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.     

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.     

Beers标准和STOPP/START标准再评价老年住院患者医嘱点评情况

目的：探讨Beers标准、STOPP/START标准两种方法在对我院老年住院患者医嘱点评进行再评价中筛查出的潜在不适当用药情况,为老年患者合理用药提供参考。方法：选取2013年3月~2015年2月医嘱点评的549份老年患者病历,分别以Beers标准、STOPP/START标准为依据,判断老年患者潜在不适当用药情况。结果：549份老年住院患者平均年龄为（77±7）岁,平均用药品种数（15±7）种。依照Beers标准,99例（18%）存在潜在不适当用药现象共104项;依照STOPP/START标准,104例（19%）存在潜在不适当用药现象共111项;155例（29%）存在处方遗漏现象共232项。结论：以Beers标准和STOPP/START标准可以筛查出大量老年住院患者潜在不适当用药情况,且两种标准筛查出的潜在不适当用药情况重复内容很少,可以形成互补对临床处方考量,促进老年人合理用药。     

解读评价老年人不适当用药的标准:2012修订版Beers标准

Beers标准是一个用于评价老年人不适当用药的非常实用的临床工具。该标准于1991年由老年医学专家Beers首次公布,随后在1997年和2003年两次修订,最近美国老年医学会更新发布了2012版。Beers标准的主要目的在于指导医务工作者对于老年患者选择适当药物,避免带来伤害的不适当用药,保障老年人的用药安全。     

Impact of inappropriate drug use among hospitalized older adults

Objective Criteria for inappropriate drug use developed by Beers have been widely used in drug utilization reviews as the basis for educational materials and to assess the quality of prescribing. However, there is inconclusive evidence that these criteria can impact on patient outcomes. The objective of this study was to evaluate the impact of inappropriate drug use on all-cause mortality, adverse drug reactions (ADRs) and length of stay among in-hospital patients.Methods We performed a retrospective, cohort study on 5,152 patients aged 65 years or older admitted to 81 hospitals in Italy between 1997 and 1998. Inappropriate drug use was defined by 2003 Beers criteria. Outcomes of the study were: (a) in-hospital mortality; (b) incidence of ADR occurring during hospital stay; (c) length of hospital stay 13 days or more.Results The mean age of 5,152 participants was 78.8 years (standard deviation = 8.4 years), and 2,463 (47.8%) were men. During hospital stay, 1,475 (28.6% of the study sample) patients received one or more inappropriate drugs. After adjusting for potential confounders, use of inappropriate drugs was not associated significantly with either mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI): 0.75–1.48], ADR (OR 1.20; 95% CI: 0.89–1.61) or length of stay 13 days or more (OR 1.09; 95% CI: 0.95–1.25).Conclusions This study did not show any significant effect of inappropriate drug use defined by Beers 2003 criteria on health outcomes among hospitalized older adults. Further studies conducted in different settings, using additional health outcomes and alternate measures of inappropriate drug use, are needed.     

Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure

BACKGROUND: Studies have found that 20% to 25% of older patients receive drugs identified as inappropriate by the 1997 Beers criteria. After the addition of 22 new drugs to the 2003 Beers criteria, the National Committee on Quality Assurance convened an expert consensus panel to identify which drugs from the 2003 Beers criteria should always be avoided in the elderly. The resulting list of drugs to avoid was added to the 2006 Health Plan Employer Data and Information Set (HEDIS) to measure the quality of prescribing for the elderly. OBJECTIVE: To use HEDIS 2006 criteria to determine the rate of potentially inappropriate prescribing in the elderly (PIPE) and to determine if patient risk factors are similar to those found using Beers criteria. METHODS: This cross-sectional database study identified older patients receiving drugs included in the HEDIS 2006 criteria using national data from the Veterans Health Administration. Patients aged 65 years or older on October 1, 1999, with at least 2 outpatient visit days during fiscal year 2000, ending September 30, or outpatient visits in fiscal years 1999 and 2000 were included (N=1,096,361). Multivariable logistic regression analyses stratified by gender identified patient characteristics associated with increased risk of HEDIS 2006 drug exposure. Since oral estrogens were considered appropriate at the time of this study, they were excluded from the list of HEDIS 2006 drugs. RESULTS: Overall, 19.6% of older veterans were exposed to HEDIS 2006 drugs. 23.3% of older veteran women and 19.2% of older veteran men. The most commonly prescribed HEDIS 2006 drugs were antihistamines (received by 9.0% of men and 10.7% of women), opioid analgesics (received by 4.6% of men and 5.8% of women), and skeletal muscle relaxants (received by 4.3% of men and 5.3% of women). Propoxyphene was the most commonly used HEDIS 2006 drug, received by 4.5% of men and 5.7% of women, followed by diphenhydramine, received by 3.5% of men and 4.7% of women, and hydroxyzine, received by 3.2% of both men and women. Patients receiving 10 or more medications of any type were at greatest risk of exposure. Men were 8.2 times more likely to receive at least 1 HEDIS 2006 drug than those taking 1 to 3 drugs of any type (95% confidence interval [CI], 8.0-8.4), while women were 9.6 times more likely (95% CI, 8.2-11.2). CONCLUSIONS: Even though we included a slightly different list of drugs to avoid, results for the HEDIS 2006 measure were similar to those of the 1997 Beers criteria. The HEDIS 2006 drugs are commonly prescribed, and there is a distinct need for direct evidence linking HEDIS 2006 PIPE exposure to adverse patient outcomes. To reduce PIPE, it seems necessary to provide additional evidence for clinicians through the conducting of a well-designed study to assess patient outcomes associated with PIPE exposure as defined by the HEDIS criteria.     

Beers标准评价我院门诊老年患者潜在性不适当用药

目的：回顾性分析我院门诊老年患者潜在的不适当用药情况。方法：以Beers标准（2012年版）为依据,对我院年龄≥60岁的老年患者的门诊处方进行分析,评价老年患者潜在性不适当用药的情况。结果：在调查的102284张处方中,与诊断或疾病无关的潜在性不适当用药处方7271张（7．11％）,其中含苯二氮萆类药物的处方3569张（49．09％）;与诊断或疾病相关的潜在性不适当用药处方78张（0．08％）;老年患者需慎用药物的处方1178张（1．15％）。结论：我院门诊老年患者与诊断或疾病无关的潜在性不适当用药情况较严重,特别是苯二氮革类药物,应采取多种措施预防其不合理用药。     

Potentially inappropriate prescribing in Canada relative to the US

OBJECTIVE: To explore the prescribing of potentially inappropriate drug therapy in Ontario, Canada where there is a restrictive drug formulary relative to the US where there is no single drug formulary. METHODS: A retrospective, cohort study using an administrative database (Ontario, Canada) compared with published survey results (US). All 1,088,680 community-dwelling adults >or=66 years of age in Ontario, Canada compared with published survey results from 2455 community-dwelling older adults in the US in 1996.Patterns of potentially inappropriate drug prescribing were compared between countries using a list of 33 potentially inappropriate drug therapies. These therapies were classified by an expert panel into three categories: (i) those to always avoid; (ii) those which are rarely appropriate; and (iii) those with only some indications to prescribe. RESULTS: Among the 33 potentially inappropriate drug therapies, 15 (45%) prescribed in the US were not available through Ontario's drug formulary. Potentially inappropriate drug therapies available through the Ontario Drug Benefit Plan (ODB) and also in the US were frequently prescribed in both Ontario and the US. Differences in prescribing patterns of individual drug therapies were noted between the two countries. Specifically, in the rarely appropriate category, diazepam, a long half-life benzodiazepine, was much more frequently dispensed in Ontario than in the US (3.18% vs 1.37%). In contrast, dextropropoxyphene, an opioid with a poor adverse event profile was more frequently prescribed in the US than in Ontario (6.21% vs 0.74%). CONCLUSION: Almost half of the potentially inappropriate drug therapies that are available in the US are unavailable from Ontario's drug formulary. Potentially inappropriate drug therapies that were available through the ODB were frequently prescribed in both countries. Alternative approaches that make information immediately accessible to physicians at the time they make prescribing decisions should be considered to improve prescribing practices.     

Inappropriate medication use among hospitalized older adults in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly

OBJECTIVE: To determine the prevalence of inappropriate medication use among hospitalized older adults and to identify predictors of this use. METHODS: A total of 5734 patients (mean age 79 years) admitted to geriatric and internal medicine wards participating in the study in 1995 and 1997 were included in this analysis. Inappropriate medication use was defined on the basis of the criteria published by Beers in 1997. Only medications used during hospital stay were considered for the present study. RESULTS: During hospital stay, 837 (14.6%) patients received one or more medications classified as inappropriate based on Beers criteria. Ticlopidine ( n=346; 6.0% of the study sample) was the most frequently used medication among those in Beers' list, followed by digoxin ( n=174; 3.0%) and amytriptyline ( n=113; 2.0%). The multivariate analysis showed that age [75-84 years vs 65-74 years, odds ratio (OR) 0.85, 95% confidence interval (CI) 0.71-1.00; >or=85 years vs 65-74 years, OR 0.58, 95% CI 0.46-0.73], cognitive impairment (OR 0.77, 95% CI 0.64-0.94), Charlson co-morbidity index (>or=2 vs 0-1, OR 1.20, 95% CI 1.02-1.40) and overall number of medications used during hospital stay (5-8 medications vs <5 medications, OR 2.20, 95% CI 1.72-2.82; >or=9 medications vs <5 medications, OR 3.68, 95% CI 2.86-4.73) were significantly associated with use of inappropriate medications. CONCLUSIONS: Inappropriate medication use was common among hospitalized older adults. The most important determinant of risk of receiving an inappropriate medication was the number of drugs being taken. Older age and cognitive impairment were associated with a reduced likelihood of using an inappropriate medication.