51
|
de Oliveira Martins S, Soares MA, Foppe van Mil JW, Cabrita J. Inappropriate drug use by Portuguese elderly outpatients--effect of the Beers criteria update. ACTA ACUST UNITED AC 2006; 28:296-301. [PMID: 17111245 DOI: 10.1007/s11096-006-9046-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2006] [Accepted: 07/05/2006] [Indexed: 12/31/2022]
Abstract
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.
Collapse
|
52
|
Affiliation(s)
- Sheldon H Preskorn
- Department of Psychiatry, University of Kansas School of Medicine-Wichita, Wichita, Kansas, USA
| |
Collapse
|
53
|
Abstract
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.
Collapse
|
54
|
Abstract
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.
Collapse
|
55
|
Spinewine A, Dumont C, Mallet L, Swine C. MEDICATION APPROPRIATENESS INDEX: RELIABILITY AND RECOMMENDATIONS FOR FUTURE USE. J Am Geriatr Soc 2006; 54:720-2. [PMID: 16686895 DOI: 10.1111/j.1532-5415.2006.00668_8.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
56
|
Linnebur SA, O'Connell MB, Wessell AM, McCord AD, Kennedy DH, DeMaagd G, Dent LA, Splinter MY, Biery JC, Chang F, Jackson RC, Miller SL, Sterling T. Pharmacy practice, research, education, and advocacy for older adults. Pharmacotherapy 2006; 25:1396-430. [PMID: 16185185 DOI: 10.1592/phco.2005.25.10.1396] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
Collapse
|
57
|
Azoulay L, Zargarzadeh A, Salahshouri Z, Oraichi D, Bérard A. Inappropriate medication prescribing in community-dwelling elderly people living in Iran. Eur J Clin Pharmacol 2005; 61:913-9. [PMID: 16307268 DOI: 10.1007/s00228-005-0036-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Accepted: 08/31/2005] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- Laurent Azoulay
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | | | | | | | | |
Collapse
|
58
|
Hajjar ER, Hanlon JT, Sloane RJ, Lindblad CI, Pieper CF, Ruby CM, Branch LC, Schmader KE. Unnecessary drug use in frail older people at hospital discharge. J Am Geriatr Soc 2005; 53:1518-23. [PMID: 16137281 DOI: 10.1111/j.1532-5415.2005.53523.x] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Emily R Hajjar
- Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | | | | | |
Collapse
|
59
|
Voyer P, Laberge S, Rail G. Elderly women show neither a shortage of strategies nor an overreliance on drugs in handling aging and in dealing with minor health problems. J Women Aging 2005; 17:83-98. [PMID: 15914421 DOI: 10.1300/j074v17n01_07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
Collapse
Affiliation(s)
- Philippe Voyer
- Faculty of Nursing, Laval University, Geriatric Research Group, Saint-Sacrement Hospital, Quebec, Canada.
| | | | | |
Collapse
|
60
|
Perri M, Menon AM, Deshpande AD, Shinde SB, Jiang R, Cooper JW, Cook CL, Griffin SC, Lorys RA. Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes. Ann Pharmacother 2005; 39:405-11. [PMID: 15671088 DOI: 10.1345/aph.1e230] [Citation(s) in RCA: 148] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Matthew Perri
- College of Pharmacy, University of Georgia, Athens, GA 30602-0002, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
61
|
Odegard PS, Goo A, Hummel J, Williams KL, Gray SL. Caring for poorly controlled diabetes mellitus: a randomized pharmacist intervention. Ann Pharmacother 2005; 39:433-40. [PMID: 15701763 DOI: 10.1345/aph.1e438] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Peggy S Odegard
- School of Pharmacy, University of Washington, 1959 NE Pacific Street, Seattle, WA 98195-7630, USA.
| | | | | | | | | |
Collapse
|
62
|
Silkey B, Preskorn SH, Golbeck A, Shah R, Neff M, Jones TL, Choi J. Complexity of medication use in the Veterans Affairs healthcare system: Part II. Antidepressant use among younger and older outpatients. J Psychiatr Pract 2005; 11:16-26. [PMID: 15650618 DOI: 10.1097/00131746-200501000-00003] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Beryl Silkey
- Via Christi Research Institute, Wichita, KS, USA
| | | | | | | | | | | | | |
Collapse
|
63
|
Fillenbaum GG, Hanlon JT, Landerman LR, Artz MB, O'Connor H, Dowd B, Gross CR, Boult C, Garrard J, Schmader KE. Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents. ACTA ACUST UNITED AC 2004; 2:92-101. [PMID: 15555485 DOI: 10.1016/s1543-5946(04)90014-1] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2004] [Indexed: 11/22/2022]
Abstract
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).
Collapse
Affiliation(s)
- Gerda G Fillenbaum
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
64
|
Wong I, Campion P, Coulton S, Cross B, Edmondson H, Farrin A, Hill G, Hilton A, Philips Z, Richmond S, Russell I. 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]. BMC Health Serv Res 2004; 4:11. [PMID: 15182379 PMCID: PMC441396 DOI: 10.1186/1472-6963-4-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2002] [Accepted: 06/07/2004] [Indexed: 11/30/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- I Wong
- School of Pharmacy, University of London, Brunswick Square, London WC1N 1AX
| | - P Campion
- Department of Public Health & Primary Care, The University of Hull, Hardy Building, Cottingham Road Hull HU6 7RX
| | - S Coulton
- Department of Health Sciences, University of York, Heslington, York YO10 5DD
| | - B Cross
- Department of Health Sciences, University of York, Heslington, York YO10 5DD
| | - H Edmondson
- Hull and East Riding Pharmacy Research Network, College House, Willerby Hill, Willerby HU10 6NS
| | - A Farrin
- Department of Health Sciences, University of York, Heslington, York YO10 5DD
| | - G Hill
- Hull and East Riding Pharmacy Research Network, College House, Willerby Hill, Willerby HU10 6NS
| | - A Hilton
- School of Pharmacy, University of Bradford, Richmond Road, Bradford BD7 1PD
| | - Z Philips
- Department of Economics, University of Nottingham, Nottingham NG10 5DD
| | - S Richmond
- Department of Public Health & Primary Care, The University of Hull, Hardy Building, Cottingham Road Hull HU6 7RX
| | - I Russell
- Institute of Medical and Social Care Research, University of Wales Bangor, Gwynedd LL57 2UW
| |
Collapse
|
65
|
Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, Francis SD, Branch LG, Lindblad CI, Artz M, Weinberger M, Feussner JR, Cohen HJ. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med 2004; 116:394-401. [PMID: 15006588 DOI: 10.1016/j.amjmed.2003.10.031] [Citation(s) in RCA: 231] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2003] [Revised: 10/02/2003] [Accepted: 10/20/2003] [Indexed: 01/19/2023]
Abstract
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.
Collapse
|
66
|
Hanlon JT, Artz MB, Pieper CF, Lindblad CI, Sloane RJ, Ruby CM, Schmader KE. Inappropriate medication use among frail elderly inpatients. Ann Pharmacother 2004; 38:9-14. [PMID: 14742785 DOI: 10.1345/aph.1d313] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Joseph T Hanlon
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, MN 55455, USA.
| | | | | | | | | | | | | |
Collapse
|
67
|
Howard M, Trim K, Woodward C, Dolovich L, Sellors C, Kaczorowski J, Sellors J. Collaboration Between Community Pharmacists and Family Physicians: Lessons Learned from the Seniors Medication Assessment Research Trial. J Am Pharm Assoc (2003) 2003; 43:566-72. [PMID: 14626748 DOI: 10.1331/154434503322452193] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- Michelle Howard
- Department of Family Medicine, McMaster University, HSC 2V10, Hamilton, Ontario, Canada.
| | | | | | | | | | | | | |
Collapse
|
68
|
Rojas-Fernandez CH. Inappropriate medications and older people: has anything changed over time? Ann Pharmacother 2003; 37:1142-4. [PMID: 12841831 DOI: 10.1345/aph.1d093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Carlos H Rojas-Fernandez
- Pharmacy Practice, School of Pharmacy, Texas Tech University, Health Sciences Center, Amarillo, TX, USA.
| |
Collapse
|
69
|
van Dijk KN, Pont LG, de Vries CS, Franken M, Brouwers JRBJ, de Jong-van den Berg LTW. Prescribing indicators for evaluating drug use in nursing homes. Ann Pharmacother 2003; 37:1136-41. [PMID: 12841830 DOI: 10.1345/aph.1c073] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Karen N van Dijk
- Department of Clinical Pharmacy, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
| | | | | | | | | | | |
Collapse
|
70
|
Etemad LR, Hay JW. Cost-effectiveness analysis of pharmaceutical care in a medicare drug benefit program. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2003; 6:425-435. [PMID: 12859583 DOI: 10.1046/j.1524-4733.2003.64255.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
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.
Collapse
Affiliation(s)
- Lida R Etemad
- Economic and Outcomes Research, Ingenix, Eden Prairie, MN, USA
| | | |
Collapse
|
71
|
Abstract
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.
Collapse
|
72
|
Hammons T, Piland NF, Small SD, Hatlie MJ, Burstin HR. Ambulatory patient safety. What we know and need to know. J Ambul Care Manage 2003; 26:63-82. [PMID: 12545516 DOI: 10.1097/00004479-200301000-00007] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- Terry Hammons
- Medical Group Management Association, Englewood, Colo., USA
| | | | | | | | | |
Collapse
|
73
|
Kassam R, Martin LG, Farris KB, Monsanto HA, Kaiser JM. Reliability of a Modified Medication Appropriateness Index in Community Pharmacies. Ann Pharmacother 2003. [DOI: 10.1177/106002800303700101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Rosemin Kassam
- Structured Pharmacy Education Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Linda G Martin
- Creighton University, Omaha, NE; Social and Administrative Pharmacy, School of Pharmacy, University of Wyoming, Laramie, WY
| | - Karen B Farris
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta; College of Pharmacy, University of Iowa, Iowa City, IA
| | - Homero A Monsanto
- Structured Pharmacy Education Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jean-Marie Kaiser
- Structured Pharmacy Education Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
74
|
Abstract
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.
Collapse
|
75
|
Abstract
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.
Collapse
Affiliation(s)
- Jane R Mort
- College of Pharmacy, South Dakota State University, Rapid City, South Dakota 57701, USA.
| | | |
Collapse
|
76
|
Hanlon JT, Fillenbaum GG, Kuchibhatla M, Artz MB, Boult C, Gross CR, Garrard J, Schmader KE. Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders. Med Care 2002; 40:166-76. [PMID: 11802089 DOI: 10.1097/00005650-200202000-00011] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Joseph T Hanlon
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
| | | | | | | | | | | | | | | |
Collapse
|
77
|
Giron MS, Wang HX, Bernsten C, Thorslund M, Winblad B, Fastbom J. The appropriateness of drug use in an older nondemented and demented population. J Am Geriatr Soc 2001; 49:277-83. [PMID: 11300238 DOI: 10.1046/j.1532-5415.2001.4930277.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- M S Giron
- Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Karolinska Institute, Stockholm, Sweden
| | | | | | | | | | | |
Collapse
|
78
|
Abstract
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.
Collapse
Affiliation(s)
- A J Muir
- Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA.
| | | | | | | |
Collapse
|
79
|
Abstract
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.
Collapse
Affiliation(s)
- J T Hanlon
- Institute for the Study of Geriatric Pharmacotherapy and the Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis 55455, USA
| | | | | | | |
Collapse
|
80
|
Pearson ML, Lee JL, Chang BL, Elliott M, Kahn KL, Rubenstein LV. Structured implicit review: a new method for monitoring nursing care quality. Med Care 2000; 38:1074-91. [PMID: 11078049 DOI: 10.1097/00005650-200011000-00003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- M L Pearson
- RAND Health, Santa Monica, California 90407-2138, USA.
| | | | | | | | | | | |
Collapse
|
81
|
Blakey SA, Hixson-Wallace JA. Clinical and economic effects of pharmacy services in geriatric ambulatory clinic. Pharmacotherapy 2000; 20:1198-203. [PMID: 11034043 DOI: 10.1592/phco.20.15.1198.34581] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
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.
Collapse
Affiliation(s)
- S A Blakey
- Department of Pharmacy Practice, Mercer University Southern School of Pharmacy, Atlanta, Georgia, USA
| | | |
Collapse
|
82
|
Spooner CH, Pickard AS, Menon D. 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. Med Care 2000; 38:948-58. [PMID: 10982116 DOI: 10.1097/00005650-200009000-00008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
Collapse
Affiliation(s)
- C H Spooner
- Division of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | | | | |
Collapse
|
83
|
Warholak-Juarez T, Rupp MT, Salazar TA, Foster S. Effect of Patient Information on the Quality of Pharmacists’ Drug Use Review Decisions. ACTA ACUST UNITED AC 2000. [DOI: 10.1016/s1086-5802(15)30396-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
84
|
Shelton PS, Fritsch MA, Scott MA. Assessing medication appropriateness in the elderly: a review of available measures. Drugs Aging 2000; 16:437-50. [PMID: 10939308 DOI: 10.2165/00002512-200016060-00004] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
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.
Collapse
Affiliation(s)
- P S Shelton
- Resources for Seniors, Inc., Raleigh, North Carolina, USA.
| | | | | |
Collapse
|
85
|
Hofer TP, Bernstein SJ, DeMonner S, Hayward RA. Discussion between reviewers does not improve reliability of peer review of hospital quality. Med Care 2000; 38:152-61. [PMID: 10659689 DOI: 10.1097/00005650-200002000-00005] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- T P Hofer
- Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor, Michigan 48113, USA.
| | | | | | | |
Collapse
|
86
|
Coste J, Venot A. An epidemiologic approach to drug prescribing quality assessment: a study in primary care practice in France. Med Care 1999; 37:1294-307. [PMID: 10599610 DOI: 10.1097/00005650-199912000-00012] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- J Coste
- Département de Biostatistique et d'Informatique Médicale, Faculté Cochin, Université Paris, France.
| | | |
Collapse
|
87
|
Chin MH, Wang LC, Jin L, Mulliken R, Walter J, Hayley DC, Karrison TG, Nerney MP, Miller A, Friedmann PD. Appropriateness of medication selection for older persons in an urban academic emergency department. Acad Emerg Med 1999; 6:1232-42. [PMID: 10609925 DOI: 10.1111/j.1553-2712.1999.tb00139.x] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- M H Chin
- Section of General Internal Medicine, University of Chicago, IL 60637, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
88
|
Spooner CH, Pickard AS, Menon D. Drug utilization reviews of oral quinolone, cephalosporin, and macrolide use in nonacute care: a systematic review. Clin Ther 1999; 21:1951-72. [PMID: 10890266 DOI: 10.1016/s0149-2918(00)86742-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- C H Spooner
- Institute of Health Economics, University of Alberta, Edmonton, Canada
| | | | | |
Collapse
|
89
|
Schmidt I, Claesson CB, Westerholm B, Svarstad BL. Resident characteristics and organizational factors influencing the quality of drug use in Swedish nursing homes. Soc Sci Med 1998; 47:961-71. [PMID: 9722115 DOI: 10.1016/s0277-9536(98)00169-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
Collapse
|
90
|
Cantrill JA, Sibbald B, Buetow S. Indicators of the appropriateness of long-term prescribing in general practice in the United Kingdom: consensus development, face and content validity, feasibility, and reliability. Qual Health Care 1998; 7:130-5. [PMID: 10185138 PMCID: PMC2483608 DOI: 10.1136/qshc.7.3.130] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
Collapse
Affiliation(s)
- J A Cantrill
- National Primary Care Research and Development Centre, University of Manchester, UK
| | | | | |
Collapse
|
91
|
Hanlon JT, Schmader KE, Koronkowski MJ, Weinberger M, Landsman PB, Samsa GP, Lewis IK. Adverse drug events in high risk older outpatients. J Am Geriatr Soc 1997; 45:945-8. [PMID: 9256846 DOI: 10.1111/j.1532-5415.1997.tb02964.x] [Citation(s) in RCA: 271] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
Collapse
Affiliation(s)
- J T Hanlon
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina, USA
| | | | | | | | | | | | | |
Collapse
|
92
|
Buetow SA, Sibbald B, Cantrill JA, Halliwell S. Appropriateness in health care: application to prescribing. Soc Sci Med 1997; 45:261-71. [PMID: 9225413 DOI: 10.1016/s0277-9536(96)00342-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- S A Buetow
- National Primary Care Research and Development Centre, University of Manchester, UK
| | | | | | | |
Collapse
|
93
|
Moride Y, Melnychuk D, Monette J, Abenhaim L. Determinants of initiation and suboptimal use of anti-ulcer medication: a study of the Quebec older population. J Am Geriatr Soc 1997; 45:853-6. [PMID: 9215338 DOI: 10.1111/j.1532-5415.1997.tb01514.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Y Moride
- Centre for Clinical Epidemiology and Community Studies, McGill University S.M.B.D. Jewish General Hospital, Montreal, Quebec, Canada
| | | | | | | |
Collapse
|
94
|
Fitzgerald LS, Hanlon JT, Shelton PS, Landsman PB, Schmader KE, Pulliam CC, Williams ME. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother 1997; 31:543-8. [PMID: 9161645 DOI: 10.1177/106002809703100503] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- L S Fitzgerald
- School of Pharmacy, University of North Carolina, Chapel Hill, USA
| | | | | | | | | | | | | |
Collapse
|
95
|
Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother 1997; 31:529-33. [PMID: 9161643 DOI: 10.1177/106002809703100501] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- K E Schmader
- Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | | | | | | | | | | |
Collapse
|
96
|
Shelton PS, Hanlon JT, Landsman PB, Scott MA, Lewis IK, Schmader KE, Samsa GP, Weinberger M. Reliability of drug utilization evaluation as an assessment of medication appropriateness. Ann Pharmacother 1997; 31:533-42. [PMID: 9161644 DOI: 10.1177/106002809703100502] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- P S Shelton
- School of Pharmacy, Campbell University, Dorothea Dix Hospital, Raleigh, NC 27603, USA
| | | | | | | | | | | | | | | |
Collapse
|
97
|
Hanlon JT, Fillenbaum GG, Studenski SA, Ziqubu-Page T, Wall WE. Factors associated with suboptimal analgesic use in community-dwelling elderly. Ann Pharmacother 1996; 30:739-44. [PMID: 8826552 DOI: 10.1177/106002809603000706] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- J T Hanlon
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | | | | | | |
Collapse
|
98
|
Hanlon JT, Weinberger M, Samsa GP, Schmader KE, Uttech KM, Lewis IK, Cowper PA, Landsman PB, Cohen HJ, Feussner JR. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med 1996; 100:428-37. [PMID: 8610730 DOI: 10.1016/s0002-9343(97)89519-8] [Citation(s) in RCA: 396] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
Collapse
Affiliation(s)
- J T Hanlon
- Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
99
|
Smith DM, Cox MR, Brizendine EJ, Hui SL, Freedman JA, Martin DK, murray MD. An intervention on discharge polypharmacy. J Am Geriatr Soc 1996; 44:416-9. [PMID: 8636588 DOI: 10.1111/j.1532-5415.1996.tb06413.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
Collapse
Affiliation(s)
- D M Smith
- Division of General Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN 46204, USA
| | | | | | | | | | | | | |
Collapse
|
100
|
Hershman DL, Simonoff PA, Frishman WH, Paston F, Aronson MK. Drug utilization in the old old and how it relates to self-perceived health and all-cause mortality: results from the Bronx Aging Study. J Am Geriatr Soc 1995; 43:356-60. [PMID: 7706623 DOI: 10.1111/j.1532-5415.1995.tb05807.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- D L Hershman
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | | | | |
Collapse
|