Use of Potentially Inappropriate Medications in an Ambulatory Medicare Population

Trends and concerns of potentially inappropriate medication use in patients with cardiovascular diseases

Introduction: The use of potentially inappropriate medications (PIM) is an alarming social risk factor in cardiovascular patients. PIM administration may result in iatrogenic disorders and adverse consequences may be attenuated by limiting PIM intake.Areas covered: The goal of this review article is to discuss the trends, risks, and concerns regarding PIM administration with focus on cardiovascular patients. To find data, we searched literature using electronic databases (Pubmed/Medline 1966-2021 and Web of Science 1975-2021). The data search terms were cardiovascular diseases, potentially inappropriate medication, potentially harmful drug-drug combination, potentially harmful drug-disease combination, drug interaction, deprescribing, and electronic health record.Expert opinion: Drugs for heart diseases are the most commonly prescribed medications in older individuals. Despite the availability of explicit and implicit PIM criteria, the incidence of PIM use in cardiovascular patients remains high ranging from 7 to 85% in different patient categories. Physician-induced disorders often occur when PIM is administered and adverse effects may be reduced by limiting PIM intake. Main strategies promising for addressing PIM use include deprescribing, implementation of systematic electronic records, pharmacist medication review, and collaboration among cardiologists, internists, geriatricians, clinical pharmacologists, pharmacists, and other healthcare professionals as basis of multidisciplinary assessment teams.

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review

OBJECTIVES

Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States.

METHODS

PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently.

KEY FINDINGS

Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States.

CONCLUSIONS

Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.

What is the epidemiology of medication errors, error-related adverse events and risk factors for errors in adults managed in community care contexts? A systematic review of the international literature

OBJECTIVE

To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients' homes.

DESIGN

Systematic review.

DATA SOURCE

Six international databases were searched for publications between 1 January 2006 and 31 December 2015.

DATA EXTRACTION AND ANALYSIS

Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines' management process and the conceptual framework from the International Classification for Patient Safety.

RESULTS

60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug-drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients' care and care being provided by family physicians/general practitioners.

CONCLUSION

A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings.

Prescrição de benzodiazepínicos para adultos e idosos de um ambulatório de saúde mental

Resumo Foi objetivo deste estudo comparar as prescrições de benzodiazepínicos (bzd) em adultos e idosos quanto aos indicadores do uso apropriado. Estudo transversal de coleta de dados de pacientes atendidos no Ambulatório Municipal de Saúde Mental de Sorocaba/SP, entre março e novembro de 2013. Foram utilizados indicadores de uso apropriado: medicamento apropriado, com adequada posologia e duração de uso; como também, o uso de apenas um bzd, como ansiolítico por menos de 3 meses, no tratamento da depressão com antidepressivo, uso por menos de 2 meses se associado ao antidepressivo e o não uso de bzd de longa ação em idoso. Dos 330 participantes, a maioria era mulheres, com histórico familiar de transtorno mental e uso de bzd, não realizava acompanhamento com psicólogo e fazia uso de outros psicotrópicos e de polifarmácia (p > 0,05). A minoria das prescrições tinha indicação de uso do bzd (37,5% para idosos e 32,4% para adultos) (p > 0,05). Apenas 5,8% das prescrições para idosos e 1,9% para adultos eram racionais (p > 0,05). O uso crônico foi observado em todos os adultos e idosos com transtornos depressivos e ansiosos (p > 0,05). Uma minoria das prescrições de bzd para adultos e idosos era apropriada.

Conceptualizing and measuring potentially inappropriate drug therapy

WHAT IS KNOWN AND OBJECTIVE

Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice.

METHODS

A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT.

RESULTS AND DISCUSSION

From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1  = 0·479) and substantial for abstracts (κ2  = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature.

WHAT IS NEW AND CONCLUSION

This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.

Potentially inappropriate medications in community-dwelling older adults

Potentially inappropriate medication (PIM) use is a significant worldwide public health problem. Community-dwelling older adults are susceptible to the negative outcomes associated with the use of PIMs. A database search (January 1991-June 2013) produced 19 prospective correlational and 10 intervention studies. The current state of the science reveals that conceptual clarity is lacking regarding the use of PIMs. The prevalence of PIM use is well documented in an abundance of descriptive studies. However, researchers have not examined an intervention's effects on health outcomes in community-dwelling older adults. Although independent older adults can acquire PIMs outside of a provider, current interventions aim to change the behavior of the prescribing physician and pharmacist. Nurses need to collaborate with other disciplines in PIM use research. Priority needs are to design interventions that reduce the use of PIMs and negative health outcomes.