The Health System Costs of Potentially Inappropriate Prescribing: A Population-Based, Retrospective Cohort Study Using Linked Health Administrative Databases in Ontario, Canada

The impact of patient-facility language discordance on potentially inappropriate prescribing of antipsychotics in long-term care home in Ontario, Canada: a retrospective population health cohort study

BACKGROUND

Appropriate use of medication is a key indicator of the quality of care provided in long-term care (LTC). The objective of this study was to determine whether resident-facility language concordance/discordance is associated with the odds of potentially inappropriate prescribing of antipsychotics (PIP-AP) in LTC.

METHODS

We conducted a population-based, retrospective cohort study of LTC residents in Ontario, Canada from 2010 to 2019. We obtained resident language from standardized resident assessments, and derived facility language by determining the proportion of residents belonging to each linguistic group within individual LTC homes. Using linked administrative databases, we identified all instances of PIP-AP during a 1-year follow-up period. PIP-AP was defined using the STOPP-START criteria, which have previously been shown to predict adverse clinical events such as emergency department (ED) visits and hospitalizations. The association between linguistic factors and PIP-AP was assessed using adjusted multivariable logistic regression analysis.

RESULTS

We identified 198,729 LTC residents consisting of 162,814 Anglophones (81.9%), 6,230 Francophones (3.1%), and 29,685 Allophones (14.9%). The odds of PIP-AP of were higher for both Francophones (aOR 1.15, 95% CI 1.08-1.23) and Allophones (aOR 1.11, 95% CI 1.08-1.15) when compared to Anglophones. When compared to English LTC homes, French LTC homes had greater odds of PIP-AP (aOR 1.12, 95% CI 1.05-1.20), while Allophone homes had lower odds of PIP-AP (aOR 0.82, 95% CI 0.77-0.86). Residents living in language-discordant LTC homes had higher odds of PIP-AP when compared to LTC residents living in language-concordant LTC homes (aOR 1.07, 95% CI 1.04-1.10).

CONCLUSION

This study identified linguistic factors related to the odds of PIP-AP in LTC, suggesting that the linguistic environment may have an impact on the quality of care provided to residents.

Enhancing medication management of older adults in Qatar: healthcare professionals' perspectives on challenges, barriers and enabling solutions

Background

Polypharmacy and potentially inappropriate medications are significant challenges in older adults' medication management. The Consolidated Framework for Implementation Research (CFIR) is a comprehensive approach used to explore barriers and enablers to the healthcare system in guiding the effective implementation of evidence-based practices.

Objectives

This study examines the barriers and enablers to promote safe medication management among older adults in Qatar from healthcare professionals' perspectives. This includes identifying critical factors within the healthcare system influencing medication management and suggesting practical solutions to improve it.

Design

The study employs a qualitative design. Focus Groups (FGs) were conducted with healthcare professionals from the geriatric, mental health and medicine departments of Hamad Medical Corporation (HMC), the leading governmental sector in Qatar serving the older adult population.

Methods

Utilising the CFIR, this study analysed feedback from healthcare professionals through FGs at HMC. A combined inductive and deductive thematic analysis was applied to transcripts from five FGs, focusing on identifying barriers and enablers to safe medication management among older adults. Two researchers transcribed the audio-recorded FG discussions verbatim, and two researchers analysed the data using a mixed inductive and deductive thematic analysis approach utilising CFIR constructs.

Results

We engaged 53 healthcare professionals (31 physicians, 10 nurses and 12 clinical pharmacists) in FGs. The analysis identified current barriers and enabler themes under different CFIR constructs, including inner settings, outer settings, individual characteristics and intervention characteristics. We identified 44 themes, with 25 classifieds as barriers and 19 as enablers. The findings revealed that barriers and enablers within the inner settings were primarily related to structural characteristics, resources, policies, communication and culture. On the other hand, barriers and enablers from the outer settings included patients and caregivers, care coordination, policies and laws, and resources.

Conclusion

This study identified several barriers and enablers to promote medication management for older adults using the CFIR constructs from the perspective of healthcare professionals. The multifaceted findings emphasise involving stakeholders like clinical leaders, policymakers and decision-makers to address medication safety factors. A robust action plan, continuously monitored under Qatar's national strategy, is vital. Further research is needed to implement recommended interventions.

Lists of potentially inappropriate medications for older people in primary care: a systematic review of health outcomes

This study is a systematic literature review of the association between lists of potentially inappropriate medications (PIM) in clinical practice and health outcomes of older adults followed up in primary health care. For this purpose, the PRISMA protocol was used to systematize the search for articles in the PubMed, Web of Science, Scopus, Cochrane Central, LIVIVO and LILACS databases, in addition to the gray literature. Studies with randomized clinical trials were selected, using explicit criteria (lists) for the identification and management of PIM in prescriptions of older patients in primary care. Of the 2,400 articles found, six were used for data extraction. The interventions resulted in significant reductions in the number of PIM and adverse drug events and, consequently, in potentially inappropriate prescriptions (PIP) in polymedicated older adults. However, there were no significant effects of the interventions on negative clinical outcomes, such as emergency room visits, hospitalizations and death, or on improving the health status of the older adults. The use of PIM lists promotes adequate medication prescriptions for older adults in primary health care, but further studies are needed to determine the impact of reducing PIM on primary clinical outcomes.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

OBJECTIVES

This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada.

DESIGN

Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0).

SETTING AND PARTICIPANTS

LTC residents in Ontario between January 1, 2016, and December 31, 2019.

METHODS

We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models.

RESULTS

The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria.

CONCLUSIONS AND IMPLICATIONS

This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

CHIME-GP trial of online education for prescribing, pathology and imaging ordering in general practice - how did it bring about behaviour change?

BACKGROUND

There is a need for scalable clinician education in rational medication prescribing and rational ordering of pathology and imaging to help improve patient safety and enable more efficient utilisation of healthcare resources. Our wider study evaluated the effectiveness of a multifaceted education intervention for general practitioners (GPs) in rational prescribing and ordering of pathology and imaging tests, in the context of Australia's online patient-controlled health record system, My Health Record (MHR), and found evidence for measurable behaviour change in pathology ordering among participants who completed the educational activities. This current study explored the mechanisms of behaviour change brought about by the intervention, with a view to informing the development of similar interventions in the future.

METHODS

This mixed methods investigation used self-reported questionnaires at baseline and post-education on MHR use and rational prescribing and test ordering. These were analysed using multi-level ordinal logistic regression models. Semi-structured interviews pre- and post-intervention were also conducted and were analysed thematically using the COM-B framework.

RESULTS

Of the 106 GPs recruited into the study, 60 completed baseline and 37 completed post-education questionnaires. Nineteen participants were interviewed at baseline and completion. Analysis of questionnaires demonstrated a significant increase in confidence using MHR and in self-reported frequency of MHR use, post-education compared with baseline. There were also similar improvements in confidence across the cohort pre-post education in deprescribing, frequency of review of pathology ordering regimens and evidence-based imaging. The qualitative findings showed an increase in GPs' perceived capability with, and the use of MHR, at post-education compared with baseline. Participants saw the education as an opportunity for learning, for reinforcing what they already knew, and for motivating change of behaviour in increasing their utilisation of MHR, and ordering fewer unnecessary tests and prescriptions.

CONCLUSIONS

Our education intervention appeared to provide its effects through providing opportunity, increasing capability and enhancing motivation to increase MHR knowledge and usage, as well as rational prescribing and test ordering behaviour. There were overlapping effects of skills acquisition and confidence across intervention arms, which may have contributed to wider changes in behaviour than the specific topic area addressed in the education.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12620000010998) (09/01/2020).

Optimizing pharmacotherapy and deprescribing strategies in older adults living with multimorbidity and polypharmacy: EuGMS SIG on pharmacology position paper

Inappropriate polypharmacy is highly prevalent among older adults and presents a significant healthcare concern. Conducting medication reviews and implementing deprescribing strategies in multimorbid older adults with polypharmacy are an inherently complex and challenging task. Recognizing this, the Special Interest Group on Pharmacology of the European Geriatric Medicine Society has compiled evidence on medication review and deprescribing in older adults and has formulated recommendations to enhance appropriate prescribing practices. The current evidence supports the need for a comprehensive and widespread transformation in education, guidelines, research, advocacy, and policy to improve the management of polypharmacy in older individuals. Furthermore, incorporating deprescribing as a routine aspect of care for the ageing population is crucial. We emphasize the importance of involving geriatricians and experts in geriatric pharmacology in driving, and actively participating in this transformative process. By doing so, we can work towards achieving optimal medication use and enhancing the well-being of older adults in the generations to come.

Health care system costs related to potentially inappropriate medication use involving opioids in older adults in Canada

BACKGROUND

Older adults are at risk of potentially inappropriate medication use given polypharmacy, multimorbidity, and age-related changes, which contribute to the growing burden associated with opioid use. The objective of this study was to estimate the costs of health service utilization attributable to opioid use and potentially inappropriate medication use involving opioids in older adults in a public health care system.

METHODS

The sample included 1201 older adults consulting in primary care, covered by the public drug plan, without a cancer diagnosis and opioid use in the year before interview. Secondary analyses were conducted using two data sources: health survey and provincial administrative data. Health system costs included inpatient and outpatient visits, physician billing, and medication costs. Unit costs were calculated using annual financial and activity reports from 2013-2014, adjusted to 2022 Canadian dollars. Opioid use and potentially inappropriate medication use involving opioids were identified over 3 years. Generalized linear models with gamma distribution were employed to model 3-year costs associated with opioid use and potentially inappropriate medication use involving opioids. A phase-based approach was implemented to provide descriptive results on the costs associated with each phase: i) no use, ii) opioid use, and iii) potentially inappropriate medication use involving opioids.

RESULTS

Opioid use and potentially inappropriate medication use involving opioids were associated with adjusted 3-year costs of $2,222 (95% CI: $1,179-$3,264) and $8,987 (95% CI: $7,370-$10,605), respectively, compared to no use. In phase-based analyses, costs were the highest during inappropriate use.

CONCLUSIONS

Potentially inappropriate medication use involving opioids is associated with higher costs compared to those observed with opioid use and no use. There is a need for more effective use of health care resources to reduce costs for the health care system.

Can peer effects explain prescribing appropriateness? a social network analysis

BACKGROUND

Optimizing prescribing practices is important due to the substantial clinical and financial costs of polypharmacy and an increasingly aging population. Prior research shows the importance of social relationships in driving prescribing behaviour. Using social network analysis, we examine the relationship between a physician practices' connectedness to peers and their prescribing performance in two German regions.

METHODS

We first mapped physician practice networks using links established between two practices that share 8 or more patients; we calculated network-level (density, average path length) and node-level measures (degree, betweenness, eigenvector). We defined prescribing performance as the total number of inappropriate medications prescribed or appropriate medications not prescribed (PIMs) to senior patients (over the age of 65) during the calendar year 2016. We used FORTA (Fit fOR The Aged) algorithm to classify medication appropriateness. Negative binomial regression models estimate the association between node-level measures and prescribing performance of physician practices controlling for patient comorbidity, provider specialization, percentage of seniors in practice, and region. We conducted two sensitivity analyses to test the robustness of our findings - i) limiting the network mapping to patients younger than 65; ii) limiting the network ties to practices that share more than 25 patients.

RESULTS

We mapped two patient-sharing networks including 436 and 270 physician practices involving 28,508 and 20,935 patients and consisting of 217,126 and 154,274 claims in the two regions respectively. Regression analyses showed a practice's network connectedness as represented by degree, betweenness, and eigenvector centrality, is significantly negatively associated with prescribing performance (degree-bottom vs. top quartile aRR = 0.04, 95%CI: 0.035,0.045; betweenness-bottom vs. top quartile aRR = 0.063 95%CI: 0.052,0.077; eigenvector-bottom vs. top quartile aRR = 0.039, 95%CI: 0.034,0.044).

CONCLUSIONS

Our study provides evidence that physician practice prescribing performance is associated with their peer connections and position within their network. We conclude that practices occupying strategic positions at the edge of networks with advantageous access to novel information are associated with better prescribing outcomes, whereas highly connected practices embedded in insulated information environments are associated with poor prescribing performance.

Randomised trial of general practitioner online education for prescribing and test ordering

INTRODUCTION

Potentially inappropriate medicine prescriptions and low-value diagnostic testing pose risks to patient safety and increases in health system costs. The aim of the Clinical and Healthcare Improvement through My Health Record usage and Education in General Practice study was to evaluate a scalable online quality improvement intervention, integrating online education regarding a national shared electronic health record and rational prescribing, pathology and imaging ordering by Australian general practitioners (GPs).

METHODS

The study was a parallel three-arm randomised trial comprising a prescribing education arm, a pathology education arm and an imaging education arm. Currently practising GPs in Australia were eligible to participate and randomised on a 1:1:1 basis to the study arms after consenting. The response to the intervention in reducing potentially unnecessary medicine prescriptions and tests in each arm was assessed using the other two arms as controls. The primary outcome was the cost per 100 consultations of predefined medication prescriptions, pathology and radiology test ordering 6 months following the intervention, compared with 6 months prior. Outcomes were assessed on intention-to-treat and post hoc per-protocol bases using multilevel regression models, with the analysts blinded to allocation.

RESULTS

In total, 106 GPs were enrolled and randomised (prescribing n=35, pathology n=36, imaging n=35). Data were available for 97 GPs at the end of trial (prescribing n=33, pathology n=32, imaging n=32) with 44 fully completing the intervention. In intention-to-treat analysis, there were no significant differences in the rates of change in costs across the three arms. Per protocol, there was a statistically significant difference in the rate of change in pathology costs (p=0.03). In the pathology arm, the rate of increase in pathology costs was significantly lower by $A187 (95% CI -$A340, -$A33) than the prescribing arm, and non-significantly $A9 (95% CI -$A128, $A110) lower than the imaging arm.

DISCUSSION

This study provides some evidence for reductions in costs for low-value pathology test ordering in those that completed the relevant online education. The study experienced slow uptake and low completion of the education intervention during the COVID-19 pandemic. Changes were not significant for the primary endpoint, which included all participants. Improving completion rates and combining real-time feedback on prescribing or test ordering may increase the overall effectiveness of the intervention. Given the purely online delivery of the education, there is scope for upscaling the intervention, which may provide cost-effectiveness benefits.

TRIAL REGISTRATION NUMBER

ACTRN12620000010998.

It's time to take a sustainable approach to health care in the face of the challenges of the 21st century

Health challenges in the 21st century have become increasingly complex and global. The recent COVID-19 pandemic has only exacerbated the many problems faced by health care systems around the world and sadly, exposed various flaws. With ageing populations, particularly in Canada, as well as unavoidable factors such as globalization and accelerating climate change, it is becoming imperative to implement a new health care approach based on intersectorality and interdisciplinarity. Furthermore, links must be forged between all the stakeholders, i.e. the researchers, the health system and its specialists, the communities and the individuals themselves. It is in this perspective, where everyone concerned must be equally involved in attaining a better quality of life, that the concepts of One Health and sustainable health must be deployed.

Association of potentially inappropriate medications and need for long-term care among older adults: a matched cohort study

BACKGROUND

With an increase in the aging population, the number of older adults who require long-term care (LTC) is growing, enhancing drug-related issues. The reduced capacity of LTC users to precisely utilize medical services poses additional challenges owing to restrictions in daily activities. We compared older adults who required LTC with those who did not require LTC to confirm differences in the use of potentially inappropriate medications (PIMs), frequently used PIMs, and associating factors in Korea.

METHODS

Using the Korean National Health Insurance Service cohort data, adults aged ≥ 65 years as of 2017 who were LTC beneficiaries (at home and LTC facilities) were selected and matched 1:1 with a control group (LTC non-beneficiaries). PIM was defined based on the 2019 American Society of Geriatrics Beers criteria. PIM use and medical resource utilization according to LTC requirements were compared for one year after the index date. After correcting for other confounding variables, differences in the risk of PIM use on person-based according to LTC eligibility were assessed using multivariate logistic regression.

RESULTS

Among the 13,251 older adults requiring LTC in 2017, 9682 were matched with counterparts and included. Among those who received an outpatient prescription including PIM at least once yearly, 83.6 and 87.6% were LTC beneficiaries and LTC non-beneficiaries, respectively (p < 0.001). Using the number of outpatient prescriptions as the baseline, 37.2 and 33.2% were LTC beneficiaries and LTC non-beneficiaries, respectively (p < 0.001). In both groups, elevated PIM use depended on increased medical resource utilization, as shown by increased outpatient visits and medical care institutions visited. Adjusting other influencing factors, the need for LTC did not significantly associated with PIM use (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.84-1.04); the number of drugs consumed (3-4: OR 1.42, 95% CI 1.25-1.61; 5-9: OR 2.24, 95% CI 1.98-2.53; 10 and more: OR 3.72, 95% CI 3.03-4.55; reference group: 2 and less), frequency of visits (7-15: OR 1.95, 95% CI 1.71-2.23; 16-26: OR 3.51, 95% CI 3.02-4.07; 27-42: OR 5.84, 95% CI 4.84-7.05; 43 and more: OR 10.30, 95% CI 8.15-13.01; reference group: 6 and less), and visits to multiple medical care institutions (3-4: OR 1.96, 95% CI 1.76-2.19; 5 and more: OR 3.21, 95% CI 2.76-3.73; reference group: 2 and less) emerged as primary influencing factors. PIMs mainly prescribed included first-generation antihistamines, benzodiazepines, and Z-drugs in both groups; quetiapine ranked second-highest among LTC beneficiaries.

CONCLUSIONS

The LTC demand did not significantly associated with PIM utilization. However, the number of drugs consumed, and the pattern of medical resource use were important factors, regardless of LTC requirements. This highlights the need to implement comprehensive drug management focusing on patients receiving polypharmacy and visiting multiple care institutions, regardless of LTC needs.

Healthcare costs of adverse drug reactions and potentially inappropriate prescribing in older adults: a population-based study

OBJECTIVES

To describe the distribution of costs based on potentially inappropriate prescribing (PIP) and adverse drug reaction (ADR) status in terms of total direct costs and costs caused by ADRs, among older adults.

DESIGN

A retrospective cohort study was conducted among older adults, identified from a random sample of the general Swedish population. PIP was identified based on the Screening Tool of Older Persons' Prescriptions (STOPP) criteria and ADRs were identified using the Howard criteria. Causality between PIP and ADRs was evaluated using Hallas' criteria. Prevalence-based direct healthcare costs were calculated for the 3-month study period, including the total cost for healthcare and drugs, and the cost caused by ADRs.

SETTING

All care levels, including primary care, other outpatient care and inpatient care.

PARTICIPANTS

813 adults ≥65 years.

PRIMARY OUTCOME MEASURES

The prevalence and cost of PIP and ADRs.

RESULTS

Total direct cost for persons with PIP was approximately twice the total cost of those without PIP (€1958 (€1428-€2616) vs €881 (€817-€1167), p=0.0020). The costs caused by ADRs was 10 times higher among persons with PIP, compared with those without PIP (€270 (€86-€545) vs €27 (€10-€61), p=0.047). For persons with ADRs caused by PIP, total direct costs were €4646 (€2617-€7931). This group represented 8% of the study population and used 25% of the costs. The main cost driver in all studied patient groups was healthcare contacts.

CONCLUSIONS

Older persons with PIP and ADRs had high healthcare costs, particularly when ADRs were caused by PIP. Since these costs appear to be substantial, the potential savings by preventing their occurrence may, to a certain degree, cover the added cost of such activities. Further studies should be undertaken to provide further evidence on the costs of PIP, ADRs and ADRs caused by PIP.

Healthcare Costs Associated with Potentially Inappropriate Medication Prescribing Detected by Computer Algorithm Among Older Patients

INTRODUCTION

Potentially inappropriate medication prescribing (PIP) among older patients is associated with an increased risk of adverse events and hospitalization, and sometimes increased healthcare costs.

OBJECTIVE

The aim of this study was to explore the association between healthcare costs and PIP exposure among older patients.

METHODS

Analyses were conducted using data from the Multidomain Alzheimer Preventive Trial (MAPT). A computer algorithm was constructed to detect PIP based on various different explicit criteria-based tools, and the results were expressed in number of medication-related potential non-compliances (MRNCs). A prescription was considered potentially inappropriate if there were one or more MRNCs. We performed a cost analysis from the French National Health Insurance perspective, and also performed a multivariate analysis to identify the association between healthcare costs and PIP (number of MRNCs).

RESULTS

The computer algorithm analyzed medication prescribing from included patients (N = 1525 aged 75.3 ± 4.4 years; 64% women [n = 978]). PIP was associated with increased total healthcare costs and non-medication healthcare costs after adjusting for potential confounders. We also noted that healthcare costs tended to increase with the number of MRNCs. The mean additional healthcare costs were €517, €921, and €1669 per patient and year for patients with one or two MRNCs, three or four MRNCs, and five or more MRNCs, respectively, in comparison with patients with appropriate medication prescriptions.

CONCLUSION

These observations led us to conclude that interventions focused on reducing PIP could result in savings.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00672685.

Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study

BACKGROUND

Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France.

METHODS

A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population.

RESULTS

The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million).

CONCLUSIONS

PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.

Patient- and Prescriber-Related Factors Associated with Potentially Inappropriate Medications and Drug-Drug Interactions in Older Adults

We aimed to evaluate the prevalence of potentially inappropriate medication (PIM) use and drug–drug interactions (DDIs) in older adults and their associated factors. This cross-sectional study used National Health Insurance data of older adults in South Korea. The 2015 AGS Beers Criteria were used to classify PIM use and DDIs. The associations of PIM use and DDIs with patient- and prescriber-related factors were evaluated using multiple logistic regression. Of the older adults who received at least one outpatient prescription (N = 1,277,289), 73.0% and 13.3% received one or more prescriptions associated with PIM use or DDIs, respectively. Chlorphenamine was most commonly associated with PIM, followed by diazepam. Co-prescriptions of corticosteroids and NSAIDs accounted for 82.8% of DDIs. Polypharmacy and mainly visiting surgeons or neurologists/psychiatrists were associated with a higher likelihood of prescriptions associated with PIM use or DDIs. Older age, high continuity of care (COC), and mainly visiting a hospital were associated with a lower likelihood of PIM use or DDIs. Prescriptions associated with PIM use and DDIS were more frequent for low COC patients or those who mainly visited clinics; therefore, patients with these characteristics are preferred intervention targets for reducing prescriptions associated with PIM use and DDIs.

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review

Purpose

To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy.

Methods

We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs.

Results

Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability.

Conclusion

Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Medication use and its impact on high-cost health care users among older adults: protocol for the population-based matched cohort HiCOSTT study

BACKGROUND

Health interventions and policies for high-cost health care users (HCUs) who are older adults need to be informed by a better understanding of their multimorbidity and medication use. This study aims to determine the financial contribution of medications to HCU expenditures and explore whether potentially inappropriate prescribing is associated with incident HCU development.

METHODS

This is a protocol for a retrospective population-based matched cohort analysis of incident older adult HCUs (those with the highest 5% of costs and 66 years of age or older) in Ontario during fiscal year 2013. We will obtain person-level data for the index year and year before HCU status from health administrative databases and match each HCU to 3 non-HCUs based on age, sex and geographic location. Average annual medication costs (per patient) and the ratio of medication to total health care costs (at population level) will be examined over the HCU transition period and compared with non-HCUs. We will explore potential quality improvement areas for prescribing by analyzing chronic conditions and the use of medications with a strong evidence base for either clinical benefit or risk of harms outweighing benefits in older adults with these diagnoses. The relation between these medication classes and incident HCU status will be explored using logistic regression.

INTERPRETATION

Using a matched cohort design and focusing on incident rather than prevalent HCUs, this protocol will explore our hypotheses that medications and the quality of their prescribing may be important triggers of HCU status and facilitate the identification of potential preventive clinical interventions or policies. Dissemination of results will occur via publications in peer-reviewed journals, presentations at conferences and academic settings, and knowledge translation activities with relevant health system and patient stakeholder groups.

STUDY REGISTRATION

Clinicaltrials.gov, no. NCT02815930.

Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil

BACKGROUND

Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population.

OBJECTIVES

To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors.

DESIGN AND SETTING

This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations.

METHODS

Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription.

RESULTS

In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications.

CONCLUSIONS

High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.

It Won't Be Easy: How to Make Universal Pharmacare Work in Canada

One of the glaring gaps in Canada’s universal healthcare system is the low level of public financing of prescription drugs - 42.7% of total spending in 2018. At the federal level there is renewed interest in moving towards universal coverage, supported by a recently commissioned report on how to achieve it. It will take superb political navigation to extract Canadian pharmaceutical policy and practice from the grasp of interests that profit handsomely from the status quo. This perspective suggests the conditions under which a genuinely fair, effective, and efficient pharmacare plan can emerge.