Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents

doi:10.1016/S1543-5946(04)90014-1

The American Journal of Geriatric Pharmacotherapy

Volume 2, Issue 2, June 2004, Pages 92-101

https://doi.org/10.1016/S1543-5946(04)90014-1 Get rights and content

Abstract

Background: There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use.

Objective: The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged ≥68 years, as determined by the relationship of these criteria to health service use in older community residents.

Methods: Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an inhome interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services.

Results: A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P < 0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry.

Conclusions: Our data suggest that in representative community residents aged >68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria).

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Citation Excerpt :
These include the Canadian McLeod’s criteria, French Consensus Patient list, Screening Tool of Older Persons’ Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria, Australian Prescribing Indicators Tool, Norwegian General Practice (NORGEP) criteria, German PRISCUS list, and Swedish indicators (Fastbom & Johnell, 2015). There is a large number of empirical studies showing that PIP among elderly adults detected by these criteria is associated with adverse health outcomes such as adverse drug reactions (Chang et al., 2005; Fick, Mion, & Beers, 2008; Stockl, Le, Zhang, & Harada, 2010), emergency department visits (Chen et al., 2009; Lai et al., 2009; Perri, Menon, Deshpande, Shinde, Jiang, & Cooper, 2005), hospitalization (Chen & Cheng, 2016), admission to a nursing home (Fillenbaum et al., 2004; Zuckerman et al., 2006), poor health-related quality of life (Chin et al., 1999; Franic & Jiang 2006), and death (Perri et al., 2005). Furthermore, PIP increases unnecessary health care costs.
To investigate the prevalence of potentially inappropriate prescribing (PIP) of central nervous system and psychotropic (CNS-PS) drugs to the Korean elderly population, and to identify PIP-associated factors.
Ambulatory care visits were identified from the 2013 National Aged Patient Sample (HIRA-APS-2013) data, composed of 20% random samples of all enrollees in the universal health security program aged ≥65 years. The CNS-PS section of Screening Tool of Older Person’s potentially inappropriate Prescriptions (STOPP) criteria version 2 was used to identify PIP at these visits.
A total of 24,427,069 prescription claims records and 1,122,080 patients were included in the study; 10.73% of the claims and 53.64% of the patients satisfied at least one STOPP criterion in the prescription of CNS-PS drugs. The highest prevalence of PIP was observed for the criteria of “first-generation antihistamines” (FGAH), followed by tricyclic antidepressants (TCA) in patients with prostatism and TCA in patients with dementia. The generalized estimating equation logistic regression analysis showed that the PIP of FGAH was significantly associated with polypharmacy (5–9 drugs: odds ratio (OR) 4.965, 95% confidence interval (CI) 4.936–4.994; ≥10 drugs: OR 5.704, 95% CI 5.604–5.807), less severe health conditions (Charlson Comorbidity Index (CCI) = 2: OR 0.852, 95% CI 0.842–0.862; CCI = 1: OR 0.975, 95% CI 0.964–0.986), prescriptions from clinics (OR > 1.0), and outpatient care by general practitioners (OR > 1.0).
Appropriate interventions to reduce PIP should be made, especially for the criteria that indicate a high PIP prevalence. Targeted strategies are necessary to modify the risk factors of PIP identified from this study.
Using the Beers criteria to identify potentially inappropriate medication use by older adult dental patients
2017, Journal of the American Dental Association
An aging population indicates that increasing numbers of older adults will seek oral health care and have multiple chronic conditions treated with a number of medications. The authors examined the Medicare Current Beneficiary Survey administrative data set to characterize potentially inappropriate medication (PIM) use by older adults visiting the dentist and related adverse experiences that may affect oral health care.
The authors used the 2015 Beers criteria to identify PIMs for older adults. The authors examined the Medicare Current Beneficiary Survey administrative data set for community-dwelling older adults with dental care visits and reported national prevalence estimates of Beers criteria medication prescribing. The authors used logistic regression to identify sociodemographic and health-related characteristics associated with potentially inappropriate prescribing. The authors described medication-related adverse experiences affecting dental care.
Among older adults with dental care visits, 56.9% received a prescription for at least 1 Beers criteria medication, and 28.3% received a prescription for 2 or more Beers criteria medications. Beers criteria medication use was associated most strongly with the number of comorbid diseases as represented by higher Charlson Index scores (odds ratios, > 1.0).
A substantial proportion of community-dwelling older adults visiting dentists had received prescriptions for 1 or more potentially age-inappropriate Beers criteria medications. Many of these medications have adverse effects that could affect patient safety and oral health care.
These results support the need for clinicians to be aware of PIM use by older adults, recognize associated medication-related adverse events, and avoid prescribing age-inappropriate medications to this vulnerable patient population.
Patient characteristics associated with polypharmacy and inappropriate prescribing of medications among older adults with cancer
2012, Journal of Geriatric Oncology
Citation Excerpt :
The prevalence of PIM use ranges from 33% to 37% of acutely ill patients presenting to hospitals, 28% of elderly community-dwelling residents, 49% of elderly patients presenting to the outpatient primary care clinic and in up to 40% of nursing home residents.1,2,8,21–24 Use of Beers Criteria Medications among older patients is associated with increased rate of outpatient visits, reduced time to hospitalization, increased frequency of emergency department visits, increased healthcare costs, and increased mortality.5,7,9,21 Use of PIMs has been shown to be associated with polypharmacy and with ADEs.25,26
To identify patient characteristics associated with polypharmacy and inappropriate medication (PIM) use among older patients with newly diagnosed cancer.
This is a cross-sectional study conducted in ambulatory oncology clinics at an academic center. Participants included 117 patients aged ≥ 65 years with newly diagnosed histologically confirmed stage I–IV cancer and were enrolled between April 2008 and September 2009. Medication review, included patient self-report and medical records. Polypharmacy was defined as the concurrent use of ≥ five medications, (Yes/No). PIM use was defined as use of ≥ one medication included in the 2003 update of Beers Criteria, (Yes/No).
The prevalence of polypharmacy and PIM use was 80% and 41%, respectively. Three independent correlates of medication use were identified. An increase in comorbidity count by one, ECOG-PS score by one, and PIM use by one, was associated with an increase in medication use by 0.48 (P = 0.0002), 0.79 (P = 0.01) and 1.22 (P = 0.006), respectively. Two independent correlates of PIM use were identified. The odds of using PIMs decreased by 10% for one unit increase in Body Mass Index [Odds Ratio (OR) 0.90, 95% CI = (0.84, 0.97)], and increased by 18% for each increase in medication count by one [OR 1.18, 95% CI = (1.04, 1.34)].
There was a high prevalence of polypharmacy and PIM use in older patients with newly diagnosed cancer. Given the co-occurrence of polypharmacy with poor performance status and multi-morbidity, multi-dimensional interventions are needed in the geriatric-oncology population to improve health and cancer outcomes.
Potentially inappropriate prescribing among older persons: A meta-analysis of observational studies
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Citation Excerpt :
We identified 2,804 articles from the 6 databases. After the selection process, we included 8 articles that are related to 6 unique studies (2 pairs of articles23–26 reported different outcome measures originating from the same studies). The flowchart with details of the selection process is shown in Figure 1.
Potentially inappropriate prescribing (PIP) is a common yet preventable medical error among older persons in primary care. It is uncertain whether PIP produces adverse outcomes in this population, however. We conducted a systematic review with meta-analysis to pool the adverse outcomes of PIP specific to primary care.
We searched PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO, and previous review articles for studies related to “older persons,” “primary care,” and “inappropriate prescribing.” Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias. Meta-analysis was conducted to pool studies with similar PIP criteria and outcome measures.
Of the 2,804 articles identified, we included 8 articles with a total of 77,624 participants. All included studies had cohort design and low risk of bias. Although PIP did not affect mortality (risk ratio [RR] 0.98; 95% CI, 0.93–1.05), it was significantly associated with the other available outcomes, including emergency room visits (RR 1.63; 95% CI, 1.32–2.00), adverse drug events (RR 1.34; 95% CI, 1.09–1.66), functional decline (RR 1.53; 95% CI, 1.08–2.18), health-related quality of life (standardized mean difference –0.26; 95% CI, –0.36 to –0.16), and hospitalizations (RR 1.25; 95% CI, 1.09–1.44). A majority of the pooled estimates had negligible heterogeneity.
This meta-analysis provides consolidated evidence on the wide-ranging impact of PIP among older persons in primary care. It highlights the need to identify PIP in primary care, calls for further research on PIP interventions in primary care, and points to the need to consider potential implications when deciding on the operational criteria of PIP.
Drug–drug interactions in elderly patients with potentially inappropriate medications in primary care, nursing home and hospital settings: A systematic review and a preliminary study
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: This work was presented in part at the Gerontological Society of America Annual Meeting, Chicago, Illinois, November 16–20, 2001, and the American College of Clinical Pharmacy Annual Meeting, Tampa, Florida, October 21–24, 2001.

View full text

Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents

Abstract

J AtE Pharm Assoc (Wash).

J AtE Pharm Assoc (Wash).

Clin Ther.

Clin Ther.

J Clin Epidemiol.

J Clin Epidemiol.

Clin Ther.

Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassessment

Age Ageing.

Adverse drug events in high risk older patients

J Am Geriatr Soc.

Prescription Drugs and the Elderly: Many Still Receive Potentially Harmful Drugs Despite Recent Improvements

Drug-drug interactions related to hospital admissions in older adults: A prospective study of 1000 patients

J Am GeHatr Soc.

Drug-associated hospital admissions in older medical patients.

J Am Geriatr Soc.

Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality

JAMA.

Sedative-hypnotic use by the elderly: Effects on hospital length of stay and costs

J Merit Health Adm.

Geriatric pharmacotherapy

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

Med Care.

Explicit criteria for determining potentially inappropriate medication use by the elderly. An update

Arch Intern Med.

Inappropriate drug use among community-dwelling elderly

Pharmacotherapy.

Questionable prescribing for elderly patients in Quebec

CMAJ.

Use of inappropriate prescription drugs by older people

J AtE Geriatr Soc.

Potentially inappropriate medication use in the community-dwelling elderly: Findings from the 1996 Medical Expenditure Panel Survey

JAMA.

Elderly patients in general practice: Diagnoses, drugs and inappropriate prescriptions. A report from the More & Romsdal Prescription Study

Fame Pract.

Appropriateness of medication prescribing in ambulatory elderly patients

J AtE Geriatr Soc.

Inappropriate prescribing and health outcomes in elderly outpatients

Ann Pharmacother.

Appropriateness of medication selection for older persons in an urban academic emergency department

Acad Emerg Med.

Drug-use patterns in black and nonblack community-dwelling elderly

Ann Pharmacother.

Frameworld and development of a comprehensive drug product coding system

Contemp Pharm Pract.