Medication Appropriateness Index Research Articles

Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly

Purpose To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients. Methods The study employed a randomized 2 × 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were ≥65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse. Results For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period ( P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period ( P <0.05). Conclusion Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.

Inappropriate medication use among frail elderly inpatients.

Inappropriate prescribing in frail elderly inpatients has not received as much investigation as in frail elderly nursing home patients. To determine the prevalence and predictors of inappropriate prescribing for hospitalized frail elderly patients. The study was conducted at 11 Veterans Affairs Medical Centers and involved a sample of 397 frail elderly inpatients. Inappropriate prescribing was measured by physician-pharmacist pair's consensus ratings for 10 criteria on the Medication Appropriateness Index (MAI). The MAI ratings generated a weighted score of 0-18 per medication (higher score = more inappropriate) and were summed across medications to achieve a patient score. Overall, 365 (91.9%) patients had > or =1 medications with > or =1 MAI criteria rated as inappropriate. The most common problems involved expensive drugs (70.0%), impractical directions (55.2%), and incorrect dosages (50.9%). The most common drug classes with appropriateness problems were gastric (50.6%), cardiovascular (47.6%), and central nervous system (23.9%). The mean +/- SD MAI score per person was 8.9 +/- 7.6. Stepwise ordinal logistic regression analyses revealed that both the number of prescription (adjusted OR 1.28; 95% CI 1.21 to 1.36) and nonprescription drugs (adjusted OR 1.17; 95% CI 1.06 to 1.29) were related to higher MAI scores. Analyses excluding the number of drugs revealed that the Charlson index (adjusted OR 1.62; 95% CI 1.12 to 2.35) and fair/poor self-rated health (adjusted OR 1.15; 95% CI 1.05 to 1.26) were related to higher MAI scores. Inappropriate drug prescribing is common for frail elderly veteran inpatients and is related to polypharmacy and specific health status characteristics.

Reliability of a Modified Medication Appropriateness Index in Community Pharmacies

Background The medication appropriateness index (MAI) has demonstrated reliability in selected outpatient clinics where medical data were easily accessible from medical charts. However, its use in the community setting where patient data may be limited has not been examined. Objective To evaluate the usefulness of a modified MAI for use in the community pharmacy setting by testing interrater reliability using 3 different rating schemes. Methods Two raters evaluated 160 medications for 32 elderly ambulatory patients. Patient information was acquired using community pharmacist-collected medication histories. A summated MAI score, percent agreement, κ, positive agreement, negative agreement, and intraclass correlation coefficient were calculated for each criterion using 3 scoring schemes. A paired samples t-test (95% CI) was used to test interrater reliability. Results The κ statistics were &gt;0.75 for indication and effectiveness, but good (0.41–0.66) for the remaining criteria using the Hanlon scoring scheme. The intraclass coefficients (0.82, 0.86, 0.87) and overall κ (0.65, 0.66, 0.61) were similar for the 3 schemes. Conclusions This study suggests that the modified MAI has the potential to detect medication appropriateness and inappropriateness in the community pharmacy setting; however, it is not without limitations. Because the MAI has the most clinimetric and psychometric data available, the instrument should be studied further to increase its reliability and generalizability.

Reliability of a modified medication appropriateness index in community pharmacies.

The medication appropriateness index (MAI) has demonstrated reliability in selected outpatient clinics where medical data were easily accessible from medical charts. However, its use in the community setting where patient data may be limited has not been examined. To evaluate the usefulness of a modified MAI for use in the community pharmacy setting by testing interrater reliability using 3 different rating schemes. Two raters evaluated 160 medications for 32 elderly ambulatory patients. Patient information was acquired using community pharmacist-collected medication histories. A summated MAI score, percent agreement, kappa, positive agreement, negative agreement, and intraclass correlation coefficient were calculated for each criterion using 3 scoring schemes. A paired samples t-test (95% CI) was used to test interrater reliability. The kappa statistics were >0.75 for indication and effectiveness, but good (0.41-0.66) for the remaining criteria using the Hanlon scoring scheme. The intraclass coefficients (0.82, 0.86, 0.87) and overall kappa (0.65, 0.66, 0.61) were similar for the 3 schemes. This study suggests that the modified MAI has the potential to detect medication appropriateness and inappropriateness in the community pharmacy setting; however, it is not without limitations. Because the MAI has the most clinimetric and psychometric data available, the instrument should be studied further to increase its reliability and generalizability.

Reliability of a Modified Medication Appropriateness Index in Community Pharmacies

Reliability of a Modified Medication Appropriateness Index in Community Pharmacies

Appropriateness in health care: Application to prescribing

To help account for and address observed variations in medical practice, evaluations of “appropriateness” have sought to supplement incomplete evidence with professional opinion. This article contributes to an understanding and refinement of the construct of appropriateness by discussing how it has been defined and applied in studies of health care in general and prescribing in particular. We suggest that appropriateness is the outcome of a process of decisiondashmaking that maximises net individual health gains within society's available resources. This definition distinguishes between (in)appropriate prescribing, as an outcome, and (ir)rational prescribing as a process. To assess appropriateness, we advocate combining explicit criteria with independent review in cases of uncertainty and disagreement. Refinements based on reviews using implicit criteria should draw on shared professional knowledge and post hoc state the process followed as explicitly as possible. The Medication Appropriateness Index is shown to provide a solid foundation for identifying dimensions of prescribing appropriateness.

Reliability of a modified medication appropriateness index in ambulatory older persons.

To evaluate the reliability of a medication appropriateness index (MAI) modified for elderly outpatients in a non-Veterans Affairs setting. Reliability study. General community. Ten community-dwelling elderly (> 65 y) taking five or more regularly scheduled medications and participating in a university-based health service intervention study. Interrater reliability of MAI ratings of 65 medications made by two clinical pharmacists for individual items and for an overall summed score was calculated by use of kappa statistics and intraclass correlation coefficient. The interrater agreement for each of the individual MAI items was high for both appropriate and inappropriate ratings and ranged from 80% to 100% (overall kappa = 0.64). Overall agreement for the summed score was good (intraclass correlation = 0.80). The modified MAI is a reliable instrument for evaluation of medication appropriateness in a non-Veterans Affairs, ambulatory, elderly population and may provide pharmacists with a practical and standard method to evaluate patients' drug regimens and identify some potential drug-related problems.

Inappropriate Prescribing and Health Outcomes in Elderly Veteran Outpatients

To determine the relationship of inappropriate prescribing in the elderly to health outcomes. General Medical Clinic of the Durham Veterans Affairs Medical Center. A total of 208 veterans more than 65 years old who were each taking five or more drugs and participated in a pharmacist intervention trial. Prescribing appropriateness was assessed by a clinical pharmacist using the medication appropriateness index (MAI). A summed MAI score was calculated, with higher scores indicating less appropriate prescribing. The health outcomes were hospitalization, unscheduled ambulatory or emergency care visits, and blood pressure control. Bivariate analyses revealed that mean MAI scores at baseline were higher for those with hospital admissions (18.9 vs. 16.9, p = 0.07) and unscheduled ambulatory or emergency care visits (18.8 vs. 16.3, p = 0.05) over the subsequent 12 months than for those without admissions and emergency care visits. MAI scores for antihypertensive medications were higher for patients with inadequate blood pressure control (> 160/90 mm Hg) than for those whose blood pressure was controlled (4.7 vs. 3.1, p = 0.02). Inappropriate prescribing appeared to be associated with adverse health outcomes. This findings needs to be confirmed in future studies that have larger samples and control for potential confounders.

Appropriateness of medication prescribing in ambulatory elderly patients.

To assess the quality of medication prescribing in ambulatory elderly patients on multiple medications using the Medication Appropriateness Index (MAI). Cross-sectional study. General Medical Clinic of the Durham VA Medical Center. 208 elderly outpatients on five or more regularly scheduled medications. Medication prescribing appropriateness was measured with the MAI, a reliable method that employs 10 implicit criteria. A weighted MAI score (range 0-18 per drug) served as a summary measure of appropriateness. There were 1644 medications evaluated; 26% received no inappropriate ratings, 37% had one, 19% had two, and 18% had three or more. Of 16,440 ratings, 2295 (14%) were evaluated as inappropriate. The percentage of inappropriate ratings varied across prescribing dimensions: drug-drug interactions, 0%; drug-disease interactions, 1.4%; medication effectiveness, 4.7%; therapeutic duplication, 5.7%; indication, 11.5%; duration of treatment, 16.5%; dosage, 17.3%; practical directions, 20.3%; cost, 29.7%; and correct directions, 32.4%. The mean MAI score for all medications was 2.2 +/- 2.1 (range 0-10) and varied by therapeutic class. MAI scores were significantly lower for medications with a high potential for adverse effects compared with those with a low potential (MAI score of 1.8 vs 2.9, P < 0.001). Regression analysis revealed that no patient characteristics were associated with a higher likelihood of inappropriate prescribing. Medication prescribing for elderly outpatients taking multiple medications was substantially appropriate. Prescribing dimensions with the most room for improvement were more exact directions, less expensive drugs, and practical directions. Drugs at high risk for adverse effects were prescribed more appropriately than those at low risk.

A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity

Inappropriate medication prescribing is an important problem in the elderly, but is difficult to measure. As part of a randomized controlled trial to evaluate the effectiveness of a pharmacist intervention among elderly veterans using many medications, we developed the Medication Appropriateness Index (MAI), which uses implicit criteria to measure elements of appropriate prescribing. This paper describes the development and validation of a weighting scheme used to produce a single summated MAI score per medication. Using this weighting scheme, two clinical pharmacists rated 105 medications prescribed to 10 elderly veterans from a general medicine clinic. The summated score demonstrated acceptable reliability (intraclass correlation coefficient = 0.74). In addition, the summated MAI adequately reflected the putative heterogeneity in prescribing appropriateness among 1644 medications prescribed to 208 elderly veterans in the same general medicine clinic. These data support the content validity of the summated MAI. The MAI appears to be a relatively reliable, valid measure of prescribing appropriateness and may be useful for research studies, quality improvement programs, and patient care.

A method for assessing drug therapy appropriateness

This study evaluated the reliability of a new medication appropriateness index. Using the index, independent assessments were made of chronic medications taken by 10 ambulatory, elderly male patients by a clinical pharmacist and an internist-geriatrician. Their overall inter-rater agreement for medication appropriateness (ppos) was 0.88, and for medication inappropriateness (pneg) was 0.95; the overall kappa was 0.83. Their intea-rater agreement for ppos was 0.94 overall, for pneg was 0.98 overall while the overall kappa was 0.92. The chronic medications taken by 10 different ambulatory elderly male patients were independently evaluated by two different clinical pharmacists. Their overall inter-rater agreement for ppos was 0.76, and for pneg was 0.93, while the overall kappa was 0.59. This new index provides a reliable method to assess drug therapy appropriateness. Its use may be applicable as a quality of care outcome measure in health services research and in institutional quality assurance programs.

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<h3>Background</h3> We investigated the benefits of the Collaborative <i>P</i>h<i>a</i>rmaceutical <i>C</i>are in <i>T</i>allaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing. <h3>Methods</h3> Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years. <h3>Findings</h3> Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann–Whitney U p&lt;0.05; PACT median −1, IQR −3.75 to 0; standard care median +1, IQR −1 to +6). <h3>Conclusions</h3> PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.