IMPACT OF MEDICATION-RELATED HARM IN OLDER ADULTS FOLLOWING HOSPITAL DISCHARGE NIKESH PAREKH A thesis submitted in partial fulfilment of the requirements of the University of Brighton and the University of Sussex for the degree of Doctor of Philosophy October 2018 DECLARATION I, Nikesh Parekh, declare that the research contained in this thesis, unless otherwise formally indicated within the text, is the original work of the author. The thesis has not been previously submitted to these or any other university for a degree, and does not incorporate any material already submitted for a degree. Nikesh Parekh TABLE OF CONTENTS ACKNOWLEDGEMENTS .........................................................................................................6 LIST OF ABBREVIATIONS .......................................................................................................7 LIST OF TABLES......................................................................................................................9 LIST OF FIGURES .................................................................................................................. 12 ABSTRACT ........................................................................................................................... 14 CHAPTER 1. ......................................................................................................................... 15 INTRODUCTION .................................................................................................................. 15 1.1 STATEMENT OF INTENT ................................................................................................. 16 1.2 IATROGENIC ILLNESS ...................................................................................................... 16 1.3 CHANGING PATTERNS OF DISEASE AND MEDICINE USE ................................................. 18 1.4 DEFINING MEDICATION-RELATED HARM ....................................................................... 21 1.5 OLDER ADULTS ARE A HIGH-RISK POPULATION .............................................................. 22 1.6 TRANSITIONS OF CARE ARE A HIGH-RISK TIME ............................................................... 24 1.7 NATIONAL POLICY LANDSCAPE AROUND MEDICATION-RELATED HARM ........................ 25 1.8 STRUCTURE OF THIS THESIS ........................................................................................... 28 CHAPTER 2. ......................................................................................................................... 29 THE EPIDEMIOLOGY OF MEDICATION-RELATED HARM IN OLDER ADULTS FOLLOWING HOSPITAL DISCHARGE: A SYSTEMATIC REVIEW .................................................................. 29 2.1 INTRODUCTION ............................................................................................................. 31 2.2 METHODS ...................................................................................................................... 34 2.2.1 SEARCH STRATEGY ....................................................................................................... 34 2.2.2 SELECTION CRITERIA..................................................................................................... 35 2.2.3 OUTCOMES................................................................................................................ 37 2.2.4 STUDY SELECTION ........................................................................................................ 37 2.2.5 DATA EXTRACTION....................................................................................................... 38 2.2.6 QUALITY ASSESSMENT .................................................................................................. 38 2.2.7 DATA SYNTHESIS ......................................................................................................... 38 2.3 RESULTS ........................................................................................................................ 39 2.3.1 STUDY SELECTION ....................................................................................................... 39 2.3.2 KEY STUDY CHARACTERISTICS ......................................................................................... 41 2.3.3 PARTICIPANT RECRUITMENT .......................................................................................... 44 2.3.4 PARTICIPANT FOLLOW-UP ............................................................................................. 44 2.3.5 DEFINITION OF MRH ................................................................................................... 44 2.3.6 DATA COLLECTION ....................................................................................................... 45 2.3.7 ASSESSMENT OF CAUSALITY ........................................................................................... 45 2.3.8 CRITICAL APPRAISAL .................................................................................................... 45 2.3.9 INCIDENCE OF MRH .................................................................................................... 49 2.3.10 SEVERITY, PREVENTABILITY AND RISK FACTORS ................................................................. 51 2.4 DISCUSSION ................................................................................................................... 53 1 2.4.1 HEALTHCARE COSTS ASSOCIATED WITH MRH .................................................................... 54 2.4.2 DEFINING MEDICATION-RELATED HARM ........................................................................... 54 2.4.3 DATA COLLECTION ...................................................................................................... 55 2.4.4 RISK FACTORS ............................................................................................................. 56 2.4.5 LIMITATIONS .............................................................................................................. 56 2.5 CONCLUSIONS ............................................................................................................... 57 CHAPTER 3. ......................................................................................................................... 58 MEDICATION-RELATED HARM: A QUALITATIVE EXPLORATION OF THE OLDER PERSON’S LIVED EXPERIENCE .............................................................................................................. 58 3.1 INTRODUCTION ............................................................................................................. 60 3.2 METHODS ...................................................................................................................... 63 3.2.1 DISEASE VERSUS ILLNESS: THE IMPORTANCE OF LIVED EXPERIENCE .......................................... 63 3.2.2 SETTING AND ETHICS .................................................................................................... 64 3.2.3 CONCEPTION AND DESIGN ............................................................................................. 64 3.2.4 PATIENT AND PUBLIC INVOLVEMENT ................................................................................ 65 3.2.5 DEFINITION ................................................................................................................ 65 3.2.6 RECRUITMENT ............................................................................................................ 66 3.2.7 HOUSEBOUND PARTICIPANTS ......................................................................................... 66 3.2.8 AMBULATORY PARTICIPANTS ......................................................................................... 67 3.2.9 DATA COLLECTION APPROACH ....................................................................................... 68 3.2.10 THEMATIC ANALYSIS .................................................................................................. 69 3.2.11 REFLEXIVITY ............................................................................................................. 70 3.3 RESULTS ........................................................................................................................ 71 3.3.1 EXPERIENCES OF THE HEALTHCARE SYSTEM ....................................................................... 73 3.3.1.1 Communication ............................................................................................... 74 3.3.1.2 Inappropriate prescribing ................................................................................ 77 3.3.1.3 Hospital discharge ........................................................................................... 77 3.3.2 PRACTICALITIES OF USING MEDICINES .............................................................................. 79 3.3.2.1 Formulation, Packaging and instructions ......................................................... 79 3.3.2.2 Side-Effects ...................................................................................................... 81 3.3.3 MANAGEMENT OF MEDICATION PROBLEMS ...................................................................... 81 3.3.3.1 Information and Support.................................................................................. 82 3.3.3.2 Non-Adherence ................................................................................................ 82 3.3.4 PARTICIPANT BELIEFS ..................................................................................................