Wright Rollin M, Sloane Richard, Pieper Carl F, Ruby-Scelsi Christine, Twersky Jack, Schmader Kenneth E, Hanlon Joseph T
Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Am J Geriatr Pharmacother. 2009 Oct;7(5):271-80. doi: 10.1016/j.amjopharm.2009.11.002.
Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood.
The aims of this work were to assess the prevalence of medication underuse and to determine whether polypharmacy or comorbidity was associated with medication underuse among physically frail older veterans transitioning from the hospital to the community.
This was a cross-sectional analysis of patients who were discharged from 11 US veterans' hospitals to outpatient care, based on data from the Geriatric Evaluation and Management Drug Study, a substudy of the Veterans Affairs Cooperative Study of geriatric evaluation and management. Patients were enrolled between August 31, 1995, and January 31, 1999. To qualify for the study, patients had to be aged > or =65 years, hospitalized in a medical or surgical ward for >48 hours, and meet > or =2 of the following criteria: moderate functional disability; recent cerebrovascular accident with residual neurological deficit; history of > or =1 fall in the previous 3 months; documented difficulty with walking (ie, requiring personal assistance or equipment), not including preadmission use of a wheelchair with ability to transfer to and from chair independently; malnutrition (admission serum albumin of 3.5 g/dL, <80% of ideal body weight, or recent > or =15-lb weight loss reported in admission history); dementia; depression; documented diagnosis of new fracture or revision needed of older fracture; unplanned admission within 3 months of previous admission; and prolonged bed rest. Clinical pharmacist/physician pairs reviewed medical records and medication lists and independently applied the Assessment of Underutilization (AOU) index to determine omissions of indicated medications. Discordances in index ratings were resolved during clinical consensus conferences. The primary outcome measure was the percentage of patients with > or =1 medication omission detected by the AOU. Multivariable logistic regression analyses identified factors associated with underuse.
A total of 384 patients were included in the study. The majority (53.6%) were between the ages of 65 and 74 years, and the mean (SD) Charlson comorbidity index was 2.44 (1.93). Overall, 374 patients (97.4%) were men and 274 (71.4%) were white. Medication undertreatment occurred in 238 participants (62.0%). Diseases of the Accepted for publication October 26, 2009. circulatory, endocrine/nutritional, musculoskeletal, and respiratory systems were the most commonly undertreated conditions. The indicated medications most likely to be omitted were nitrates for those with a history of myocardial infarction, multivitamins in those with malnutrition, and inhaled anticholinergics for chronic obstructive airways disease. Statistically significant factors associated with medication underuse included limitations in activities of daily living (adjusted odds ratio [AOR], 2.17 [95% CI, 1.27-3.71]; P = 0.01), being white (AOR, 1.70 [95% CI, 1.06-2.71]; P = 0.03), and Charlson comorbidity index (AOR, 1.13 for each 1-point increase [95% CI, 1.00-1.27]; P = 0.04). Discharge from a general medicine service as opposed to a surgical service was associated with lower risk of medication underuse (AOR, 0.61 [95% CI, 0.38-0.98]; P = 0.04).
Medication underuse was relatively common in this study. Patients with greater comorbidity, but not polypharmacy, had increased odds of undertreatment.
药物治疗不足，即未使用对疾病管理有潜在益处的药物，在老年人中很常见，但人们对此了解甚少。
本研究旨在评估药物治疗不足的发生率，并确定多重用药或共病是否与从医院过渡到社区的身体虚弱的老年退伍军人的药物治疗不足有关。
这是一项横断面分析，基于老年评估与管理药物研究的数据，该研究是退伍军人事务部老年评估与管理合作研究的子研究，研究对象为从11家美国退伍军人医院出院并接受门诊治疗的患者。患者于1995年8月31日至1999年1月31日入组。为符合研究条件，患者年龄须≥65岁，在医疗或外科病房住院超过48小时，并符合以下至少2项标准：中度功能残疾；近期脑血管意外伴残留神经功能缺损；过去3个月内有≥1次跌倒史；有行走困难记录（即需要个人协助或使用设备），不包括入院前使用轮椅且能够独立上下轮椅的情况；营养不良（入院时血清白蛋白<3.5 g/dL、<理想体重的80%或入院记录中有近期≥15磅体重减轻）；痴呆；抑郁；有新骨折诊断记录或需要对陈旧性骨折进行翻修；在前次入院后3个月内非计划入院；以及长期卧床休息。临床药剂师/医生对审查病历和用药清单，并独立应用药物治疗不足评估（AOU）指数来确定是否遗漏了指示用药。在临床共识会议期间解决指数评级的不一致问题。主要结局指标是AOU检测到有≥1种药物遗漏的患者百分比。多变量逻辑回归分析确定了与治疗不足相关的因素。
本研究共纳入384例患者。大多数（53.6%）年龄在65至74岁之间，Charlson共病指数的平均值（标准差）为2.44（1.93）。总体而言，374例患者（97.4%）为男性，274例（71.4%）为白人。238名参与者（62.0%）存在药物治疗不足。循环系统、内分泌/营养系统、肌肉骨骼系统和呼吸系统疾病是最常治疗不足的疾病。最有可能被遗漏的指示用药是心肌梗死病史患者的硝酸盐类药物、营养不良患者的多种维生素以及慢性阻塞性气道疾病患者的吸入性抗胆碱能药物。与药物治疗不足相关的具有统计学意义的因素包括日常生活活动受限（调整后的优势比[AOR]，2.17[95%置信区间，1.27 - 3.71]；P = 0.01）、白人（AOR，1.70[95%置信区间，1.06 - 2.71]；P = 0.03）以及Charlson共病指数（每增加1分的AOR，1.13[95%置信区间，1.00 - 1.27]；P = 0.04）。与外科服务相比，从普通内科服务出院与药物治疗不足风险较低相关（AOR，0.61[95%置信区间，0.38 - 0.98]；P = 0.04）。
本研究中药物治疗不足相对常见。共病较多但非多重用药的患者治疗不足的几率增加。
