment from diabetes was not found with a large reduction in proinflammatory cytokines and instead appears to be as a result of a direct effect on the cells of the mesangium. Baricitinib also reduced the circulating levels of cholesterol with a positive effect on the LDL: HDL ratio of diabetic mice. This reduction in cholesterol appears to be because of the abolition of GLP- 1 signalling, initiating an increase in blood insulin, preventing lipid flux and inhibiting LDL formation. Both of these changes in key diabetic complications were not accompanied by an increase in sensitivity to insulin compared with vehicle treated diabetic mice. These results show that baricitinib has a beneficial effect on two key aspects of the diabetic condition but that it does not modify insulin sensitivity itself. Baricitinib may represent a potential treatment for these diabetes-associated pathologies but only in combination with traditional anti-diabetic treatments.

With many individuals experiencing multimorbidity, individuals are being prescribed more medications. Although there are benefits to taking medications to manage symptoms and treat disease processes, there are also risks to taking multiple medications. The purpose of this phenomenological study was to explore participants' understanding of the risks associated with practicing polypharmacy. Game theory, credibility theory, and belief bias were the conceptual frameworks used to explain how individuals experienced their care and being prescribed 5 or more medications. Eight participants residing in subsidized housing in a small Midwest city, who were taking 5 or more medications volunteered to take part in semi-structured interviews answering a series of 10 questions. Phenomenological analysis was used to organize the data and to assist with the development of themes regarding the nature of the participants' lived experiences. According to study findings, 7 out of 8 participants stated that they trusted their providers and that their providers used a more directive approach to prescribing medications instead of offering choices to the participants. In addition, participants lacked knowledge of the risks associated with taking all medications collectively, indicating that more education is needed for individuals. Results of the study may be used in both provider training and patient training to stimulate social change that may improve provider patient communication, increase understanding of provider patient interactions, elicit positive patient outcomes by providing knowledge of awareness, communication, and interaction styles, which play a role in patient outcomes.

ix Objectives: To quantify polypharmacy and assess the socio-economic predictors of medication use and expenditure in diabetics. Methods: This study analyzed adult diabetes patients using a nationally representative sample in Medical Expenditure Panel Survey in 2006. Top ten most highly utilized drug classes were identified. Descriptive statistics were used to portray the patients’ medication utilization and spending. Generalized linear models were conducted to assess the socio-economic variants in drug use and spending. Results: On average, a diabetes patient had 45 prescriptions in 2006, for total annual spending of $3,161. A diabetes patient used drugs from 3.43 classes within top ten drug classes. Races and insurance coverage are associated with drug use and spending, holding other factors constant. Conclusion: Diabetes patients use multiple classes of drugs. Insurance coverage and races are related with drug spending and utilization. More research is needed to evaluate the potential risks of drug-drug interactions due to polypharmacy.