Inappropriate medication prescribing for the elderly by office-based physicians

Outpatient Quality Improvement in Academic Faculty Practice Plans: Does it Exist?

The purpose of this study was to (a) investigate the extent to which academic faculty practice plans (FPPs) are currently involved in ambulatory care quality improvement (QI), (b) describe the structure of QI initiatives at outpatient FPPs, and (c) delineate facilitators and barriers to development of FPP outpatient QI initiatives. Members of the Steering Committee of the Group Practice Council of the University HealthSystem Consortium (UHC), representing the leadership of 88 FPPs, were asked to respond to a 38-item Web-based questionnaire during February and March 2003. The survey elicited information on the organizational characteristics of FPPs, their current degree of engagement in outpatient QI activities, and factors driving interest and barriers impeding efforts to conduct outpatient QI initiatives. Descriptive statistics for all variables of interest were performed. Responses were received from 33 participants believed to represent at least 28 of the total 88 FPP members of the UHC. Nearly all respondents indicated that some types of outpatient QI initiatives were currently taking place in their FPP. However, only 12% of respondents met 4 or more of the 6 criteria deemed to be essential to having a robust outpatient QI program. Among key QI indicators, one third of respondents reported that their FPP had a separate and distinct outpatient quality committee, and some one fifth had a budget for outpatient QI or financial incentives for outpatient clinics to engage in QI (or both). The majority of respondents stated that at least some departments in their FPP were collecting quality data. Most respondents reported that patient safety and external demand for outpatient QI were the "more important" factors driving QI efforts, whereas lack of human resources and other resources were the "more significant" barriers hindering QI initiatives. The results of the study suggest that, although FPPs showed a strong interest in outpatient QI initiatives, FPPs' efforts are still in an infancy phase and lag far behind inpatient performance measurement activities. Without appropriate resources, it appears unlikely that FPPs will be able to move the agenda forward to develop a quality culture and robust program of self-assessment and improvement in the outpatient setting.

Potentially inappropriate anticholinergic medication use in community-dwelling older adults: a national cross-sectional study

BACKGROUND

Inappropriate medications are often used in older adults despite their unfavourable risk-to-benefit profile. Although many of the medications in the American Geriatrics Society (AGS) Beers list are potentially inappropriate because of their anticholinergic properties, little is known regarding the nature and extent of potentially inappropriate anticholinergic medication use in older adults.

OBJECTIVES

To determine the prevalence of, and factors associated with, potentially inappropriate anticholinergic medication use in the older population.

METHODS

A retrospective, cross-sectional study was conducted, involving older adults (aged 65 years and older), using 2009-2010 Medical Expenditure Panel Survey (MEPS) data. The 2012 AGS Beers Criteria were used to define potentially inappropriate anticholinergic medications on the basis of the list of medications to avoid using in older adults irrespective of the diagnosis. Descriptive analyses were used to examine the nature and extent of potentially inappropriate anticholinergic medication use. Multivariable logistic regression within the conceptual framework of the Andersen Behavioral Model was used to identify the factors associated with potentially inappropriate anticholinergic use in older adults.

RESULTS

According to the MEPS, there were 78.60 million older adults in the USA; an estimated 7.51 million (9.56 %) of these older adults used potentially inappropriate anticholinergic medications in 2009-2010. The most frequently used potentially inappropriate anticholinergics were cyclobenzaprine, promethazine, amitriptyline, hydroxyzine and dicyclomine. Multivariable regression analyses revealed that female sex, residing in the South and the presence of anxiety disorder increased the likelihood of receiving potentially inappropriate anticholinergic medications, whereas older adults aged 75-84 or ≥ 85 years, and those with over 15 years of education, had a decreased likelihood of receiving potentially inappropriate anticholinergic medications.

CONCLUSION

The study found that approximately one in ten older adults used potentially inappropriate anticholinergic medications. Several predisposing, enabling and need factors were associated with the use of potentially inappropriate anticholinergic medications. Concerted efforts are needed to optimize potentially inappropriate anticholinergic medication use in older adults.

[Suitability of pharmacological treatment in patients with multiple chronic conditions]

OBJECTIVE

To identify tools for measuring the appropriateness of drug therapy useful in patients with multiple chronic conditions.

DESIGN

We performed a literature review.

DATA SOURCES

The following database were consulted (December 2009): Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME) to detect tools for measuring the appropriateness of treatment in patients with multiple chronic conditions, or otherwise elderly or polypharmacy.

STUDY SELECTION

Studies were identified both qualitative and quantitative methodology, both theoretical and field work, both original and revised work and included work from all areas of the health system. 108 articles were retrieved, of which we selected 59. The consultation of their references include 20 jobs allowed, resulting in a total of 59 articles.

DATA EXTRACTION

Of all the tools identified, the researchers performed a selection of those with possible utility for classified PP. The articles were classified into implicit and explicit methods and the characteristics of the field works were tabulated.

RESULTS

We identified two implicit methods (MAI and Hamdy) and 6 explicit methods (Beers criteria, IPET, STOPP/START, ACOVE, CRIME and NORGEP). None was specific to patients with multiple chronic conditions. The questionnaire MAI, the Beers criteria and its modifications are most often used in literature. The advantages of explicit criteria means that many of them have been developed recently.

CONCLUSION

There are several tools to measure the appropriateness and none of them has been designed for a population of patients with multiple chronic conditions yet, which by its nature requires a specific approach spreads.

Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review

BACKGROUND

Inappropriate medication prescription is a common cause of preventable adverse drug events among elderly persons in the primary care setting.

OBJECTIVE

The aim of this systematic review is to quantify the extent of inappropriate prescription to elderly persons in the primary care setting.

METHODS

We systematically searched Ovid-Medline and Ovid-EMBASE from 1950 and 1980 respectively to March 2012. Two independent reviewers screened and selected primary studies published in English that measured (in)appropriate medication prescription among elderly persons (>65 years) in the primary care setting. We extracted data sources, instruments for assessing medication prescription appropriateness, and the rate of inappropriate medication prescriptions. We grouped the reported individual medications according to the Anatomical Therapeutic and Chemical (ATC) classification and compared the median rate of inappropriate medication prescription and its range within each therapeutic class.

RESULTS

We included 19 studies, 14 of which used the Beers criteria as the instrument for assessing appropriateness of prescriptions. The median rate of inappropriate medication prescriptions (IMP) was 20.5% [IQR 18.1 to 25.6%.]. Medications with largest median rate of inappropriate medication prescriptions were propoxyphene 4.52 (0.10-23.30)%, doxazosin 3.96 (0.32 15.70)%, diphenhydramine 3.30 (0.02-4.40)% and amitriptiline 3.20 (0.05-20.5)% in a decreasing order of IMP rate. Available studies described unequal sets of medications and different measurement tools to estimate the overall prevalence of inappropriate prescription.

CONCLUSIONS

Approximately one in five prescriptions to elderly persons in primary care is inappropropriate despite the attention that has been directed to quality of prescription. Diphenhydramine and amitriptiline are the most common inappropriately prescribed medications with high risk adverse events while propoxyphene and doxazoxin are the most commonly prescribed medications with low risk adverse events. These medications are good candidates for being targeted for improvement e.g. by computerized clinical decision support.

Effects of self-empowered teams on rates of adverse drug events in primary care

Background. Most safety issues in primary care arise from adverse drug events. Team Resource Management intervention was developed to identify systemic safety issues to design and implement interventions to address prioritized issues. Objectives. Evaluate impact of intervention on rates of events and preventable events in a vulnerable population. Design. Cluster randomized trial. 12 practices randomly assigned to either: (1) Intervention; (2) Intervention with Practice Enhancement Assistants; (3) No intervention. The intervention took 12 months. Main Outcome Measure. Rate and severity of events and preventable events measured using a Trigger Tool chart review method for the 12-month periods before and after the start of the intervention. Results. In the ''intervention with Assistants" group there was a statistically significant decrease in the overall rate of events and in the rate of moderate/severe events. Analysis of Variance with study arm and time as the factors and moderate/severe events as the outcome showed a significant interaction between arm and time supporting the notion that the ''Intervention with Assistants" practices had a greater reduction in moderate/severe preventable events. Conclusions. The intervention had a significant effect on medication safety as estimated using a trigger tool. Further exploration of role of Assistants and trigger tool is warranted.

Potentially inappropriate medication use in Indian elderly: comparison of Beers' criteria and Screening Tool of Older Persons' potentially inappropriate Prescriptions

AIM

To compare Beers' criteria (BC) and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) for prevalence, specificity, sensitivity and predictors for potentially inappropriate medication (PIM) use.

METHODS

Patients aged ≥ 60 years from medicine wards of a tertiary care hospital were included. Comparisons between BC and STOPP were made using Pearson's χ(2) -test for categorical variables and Mann-Whitney U-test for continuous variables. Specificity and sensitivity were assessed by using 2 × 2 contingency table. Bivariate analysis and subsequent multivariate logistic regression was used to identify the predictors of PIM use.

RESULTS

In the 540 patients included, prevalence of PIM use as per BC and STOPP was 24.6% and 13.3%, respectively. Sensitivity and specificity of BC in detecting PIM was 0.65 and 0.53, respectively. Considering the diagnoses/conditions, sensitivity and specificity of BC was 0.12 and 0.48, respectively, whereas independent of diagnoses/conditions, corresponding values were 0.75 and 0.54. PIM as per BC and STOPP accounted for 11 and 6 adverse drug reactions (ADR), respectively. Medications not listed in BC or STOPP were more likely to be associated with ADR. Multiple diseases (≥ 4) and use of more drugs during hospital stay (10-14) predicted PIM use as per BC, whereas age (60-74 years) predicted PIM use as per STOPP.

CONCLUSION

Overall, BC is useful in the detection of PIM use independent of diagnoses/conditions, whereas STOPP is useful in detection of PIM use considering the diagnoses/conditions. There is a need for consensus on using the tool for detection of PIM use in Indian elderly.

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Evaluation of pharmaceutical services: (2) Methods and measures

Numerous studies have been undertaken to evaluate pharmaceutical services. These include both the evaluation of existing practice and assessments of innovative services in both hospital and community settings. Evaluation requires employment of methods and measures to ensure that relevant data on the effects of a programme are obtained. To evaluate a service from different perspectives (eg, acceptability to health professionals or patients, uptake, clinical outcomes or resource implications), a number of methods may be required. The outcomes may also be wide-ranging. Measures must be selected which provide a true reflection of the extent to which these outcomes are, or are not, achieved. Designs and frameworks used in the evaluation of pharmacy services have been discussed previously,1 this paper reviews the methods and measures that have been employed.

Occurrence of potential drug-drug interactions in nursing home residents

Objective

It has been suggested that elderly people are at increased risk of drug-related problems such as drug-induced adverse effects, drug-drug interactions and drug-disease interactions. This is particularly the case for nursing home residents because of the often complicated and multiple co-morbidity that occurs in these people. The aim of this study was to develop prescribing indicators to assess systematically the occurrence and nature of potential drug-drug interactions (DDIs) in a cohort of Dutch nursing home residents.

Method

The study was conducted in residents aged 65 years and over in six nursing homes (n=2,355, two-year study period). Computerised medication data for the residents were evaluated with respect to co-prescribing of potentially interacting drugs. All DDIs that were classified as clinically relevant according to the Dutch National Drug Interaction Database were studied. DDIs were classified into three categories according to their pharmacological mechanism: 1 — pharmacokinetic interactions at the level of gastrointestinal (GI) absorption; 2 — pharmacokinetic interactions at the level of metabolism and excretion; and 3 — pharmacodynamic interactions.

Key findings

Thirty-two per cent (n=748) of all residents were exposed to one or more combinations of drugs that could lead to clinically adverse outcomes. The numbers of residents who received drug combinations with a mechanism of interaction from category 1, 2 or 3 were 73 (3 per cent), 164 (7 per cent) and 612 (26 per cent) respectively. The number of medications prescribed was significantly associated with the occurrence of a potential DDI (P<0.05). Drugs most frequently involved were oral anticoagulants, antibiotics and theophylline.

Conclusion

During the two-year study period, about one-third of the residents were exposed to at least one drug interaction considered clinically relevant. Adequate surveillance systems are needed to enable better identification of these interactions with a view to preventing potential clinical problems. Using the prescribing indicators developed in this study, such surveillance could focus on detection and clinical aspects of potential DDIs and possible alternative treatments.

Health Services Research Methods In Pharmacy

The aim of this paper is to review the methodologies employed by health service and pharmacy practice researchers in the evaluation of pharmacy services. The review is in two parts. Part 1 discusses the application of different study designs and frameworks in the evaluation of existing and innovative services and interventions; part 2, to be published in a later issue, will address the methods and measures employed in the evaluation process. The studies included in this review were selected to give examples of different study objectives, designs and frameworks and their application in pharmacy settings. Although many of the issues regarding study design and evaluation frameworks may be relevant to clinical trials comparing the efficacy of alternative drug therapies, the focus of this paper is on pharmacy services.

Preventing hospital admissions by reviewing medication (PHARM) in primary care: design of the cluster randomised, controlled, multi-centre PHARM-study

BACKGROUND

Medication can be effective but can also be harmful and even cause hospital admissions. Medication review or pharmacotherapy review has often been proposed as a solution to prevent these admissions and to improve the effectiveness and safety of pharmacotherapy. However, most published randomised controlled trials on pharmacotherapy reviews showed no or little effect on morbidity and mortality. Therefore we designed the PHARM (Preventing Hospital Admissions by Reviewing Medication)-study with the objective to study the effect of the total pharmaceutical care process on medication related hospital admissions and on adverse drug events, survival and quality of life.

METHODS/DESIGN

The PHARM-study is designed as a cluster randomised, controlled, multi-centre study in an integrated primary care setting. Patients with a high risk of a medication related hospital admission are included in the study with randomisation at GP (general practitioner) level. We aim to include 14200 patients, 7100 in each arm, from at least 142 pharmacy practices.The intervention consists of a patient-centred, structured, pharmaceutical care process. This process consists of several steps, is continuous and occurs over multiple encounters of patients and clinicians. The steps of this pharmaceutical care process are a pharmaceutical anamnesis, a review of the patient's pharmacotherapy, the formulation and execution of a pharmaceutical care plan combined with the monitoring and follow up evaluation of the care plan and pharmacotherapy. The patient's own pharmacist and GP carry out the intervention. The control group receives usual care.The primary outcome of the study is the frequency of hospital admissions related to medication within the study period of 12 months of each patient. The secondary outcomes are survival, quality of life, adverse drug events and severe adverse drug events. The outcomes will be analysed by using mixed-effects Cox models.

DISCUSSION

The PHARM-study is one of the largest controlled trials to study the effectiveness of the total pharmaceutical care process. The study should therefore provide evidence as to whether such a pharmaceutical care process should be implemented in the primary care setting.

TRIAL REGISTRATION

TRIAL NUMBER

NTR 2647.

Polypharmacy status as an indicator of mortality in an elderly population

BACKGROUND

Increased use of drugs has raised concern about the risks of polypharmacy in elderly populations. Adverse outcomes, such as hospitalizations and falls, have been shown to be associated with polypharmacy. So far, little information is available on the association between polypharmacy status and mortality.

OBJECTIVE

To assess whether polypharmacy (six to nine drugs) or excessive polypharmacy (ten or more drugs) could be indicators of mortality in elderly persons.

METHODS

This was a population-based cohort study conducted between 1998 and 2003 with mortality follow-up through to 2007. The data in this study were derived from the population-based Kuopio 75+ Study, which involved elderly persons aged>or=75 years living in the city of Kuopio, Finland. The initial sample (sample frame n=4518, random sample n=700) was drawn from the population register. For the purpose of this study, two separate analyses were carried out. In the first phase, participants (aged>or=75 years, n=601) were followed from 1998 (baseline) to 2002. In the second phase, survivors (aged>or=80 years, n=339) were followed from 2003 to 2007. Current medications were determined from drug containers and prescriptions during interviews conducted by a trained nurse. The Kaplan-Meier method and Cox proportional hazards regression were used to examine the association between polypharmacy status and mortality.

RESULTS

In the first phase, 28% (n=167) belonged to the excessive polypharmacy group, 33% (n=200) to the polypharmacy group, and the remaining 39% (n=234) to the non-polypharmacy (0-5 drugs) group. The corresponding figures in the second phase were 28% (n=95), 39% (n=132) and 33% (n=112), respectively. The mortality rate was 37% in the first phase and 40% in the second phase. In both phases, the survival curves showed a significant difference in all-cause mortality between the three polypharmacy groups. In the first phase, the univariate model showed an association between excessive polypharmacy and mortality (hazard ratio [HR] 2.53, 95% CI 1.83, 3.48); however, after adjustment for demographics and other variables measuring functional and cognitive status, this association did not remain statistically significant (HR 1.28, 95% CI 0.86, 1.91). In the second phase, the association between excessive polypharmacy and mortality (HR 2.23, 95% CI 1.21, 4.12) remained significant after adjustments. Age, male sex and dependency according to the Instrumental Activities of Daily Living screening instrument were associated with mortality in both phases.

CONCLUSION

This study points to the importance of excessive polypharmacy as an indicator for mortality in elderly persons. This association needs to be confirmed following adjustment for co-morbidities.

Medication errors in psychiatry: a comprehensive review

Medication errors are among the most common medical errors and cause significant morbidity and in some cases mortality. The objective of this article is to review the literature on medication errors in psychiatry. We completed a comprehensive search of both peer- and non-peer-reviewed articles that investigated medication errors in psychiatry. Our primary focus was to examine patient-, provider- and system-related factors that contributed to medication errors. Due to differences in research design and denominators used to determine error rates, the reported prevalence rates of medication errors in psychiatry vary widely. Patient-related factors identified as contributing to medication errors included non-adherence to medication, failure of patients to inform their various care providers about the medications they are taking and symptoms of psychiatric illnesses. Provider-related factors identified as contributing to medication errors were also identified and included clinical practices associated with prescribing, transcription, dispensing, administration and monitoring. Finally, the healthcare system also has a major role to play in reducing medication errors by ensuring seamless continuity of care, mandating medication reconciliation programmes, ensuring adequate clinical pharmacy services and supporting a nonpunitive medication error reporting system. Although the literature raises awareness of these specific contributing factors, there is still a great need for more systematic evaluations of the problem including root cause analysis. Medication errors in psychiatry have been studied almost exclusively in the inpatient setting and thus little is known about the incidence and significance in outpatient and community settings.

Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

BACKGROUND

The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.

AIM

To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.

DESIGN OF STUDY

Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months' participation in pharmaceutical care.

SETTING

In 2002, 760 patients, aged > or =75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.

METHOD

Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form-36 Health Survey (SF-36), and serious adverse events.

RESULTS

The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.

CONCLUSION

The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.

Medication inappropriateness for older adults receiving hospice care: a pilot survey

OBJECTIVE

To test the feasibility and reliability of a tool and methodology for evaluating expert clinicians' perceptions about the application of the Beers criteria in hospice.

DESIGN

A pilot survey.

SETTING

A national medication therapy management provider specializing in hospice care.

PARTICIPANTS

Thirty-five participants from a multidisciplinary panel were invited to complete the survey. They were selected to represent acute, long-term care, and community practice settings with various levels of experience and judgment.

INTERVENTION

Respondents were asked to complete the survey by rating their agreement or disagreement with the inappropriateness of the medications or medication classes for hospice patients, using a five-point Likert scale from strongly agree (1) to strongly disagree (5), with the midpoint (3) expressing equivocation.

MAIN OUTCOME MEASURES

Feasibility as measured by the percentage of returned and completed surveys. A secondary aim was to measure inter-rater reliability and response.

RESULTS

Twenty-four clinicians (69%) completed the survey, including 13 clinical pharmacists, 6 nurses, and 5 physicians. Twenty-nine responses (2%) were furnished by imputation methods. The intraclass correlation for medication inappropriateness for hospice patients was 0.89 (0.81-0.95), indicating "good" inter-rater reliability. Short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines were considered appropriate for use in older hospice patients, but they are considered inappropriate according to the Beers criteria.

CONCLUSION

We established a viable methodology for evaluating clinician judgment about medication inappropriateness in older hospice patients. Some medications routinely considered to be inappropriate may be appropriate at end of life; different criteria may be needed to determine medication inappropriateness in hospice care.

A comprehensive appropriateness of prescribing questionnaire was validated by nominal consensus group

OBJECTIVE

To develop and validate a comprehensive Appropriateness of Prescribing Evaluation Questionnaire (APEQ) suitable for human and computer use.

STUDY DESIGN AND SETTING

This study was part of an ongoing research program examining the effectiveness and cost-effectiveness of computerized prescribing decision support for providers, patients, and drug policy. A nominal group consensus process involved physicians, both primary care physicians and specialists, pharmacists, drug plan managers, patients, patient advocates, and pharmaceutical industry. Structured case scenarios of musculoskeletal problems were used to evaluate APEQ's validity and responsiveness.

RESULTS

Seventeen panelists evaluated 72 patient scenarios in two rounds. Their ratings of appropriateness, assessed by ANOVA, showed significant agreement with the experts' scores in the two rounds, which evaluated appropriateness and responsiveness, respectively. Interrater and intrarater agreement was moderate to good.

CONCLUSION

This formal assessment suggests that APEQ has reasonable validity, reliability, and responsiveness. Such tools could be very useful in e-prescribing and e-claims reimbursement environments and should be further explored.

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.

Pharmacists and their effectiveness in ensuring the appropriateness of the chronic medication regimens of geriatric inpatients

OBJECTIVE

Geriatric patients are prescribed multiple medications by multiple physicians, leaving them at an increased risk for adverse events. The Beers criteria for determining inappropriately prescribed medications have been applied to elderly patients in various geriatric settings. Using the 1997 Beers criteria, we planned to determine if the Acute Care for Elders (ACE) team pharmacist improved the medication regimens of geriatric inpatients.

DESIGN

This study was a retrospective, case series design.

SETTING

The setting for this study was a large teaching hospital.

PATIENTS

There were 99 patients who met the inclusion criteria.

MAIN OUTCOME MEASURES

Age, gender, race, and medication data were collected for all eligible patients. The prevalence of inappropriately prescribed medications and the number of medications were determined both upon admission and at discharge. Statistical analyses were conducted where appropriate.

RESULTS

Upon admission to the hospital, 10.1% of the patients were prescribed inappropriate medications. At discharge, 2.02% of patients consulted by the ACE team were prescribed an inappropriate medication. This was a statistically significant difference (P < 0.02). The number of medications at admission compared with discharge showed no statistical difference (P = 0.15).

CONCLUSION

Based on the Beers criteria, the ACE team pharmacist was able to make a statistically significant difference in the number of elderly patients being prescribed inappropriate medications upon discharge when compared with admission medication regimens. The number of medications a patient was prescribed did not decrease.

Potentially Inappropriate Medication Use by Medicaid+Choice Beneficiaries in the Last Year of Life

BACKGROUND

Regardless of the payer and the period studied the prevalence of potentially inappropriate medication use in the elderly ranged from 21% to 40%.

OBJECTIVE

To look at potentially inappropriate prescribing in a group of Medicare+Choice beneficiaries in their last year of life (LYOL) in a large national managed care organization.

RESEARCH DESIGN

Retrospective review of Medicare+Choice decedents' drug claims and enrollment data collected between January 1998 and December 2000, supplemented by the Medicare denominator file and 1990 Census data.

SUBJECTS

Four thousand six hundred two beneficiaries in a large national managed care organization.

MEASURES

We analyzed the relationship between disagreement with the Beers' criteria and sociodemographic descriptors, insurance characteristics, and cause of death. We used logistic regression techniques to estimate factors associated with the disagreement.

RESULTS

Two thousand thirty-one beneficiaries (44%) had at least one claim in the LYOL that disagreed with a Beers' criterion, 15% experienced more than one unique Beers' disagreement. The most common disagreements were for the use of propoxyphene (15.0%), followed by zolpidem (3.8%), and amitriptyline (2.8%). Based on total claims, cancer patients were most likely to receive propoxyphene (35.3%) followed by patients with a heart condition (29.6%). A large proportion of the potentially inappropriate prescribing involves psychoactive drugs. The logistic model showed fewer Beers' criteria breaches associated with being male and being non-white. Beers' breaches were more common if the beneficiary has increasing prescription use or died from cancer.

CONCLUSION

This study showed that many beneficiaries have prescriptions that contravene the Beers' criteria.

Propoxyphene (dextropropoxyphene): a critical review of a weak opioid analgesic that should remain in antiquity

Propoxyphene (dextropropoxyphene) is a synthetic weak opioid introduced into the United States in 1957. It is most frequently prescribed in combination with acetaminophen and/or aspirin. After its ubiquitous introductory phase, it was soon discovered that this drug's iatrogenic events (cardiotoxicity, seizures, etc.) far outweighed any perceived therapeutic benefit. Propoxyphene analgesia was equated with that of merely acetaminophen or aspirin independently. The propoxyphenes euphorigenic component has created a problem in its prescribing. Use of this agent in the elderly should be avoided because of its complex pharmacokinetics and pharmacodynamics. The pharmacokinetics, pharmacodynamics, and pharmacology of this drug are discussed thoroughly in this article, including its arrhythmogenicity. Additional noncardiovascular pharmacotherapies that produce QTc prolongation or arrhythmogenicity are described. A list of the cytochrome P450 2D6 pharmacotherapies that will interact with propoxyphene is provided in the article. The use of this agent is highly discouraged. The rationale for this is discussed fully within this article. The toxicity of this drug is partially related to nor-propoxyphene a non-opioid cardiotoxic metabolite. The mere warnings of fatalities within the package insert should alert any cautious prescriber on the dangers of this agent and dampen its prescribing potential.

Inappropriate medication use in elderly lebanese outpatients: prevalence and risk factors

BACKGROUND

Inappropriate use of medications has become an international cause for concern in geriatric patients, who are at high risk of drug-related morbidity. This study is the first attempt to determine the prevalence of inappropriate drug use in elderly Lebanese outpatients, using community pharmacy data, and to identify factors that predict potentially inappropriate drug intake in this population.

METHODS

Records of elderly patients aged > or =65 years were selected from different community pharmacies. Each patient profile was reviewed and to confirm patient record information, in-person interviews were conducted with elderly patients between November 2004 and May 2005 by qualified pharmacists. Based on a literature review describing guidelines for the inappropriate use of medications in the elderly, courses of therapy were assessed and classified as either appropriate or inappropriate. Courses of therapy that were judged inappropriate were further classified according to the specific area of inappropriate use (i.e. Beers' criteria, duplicate therapy, indication, dose, dose frequency including missing doses, duration and discontinuation of therapy, adverse effects, drug-drug and/or drug-disease interactions, and poor memory). Statistical analyses were performed to estimate the prevalence of inappropriate medication use and to identify potentially predictive factors of such use arising from patients' sociodemographic characteristics, health factors and drug regimen intake.

RESULTS

A total of 350 elderly patient profiles were reviewed, from which 277 evaluable records were obtained. More than half (59.6%) of the patients taking drugs at the time of the study were taking at least one inappropriate medication. Inappropriate medication use was most frequently identified in terms of Beers' criteria (22.4%), missing doses (18.8%) or incorrect frequency of administration of drugs (13.0%). Factors predicting potentially inappropriate drug intake included female sex (65.7% vs 53.3% for males, p = 0.03) and alcohol intake (p = 0.007). There were also significant associations between the likelihood of use of an inappropriate drug and (i) increased number of medical illnesses (p < 0.00002); and (ii) consumption of an over-the-counter drug (OTC) and/or prescription drug (p = 0.048 and p = 0.0035, respectively). The likelihood of use of an inappropriate drug was higher again when patients concurrently used both OTC and prescription drugs (p < 0.0002).

CONCLUSION

The present study is the first to describe and assess inappropriate medication use by elderly outpatients in the Lebanese community setting. With increasing availability of newer and more appropriate medications, use of potentially inappropriate drugs may decrease. Pharmacists have a major role to play in counselling patients about the importance of appropriate drug use.

Is inappropriate medication use a major cause of adverse drug reactions in the elderly?

AIM

To study the occurrence of adverse drug reactions (ADRs) linked to inappropriate medication (IM) use in elderly people admitted to an acute medical geriatric unit.

METHODS

All the elderly people aged > or = 70 years admitted to the acute medical geriatric unit of Limoges University hospital (France) over a 49-month period were included, whatever their medical condition. For all the patients, clinical pharmacologists listed the medications given before admission and identified the possible ADRs. The appropriateness of these medications and the causal relationship between drugs (either appropriate or not) and ADRs were evaluated.

RESULTS

Two thousand and eighteen patients were included. The number of drugs taken was 7.3 +/- 3.0 in the patients with ADRs and 6.0 +/- 3.0 in those without ADRs (P < 0.0001). Sixty-six percent of the patients were given at least one IM prior to admission. ADR prevalence was 20.4% among the 1331 patients using IMs and 16.4% among those using only appropriate drugs (P < 0.03). In only 79 of the 1331 IM users (5.9%) were ADRs directly attributable to IMs. The IMs most often involved in patients with ADRs were: anticholinergic antidepressants, cerebral vasodilators, long-acting benzodiazepines and concomitant use of two or more psychotropic drugs from the same therapeutic class. Using multivariate analysis, after adjusting for confounding factors, IM use was not associated with a significant increased risk of ADRs (odds ratio 1.0, 95% confidence interval 0.8, 1.3).

CONCLUSION

Besides a reduction in the number of drugs given to the elderly, a good prescription should involve a reduction in the proportion of IMs and should take into consideration the frailty of these patients.

Inappropriate drug use and risk of transition to nursing homes among community-dwelling older adults

BACKGROUND

Adverse events from inappropriate medications are preventable risk factors for nursing home admissions.

OBJECTIVE

We sought to investigate the relationship between inappropriate medications in older adults and transitions to nursing home.

METHODS

A retrospective cohort of Medicare beneficiaries with employer-sponsored supplemental health insurance was analyzed using a longitudinal data set of Medicare supplemental insurance claims. After a baseline year with no nursing home admissions, subjects were followed until the first month of transition to nursing home, loss to follow-up, or the end of the 24-month follow-up period. Survival analysis was used to compare the risk of nursing home transition among those with and without inappropriate drug use in the previous 3 months.

RESULTS

Of the 487,383 subjects in the cohort, 22,042 (4.5%) had a nursing home admission. Use of inappropriate drugs was associated with a 31% increase in risk of nursing home admission, compared with no use of inappropriate drugs (adjusted relative risk 1.31, 99% confidence interval [CI] 1.26-1.36). Analyses of individual drug classes showed the risk of nursing home admission was similar, or lower, for inappropriate drugs versus other drugs of the same class. For example, the relative risk of nursing home admission was 2.34 (99% CI 2.20-2.47) for inappropriate narcotics and 2.68 (99% CI 2.55-2.82) for other narcotics, compared with no narcotic use.

CONCLUSION

Inappropriate drug use was associated with increased risk of nursing home transition, but the increased risk may be explained by underlying patient conditions for which the drugs were prescribed rather than the inappropriate drug.

Prescribing to older ED patients

The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.

Prevalence of inappropriate medication using Beers criteria in Japanese long-term care facilities

Background

The prevalence and risk factors of potentially inappropriate medication use among the elderly patients have been studied in various countries, but because of the difficulty of obtaining data on patient characteristics and medications they have not been studied in Japan.

Methods

We conducted a retrospective cross-sectional study in 17 Japanese long-term care (LTC) facilities by collecting data from the comprehensive MDS assessment forms for 1669 patients aged 65 years and over who were assessed between January and July of 2002. Potentially inappropriate medications were identified on the basis of the 2003 Beers criteria.

Results

The patients in the sample were similar in terms of demographic characteristics to those in the national survey. Our study revealed that 356 (21.1%) of the patients were treated with potentially inappropriate medication independent of disease or condition. The most commonly inappropriately prescribed medication was ticlopidine, which had been prescribed for 107 patients (6.3%). There were 300 (18.0%) patients treated with at least 1 inappropriate medication dependent on the disease or condition. The highest prevalence of inappropriate medication use dependent on the disease or condition was found in patients with chronic constipation. Multiple logistic regression analysis revealed psychotropic drug use (OR = 1.511), medication cost of per day (OR = 1.173), number of medications (OR = 1.140), and age (OR = 0.981) as factors related to inappropriate medication use independent of disease or condition. Neither patient characteristics nor facility characteristics emerged as predictors of inappropriate prescription.

Conclusion

The prevalence and predictors of inappropriate medication use in Japanese LTC facilities were similar to those in other countries.

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.

Potentially inappropriate prescribing before and after nursing home admission among patients with and without dementia

OBJECTIVES

This study was designed to describe changes in the prevalence of potentially inappropriate medication prescribing before and after nursing home admission, and to compare prevalence among residents with and without dementia. This paper extends the research on inappropriate medication prescribing among residents entering a nursing home, with the added feature of comparison by dementia status.

METHODS

This retrospective cohort study was conducted using data from 59 randomly selected nursing homes in Maryland. Dually eligible (Medicare/Medicaid) residents aged > or = 65 years who were admitted to one of these nursing homes from 1992 to 1995 were eligible for inclusion in the cohort. An expert panel of physicians determined dementia status at admission. Potentially inappropriate prescribing, as defined by the 1997 Beers criteria, was compared using Medicaid prescription claims for up to 12 months before and after admission to characterize monthly prescribing patterns.

RESULTS

The study group included 546 dually eligible nursing home residents with > or = 1 paid prescription claim for the 12 months before or after their admission date. A total of 372 (68%) residents were white, 443 (81%) were unmarried, 408 (75%) were female, and 334 (61%) were diagnosed with dementia at admission. Before nursing home admission, the mean monthly prevalence of potentially inappropriate medications for residents with and without dementia was 20% and 23%, respectively. After admission, the mean monthly prevalence increased to 28% among residents without dementia and decreased to 19% among residents with dementia. After adjusting for the mean number of other prescriptions, sociodemographic factors, and number of comorbid conditions, residents with dementia were as likely as residents without dementia to receive a potentially inappropriate drug before admission (prevalence ratio, 0.97; 95% CI, 0.58-1.62). After admission, residents with dementia were 27% less likely than residents without dementia to receive a potentially inappropriate drug, although the difference did not reach statistical significance (prevalence ratio, 0.73; 95% CI, 0.53-1.01).

CONCLUSIONS

Inappropriate medication prescribing was similar before nursing home admission among patients with and without dementia. After admission, the prevalence was lower among residents with dementia, but it did not reach statistical significance.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Relationship Between Patient Age and Duration of Physician Visit in Ambulatory Setting: Does One Size Fit All?

OBJECTIVES

To determine whether patient age, the presence of comorbid illness, and the number of prescribed medications influence the duration of a physician visit in an ambulatory care setting.

DESIGN

A cross-sectional study of ambulatory care visits made by adults aged 45 and older to primary care physicians.

SETTING

A probability sample of outpatient follow-up visits in the United States using the National Ambulatory Medical Care Survey (NAMCS) 2002 database.

PARTICIPANTS

Of 28,738 physician visits in the 2002 NAMCS data set, there were 3,819 visits by adults aged 45 and older included in this study for analysis.

MEASUREMENTS

The primary endpoint was the time that a physician spent with a patient at each visit. Covariates included for analyses were patient characteristics, physician characteristics, visit characteristics, and source of payment. Visit characteristics, including the number of diagnoses and the number of prescribed medications, the major diagnoses, and the therapeutic class of prescribed medications, were compared for different age groups (45-64, 65-74, and > or =75) to determine the complexity of the patient's medical conditions. Endpoint estimates were computed by age group and were also estimated based on study covariates using univariate and multivariate linear regression.

RESULTS

The mean time+/-standard deviation spent with a physician was 17.9+/-8.5 minutes. There were no differences in the duration of visits between the age groups before or after adjustment for patient covariates. Patients aged 75 and older had more comorbid illness and were prescribed more medications than patients aged 45 to 64 and 65 to 74 (P<.001). Patients aged 75 and older were also prescribed more medications that require specific monitoring and counseling (warfarin, digoxin, angiotensin-converting enzyme inhibitors, diuretics, and levothyroxine) than were patients in other age groups (P<.001). Hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, cerebrovascular disease, and transient ischemic attack were more common in patients aged 75 and older than in other age groups (P<.001). Despite these differences, there were no differences in unadjusted or adjusted duration of physician visit between the age groups.

CONCLUSION

Although patients aged 75 and older had more medical conditions and were at higher risk for drug-related problems than younger patients, the duration of physician visits was similar across the age groups. These findings suggest that elderly patients may require a multidisciplinary approach to optimize patient care in the ambulatory setting.

Examining Nurses’ Decision Process for Medication Management in Home Care

BACKGROUND

The process of medication management within home care agencies was prospectively described, with a focus on the nurse's role and critical points in the process. The process the nurse must follow includes preparing, checking, and administering medications; updating knowledge of medications; monitoring the effectiveness of treatment; reporting adverse reactions; and teaching patients about their drugs.

PROCESSES FOR MEDICATION MANAGEMENT IN HOME HEALTH CARE

The steps that home health nurses (HHNs) go through with families and the system changes that could be developed to decrease errors were identified. The approach was based on Failure Mode and Effects Analysis-a method to identify and prevent process problems before they occur. The medication management process was divided into drug utilization review (DUR) for duplicative and harmful interactions; drug administration by the patient, family member, and/or caregiver; and side effects. Failure modes were developed for a DUR for duplicative and harmful interactions.

DISCUSSION

Home health agencies should analyze the medication management process in their own agencies and identify system solutions. The difficulty encountered by HHNs in contacting physicians to discuss changes to the drug regimen following the assessment of potential drug interactions or duplications is an ongoing problem. Careful monitoring by HHNs could decrease the impact of adverse drug effects.

Comparison of the association between disease burden and inappropriate medication use across three cohorts of older adults

BACKGROUND

Use of potentially inappropriate medications is common in nursing facilities (NFs), in which frail older adults are particularly vulnerable to adverse drug effects. The community-dwelling elderly are generally healthier and have lower overall rates of medication use, but their prescribed medications are not subjected to the same degree of regulatory scrutiny as those of residents in NFs. Frail elderly (FE) adults who are nursing home eligible but are receiving home- and community-based services (HCBS) constitute a distinct group sharing a high disease burden and high levels of medication use with the NF population.

OBJECTIVE

The goal of this study was to examine the relationship between disease burden and inappropriate medication use in these 3 cohorts, with adjustment for demographic and clinical differences.

METHODS

We performed retrospective analyses of Medicaid claims data from May 2000 through April 2001 to identify 3 cohorts of Kansas Medicaid beneficiaries: community-dwelling older adults (the ambulatory cohort); persons receiving HCBS through the Kansas Frail Elderly Program (the FE cohort); and elderly NF residents (the NF cohort). Demographic, clinical, and medication data were extracted from the Medicaid claims data. Unconditionally inappropriate medications were identified using the 1997 Beers criteria. The Cumulative Illness Rating Scale for Geriatrics was used to calculate the disease burden sum, classified as 0 or 1, 2 or 3, 4 or 5, or > or =6 disease categories. Odds ratios for inappropriate medication use at each level of disease burden in each cohort were derived using multivariable models adjusted for demographic and clinical factors, including overall level of medication use.

RESULTS

The final sample included 3185 persons in the 3 cohorts (1163 ambulatory, 858 FE, 1164 NF). Inappropriate medication use was determined to have occurred in 21%, 48%, and 38% of the respective cohorts and was highest in FE cohort members with the greatest disease burden (61%). For the ambulatory and FE cohorts, inappropriate medication use rose as the disease burden increased. The same was not observed in the NF cohort, in whom rates of inappropriate medication use showed little variation regardless of disease burden.

CONCLUSIONS

The relationship between disease burden and inappropriate medication use varied by setting. Those members of the FE cohort with the highest disease burden had the greatest risk for inappropriate medication use.

Adverse Outcomes Associated with Inappropriate Drug Use in Nursing Homes

BACKGROUND:

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

OBJECTIVE:

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

METHODS:

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

RESULTS:

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

CONCLUSIONS:

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

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.

Inappropriate Medication Administration to the Acutely Ill Elderly: A Nationwide Emergency Department Study, 1992–2000

OBJECTIVES

To determine the national rate and trend of inappropriate medication administration to elderly emergency department (ED) patients. Secondary objectives were to identify risk factors for receiving an inappropriate medication and to determine whether administration is sometimes justified based on diagnosis.

DESIGN

Retrospective analysis of ED visits in the 1992-2000 National Hospital Ambulatory Medical Care Survey. Inappropriate medications identified using Beers' 1997 explicit criteria.

SETTING

EDs of U.S. noninstitutionalized general and short-stay hospitals.

PARTICIPANTS

ED survey patients aged 65 and older.

MEASUREMENTS

Magnitude and rate of administration of 36 medications.

RESULTS

Inappropriate medications were administered in an estimated 16.1 million (95% confidence interval (CI)=14.9-17.3 million) or 12.6% (95% CI=11.6-13.5%) of elderly ED visits from 1992 to 2000. The rate of inappropriate administration was unchanged throughout the study period (P=.40). Six drugs accounted for 70.8% of inappropriate administration: promethazine (22.2%), meperidine (18.0%), propoxyphene (17.2%), hydroxyzine (10.3%), diphenhydramine (7.1%), and diazepam (6.0%). In multivariate analysis, number of ED medications was the strongest predictor, with an odds ratio for two to three medications of 6.0 (95% CI=5.3-6.7) and for four to six medications of 8.1 (95% CI=7.2-9.2). Diagnoses indicating potentially appropriate uses of these medications were rarely present. For example, only 42.4% of patients receiving diphenhydramine and 7.4% receiving hydroxyzine were diagnosed with an allergic process.

CONCLUSION

Elderly ED patients are frequently administered inappropriate medications. Potentially appropriate uses of generally inappropriate drugs cannot account for such administrations. Inappropriate administration rates remain unchanged despite the 1997 publication of explicit criteria.

Potentially inappropriate medication prescriptions among elderly nursing home residents: their scope and associated resident and facility characteristics

OBJECTIVE

To estimate the scope of potentially inappropriate medication prescriptions (PIRx) among elderly residents in U.S. nursing homes (NHs), and to examine associated resident and facility characteristics.

DATA SOURCES

The 1996 Medical Expenditure Panel Survey Nursing Home Component (MEPS NHC), a survey of a nationally representative sample of NHs and residents.

STUDY DESIGN

The PIRx, defined by Beers's consensus criteria (1991, 1997), was identified using up to a year's worth of NH prescribed medicine data for each resident. The study sample represented 1.6 million NH residents (n=3,372).

RESULTS

At a minimum, 50 percent of all residents aged 65 or older, with an NH stay of three months or longer received at least one PIRx in 1996. The most common PIRx involved propoxyphene, diphenhydramine, hydroxyzine, oxybutynin, amitriptyline, cyproheptadine, iron supplements, and ranitidine. Resident factors associated with greater odds of PIRx were Medicaid coverage, no high school diploma, and nondementia mental disorders. Facility factors were more beds and lower RN-to-resident ratio. Factors associated with lower odds of PIRx were fewer medications, residents with communication problems, and being in an accredited NH. Onsite availability of pharmacists or mental health providers was not related.

IMPLICATIONS

With quality of care and patient safety as major public health concerns, effective policies are needed to avoid PIRx occurrences and improve the quality of prescribing among elderly residents in NHs. Additional studies are needed to determine the impact of PIRx on this NH population.

Potentially Inappropriate Drug Prescribing Among First-Visit Elderly Outpatients in Taiwan

STUDY OBJECTIVE

To determine the prevalence and risk factors of potentially inappropriate drug prescribing among first-visit elderly outpatients.

DESIGN

Cross-sectional survey.

SETTING

An urban tertiary care and academic medical center in southern Taiwan.

PATIENTS

Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001.

MEASUREMENTS AND MAIN RESULTS

Potentially inappropriate drug prescribing was assessed according to updated Beers criteria. Ninety-seven potentially inappropriate drugs were identified in 93 (10.5%) patients. The most common classes were sedative-hypnotics (18.6%) and muscle relaxants (17.5%). Twenty (20.6%) of these inappropriate drugs had a high severity potential according to the Beers criteria. Patients prescribed potentially inappropriate drugs were more likely to be prescribed several drugs versus those who were not prescribed potentially inappropriate drugs (4.0+/-1.9 vs 2.8+/-1.4, p<0.001). Multiple logistic regression analysis revealed an interaction between age and the number of prescribed drugs on the risk of having potentially inappropriate drugs prescribed. In patients who were prescribed four agents or less, the risk was not associated with increasing age; in those who were prescribed five drugs or more, the risk was positively associated with increasing age.

CONCLUSION

Potentially inappropriate drug prescribing among first-visit elderly outpatients was relatively low. Increasing patient age combined with increased number of drugs prescribed was associated with increased risk of having potentially inappropriate drugs prescribed.

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

BACKGROUND

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

DESIGN

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

Potentially inappropriate medication use by elderly Mexican Americans

BACKGROUND

Use of inappropriate medications by the elderly is a public health concern with potentially serious health consequences. Research indicates relatively high rates of inappropriate prescription drug usage for older whites and African Americans. However, rates for older Mexican Americans are unknown.

OBJECTIVE

To examine the prevalence and predictors of inappropriate prescription medication use by older Mexican Americans.

METHODS

A cross-sectional study of 3050 Mexican Americans aged > or =65 years living in the southwestern US was conducted. In-home interviews in 1993 and 1994 assessed prescription medication use. Descriptive statistics and logistic regression models were used to estimate prevalence and risk of inappropriate prescription drug use.

RESULTS

Approximately 12% (n = 365) of the sample had used at least 1 of 32 potentially inappropriate prescription medications within 2 weeks of the baseline assessment. Four drugs, chlorpropamide, propoxyphene, amitriptyline, and dipyridamole, accounted for 54% of all inappropriate prescribing. Unmarried subjects, those with >/=1 chronic diseases, high depressive symptoms, frequent physician visits, and combined Medicaid and Medicare insurance were more likely to have used at least 1 of the 32 potentially inappropriate drugs.

CONCLUSIONS

The prevalence of inappropriate medication use is lower in older Mexican Americans than in similar white and African American populations. More studies are needed on the pattern of inappropriate prescribing over time and on intervention programs to reduce potentially adverse health outcomes in older Mexican Americans most at risk.

Propoxyphene use by community-dwelling and institutionalized elderly Medicare beneficiaries

OBJECTIVES

To provide the first comparable national prevalence estimates on use of propoxyphene, a potentially inappropriate drug, by elderly Medicare beneficiaries living in the community and institutions and to determine whether institutionalized beneficiaries are at a greater risk for receiving propoxyphene than community-dwelling beneficiaries.

DESIGN

Cross-sectional study.

SETTING

U.S. representative sample of elderly using Medicare database.

PARTICIPANTS

Nationally representative sample of community-dwelling (n = 9,851, weighted n = 32.5 million) and institutionalized (n = 1,099, weighted n = 2.3 million) Medicare beneficiaries aged 65 and older.

MEASUREMENTS

National estimates on prevalence of propoxyphene use and the odds of receiving propoxyphene were the two main outcome measures.

RESULTS

Annual prevalence of propoxyphene use in 1998 was 6.8% by all community-dwelling elderly beneficiaries and 15.5% by institutionalized elderly beneficiaries. Beneficiaries in long-term care facilities had almost 40% higher odds of receiving propoxyphene (odds ratio = 1.38, 95% confidence interval = 1.1-1.8) than beneficiaries in the community even after controlling for other factors in a logistic regression. Other risk factors include female, rural residence, poor health, and history of osteoporosis or hip fracture. Beneficiaries residing in regions in the midwest and south were more than twice as likely to receive propoxyphene as those in the mid-Atlantic area.

CONCLUSION

These results show that propoxyphene use by U.S. community-dwelling seniors is high but is much higher in the institutionalized population. These findings suggest that prescribing for older adults with pain could be improved, especially for vulnerable long-term care residents.

What do we know about medication errors in inpatient psychiatry?

BACKGROUND

Adverse drug events (ADEs) have been implicated as a cause of substantial morbidity and mortality. Psychiatrists have successfully characterized one category of ADE--adverse drug reactions (ADRs), which have been studied from a medication-specific psychopharmacology frame of reference. The literature on ADEs, both preventable and nonpreventable, was reviewed within the broader patient safety framework.

METHODS

English-language studies involving ADEs and medication errors in psychiatry for 1996 through 2003 were identified on MEDLINE and by using a hand search of bibliographies.

RESULTS

Few reports on the incidence and characteristics of medication errors in psychiatric hospitals could be found. Psychiatrists may not be sufficiently aware of the harm caused by errors, methodological issues regarding error detection, the validity of reported medication error rates, and the challenge of creating a nonpunitive error-reporting culture. PREVENTION STRATEGIES: Application of a systems-oriented approach to ADE reduction and the promotion of a nonpunitive culture are essential. Clinical and pharmacy staff could monitor the literature for published reports of preventable adverse events and review those reports in multidisciplinary team meetings.

CONCLUSIONS

Psychiatry would benefit from learning about the terminology used in describing medication errors and ADEs. Relatively few data are available regarding the frequency and consequences of medication errors in psychiatry; more research is needed.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Inappropriate medication use among hospitalized older adults in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly

OBJECTIVE

To determine the prevalence of inappropriate medication use among hospitalized older adults and to identify predictors of this use.

METHODS

A total of 5734 patients (mean age 79 years) admitted to geriatric and internal medicine wards participating in the study in 1995 and 1997 were included in this analysis. Inappropriate medication use was defined on the basis of the criteria published by Beers in 1997. Only medications used during hospital stay were considered for the present study.

RESULTS

During hospital stay, 837 (14.6%) patients received one or more medications classified as inappropriate based on Beers criteria. Ticlopidine ( n=346; 6.0% of the study sample) was the most frequently used medication among those in Beers' list, followed by digoxin ( n=174; 3.0%) and amytriptyline ( n=113; 2.0%). The multivariate analysis showed that age [75-84 years vs 65-74 years, odds ratio (OR) 0.85, 95% confidence interval (CI) 0.71-1.00; >or=85 years vs 65-74 years, OR 0.58, 95% CI 0.46-0.73], cognitive impairment (OR 0.77, 95% CI 0.64-0.94), Charlson co-morbidity index (>or=2 vs 0-1, OR 1.20, 95% CI 1.02-1.40) and overall number of medications used during hospital stay (5-8 medications vs <5 medications, OR 2.20, 95% CI 1.72-2.82; >or=9 medications vs <5 medications, OR 3.68, 95% CI 2.86-4.73) were significantly associated with use of inappropriate medications.

CONCLUSIONS

Inappropriate medication use was common among hospitalized older adults. The most important determinant of risk of receiving an inappropriate medication was the number of drugs being taken. Older age and cognitive impairment were associated with a reduced likelihood of using an inappropriate medication.