Auditing prescription practice using explicit criteria and computerized drug benefit claims data

Should we screen aging physicians for cognitive decline?

OBJECTIVES

To synthesize evidence relevant for informed decisions concerning cognitive testing of older physicians.

METHODS

Relevant literature was systematically searched in Medline, EMBASE, PsycInfo, and ERIC, with key findings abstracted and synthesized.

RESULTS

Cognitive abilities of physicians may decline in an age range where they are still practicing. Physician competence and clinical performance may also decline with age. Cognitive scores are lower in physicians referred for assessment because of competency or performance concerns. Many physicians do not accurately self-assess and continue to practice despite declining quality of care; however, perceived cognitive decline, although not an accurate indicator of ability, may accelerate physicians' decision to retire. Physicians are reluctant to report colleagues' cognitive problems. Several issues should be considered in implementing cognitive screening. Most cognitive assessment tools lack normative data for physicians. Scientific evidence linking cognitive test results with physician performance is limited. There is no known level of cognitive decline at which a doctor is no longer fit to practice. Finally, relevant domains of cognitive ability vary across medical specialties.

CONCLUSION

Physician cognitive decline may impact clinical performance. If cognitive assessment of older physicians is to be implemented, it should consider challenges of cognitive test result interpretation.

Effectiveness of Interventions to Reduce Potentially Inappropriate Medication in Older Patients: A Systematic Review

Background: Age-related multiple comorbidities cause older adults to be prone to the use of potentially inappropriate medicines (PIM) resulting in an increased risk of adverse events. Several strategies have emerged to support PIM prescription, and a huge number of interventions to reduce PIM have been proposed. This work aims to analyze the effectiveness of PIM interventions directed to older adults.

Methods: A systematic review was performed searching the literature in the MEDLINE PubMed, EMBASE, and Cochrane scientific databases for interventional studies that assessed the PIM interventions in older adults (≥65 years).

Results: Forty-seven articles were included, involving 52 to 124,802 patients. Various types of interventions were analyzed such as medication review, educational strategies, clinical decision support system, and organizational and multifaceted approaches. In the hospital, the most successful intervention was medication review (75.0%), while in primary care, the analysis of all included studies revealed that educational strategies were the most effective. However, the analysis of interventions that have greater evidence by its design was inconclusive.

Conclusion: The results obtained in this work suggested that PIM-setting-directed interventions should be developed to promote the wellbeing of the patients through PIM reduction. Although the data obtained suggested that medication review was the most assertive strategy to decrease the number of PIM in the hospital setting, more studies are necessary.

Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021233484], identifier [PROSPERO 2021 CRD42021233484].

Drug Safety in Geriatric Patients: Current Status and Proposed Way Forward

Elderly patients are the main users of drugs and they differ from younger patients. They are a heterogeneous population that cannot be defined only by age but should rather be stratified based on their frailty. The elderly have distinctive pharmacokinetic and pharmacodynamic characteristics, are frequently polymorbid, and are therefore treated with multiple drugs. They may experience adverse reactions that are difficult to recognize, since some of them present non-specific symptoms easily mistaken for geriatric conditions. Paradoxically, the elderly are underrepresented in clinical trials, especially the frail individuals whose pharmacological response and expected treatment outcome can be different from those of non-frail patients. This means that the benefit-risk balance of drugs used in frail elderly patients is frequently unknown. We present some proposals to overcome the barriers preventing the enrollment of frail elderly patients in clinical trials, and strategies for monitoring their therapy to minimize the risk of adverse reactions. Automated alerts for drug and drug-disease interactions could help appropriate prescribing but should flag only clinically relevant interactions. Pharmaceutical forms should be designed to allow easy dose adjustment and, together with packaging and labeling, should account for the physical and cognitive limitations of frail elderly patients. Aggregate pharmacovigilance reports should summarize the safety profile in the elderly, but rather than presenting the results by age they should focus on patients' frailty, perhaps using the number of comorbidities as a proxy when information on frailty is not available.

Potentially inappropriate medication use among older patients attending a geriatric centre in south-west Nigeria

Objectives

To determine the prevalence and describe factors associated with the use of potentially inappropriate medication (PIM) among older patients.

Methods

Cross sectional study of 400 older patients selected systematically at the geriatric centre, University College Hospital, Ibadan between July and September 2016. With the aid of semi-structured questionnaires, information on the socio-demographic characteristics, lifestyle habits, healthcare utilisation and morbidities was obtained. The Beer's criteria 2015 update was used to identify the PIMs. Predictors of PIMs were determined using multivariate analyses at alpha 0.05.

Results

Age was 70.2 (SD=5.9) years and 240 (60%) were females. General prescription pattern showed antihypertensives (34.7%) as the commonest medications used. The point prevalence of PIMs use was 31%. In all, 10 PIMs were used by the respondents. The majority (81.5%) were using one PIM, while (17.7%) used two PIMs and (0.8%) 3 PIMs. NSAIDs (72.6%) were the commonest PIMs identified, followed by the benzodiazepines (24.2%). Respondents had an average of 1.9 morbidities, and mulitmorbidity found in 60.5%. Logistic regression analysis showed self-rated health assessed as better compared with age-mates [OR =1.718 (1.080-2.725)] and being physically active [OR =1.879 (1.026-3.436)] as the most significantly associated with PIMs use.

Conclusions

The use of PIMs among older patients in our setting was high with NSAIDs being the most frequently used medications. An interdisciplinary approach, of medication review by pharmacists', working with physicians may improve prescribing practices among older persons. Therefore, it is necessary to create public health awareness on the use of PIMs among older persons.

Trends in Prevalence and Determinants of Potentially Inappropriate Prescribing in the United States: 2007 to 2012

OBJECTIVES

To estimate the prevalence and determinants of the use of potentially inappropriate medications (PIMs) in older U.S. adults using the 2012 Beers criteria.

DESIGN

Retrospective cohort study in a random national sample of Medicare beneficiaries.

SETTING

Fee-for-service Medicare beneficiaries from 2007 to 2012.

PARTICIPANTS

U.S. population aged 65 and older with Parts A, B, and D enrollment in at least 1 month during a calendar year (N = 38,250 individuals; 1,308,116 observations).

MEASUREMENTS

The 2012 Beers criteria were used to estimate the prevalence of the use of PIMs in each calendar month and over a 12-month period using data on diagnoses or conditions present in the previous 12 months. Generalized estimating equations were used to account for the dependence of multiple monthly observations of a single person when estimating 95% confidence intervals (CIs), and logistic regression was used to identify independent determinants of PIM use.

RESULTS

The point prevalence of the use of PIMs decreased from 37.6% (95% CI = 37.0-38.1) in 2007 to 34.2% (95% CI = 33.6-34.7) in 2012, with a statistically significant 2% (95% CI = 1-3%) decline per year assuming a linear trend. The 1-year period prevalence declined from 64.9% in 2007 to 56.6% in 2012. The strongest predictor of PIM use was the number of drugs dispensed. Individuals aged 70 and older and those seen by a geriatrician were less likely to receive a PIM.

CONCLUSION

From 2007 to 2012, the prevalence of PIM use in older U.S. adults decreased according to the 2012 Beers criteria, although it remains high, still affecting one-third each month and more than half over 12 months. The number of dispensed prescriptions could be used to target future interventions.

Drugs prescribed for patients hospitalized in a geriatric oncology unit: Potentially inappropriate medications and impact of a clinical pharmacist

OBJECTIVES

The aim of this study was to assess the prevalence of potentially inappropriate medication (PIM) use upon admission and at discharge in a geriatric oncology unit after involving a clinical pharmacist. Although the few studies conducted in geriatric oncology units used the 2003 Beers criteria, this study used START and STOPP criteria, a more appropriate tool for European formularies.

MATERIALS AND METHODS

Prospective study in older (≥70years) patients consecutively admitted to a geriatric oncology unit in a cancer center from July 2011 to April 2012. Clinical pharmacist conducted a complete comprehensive medication review including non-prescription and complementary (herbals) medications. This information coupled with the patient's medical history allows identifying PIMs using the STOPP and START criteria. The number of PIMs at admission and at discharge from the hospital was compared after clinical pharmacist intervention.

RESULTS

Ninety-one older patients with cancer (mean age±SD=79±6years) were included in the study. START criteria identified 41 PIMs for 31 persons (34%) at admission compared to 7 PIMs for 6 persons (7%) at discharge. STOPP criteria identified 50 PIMs at admission for 29 persons (32%) compared to 16 PIMs at discharge for 14 persons (16%). Results showed significantly lower START scores at discharge than at admission (p<0.001); similarly, STOPP criteria demonstrated fewer PIMs at discharge than at admission (p<0.001).

CONCLUSION

The use of START and STOPP criteria by a clinical pharmacist allows identifying PIMs and changing prescriptions for older patients with cancer in agreement with the oncologist and geriatrician of the team.

Appropriate prescribing in the elderly: Current perspectives

Advances in medical therapeutics have undoubtedly contributed to health gains and increases in life expectancy over the last century. However, there is growing evidence to suggest that therapeutic decisions in older patients are frequently suboptimal or potentially inappropriate and often result in negative outcomes such as adverse drug events, hospitalisation and increased healthcare resource utilisation. Several factors influence the appropriateness of medication selection in older patients including age-related changes in pharmacokinetics and pharmacodynamics, high numbers of concurrent medications, functional status and burden of co-morbid illness. With ever-increasing therapeutic options, escalating proportions of older patients worldwide, and varying degrees of prescriber education in geriatric pharmacotherapy, strategies to assist physicians in choosing appropriate pharmacotherapy for older patients may be helpful. In this paper, we describe important age-related pharmacological changes as well as the principal domains of prescribing appropriateness in older people. We highlight common examples of drug-drug and drug-disease interactions in older people. We present a clinical case in which the appropriateness of prescription medications is reviewed and corrective strategies suggested. We also discuss various approaches to optimising prescribing appropriateness in this population including the use of explicit and implicit prescribing appropriateness criteria, comprehensive geriatric assessment, clinical pharmacist review, prescriber education and computerized decision support tools.

Prevalência e fatores associados a potenciais interações medicamentosas entre idosos em um estudo de base populacional

Objetivo: Determinar a prevalência de potenciais interações medicamentosas e os fatores a elas associados entre idosos cadastrados nas equipes da Estratégia Saúde da Família (ESF) do município de Timóteo, MG. Métodos: Estudo transversal, utilizando amostragem aleatória estratificada. Foram realizadas 273 entrevistas domiciliares, com indivíduos de 60 anos ou mais de idade, por meio de formulário que continha perguntas de identificação, sociodemográficas e questões relacionadas às condições de saúde do idoso e ao consumo de medicamentos. As interações medicamentosas foram identificadas e classificadas de acordo com o software Micromedex®. Resultados: A prevalência de potenciais interações medicamentosas foi de 55,6%, perfazendo um total de 466 ocorrências, das quais 5,6% eram leves, 81,6% eram moderadas e 12,8% eram de maior gravidade. As classes terapêuticas mais frequentemente envolvidas foram anti-inflamatórios e, principalmente, fármacos utilizados em doenças cardiovasculares. A ausência de internação hospitalar nos últimos 4 meses associou-se significativamente a uma menor chance de interações graves, e a maior parte dos pacientes que não tiveram nenhum tipo de interação moderada utilizava apenas medicamentos prescritos por médicos. Conclusões: A prevalência de interações medicamentosas encontrada foi semelhante à descrita na literatura, demonstrando alta frequência entre idosos. A ausência de internação hospitalar prévia e a prescrição de medicamentos por profissionais médicos associaram-se a uma menor frequência desse fenômeno. A prescrição de múltiplos medicamentos simultaneamente aos idosos pode comprometer a segurança e a saúde dessa população, requerendo, por parte dos cuidadores, observação atenta quanto à ocorrência de interações medicamentosas.

Do we need individualised prescribing quality assessment? The case of diabetes treatment

Prescribing quality assessment is increasingly used in improvement programs and pay-for-performance policies. Within the area of diabetes many quality indicators have been developed. Some measure prescribing on a general level, e.g. calculating percentages of patients prescribed any statins. Others are very specific, e.g. percentages of patients with an elevated LDL-cholesterol in whom lipid-lowering treatment is started unless contraindicated or return to control within 3 months. Although the latter seems more precise, we question how far one should go in developing such indicators. Using the example of diabetes treatment, we highlight the need, opportunities, and feasibility of assessing prescribing quality in the context of individualised treatment. We conclude that it is not realistic to develop indicators that take all possible aspects of therapy non-response, intolerance and patient preferences into account. We do recommend further development of indicators that better address subpopulations in need of adjusted treatment, such as elderly or patients with comorbidity.

Medication Assessments by Care Managers Reveal Potential Safety Issues in Homebound Older Adults

Background

Over-the-counter (OTC) medications, benzodiazepines, and barbiturates are not covered under many Medicare drug benefit plans; hence, their use by homebound older adults is largely unreported. Furthermore, the tiered design of Medicare drug formularies may in fact promote the use of older but potentially inappropriate medications. Little is known about the use of these medications in the homebound older adult population.

Objective:

To determine the prevalence of the use by homebound older adults of OTC drugs, dietary supplements (vitamins, minerals, and herbal products), Part D-excluded medications (benzodiazepines and barbiturates), and potentially inappropriate medications (according to Beers criteria).

Methods:

Patients were enrollees in a home and community-based Medicaid waiver provider. All clients were older than 65 and were dually eligible for Medicare and Medicaid. All clients met Florida Medicaid's medical and financial criteria for nursing home placement. The medication list was obtained by geriatric care managers during a home assessment.

Results:

A total of 3911 older adults (mean [SD] age 83.6 [8.0] years) were taking an average of 9.9 [4.8] drugs. Of these individuals. 74.5% were using an OTC medication, 41.9% were using a dietary supplement, 29.6% were using a benzodiazepine or barbiturate, and 25.2% were using at least 1 potentially inappropriate medication.

Conclusions:

Based on data gathered by a geriatric care management assessment, we found that most of the homebound older adults enrolled in our study used medications not included in their Medicare drug benefit. The use of potentially inappropriate medications was also common in this population. Future drug safety initiatives involving the elderly will benefit from engaging care managers in identifying and addressing the potential hazards posed by commonly used prescribed and nonprescribed medications.

A systematic literature review: prescribing indicators related to type 2 diabetes mellitus and cardiovascular risk management

PURPOSE

Valid prescribing indicators (PI) are needed for reliable assessment of prescribing quality. The purpose of this study is to describe the validity of existing PI for type 2 diabetes mellitus and cardiovascular risk management.

METHODS

We conducted a systematic literature search for studies describing the development and assessment of relevant PIs between January 1990 and January 2009. We grouped identified PI as drug- or disease-oriented, and according to the aspects of prescribing addressed and the additional clinical information included. We reviewed the clinimetric characteristics of the different types of PI.

RESULTS

We identified 59 documents describing the clinimetrics of 16 types of PI covering relevant prescribing aspects, including first-choice treatment, safety issues, dosing, costs, sufficient and timely treatment. We identified three types of drug-oriented, and five types of disease-oriented PI with proven face and content validity as well as operational feasibility in different settings. PI focusing on treatment modifications were the only indicators that showed concurrent validity. Several solutions were proposed for dealing with case-mix and sample size problems, but their actual effect on PI scores was insufficiently assessed. Predictive validity of individual PI is not yet known.

CONCLUSION

We identified a range of existing PI that are valid for internal quality assessment as they are evidence-based, accepted by professionals, and reliable. For external use, problems of patient case-mix and sample size per PI should be better addressed. Further research is needed for selecting indicators that predict clinical outcomes.

Chagas' disease and ageing: the coexistence of other chronic diseases with Chagas' disease in elderly patients

This study aimed to identify the main comorbidities in elderly chagasic patients treated in a reference service and identify possible associations between the clinical form of Chagas' disease and chronic diseases. Ninety patients aged 60 years-old or over were interviewed and their clinical diagnoses recorded. The study population profile was: women (55.6%); median age (67 years); married (51.1%); retired (73.3%); up to four years' education (64.4%); and earning less than two minimum wages (67.8%). The predominant forms of Chagas' disease were the cardiac (46.7%) and mixed forms (30%). There was a greater proportion of mild cardiac dysfunction (84.1%), frequently in association with megaesophagus. The mean number of concurrent diseases was 2.856 +/- 1.845, and 33% of the patients had four or more comorbidities. The most frequent were systemic arterial hypertension (56.7%), osteoporosis (23.3%), osteoarthritis (21.2%) and dyslipidemia (20%). Positive correlations were verified between sex and comorbidities and between age group and comorbidities.

Trends of the potentially inappropriate medication consumption over 10 years in older adults in the East of France

PURPOSE

To describe the trends of potentially inappropriate medication (PIM) use in older adults from 1995 to 2004 in the East of France, by using the 1997 Beers criteria and its French update, and to assess risk factors for this PIM use.

METHODS

We carried out a repeated cross-sectional study using data collected among people aged >/=65 years, examined in the Center for Preventive Medicine. Studied variables were socio-demographic, clinical data, medication consumption and the self-health status. Joinpoint regression analysis was used to estimate the temporal changes in PIM rate.

RESULTS

30 683 participants were included. 51.2% were women. The mean age was 70.1 +/- 4.3 years [65-99]. The annual overall rate of PIM use decreased significantly during the study period. These rates range from 14.9% in 1995 to 9.0% in 2004 according the Beers criteria (-3.4% per year) and from 33.5% in 1995 to 19.3% in 2004 according to the French update criteria (-3.6% per year). The annual rate of medication users increased during the same period (+0.75% per year). The risk of PIM consumption increased with age, number of drugs and frequency of the visits to the physician (OR = 1.26 [1.18-1.35]). This risk was also higher among women (OR = 1.29 [1.18-1.40]), elderly living alone (OR = 1.09 [1.02-1.17]) and with those with low education level (OR = 1.19 [1.02-1.38]).

CONCLUSION

This study shows a decrease in PIM consumption. Despite an increase of drug use in the elderly, an improving of the quality of this consumption remains possible.

The relationship between variations in antipsychotic prescribing across nursing homes and short-term mortality: quality of care implications

BACKGROUND

High rates of antipsychotic drug prescribing in nursing homes can signal poor quality processes, but also raise concerns about drug safety due to the mortality risk of this therapy. Determining the extent to which variations in antipsychotic use are a symptom of facility-level quality problems as compared with a drug safety issue is important for selecting the correct interventions to effect change.

OBJECTIVE

To determine whether nursing homes with higher rates of antipsychotic dispensing had higher rates of short-term mortality among their residents.

METHODS

This population-based study examined 60,105 older adults newly admitted to nursing homes in Ontario between April 1, 2000 and March 31, 2004. Using adjusted Cox proportional hazard models, we explored the relationship between facility-level dispensing rates and mortality, controlling for resident characteristics. Facilities were grouped into quintiles according to mean antipsychotic rate. All-cause mortality at 30 and 120 days after admission was stratified by recent hospital discharge and analyzed by quintile.

RESULTS

Average antipsychotic dispensing ranged from 11.6% in the lowest quintile to 30.0% in the highest. Among residents with no recent hospitalization, all-cause mortality at 30 days was 2.5% in the lowest compared with 3.3% in the highest quintile (adjusted hazard ratio: 1.28, confidence interval: 1.06-1.56) and at 120 days was 9.3% compared with 11.7% (adjusted hazard ratio: 1.25, confidence interval: 1.13-1.39).

CONCLUSION

Residents were at increased risk of death simply by being admitted to a facility with a higher intensity of antipsychotic drug use, despite similar clinical characteristics at admission.

Magnitude of potentially inappropriate prescribing in Germany among older patients with generalized anxiety disorder

Background

Several medications commonly used to treat generalized anxiety disorder (GAD) have been designated "potentially inappropriate" for use in patients aged ≥65 years because their risks may outweigh their potential benefits. The actual extent of use of these agents in clinical practice is unknown, however.

Methods

Using a database with information from encounters with general practitioners (GP) in Germany, we identified all patients, aged ≥65 years, with any GP office visits or dispensed prescriptions with a diagnosis of GAD (ICD-10 diagnosis code F41.1) between 10/1/2003 and 9/30/2004 ("GAD patients"). Among GAD-related medications (including benzodiazepines, tricyclic antidepressants [TCAs], selective serotonin reuptake inhibitors, venlafaxine, hydroxyzine, buspirone, pregabalin, and trifluoperazine), long-acting benzodiazepines, selected short-acting benzodiazepines at relatively high dosages, selected TCAs, and hydroxyzine were designated "potentially inappropriate" for use in patients aged ≥ 65 years, based on published criteria.

Results

A total of 975 elderly patients with GAD were identified. Mean age was 75 years, and 72% were women; 29% had diagnoses of comorbid depression. Forty percent of study subjects received potentially inappropriate agents – most commonly, bromazepam (10% of all subjects), diazepam (9%), doxepin (7%), amitriptyline (5%), and lorazepam (5%). Twenty-three percent of study subjects received long-acting benzodiazepines, 10% received short-acting benzodiazepines at relatively high doses, and 12% received TCAs designated as potentially inappropriate.

Conclusion

GPs in Germany often prescribe medications that have been designated as potentially inappropriate to their elderly patients with GAD – especially those with comorbid depressive disorders. Further research is needed to ascertain whether there are specific subgoups of elderly patients with GAD for whom the benefits of these medications outweigh their risks.

Non-steroidal anti-inflammatory drugs, Cyclooxygenase-2 inhibitors and paracetamol use in Queensland and in the whole of Australia

BACKGROUND

Cross national drug utilization studies can provide information about different influences on physician prescribing. This is important for medicines with issues around safety and quality of use, like non selective non-steroidal anti-inflammatory drugs (ns-NSAIDs) and cyclo-oxygenase-2 (COX-2) inhibitors. To enable comparison of prescription medicine use across different jurisdictions with a range of population sizes, data first need to be compared within Australia to understand whether use in a smaller sub-population may be considered as representative of the total use within Australia. The aim of this study was to compare the utilization of non selective NSAID, COX-2 inhibitors and paracetamol between Queensland and Australia.

METHOD

Dispensing data were obtained for concession beneficiaries for Australia for ns-NSAIDs, COX-2 inhibitors and paracetamol subsidized by the PBS over the period 1997-2003. The same data were purchased for Queensland. Data were converted to Defined Daily Dose (DDD)/1000 beneficiaries/day (World Health Organization anatomical therapeutic chemical classification, 2005).

RESULTS

Total NSAID and paracetamol consumption were similar in Australia and Queensland. Ns-NSAID use decreased sharply with the introduction of COX-2 inhibitors (from approximately 80 to 40 DDD/1000 beneficiaries/day). Paracetamol was constant (approximately 45 DDD/1000 beneficiaries/day). COX-2 inhibitors consumption was initially higher in Queensland than in the whole of Australia.

CONCLUSION

Despite initial divergence in celecoxib use between Queensland and Australia, the use of ns-NSAIDs, COX-2 inhibitors and paracetamol overall, in concession beneficiaries, was comparable in Australia and Queensland.

The Ontario printed educational message (OPEM) trial to narrow the evidence-practice gap with respect to prescribing practices of general and family physicians: a cluster randomized controlled trial, targeting the care of individuals with diabetes and hypertension in Ontario, Canada

Background

There are gaps between what family practitioners do in clinical practice and the evidence-based ideal. The most commonly used strategy to narrow these gaps is the printed educational message (PEM); however, the attributes of successful printed educational messages and their overall effectiveness in changing physician practice are not clear. The current endeavor aims to determine whether such messages change prescribing quality in primary care practice, and whether these effects differ with the format of the message.

Methods/design

The design is a large, simple, factorial, unblinded cluster-randomized controlled trial. PEMs will be distributed with informed, a quarterly evidence-based synopsis of current clinical information produced by the Institute for Clinical Evaluative Sciences, Toronto, Canada, and will be sent to all eligible general and family practitioners in Ontario. There will be three replicates of the trial, with three different educational messages, each aimed at narrowing a specific evidence-practice gap as follows: 1) angiotensin-converting enzyme inhibitors, hypertension treatment, and cholesterol lowering agents for diabetes; 2) retinal screening for diabetes; and 3) diuretics for hypertension.

For each of the three replicates there will be three intervention groups. The first group will receive informed with an attached postcard-sized, short, directive "outsert." The second intervention group will receive informed with a two-page explanatory "insert" on the same topic. The third intervention group will receive informed, with both the above-mentioned outsert and insert. The control group will receive informed only, without either an outsert or insert.

Routinely collected physician billing, prescription, and hospital data found in Ontario's administrative databases will be used to monitor pre-defined prescribing changes relevant and specific to each replicate, following delivery of the educational messages. Multi-level modeling will be used to study patterns in physician-prescribing quality over four quarters, before and after each of the three interventions. Subgroup analyses will be performed to assess the association between the characteristics of the physician's place of practice and target behaviours.

A further analysis of the immediate and delayed impacts of the PEMs will be performed using time-series analysis and interventional, auto-regressive, integrated moving average modeling.

Trial registration number

Current controlled trial ISRCTN72772651.

Sex differences in inappropriate prescribing among elderly veterans

BACKGROUND

Previous studies have suggested that older women may be more likely than older men to receive potentially inappropriate prescriptions. A better understanding of sex differences in inappropriate prescribing can help inform the development of effective interventions.

OBJECTIVE

This study was conducted to assess sex differences in rates of inappropriate prescribing before and after accounting for potentially appropriate indications and to examine sex differences in predictors of inappropriate drug use.

METHODS

This was a retrospective cohort study of administrative data from the national Veterans Health Administration (VA). Participants were veterans aged >or=65 years who had >or=1 patient visit at VA outpatient facilities in fiscal year 1999 (FY99) and 2000 (FY00). The main outcome measure was the diagnosis-adjusted prevalence of 33 potentially inappropriate medications as judged by the Beers criteria in FY00: overall, by individual drug, and in 3 categories grouped by potential indication ("always avoid," "rarely appropriate," and "some indications").

RESULTS

The study population included 965,756 patients (946,641 men and 19,115 women). Women were more likely than men to receive inappropriate medications overall and in all 3 categories, even after accounting for diagnoses that may have justified the prescription. Women were more likely to receive 16 of the 33 medications (analgesics, psychotropic drugs, and anticholinergic agents), and men were more likely to receive 3 of the 33. After controlling for sociodemographic characteristics, number of medications, and care characteristics, women remained more likely to receive inappropriate drugs. Receipt of geriatric care was equally protective for men and women, although only a small proportion received this care. Psychiatric comorbidity was associated with inappropriate prescribing for men but not for women.

CONCLUSIONS

Analgesic, psychotropic, and anticholinergic medications that should be avoided contributed to higher rates of inappropriate drug use among older women than among older men. Targeted efforts to avoid these medications in older women may help reduce overall rates of inappropriate prescribing. Sex-stratified reporting of quality indicators that assess inappropriate prescribing among community-dwelling elders would help monitor the effectiveness of improvement efforts.

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study

BACKGROUND

In the US, a growing body of epidemiological studies has documented widespread potentially inappropriate medication prescribing among the elderly in outpatient settings. However, only limited information exists in Europe.

OBJECTIVE

To evaluate the prevalence of potentially inappropriate medication prescribing among elderly outpatients in Emilia Romagna, Italy and to investigate factors associated with potentially inappropriate medication prescribing in that setting.

METHODS

Retrospective cohort study using the Emilia Romagna outpatient prescription claims database from 1 January 2001 to 31 December 2001 linked with information (age, sex and other variables) available from a demographic file of approximately 1 million Emilia Romagna residents aged >or=65 years. The cohort comprised 849 425 elderly patients who had at least one drug prescription during the study period. The prevalence of potentially inappropriate medication prescribing, as defined by the 2002 Beers' criteria, was measured together with predictors associated with potentially inappropriate medication prescribing.

RESULTS

A total of 152 641 (18%) elderly Emilia Romagna outpatients had one or more occurrences of potentially inappropriate medication prescribing. Of these, 11.5% received prescriptions for two medications of concern and 1.7% for three or more. Doxazosin (prescribed to 23% of subjects) was the most frequently occurring potentially inappropriate prescribed medication, followed by ketorolac (20.5%), ticlopidine (18.3%) and amiodarone (12.6%). Factors associated with greater likelihood of potentially inappropriate medication prescribing were older age, overall number of drugs prescribed and greater number of chronic conditions. The odds of receiving potentially inappropriate prescribed medications were lower for females, subjects living in more urban areas and subjects with a higher income level.

CONCLUSIONS

This study provides strong evidence that potentially inappropriate medication prescribing for elderly outpatients is a substantial problem in Emilia Romagna. Focusing on the prevalence of potentially inappropriate medication prescribing and associated predictors can help in the development of educational programmes targeting outpatient practitioners to influence prescribing behaviour and, therefore, reduce potentially inappropriate medication prescribing.

The independent effect of age of general practitioner on clinical practice

OBJECTIVE

To establish the extent to which general practitioner age alone explains variations in patient morbidity and treatment patterns.

SETTING

An on-going, national survey of general practice activity in Australia.

PARTICIPANTS

A random sample of 5013 GPs with a minimum of 375 general practice Medicare items claimed in the previous 3 months. Each GP contributed details of 100 consecutive encounters, with about 1000 GPs sampled each year between 1998 and 2003.

MAIN OUTCOME MEASURES

Effect of practitioner age on GP activity after removing the influence of measured confounding factors: doctor, patient and practice characteristics; number of problems; and morbidity managed at encounters.

RESULTS

GP age played a significant role in practice style. In comparison with young GPs (< 35 years), older GPs provided more home visits (P < 0.001) and attendances at residential aged-care facilities (P = 0.044); were more likely to manage chronic problems (P < 0.001); had higher prescribing rates (P < 0.001), and lower rates of pathology ordering (P < 0.001) and non-pharmacological treatments (P < 0.001). Individual body system management rates also differed significantly between younger and older GPs.

CONCLUSION

A GP's age plays a significant role in determining practice style. Our results have implications in terms of the ageing GP population and in the wider context of the ageing medical labour force.

Overprescribing of lipid lowering agents

BACKGROUND

Undertreatment of hyperlipidemia has received considerable attention. However, little is known about trends in overprescribing of lipid lowering agents. We examined these trends and their associations with physician, practice, and organisational factors.

METHODS

2034 physicians were surveyed twice: baseline (1996-7) and follow up (1998-9). On each occasion they were asked: "For what percentage of 50 year old men without other cardiac risk factors would you recommend an oral agent for total cholesterol of 240, LDL 150, and HDL 50 after 6 months on a low cholesterol diet?" During the survey period the National Cholesterol Education Program guidelines did not recommend prescribing for these patients. Binomial and multinomial logistic regressions assessed baseline overprescribing and longitudinal changes in overprescribing, accounting for complex sampling.

RESULTS

39% of physicians recommended prescribing at baseline (round 1), increasing at follow up (round 2) to 51% (p < 0.001). Physicians who were more likely to overprescribe at baseline were less likely to be board certified (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.38 to 0.63; p < 0.001), were in solo or two-physician practices (OR 1.88, 95% CI 1.46 to 2.41; p < 0.001), had more revenue from Medicare (OR 1.10, 95% CI 1.03 to 1.17; p = 0.004) or Medicaid (OR 1.09, 95% CI 1.01 to 1.18; p = 0.03), or were family physicians (OR 1.87, 95% CI 1.35 to 2.58; p < 0.001). Physicians with large increases in overprescibing were more likely than those with small increases in overprescribing to be international medical graduates (OR 2.09, 95% CI 1.20 to 3.64; p = 0.011) and to spend more hours in patient care (OR 1.14, 95% CI 1.03 to 1.26; p = 0.016).

CONCLUSIONS

Overprescribing of lipid lowering agents is commonplace and increased. At baseline and longitudinally, overprescribing was primarily associated with physician and practice characteristics and not with organisational factors.

L’évaluation des pratiques cliniques : quels modes de recueil des données et à partir de quelles sources d’information?

OBJECTIVE

The aim of our study is to present the methods used to observe clinical practices, to evaluate their advantages and limits, and to specify the context in which they are preformed.

METHODS

We conducted a bibliographical search on MEDLINE using key words, completed by an offline search. We selected articles published in French or English between 1985 and 2003.

RESULTS

Thirty articles, of which 3 were reviews, as well as an additional 5 reports and 9 books, were selected. We distinguished direct or objective approaches to clinical practices as well as indirect or declarative approaches. We also noted whether the approach was individual with data collected from individual practitioners, or collective, with data coming from databases. Most methods of collecting data used medical records, often in the context of internal or external clinical audits or peer reviews. The other sources of data were self-administered questionnaires, written case simulations and simulated patients. Data was also extracted from previously existing databases: claims databases, registries and ad hoc databases.

CONCLUSION

An objective individual approach insures the highest quality of information, but possible high costs can limit the use of this approach. It is necessary to continue researching the best means of collecting data on clinical practices, because of the obligation of each practitioner to evaluate individual clinical practices.

National trends in and predictors of propoxyphene use in community-dwelling older adults

BACKGROUND

Several pain management guidelines and explicit medication-use criteria identify propoxyphene as an inappropriate medication for use in older adults.

OBJECTIVE

This study was conducted to estimate trends in propoxyphene use among community-dwelling elderly (age > or = 65 years) Medicare beneficiaries from 1993 through 1999 and to determine whether beneficiaries' drug coverage and specific characteristics of their physicians were associated with receipt of propoxyphene in 1999.

METHODS

Data from the Medicare Current Beneficiary Survey (MCBS) were used to examine the prevalence of propoxyphene use in cross-sections of nationally representative samples of community-dwelling elderly Medicare beneficiaries from 1993 through 1999. The 1999 MCBS was linked with the 1999 Area Resource File to examine patient and physician factors associated with propoxyphene use in the community-dwelling elderly at the county level.

RESULTS

Rates of propoxyphene use were generally stable over the 7-year period, from an annual prevalence of 6.8% in 1993 to the slightly decreased prevalence of 6.6% in 1999. No protective effects against propoxyphene use were observed based on beneficiaries' drug coverage or type of drug coverage. Rather, Medicaid beneficiaries were more likely to receive propoxyphene than those without drug coverage (odds ratio [OR] = 1.40; 95% CI, 1.02-1.92). Among physician characteristics, male sex (OR = 1.34; 95% CI, 1.02-1.75) and medical specialty (OR = 0.81; 95% CI, 0.65-1.00) were strongly correlated with prescribing of propoxyphene.

CONCLUSION

This study found a continuing high prevalence of propoxyphene use in the community-dwelling elderly Medicare population from 1993 through 1999, with > 2 million beneficiaries receiving the drug in 1999.

Risk of adverse drug events by patient destination after hospital discharge

PURPOSE

The prevalence of risk factors for adverse drug events (ADEs) in patients discharged from the hospital to various care settings was studied.

METHODS

Data on patient risk characteristics for ADEs were collected for hospital discharges for 2000. Differences in the prevalence of 10 risk characteristics among home health care (HHC), self-care (SC), and long-term-care (LTC) patients at the point of discharge were determined.

RESULTS

Data for 4250 discharges were analyzed. The three groups differed significantly in the distribution of risk characteristics. HHC patients had the highest prevalence of heart failure, cardiovascular medication use, and polypharmacy, and LTC patients had the highest prevalence of hypoalbuminemia, cognitive impairment, and psychiatric drug use.

CONCLUSION

The risk of ADEs in patients discharged to HHC appeared to be comparable to or higher than that in patients discharged to LTC.

A terapia medicamentosa no idoso: cuidados na medicação

A literatura médica reconhece que o envelhecimento predispõe a um consumo aumentado de medicamentos prescritos e não-prescritos. No entanto, mudanças fisiológicas relacionadas ao envelhecimento, tais como a modificação da composição corporal e a redução das funções renal e hepática, podem alterar em muito a farmacocinética e a farmacodinâmica de diversos fármacos, fazendo com que indivíduos idosos estejam suscetíveis com maior freqüência a efeitos adversos ou terapêuticos mais intensos. Neste cenário, a literatura médica tem sido constantemente enriquecida com estudos que apontam explicitamente para medicamentos específicos ou categorias de medicamentos cujo consumo por indivíduos idosos deve ser evitado ou utilizado com cautela. Este trabalho se propõe a descrever brevemente algumas informações consensuais acerca destes medicamentos impróprios para idosos, ressaltando alguns fármacos que se encontram disponíveis à população brasileira.

Prevalence and correlates of potentially inappropriate prescribing among ambulatory older patients in the year 2001: Comparison of three explicit criteria

OBJECTIVES

The aims of this study were to determine the prevalence of prescribing potentially inappropriate medications (PIMs) based on the 2002 Beers criteria among ambulatory patients aged > or =65 years, to compare PIM prevalence rates based on the 1997 Beers criteria and Zhan criteria with the rate obtained using the 2002 Beers criteria, and to examine patient, provider, and visit characteristics associated with receiving a PIM.

METHODS

Retrospective analysis was conducted of the year-2001 public-use data files of the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. The 2002 Beers criteria 1997 Beers criteria, and Zhan criteria were used to determine presence of PIMs. Multivariate logistic regression was performed to identify patient, visit, and provider characteristics associated with receiving a PIM.

RESULTS

A total of 7243 ambulatory visits by individuals aged > or =65 years with > or =1 prescription were projected to an estimated 157 million such ambulatory visits. An estimated 21 million visits (13.4%) involved PIMs based on the 2002 Beers criteria, compared with 13.9 million visits (8.8%) based on the 1997 Beers criteria and 6.6 million visits (4.2%) based on the Zhan criteria. An additional 7.2 million visits (4.6%) by eligible patients involved medications defined by the Zhan criteria as having some indications but often being misused. After adjusting for other factors, visits made in metropolitan areas (odds ratio [OR], 2.42 195% Cl, 1.14-5.12) or by referred patients (OR, 2.28 195% CI, 1.43-3.61) were more likely to involve a PIM. Compared with visits involving 1 medication, those involving 2 (OR, 2.39 [95% CI, 1.30-4.41]), 3 (OR, 7.01 [95% Cl, 3.42-14.35]), or > or =4 medications (OR, 7.35 [95% Cl, 4.44-12.17]) were more likely to be associated with a PIM.

CONCLUSIONS

Prevalence of PIMs among ambulatory patients aged > or =65 years is high. The most frequently prescribed PIMs and positive risk factors warrant greater attention from a policy perspective.

Frequency and risk factors of potentially inappropriate medication use in a community-dwelling elderly population: results from the 3C Study

OBJECTIVE

To estimate the frequency of potentially inappropriate medication use among community-dwelling elderly subjects and to identify socio-demographic factors associated with this use.

METHODS

Data were collected in the Three-City Study, a French longitudinal study on vascular factors and cognitive decline. The study population was composed of 9,294 subjects aged 65 years and older, living in the community. Inappropriate medication use was assessed using a list derived from the Beers criteria by a panel of French experts.

RESULTS

Nearly 40% of the participants used at least one potentially inappropriate medication: 23.4% used cerebral vasodilators, 9.2% long-acting benzodiazepines and 6.4% drugs with anticholinergic properties. Excluding cerebral vasodilators from the list, the frequency of potentially inappropriate medication use was 21.7%. This use was significantly more frequent among women, older subjects and poorly educated subjects. Adjusted analyses showed that these associations could not be explained by a confounding effect of medical factors. Compared with 13.0% of men with a high educational level, 27.9% of women with a low educational level used at least one potentially inappropriate medication (odds ratio=2.0; 95% confidence interval: 1.7-2.3).

CONCLUSION

This study is the first attempt to evaluate the frequency of potentially inappropriate medication use in the elderly French population. Female gender and low socio-economic characteristics reduced the chances of receiving optimal pharmacotherapy. The proportion of elderly subjects receiving potentially inappropriate medication was higher than shown in previous studies. This is mainly explained by differences in the use of cerebral vasodilators.

Use of potentially inappropriate pain-related medications in older adults with painful neuropathic disorders

BACKGROUND

Although older adults with painful neuropathic disorders (PNDs) would appear to be at elevated risk for receiving potentially inappropriate pain-related medications, the extent of such drug use in this population is unknown.

OBJECTIVE

The goal of this study was to assess the use of potentially inappropriate pain-related medications among patients with PNDs aged >or=65 years.

METHODS

Using a large, integrated US health insurance database, we identified all persons aged >or=65 years with >or=2 medical encounters involving diagnoses of PNDs during calendar year 2000. Patients with <30 days of continuous eligibility for health benefits during the study year were excluded from the sample. Use of potentially inappropriate pain-related medications (as defined by the 1997 Beers criteria) was then examined based on information contained in paid pharmacy claims for all remaining patients.

RESULTS

We identified 22,668 patients with PNDs aged >or=65 years (mean [SD] age, 73.9 [6.0] years; 58.6% female). Almost one half (11,233 [49.6%]) of patients received >or=1 potentially inappropriate pain-related medication, including propoxyphene (26.7%) and amitriptyline (10.2%). Women were more likely than men to receive these medications (54.2% vs 43.0%, respectively; P<0.01), and use increased with age (47.6%, 51.8%, and 52.8% in those aged 65-74 years, 75-84 years, and >or=85 years, respectively; overall comparison, P<0.01). Among patients with only 1 PND, the use of potentially inappropriate medications was highest among those with postherpetic neuralgia (70.1%).

CONCLUSIONS

Use of potentially inappropriate pain-related medications among older adults with PNDs is common. Further research is needed to ascertain whether the benefits of these agents outweigh their risks in this population.

Longitudinal prescribing patterns for psychoactive medications in community-based individuals with developmental disabilities: utilization of pharmacy records

BACKGROUND

Little is known about longitudinal prescribing practices for psychoactive medications for individuals with intellectual disabilities and developmental disabilities (IDDD) who are living in community settings.

METHODS

Computerized pharmacy records were accessed for 2344 community-based individuals with IDDD for whom a total of 3421 prescriptions were written during a 17-month period of study. Forty-two psychoactive medications were rank ordered in terms of prescription frequency.

RESULTS

Fifty-two per cent (52%) of all prescriptions written during the study period were for psychoactive medications. Anticonvulsant, antipsychotic and antidepressant medications were the most commonly filled prescriptions among psychoactive medications. Sixty per cent (62%) of the study population was given prescriptions for more than one psychoactive medication and 36% received three or more psychoactive medications. During the study period there was a statistically significant increase in prescriptions filled for olanzapine, risperidone, valproic acid, and clonazepam whereas prescriptions filled for thioridazine, haloperidol, and benzotropine showed a significant decline (P < 0.05-0.001). Distribution of psychoactive drug class by age showed that the majority of prescriptions were filled for individuals between 20 and 50 years with the exception of prescriptions for psychostimulants which peaked for individuals prior to 20 years.

CONCLUSIONS

(1) Analysis of pharmacy billing records provides a method for assessing prescribing patterns of psychoactive medications in community-based individuals with IDDD. (2) Polypharmacy for psychoactive medications is prevalent in this setting. (3) The second-generation antipsychotic medications are prominently represented by an increasing number of filled prescriptions during the study period.

Relationship between general practitioner certification and characteristics of care

BACKGROUND

The introduction of mandatory or quasimandatory certification processes for general/family doctors has become common in many countries, including Australia. Whether certification effects the care provided is rarely investigated.

OBJECTIVES

The objective of this study was to determine whether certification of general/family physicians is associated with clinical performance.

RESEARCH DESIGN

We conducted a secondary comparative analysis of data from an Australian national cross-sectional survey (April 2000-March 2002).

SUBJECTS

Subjects consisted of a random sample of 1982 general practitioners (GPs)

METHODS

Each participant provided demographic details and information about 100 consecutive patient encounters (total 197,500). We compared characteristics of certified and uncertified general practitioners (GPs), their patients, encounters, problems, management actions, and tested 34 performance indicators. We investigated whether differences identified in descriptive analyses were explained by other factors.

RESULTS

Of 1975 GPs who indicated certification status, 659 (33.4%) were vocationally certified. Certificants were more likely to be female, younger, Australian graduates, working fewer sessions, in larger practices, in accredited practices, and using computers for clinical purposes. Their patients were younger, more often female, and less likely to hold a healthcare concession card. Their consultations were longer; they prescribed fewer medications and more clinical treatments and procedures, ordered more pathology tests, and referred more to other health professionals. After adjustment for GP/practice, patient and morbidity differences, certificants had longer consultations, did more therapeutic procedures, prescribed less overall, prescribed fewer nonsteroidal antiinflammatory drugs in the elderly, and fewer antibiotics for upper respiratory infections.

CONCLUSION

Certification of general practitioners has a significant association with consultation behavior and patient management.

Potentially Inappropriate Prescribing in Ontario Community-Dwelling Older Adults and Nursing Home Residents

OBJECTIVES

To compare patterns of potentially inappropriate drug therapy prescribing in community-dwelling older adults and nursing home residents in Ontario, Canada.

DESIGN

A retrospective cohort study using administrative databases.

SETTING

Ontario community and nursing home facilities.

PARTICIPANTS

All 1,275,619 older adults aged 66 and older in Ontario (1,216,900 community-dwelling and 58,719 nursing home residents) who were dispensed at least one prescription from the comprehensive provincial drug plan in 2001. In Ontario, the provision of clinical pharmacy services is mandated in the nursing home setting. No comparable program exists for older adults in the community setting.

MEASUREMENTS

Potentially inappropriate drug prescribing was compared between community-dwelling and nursing home residents in two categories: those to always avoid and therapies considered rarely appropriate to prescribe.

RESULTS

Of the 1,275,619 adults in the cohort, nursing home residents were older (mean age+/-standard deviation=84.2+/-7.6 vs 75.0+/-6.5, P<.001), included more women (73.3% vs 57.7%, P<.001), had higher comorbidity scores (measured by the number of distinct drug therapies dispensed in the prior year (10.7+/-6.8 vs 7.2+/-5.7, P<.001) and Charlson comorbidity scores (1.4+/-1.6 vs 0.9+/-1.5, P<.001)) than community-dwelling individuals. Community-dwelling older adults were significantly more likely to be dispensed at least one drug therapy in the always avoid or rarely appropriate category than nursing home residents (3.3% vs 2.3%, P<.001). Using a logistic regression model that controlled for age, sex, and comorbidity (number of distinct drug therapies dispensed in the prior year), nursing home residents were close to half as likely to be dispensed one of these potentially inappropriate drug therapies as community-dwelling older adults (odds ratio=0.52, 95% confidence interval=0.49-0.55, P<.001).

CONCLUSION

Potentially inappropriate drug therapy in the always avoid and rarely indicated categories is dispensed less often to nursing home residents than to older community-dwelling adults. Clinical pharmacist services, which are mandated in the nursing home setting, may be responsible for these differences in Ontario, Canada.

Neuroleptic Drug Therapy in Older Adults Newly Admitted to Nursing Homes: Incidence, Dose, and Specialist Contact

OBJECTIVES

To describe the incidence and dose of neuroleptic drug therapy newly dispensed for behavioral disorders to older adults admitted to nursing homes and to determine whether this use is associated with patient characteristics and contact with specialists.

DESIGN

A retrospective cohort study using administrative data from a comprehensive and universal drug program.

SETTING

All licensed nursing homes in Ontario, Canada.

PARTICIPANTS

All 19,780 adults aged 66 and older who had no evidence of neuroleptic drug use in the previous year and no history of major psychosis and were newly admitted to a nursing home between April 1, 1998, and March 31, 2000.

MEASUREMENTS

Exposure to neuroleptic drug therapy and initial dose were measured using claims submitted to the Ontario Drug Benefit Program.

RESULTS

A prescription for a neuroleptic therapy was dispensed to 17% of older adults with no previous neuroleptic exposure within 100 days and to 24% within 1 year of their nursing home admission. New exposure to a neuroleptic therapy was less likely in women (odds ratio (OR)=0.7, 95% confidence interval (CI)=0.6-0.8) and more likely in residents with dementia (OR=3.5, 95% CI=3.2-3.8). Almost 10% of nursing home residents received an initial dose that exceeded recommended thresholds. Only 14% of those newly exposed had prior contact with a geriatrician or psychiatrist.

CONCLUSION

Incident use of neuroleptics in Ontario nursing homes is substantial. Use of high doses suggests that some physicians may need better information about using these agents, particularly given the rapid adoption of atypical neuroleptic drug therapies.

Inappropriate prescribing before and after nursing home admission

OBJECTIVES

To compare the prevalence of inappropriate prescribing before and after nursing home admission and to determine which patient and physician characteristics are associated with inappropriate prescribing in the nursing home setting.

DESIGN

A pre/post retrospective, cohort study.

SETTING

All licensed nursing homes in Ontario, Canada.

PARTICIPANTS

Nineteen thousand nine hundred eleven individuals aged 66 and older, newly admitted to nursing homes in Ontario between April 1, 1997, and March 31, 1999.

MEASUREMENTS

For each patient in the cohort, a subset of the Beers criteria was used to characterize and compare the prevalence of inappropriate prescribing (as indicated by the prescription of one of 49 inappropriate drugs) before and after nursing home admission. A logistic regression model was used to study the association between inappropriate prescribing and patient and physician characteristics.

RESULTS

The proportion of patients receiving a prescription for at least one inappropriate drug decreased from 25.4% before nursing home admission to 20.8% afterward (P <.001). Most patients who had been prescribed an inappropriate agent before nursing home entry had that agent discontinued after admission. The most commonly prescribed inappropriate drugs after nursing home admission were strongly anticholinergic antidepressants (6.4%) and long-half-life benzodiazepines (5.9%). Patients younger than 85 were more likely to receive inappropriate drug therapy (odds ratio (OR) = 1.25, 95% confidence interval (CI) = 1.15-1.35) than those aged 85 and older. Other significant predictors were having more than one prescriber (OR = 1.40, 95% CI = 1.29-1.51), having a physician aged 50 or older (OR = 1.14, 95% CI = 1.05-1.23), having a male physician (OR = 1.20, 95% CI = 1.05-1.37), having a nonspecialist physician (OR = 1.23, 95% CI = 1.01-1.49), having a nonurban physician (OR = 1.13, 95% CI = 1.03-1.24), and having a physician practicing outside the greater Ontario metropolitan area (OR = 1.31, 95% CI = 1.19-1.51).

CONCLUSIONS

Although a substantial number of nursing home residents receive inappropriate drug therapy, the prevalence of inappropriate prescriptions in our cohort declined after nursing home admission despite an overall increase in drug use. Patient and physician characteristics were associated with inappropriate prescribing. Targeted interventions such as regionally based education programs or drug use restrictions may reduce the prevalence of inappropriate prescribing.

Inappropriate use of digoxin in older hospitalized heart failure patients

BACKGROUND

Older adults are more likely to suffer from the adverse effects of digoxin. Studies have described the inappropriate use of digoxin in various populations. The objective of this study was to determine the correlates of inappropriate digoxin use in older heart failure patients.

METHODS

We studied older hospitalized heart failure patients with documented left ventricular (LV) function evaluation and electrocardiography. Digoxin use was considered inappropriate if patients had preserved LV systolic function (ejection fraction greater > or =40%) or if they had no atrial fibrillation (AF). We compared baseline patient characteristics by indication for digoxin and tested statistical significance using Pearson's chi-square analysis and Student's t tests. Using logistic regression, we determined the correlates of inappropriate use and initiation of digoxin.

RESULTS

Subjects (N = 603) had a mean age of 79 (+/-7) years; 59% were women, and 18% were African American. A total of 376 patients (62%) were discharged on digoxin, and 223 (37%) had no indication for its use. Half of the patients without an indication for digoxin received the drug. Of 132 patients without an indication and not already on digoxin, 38 (29%) were initiated on it. After adjustment for various patient and care characteristics, prior digoxin use (adjusted odds ratio [OR] 11.47, 95% confidence interval [CI] 5.72-23.02) and pulse > or =100/min (adjusted OR 2.33, 95% CI 1.10-4.94) were associated with inappropriate digoxin use. Pulse > or =100/min was also associated with inappropriate initiation of the drug (adjusted OR 2.95, 95% CI 1.28-6.78).

CONCLUSIONS

Inappropriate use of digoxin was common and was associated with prior use. Tachycardia was associated with inappropriate use and initiation. Electrocardiography and echocardiography should be performed in all older heart failure patients. Digoxin therapy should not be initiated or continued in patients without any evidence of LV systolic dysfunction or chronic AF.

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

BACKGROUND

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

OBJECTIVES

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

RESEARCH DESIGN

Cohort study.

SUBJECTS

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

MEASURES

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

RESULTS

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

CONCLUSIONS

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

Matching prescription claims with medication data for nursing home residents: implications for prescriber feedback, drug utilisation studies and selection of prescription claims database

Medication data retrieved from Australian Repatriation Pharmaceutical Benefits Scheme (RPBS) claims for 44 veterans residing in nursing homes and Pharmaceutical Benefits Scheme (PBS) claims for 898 nursing home residents were compared with medication data from nursing home records to determine the optimal time interval for retrieving claims data and its validity. Optimal matching was achieved using 12 weeks of RPBS claims data, with 60% of medications in the RPBS claims located in nursing home administration records, and 78% of medications administered to nursing home residents identified in RPBS claims. In comparison, 48% of medications administered to nursing home residents could be found in 12 weeks of PBS data, and 56% of medications present in PBS claims could be matched with nursing home administration records. RPBS claims data was superior to PBS, due to the larger number of scheduled items available to veterans and the veteran's file number, which acts as a unique identifier. These findings should be taken into account when using prescription claims data for medication histories, prescriber feedback, drug utilisation, intervention or epidemiological studies.

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

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

Inappropriate drug use among community-dwelling elderly

This study examined inappropriate drug use defined by updated criteria among respondents in the second and third in-person waves of the Duke Established Populations for Epidemiologic Studies of the Elderly. Information about sociodemographics, health status, access to health care, and drug use was determined by in-home interviews. Drug use was coded for therapeutic class and appropriateness by applying explicit criteria. Among participants, 27% of the second and 22.5% of the third in-person wave took one or more inappropriate agents. Of these drugs, the most common therapeutic classes were central nervous system and cardiovascular. Longitudinal multivariate analyses found that persons taking several prescription drugs, those having continuity of care, those who previously took inappropriate drugs, and those with many health visits were most likely (p<0.05) to use inappropriate drugs. We conclude that inappropriate drug use is common among community-dwelling elderly.