The influence of the Pharmaceutical Benefits Scheme (PBS) on inappropriate prescribing in Australian nursing homes

Objectives: To determine the prevalence of inappropriate prescribing, defined by applying modified Beers’ criteria, and to examine the influence of the Pharmaceutical Benefits Scheme (PBS), Australia’s national scheme for subsidising medicines, on inappropriate prescribing.Methods: Cross-sectional survey of nursing home records, including 7-days data from medication charts.Setting: Fiveteen randomly selected nursing homes (998 residents) in Southeast Queensland and Northern New South Wales, Australia.Main outcome measures: The prevalence of inappropriate prescribing as defined by modified Beers’ criteria and its correlation with PBS restrictions.Results: 18.5% of residents were ordered one or more inappropriate medications, and 1.5% of residents were ordered two or more. The level of PBS restriction and the percentage of residents ordered a medication were highly correlated (ρ = -0.87, P<0.001). Medications in Beers’ criteria that were not listed (subsidised) on the PBS were not ordered for any resident. PBS medicines with subsidies restricted to certain populations or indications were ordered for 0% to 0.1% of residents. Dextropropoxyphene, diazepam, amitriptyline and methyldopa were the only medications in Beers’ criteria prescribed to more than 0.5% of residents. Dextropropoxyphene was only subsidised for war veterans, with a caution warning of its potential to cause drug dependence, while diazepam, amitriptyline and methyldopa were listed on the PBS without any subsidy restrictions.Conclusion: Increases in the level of PBS restriction were associated with decreases in the prevalence of inappropriate prescribing, The targeting of drug subsidies to reduce inappropriate prescribing warrants further investigation.     

Prevalence of inappropriate prescribing in primary care

Objective To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. Setting A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen. Method Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients’ own GPs. The GPs were asked to provide baseline information regarding the patients’ medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded. Results 212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as ‘not indicated’, 6% were rated as ‘ineffective’, 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug–drug interactions, 8.6% had clinically significant drug–disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. Conclusion The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.     

Medication regimen complexity and prevalence of potentially inappropriate medicines in older patients after hospitalisation

Background There is a relative paucity of information to characterise potential changes in medication regimen complexity and prevalence of prescribing of potentially inappropriate medications after hospitalisation, both in Australia and elsewhere. Objective To evaluate medication regimen complexity and the prevalence of potentially inappropriate medications before and after admission to hospital. Setting General medical units of a tertiary care hospital in Australia. Methods Retrospective cohort study of patients aged 65 years and above. Medication complexity was measured by using the Medication Regimen Complexity Index (MRCI). Main outcome measure The primary outcome was the change in the Medication Regimen Complexity Index for all prescribed medications after hospitalization. Results A convenience sample of 100 patients was included in the study. There was a significant change in the mean medication complexity score (as measured using the MRCI), increasing from 29 at the time of admission to 32 at the time of discharge (p < 0.05). Factors such as baseline medication regimen complexity (pre-admission MRCI) and length of stay in the hospitals appear to influence the change in medication complexity. However, the proportion of patients prescribed at least one potentially inappropriate medicine (PIM) decreased significantly, from 52% pre-hospitalization to 42% at discharge (p = 0.04). Conclusions Relative to the time of admission, overall medication complexity increased and the proportion of patients who were prescribed PIMs decreased after hospitalisation.

     

Assessment of sotalol prescribing in a community hospital: opportunities for clinical pharmacist involvement

Objective Due to risk of serious adverse drug events (ADEs) sotalol use is limited in renal insufficiency and heart failure. To reduce potential life‐threatening ADEs, medication safety initiatives that ensure appropriate dosing of sotalol are necessary. Pharmacist‐managed renal dosing assessment programmes ensure appropriate dosing of renally eliminated medications. A prospective medication safety evaluation was conducted to assess the need to include sotalol in an existing renal dosing assessment programme as well as the impact of clinical pharmacist assessment on sotalol prescribing. Methods Patients in a 736‐bed community hospital, receiving sotalol during a 6‐week period, were prospectively evaluated. Information was collected on indication, dosing, concomitant disease states and medications, renal function, QTc length, symptoms of toxicity and readmissions. Pharmacist recommendations were made when necessary and were followed to determine acceptance rate and patient outcomes. Key findings Thirty‐six patients were prescribed sotalol for atrial tachyarrhythmias. Thirty‐two (89%) were dosed inappropriately with respect to renal function. Twenty (56%) had left‐ventricular dysfunction as defined by an ejection fraction of ≤40%. At time of initial assessment, 15 (42%) were exhibiting signs of potential sotalol toxicity. Pharmacists provided recommendations regarding discontinuation or dosage adjustment on 32 patients with a 38% full and a 12% partial acceptance rate. All‐cause readmission rates for patients receiving appropriate therapy, including those after pharmacist recommendations were accepted (Group A; n = 16), were compared to those remaining on inappropriate therapy (Group B; n = 20). Readmission rates within 6 months differed between groups (31% for Group A, 55% for Group B; P = 0.095, odds ratio 3.7). Conclusion This medication safety evaluation suggests the need for pharmacist assessment in patients receiving sotalol. Dosage adjustment or avoidance in patients with renal insufficiency, heart failure and other relative contraindications is often necessary to avoid toxicity. Sotalol was inappropriately prescribed in the majority of patients secondary to renal insufficiency. Based on this evaluation, it was recommended to add sotalol to the institution's pharmacist‐managed renal dosing adjustment programme. Ensuring clinical pharmacist assessment when sotalol is prescribed can help reduce potential life‐threatening ADEs and hospital readmissions.     

天津医科大学总医院半年内老年患者潜在不适当用药及影响因素分析

目的 调查天津医科大学总医院老年住院患者潜在不适当用药情况,并对其影响因素进行分析。方法 以Beers标准（2015年版）为依据,对该院2017年1月~6月收治年龄≥ 65岁的1 800例老年住院患者的潜在不适当用药进行评价,利用χ²检验和多因素Logistic回归分析确定其影响因素。结果 依据Beers标准,614例（34.11%）老年患者存在潜在不适当用药955例次;罹患疾病数和联合用药数可促使潜在不适当用药的发生。结论 Beers标准是评估老年患者潜在用药风险的重要依据,临床治疗中应对造成不适当用药的相关影响因素进行适当控制,以促进合理用药,确保用药安全。