What factors predict potentially inappropriate primary care prescribing in older people? Analysis of UK primary care patient record database

BACKGROUND: Potentially inappropriate prescribing (PIP) in older people has been identified as a substantial problem, but few large population-based studies have investigated the underlying factors that predict it. OBJECTIVE: To: (i) examine trends in PIP in UK older primary care patients; and (ii) assess factors associated with PIP. METHODS: An analysis of routine, anonymized, computerized patient records of 201 UK general practices providing data to the DIN-LINK database between 1996 and 2005, which included approximately 230 000 registered patients per year aged > or = 65 years. The main outcome measures were the number of different drugs prescribed per patient annually and the percentage of patients prescribed a PIP drug (modified 2003 Beers criteria). These were assessed for all drugs, and then for selected sub-classes (analgesics, antidepressants and sedatives/anxiolytics). RESULTS: Whilst the number of drugs prescribed per patient increased, the percentage of subjects receiving a PIP drug declined from 32.2% in 1996 to 28.3% in 2005, largely due to a fall in co-proxamol (dextropropoxyphene/paracetamol [acetaminophen]) prescribing. In 2005, female gender, being older, more socio-economically deprived or in a care home were strongly associated with PIP. However, the number of drugs prescribed was strongly associated with these variables and the strongest predictor of PIP; adjusting for number of drugs dramatically reduced the strength of all other associations except female gender with PIP. Factors predicting PIP in drug sub-groups were similarly reduced when adjusted for polypharmacy. However, some age trends remained: in the oldest group (aged > or = 85 years), PIP of analgesics was less likely (odds ratio [OR] = 0.70, 95% CI 0.66, 0.75) while PIP of antidepressants was more likely (OR = 1.39, 95% CI 1.28, 1.51). CONCLUSION: PIP amongst older people in the UK, although declining, remains at a high level. The association of PIP with age, deprivation and care homes is largely explained by the higher overall prescribing rates in these groups. The overall rise in prescribing emphasizes that polypharmacy does not necessarily increase PIP and attempts to reduce PIP by focusing on polypharmacy have not been successful. Reductions in PIP have previously been achieved by introducing national guidelines (e.g. co-proxamol), but might also be achieved by alerting practitioners at the point of prescribing.     

Regional variation in the prescribing for diabetes and use of secondary preventative therapies in Ireland

PURPOSE: To compare the prescribing of secondary preventative therapies for patients with both insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) in the eight health board regions of Ireland. METHODS: We utilized data from the national general medical services (GMS) prescribing database to examine the variability of prescribing for diabetes and associated secondary therapies between regions in those aged 45 years or more. Age-sex standardized prescribing rates of six secondary preventative therapies (aspirin, beta-blockers, statins, ACE inhibitors, angiotensin receptor (AT2) antagonists, and fibrates) were calculated for each region. RESULTS: Variations exist between regions for treated NIDDM (1.5-fold) and IDDM (1.5-fold). Wide variations were observed between regions for prescribing of secondary preventative therapies with the highest variability observed for statin prescribing (1.5- to 1.6-fold) and for AT2 antagonist prescribing (2.0-fold) in NIDDM patients. In those with NIDDM, men were more likely to receive aspirin OR=1.26 (1.21--1.31), ACE inhibitors 1.14 (1.101.18), and fibrates OR=1.55 (1.23--1.96) than women and those aged over 75 years were less likely to receive statins OR=0.60 (0.56--0.65) and fibrates OR=0.25 (0.17--0.37) than those aged 45--74. Similar results were also shown for patients with IDDM. CONCLUSIONS: The results suggest that access to secondary preventative therapy in diabetes patients is not equitable across regions, gender, and age in Ireland. While much of the variability remains unexplained, it may be due to differences in screening and health promotion between regions, prescriber uncertainty, variability in clinical need, or may be derived from a socioeconomic disparity among regions.     

Predictors of Illicit Drug Use Among Prisoners

Background: The United States of America currently has the highest incarceration rate in the world, and approximately 80% of incarcerated individuals have a history of illicit drug use. Despite institutional prohibitions, drug use continues in prison, and is associated with a range of negative outcomes. Objectives: To assess the relationship between prison drug use, duration of incarceration, and a range of covariates. Results: Most participants self-reported a history of illicit drug use (77.5%). Seven percent reportedly used drugs during the previous six months of incarceration (n = 100). Participants who had been incarcerated for more than a year were less likely than those incarcerated for longer than a year to report using drugs (OR = 0.50; 95% CI = 0.26–0.98). Participants aged 37–89 were less likely than younger prisoners to use drugs (OR = 0.39; 95% CI = 0.19–0.80). Heroin users were twice as likely as nonheroin users to use drugs (OR = 2.28; 95% CI = 1.04–5.03); crack cocaine users were also twice as likely as participants with no history of crack cocaine usage to report drug use (OR = 2.53; 95% CI = 1.13–5.69). Conclusions: Correctional institutions should be used as a resource to offer evidence-based services to curb drug usage. Drug treatment programs for younger prisoners, heroin and crack cocaine users, and at the beginning of a prisoner's sentence should be considered for this population.     

Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients

STUDY OBJECTIVE: To determine whether the Beers criteria can predict adverse drug reactions (ADRs) in first-visit elderly outpatients. DESIGN: Prospective cohort study. SETTING: Outpatient clinics of a tertiary care and academic medical center in southern Taiwan. PATIENTS: Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001. INTERVENTION: Telephone survey conducted 1 week after clinic visit. MEASUREMENTS AND MAIN RESULTS: Potentially inappropriate drugs were assessed by the updated Beers criteria. Adverse drug reactions were detected by telephone survey and evaluated by the Naranjo criteria 1 week after drug administration. Of the 550 respondents, 64 (11.6%) had potentially inappropriate drugs prescribed and 126 (22.9%) had ADRs. Multiple logistic regression analysis revealed associations between ADRs and potentially inappropriate drug prescribing (relative risk [RR] 15.3, 95% confidence interval [CI] 4.0-58.8), number of prescribed drugs (RR 1.3, 95% CI 1.1-1.5), history of ADRs (RR 2.1, 95% CI 1.3-3.4), and noncompliance with prescribed drugs (RR 2.0, 95% CI 1.1-3.7). In patients who had potentially inappropriate drugs prescribed, the number of prescribed drugs was not significantly associated with ADRs (RR 0.8, 95% CI 0.6-1.1). In patients who did not have potentially inappropriate drugs prescribed, more prescribed drugs increased the risk of ADRs (RR 1.3, 95% CI 1.1-1.5). CONCLUSION: A positive association exists between potentially inappropriate drug prescribing, as defined by the Beers criteria, and ADRs in first-visit elderly outpatients. Clinicians should be alert to the possibility of ADRs if a patient takes more than five drugs, has a history of ADRs, or exhibits poor compliance with prescribed drugs.     

深圳市某院门诊合理用药现状及相关影响因素研究

目的：对医院门诊合理用药国际指标等进行调研,分析合理用药相关影响因素,为进一步制定门诊合理用药干预措施提供科学依据。方法：采用系统抽样的方法对深圳市某医院部分门诊患者进行问卷调查及处方资料收集,利用多因素Logistic回归分析筛选影响门诊患者合理用药的影响因素。结果：对867份处方进行合理性评价,其中76份处方被判定为不合理处方,处方不合理率7.73%。867张处方中,门诊患者平均用药（2.20±1.21）种,处方中抗菌药物应用率为26.30%、注射剂应用率达14.07%,基本药物应用率达16.96%,患者对正确用药方式知晓率为84.54%,药品通用名使用率、药品标示完整率、实际药品调配率为100%,医生平均诊治时间3.78min,药品平均调配时间2.39min。以处方合理性判定结果作为因变量（合理处方：Y=1,不合理处方：Y=0）,进行Lo－gistic回归分析,结果显示：开方医生的职称越高所开处方为合理处方的可能性越高（OR=2.213）,开方医生工作年限越长处方合理性概率越高（OR=2.130）,用药种类数越多不合理处方的风险越高（OR=0.969）。结论：不合理处方占比较低,抗菌药物和注射剂的使用得到有效控制,基本药物使用比例偏低,医师职称、工作年限是影响处方合理性的重要因素。     

Potentially inappropriate drug prescribing among first-visit elderly outpatients in Taiwan

STUDY OBJECTIVE: To determine the prevalence and risk factors of potentially inappropriate drug prescribing among first-visit elderly outpatients. DESIGN: Cross-sectional survey. SETTING: An urban tertiary care and academic medical center in southern Taiwan. PATIENTS: Eight hundred eighty-two patients aged 65 years or older who were prescribed drugs at their first visit to either the medical center's outpatient internal medicine clinic or family medicine clinic between March 1, 2001, and July 31, 2001. MEASUREMENTS AND MAIN RESULTS: Potentially inappropriate drug prescribing was assessed according to updated Beers criteria. Ninety-seven potentially inappropriate drugs were identified in 93 (10.5%) patients. The most common classes were sedative-hypnotics (18.6%) and muscle relaxants (17.5%). Twenty (20.6%) of these inappropriate drugs had a high severity potential according to the Beers criteria. Patients prescribed potentially inappropriate drugs were more likely to be prescribed several drugs versus those who were not prescribed potentially inappropriate drugs (4.0+/-1.9 vs 2.8+/-1.4, p<0.001). Multiple logistic regression analysis revealed an interaction between age and the number of prescribed drugs on the risk of having potentially inappropriate drugs prescribed. In patients who were prescribed four agents or less, the risk was not associated with increasing age; in those who were prescribed five drugs or more, the risk was positively associated with increasing age. CONCLUSION: Potentially inappropriate drug prescribing among first-visit elderly outpatients was relatively low. Increasing patient age combined with increased number of drugs prescribed was associated with increased risk of having potentially inappropriate drugs prescribed.