Updated Beers Criteria: A more comprehensive guide to medication safety in older adults

Understanding geographic patterns of high-risk medication (HRM) prescribed and dispensed among older adults may help the Centers for Medicare & Medicaid Services and their partners develop and tailor prevention strategies. To compare the geographic variation in the prevalence of HRM use among Medicare Part D beneficiaries from 2011 to 2013, for Medicare Advantage Prescription Drug (MA-PD) plans and stand-alone Prescription Drug Plans (PDPs). This retrospective study used the data of a 5% national Medicare sample (2011-2013). Beneficiaries were included in the study if they were aged ≥ 65 years, continuously enrolled in MA-PDs or PDPs (~1.3 million each year), and had ≥ 2 prescriptions for the same HRM (e.g., amitriptyline) prescribed and dispensed during the year based on the Pharmacy Quality Alliance's (PQA) quality measures for HRM use. Multivariable logistic regression was used to estimate adjusted annual HRM use rates (i.e., adjusted predictions, average marginal predictions, or model-adjusted risk) across 306 Dartmouth Atlas of Health Care hospital referral regions (HRRs), controlling for sociodemographic, health-status, and access-to-care factors. Among eligible beneficiaries each year (1,161,076 in 2011, 1,237,653 in 2012, and 1,402,861 in 2013), nearly 40% were enrolled in MA-PD plans, whereas the remaining 60% were in PDP plans. The adjusted prevalence of HRM use significantly decreased among Medicare beneficiaries enrolled in MA-PD (13.1%-8.4%, P < 0.001) and PDP (16.2%-12.2%, P < 0.001) plans from 2011 to 2013. For MA-PD and PDP beneficiaries, HRM users were more likely to be (all P < 0.001) the following: female (MA-PD: 70.4% vs. 59.9%; PDP: 72.8% vs. 62.5%); White (MA-PD: 84.6% vs. 81.4%; PDP: 86.6% vs. 85.3%); with low-income subsidy or dual eligibility for Medicaid (MA-PD: 22.3% vs. 16.6%; PDP: 29.2% vs. 23.3%); and disabled (MA-PD: 15.6% vs. 8.7%; PDP: 15.4% vs. 8.5%) compared with non-HRM users in 2013. In 2013, significant geographic variation existed, with the ratios of 75th-25th percentiles of HRM use rates across HRRs as 1.42 for MA-PDs and 1.31 for PDPs. For MA-PDs, the top 5 HRRs with the highest HRM use rates in 2013 were Casper, WY (20.4%), Waco, TX (16.7%), Lubbock, TX (15.7%), Santa Barbara, CA (15.2%), and Temple, TX (15.1%); for PDPs, they were Lawton, OK (18.8%), Alexandria, LA (18.8%), Lake Charles, LA (18.6%), Oklahoma City, OK (18.0%), and Slidell, LA (18.0%). Substantial geographic variation exists in the prevalence of HRM use among older adults in Medicare, regardless of prescription drug plan. Areas with high prevalence of HRM use may benefit from targeted interventions (e.g., medication therapy management monitoring or alternative medication substitutions) to prevent potential adverse consequences. No outside funding supported this study. The authors have nothing to disclose. This study was presented as a poster at the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) Asia Pacific Meeting; September 8-11, 2018; Tokyo, Japan.

PHP19 - Geographic Variation of High-Risk Medication Use Among Medicare Beneficiaries in the United States

PNS111 HEALTH PLAN PERFORMANCE ON HIGH-RISK MEDICATION USE AMONG MEDICARE PART D BENEFICIARIES: IMPACT OF RISK ADJUSTMENT

Updated 2012 Beers Criteria: What’s Noteworthy and Cautionary?

Older adults with dementia are susceptible to receiving potentially inappropriate medications (PIMs), where the risks likely outweigh the benefits. Medicare advantage prescription drug plans (MA-PDs) cover both medical and prescription drug benefits, creating a financial incentive to reduce PIM use and unnecessary health care costs from adverse drug events, whereas standalone Medicare prescription drug plans (PDPs) used by traditional Medicare beneficiaries are only responsible for outpatient prescription drug costs. The objective is to compare the use of PIMs between PDP and MA-PD enrollees with dementia. Using 2016-2019 Medicare claims and encounter data, we estimated the associations between Medicare enrollment type and PIM use: (1) potentially harmful drug-disease interactions in older adults with dementia; (2) potentially harmful drug-disease interactions in older adults with dementia and a history of falls; and (3) high-risk medication use in older adults. MA-PD enrollees had significantly lower utilization of PIMs than standalone PDP enrollees: a 0.7 percentage-point [95% CI: 0.5, 0.8] lower prevalence of potentially harmful drug-disease interactions in older adults with dementia; a 3.1 percentage-point [2.6, 3.5] lower prevalence of potentially harmful drug-disease interactions in older adults with dementia and a history of falls; and a 0.5 percentage-point [0.4, 0.6] lower prevalence of high-risk medications in older adults. MA-PD enrollees with dementia experienced consistently lower prevalence of PIM use than those in PDP. As Medicare advantage enrollment continues to grow, it will be increasingly important to identify and leverage the features of MA-PD plans that promote safe medication prescribing for Medicare beneficiaries with dementia.

Association of low-income subsidy, medicaid dual eligibility, and disability status with high-risk medication use among Medicare Part D beneficiaries.

The National Committee for Quality Assurance(NCQA)and the Pharmacy Quality Alliance(PQA)used the American Geriatrics Society(AGS)Beers Criteria to establish the quality measure system of high-risk medications and potentially harmful drug-disease interactions in the elderly.Medications included may be harmful to elderly adults, and negatively affect health care plans' quality ratings.AGS experts conducted a comprehensive literature review and prepared a list of drug-therapy alternatives with supporting references.NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches.Prescribers, pharmacists, patients, and health care plans may benefit from this list. Key words: Inappropriate medications; Beers criteria

High-risk medication use is associated with an increased risk of adverse events, but little is known about its chronic utilization by key demographic groups. We aimed to study the associations between age, sex, and race/ethnicity with new chronic use of high-risk medications in older adults. In this retrospective cohort study, we analyzed data from older adults aged ≥65 years enrolled in a national health insurer who started a high-risk medication between 2017 and 2022 across 16 high-risk medication classes. We used generalized estimating equations to estimate the associations between sociodemographic classifications and the onset of chronic high-risk medication use after initiation (≥90 days' supply across ≥2 fills within 180 days). We adjusted the analyses for sociodemographic and clinical patient characteristics and added three-way interaction terms for race/ethnicity, sex, and age to explore whether the outcome varied across different subgroups of race/ethnicity, age, and sex. Across 2,751,069 patients (mean age: 74 years [SD = 7], 72% White, 60% Female), 406,075 (15%) became new chronic users of ≥1 high-risk medication. Compared to White older adults, Asian (RR = 0.81, 95% CI: 0.79-0.84), Black (RR = 0.92, 95% CI: 0.90-0.94), and Hispanic (RR = 0.85, 95% CI: 0.83-0.86) older adults had a lower risk of becoming new chronic users. Men had a higher risk compared to women (RR = 1.09, 95% CI: 1.08-1.10). Age was not significantly associated with new chronic high-risk medication use (≥75 years: RR = 1.00, 95% CI: 1.00-1.01). We observed differences across some medication classes, like benzodiazepines, first-generation antihistamines, and antimuscarinics for which non-White older adults were at a higher risk. The joint presence of specific age, sex, and race/ethnicity characteristics decreased the risk of becoming a new chronic user (e.g., Hispanic/Female/65-74 years: RR = 0.96, 95% CI: 0.94-0.99). New chronic high-risk medication use varied across older adults by sociodemographic characteristics, suggesting the need to individualize medication optimization approaches and better understand how systematic barriers in access to health care may influence differences in high-risk medication use in older adults.

The National Committee for Quality Assurance (NCQA) and the Pharmacy Quality Alliance (PQA) use the American Geriatrics Society (AGS) Beers Criteria to designate the quality measure Use of High-Risk Medications in the Elderly (HRM). The Centers for Medicare and Medicaid Services (CMS) use the HRM measure to monitor and evaluate the quality of care provided to Medicare beneficiaries. NCQA additionally uses the AGS Beers Criteria to designate the quality measure Potentially Harmful Drug-Disease Interactions in the Elderly. Medications included in these measures may be harmful to elderly adults and negatively affect a healthcare plan's quality ratings. Prescribers, pharmacists, patients, and healthcare plans may benefit from evidence-based alternative medication treatments to avoid these problems. Therefore the goal of this work was to develop a list of alternative medications to those included in the two measures. The authors conducted a comprehensive literature review from 2000 to 2015 and a search of their personal files. From the evidence, they prepared a list of drug-therapy alternatives with supporting references. A reference list of nonpharmacological approaches was also provided when appropriate. NCQA, PQA, the 2015 AGS Beers Criteria panel, and the Executive Committee of the AGS reviewed the drug therapy alternatives and nonpharmacological approaches. Recommendations by these groups were incorporated into the final list of alternatives. The final product of drug-therapy alternatives to medications included in the two quality measures and some nonpharmacological resources will be useful to health professionals, consumers, payers, and health systems that care for older adults.

For longer than 20 years, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults has been the most consulted source of information about the safety of prescribing medications for older adults. The late Mark Beers, MD, a geriatrician, first published the criteria in 1991 with the help of a team of experts. In its initial incarnation, the Beers Criteria focused on nursing home residents, identifying medications that posed risks that outweighed potential benefits in these older adults. In 1997 and 2003, Dr. Beers and colleagues updated and expanded the scope of the criteria to include medications that were potentially inappropriate for all adults aged 65 and older, regardless of where they lived or received care. Although the Beers Criteria is best known as an invaluable reference for clinicians, it also plays other important roles in older adults' health care. The set of criteria is widely used in research and in the training of healthcare professionals. The Beers Criteria also informs quality measures. Organizations and agencies such as the National Committee for Quality Assurance (NCQA), the Pharmacy Quality Alliance, and the Centers for Medicare and Medicaid Services (CMS) have relied on the criteria when developing quality measures addressing the pharmacological care of older adults. CMS has also incorporated the Beers Criteria into Medicare Part D policy and uses it to evaluate nursing home adherence to medication-related regulations. In 2011, the American Geriatrics Society (AGS) sponsored an update of the criteria, assembling a panel of 11 experts in geriatrics and pharmacology who used an enhanced, evidence-based methodology to develop the 2012 Beers Criteria. This new edition of the criteria appears in this issue of the Journal of the American Geriatrics Society. Improving the quality of care for all older adults has been the mission of the AGS since its founding in 1942. In light of this, it is only appropriate that the society take a leading role in updating the criteria. Improving prescribing for older adults has long been a focus of the AGS annual scientific meetings, research conferences, clinical practice guidelines, and educational programs and tools, as well as numerous articles in this journal and AGS's other journals: Clinical Geriatrics, Annals of Long-Term Care, and The American Journal of Geriatric Pharmacotherapy. It has also been a focus of the society's public policy advocacy work. AGS leaders, members, and staff regularly meet with lawmakers and their staff to discuss issues concerning health care for older adults—including appropriate and safe prescribing. Society leaders have been invited to testify before the Senate Select Committee on Aging regarding this and other subjects. The AGS is also active in quality measure review and development and works with organizations such as the NCQA to ensure that quality measures concerning pharmacotherapy and other elements of care take into account the needs of all older adults, including the most complex and vulnerable. The new, 2012 Beers Criteria differs from earlier editions in a number of ways. Medications that are no longer available have been removed, and drugs introduced since 2003 have been added. Research on drugs included in earlier versions is updated, and new information is provided about appropriate prescribing of medications for an expanded list of common geriatric conditions. In updating the Beers Criteria, the interdisciplinary panel followed an evidence-based approach that the Institute of Medicine recommended in its 2011 report on developing practice guidelines. The new criteria also include ratings of the quality of the evidence supporting the panel's recommendations and the panel's assessment of the strength of these recommendations. Although the criteria provide invaluable information regarding prescribing for older patients, there are important caveats concerning their use. As the panelists emphasize, the Beers Criteria should not substitute for professional judgment or dictate prescribing for an individual patient. That would be at odds with the principles of geriatrics, which call for tailoring care to each patient's individual needs, circumstances, and wishes. The criteria, the panel points out, are not applicable in all circumstances. Among other things, they do not address the needs of individuals receiving palliative and hospice care. For example, a clinician prescribing for an individual receiving end-of-life care might determine that a medication in Table 2 of the criteria—a table listing medications that are potentially inappropriate for older adults—is the only reasonable choice for that individual, but in this and other cases in which Table 2 medications appear to be the best choice for a given individual, the criteria may play a supplementary role by highlighting potential side effects. The panelists add, "If a provider is not able to find an alternative and chooses to continue to use a drug on this list in an individual patient, designation of the medication as potentially inappropriate can serve as a reminder for close monitoring so that [adverse drug effects] can be incorporated into the electronic health record and prevented or detected early."1 Just as the criteria should not dictate prescribing, they should not be the sole basis for formulary decisions, nor should they be used in any punitive manner, the panelists emphasize. We agree strongly. Rather, the role of the 2012 Beers Criteria should be to inform clinical decision-making, research, training, and policy to improve the quality and safety of prescribing medications for older adults. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Barbara Resnick and James T. Pacala contributed to the concept, design, and preparation of the manuscript. Sponsor's Role: Research and administrative support were provided by The American Geriatrics Society.

In 2007, the Centers for Medicare & Medicaid Services (CMS) instituted a star rating system using performance outcome measures to assess Medicare Advantage Prescription Drug (MAPD) and Prescription Drug Plan (PDP) providers. To assess the relationship between 2 performance outcome measures for Medicare insurance providers, comprehensive medication reviews (CMRs), and high-risk medication use. This cross-sectional study included Medicare Part C and Part D performance data from the 2014 and 2015 calendar years. Performance data were downloaded per Medicare contract from the CMS. We matched Medicare insurance provider performance data with the enrollment data of each contract. Mann Whitney U and Spearman rho tests and a hierarchical linear regression model assessed the relationship between provider characteristics, high-risk medication use, and CMR completion rate outcome measures. In 2014, an inverse correlation between CMR completion rate and high-risk medication use was identified among MAPD plan providers. This relationship was further strengthened in 2015. No correlation was detected between the CMR completion rate and high-risk medication use among PDP plan providers in either year. A multivariate regression found an inverse association with high-risk medication use among MAPD plan providers in comparison with PDP plan providers in 2014 (beta = -0.358, P < 0.001) and 2015 (beta = -0.350, P < 0.001), the CMR completion rate in 2015 (beta = -0.221, P < 0.001), and enrollee population size in 2015 (beta = -0.203, P = 0.001). This study found that MAPD plan providers and higher CMR completion rates were associated with lower use of high-risk medications among beneficiaries. No outside funding supported this study. Silva Almodovar reports a fellowship funded by SinfoniaRx, Tucson, Arizona, during the time of this study. The other authors have nothing to disclose.

Health plan starts P4P program for community pharmacies

Improving the quality of medication use and medication safety in older adults is an important public health priority and is of paramount importance for clinicians who care for them. We selected four important articles from 2017 that address these issues to annotate and critique, and we discuss the broader implications for optimizing medication use. A longer list of articles is given in an online appendix. The first study provides national data on the prevalence of central nervous system-active medication polypharmacy in older adults and how this has changed over a 9-year period (2004-2013). The second study characterizes prevalence of and factors associated with nonadherence to antiepileptic drugs in 36,912 older adults with epilepsy, with an emphasis on minorities. The third study describes the extent of antibiotic use in residents of 381 long-term care facilities (LTCF) in British Columbia, Canada, from 2007 to 2014. Finally, we discuss a meta-analysis of 42 studies that evaluated the prevalence of hospital admissions caused by adverse drug reactions in older adults. This article is intended to provide a narrative review of important publications on medication use quality and safety for clinicians and researchers committed to optimizing medication use in older adults. J Am Geriatr Soc 66:2254-2258, 2018.

Beers revised: Drugs not to use in older adults

AUA White Paper on the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults