Roth McClurg Baseline Study Shows Racial Differences in Medication Use by the Elderly

Divisions Faculty Pharmaceutical Outcomes and Policy Research,

Grayson Mendenhall
February 1, 2010

New research by Mary Roth McClurg, PharmD, MHS, and colleagues shows that older black patients have more medication-related problems than their white counterparts, and nonadherence (not taking their medicines as directed) is a particular issue for this group. Roth McClurg is an associate professor in the Division of Pharmaceutical Outcomes and Policy at the UNC Eshelman School of Pharmacy.

Older adults experience a number of medication-related problems, including underuse of needed medications, use of suboptimal drugs, suboptimal dosing, and non-adherence, which not only have negative effects on their health and quality of life, but cost the health care industry billions of dollars each year. They are likely to have a number of coexisting, chronic diseases, visit more than one doctor, and use multiple drugs, which puts them at greater risk of developing medication-related problems. As a consequence, their health and quality of life can be compromised.

Roth McClurg says that she and her colleagues are studying the quality of medication use from a different perspective compared to past research. Rather than focusing on certain medication-related problems, specific diseases, or a list of predefined quality indicators for appropriate medication use, her research team is looking at the overall quality of medication use for individuals. Their work also assessed the effect of race on the overall quality of medication use, another new dimension. Their paper, “Racial Disparities in the Quality of Medication Use in Older Adults: Baseline Findings from a Longitudinal Study,” was published in the Journal of General Internal Medicine.

“Older adults often take multiple medications, including prescription, over-the-counter, and complementary and alternative medicines,” Roth McClurg says. “Our focus is on the person and all the medications he or she is taking. The goal is to ensure that individuals are receiving necessary medications, and that all the medications a person may be taking, regardless of the number or types of medications, are effective, safe, and as affordable as possible for the individual.”

From the perspective of the research team, this will likely require ongoing evaluation and management of medications by a clinical pharmacist working together with the patient’s health care providers, she says.

“Our goal is to work collaboratively with the patient’s health-care providers to improve the quality of medication use for individuals, thereby improving their health and quality of life. At a time when health care is so fragmented, it is critical that we test innovative strategies to improve coordination of care and quality around medication use,” Roth McClurg says.

A total of 200 (100 white and 100 black) adults sixty years of age and older were recruited through the N.C. Department of Aging and two senior housing complexes in North Carolina. They were interviewed three times in their homes: once at the start of the study, after six months, and at one year. Roth measured quality of medication use in two ways: the Assessing Care of Vulnerable Elders quality indicators and a clinical pharmacist’s judgment using a framework developed and tested by study investigators. There was no intervention by a health-care professional in this study to improve medication use. This paper presents baseline findings from the pharmacist assessment of quality medication use.

The researchers found that whites used more medications than blacks (11.6 vs. 9.7), had a greater number of chronic medical conditions, and used more physicians. Nearly a third of blacks (28 percent) could not purchase their medication due to cost compared to only 12 percent of whites. Whites were more likely to have adequate health-literacy skills than blacks (58 percent compared to 29 percent).

Each participant had at least one medication-related problem. The most common problems for both whites and blacks were undertreatment (not receiving necessary drugs; 83 percent vs. 87 percent), suboptimal drug use (59 percent vs. 66 percent), suboptimal dosing (48 percent vs. 56 percent), nonadherence (42 percent vs. 68 percent), and need for medication monitoring (15 percent vs. 29 percent). The difference between whites and blacks was particularly noteworthy for nonadherence to medications, with smaller differences noted for inadequate medication monitoring. It was interesting that although blacks were prescribed fewer medications than whites, they had significantly more medication-related problems than whites, Roth McClurg says.

“This study supports previous findings that elderly blacks have higher rates of nonadherence than whites,” she says. ”But it also suggests that medication-related problems, in general, are prevalent in older adults, persist over time when no one intervenes, and appear to be more prevalent in blacks than whites.”

The authors conclude, “Strategies to better measure the quality of medication use in older adults are needed, and efforts to improve the quality of medication use in older adults must account for potential differences in both the number and types of problems affecting whites and blacks.”

Roth’s coauthors on the paper are Denise A. Esserman, PhD, a research assistant professor in the UNC School of Medicine and the UNC Gillings School of Global Public Health; Jena Ivey Burkhart, PharmD, clinical assistant professor at the UNC Eshelman School of Pharmacy; and Morris Weinberger, PhD, Vergil N. Slee Distinguished Professor of Health Policy Management at the UNC Gillings School of Global Public Health and senior career scientist for health services research at the Durham VA Medical Center.

This study is part of a larger research agenda to test the feasibility and effectiveness of a medication-management program in improving the quality of medication use and health outcomes in older adults. Currently data from this study are being used to test the reliability of the measure of quality medication use and design the medication management intervention. Beginning in March 2010, Roth McClurg and colleagues will begin testing the intervention, using clinical pharmacists working collaboratively within an ambulatory-care physician practice in the community, to improve the quality of medication use and health outcomes for older adults. In addition, the research team will be collecting data on the cost of the intervention in order to eventually justify the business model for such a service. Ivey Burkhart and Macary Weck Marciniak, PharmD, both practitioners in the School’s Division of Pharmacy Practice and Experiential Education, will be instrumental in delivering the intervention.

Using the data gathered from these studies, Roth McClurg and colleagues plan to apply for funding to test the effectiveness and cost effectiveness of the intervention through a randomized controlled trial.

“Improving the process by which medications are evaluated and managed within our health care system may bring us one step closer to improving the quality of medication use for generations to come,” she says.