Prescriber variation in potentially inappropriate prescribing in older populations in Ireland

Work accident effect on the use of psychotropic drugs: the case of benzodiazepines

BACKGROUND

A work accident constitutes a shock to health, likely to alter mental states and affect the use of psychotropic drugs. We focus on the use of benzodiazepines, which are a class of drugs commonly used to treat anxiety and insomnia. Prolonged use can lead to dependence. Our objective is to determine the extent to which work accidents lead to benzodiazepine use and overuse (i.e. exceedance of medical guidelines).

METHOD

We use a two-step selection model (the Heckman method) based on data from the French National Health Data System (Système National des Données de Santé, SNDS). Our study sample includes all general plan members who experienced a single work accident in 2016 (and not since 2007). This sample includes 350,000 individuals in the work accident group and more than 1.1 million people randomly drawn from the population without work accidents from 2007 to 2017 (the non-work accident group).

RESULTS

The occurrence of a work accident leads to an increase in benzodiazepine use and overuse the following year. The selection model shows a clear influence of the accident on the use probability (+ 39%), but a very slight impact on the risk of overuse among users (+ 1.7%), once considered the selection effect. The effect on overuse risk is higher for more severe accidents and among women.

CONCLUSION

The increase in the risk of benzodiazepine overuse is due to an increase in the likelihood of using benzodiazepines after a work accident that leads to overuse, rather than an increase in likelihood of overuse among people who use benzodiazepines. Results call for targeting the first-time prescription to limit the risk of overuse after a work accident.

Prevalence of polypharmacy in community-dwelling older adults from seven centres in five European countries: a cross-sectional study of DO-HEALTH

OBJECTIVE

To investigate the prevalence of polypharmacy and characteristics associated with polypharmacy in older adults from seven European cities.

DESIGN

Cross-sectional study of baseline data from DO-HEALTH.

SETTING AND PARTICIPANTS

DO-HEALTH enrolled 2157 community-dwelling adults age 70 and older from seven centres in Europe. Participants were excluded if they had major health problems or Mini-Mental State Examination Score <24 at baseline.

PRIMARY OUTCOME MEASURES

Extensive information on prescription and over-the-counter medications were recorded. Polypharmacy was defined as the concomitant use of five or more medications, excluding vitamins or dietary supplements. Bivariate and multivariable logistic regression was used to test the association of sociodemographic factors (age, sex, years of education, living situation and city) and health-related indicators (number of comorbidities, cognitive function, frailty status, body mass index (BMI), prior fall, self-rated health and smoking status) with polypharmacy.

RESULTS

27.2% of participants reported polypharmacy ranging from 16.4% in Geneva to 60.8% in Coimbra. In the multivariable logistic regression analyses, older age (OR 1.07; 95% CI 1.04 to 1.10), greater BMI (OR 1.09; 95% CI 1.06 to 1.12) and increased number of comorbidities (OR 2.13; 95% CI 1.92 to 2.36) were associated with polypharmacy. Women were less likely to report polypharmacy than men (OR 0.65; 95% CI 0.51 to 0.84). In comparison to participants from Zurich, participants from Coimbra were more likely to report polypharmacy (OR 2.36; 95% CI 1.56 to 3.55), while participants from Geneva or Toulouse were less likely to report polypharmacy ((OR 0.36; 95% CI 0.22 to 0.59 and OR 0.64; 95% CI 0.42 to 0.96), respectively). Living situation, smoking status, years of education, prior fall, cognitive function, self-rated health and frailty status were not significantly associated with polypharmacy.

CONCLUSION

Polypharmacy is common among relatively healthy older adults, with moderate variability across seven European cities. Independent of several confounders, being a woman, older age, greater BMI and greater number of comorbidities were associated with increased odds for polypharmacy.

TRIAL REGISTRATION NUMBER

NCT01745263.

Chronic care services and variation between Danish general practices: a nationwide cohort study

Background

Little is known about variations in the provision of chronic care services in primary care.

Aim

To describe the frequency of chronic care services provided by GPs and analyse the extent of non-random variation in service provision.

Design and setting

Nationwide cohort study undertaken in Denmark using data from 2016.

Method

Information on chronic care services was obtained from national health registers, including annual chronic care consultations, chronic care procedures, outreach home visits, and talk therapy. The associations between services provided, patient morbidity, and socioeconomic factors were estimated. Service variations were analysed, and excess variation related to practice-specific factors was estimated while accounting for random variation.

Results

Chronic care provision was associated with increasing patient age, increasing number of long-term conditions, and indicators of low socioeconomic status. Variation across practices ranged from 1.4 to 128 times more than expected after adjusting for differences in patient population and random variation. Variation related to practice-specific factors was present for all the chronic care services that were investigated. Older patients with lower socioeconomic status and multimorbidity were clustered in practices with low propensity to provide certain chronic care services.

Conclusion

Chronic care was provided to patients typically in need of health care, that is, older adults, those with multimorbidity, and those with low socioeconomic status, but service provision varied more than expected across practices. GPs provided slightly fewer chronic care services than expected in practices where many patients with multimorbidity and low socioeconomic status were clustered, suggesting inverse care law mechanisms.

Factors associated with potentially inappropriate prescriptions and barriers to medicines optimisation among older adults in primary care settings: a systematic review

OBJECTIVE

To identify factors that likely contribute to potentially inappropriate prescriptions (PIPs) among older adults in primary care settings, as well as barriers to medicines optimisation and recommended potential solutions.

DESIGN

Systematic review.

ELIGIBILITY CRITERIA

Quantitative studies that analysed the factors associated with PIPs among older adults (≥65 years) in primary care settings, and qualitative studies that explored perceived barriers and potential solutions to medicines optimisation for this population.

INFORMATION SOURCES

PubMed, EMBASE, Scopus, CINAHL, PsycINFO, Web of Science, CNKI and Wanfang.

RESULTS

Of the 13 167 studies identified, 50 were included (14 qualitative, 34 cross-sectional and 2 cohort). Nearly all quantitative studies examined patient-related non-clinical factors (eg, age) and clinical factors (eg, number of medications) and nine studies examined prescriber-related factors (eg, physician age). A greater number of medications were identified as positively associated with PIPs in 25 quantitative studies, and a higher number of comorbidities, physical comorbidities and psychiatric comorbidities were identified as patient-related clinical risk factors for PIPs. However, other factors showed inconsistent associations with the PIPs. Barriers to medicines optimisation emerged within four analytical themes: prescriber related (eg, inadequate knowledge, concerns of adverse consequences, clinical inertia, lack of communication), patient related (eg, limited understanding, patient non-adherence, drug dependency), environment related (eg, lack of integrated care, insufficient investment, time constraints) and technology related (eg, complexity of implementation and inapplicable guidance). Recommended potential solutions were based on each theme of the barriers identified accordingly (eg, prescriber-related factors: incorporating training courses into continuing medical education).

CONCLUSIONS

Older adults with more drugs prescribed and comorbidities may have a greater risk of receiving PIPs in the primary care setting, but it remains unclear whether other factors are related. Barriers to medicines optimisation among primary care older adults comprise multiple factors, and evidence-based and targeted interventions are needed to address these difficulties.

PROSPERO REGISTRATION NUMBER

CRD42020216258.

Potentially inappropriate medications (PIMs): frequency and extent of GP-related variation in PIMs: a register-based cohort study

OBJECTIVES

Potentially inappropriate medications (PIMs) pose an increasing challenge in the ageing population. We aimed to assess the extent of PIMs and the prescriber-related variation in PIM prevalence.

DESIGN

Nationwide register-based cohort study.

SETTING

General practice.

PARTICIPANTS

The 4.2 million adults listed with general practitioner (GP) clinics in Denmark (n=1906) in 2016.

MAIN OUTCOME MEASURES

We estimated the patients' time with PIMs by using 29 register-operationalised STOPP criteria linking GP clinics and redeemed prescriptions. For each criterion and each GP clinic, we calculated ratios between the observed PIM time and that predicted by multivariate Poisson regressions on the patients. The observed variation was measured as the 90th/10th percentile ratios of these ratios. The extent of expectable random variation was assessed as the 90th/10th percentile ratios in randomly sampled GP populations (ie, the sampled variation). The GP-related excess variation was calculated as the ratio between the observed variation and sampled variation. The linear correlation between the observed/expected ratio for each of the criteria and the observed/expected ratio of total PIM time (for each clinic) was measured by Pearson's rho.

RESULTS

Overall, 294 542 individuals were exposed to 1 44 117 years of PIMs. The two most prevalent PIMs were long-term use (>3 months) of non-steroidal anti-inflammatory drugs (51 074 years of PIMs) or benzodiazepines (48 723 years of PIMs). These two criteria showed considerable excess variation of 2.33 and 3.05, respectively; for total PIMs, this figure was 1.65. For more than half of the criteria, we observed a positive correlation between the specific PIM and the sum of remaining PIMs.

CONCLUSIONS

This study documents considerable variations in the prescribing practice of GPs for certain PIMs. These findings highlight a need for exploring the causal explanations for such variations, which could be markers of suboptimal GP-prescribing strategies.

[Analysis of potentially inappropriate prescriptions according to the START criteria in nursing homes]

BACKGROUND AND OBJECTIVE

The potentially inappropriate prescription by omission of a drug is defined as the failure to prescribe drugs that are clinically indicated. The objective of this article is to describe and analyse the evolution of inappropriate prescriptions by omission in nursing homes of a health department.

MATERIAL AND METHODS

Retrospective observational descriptive study carried out in nursing homes of the Valencia-Clínico-Malvarrosa health department during the period 2016-2018. All institutionalized patients during this period were included. The prevalence of potentially inappropriate prescriptions by omission was assessed based on version 2 of the START criteria. The variables came from the electronic medical records of ambulatory care of the Conselleria de Sanitat (Abucasis).

RESULTS

2251 different patients were selected, mean age of 79,53years, 69% women, and an average of 4,60 chronic drugs/resident. A total of 2647 inappropriate prescriptions by omission were identified during the study period, and the results were similar during these 3years. The most prevalent START criteria were those related to the musculoskeletal system and the cardiovascular system, and those related to analgesic consumption. The mean value of inappropriate prescriptions by omission prevalence for the period studied were 39.54%.

CONCLUSION

The results of our study confirm a high prevalence of potentially inappropriate prescriptions by omission in residents of nursing homes, and the maintenance of this prevalence during the 3years of the study.

Potential Statin Overuse in Older Patients: A Retrospective Cross-Sectional Study Using French Health Insurance Databases

BACKGROUND

Although compelling evidence exists supporting statins (HMG-CoA reductase inhibitors) for secondary prevention in older patients with clinical atherosclerotic diseases, the same cannot be said for primary prevention.

OBJECTIVES

The objectives of this study were to estimate the frequency of potential statin overuse in older patients, the potential drug cost savings if corrected, and the associated factors.

METHODS

A retrospective cross-sectional study was conducted in Alsace and Lorraine (France) from 1 January to 30 April 2017. All statin users aged 80 years or over living in the community (including nursing homes) and identified from the French health insurance database were analyzed. Potential statin overuse was defined according to the STOPP/START (Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment) criteria.

RESULTS

Among the 38,268 aged insured, 23,228 (60.7%) had potential statin overuse. Of those living in the community, 22,132 (60.0%) patients had potential statin overuse: 12,352 (55.8%) for primary and 9780 (44.2%) for secondary prevention. Among nursing home residents, 1096 (79.0%) had potential statin overuse: 394 (35.9%) for primary and 702 (64.1%) for secondary prevention. The potential drug cost savings associated with the adjustment of potential statin overuse were €924,100 for the study period. Living in nursing home [adjusted odds ratio (OR_adjusted) 3.91, 95% confidence interval (CI) 2.82-5.41] and being a female (OR_adjusted 2.84, 95% CI 2.54-3.17) were the main risk factors associated with potential statin overuse.

CONCLUSION

The frequency of potential statin overuse is very high among older people aged 80 years or over, highlighting the need to re-evaluate statin therapy and consider deprescribing, particularly for primary prevention and in nursing homes.

Detecting and Visualizing Outliers in Provider Profiling Using Funnel Plots and Mixed Effects Models-An Example from Prescription Claims Data

When prescribing a drug for a patient, a physician also has to consider economic aspects. We were interested in the feasibility and validity of profiling based on funnel plots and mixed effect models for the surveillance of German ambulatory care physicians’ prescribing. We analyzed prescriptions issued to patients with a health insurance card attending neurologists’ and psychiatrists’ ambulatory practices in the German federal state of Saarland. The German National Association of Statutory Health Insurance Physicians developed a prescribing assessment scheme (PAS) which contains a systematic appraisal of the benefit of drugs for so far 12 different indications. The drugs have been classified on the basis of their clinical evidence as “standard”, “reserve” or “third level” medication. We had 152.583 prescriptions in 56 practices available for analysis. A total of 38.796 patients received these prescriptions. The funnel plot approach with additive correction for overdispersion was almost equivalent to a mixed effects model which directly took the multilevel structure of the data into account. In the first case three practices were labeled as outliers, the mixed effects model resulted in two outliers. We suggest that both techniques should be routinely applied within a surveillance system of prescription claims data.

Patient- and health care-related factors associated with initiation of potentially inappropriate medication in community-dwelling older persons

Potentially inappropriate medications (PIMs) in older persons are defined as medications of which the potential harms outweigh their benefits. The purpose of this study was to determine how initiation of PIMs accumulate in community-dwelling persons aged 65-74 and ≥75 years, and which patient- and health care-related factors are associated with PIM initiation over time. Data of this study were gathered from population-based registers by a 10% random sample of persons (n = 28 497) aged ≥65 years with no prior PIMs within a 2-year period preceding the index date (1 January 2002), and the study individuals were followed until 2013. The Finnish Prescription Register was linked using a personal identity code to register on inpatient care and causes of deaths and socio-economic data. In this study, 10 698 (37.5%) persons initiated PIMs during the study period. Female gender was associated with PIM initiation in 65-74-year-olds, but not in ≥75-year-olds. In 65-74-year-olds, the risk of PIM initiation increased with the higher income, whereas in ≥75-year-olds, the association between PIM initiation and the high income was not significant. The prescribing physician explained 9%-16% of the variation in the probability of PIM initiation. In conclusion, there were age-related differences in the factors associated with PIM initiation in relation to gender and socio-economic status. Overall, patient-related factors explained a large proportion of variation of PIM initiation, but there were also differences in PIM prescribing among physicians. However, physician-related variance of PIM initiations decreased during the 12-year follow-up.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015

AIMS

The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland.

METHODS

A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated.

RESULTS

Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period.

CONCLUSIONS

Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

Variation of polypharmacy in older primary care attenders occurs at prescriber level

BACKGROUND

Polypharmacy is particularly important in older persons as they are more likely to experience adverse events compared to the rest of the population. Despite the relevance, there is a lack of studies on the possible association of patient, prescriber and practice characteristics with polypharmacy. Thus, the aim of this study was to determine the rate of polypharmacy among older persons attending public and private primary care clinics, and its association with patient, prescriber and practice characteristics.

METHODS

We used data from The National Medical Care Survey (NMCS), a national cross-sectional survey of patients' visits to primary care clinics in Malaysia. A weighted total of 22,832 encounters of patients aged ≥65 years were analysed. Polypharmacy was defined as concomitant use of five medications and above. Multilevel logistic regression was performed to examine the association of polypharmacy with patient, prescriber and practice characteristics.

RESULTS

A total of 20.3% of the older primary care attenders experienced polypharmacy (26.7%% in public and 11.0% in private practice). The adjusted odds ratio (OR) of polypharmacy were 6.37 times greater in public practices. Polypharmacy was associated with patients of female gender (OR 1.49), primary education level (OR 1.61) and multimorbidity (OR 14.21). The variation in rate of polypharmacy was mainly found at prescriber level.

CONCLUSION

Polypharmacy is common among older persons visiting primary care practices. Given the possible adverse outcomes, interventions to reduce the burden of polypharmacy are best to be directed at individual prescribers.

Pharmacoepidemiology resources in Ireland-an introduction to pharmacy claims data

Introduction

Administrative health data, such as pharmacy claims data, present a valuable resource for conducting pharmacoepidemiological and health services research. Often, data are available for whole populations allowing population level analyses. Moreover, their routine collection ensures that the data reflect health care utilisation in the real-world setting compared to data collected in clinical trials.

Setting and methods

The Irish Health Service Executive-Primary Care Reimbursement Service (HSE-PCRS) community pharmacy claims database is described. The availability of demographic variables and drug-related information is discussed. The strengths and limitations associated using this database for conducting research are presented, in particular, internal and external validity. Examples of recently conducted research using the HSE-PCRS pharmacy claims database are used to illustrate the breadth of its use.

Results and conclusions

The HSE-PCRS national pharmacy claims database is a large, high-quality, valid and accurate data source for measuring drug exposure in specific populations in Ireland. The main limitation is the lack of generalisability for those aged <70 years and the lack of information on indication or outcome.

High-risk prescribing in an Irish primary care population: trends and variation

AIMS

The aims of the present study were to examine the prevalence of high-risk prescribing (HRP) in community-dwelling adults in Ireland from 2011-2015 using consensus-validated indicators, factors associated with HRP, and the variation in HRP between general practitioners (GPs) and in the dispensing of high-risk prescriptions between pharmacies.

METHODS

A repeated cross-sectional national pharmacy claims database study was conducted. Prescribing indicators were based on those developed in formal consensus studies and applicable to pharmacy claims data. Multilevel logistic regression was used to examine factors associated with HRP and dispensing.

RESULTS

There were significant reductions in the rates of most indicators over time (P < 0.001). A total of 66 022 of 300 906 patients at risk in 2011 [21.9%, 95% confidence interval (CI) 21.8, 22.1%], and 42 109 of 278 469 in 2015 (15.1%, 95% CI 15.0, 15.3%), received ≥1 high-risk prescription (P < 0.001). In 2015, indicators with the highest rates of HRP were prescription of a nonsteroidal anti-inflammatory drug (NSAID) without gastroprotection in those ≥75 years (37.2% of those on NSAIDs), coprescription of warfarin and an antiplatelet agent or high-risk antibiotic (19.5% and 16.2% of those on warfarin, respectively) and prescription of digoxin ≥250 μg day^-1 in those ≥65 years (14.0% of those on digoxin). Any HRP increased significantly with age and number of chronic medications (P < 0.001). a) After controlling for patient variables, the variation in the rate of HRP between GPs was significant (P < 0.05); and b) after controlling for patient variables and the prescribing GP, the variation in the rate of dispensing of high-risk prescriptions between pharmacies was significant (P < 0.05).

CONCLUSIONS

HRP in Ireland has declined over time, although some indicators persist. The variation between GPs and pharmacies suggests the potential for improvement in safe medicines use in community care, particularly in vulnerable older populations.

[Potentially inappropriate prescribing in older Spanish population according to STOPP/START criteria (STARTREC study)]

Objetivo

Racionalizar la prescripción en la población anciana es una prioridad de los sistemas sanitarios. Los criterios STOPP/START permiten detectar la prescripción potencialmente inadecuada (PPI) a nivel individual. Su aplicación a nivel poblacional permite determinar la prevalencia de PPI y su relación con diversas variables del paciente y del sistema sanitario. El objetivo de este estudio es analizar la prevalencia de PPI en población anciana a partir de bases de datos clínicos y de farmacia.

Diseño

Estudio descriptivo transversal.

Emplazamiento

Ámbito de atención primaria de la Región Sanitaria de Lleida, España.

Participantes

Se incluyen 45.408 pacientes de 70 años o más atendidos en los centros de salud como mínimo una vez en el último año.

Mediciones principales

Se calcula la frecuencia de incumplimiento de 43 indicadores STOPP y 12 indicadores START, a partir de los fármacos prescritos durante un año y se ajustan modelos de regresión logística para evaluar su asociación con diversas variables.

Resultados

El 58% son mujeres. La edad media es de 79,7 años. El 58,1% incumplen como mínimo un criterio STOPP y/o START, relacionados principalmente con el uso de benzodiacepinas, antiinflamatorios no esteroideos e inhibidores de la bomba de protones por exceso, y los tratamientos para la osteoporosis, antiagregantes, estatinas, metformina y betabloqueantes por omisión. La PPI aumenta con la edad y la polifarmacia y es superior en pacientes ingresados en centros geriátricos y domiciliarios que en los ambulatorios.

Conclusiones

Los criterios STOPP/START identifican PPI en más de la mitad de pacientes ancianos de una región sanitaria española.

Introducing pharmacogenetic testing with clinical decision support into primary care: a feasibility study

BACKGROUND

Inappropriate prescribing increases patient illness and death owing to adverse drug events. The inclusion of genetic information into primary care medication practices is one solution. Our aim was to assess the ability to obtain and genotype saliva samples and to determine the levels of use of a decision support tool that creates medication options adjusted for patient characteristics, drug-drug interactions and pharmacogenetics.

METHODS

We conducted a cohort study in 6 primary care settings (5 family practices and 1 pharmacy), enrolling 191 adults with at least 1 of 10 common diseases. Saliva samples were obtained in the physician's office or pharmacy and sent to our laboratory, where DNA was extracted and genotyped and reports were generated. The reports were sent directly to the family physician/pharmacist and linked to an evidence-based prescribing decision support system. The primary outcome was ability to obtain and genotype samples. The secondary outcomes were yield and purity of DNA samples, ability to link results to decision support software and use of the decision support software.

RESULTS

Genotyping resulted in linking of 189 patients (99%) with pharmacogenetic reports to the decision support program. A total of 96.8% of samples had at least 1 actionable genotype for medications included in the decision support system. The medication support system was used by the physicians and pharmacists 236 times over 3 months.

INTERPRETATION

Physicians and pharmacists can collect saliva samples of sufficient quantity and quality for DNA extraction, purification and genotyping. A clinical decision support system with integrated data from pharmacogenetic tests may enable personalized prescribing within primary care. Trial registration: ClinicalTrials.gov, NCT02383290.

Inter-practice variation in polypharmacy prevalence amongst older patients in primary care

PURPOSE

Complex medication management in older people with multiple chronic conditions can introduce practice variation in polypharmacy prevalence. This study aimed to determine the inter-practice variation in polypharmacy prevalence and examine how this variation was influenced by patient and practice characteristics.

METHODS

This cohort study included 45,731 patients aged 55 years and older with at least one prescribed medication from 126 general practices that participated in NIVEL Primary Care Database in the Netherlands. Medication dispensing data of the year 2012 were used to determine polypharmacy. Polypharmacy was defined as the chronic and simultaneous use of at least five different medications. Multilevel logistic regression models were constructed to quantify the polypharmacy prevalence variation between practices. Patient characteristics (age, gender, socioeconomic status, number, and type of chronic conditions) and practice characteristics (practice location and practice population) were added to the models.

RESULTS

After accounting for differences in patient and practice characteristics, polypharmacy rates varied with a factor of 2.4 between practices (from 12.4% to 30.1%) and an overall mean of 19.8%. Age and type of conditions were highly positively associated with polypharmacy, and to a lesser extent a lower socioeconomic status.

CONCLUSIONS

Considerable variation in polypharmacy rates existed between general practices, even after accounting for patient and practice characteristics, which suggests that there is not much agreement concerning medication management in this complex patient group. Initiatives that could reduce inappropriate heterogeneity in medication management can add value to the care delivered to these patients. Copyright © 2016 John Wiley & Sons, Ltd.

[Prevalence of inappropriate prescription to polymedicated patients over 65 years old in a rural health area]

OBJECTIVE

Describe the inappropriate prescription to polymedicated patients over 65 years old in rural areas.

MATERIAL AND METHOD

An observational, descriptive, cross-sectional study conducted in health care units in the Guadalhorce Valley, a rural area of Malaga, Spain. The district has a catchment population of about 144,993 inhabitants. This study is focused on the population that is older than 65 years, and who use 10 or more medications (4.344 patients). The study has as a primary variable: the rates of inappropriate prescription. These are classified using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, as well as the criteria of the strategy of the approach to polymedicated of the Andalusian Health System. An application was used to create individualised forms that identified inappropriate prescribing criteria. For each patient, we used variables, such as the unit, drug group, medications, dose, and use of the STOPP and Andalusian Health System criteria were recorded for each patient.

RESULTS

More than one-third (35.5%) of all patients have inappropriate prescription, according to STOPP criteria, related to some health problem (direct problems). The large majority (94%) have potentially inappropriate prescription according to the criteria of the Andalusian Health System. If the criteria directly related to prescribing medication for people over 65 (general) is taken into account, 100% of patients have some form of inappropriate or potentially inappropriate prescribing.

CONCLUSIONS

The prevalence of polypharmacy and inappropriate prescription is a real problem in the population over 65 years old. An informatics tool provides us with the facilities to identify and approach inappropriate prescribing.

The St Vincent's potentially inappropriate medicines study: development of a disease-specific consensus list and its evaluation in ambulatory heart failure care

AIMS

Heart failure (HF) patients may be at risk of prescription of potentially inappropriate medicines (PIMs) yet no disease-specific list is available to assess PIM use in this population. A Consensus Potentially Inappropriate Medicines in Heart Failure (PIMHF) list was developed, assessed, and compared with an established, general tool in an ambulatory HF population.

METHODS AND RESULTS

The Consensus PIMHF list was compiled using modified Delphi methodology with a multidisciplinary team. The list consisted of 11 items. The medication profile of 350 patients was assessed. The association of a Consensus PIMHF item use over a median follow-up period of 1.8 (interquartile range 1.3-2.1) years with the primary endpoint of death, acute hospitalization, or unscheduled outpatient visit was examined. Fifty-one patients (14.6%) were prescribed ≥1 Consensus PIMHF item. In univariable analysis, patients prescribed ≥1 Consensus PIMHF item were 58% more likely to experience the primary endpoint than those with none [95% confidence interval (CI) 1.02-2.45]. When adjusted for age, sex, and HF severity, this difference remained [hazard ratio (HR) 1.88, 95% CI 1.16-3.06] and these associations were in contrast to the use of a more general tool (HR 1.24, 95% CI 0.83-1.84). However, when further adjusted to include co-morbidity score and polypharmacy, there was no association with outcome using either tool (HR 1.40, 95% CI 0.83-2.38; HR 1.05, 95% CI 0.69-1.60, respectively).

CONCLUSION

The Consensus PIMHF list provides the first HF-specific medicines review tool. These results provide some support for more disease-specific tools with limited lists of PIMs to rationalize medicines management in HF. However, more prospective work on the application of these tools in practice is needed.