Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use

Physicians’ Knowledge, Altitudes, and Perceived Barriers of Inappropriate Prescribing for Older Patients in Shanghai, China

Background: Inappropriate medication use is common around the world, particularly among older patients, and, despite potentially being preventable, often leads to adverse clinical and economic outcomes. However, there is a dearth of information regarding this prominent issue in China.

Objectives: To evaluate the extent to which the physician can correctly identify potentially inappropriate medication (PIM) in older patients and to understand physicians’ attitudes towards improving PIM knowledge.

Methods: An online, cross-sectional survey was conducted anonymously among practicing physicians in China from November through December 2020. Knowledge of PIM was accessed using seven clinical vignettes covering a wide variety of therapeutic areas. Source of information and perceived barriers regarding PIM were also evaluated. We performed the ordinary least square regression analysis to understand the potential factors related to physicians’ knowledge of PIM.

Results: A total of 597 study participants were included in the analysis. More than half of them had never heard of any screening tool for PIMs (n = 328, 54.9%) and the most frequently acknowledged tool was the China PIM Criteria (n = 259, 43.4%). For the seven clinical vignettes testing physicians’ knowledge on the medications that should be generally avoided in older patients, the mean score was 2.91 points out of 7 (SD: 1.32), with the median score of three points (IQR: 2–4). Only one-third of the respondents were feeling confident when prescribing for older patients (n = 255, 35.08%). Package inserts have been used as the major source of PIM information (always, n = 177, 29.65%; frequently, n = 286, 47.91%). Perceived barriers to appropriate prescribing include polypharmacy (n = 460, 77.05%), lack of formal education on prescribing for the older patients (n = 428, 71.69%).

Conclusion: In this online survey evaluating physicians’ ability to detect PIM for older patients, approximately 40% of PIM were recognized, suggesting an insufficient level of knowledge about appropriate prescribing.

Use of potentially inappropriate medications for heart failure according to the three sets of heart failure-specific criteria in Thai older patients with heart failure

OBJECTIVE

To study the prevalence of potentially inappropriate medications for patients with heart failure (PIMHF) use and to identify factors associated with PIMHF use in Thai older HF patients.

METHODS

This cross-sectional analytical survey included data on older (≥ 60 years) HF patients obtained from the electronic medical record databases of secondary- and tertiary-care hospitals. The medication profiles of patients were assessed to examine whether they were prescribed any PIMHF after an HF diagnosis. For PIMHF detection, the HF-specific criteria, including 2014 St Vincent criteria, 2019 Beers criteria, and 2021 Thailand criteria were applied. The prevalence of PIMHF use was expressed as percentages. The associated factors were identified using a binary logistic regression analysis, expressed as the adjusted odds ratio (aOR) and 95% confidence interval (95% CI).

RESULTS

A total of 2,639 patients were included in the study. Thirty-two PIMHF were found to have been prescribed to these patients. The prevalence of PIMHF use identified by the ST Vincent criteria, the Beers criteria, the Thailand criteria, and the three combined criteria was 23.76%, 19.67%, 21.18%, and 25.16%, respectively. The factors associated with PIMHF use were secondary-care hospital (aOR = 1.54, 95% CI: 1.26-1.87), HF with preserved ejection fraction (HFpEF) (aOR = 1.81, 95% CI: 1.38-2.38), hypertension (HTN) (aOR = 1.24, 95% CI: 1.02-1.51), diabetes mellitus (DM) (aOR = 1.39, 95% CI: 1.10-1.75), chronic pulmonary diseases (CPD) (aOR = 2.09, 95% CI: 1.56-2.80), and connective tissue diseases (CTD) (aOR = 5.10, 95% CI: 2.20-11.83).

CONCLUSIONS

PIMHF are commonly used in Thai older HF patients. The factors associated with PIMHF use identified in this study include secondary-care hospital, HFpEF, HTN, DM, CPD, and CTD.

Potentially Inappropriate Medication and Polypharmacy in Nursing Home Residents: A Cross-Sectional Study

Inappropriate prescribing in the elderly is a risk factor for higher adverse drugs reactions, hospitalisation, and mortality rates. Therefore, it is necessary to identify irrational prescriptions and implement interventions to improve geriatric clinical practices in nursing homes. This study aimed to examine and compare the prevalence of potentially inappropriate medications in nursing home residents using three different updated criteria: 2019 Beers criteria, PRISCUS list, and v2 STOPP criteria, and to determine the prevalence of potential prescribing omissions according to v2 START criteria. A descriptive, observational, and cross-sectional study design was used. A total of 218 residents were involved in this study. Data on drug use were collected from medical charts. Information was screened with the software CheckTheMeds. Potentially inappropriate medications were present in 96.3%, 90.8%, and 35.3% of residents, according to the STOPP, Beers, and PRISCUS criteria or list, respectively. Inappropriate medication was found to be significantly associated with polypharmacy and severe or moderate drug–drug interactions with the three tools and with pathologies and unnecessary drugs only for STOPP criteria. The most frequent inappropriate medications were benzodiazepines and proton pump inhibitors. A regular use of software to review medications in nursing home residents would help to reduce the risk of these drug-related problems.

Prevalence and Factors that Influence Potentially Inappropriate Medication Use among Thai Elderly in Primary Care Settings

Background

Older age increases the likelihood of chronic diseases and polypharmacy with the likelihood of potentially inappropriate medications (PIMs) in secondary and tertiary care levels, but in the primary care settings of Thailand there still is a need for more evidence. This study aimed to examine the prevalence of PIM in primary care settings, and to identify factors that influence the use of PIM.

Methods

A cross-sectional retrospective study was conducted in 2017. Eight primary care units from four regions of Thailand were randomly selected. People aged ≥ 60 years in the eight units were studied as participants. The List of Risk Drugs for Thai Elderly (LRDTE) was used as the reference. Multivariate logistic regression was carried out to identify factors that influence.

Results

A total of 4,848 patients aged ≥60 years with 20,671 prescriptions were studied. The mean age was 70.7±8.3 years for males, and 61.2% for females. A little more than 5% (5.1%) had ≥ 3 chronic diseases and 15.0% received polypharmacy (≥5 medications). The prevalence of prescriptions with PIMs was 65.9%. The most frequent PIMs were antidepressants: amitriptyline (28.1%), antihistamines: dimenhydrinate (22.4%) and chlorpheniramine maleate (CPM) (11.2%); and Benzodiazepines: lorazepam (6.5%). Three factors that significantly influenced prescribing of PIMs were polypharmacy (adjusted OR 3.51; 95% CI 2.81-4.32), having ≥3 chronic diseases (adjusted OR 1.44; 95% CI 1.04-2.01), and age ≥75 years (adjusted OR 1.18; 95% CI 1.01-1.38).

Conclusion

More than two-thirds of elderly Thai patients in the primary care settings were prescribed PIMs. Multidisciplinary prescription review and PIM screening in patients aged ≥75 years who have ≥3 chronic diseases or polypharmacy should be implemented in primary care and supportive computerized PIMs alert system is needed.

Elderly Patients in Primary Care are Still at Risks of Receiving Potentially Inappropriate Medications

Background

Most older adults with comorbidities in primary care clinics use multiple medications and are at risk of potentially inappropriate medications (PIMs) prescription.

Objective

This study examined the prevalence of polypharmacy and PIMs using Thai criteria for PIMs.

Methods

This study was a retrospective cross-sectional study. Data were collected from electronic medical records in a primary care clinic in 2018. Samples were patients aged ≥65 years old with at least 1 prescription. Variables included age, gender, comorbidities, and medications. The list of risk drugs for Thai elderly version 2 was the criteria for PIMs. The prevalence of polypharmacy and PIMs were calculated, and multiple logistic regression was conducted to examine associations between variables and PIMs.

Results

Of 2806 patients, 27.5% and 43.7% used ≥5 medications and PIMs, respectively. Of 10 290 prescriptions, 47% had at least 1 PIM. The top 3 PIMs were anticholinergics, proton-pump inhibitors, and nonsteroidal anti-inflammatory drugs (NSAIDs). Polypharmacy and dyspepsia were associated with PIM prescriptions (adjusted odds ratio 2.48 [95% confident interval or 95% CI 2.07-2.96] and 3.88 [95% CI 2.65-5.68], respectively).

Conclusion

Prescriptions with PIMs were high in the primary care clinic. Describing unnecessary medications is crucial to prevent negative health outcomes from PIMs. Computer-based clinical decision support, pharmacy-led interventions, and patient-specific drug recommendations are promising interventions to reduce PIMs in a primary care setting.

Impact of Geriatric Pharmacy Specialist Interventions to Reduce Potentially Inappropriate Medication Among Hospitalized Elderly Patients at Medical Wards: A Prospective Quasi-Experimental Study

Background

Elderly patients are at greater risk of receiving potentially inappropriate medications (PIMs) and developing adverse drug events. Identification and correction of PIMs is essential to maximize medication safety.

Objective

To determine the prevalence of PIMs on admission in Thai elderly patients admitted to a medical ward and to compare changes of PIMs on discharge, following comprehensive care by a ward pharmacist with or without a geriatric pharmacy specialist.

Patients and method

A prospective, quasi-experimental study was performed at a tertiary university hospital in Bangkok, Thailand. Patients aged ≥ 60 years who were admitted to the medical ward were recruited and allocated to one of two groups: intervention (IG) and control (CG). The CG received pharmaceutical care from the ward pharmacist. The IG received pharmaceutical care from the geriatric pharmacy specialist along with the ward pharmacist. The 2012 Beers criteria were used to identify PIMs on admission, during hospitalization, and on discharge.

Results

Prevalence of PIMs on admission was 43.3% (N = 187). On discharge, prevalence of PIMs in the IG decreased significantly compared to that on admission (21.3% and 43.3%, p < 0.05) and was significantly lower than in the CG (21.3% and 40.9%, p = 0.036). Moreover, the percentage of patients without PIMs on discharge in the IG was significantly higher than in the CG (78.7% and 59.1%, p < 0.0001).

Conclusion

Use of PIMs was common among hospitalized elderly patients on admission. Pharmaceutical care provided by a geriatric pharmacy specialist in conjunction with a ward pharmacist significantly reduced the prevalence of PIMs on discharge compared with on admission.

Potentially inappropriate medications among the elderly in primary care in Thailand from three different sets of criteria

Objective:

The primary objective was to examine potentially inappropriate medications (or PIMs) in the elderly using three different criteria: Beers 2015, STOPP version 2, and Winit-Watjana (for Thai elderly patients). The secondary objective was to examine PIM-related factors.

Methods:

This is a retrospective cross-sectional study. Eligible patients were aged ≥65 years in a primary care unit. Demographic data, medical prescriptions in the past year, clinical data and diagnoses were collected from electronic medical records. PIMs, including the use of ≥2 medications, were identified using the three criteria. Descriptive and analytical statistics were conducted. The type I error was 0.05. Multiple logistic regression analysis was used to examine associations between PIMs and other factors.

Results:

A total of 400 patients were recruited, and 1,640 prescriptions were reviewed. The median age was 70.5 years, and the median numbers of diseases, medications, and prescriptions were 3 (interquartile range or IQR=2), 11 (IQR=20), and 3 (IQR=4), respectively. Of all the patients, 213 (53.3%) showed a use of ≥5 medications, and 301 (75.3%) were prescribed PIMs. Of the 1,640 prescriptions, 60% had at least one PIM. The Winit-Watjana criteria, Beers 2015 criteria and STOPP version 2 identified 66.8%, 59.0% and 40.3% of the patients receiving PIMs, respectively. Approximately 16% of the patients showed at least one potential drug-drug interaction. The use of duplicate drug classes accounted for the highest proportion of potential drug-drug interactions (41.3%). Polypharmacy (odds ratio or OR 3.93, 95% confidence interval or 95%CI 2.17-71.2) and the presence of ≥4 diseases (OR 2.78, 95%CI 1.39-5.56) were associated with PIMs.

Conclusions:

PIMs are common among the elderly patients in primary care in Thailand. Prescriptions of the elderly with polypharmacy or multiple concurrent diagnoses should be reviewed for PIMs because they have a high chance of receiving PIMs.

Effect of a computerized decision support system on potentially inappropriate medication prescriptions for elderly patients in Thailand

RATIONALE, AIMS, AND OBJECTIVES

The prescription of potentially inappropriate medication (PIM) is a global issue associated with increased adverse drug events, mortality, and health care expenditure. Computerized decision support system (CDSS) for the detection of PIM is a novel alert system in Thailand for reducing PIM prescriptions. The aim of this study was to evaluate the effect of a CDSS on PIM prescriptions for elderly patients in Thai community hospitals.

METHODS

The study design comprised two phases with a duration of 12 months each: pre-CDSS implementation (October 2015-March 2016) and post-CDSS implementation (October 2016-March 2017). Medical services and prescription claims data from four hospitals were used to calculate the prevalence of PIM prescriptions among elderly patients aged 60 years and older. Chi-square tests were used to analyse changes in PIM prescriptions across hospitals post CDSS.

RESULTS

The overall prevalence of PIM prescriptions post-CDSS implementation significantly decreased from 87.7% to 74.4%. The severity of mild and moderate PIMs was significantly reduced from 71.9% to 49.0% and from 64.5% to 48.7%, respectively. All hospitals had only one severe PIM, which was hyoscine. It was reduced from 4.7% to 1.5%, but the change was not significant (P = 0.74). The proportion of frequently prescribed PIMs in all PIM levels was significantly decreased, regardless of existing alternative medications.

CONCLUSIONS

Specific CDSS for PIM in community hospital setting was associated with a reduction of PIM prescription in elderly patients. This CDSS can change physician's prescription behaviour to avoid inappropriate medications.

Physician's Knowledge of Appropriate Prescribing for the Elderly-A Survey Among Family and Internal Medicine Physicians in Nigeria

Background: Prescription and use of inappropriate medications have been identified as a major cause of morbidity among the elderly. Several screening tools have been developed to identify inappropriate medications prescribed for elderly patients. There is dearth of information about the knowledge of Nigerian physicians regarding these screening tools and appropriate prescribing for the elderly in general. The primary objective of this study was to assess the knowledge of Nigerian physicians about these screening tools and appropriate prescribing of medications for the elderly.

Methods: The study was a cross-sectional questionnaire-based study conducted among physicians working in Family Medicine and Internal Medicine departments of four tertiary health care facilities in Nigeria. The questionnaire consisted of sections on general characteristics of respondents and their knowledge of four selected screening tools for inappropriate medications in the elderly. Ten clinical vignettes representing different therapeutic areas (using the best option type questions) about medicine use in the elderly were included with a score of 1 and 0 for correct and wrong answers, respectively. The knowledge of respondents was classified as (total score, over 10): poor (score, < 5), average (score, 5-6), and good (score, 7-10).

Results: One hundred and five physicians returned completed questionnaires. Twenty percent of respondents knew about Beers criteria, whereas 15.6% were familiar with the STOPP criteria. Majority (83; 84.7%) of the respondents were confident of their ability to prescribeappropriately for elderly patients. The mean knowledge score was 5.3 ± 2.0 with 32 (30.5%), 41 (39%), and 32 (30.5%) having low, average, and good scores, respectively. The association between the knowledge score, duration of practice, and seniority was statistically significant (OR, 3.6, p = .004 and OR, 3; p = .012), respectively.

Conclusion: There are significant gaps in the knowledge of Nigerian physicians about screening tools for inappropriate medications. There is a need for stakeholders involved in the care of elderly Nigerian patients to develop new strategies to improve services being offered. These may include introduction of modules on appropriate prescribing in the curriculum of undergraduate and postgraduate medical education and the routine use of some screening tools for inappropriate medications in daily clinical practice.