Explicit definitions to identify preventable drug-related morbidity in an elderly population and their use as an indicator of quality in the medication use

165 Pages·2001·6.4 MB·English

by  Faris, Richard Joseph.

EXPLICITDEFINITIONSTOIDENTIFYPREVENTABLEDRUG-RELATED
MORBIDITYINANELDERLYPOPULATIONANDTHEIRUSEASAN
INDICATOROFQUALITYINTHEMEDICATIONUSESYSTEM
By
RICHARDJOSEPHFARIS
ADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOL
OFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENT
OFTHEREQUIREMENTSFORTHEDEGREEOF
DOCTOROFPHILOSOPHY
UNIVERSITYOFFLORIDA
2001
Copyright2001
By
RICHARDJOSEPHFARIS
Thisdissertationisdedicatedtomylovelywife,LeanneandwonderfulsonSeth. Thank
youforyourlove,supportandacceptance,regardlessofthecircumstances.
Iwouldalsoliketodedicatethisdissertationto3familymemberswhopassedaway
whileIwascompletingthisprocess;RichardJ.Faris,MargaretCalamandVirgilA.
Minor. ThelateRichardJ.Farisismygrandfatherandnamesake. Iamtrulyproudto
carryonhisname. ThelateMargaretCalamismygrandmother. Throughthesimple
gameofcheckers,shetaughtmeearlythattherearenoeasyvictories. ThelateVirgilA.
Minoristhefatherofmywifeandistrulymissed. Iwisheachofyoucouldbehereto
shareinthisaccomplishment.
ACKNOWLEDGMENTS
Iwouldliketoacknowledgemydissertationchair,Dr.CharlesD.Hepler,forall
histimeandpatiencewithmethroughthisprocess. Thedepthofmygratitudeisbeyond
words. Ihavetrulylearnedalotandgrownasaperson. Ihavegainedamentoranda
friendandIhopethatIcancarryonhishighstandardforresearchandwriting.
Ithankthemembersofmysupervisingcommitteefortheirhardworkand
patience. IthankDrs.RichardSegalandEarleneLipowskifortheirfriendshipand
guidancethroughtheprogram. TheirsupporthasbeeninvaluableandsomethingIwill
alwaystreasure. IthankDr.DavidMillerforshowingmethereismoretostatisticsthan
mathematicalequations! Hehassparkedmylearningintheapplicationofmeasurement.
IacknowledgetheAmericanFoundationforPharmaceuticalEducationfortheir
supportofmyeducationthroughthefellowshipprogram. Ialsoacknowledgethesupport
ofMerckandCompanyfortheirfinancialsupportofmyresearch.
IwouldliketoacknowledgetheworkandfriendshipofDr.NeilMacKinnon. I
havestoodonhisshouldersinthiswork.
IwouldliketoacknowledgeDr.GeorgeMayzellandDeborahSwartwoodfor
theirsupportandguidancefromthemanagedcareproviderperspective.
IacknowledgeDebbieSirota,BrendaHudsonandJohnWegenkafortheirefforts
withmydissertation. Eachplayedakeyroleinmydissertationinareasthatcouldhave
causedgreatconfusionwithouttheirinvolvement.
IV
Dr.TimFolsehasbeenabrotherandfriendthroughoutthisprocess. Iamgladhe
gottoshareinthisresearchwithme!
Ihavehadtheblessingofwonderfulmentorsinmyprevioustraining. Dr.
MickeyC.Smith,BruceScott,BobWilliams,andMikeFlagstadhaveinvestedtimeand
efforttopreparemetobealeader. IwouldliketoacknowledgeWilliamGreene. Imiss
workingwithandlearningfromhim!
IthankDanielAshbyfortakingachanceonme-twice! Iappreciatehis
friendship,effortandunwaveringsupportinmycompletionofthisdegree. Hehasgiven
methelatitudetocompletethisimportantchapterinmylife.
IwouldliketoacknowledgePatandLindaAmersonfortheirloveandsupportto
myfamilythroughthisprocess. IhavebeenblessedtohaveGod'speoplecareforusas
theyhave.
Thanksgotomyfamilyforalltheirloveandsupport. ToMom,Dad,Nath,Bob,
Tara,Jim,Mark,andSusanIsay,"itisdone"! Withoutthem,Iwouldnothaveachieved
thishonor.
Withoutfaith,Ihavenothing. TomyLordandSavior,thanksforgivingmethe
mind,strength,andperseverancetofinishthisprocess. Ipraythattheworkdoneand
futureopportunitieswillbringglorytoYourName.
Last,butcertainlynotleast,Isaythankyoutomylovingwife,Leanne,andson,
Seth. Theyhavetrulybeenaninspiration. Whenthetimesappeareddarkandthetrail
withoutend,theyweretheretoencourage. LeannedeservesthishonorfarmorethanI
do. Iwishhernamecouldreplacemine.
TABLEOFCONTENTS
page
ACKNOWLEDGMENTS iv
ABSTRACT xi
CHAPTERS
1INTRODUCTION 1
TheNeedfortheStudy 1
ProblemStatement 4
StudyObjectives 5
ResearchQuestions 5
ResearchQuestion1 5
ResearchQuestion2 6
ResearchQuestion3 6
ResearchQuestion4 6
ResearchQuestion5 6
ResearchQuestion6 6
ResearchQuestion7 6
2REVIEWOFLITERATUREANDFRAMEWORK 7
MedicationUse 7
ImpactofDrug-RelatedMorbidity 8
Cost 8
Quality 9
Access 10
PreventabilityofDrug-RelatedMorbidity 10
QualityAssessmentandImprovement 12
Structure,ProcessandOutcome 13
RootCauseAnalysis 14
TheMedicationUseSystem 15
DefiningandMeasuringDrug-RelatedMorbidity 16
AdverseDrugReactions 16
MedicationErrors 19
AdverseDrugEvents 20
Drug-RelatedMorbidity 21
vi
StudyPopulations 23
Measurement 24
Implicit 24
StructuredImplicit 25
Explicit 26
UseofComputerDatabases 27
Validity 29
TriarchicValidity 30
Messick'sValidityFramework 31
PreventableDrug-RelatedMorbidityandValidity 33
NumberofMedications 33
NumberofPrescribers 34
CardiovascularDrugs 34
Gender 34
NumberofDiagnoses 34
Age 34
HealthCareResourceUtilizationandCost 35
3METHODOLOGY 36
Introduction 36
PhaseI:DefiningPreventableDrug-RelatedMorbidity 36
DelphiPanel 36
MacKinnon'sDefinitions 37
PhaseII:OperationalizingDefinitions 38
MedicalEventCoding 39
MedicationCoding 40
PhaseIII:MeasurementofPreventableDrug-RelatedMorbidityandValidity 41
StudyPeriodandPopulation 41
ManagedCareDatabase 42
DataFields 42
StudyVariables 44
Preventabledrug-relatedmorbidity 44
Riskfactors 44
Healthcareresourceuseandcosts 44
PhaseIV:RootCauseAnalysis 45
StatisticalAnalysis 46
PreventableDrug-RelatedMorbidity 46
FactorsAssociatedWithValidity 46
Riskfactorsasconfirmatoryhypotheses 46
Resourceuseasconfirmatoryhypotheses 47
PatternofCareandOutcomeAnalysis 48
DaysBetweenthePatternofCareandOutcome 48
Process-To-OutcomeValue 50
vn
4RESULTS 51
Overview 51
GeriatricMedicineExpertPanel 51
Mnemonics 52
MacKinnon'sDefinitionsAcceptedbythePanel 52
MacKinnon'sRejectedDefinitions 53
DelphiPanelSurveyResults 55
IndividualPanelMemberVotingResults 56
DisqualificationofPanelMember 57
OperationalizationofDefinitions 58
MedicalEventCoding 58
PhysicianReviewofCodes 59
PreventableDrug-RelatedMorbidityMeasurement 59
StudyPopulation 59
PreventableDrug-RelatedMorbidity 59
PatternofCareandOutcomeMeasurement 60
DaysBetweenPatternofCareandOutcome 62
AdjustedDaysforPreventableDrug-RelatedMorbidity 63
PatientsWiththePatternofCareAfterAdjustment 65
Process-To-OutcomeValue 65
ConfirmatoryHypotheses 66
RiskFactors 66
ResourceUtilizationandCost 68
RootCauseAnalysis 68
5DISCUSSION 70
Introduction 70
GeriatricMedicineExpertPanel 70
ReplicationofMacKinnon'sWork 70
Consensus-ApprovedDefinitions 71
Evidence-BasedMedicineandthePanel 72
PanelDevelopedExplicitDefinitionsVersusImplicitJudgement 73
ThePanelandPreventabilityFramework 73
Operationalization 75
Measurement 75
PrevalenceofPreventableDrug-RelatedMorbidity 75
ComparisonofPDRMDetectionWithMacKinnon'sStudy 76
DefinitionsWithNoEventsScreenedPositive 78
PatternofCareandOutcomeAssessment 79
Process-To-OutcomeValue 80
DefinitionsWithaLowPTOV 82
PreventableDrug-RelatedMorbidityasanExtensionofDrugUseEvaluation 83
ValidityofaMeasureofPreventableDrug-RelatedMorbidity 85
EvidentiaryBasisforInterpretation 85
viii
1
Faceandcontentvalidity 85
Riskfactors 86
Resourceuse 86
EvidentialBasisforUse 87
Rootcauseanalysis 88
ConsequentialBasisforInterpretation 89
ConsequentialBasisforUse 90
Conclusion 91
PotentialLimitations 93
SignificanceofStudy 95
TheoreticalContribution 96
ContributiontoHealthCare 97
ContributiontotheProfessionofPharmacy 98
FutureAreasforStudy 98
APPENDICIES
A:GERIATRICMEDICINEEXPERTPANELMEMBERS 100
B:INITIALMAILINGANDINSTRUCTIONSTOTHEDELPHIPANEL 101
C:ROOTCAUSEANALYSISEXPERTPANEL 104
D:FINALPREVENTABLEDRUG-RELATEDMORBIDITYDEFINITIONS 105
E:MNEMONICSFORCONSENSUS-APPROVEDDEFINITIONS 114
F:ALPHABETICALMNEMONICLIST 115
G:NUMBEROFPATIENTSWITHEACHPDRMDEFINITION 117
H:PDRM,PATTERNOFCAREONLY,ANDOUTCOMEONLY 119
I:CUT-OFFDAYSFORPDRMDEFINITIONSBASEDONMETHOD 121
J:PATTERNOFCAREONLYMEASURESBASEDON95%CUT-OFFVALUE..122
K:CONGESTIVEHEARTFAILURECAUSE-AND-EFFECTDIAGRAM 123
L:GASTROINTESTINALCAUSE-AND-EFFECTDIAGRAM 125
M:MYOCARDIALINFARCTIONCAUSE-AND-EFFECTDIAGRAM 127
N:MISCELLANEOUSCAUSE-AND-EFFECTDIAGRAM 129
O:CONSULTANTANALYSISOFROOTCAUSEANALYSIS 13
P:MACKINNON'STOP12DEFINITIONS 135
ix
Q:FARIS'TOP10DEFINITIONS 138
R:PROCESS-TO-OUTCOMEVALUEAFTERADJUSTMENTFORNDPO 140
LISTOFREFERENCES 141
BIOGRAPHICALSKETCH 152