1 The potentially inappropriate medicines in heart failure tool: application in an irish long-term care setting

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Abstract

Introduction

A number of medicines have been identified as contraindicated or cautioned for use in heart failure (HF) patients as their use may lead to worsening HF or poorer prognosis. Heart failure prevalence among elderly residents of long-term care facilities may be as high as 45%. However, there are few data describing the prescription of potentially inappropriate medicines (PIMs) to HF patients residing in this setting. This study will assess the prescription of PIMs in elderly HF patients in long-term care using a disease-specific tool and identify patient factors associated with the prescription of PIMs in these patients.

Methods

This is an observational study of residents aged >65 years in 14 long-term care facilities in Cork, Ireland. HF was documented on the patient medical chart or identified by prescription of a loop diuretic. The Potentially Inappropriate Medicines in Heart Failure (PIMHF) tool was used to identify PIMs. This is a HF-specific tool that includes 11 medicines or medicine classes. Comparisons between patients were conducted using independent sample t-tests for continuous variables and chi-squared tests for categorical variables. Univariable and multivariable logistic regression was used to determine the associates of PIMHF use. The model was adjusted for age and sex and the adjusted odds ratio (OR) and 95% confidence interval (CI) were determined.

Results

The total number of residents was 732, of whom 265 (36.2%) had HF. Average age of HF patients was 84.8 ±7.4 years and 30% were male. A PIMHF item was prescribed to 74 (28.0%) HF patients. Of these, 19 (7.2%) were prescribed ≥2 PIMHF items. The most commonly prescribed PIMHF items were non-steroidal anti-inflammatory drugs (n=26); oral corticosteroids (n=21); high sodium containing formulations (n=19) and pregabalin (n=14). Residents with HF who were prescribed a PIMHF were younger than those with no PIMHF (83.6 ±7.3 vs. 85.2 ±7.4 years, p<0.001), were prescribed more medicines (13.6 ±3.3 vs.12.1 ±3.8, p<0.001), had a greater number of comorbidities (11.7±3.8 vs. 10.9±4.3, p<0.001) and were more likely to have diabetes (27.3% vs. 9.4%, p<0.001) than those who were not prescribed a PIMHF item. Residents prescribed a PIMHF item had a lower rate of loop diuretic prescription (81.0% vs. 90.1%, p=0.047) than those with no PIMHF item prescribed. In the adjusted multivariate logistic regression model, the patient characteristics significantly associated with prescription of one or more PIMHF items were: higher number of medicines (OR=1.09, 95%CI 1.01-1.18) and diabetes (OR=3.30, 95%CI 1.59-6.80).

Conclusions

In this Irish long-term care setting, more than one-in-four residents with HF was prescribed a medicine that is considered inappropriate in HF. The PIMHF tool may be of use for those prescribing or reviewing medicines in long-term care residents with HF.

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