A Physician-Focused Intervention to Reduce Potentially Inappropriate Medication Prescribing in Older People
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Potentially inappropriate medications (PIMs) are a preventable cause of negative clinical and economic consequences in older people. A range of educational interventions have attempted to address this in the past and have produced mixed results.
The objective of this study was to assess the effect of a physician-focused, multi-factorial, quality-improvement intervention on PIM prescribing in older patients in primary care.
This 3-year, multi-phase, prospective, proof-of-concept project introduced in 2007 was aimed at engaging all 303 general practitioners (GPs) in the Local Health Authority (LHA) of Parma, Italy, to positively influence the quality of prescribing to the entire older outpatient population (those aged at least 65 years) served by these physicians. The intervention focused on increasing GPs’ awareness of prescribing for older people and included three key elements: (1) initial dissemination of a developed list of PIMs to always be avoided, along with a list of alternative drugs; (2) annual reviews of PIM incidence data; and (3) educational sessions on PIMs via academic detailing and case study reviews. Quarterly incidence rates of PIM exposure were calculated among all Parma LHA older outpatients who had received a prescription for any medication from their GP in a given quarter. The intervention was assessed by evaluating the changes in these rates between the study baseline (2007 fourth quarter [Q4]) and the end of the study (post-intervention: 2009 Q4). To reduce bias and confounding from background influences that may have acted to reduce PIM incidence rates independent of the intervention, these rate changes were also compared with those drawn from a similar neighbouring LHA over the same time period.
Quarterly PIM exposure incidence rates among the older Parma LHA patients declined 31.4 % (7.8 % baseline to 5.3 % post-intervention), compared with 21.6 % in the comparator LHA (7.7 % to 6.1 %). The reduction in rates was significantly greater in the Parma LHA (p < 0.001), where the intervention resulted in 608 older patients (12.4 % of expected) being spared PIM exposure during 2009 Q4. PIM exposure rate reductions for NSAIDs and digoxin were each significantly greater in the Parma LHA than in the comparator LHA.
By reaching out to GPs and maintaining contact with them, this quality intervention appears to have positively impacted physicians’ awareness and prescribing behaviour, which led to significant reductions in PIM exposures and likely translated to significant population health benefits among their older patients. Similar interventions tailored to target specific PIMs or focus on certain subpopulations of GPs may further improve prescribing quality among older people.
- Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication use in community-residing older persons. Arch Intern Med. 1994;154(19):2195–200. CrossRef
- Chang CM, Liu PY, Yang YH, et al. Use of the Beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005;25(6):831–8. CrossRef
- Fillenbaum GG, Hanlon JT, Landerman LR, et al. Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents. Am J Geriatr Pharmacother. 2004;2(2):92–101. CrossRef
- Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in the elderly. J Am Geriatr Soc. 2004;52(11):1934–9. CrossRef
- Klarin I, Wimo A, Fastbom J. The association of inappropriate drug use with hospitalisation and mortality: a population-based study of the very old. Drugs Aging. 2005;22(1):69–82. CrossRef
- Fick DM, Waller JL, Maclean JR, et al. Potentially inappropriate medication use in a Medicare managed care population: association with higher costs and utilization. JMCP. 2001;7(5):407–13.
- Gupta S, Rappaport HM, Bennett LT. Inappropriate drug prescribing and related outcomes for elderly medicaid beneficiaries residing in nursing homes. Clin Ther. 1996;18(1):183–96. CrossRef
- Jano E, Aparasu RR. Healthcare outcomes associated with Beers’ criteria: a systematic review. Ann Pharmacother. 2007;41(3):438–47. CrossRef
- Kaur S, Mitchell G, Vitetta L, et al. Interventions that can reduce inappropriate prescribing in the elderly: a systematic review. Drugs Aging. 2009;26(12):1013–28. CrossRef
- Siriwardena AN. Engaging clinicians in quality improvement initiatives: art or science? Qual Prim Care. 2009;17(5):303–5.
- Bain KT. Barriers and strategies to influencing physician behavior. Am J Med Qual. 2007;22(1):5–7. CrossRef
- Lu CY, Ross-Degnan D, Soumerai SB, et al. Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature—2001–2007. BMC Health Serv Res. 2008;8:75. CrossRef
- Maio V, Yuen EJ, Novielli K, et al. Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study. Drugs Aging. 2006;23(11):915–24. CrossRef
- Agenzia Italiana del Farmaco. Piroxicam: ulteriori restrizioni e avvertenze sulla sicurezza. Farmacovigilanza. 2007 Dec 20; Bif XIV No. 6: 261–262. http://www.agenziafarmaco.gov.it/sites/default/files/bif6_piroxicam.pdf. Accessed 2012 Mar 10.
- France G, Taroni F, Donatini A. The Italian health-care system. Health Econ. 2005;14(Suppl 1):S187–202. CrossRef
- Maio V, Del Canale S, Abouzaid S. Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther. 2010;35(2):219–29. CrossRef
- Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003;163(22):2716–24. CrossRef
- European Medicines Agency Press Office. Key elements for the summaries of product characteristics of non-selective NSAIDs adopted by the CHMP during its meeting in October 2005 (EMEA/CHMP/343456/2005). London: EMEA; 2005. http://www.ema.europa.eu/docs/en_GB/document_library/Other/2010/02/WC500074137.pdf. 2012 Mar 21.
- Maio V, Jutkowitz E, Herrera K, et al. Appropriate medication prescribing in elderly patients: how knowledgeable are primary care physicians? A survey study in Parma, Italy. J Clin Pharm Ther. 2011;36(4):468–80. CrossRef
- Louis DZ, Yuen EJ, Maio V, et al. A population-based longitudinal healthcare database in the Emilia-Romagna Region, Italy: a resource for planning and research. Health Policy Newsletter. 2005;18(2):6.
- Institute of Internal Medicine (IOM). To err is human: building a safer health system. Washington, D.C: National Academy Press; 2001.
- Levy HB, Marcus EL, Christen C. Beyond the beers criteria: a comparative overview of explicit criteria. Ann Pharmacother. 2010;44(12):1968–75. CrossRef
- Wessell AM, Nietert PJ, Jenkins RG, et al. Inappropriate medication use in the elderly: results from a quality improvement project in 99 primary care practices. Am J Geriatr Pharmacother. 2008;6(1):21–7. CrossRef
- United States Food and Drug Administration. Pergolizzi VM. Addressing NSAID safe use: primum non nocere. Silver Spring: FDA; 2009. http://www.fda.gov/downloads/Drugs/NewsEvents/UCM234184.pdf. Accessed 2012 Mar 21.
- Solomon DH, Schneeweiss S, Levin R, et al. Relationship between COX-2 specific inhibitors and hypertension. Hypertension. 2004;44(2):140–5. CrossRef
- Epstein M. Non-steroidal anti-inflammatory drugs and the continuum of renal dysfunction. J Hypertens Suppl. 2002;20(6):S17–23.
- Griffin MR, Yared A, Ray WA. Nonsteroidal antiinflammatory drugs and acute renal failure in elderly persons. Am J Epidemiol. 2000;151(5):488–96. CrossRef
- Onder G, Pedone C, Landi F, et al. Adverse drug reactions as cause of hospital admissions: results from the Italian Group of Pharmacoepidemiology in the Elderly (GIFA). J Am Geriatr Soc. 2002;50(12):1962–8. CrossRef
- Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011;365(21):2002–12. CrossRef
- Currie GM, Wheat JM, Kiat H. Pharmacokinetic considerations for digoxin in older people. Open Cardiovasc Med J. 2011;5:130–5. CrossRef
- Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151(9):1825–32. CrossRef
- A Physician-Focused Intervention to Reduce Potentially Inappropriate Medication Prescribing in Older People
Drugs & Aging
Volume 30, Issue 2 , pp 119-127
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- 1. Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, 1015 Chestnut St., Suite M100, Philadelphia, PA, 19107, USA
- 2. Jefferson School of Population Health, Thomas Jefferson University, 1015 Walnut St., Suite 115, Philadelphia, PA, 19107, USA
- 3. Center for Research in Medical Education and Health Care, Jefferson Medical College of Thomas Jefferson University, 1015 Walnut St., Suite 119, Philadelphia, PA, 19107, USA
- 4. Local Health Authority, Via Giuseppe Garibaldi 9, 43022, Montechiarugolo, Parma, Italy