Pharmacotherapeutic Management and Care Transitions among Nursing Home Residents with Atrial Fibrillation

Abstract

Nursing home (NH) residents are a vulnerable population who experience a high rate of transitions across care settings. This population is also at risk for adverse drug events, given their multimorbidity and polypharmacy. However, the relationship between the quality of medication use and transitions in this population is unknown. This study investigates this relationship in the context of atrial fibrillation (AFIB), as pharmacotherapeutic management of AFIB, especially the use of warfarin, can be problematic, and poor management of AFIB can result in hospitalization. This study has three specific aims, all conducted among long-stay NH residents with AFIB: 1) To describe and identify factors associated with pharmacotherapeutic management of AFIB in the NH; 2) To quantify changes in pharmacotherapeutic management for AFIB across a hospital transition; 3) To determine the bidirectional relationship between quality of AFIB management and hospital transitions. This study used 2006-2009 Medicare administrative data, the NH Minimum Dataset, and NH facility data. The first and third aims used a nonconcurrent prospective cohort design with monthly measures of medication use and hospitalizations. The second aim used a pre-post design to compare medication use before and after a hospitalization. The cohort comprised 16,174 older, long-stay NH residents with AFIB, contributing 219,571 person-months of observation. Forty-eight percent were receiving any antithrombotic, of which warfarin was a majority (78.0%). Among person-months with warfarin use, 84.3% had regular INR monitoring. Approximately 12% of hospitalized individuals experienced a change in their antithrombotic regimen. A hospitalization was associated with 28% higher odds of warfarin use but 29% lower odds of INR monitoring. Conversely, warfarin use was associated with 10% lower odds of any hospitalization, but not with an AFIB-related hospitalization. INR monitoring was not significantly associated with hospitalization. Results from this study suggest that targeting clinicians to increase adherence to management guidelines for chronic conditions such as AFIB and expanding medication reconciliation interventions can improve the quality of care for NH residents and avoid unnecessary care transitions.