Appropriateness of medication prescribing in ambulatory elderly patients

Inappropriate drug use by Portuguese elderly outpatients--effect of the Beers criteria update

OBJECTIVE

To characterize the use of medicines and to evaluate the inappropriateness of drugs in elderly outpatient population.

SETTING

Twelve community pharmacies in different districts of Lisbon-Portugal.

METHOD

Observational cross-sectional survey, in a sample of 213 elderly outpatients (age>or=65-years-old) presenting a prescription with two or more drugs, for their own use.

MAIN OUTCOME MEASURES

Drug use pattern and prevalence of potentially inappropriate medication.

RESULTS

We have studied 213 outpatients, who were taking a total of 1,543 drugs, with an average of 7.23 per patient. The drugs were distributed mainly in the following 3 ATC (Anatomical Therapeutic Chemical Classification) classes: C (cardiovascular system), N (nervous system) and A (alimentary tract). Using the 1997 Beers Explicit criteria, 75 occurrences of inappropriate medicines were detected in 59 patients (27.7%), while with the 2003 Beers Explicit criteria we detected 114 cases of inappropriate medication in 82 patients (38.5%). The occurrence of inappropriate medicines was significantly associated with the consumption of a high number of drugs. According to the ATC Classification, more than one half of the cases of inappropriateness were related with long acting benzodiazepines and with ticlopidine. The 2003 version detected a significantly higher prevalence of inappropriate drug use having potentially adverse outcomes of high severity.

CONCLUSIONS

The application of the updated Beers criteria lead to higher rates of potentially inappropriate medication, and especially those responsible for more severe adverse outcomes. The results suggest that there is a need for interventions to improve instructions for safe drug use in the elderly patients and to decrease the number of medications whenever it is possible. This study suggests a high prevalence of potentially inappropriate drug use by the elderly patients of Lisbon region, Portugal.

Evidence-based guideline. Improving medication management for older adult clients

All providers and professionals who care for older adults have an important role to play in the process of managing medications. The evidence-based guideline "Improving Medication Management for Older Adult Clients" (Bergman-Evans, 2004) provides assessments and interventions that are useful across settings. By focusing on reducing inappropriate prescribing, decreasing polypharmacy, avoiding adverse events, and maintaining function, professionals and providers have the opportunity to improve outcomes for this important population.

AIDES to improving medication adherence in older adults

Medication regimens for older adults are often complex and costly. Designing, implementing, and maintaining an appropriate treatment regimen is challenging. The AIDES method is built on the principles of completing a comprehensive medication Assessment; partnering with patients to ensure Individualization of the regimen; choosing appropriate Documentation; providing accurate and ongoing Education tailored to the age group and needs of the individual; and continuing Supervision after initiation.

Pharmacy practice, research, education, and advocacy for older adults

In the United States, older adults have become the fastest growing segment of the population and are expected to double in number to 70 million by 2030. As a whole, older adults have different health care needs than younger patients, and some of these needs should be met by pharmacists. Clinical pharmacy practice affecting older adults occurs in a variety of settings, including community, ambulatory care, primary care, hospital, assisted living, nursing home, home health care, hospice, and Alzheimer's disease units. Although specialty training in geriatrics or gerontology is not required for pharmacists to care for older adults, it is extremely helpful. Pharmacy education related to the care of older adults has improved slightly in the past several years but will need to increase even more to provide all pharmacists with the basic skills and knowledge to care for this unique group of patients. In addition, pharmacotherapy research targeting older adults needs to increase. Although it can be challenging, funding for this type of research is available. Patient and political advocacy is also important to support this growing population.

Inappropriate medication prescribing in community-dwelling elderly people living in Iran

OBJECTIVES

To determine the prevalence of inappropriate medication prescribing in Middle Eastern community-dwelling elderly persons, and to determine factors associated with inappropriate prescribing.

METHODS

Prescriptions from 3,000 elderly-patient visits (> or =65 years) to physicians in Isfahan, Iran were collected between September and December 2002; only the first patient visit was considered in the study. Inappropriate prescriptions were defined according to Beers' explicit criteria (1997). The presence of at least one drug-drug interaction (DDI) and at least one drug-class duplication within each patient visit was also determined. Multivariate analyses were performed to determine factors associated with receiving at least one inappropriate medication. These factors included age, gender, number of prescribed medications per visit, DDIs, duplications, and physician's number of years of experience. Similar analyses were performed to determine whether these factors were associated with a composite index (defined as having at least one of the following: receiving at least one inappropriate prescription, DDI, or duplication).

RESULTS

The mean age of our cohort was 72.6 (+/-5.7) years, and 1,735 (57.8%) were females. A total of 829 (27.6%) patients received at least one inappropriate prescription, 285 (9.5%) had at least one DDI during the visit, and 746 (24.9%) had at least one duplication during the visit. The three most inappropriately prescribed medication classes were antihistamines (29%), non-steroidal anti-inflammatory agents (23%) and benzodiazepines (16%). In multivariate analyses, the number of prescribed medications per visit was the only factor significantly associated with receiving at least one inappropriate prescription (OR 1.24; 95%CI: 1.16-1.32); analyses using the composite index as outcome gave similar results (OR: 1.70; 95%CI: 1.60-1.80).

CONCLUSION

Our findings indicate a high prevalence of inappropriate prescribing in elderly patients. Given the potential severity of this problem, further steps need to be implemented to prevent this occurrence.

Unnecessary drug use in frail older people at hospital discharge

OBJECTIVES

To determine the prevalence and predictors of unnecessary drug use at hospital discharge in frail elderly patients.

DESIGN

Cross-sectional.

SETTING

Eleven Veterans Affairs Medical Centers.

PARTICIPANTS

Three hundred eighty-four frail older patients from the Geriatric Evaluation and Management Drug Study.

MEASUREMENTS

Assessment of unnecessary drug use was determined by the consensus of a clinical pharmacist and physician pair applying the Medication Appropriateness Index to each regularly scheduled medication at hospital discharge. Those drugs that received an inappropriate rating for indication, efficacy, or therapeutic duplication were defined as unnecessary.

RESULTS

Forty-four percent of patients had at least one unnecessary drug, with the most common reason being lack of indication. The most commonly prescribed unnecessary drug classes were gastrointestinal, central nervous system, and therapeutic nutrients/minerals. Factors associated (P<.05) with unnecessary drug use included hypertension (adjusted odds ratio (AOR)=0.61, 95% confidence interval (CI)=0.38-0.96), multiple prescribers (AOR=3.35, 95% CI=1.16-9.68), and nine or more medications (AOR=2.24, 95% CI=1.25-3.99).

CONCLUSION

A high prevalence of unnecessary drug use at discharge was found in frail hospitalized elderly patients. Additional studies are needed to identify predictors and prevalence of unnecessary drug use in nonveteran populations so that interventions can be designed to reduce the problem.

Elderly women show neither a shortage of strategies nor an overreliance on drugs in handling aging and in dealing with minor health problems

Women 65 years old and over make up the fastest growing population segment in North America. They are, particularly among the underprivileged, known to be heavy consumers of prescribed and over-the-counter drugs. The objective of this study was to identify the role of medication in underprivileged elderly women's strategies for aging well and dealing with minor health problems. A qualitative study was conducted among 40 women aged 65 to 75. Results show that elderly women seldom mention resorting to medication to "age well" although they report using this strategy to deal with minor health problems. Overall, the elderly women mentioned a wide range of strategies to cope with aging and minor health problems, which suggests that they are well equipped to face the challenges of aging.

Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes

BACKGROUND:

Little empirical evidence exists regarding the influence and outcomes of inappropriate medication use among elderly nursing home residents.

OBJECTIVE:

To identify the prevalence of inappropriate medication use among elderly patients in Georgia nursing homes using the Beers criteria and identify the relationship between inappropriate drug use and the likelihood of an adverse health outcome.

METHODS:

A cohort design was used to review 1117 patient medical records in 15 Georgia nursing homes with a high risk of polypharmacy. Prevalence of inappropriate medication use among elderly patients, as defined by the Beers criteria, was estimated. The adverse health outcomes of hospitalizations, emergency department visits, or deaths were identified from Medicaid claims data.

RESULTS:

A total of 519 (46.5%) patients received at least one inappropriate medication and 143 (12.8%) patients experienced at least one adverse health outcome. Logistic regression revealed that the total number of medications taken (OR 1.139, 95% CI 1.105 to 1.173) significantly increased the likelihood of receiving an inappropriate drug, while having a diagnosis of “dementia” (OR 0.748, 95% CI 0.565 to 0.991) decreased the likelihood. Inappropriate medication use increased the likelihood of experiencing at least one adverse health outcome more than twofold (OR 2.34, 95% CI 1.61 to 3.40). Propoxyphene use alone was significantly associated with the occurrence of an adverse health outcome (OR 2.39, 95% CI 1.54 to 3.71).

CONCLUSIONS:

Inappropriate drug use was common in our study cohort. Inappropriate use of medication in the elderly, particularly propoxyphene, is associated with a higher risk of adverse health outcomes.

Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention

BACKGROUND

There is limited information from randomized controlled studies about the influence of pharmacist interventions on diabetes control.

OBJECTIVE

To evaluate the effect of a pharmacist intervention on improving diabetes control; secondary endpoints were medication appropriateness and self-reported adherence.

METHODS

A randomized, controlled, multi-clinic trial was conducted in the University of Washington Medicine Neighborhood Clinics. Seventy-seven subjects, > or =18 years old with a hemoglobin (Hb) A(1c) > or =9% at baseline and taking at least one oral diabetes medication, were randomized to receive a pharmacist intervention (n = 43) or usual care (n = 34) for 6 months followed by a 6-month usual-care observation period for both groups. Subjects met with a clinical pharmacist to establish and initiate a diabetes care plan followed by weekly visits or telephone calls to facilitate diabetes management and adherence. HbA(1c), medication appropriateness, and self-reported adherence were assessed at baseline, 6 months, and 12 months.

RESULTS

The mean HbA(1c) did not differ between groups over the 12-month period (p = 0.61). A reduction in HbA(1c) was noted for both groups over time compared with baseline (p = 0.001); however, control subjects relied more heavily on provider visits. Medication appropriateness was not improved for diabetes medications (p = 0.65). Self-reported adherence was not significantly improved by the intervention.

CONCLUSIONS

This pharmacist intervention did not significantly improve diabetes control, but did allow for similar HbA(1c) control with fewer physician visits. Medication appropriateness and self-reported adherence compared with usual care in individuals with poorly controlled diabetes were not changed.

Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients

CONTEXT

A previous study, described in Part I of this report, found that 71% of a sample of 5,003 general outpatients in the Veterans Affairs healthcare system were receiving a unique drug regimen (i.e., total specific drug entities regardless of dose, formulation, or administration schedule). The simplest regimens contained only one drug, while the most complex regimens exceeded 20 different drugs. The purpose of the present study was to determine if patients receiving a specific therapeutic class of medications (e.g., antidepressants) have more homogeneous drug regimens.

OBJECTIVE

to examine the extent and complexity of multiple medication use in younger and older adult outpatients receiving antidepressants compared with those not receiving antidepressants. The study focused on drugs that act systemically or gastrointestinally and hence have the potential to interact.

DESIGN, SETTING, AND PARTICIPANTS

Two subsets of stratified random samples of outpatients selected from prescription databases of U.S. Veterans Integrated Service Network 15. The first group involved 1,991 patients deemed to be on antidepressants (AD patients): 891 aged < 60 years and 1,100 aged > or = 60 years. The second group involved 3,732 patients who had received no antidepressants within the previous 365 days but who had a supply of at least one other current prescription (NoAD patients): 1,195 aged < 60 years and 2,535 aged > or = 60 years; 2 missing age information.

MAIN OUTCOME MEASURES

number of drugs, frequency of drug regimens, level of multiple medication use including and excluding antidepressants.

RESULTS

Younger AD patients received 3 more drugs than younger NoAD patients. 23.6% of younger AD patients, versus 5.9% of younger NoAD patients, received > or = 8 drugs. Older AD patients received 2 more drugs than older NoAD patients. 37.6% of older AD patients, versus 12.8% of older NoAD patients, received > or = 8 drugs. In both the AD and NoAD groups, 62%-96% of patients of all ages were receiving unique drug regimens. Each drug regimen containing 2 or more drugs occurred in fewer than 1% of patients.

CONCLUSIONS

AD patients were receiving more complex drug regimens and had a higher frequency of unique drug regimens than NoAD patients, even when the results were adjusted for age group and number of prescribers. The high prevalence of unique drug combinations in all patient groups in this study indicates that clinicians in this system have only limited experience with the total effects of all of the medications their patients are receiving and thus cannot rely on experience to guard against adverse multi-drug interactions. This fact is a particular concern with psychiatric medications because adverse DDIs involving these medications can mimic psychiatric symptoms and may therefore be more difficult to detect.

Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents

BACKGROUND

There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use.

OBJECTIVE

The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged >or=68 years, as determined by the relationship of these criteria to health service use in older community residents.

METHODS

Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an in-home interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services.

RESULTS

A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P<0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry.

CONCLUSIONS

Our data suggest that in representative community residents aged >or=68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria).

Pharmaceutical care for elderly patients shared between community pharmacists and general practitioners: a randomised evaluation. RESPECT (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) [ISRCTN16932128]

BACKGROUND

This trial aims to investigate the effectiveness and cost implications of 'pharmaceutical care' provided by community pharmacists to elderly patients in the community. As the UK government has proposed that by 2004 pharmaceutical care services should extend nationwide, this provides an opportunity to evaluate the effect of pharmaceutical care for the elderly.

DESIGN

The trial design is a randomised multiple interrupted time series. We aim to recruit 700 patients from about 20 general practices, each associated with about three community pharmacies, from each of the five Primary Care Trusts in North and East Yorkshire. We shall randomise the five resulting groups of practices, pharmacies and patients to begin pharmaceutical care in five successive phases. All five will act as controls until they receive the intervention in a random sequence. Until they receive training community pharmacists will provide their usual dispensing services and so act as controls. The community pharmacists and general practitioners will receive training in pharmaceutical care for the elderly. Once trained, community pharmacists will meet recruited patients, either in their pharmacies (in a consultation room or dispensary to preserve confidentiality) or at home. They will identify drug-related issues/problems, and design a pharmaceutical care plan in conjunction with both the GP and the patient. They will implement, monitor, and update this plan monthly. The primary outcome measure is the 'Medication Appropriateness Index'. Secondary measures include adverse events, quality of life, and patient knowledge and compliance. We shall also investigate the cost of pharmaceutical care to the NHS, to patients and to society as a whole.

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly

PURPOSE

To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients.

METHODS

The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse.

RESULTS

For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05).

CONCLUSION

Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.

Inappropriate medication use among frail elderly inpatients

BACKGROUND

Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients.

OBJECTIVE

To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients.

METHODS

The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score.

RESULTS

Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores.

CONCLUSIONS

Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Collaboration Between Community Pharmacists and Family Physicians: Lessons Learned from the Seniors Medication Assessment Research Trial

OBJECTIVES

To learn about the experiences of specially trained expanded role pharmacists (ERPs) and family physicians in a program in which they worked together to optimize drug therapy for elderly patients (aged 65 and older) and to identify shortcomings of the program, obstacles to its implementation, and strategies to overcome these obstacles.

DESIGN

Qualitative opinion analysis.

PARTICIPANTS

Six family physicians and six community-based ERPs who had participated in a randomized controlled trial (Seniors Medication Assessment Research Trial [SMART]).

INTERVENTION

In-depth interviews.

MAIN OUTCOME MEASURES

Themes that emerged from the interviews regarding the strengths and weaknesses of and ways to improve the program.

RESULTS

ERPs and physicians differed in their perceptions of appropriate roles for ERPs. ERPs saw the program as an opportunity to take on new professional roles. Physicians appreciated the information they received from ERPs about their patients' adherence and use of nonprescription medications, but they did not want ERPs to directly counsel their patients. Some physicians questioned the value of the program for some patients, since the inclusion criteria for patients were broad and not all patients meeting the criteria needed intense interventions by ERPs. Both ERPs and physicians identified the need to refine the referral process and to work out professional role relationships and ongoing collaboration more fully. If the program were to be implemented as a routine service, physicians were concerned about the demands on their staff and office space and the need for an external compensation mechanism.

CONCLUSION

Issues to be addressed for future programs include clarification of the roles of pharmacist and physician when the professionals work together, targeting of appropriate patients for the program, identification of a more efficient way to deliver recommendations, and development of an appropriate compensation mechanism.

Prescribing indicators for evaluating drug use in nursing homes

OBJECTIVE

To evaluate drug use in 2 Dutch nursing homes (254 residents) by developing and evaluating prescribing indicators based on pharmacy prescription data.

METHODS

We evaluated the prescribing of benzodiazepines, nonsteroidal antiinflammatory drugs (NSAIDs), ulcer-healing drugs, and diuretics. Prescribing indicators were used to identify prescribing that was potentially not in line with recommendations in national and regional prescribing guidelines. We used both descriptive indicators, such as the number and percentage of users, and indicators reflecting potentially suboptimal prescribing, such as use of drugs outside the regional drug formulary, use of >1 drug from the same drug class, and prescription of drug dosages above recommended values. When potentially suboptimal prescribing was found, we verified the findings by means of an interview with 1 of the prescribers.

RESULTS

The prescribing indicators we assessed were generally in agreement with national and regional guidelines. However, prescribing of NSAIDs without concomitant prescribing of gastroprotective drugs was found in a relatively high number of patients. After prescriber interview and patient chart review, it was found that some prescribing indicators, such as dosages above recommended values, were not always indicative for suboptimal prescribing.

CONCLUSIONS

This pilot study showed that prescribing indicators based solely on pharmacy prescription data can be a useful tool to evaluate drug prescribing. With some of these prescribing indicators, we identified cases of potentially suboptimal prescribing. However, with other indicators such as those based on drug dosages, we could not identify suboptimal prescribing, and clinical information from the prescriber was necessary to get insight into the appropriateness of prescribing.

Cost-effectiveness analysis of pharmaceutical care in a medicare drug benefit program

OBJECTIVES

Although there has recently been substantial interest in a Medicare drug benefit program, little attention has focused on ensuring improved access to medication monitoring for Medicare beneficiaries. Using a societal perspective, we evaluated the impact pharmacists could have on inappropriate prescribing, patient compliance, and medication-related morbidity and mortality within a Medicare drug benefits program.

METHODS

A cost-effectiveness analysis from a societal perspective was performed. A comprehensive MEDLINE search for relevant literature identified data sources and model parameters.

RESULTS

In the base case, a pharmaceutical care benefit in the elderly population would cost US dollars 2100 (year 2000 prices) per life-year saved, which is highly cost-effective. Reasonable changes in model parameters did not raise the cost-effectiveness ratio above US dollars 13000 per life-year saved.

CONCLUSION

Despite limitations in both the quantity and the specificity of data available, pharmaceutical care appears to be a highly cost-effective augmentation to a Medicare drug benefit program. This result is robust to model parameter changes. This model is conservative in that it does not include ongoing benefits from medication monitoring or increased elderly drug utilization and polypharmacy as the Medicare drug program is phased in.

Polypharmacy and the elderly

Polypharmacy is the concurrent use of several different medications used by the same individual, which in some cases can lead to drug-drug interactions. Elderly patients often are faced with polypharmacy when they have multiple disease processes. Declining organ function, as part of the normal aging process, adds to the problem of adverse drug effects in this population. To minimize polypharmacy, prescribers aim to treat multiple disease conditions with a single agent if possible. Pharmacists can often help in drug selection, if given a set of criteria. This article is intended to help infusion professionals provide safe medication treatment by understanding how aging organ systems and medications affect the elderly.

Ambulatory patient safety. What we know and need to know

While safety risks are widespread in ambulatory settings, there has been insufficient attention directed at developing the evidence base that is needed to improve ambulatory safety. In this article, the current state of knowledge about ambulatory safety is reviewed. A research agenda in ambulatory safety is proposed, as well as a series of potential interventions that could be used to improve safety in the ambulatory setting.

Reliability of a Modified Medication Appropriateness Index in Community Pharmacies

Background

The medication appropriateness index (MAI) has demonstrated reliability in selected outpatient clinics where medical data were easily accessible from medical charts. However, its use in the community setting where patient data may be limited has not been examined.

Objective

To evaluate the usefulness of a modified MAI for use in the community pharmacy setting by testing interrater reliability using 3 different rating schemes.

Methods

Two raters evaluated 160 medications for 32 elderly ambulatory patients. Patient information was acquired using community pharmacist-collected medication histories. A summated MAI score, percent agreement, κ, positive agreement, negative agreement, and intraclass correlation coefficient were calculated for each criterion using 3 scoring schemes. A paired samples t-test (95% CI) was used to test interrater reliability.

Results

The κ statistics were >0.75 for indication and effectiveness, but good (0.41–0.66) for the remaining criteria using the Hanlon scoring scheme. The intraclass coefficients (0.82, 0.86, 0.87) and overall κ (0.65, 0.66, 0.61) were similar for the 3 schemes.

Conclusions

This study suggests that the modified MAI has the potential to detect medication appropriateness and inappropriateness in the community pharmacy setting; however, it is not without limitations. Because the MAI has the most clinimetric and psychometric data available, the instrument should be studied further to increase its reliability and generalizability.

Medication decisions--right and wrong

This paper reviews the recent literature on problems associated with prescription drug use in older adults. The authors address four major issues: Why giving patients the wrong drug is so common; how taking the wrong amount is an even larger problem; why good drugs may be wrong for particular patients; and how high out-of-pocket spending and inadequate insurance coverage may disrupt otherwise sound drug regimens. The organizing theme of this review is the right drug for the right patient, taken in the right way at the right price. Despite significant gaps in the research record the evidence leaves no doubt that elderly individuals are at significant risk for inappropriate medication use. The paper concludes with an agenda for future studies: the need to validate standards for geriatric drug use, assess inappropriate drug use at the national level, establish population-based risk factors, and target research to the most significant adverse outcomes.

Prescribing of psychotropics in the elderly: why is it so often inappropriate?

Psychotropic medications are an important treatment approach to mental health disorders; such disorders are common in the elderly population. Elderly patients are more likely to experience adverse effects from these agents than their younger counterparts due to age-related changes in pharmacodynamic and pharmacokinetic parameters. Because of these factors, inappropriate use of psychotropic medications in elderly patients has become a focus of concern. In general an agent is considered inappropriate if the risk associated with its use exceeds its benefit. Implicit and explicit criteria for inappropriate use of medications in the elderly have been created and include psychotropic agents. These criteria vary in their make-up but the explicit criteria tend to agree that amitriptyline, doxepin, and benzodiazepines that have long half-lives are not appropriate. Although explicit inappropriate medication criteria have been in existence since 1991, elderly patients continue to receive inappropriate psychotropic medications. A wide array of factors may be responsible for this practice. Provider-related causes include deficits in knowledge, confusion due to the lack of a consensus on the inappropriate psychotropic criteria, difficulties in addressing an inappropriate medication started by a previous provider, multiple prescribers and pharmacies involved in the care of a patient, negative perceptions regarding aging, and cost issues. Patients may contribute to the problem by demanding an inappropriate medication. Finally, the healthcare setting may inadvertently contribute to inappropriate prescribing by such policies as restrictive formularies or lack of reimbursement for pharmacists' clinical services. Successful approaches to optimising prescribing have been either educational or administrative. Educational approaches (e.g. one-on-one sessions, academic detailing) seek to influence decision making, while administrative approaches attempt to enforce policies to curtail the undesired practice. The US Omnibus Budget Reconciliation Act of 1987, which improved psychotropic medication use in long-term care, is an excellent example of administrative intervention. More research specifically focused on the causes of inappropriate psychotropic medication use and methods to avoid this practice is needed before targeted recommendations can be made.

Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders

BACKGROUND

The predictive validity of Drug Utilization Review (DUR) and drugs-to-avoid criteria in elders is unknown.

OBJECTIVES

To evaluate the relationship between use of inappropriate drugs as determined by these explicit criteria and mortality and decline in functional status in community dwelling elders.

RESEARCH DESIGN

Cohort study.

SUBJECTS

The fourth wave (3234 participants) of the Duke Established Populations for Epidemiologic Studies of the Elderly.

MEASURES

Two sets of inappropriate drug-use criteria: (1) DUR with respect to dosage, duplication, drug-drug interactions, duration, and drug-disease interactions; and (2) Beers-modified criteria regarding drugs-to-avoid were applied to drug use reported in an in-home interview. Death was identified from the National Death Index; change in four functional status measures (basic self-care, intermediate self-care, complex self-management, physical function) was determined during the following 3 years.

RESULTS

Use of inappropriate drugs identified by either set of criteria was not significantly associated with mortality. The drugs-to-avoid criteria identified no significant associations between use of these drugs and decline in functional status. With DUR criteria, however, the association between use of inappropriate drugs and basic self-care was significant and pronounced among those with drug-drug or drug-disease interaction problems (Adj. OR 2.04; 95% CI 1.32-3.16).

CONCLUSIONS

Identifying the impact of inappropriate drug use may depend on the criteria applied. Further studies are needed that measure additional outcomes and use alternate measures of inappropriate drug use.

The appropriateness of drug use in an older nondemented and demented population

OBJECTIVE

To assess the extent of inappropriateness of drug use in an older nondemented and demented population.

DESIGN

Descriptive analysis based on data from a sample of older subjects age 81 years and older. Data were collected from the second follow-up conducted in 1994-1996.

SETTING

A population-based study of the Kungsholmen project in Stockholm, Sweden.

PARTICIPANTS

Drug information was obtained from 681 subjects with a mean age of 86.9 years. The subjects were predominantly women (78%). Thirteen percent resided in institutions and 27.6% were diagnosed with dementia.

MEASUREMENTS

Dementia diagnosis based on DSM III-R. Criteria for inappropriateness of drug use: use of drugs with potent anticholinergic properties, drug duplication, potential drug-drug and drug-disease interactions, and inappropriate drug dosage.

RESULTS

The mean number of drugs used was 4.6: 4.5 drugs for nondemented and 4.8 for demented subjects. Nondemented subjects more commonly used cardiovascular-system drugs and demented subjects used nervous-system drugs. Demented subjects were more commonly exposed to drug duplication and to drugs with potent anticholinergic properties, both involving the use of psychotropic drugs. Nondemented subjects were more commonly exposed to potential drug-disease interactions, mostly with the use of cardiovascular drugs. The most common drug combination leading to a potential interaction was the use of digoxin with furosemide, occurring more frequently among nondemented subjects. The most common drug-disease interaction was the use of beta-blockers and calcium antagonists in subjects with congestive heart failure. The doses of drugs taken by both nondemented and demented subjects were mostly lower than the defined daily dose.

CONCLUSION

There was substantial exposure to presumptive inappropriateness of drug use in this very old nondemented and demented population. The exposure of demented subjects to psychotropic drugs and nondemented subjects to cardiovascular drugs reflect the high frequency of prescribing these drugs in this population.

Reducing medication regimen complexity: a controlled trial

OBJECTIVE

To determine if a visual intervention (medication grid) delivered to physicians can reduce medication regimen complexity.

DESIGN

Nonrandomized, controlled trial.

SETTING

Veterans Affairs medical center.

PATIENTS/PARTICIPANTS

Eight hundred thirty-six patients taking at least 5 medications at the time of admission and the 48 teams of physicians and students on the general medicine inpatient service.

INTERVENTION

For intervention patients, a medication grid was created that displayed all of the patients' medicines and the times of administration for 1 week. This grid was delivered to the admitting resident soon after admission.

MEASUREMENTS AND MAIN RESULTS

For the patients of each team of physicians, we calculated the change in the average number of medications and doses from admission to discharge. The number of medications in the intervention group decreased by 0.92 per patient, and increased by 1.65 in the control group (P <.001). The mean number of doses per day in the intervention group decreased by 2.47 per patient and increased by 3.83 in the control group (P <.001).

CONCLUSIONS

This simple intervention had a significant impact on medication regimen complexity in this population. Apparently, physicians were able to address polypharmacy when the issue was brought to their attention.

Suboptimal prescribing in older inpatients and outpatients

Investigators searched Medline and HealthSTAR databases from January 1, 1985 through June 30, 1999 to identify articles on suboptimal prescribing in those age 65 years and older. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. The definitions for various types of suboptimal prescribing (polypharmacy, inappropriate, and underutilization) are numerous, and measurement varies from study to study. The literature suggests that suboptimal prescribing is common in older outpatients and inpatients. Moreover, there is significant morbidity and mortality associated with suboptimal prescribing for these older patients. Evidence from well-controlled studies suggests that multidisciplinary teams and clinical pharmacy interventions can modify suboptimal drug use in older people. Future research is necessary to measure and test other methods for tackling this major public health problem facing older people.

Structured implicit review: a new method for monitoring nursing care quality

BACKGROUND

Nurses' independent decisions about assessment, treatment, and nursing interventions for hospitalized patients are important determinants of quality of care. Physician peer implicit review of medical records has been central to Medicare quality management and is considered the gold standard for reviewing physician care, but peer implicit review of nursing processes of care has not received similar attention.

OBJECTIVE

The objective of this study was to develop and evaluate nurse structured implicit review (SIR) methods.

RESEARCH DESIGN

We developed SIR instruments for rating the quality of inpatient nursing care for congestive heart failure (CHF) and cerebrovascular accident (CVA). Nurse reviewers used the SIR form to rate a nationally representative sample of randomly selected medical records for each disease from 297 acute care hospitals in 5 states (collected by the RAND-HCFA Prospective Payment System study).

SUBJECTS

The study subjects were elderly Medicare inpatients with CHF (n = 291) or CVA (n = 283).

MEASURES

We developed and tested scales reflecting domains of nursing process, evaluated interrater and interitem reliability, and assessed the extent to which items and scales predicted overall ratings of the quality of nursing care.

RESULTS

Interrater reliability for 14 of 16 scales (CHF) or 10 of 16 scales (CVA) was > or = 0.40. Interitem reliability was > 0.80 for all but 1 scale (both diseases). Functional Assessment, Physical Assessment, and Medication Tracking ratings were the strongest predictors of overall nursing quality ratings (P < 0.001 for each).

CONCLUSIONS

Nurse peer review with SIR has adequate interrater and excellent scale reliabilities and can be a valuable tool for assessing nurse performance.

Clinical and economic effects of pharmacy services in geriatric ambulatory clinic

Pharmacy services were introduced in an established multidisciplinary geriatric ambulatory clinic. The pharmacist collaborated with primary care providers to optimize patients' drug regimens. Over 8 months there were 250 patient visits to the clinic. Traditional medical care was provided at 144 (57.6%) of these visits and traditional medical care plus pharmacist evaluation was provided at 106 (42.4%). The pharmacist identified 220 potential and actual drug-related problems. Acceptance of pharmacist-recommended changes in drug therapy was 98.6%. A mean reduction of 3.4 agents/patient was achieved in the intervention group (p<0.0001). Clinical outcomes of changes in drug therapy were neutral or positive in 99.5% of cases. Pharmacy services resulted in net savings of $7,788 annually.

Edmonton Quality Assessment Tool for Drug Utilization Reviews: EQUATDUR-2: the development of a scale to assess the methodological quality of a drug utilization review

OBJECTIVE

The objective of this study was to develop an instrument that will assist in evaluating the methodological quality of drug utilization reviews (DURs) and studies of prescribing appropriateness.

DESIGN

An expert committee followed accepted steps for developing and testing new instruments. Consultations on content, face validity, and scoring of items were solicited from external experts. Seven raters tested an initial version; subsequently, a refined instrument was designed. The Edmonton Quality Assessment Tool for Drug Utilization Reviews (EQUATDUR-2) evaluates 3 domains: sample selection (1 item), data collection (1 item), and data analysis (3 items). Sixteen raters tested EQUATDUR-2 on a random sample of DURs.

MEASURES

The study measures were reliability-using random effects interclass correlation coefficients for ratings by individual raters (ICC2,1) and the mean of ratings (ICC2,k)-and variability between DUR quality levels and rater groups.

RESULTS

There were significant differences in methodological quality (P <0.001) and in mean scores comparing low-, moderate-, and high-quality DURs. Nonmethodologists' ratings exhibited significant variability (P = 0.03) and tended to be higher. Agreement varied for individual items (ICC2,1, 0.22 to 0.44; ICC2,k, 0.81 to 0.91) and for mean summary ratings (ICC2,1, 0.42 [95% CI, 0.28 to 0.61]; ICC2,k, 0.92 [95% CI, 0.86 to 0.96]). The average time to rate each DUR was 10.0 minutes (95% CI, 9.2 to 10.9).

CONCLUSIONS

EQUATDUR-2 is a succinct, self-administered instrument with evidence of validity and reliability. We recommend that > or =2 raters independently assess each DUR and resolve disagreements by consensus. EQUATDUR-2 will help clinicians and decision makers to evaluate the quality of DUR studies and provide a framework for enhancing rigor in the design, conduct, and reporting of DURs.

Assessing medication appropriateness in the elderly: a review of available measures

The disproportionate use of medications, combined with age-related pharmacokinetic and pharmacodynamic changes, places older adults at high risk for medication related problems (MRPs). MRPs demonstrate significant morbidity, mortality and economic impact among healthcare systems. The negative outcomes associated with MRPs emphasise the need for more careful and thorough assessments of drug therapy among older adults. In the 1990s a number of methods and instruments were developed to assist in the assessment of medication appropriateness. These tools may be categorised by criteria as: implicit, explicit or one utilising a combination of implicit and explicit criteria. This article reviews these available tools and outlines the advantages and disadvantages of each. In conclusion, those instruments considered to be comprised of both implicit and explicit criteria offer a more thorough assessment of medication appropriateness.

Discussion between reviewers does not improve reliability of peer review of hospital quality

OBJECTIVES

Peer review is used to make final judgments about quality of care in many quality assurance activities. To overcome the low reliability of peer review, discussion between several reviewers is often recommended to point out overlooked information or allow for reconsideration of opinions and thus improve reliability. The authors assessed the impact of discussion between 2 reviewers on the reliability of peer review.

METHODS

A group of 13 board-certified physicians completed a total of 741 structured implicit record reviews of 95 records for patients who experienced severe adverse events related to laboratory abnormalities while in the hospital (hypokalemia, hyperkalemia, renal failure, hyponatremia, and digoxin toxicity). They independently assessed the degree to which each adverse event was caused by medical care and the quality of the care leading up to the adverse event. Working in pairs, they then discussed differences of opinion, clarified factual discrepancies, and rerated the record. The authors compared the reliability of each measure before and after discussion, and between and within pairs of reviewers, using the intraclass correlation coefficient for continuous ratings and the kappa statistic for a dichotomized rating.

RESULTS

The assessment of whether the laboratory abnormality was iatrogenic had a reliability of 0.46 before discussion and 0.71 after discussion between paired reviewers, indicating considerably improved agreement between the members of a pair. However, across reviewer pairs, the reviewer reliability was 0.36 before discussion and 0.40 after discussion. Similarly, for the rating of overall quality of care, reliability of physician review went from 0.35 before discussion to 0.58 after discussion as assessed by pair. However, across pairs the reliability increased only from 0.14 to 0.17. Even for prediscussion ratings, reliability was substantially higher between 2 members of a pair than across pairs, suggesting that reviewers who work in pairs learn to be more consistent with each other even before discussion, but this consistency also did not improve overall reliability across pairs.

CONCLUSIONS

When 2 physicians discuss a record that they are reviewing, it substantially improves the agreement between those 2 physicians. However, this improvement is illusory, as discussion does not improve the overall reliability as assessed by examining the reliability between physicians who were part of different discussions. This finding may also have implications with regard to how disagreements are resolved on consensus panels, guideline committees, and reviews of literature quality for meta-analyses.

An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France

OBJECTIVE

To assess drug prescribing by primary care physicians in France for various types of conditions, and to identify patterns and risk factors for poor prescribing quality.

METHODS

The orders (n = 23,080) written for patients with five target diseases (acute nasopharyngitis, acute tonsillitis, essential hypertension, osteoarthrosis, and back and periarticular disorders), by primary care physicians (n = 1,049) were extracted from a nationwide prescription database and analyzed according to 17 quantitative indicators of drug prescribing quality constructed on explicit a priori criteria.

RESULTS

Ineffective drugs were prescribed in 32% to 88% of orders according to the target disease. Six percent to 40% of orders resulted in drug interactions, age problems, and overdosage. A consistent pattern of associations between indicators was found, which suggests that drug prescribing quality is multidimensional and is composed of at least five dimensions: placebo, novelty, exoticism, misdosage, and interaction. Several factors associated with indicators were also identified, some of them defining groups of patients at risk (women, elderly, and less educated), physicians at risk (women, aged, and isolated), and contexts at risk (patient's home and disease frequently treated by the physician) of poor drug prescribing quality.

CONCLUSIONS

Drug prescribing by French primary care physicians appears nonoptimal, in terms of both risk of iatrogeny and waste of money. This study further documents the complexity and the multidimensionality of drug prescribing quality. It suggests that more attention must be paid to patients' and physicians' risk factors for poor drug prescribing quality if educational programs and regulatory processes are to succeed in promoting safer and more cost-effective practices.

Appropriateness of medication selection for older persons in an urban academic emergency department

OBJECTIVES

To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes.

METHODS

The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study.

RESULTS

Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death.

CONCLUSIONS

Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.

Drug utilization reviews of oral quinolone, cephalosporin, and macrolide use in nonacute care: a systematic review

Drug utilization review (DUR) is a tool for monitoring the appropriateness of physicians' prescribing patterns. The present systematic overview was undertaken to determine the extent of appropriate use of oral quinolones, cephalosporins, and macrolides in nonacute-care settings in North America reported in published DUR studies. Potentially relevant DURs conducted since 1987 were retrieved from an electronic search of 6 databases (augmented by manual searches of bibliographies of appropriate articles) and from personal communications with local experts. Independent reviewers applied objective criteria to select the DURs for inclusion. Quality assessments were performed by 4 independent reviewers using the Edmonton Quality Assessment Tool for Drug Utilization Reviews, an instrument developed to assess the potential for systematic bias in a DUR. Data from the studies included were abstracted independently by 2 reviewers using a standard data-collection form. Twelve of 587 (2.0%) articles met the inclusion criteria. Eight studies targeted the appropriateness of prescriptions for ciprofloxacin (appropriateness range, 5% to 95%), 3 included cephalosporins (range, 0% to 100%), and 2 examined erythromycin (40%). There were 2 primary reasons for a rating of inappropriate: (1) the prescription was not first-line therapy, or (2) there was insufficient documentation in the patient record. The designation inappropriate did not mean that the drug did not benefit the patient. Of the 4 intervention-based DURs, 1 study showed a significant improvement in appropriate use. Because of heterogeneity in study design, delivery of interventions, and outcome assessment, a pooled estimate of effect was not derived. Four studies estimated the cost of inappropriate prescribing to the institutional study site, which ranged from $20,500 to $173,359 annually; however, these estimates cannot be generalized because of various limitations. When the 12 studies were assessed for methodologic quality, 1 study was rated as high, 7 as moderate, and 4 as low. Levels of prescribing appropriateness reported in the DUR literature should be interpreted cautiously. The DUR studies included in this review varied greatly in the methodologic rigor applied to sample selection, standardized data collection, application of standardized screening criteria, and validated data analysis.

Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes

Appropriateness of drug use is an important indicator of the quality of care in nursing homes. In this study, we analyzed the influence of resident characteristics and selected organizational factors on the appropriateness of psychotropic drug use in 33 Swedish nursing homes. Specific criteria based on published guidelines and recommendations were developed to measure appropriateness. Residents diagnosed with a psychiatric disorder and younger residents had more deviations from the criteria; however, resident mix did not explain variations in appropriateness of drug use at the facility level. Facilities with better nurse staffing and drug intervention teams had fewer deviations from the criteria, but only 15-20% of the variation in drug prescribing was explained by these predictors.

Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability

OBJECTIVES

To develop valid, reliable indicators of the appropriateness of long-term prescribing in general practice medical records in the United Kingdom.

DESIGN

A nominal group was used to identify potential indicators of appropriateness of prescribing. Their face and content validity were subsequently assessed in a two round Delphi exercise. Feasibility and reliability between raters were evaluated for the indicators for which consensus was reached and were suitable for application.

PARTICIPANTS

The nominal group comprised a disciplinary mix of nine opinion leaders and prominent academics in the field of prescribing. The Delphi panel was composed of 100 general practitioners and 100 community pharmacists.

RESULTS

The nominal group resulted in 20 items which were refined to produce 34 statements for the Delphi exercise. Consensus was reached on 30, from which 13 indicators suitable for application were produced. These were applied by two independent raters to the records of 49 purposively sampled patients in one general practice. Nine indicators showed acceptable reliability between raters.

CONCLUSIONS

9 indicators of prescribing appropriateness were produced suitable for application to the medical record of any patient on long term medication in United Kingdom general practice. Although the use of the medical record has limitations, this is currently the only available method to assess a patient's drug regimen in its entirety.

Adverse drug events in high risk older outpatients

OBJECTIVE

To describe the prevalence, types, and consequences of adverse drug events (ADEs) in older outpatients with polypharmacy.

DESIGN

A cohort study.

SETTING

General Medicine Clinic at the Durham Veterans Affairs Medical Center.

PATIENTS

A total of 167 high risk (taking > or = 5 scheduled medications) ambulatory older veterans who participated in a year long health service intervention trial.

MEASUREMENTS

Potential ADEs were identified by asking patients during closeout interviews whether, in the past year, they had experienced any side effects, unwanted reactions, or other problems from any medication. All reported medications and corresponding adverse experiences were assessed for plausibility by a research clinical pharmacist using two standard pharmacological textbooks and categorized by predictability, therapeutic class, and organ system.

RESULTS

Eighty self-reported ADEs involving 72 medications taken by 58 (35%) of 167 patients were textbook confirmed. Seventy-six of 80 (95%) ADEs were classified as Type A (predictable) reactions. Cardiovascular (33.3%) and central nervous system (27.8%) medication classes were most commonly implicated. Gastrointestinal (30%) and central nervous system (28.8%) ADE symptoms were common. Sixty-three percent of patients with ADEs required physician contacts, 10% emergency room visits, and 11% hospitalization. Twenty percent of medications implicated with ADEs required dosage adjustments, and 48% of ADE-related medications were discontinued. No significant differences (P > .05) were observed when ADE reporters (n = 58) and nonreporters (n = 109) were compared.

CONCLUSION

Predictable ADEs are common in high risk older outpatients, resulting in considerable medication modification and substantial healthcare utilization.

Appropriateness in health care: application to prescribing

To help account for and address observed variations in medical practice, evaluations of "appropriateness" have sought to supplement incomplete evidence with professional opinion. This article contributes to an understanding and refinement of the construct of appropriateness by discussing how it has been defined and applied in studies of health care in general and prescribing in particular. We suggest that appropriateness is the outcome of a process of decision-making that maximises net individual health gains within society's available resources. This definition distinguishes between (in)appropriate prescribing, as an outcome, and (ir)rational prescribing as a process. To assess appropriateness, we advocate combining explicit criteria with independent review in cases of uncertainty and disagreement. Refinements based on reviews using implicit criteria should draw on shared professional knowledge and post hoc state the process followed as explicitly as possible. The Medication Appropriateness Index is shown to provide a solid foundation for identifying dimensions of prescribing appropriateness.

Determinants of initiation and suboptimal use of anti-ulcer medication: a study of the Quebec older population

OBJECTIVES

To describe the use of anti-ulcer medication in the Quebec older population; to examine determinants of initiation, suboptimal use, and switches between products.

DESIGN

Population-based retrospective cohort study.

SETTING

Universal health program for older adults in Quebec.

PARTICIPANTS

5000 users and 5000 non-users of anti-ulcer medications were selected randomly. Use was defined as the presence in the 1991 prescription database of an anti-ulcer prescription. Among users, 1697 (34%) were new users and were considered as the exposure group. Subjects were followed for 365 days after inclusion.

MEASUREMENTS

Measured were patient's age, gender, prescribed duration of anti-ulcer medication, concomitant medications, and gastrointestinal diagnostic procedures.

RESULTS

A total of 17% of new users had unusually short courses; 18% were long-term users. There was no difference in duration for omeprazole compared with other anti-ulcer medications. First-time use of NSAIDs was the strongest predictor of initiation of anti-ulcer medication (odds ratio = 3.21; 95% CI, 2.66-3.88). Twenty-six percent of users switched brands. Only 9.5% of new users underwent a diagnostic procedure before initiation of therapy, and 49% of long-term users ever underwent such procedure.

CONCLUSION

Despite a relatively homogeneous recommended duration of therapy, patterns of use of anti-ulcer medication among older people are highly variable, and treatment is often not accompanied by a diagnostic procedure.

Reliability of a modified medication appropriateness index in ambulatory older persons

OBJECTIVE

To evaluate the reliability of a medication appropriateness index (MAI) modified for elderly outpatients in a non-Veterans Affairs setting.

DESIGN

Reliability study.

SETTING

General community.

PARTICIPANTS

Ten community-dwelling elderly (> 65 y) taking five or more regularly scheduled medications and participating in a university-based health service intervention study.

MAIN OUTCOME MEASURES

Interrater reliability of MAI ratings of 65 medications made by two clinical pharmacists for individual items and for an overall summed score was calculated by use of kappa statistics and intraclass correlation coefficient.

RESULTS

The interrater agreement for each of the individual MAI items was high for both appropriate and inappropriate ratings and ranged from 80% to 100% (overall kappa = 0.64). Overall agreement for the summed score was good (intraclass correlation = 0.80).

CONCLUSIONS

The modified MAI is a reliable instrument for evaluation of medication appropriateness in a non-Veterans Affairs, ambulatory, elderly population and may provide pharmacists with a practical and standard method to evaluate patients' drug regimens and identify some potential drug-related problems.

Inappropriate prescribing and health outcomes in elderly veteran outpatients

OBJECTIVE

To determine the relationship of inappropriate prescribing in the elderly to health outcomes.

SETTING

General Medical Clinic of the Durham Veterans Affairs Medical Center.

PATIENTS

A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial.

MEASUREMENTS

Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control.

RESULTS

Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02).

CONCLUSIONS

Inappropriate prescribing appeared to be associated with adverse health outcomes. This findings needs to be confirmed in future studies that have larger samples and control for potential confounders.

Reliability of drug utilization evaluation as an assessment of medication appropriateness

OBJECTIVE

To test the reliability of drug utilization evaluation (DUE) applied to medications commonly used by the ambulatory elderly.

METHODS

A DUE model was developed for four domains: (1) justification for use, (2) critical process indicators, (3) complications, and (4) clinical outcomes. DUE criteria specific to use in the elderly were developed for angiotensin-converting enzyme (ACE) inhibitors and histamine2 (H2)-antagonists, and consensus was reached by an external expert panel. After pilot testing, two clinical pharmacists independently evaluated these medications, applying the DUE criteria and rating each item as appropriate or inappropriate. Interrater and intrarater reliability was assessed by using kappa statistics.

RESULTS

In a sample of 208 ambulatory elderly veterans, 42 (20.2%) were taking an ACE inhibitor and 56 (26.9%) an H2-antagonist. The interrater agreement for individual domains, represented by kappa statistics, were 0.10-0.58 and 0-0.83 for ACE inhibitors and H2-antagonists, respectively. The kappa statistic for overall agreement, which considered ratings from all criteria across all domains, was 0.24 for ACE inhibitors and 0.18 for H2-antagonists. Intrarater reliability was assessed 3 months later, and kappa statistics were 0.61-0.65 (0.49 overall) and 0-0.96 (0.81 overall) for ACE inhibitors and H2-antagonists, respectively.

CONCLUSIONS

Intrarater reliability for DUE was good to excellent. However, interrater reliability exhibited only marginal reproducibility, particularly where evaluators were required to use subjective judgement (i.e., complications, clinical outcomes). DUE may not be a suitable standard for assessing medication appropriateness in ambulatory elderly patients.

Factors associated with suboptimal analgesic use in community-dwelling elderly

OBJECTIVE

To examine patterns and factors associated with overall and suboptimal analgesic use among community-dwelling elderly.

DESIGN

Cross-sectional survey.

SETTING

Five-county urban and rural region in Piedmont, NC.

PARTICIPANTS

A stratified random sample from the Duke Established Populations for Epidemiologic Studies of the Elderly of 3973 participants aged 65 years or older.

MAIN OUTCOME MEASURES

Use of any analgesic medication, suboptimal analgesic use (taking 2 or more analgesics from the same class, using 3 or more analgesics concurrently, or use of an analgesic that has a major interaction with another drug).

RESULTS

Analgesics were used by 60.4% of the participants. Use was more likely for those who had physical functional impairment, a history of cardiovascular disease, one or more health visits in the previous year, or were female. Use was less likely for older participants and for African-Americans with adequate financial status. Suboptimal use occurred in 9.2% of analgesic users. Therapeutic duplication was more likely in those who were depressed, needed help with basic activities of daily living, or used alcohol, and was less likely in those with adequate financial status. Multiple analgesic use was more likely in those who were depressed, had impaired physical functional status, had one or more health visits in the previous year, were African-American (of either sex), or were white women. Only two persons had a potential major analgesic-drug interaction.

CONCLUSIONS

Suboptimal analgesic use is common in community-dwelling elderly, and its risk in consistently increased in those who are depressed or have impaired physical functional status.

A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy

PURPOSE

To evaluate the effect of sustained clinical pharmacist interventions involving elderly outpatients with polypharmacy and their primary physicians.

PATIENTS AND METHODS

Randomized, controlled trial of 208 patients aged 65 years or older with polypharmacy (> or = 5 chronic medications) from a general medicine clinic of a Veterans Affairs Medical Center. A clinical pharmacist met with intervention group patients during all scheduled visits to evaluate their drug regimens and make recommendations to them and their physicians. Outcome measures were prescribing appropriateness, health-related quality of life, adverse drug events, medication compliance and knowledge, number of medications, patient satisfaction, and physician receptivity.

RESULTS

Inappropriate prescribing scores declined significantly more in the intervention group than in the control group by 3 months (decrease 24% versus 6%, respectively; P = 0.0006) and was sustained at 12 months (decrease 28% versus 5%, respectively; P = 0.0002). There was no difference between groups at closeout in health-related quality of life (P = 0.99). Fewer intervention than control patients (30.2%) versus 40.0%; P = 0.19) experienced adverse drug events. Measures for most other outcomes remained unchanged in both groups. Physicians were receptive to the intervention and enacted changes recommended by the clinical pharmacist more frequently than they enacted changes independently for control patients (55.1% versus 19.8%; P <0.001).

CONCLUSIONS

This study demonstrates that a clinical pharmacist providing pharmaceutical care for elderly primary care patients can reduce inappropriate prescribing and possibly adverse drug effects without adversely affecting health-related quality of life.

An intervention on discharge polypharmacy

OBJECTIVE

To determine if providing a way to cancel pre-admission prescriptions would reduce the number of active drug prescriptions (RXs) at discharge.

DESIGN

A randomized non-blinded clinical trial.

SETTING

Inpatient acute medical service of a university affiliated Veterans Administration medical center.

PARTICIPANTS

Twelve medicine ward teams were randomized to control and intervention groups. Patients controlled had been discharged from these teams during 12 weeks and were receiving outpatient medications from this facility at hospital admission; control = 180, intervention = 168.

INTERVENTION

At discharge, intervention teams used a computer-generated drug list to cancel or renew previous outpatient RXs or to prescribe new medications. Control teams could not cancel outpatient drugs and wrote all medications on individual prescriptions.

MEASUREMENTS

The difference between admission and discharge RXs.

RESULTS

There were no significant differences in patients' age, sex, race, Charlson Index (CI), or LOS between patient groups at discharge. The intervention group had fewer RXs on admission (5.4 vs 6.2, P < .05) and at discharge was not significantly different (2.9 vs 2.9, P = .87) from the control group.

CONCLUSIONS

Providing a method for canceling pre-admission medications did not reduce the number of RXs at discharge. Further research is needed to evaluate the appropriateness of the large increase in RXs from admission to discharge for patients in acute hospital settings.

Drug utilization in the old old and how it relates to self-perceived health and all-cause mortality: results from the Bronx Aging Study

OBJECTIVE

To characterize medication use in a "well" very old population and relate the quantity and type of medication use to 10-year mortality.

DESIGN AND SUBJECTS

A longitudinal, 10-year, follow-up study involving 488 healthy, community-dwelling volunteers aged 75 to 85 years. The subjects underwent a detailed baseline evaluation and annual assessments that included comprehensive physical exams, laboratory and diagnostic tests, and related interviews. Prescription and nonprescription drug use was determined by self report, confirmation through hospital records, and reports by subjects and significant others.

RESULTS

At study baseline, the mean number of prescription and nonprescription medications used was 2.3 and 1.5, respectively. Female subjects (n = 315), those older than 80 years, or those who reported themselves to be in fair or poor health on initial health self-report were found to show significantly increased use of prescription medications. The most commonly used classes of medications were cardiovascular drugs and analgesics. Subjects who were consuming a greater number of prescription and nonprescription medications did not have higher mortality rates. After correcting for differences in cardiovascular health status between users and nonusers, only digoxin approached significance as an independent predictor of death (P < .08).

CONCLUSION

This study confirmed that medication use in an ambulatory, old old population is not excessive. The oldest subjects in the cohort consumed more medications than did the younger subjects. Women used more prescription drugs than men. Increased medication use was associated with worse ratings on health self report. Medication use alone, however, was not a predictor of 10-year mortality in this population. Questions are raised about the inappropriate prescription of digoxin in older subjects.