Potentially Inappropriate Medication Prescribing Research Articles

Association between potentially inappropriate medications and anxiety in Japanese older patients.

The use of potentially inappropriate medications (PIMs) for older patients is a major public health problem. However, there is little information regarding PIMs in Japanese primary care settings, and the association between psychological problems and PIMs is unknown. The present study was carried out to explore the prevalence of PIMs among older patients in a primary care setting in Tokyo, and to assess the association between PIMs and depression and anxiety. A cross-sectional study in a Japanese outpatient clinic providing primary care was carried out. Data were collected from January 2016 to March 2016. A total of 740 patients aged ≥65years with chronic diseases were enrolled. Information regarding sociodemographic status, comorbidities, and prescription and psychological status was collected using a questionnaire that patients were required to complete, and by reviewing the patients' medical records. The Screening Tool of Older Person's Prescriptions criteria version2 revealed PIM prescription for 32.3% of patients. Benzodiazepines, hypnotic Z-drugs and proton pump inhibitors accounted for a majority of PIMs. After adjusting for age, sex, comorbidities, estimated glomerular filtration rate and the number of medications, anxiety was identified as a predictor for PIMs. PIMs among older patients are common in Japanese primary care settings, and prescription of benzodiazepines or hypnotic Z-drugs and proton pump inhibitors was frequent as PIMs. PIMs might be associated with anxiety; therefore, their association should be focused on and addressed to reduce PIMs. Geriatr Gerontol Int 2017; 17: 2520-2526.

Physician Factors Associated with Polypharmacy and Potentially Inappropriate Medication Use.

Despite accumulating evidence about the harm of polypharmacy in family medicine, few studies have investigated factors related to polypharmacy. The objective of this study was to explore factors related to physicians' prescribing behavior. We conducted a survey of physicians at 5 family medicine residency practices and a linked health record review of their patients ≥65 years old. The determinants of physicians' mean number of prescriptions and potentially inappropriate medications (PIMs) were examined using a generalized linear model. A total of 61 physicians (38 residents, 23 fellows/faculty) completed the survey, and 2103 visits by 932 patients seen by these physicians were analyzed. The mean numbers of prescriptions and PIMs per visit per physician were 9.50 and 0.46, respectively. After controlling for patient race and age, low prescribers were more likely to consider the number of medications (P = .007) and benefit/risk information for deprescribing (P = .017) when making prescribing decisions. Use of the Beers List was marginally significant in lower PIM prescribing (P = .05). Physicians' sex, duration of experience, and perceived confidence were not associated with prescribing patterns. Conscious consideration concerning the number of medications and benefit/risk information, as well as using the Beers List, were associated with less polypharmacy and fewer PIMs.

Enhancing Quality of Provider Practices for Older Adults in the Emergency Department (EQUiPPED).

EQUiPPED is a multicomponent quality improvement initiative combining education, electronic clinical decision support, and individual provider feedback to influence prescribing and improve medication safety for older adults. The objective here was to evaluate the effectiveness and sustainability of EQUiPPED to reduce the use of potentially inappropriate medications (PIMs), as defined by the American Geriatrics Society 2012 Beers Criteria, prescribed to older Veterans at the time of emergency department (ED) discharge. This evaluation represents a pre- and post-intervention comparison of PIM prescriptions at 4 urban Veteran Affairs (VA) Medical Center EDs. Poisson regression was used to compare the number of PIMs prescribed to Veterans 65years or older discharged from the ED for at least 6months prior to the first EQUiPPED intervention at each site and for at least 12months following the final EQUiPPED intervention. The implementation timeline varied by site depending on local resources. All 4 sites showed a significant and sustained reduction in use of PIMs. The proportion of PIMs at site one decreased from 11.9% (SD 1.8) pre-EQUiPPED to 5.1% (SD 1.4) post-EQUiPPED (P<.0001); site 2 from 8.2% (SD 0.8) pre to 4.5% (SD 1.0) post (P<.0001); site 3 from 8.9% (SD 1.9) pre to 6.1% (SD 1.7) post (P=.0007); and site 4 from 7.4% (SD 1.7) pre to 5.7% (SD 0.8) post (P=.04). These results suggest a multicomponent program to influence provider prescribing behavior leads to safer prescribing for older adults discharged from the ED and is sustainable across multiple VA ED sites.

Health Service Use, Costs, and Adverse Events Associated with Potentially Inappropriate Medication in Old Age in Germany: Retrospective Matched Cohort Study.

Drug-related problems are an important healthcare safety concern in the growing population of older people. Prescription of potentially inappropriate medication (PIM) is one aspect of this concern that is considered to increase the risk of adverse health outcomes. The aim of the Health Economics of Potentially Inappropriate Medication (HEPIME) study was to analyze the association between the prescription of PIMs according to the German PRISCUS list and healthcare utilization, healthcare costs, and the occurrence of adverse events in old age. Insurants of a large German health insurance company aged 65+ years were included in a retrospective matched cohort study. A total of 3,953,423 individuals with no exposure to PIM in 2011 were matched to 521,644 exposed individuals and compared in terms of outpatient healthcare utilization, healthcare costs, and the occurrence of adverse events in outpatient, hospital, and rehabilitation sectors during a 12-month follow-up. On average, individuals in the exposed group had additional 143 [95% confidence interval (CI) 140-146] daily defined doses of pharmaceuticals and 4.5 (95% CI 4.4-4.6) days in hospital. Mean annual total healthcare costs per individual in the exposed group exceeded those in the non-exposed group by €2321 (95% CI 2269-2372), resulting mainly from differences in hospitalization costs of €1718 (95% CI 1678-1759). Odds ratios for the occurrence of adverse events in the exposed group were 1.32 (95% CI 1.32-1.34) in the outpatient sector, 1.76 (95% CI 1.73-1.79) in the hospital sector, and 1.82 (95% CI 1.76-1.89) in the rehabilitation sector. Increased healthcare utilization and costs as well as an increased probability for adverse events in individuals exposed to PIM demonstrate the health economic relevance of PIM prescriptions. Whether avoiding PIM listed on the PRISCUS list may potentially improve the quality and efficiency of healthcare is currently unknown.

The use of potentially inappropriate medications among the Lithuanian elderly according to Beers and EU(7)-PIM list - a nationwide cross-sectional study on reimbursement claims data

The prevalence and risk factors for prescribing and using potentially inappropriate medications (PIMs) has been extensively researched in Western Europe and the United States of America; however, research in Central and Eastern Europe remains highly limited. According to a recent systematic review, the overall estimated weighted prevalence of PIM prescribing in community-dwelling elderly in Europe (expressed as a percentage of patients or prescriptions with ≥1 PIM) was 22·6% (95% CI: 19·5%-26·7%). The main objective of this study was to investigate the prevalence of use of PIMs among the elderly in Lithuania according to different sets of published explicit criteria and compare the results with similar research carried out in other European countries. This was a retrospective, observational cross-sectional population-based (n = 431 625) study using the medicines reimbursement claims data covering a 1-year period. The use of PIMs was measured based on 2003 Beers criteria, 2015 AGS Beers criteria and the EU(7)-PIM list. The prevalence was measured as the percentage of patients with at least 1 PIM during 1-year period. Multivariate logistic regression was used to identify risk factors for PIM prescription. The prevalence of PIM use varied from 24·1% according to 2003 Beers criteria and 25·9% according to 2015 AGS Beers criteria, to 57·2% according to the EU(7)-PIM list. Polypharmacy and increasing age had increased the risk of PIM use. Women had an increased risk for prescription of the EU(7)-PIM listed medications compared with men, whereas for Beers drugs the risk in women was lower. Benzodiazepines were the most commonly prescribed PIMs according to all criteria. The use of PIMs is highly prevalent among the Lithuanian elderly and there is a great need of interventions to improve the pharmacotherapy in this age group.

PRESCRIÇÃO INAPROPRIADA DE 2 MEDICAMENTOS A IDOSOS: ANÁLISE DOS CRITÉRIOS PUBLICADOS DE 2011 A 2016

Introduction: The prescription of identify potentially inappropriate medications (PIM) for the elderly is a major problem in geriatric pharmacotherapy. Objective: To identify PIM prescribing criteria for older adults published in the last five years. Method: The bibliographic research was performed in the Medline database. Inclusion criteria were articles published in the period from 2011 to 2016 that addressed the development and / or updating of PIM lists for the elderly. The selected publications were analyzed in relation to the type of criterion, the method used in the development, origin and study scenario. Regarding the structure and content of the criteria, we verified the availability of information on: inadequate dose, duration of pharmacotherapy, duplication, interactions, alternative pharmacotherapeutic and deprescription. Results: A total of 12 were identified PIM prescribing criteria, and three criteria refer to the update of previous versions. In Europe, 9 (75.0%) criteria were elaborated. It was evidenced that 10 (83.3%) were explicit criteria, developed by the Delphi method and intended for the elderly with age ≥ 65 years. Among the parameters included in the PIM criteria, the inadequate dose approach was the most frequent, followed by information on the duration of pharmacotherapy, drug-drug interactions. The STOPP and Beers 2015 criteria responded in greater proportion to the parameters of quality of prescription analyzed. Conclusion: The number of explicit and implicit guiding criteria for the prescription of drugs in the elderly population, developed and updated were significant in the period studied. The prescribing parameters that compose the different criteria present heterogeneity Descriptors: elderly, pharmacotherapy, inappropriate prescription, List of Potentially Inappropriate Medications. Doi: 10.30968/rbfhss.2017.084.006

Potentially inappropriate prescribing andthe risk of adverse drug reactions in critically ill older adults.

Background:Potentially inappropriate medication (PIM) use in the elderly is associated with increased risk of adverse drug reactions (ADRs), but there is limited information regarding PIM use in the intensive care unit (ICU) setting.Objective:The aim of the study is to describe the prevalence and factors associated with the use of PIM and the occurrence of PIM-related adverse reactions in the critically ill elderly.Methods:This study enrolled all critically ill older adults (60 years or more) admitted to medical or cardiovascular ICUs between January and December 2013, in a large tertiary teaching hospital. For all patients, clinical pharmacists listed the medications given during the ICU stay and data on drugs were analyzed using 2012 Beers Criteria, to identify the prevalence of PIM. For each identified PIM the medical records were analyzed to evaluate factors associated with its use. The frequency of ADRs and, the causal relationship between PIM and the ADRs identified were also evaluated through review of medical records.Results:According to 2012 Beers Criteria, 98.2% of elderly patients used at least one PIM (n=599), of which 24.8% were newly started in the ICUs. In 29.6% of PIMs, there was a clinical circumstance that justified their prescription. The number of PIMs was associated with ICU length of stay and total number of medications. There was at least one ADR identified in 17.8% of patients; more than 40% were attributed to PIM, but there was no statistical association.Conclusions:There is a high prevalence of PIM used in acutely ill older people, but they do not seem to be the major cause of adverse drug reactions in this population. Although many PIMs had a clinical circumstance that led to their prescription during the course of ICU hospitalization, many were still present upon hospital discharge. Therefore, prescription of PIMs should be minimized to improve the safety of elderly patients.

Potentially inappropriate medications in elderly Japanese patients: effects of pharmacists' assessment and intervention based on Screening Tool of Older Persons' Potentially Inappropriate Prescriptions criteria ver.2.

The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (stopp) criteria were updated in 2014 (stopp criteria ver.2), but few studies have evaluated the usefulness of stopp criteria in elderly patients. This prospective observational study evaluated the prevalence of potentially inappropriate medications (PIMs), and the efficacy of hospital pharmacists' assessment and intervention based on stopp criteria ver.2. The study was conducted at three medical units of Kobe University Hospital between April 2015 and March 2016. Pharmacists assessed and detected PIMs based on stopp criteria ver.2 and considered the patient's intention to change the prescription at the time of admission of each patient. If the pharmacists judged that benefits outweighed risks of prescription change and the patients consented to change the medications, they recommended the doctor to change the prescription. If there was a risk of exacerbation of disease by the change of medications and the pharmacists judged it to be difficult to adjust medications during hospitalization or the patients did not consent to change the medications, they did not recommend to change it. The pharmacists and the doctors discussed and finally decided whether to change the PIMs or not. The number of patients prescribed PIMs, the number and contents of PIMs, and the number of medications changed after pharmacists' intervention were calculated. Totally, 822 new inpatients aged ≥65 years prescribed ≥1 daily medicine were included. Their median (interquartile range) age was 75·0 (71·0-80·0) years, and 54·9% were male. According to the criteria, 346 patients (42·1%) were prescribed ≥1 PIMs. Patients prescribed PIMs took significantly more medications than others: 10·0 (7·0-13·0) vs. 6·0 (4·0-9·0), P < 0·001. The total number of PIMs was 651%, 47·6% of which (n = 310) were recommended the doctors to change, and 292 of 651 PIMs (44·9%) were finally discontinued/changed after pharmacists' assessment and intervention. PIMs related to benzodiazepines, including Z-drugs, were most frequent, with a detailed classifications as follows (changed/total): (i) benzodiazepines for 4 or more weeks (75/205), (ii) drugs that predictably increase the risk of falls in older people (benzodiazepines) (30/67) and (iii) drugs that predictably increase the risk of falls in older people (hypnotic Z-drugs) (15/31). Over 40% elderly patients were prescribed PIMs, and pharmacists' assessments and interventions based on stopp criteria ver.2 were useful in detecting and correcting prescription of PIMs.

Effects of an intervention (SÄKLÄK) on prescription of potentially inappropriate medication in elderly patients.

Polypharmacy is known to increase the risk for drug-related problems, and some drugs, potentially inappropriate medications (PIMs), are especially troublesome. To analyse the effects on prescription of PIMs of the SÄKLÄK project, an intervention model created to improve medication safety for elderly patients in primary care. The SÄKLÄK project was a multiprofessional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. Five Swedish primary care centres participated in the intervention and five served as comparison group. Data were collected from the Swedish Prescribed Drug Register on PIMs (long-acting benzodiazepines, anticholinergics, tramadol, propiomazine, antipsychotics and non-steroidal anti-inflammatory drugs) prescribed to patients aged 65 years and older. Total number of patients and change in patients using PIMs before and after intervention with-in groups was analysed as well as differences between intervention and comparison group. A total of 32566 prescriptions of PIMs were dispensed before the intervention, 19796 in the intervention group and 12770 in the comparison group. After intervention a decrease was seen in both groups, intervention-22.2% and comparison-8.8%. All groups of PIMs decreased, except for antipsychotics in the comparison group. For the intervention group, a significant decrease in mean dose/patient was seen after the intervention but not in the comparison group. Our study shows this method has some effects on prescription of PIMs. The evaluation indicates this is a feasible method for improvement of medication use in primary care and the method should be tested on a larger scale.

Potentially Inappropriate Medication in Community-Dwelling Primary Care Patients who were Screened Positive for Dementia.

Background: Potentially inappropriate medication (PIM) in older people is a risk factor for adverse drug effects. This risk is even higher in older people with dementia (PWD).Objective: Our study aimed to determine (1) the prevalence of PIM among primary care patients who were screened positive for dementia and (2) the sociodemographic and clinical variables associated with the use of PIM.Methods: DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg–Western Pomerania) is a general practitioner-based, cluster-randomized, controlled intervention study to implement and evaluate an innovative concept of collaborative dementia care management in Germany. The comprehensive baseline assessment includes a home medication review. The present analyses are based on the data from 448 study participants (age 70+, DemTect <9). PIMs were identified using the list of Potentially Inappropriate Medications in the Elderly (Priscus).Results: (1) A total of 99 study participants (22%) received at least one PIM. The highest prevalence was found for antidepressants, benzodiazepines, and analgetics. The most frequently prescribed PIMs were amitriptyline, etoricoxib, and doxazosin. (2) Use of a PIM was significantly associated with a diagnosis of a mental or behavioral disorder.Conclusions: The prescription rate of PIMs for community-dwelling PWD was comparable with the rates found for the general population of older people in Germany (20–29%). Antidepressants with anticholinergic properties and long-acting benzodiazepines were the most prescribed PIMs, despite having an unfavorable benefit-risk ratio. This high prevalence of PIM prescriptions in a vulnerable population of PWD indicates that standard care for dementia should include careful medication review and management.

Using two tools to identify Potentially Inappropriate Medications (PIM) in elderly patients in Southern Chile

ObjectivesTo assess and compare the prevalence of prescribing of potentially inappropriate medications (PIMs) identified using the Beers and STOPP criteria; and to determine the clinical variables related with the prescription of PIMs in older adults. MethodsAn observational study of 250 patients aged 65 years or older was conducted in a large teaching hospital. Beers (2012) and STOPP (2008) criteria were utilized to identify PIMs. Data on age, sex, admission and discharge dates, diagnoses, and medications prescribed were obtained from medical records. Multivariate logistic regression was used to determine patient variables related with the prescription of PIMs. Key findingsUsing Beers criteria, 375 PIMs were identified in 198 patients. 32% of these patients were prescribed one PIM, 20% were prescribed two PIMs, and 48% were prescribed more than two PIMs. Using STOPP criteria, 148 PIMs were identified in 120 patients. 41% of these patients were prescribed one PIM, 51% were prescribed two PIMs, and 8% were prescribed more than two PIMs. An association between PIM prescribing and polypharmacy was detected with both criteria. After adjusting for confounding variables, the prescription of Beers-identified PIMs was significantly associated with patients older than 80 (OR: 2.99; 95% CI: 1.13–7.89) and with length of hospital stay of more than 15days (OR: 2.78; 95% CI: 1.20–6.44). ConclusionThese two criteria showed that the prescription of PIMs is prevalent in hospitalized elderly patients. It may be beneficial to educate healthcare teams about these criteria to reduce the prescription of PIMs.

Potentially Inappropriate Medication Use in Multimorbid Elderly Inpatients: Differences Between the FORTA, PRISCUS and STOPP Ratings.

BackgroundSeveral classifications to identify and avoid use of potentially inappropriate medications (PIMs) in the elderly have been published. To what extent these classifications match each other and whether there are differences in the prevalence of PIM use at admission, during the inpatient stay and at discharge are largely unreported.ObjectivesTo determine the PIM prevalence in elderly patients at a university hospital, with a special focus on different classification systems and the chronological sequence, and to examine a possible association between PIM use and the reason for admission, as well as severe side effects and consequences of PIM use during hospitalization.MethodsOn the basis of the criteria provided by FORTA (Fit for the Aged), PRISCUS (Latin for ‘time-honoured’) and STOPP (Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions), medication in patients over the age of 65 years was screened retrospectively within four point prevalence analyses at admission, during the inpatient stay and at discharge. Evaluation of a possible association between PIM use and the primary diagnosis or severe side effects during hospitalization was performed according to an analysis using the World Health Organization Uppsala Monitoring Centre system for standardized case causality assessment.ResultsOf 200 patients, 176 (88 %) received at least one PIM at admission, during the inpatient stay and/or at discharge (116 patients according to FORTA, 113 according to PRISCUS and 138 according to STOPP). When the PIM prevalence was compared between the three different sets of criteria, STOPP identified significantly more patients receiving PIMs than FORTA (P = 0.022) and PRISCUS (P = 0.010). At the patient level and at the drug level, the use of PIMs increased during the inpatient stay; however, the PIM prevalence was similar at admission and at discharge, both at the patient level and at the drug level.ConclusionMedication is rated significantly differently by FORTA, PRISCUS and STOPP. In addition, a significant rise in prescribing of PIMs during the inpatient stay illustrates that a reduction in PIM use during the inpatient stay is essential, as it is known that avoiding PIM use in older adults is one strategy to decrease the risk of adverse events.Electronic supplementary materialThe online version of this article (doi:10.1007/s40801-016-0085-2) contains supplementary material, which is available to authorized users.

Why do family doctors prescribe potentially inappropriate medication to elderly patients?

BackgroundBased on changes in pharmacokinetics and –dynamics in elderly patients, there are potentially inappropriate medications (PIM) that should be avoided in patients aged ≥ 65 years. Current studies showed prescription rates of PIM between 22.5 and 28.4 % in the primary care setting. The evidence concerning reasons for PIM prescription by FPs is limited.MethodsThis mixed method study consisted of three research parts: 1) semi-standardized content analysis of patients’ records, 2) qualitative interviews with FPs using a) open questions and b) selected patient-specific case vignettes and 3) qualitative interviews with FPs’ medical assistants. The integration of qualitative interviews was used to explain the quantitative results (triangulation design). PIM were identified according to the German PRISCUS list. Descriptive and multivariate statistical analysis was done using SPSS 22.0. Qualitative content analysis of interviews was used to classify the content of the interviews for indicating pertinent categories. All data were pseudonymously recorded and analyzed.ResultsContent analysis of 1846 patients’ records and interviews with 7 related FPs were conducted. Elderly patients [n = 1241, mean age: 76, females: 56.6 %] were characterized in average by 8.3 documented chronic diagnosis. 23.9 % of elderly patients received at least one PIM prescription. Sedatives/hypnotics were the most frequent prescribed PIM-drugs (13.7 %). Mental disorders, gender and number of long-term medication were detected as predictors for the probability of a PIM prescription. Common reported reasons for PIM prescription by FPs concerned limited knowledge regarding PIM, limited applicability of PIM lists in daily practice, lack of time, having no alternatives in medication, stronger patient-related factors than age that influence prescription, own bad experiences regarding changes of medication or refusal of following prescriptions of sedative/hypnotics.ConclusionsIt is essential to see FPs in a complex decision making situation with several influencing factors on their prescribing, including: patient-oriented prioritization, FPs’ experiences in daily practice, FPs’ knowledge regarding existing recommendations and their trust in it and organizational characteristics of FPs’ daily medical practice. These pros and cons of PIM prescription in elderly patients should be considered in FPs’ advanced training.

Evaluating the Impact of Medication Safety Alerts on Prescribing of Potentially Inappropriate Medications for Older Veterans in an Ambulatory Care Setting

Potentially inappropriate medications (PIMs) have been associated with poor outcomes in older adults. Electronic health record (EHR)-based interventions may be an effective way to reduce PIM prescribing. The main objective of this study was to evaluate changes in PIM prescribing to older adult veterans ≥65 years old in the ambulatory care setting preimplementation and postimplementation of medication alert messages at the point of computerized provider order entry (CPOE). Additional exploratory objectives included evaluating provider type and patient–provider relationship as a factor for change in PIM prescribing. A total of 1539 patients prealert and 1490 patients postalert were prescribed 1952 and 1897 PIMs, respectively. End points were reported as the proportion of new PIM orders of total new prescriptions. There was no significant difference in the rate of new PIMs prealert and postalert overall, 12.6% to 12.0% (P = .13). However, there was a significant reduction in the rate of the top 10 most common newly prescribed PIMs, 9.0% to 8.3% (P = .016), and resident providers prescribed fewer PIMs during both time periods. A simple, age-specific medication alert message during CPOE decreased the incidence of the most frequently prescribed PIMs in older adults receiving care in an ambulatory care setting.

Prescription of potentially inappropriate medication in Korean older adults based on 2012 Beers Criteria: a cross-sectional population based study

BackgroundA high number of elderly people with multiple comorbidities are exposed to the risk of polypharmacy and prescription of potentially inappropriate medication (PIM). The purpose of this study was to determine the prevalence and patterns of PIM prescription in Korean older adults according to the 2012 Beers Criteria.MethodsA retrospective study was conducted using data from the Korean Health Insurance Review and Assessment (KHIRA) database of outpatient prescription claims collected from January 1, 2009 to December 31, 2011. A total of 523,811 elderly subjects aged 65 years and older were included in the study, and several covariates related to the prescription of PIMs were obtained from the KHIRA database. These covariates were analyzed using Student’s t test and the chi-square test; furthermore, multivariate logistic regression analysis was used to evaluate the risk factors associated with the prescription of PIMs.ResultsA total of 80.96 % subjects were prescribed at least one PIM independent of their diagnosis or condition according to the 2012 Beers Criteria. The most commonly prescribed medication class was first-generation antihistamines with anticholinergic properties (52.33 %). Pain medications (43.04 %) and benzodiazepines (42.53 %) were next in line. When considering subjects’ diagnoses or conditions, subjects diagnosed with central nervous system conditions were most often prescribed PIMs. Female sex, severity of comorbidities, and polypharmacy were significant risk factors for PIM prescriptions.ConclusionsThis study confirmed that PIM prescription is common among elderly Koreans. A clinical decision support system should be developed to decrease the prevalence of PIM prescriptions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0285-3) contains supplementary material, which is available to authorized users.

Impact of Clinical Pharmacy Specialists on the Design and Implementation of a Quality Improvement Initiative to Decrease Inappropriate Medications in a Veterans Affairs Emergency Department.

As the proportion of older adult patients who interface with the health care system grows, clinical pharmacy specialists (CPS) have a pivotal role in reducing potentially inappropriate medication (PIM) use in this population. To (a) describe CPS involvement in the design and implementation of a quality improvement (QI) initiative to decrease PIM prescribing in a Veterans Affairs (VA) emergency department (ED) and (b) report on changes in PIM prescribing before and after the initiative. Enhancing Quality of Prescribing Practices for Veterans Discharged from the Emergency Department (EQUiPPED) is an ongoing multisite QI project that aims to decrease ED PIM prescribing. We used a mixed-method approach that applied qualitative and quantitative measures in describing the CPS role and evaluating PIM rates. PIMs were defined using the 2012 Beers Criteria. We reported monthly PIM rates in patients aged 65 years and older who were discharged from the ED from January 2012 to November 2014. A piecewise, nonlinear regression model evaluated the pattern in PIM prescriptions over time. At the Durham, North Carolina, VA Medical Center, a total of 4 CPS were involved with tailoring the design and implementation of the EQUiPPED intervention for local use. CPS input led to 3 key innovations: academic detailing performed by a physician-CPS pair, medication alert messages identifying medications as PIMs in the computerized patient record system, and automated reports describing the frequency and type of PIMs prescribed by each ED provider. Between February 2013 and November 2014, 73 ED providers received the academic detailing. The ED facility experienced a relative reduction of 47.5% in the rate of PIM prescribing over the observation period. This QI project resulted in a meaningful decrease in PIM prescribing in older ED adults. CPS contributions to QI can extend beyond pharmacotherapy and provider education to also include information technology tools using formulary management expertise.

Potentially Inappropriate Medication and Health Care Outcomes: An Instrumental Variable Approach.

To examine the effects of potentially inappropriate medication (PIM) use on health care outcomes in elderly individuals using an instrumental variable (IV) approach. Representative claim data from the universal health insurance program in Taiwan from 2007 to 2010. We employed a panel study design to examine the relationship between PIM and hospitalization. We applied both the naive generalized estimating equation(GEE) model, which controlled for the observed patient and hospital characteristics, and the two-stage residual inclusion (2SRI) GEE model, which further accounted for the unobserved confounding factors. The PIM prescription rate of the physician most frequently visited by each patient was used as the IV. The naive GEE models indicated that patient PIM use was associated with a higher likelihood of hospitalization (odds ratio [OR], 1.399; 95 percent confidence interval [CI], 1.363-1.435). Using the physician PIM prescribing rate as an IV, we identified a stronger significant association between PIM and hospitalization (OR, 1.990; 95 percent CI, 1.647-2.403). PIM use is associated with increased hospitalization in elderly individuals. Adjusting for unobserved confounders is needed to obtain unbiased estimates of the relationship between PIM and health care outcomes.

Potentially inappropriate medication use at ambulatory care visits by elderly patients covered by National Health Insurance in Korea.

Potentially inappropriate medication (PIM) use is an important and preventable safety concern in the care of elderly patients and has been associated with adverse drug reactions, hospitalization, and mortality. Although PIM use for the elderly is a common and serious public health issue worldwide, there are few studies examining PIM use in the ambulatory care setting in Korea. To examine the prevalence and risk factors of PIM use from ambulatory care visits by elderly patients covered by National Health Insurance (NHI) in Korea, the nationwide prescription claims data of elderly patients' ambulatory care visits in 2006 were analyzed. Potentially inappropriate prescriptions were identified using extensive criteria that included Beers', Zhan's, and Canadian criteria. In 2006, 3,770,978 elderly patients received 40,995,267 prescriptions. 36.7% of the total prescriptions for elderly patients who visited ambulatory care clinics were identified as PIM use. Findings in this study indicated that the strongest risk factors for PIM prescriptions were the number of drugs prescribed and visit characteristics. Therefore, it is necessary to develop the explicit criteria of PIM prescription in Korea that can be included in the Drug Utilization Review (DUR) system, which is expected to lead to more appropriate and judicious prescribing.

Correlation of Incident Potentially Inappropriate Medication Prescriptions and Hospitalization: An Analysis Based on the PRISCUS List.

BackgroundMultimorbidity and polypharmacy represent a major problem for elderly patients. Potentially inappropriate medication (PIM) use is highly prevalent among the elderly. PIMs are considered high-risk drugs and are suspected to be responsible for adverse drug events (ADEs) leading to hospitalization.ObjectiveThe objective of this study was to determine hospitalization rates related to selected ADEs in elderly patients with an incident prescription of a PIM as defined by the PRISCUS list. A second objective was to identify other factors independently associated with hospitalization.MethodsWe retrospectively analysed a full census of pharmaceutical claims, from one of the largest public sickness funds in Germany, for 647,073 patients aged ≥65 years in 2010, the year of publication of the PRISCUS list. Patients who received an incident PIM in 2010 were assigned to the intervention group. Propensity score matching was used to build a control group of patients at a comparable risk level who received an incident equivalent non-PIM. The risk of hospitalization due to PIM prescription was estimated via the odds ratio (OR). Risk factors were analysed via logistic regression models.ResultsThe results showed significantly more ADEs in the PIM group. The OR for hospitalization was 1.54 [95 % confidence interval (CI) 1.23–1.93] for patients receiving any PIM compared with those who received a non-PIM. This trend remained stable [OR 1.46 (95 % CI 1.16–1.84)] after adjustment for relevant covariates in the logistic regression models showing ORs for each risk factor. Besides PIMs, common risk factors such as greater age, comorbidity and specific drug classes were significantly responsible for hospitalization.ConclusionPIMs (as defined by the PRISCUS list) are associated with high rates of ADEs associated with hospitalization. Our study suggests that PIM reduction may result in a lower risk of hospitalization in the elderly.

Psychotropic Drug Consumption Among Older People Enrolled in a French Private Health Insurance Plan.

BackgroundIn France, little information exists on psychotropic drug consumption in the elderly.ObjectiveThis study aimed to describe the patterns of psychotropic drug consumption, including the extent of inappropriate prescribing, in elderly subjects enrolled in a large health insurance plan in France (MGEN).MethodsIn 2011, 5840 MGEN affiliates aged at least 65 years were randomly selected. Reimbursement claims were organized into a 1-year cross-sectional data set. The EphMRA (European Pharmaceutical Market Research Association) classification was used to identify prescriptions of psychotropic drugs, and the Laroche criteria to identify potentially inappropriate medications (PIMs). Treatment duration was estimated using WHO defined daily doses (DDDs). A multivariate analysis was performed to identify factors associated with the prescription of PIMs.ResultsIn 2011, 2213 subjects (37.9 %) made at least one reimbursement claim for a psychotropic drug, with the claims rate increasing with age. The mean annual volume of prescriptions per user was 193 DDDs. General practitioners were found to generate most of these prescriptions (81.8 %). Of these 2213 users, only 137 (6.2 %) had consulted a mental health specialist, and this rate decreased with age. Moreover, 1428 (64.5 %) subjects were prescribed at least one PIM, rising to 1711 (77.3 %) when including concomitant use of psychotropic drugs. Finally, the number of psychotropic drugs prescribed was associated with a higher odds ratio (OR) of PIM prescription.ConclusionsEfforts should be made to reduce psychotropic drug prescriptions in elderly patients. This may contribute to reduce the amount of PIM prescriptions and the occurrence of iatrogenic side effects.