Advertisement

European Journal of Clinical Pharmacology

, Volume 68, Issue 10, pp 1425–1433 | Cite as

Potentially inappropriate prescribing and cost outcomes for older people: a cross-sectional study using the Northern Ireland Enhanced Prescribing Database

  • Marie C. BradleyEmail author
  • Tom Fahey
  • Caitriona Cahir
  • Kathleen Bennett
  • Dermot O’Reilly
  • Carole Parsons
  • Carmel M. Hughes
Pharmacoepidemiology and Prescription

Abstract

Purpose

We sought to estimate the prevalence of potentially inappropriate prescribing (PIP) in the Northern Ireland (NI) population aged ≥70 years, to investigate factors associated with PIP and to calculate total gross cost of PIP.

Methods

A retrospective cross-sectional population study was carried out in those aged ≥70 years in 2009/2010 who were in primary care in NI. Data were extracted from the Enhanced Prescribing Database, which provides details of prescribed and dispensed medications for each individual registered with a general practitioner. Twenty-eight PIP indicators from the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) criteria were applied to these data. PIP prevalence according to individual STOPP criteria and the overall prevalence of PIP were estimated. The relationship between PIP and polypharmacy, age and gender was examined using logistic regression. Gross cost of PIP was ascertained.

Results

The overall prevalence of PIP in the study population (n = 166,108) was 34 %. The most common examples of PIP identified were proton pump inhibitors at maximum therapeutic dose for >8 weeks (17,931 patients, 11 %), non-steroidal anti-inflammatory drugs >3 months (14,545 patients, 9 %) and long-term long-acting benzodiazepines (10,147 patients, 6 %). PIP was strongly associated with polypharmacy, with those receiving seven different medications being fivefold more likely to be exposed to PIP than those on zero to three medications (odds ratio 5.04, 95 % confidence interval 4.84–5.25) The gross cost of PIP was estimated to be €6,098,419

Conclusions

Consistent with other research, the prevalence of PIP was high among the study cohort, increased with polypharmacy and was associated with significant cost.

Keywords

Potentially inappropriate prescribing STOPP Older people Quality Cost 

Notes

Acknowledgements

We wish to thank the staff at the National Health Service, Business Services Organization (NHS BSO), Information and Registration Unit, for supplying the data from the EPD database and providing technical support, and the Irish Health Research Board for financial support. We wish in particular to acknowledge Maciej Domanski’s contribution (Centre for Public Health and the Centre for Health Improvement, Queen’s University Belfast) in helping with data extraction for this research.

Financial disclosure

The Health Research Board provided financial support for this study: grant reference HRC-2007-1

Sponsor’s role

The sponsor had no role in any aspect of the study apart from providing funding.

Conflict of interest

None.

References

  1. 1.
    O'Mahony D, Gallagher PF (2008) Inappropriate prescribing in the older population: need for new criteria. Age Ageing 37:138–141PubMedCrossRefGoogle Scholar
  2. 2.
    Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370:173–184PubMedCrossRefGoogle Scholar
  3. 3.
    Fialova D, Onder G (2009) Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol 67:641–645PubMedCrossRefGoogle Scholar
  4. 4.
    McLeod P, Huang AR, Tamblyn RM, Gayton DC (1997) Defining inappropriate practices in prescribing for elderly people: a national consensus panel. Can Med Assoc J 156:385–391Google Scholar
  5. 5.
    Naugler CT, Brymer C, Stolee P, Arcese ZA (2000) Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol 7:103–107PubMedGoogle Scholar
  6. 6.
    Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH (2003) Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 163:2716–2724PubMedCrossRefGoogle Scholar
  7. 7.
    Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ (1994) A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol 4:891–896CrossRefGoogle Scholar
  8. 8.
    van der Hooft CS, Jong GW, Dieleman JP, Verhamme KM, van der Cammen TJ, Stricker BH, Sturkenboom MC (2005) Inappropriate drug prescribing in older adults: the updated 2002 Beers criteria–a population-based cohort study. Br J Clin Pharmacol 60:137–144PubMedCrossRefGoogle Scholar
  9. 9.
    Beers MH (1997) explicit criteria for determining potentially inappropriate medication use by the elderly an update. Arch Intern Med 157:1531–1536PubMedCrossRefGoogle Scholar
  10. 10.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D (2008) STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 46:72–83PubMedGoogle Scholar
  11. 11.
    Gallagher P, Baeyens JP, Topinkova E, Madlova P, Cherubini A, Gasperini B, Cruz-Jentoft A, Montero B, Lang PO, Michel JP, O'Mahony D (2009) Inter-rater reliability of STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria amongst physicians in six European countries. Age Ageing 38:603–606PubMedCrossRefGoogle Scholar
  12. 12.
    Fialová D, Topinková E, Gambassi G, Finne-Soveri H, Jónsson PV, Carpenter I, Schroll M, Onder G, Sørbye LW, Wagner C, Reissigová J, Bernabei R, AdHOC Project Research Group (2005) Potentially inappropriate medication use among elderly home care patients in Europe. JAMA 293:1348–1358PubMedCrossRefGoogle Scholar
  13. 13.
    Carey IM, De Wilde S, Harris T, Victor C, Richards N, Hilton SR, Cook DG (2008) What factors predict potentially inappropriate primary care prescribing in older people? Analysis of UK primary care patient record database. Drugs Aging 25:639–706CrossRefGoogle Scholar
  14. 14.
    Gallagher P, Lang PO, Cherubini A, Topinková E, Cruz-Jentoft A, Montero Errasquín B, Mádlová P, Gasperini B, Baeyens H, Baeyens JP, Michel JP, O'Mahony D (2011) Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol 67:1175–1188PubMedCrossRefGoogle Scholar
  15. 15.
    Gallagher P, Barry P, O'Mahony D (2007) Inappropriate prescribing in the elderly. J Clin Pharm Ther 32:113–121PubMedCrossRefGoogle Scholar
  16. 16.
    Klarin I, Wimo A, Fastbom J (2005) The association of inappropriate drug use with hospitalisation and mortality: a population-based study of the very old. Drugs Aging 22:69–82PubMedCrossRefGoogle Scholar
  17. 17.
    Hanlon JT, Maher R, Lindblad CI, Ruby CM, Twersky J, Cohen HJ, Schmader KE (2001) Comparison of methods for detecting potential adverse drug events in frail elderly inpatients and outpatients. Am J Health Syst Pharm 58:1622–1626PubMedGoogle Scholar
  18. 18.
    Lund BC, Carnahan RM, Egge JA, Chrischilles EA, Kaboli PJ (2010) Inappropriate prescribing predicts adverse drugevents in older adults. Ann Pharmacother 44:957–963PubMedCrossRefGoogle Scholar
  19. 19.
    Hamilton H, Gallagher P, Ryan C, Byrne S, O'Mahony (2011) Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med 171:1013–1019PubMedCrossRefGoogle Scholar
  20. 20.
    Cahir C, Fahey T, Teeling M, Teljeur C, Feely J, Bennett K (2010) Potentially inappropriate prescribing and cost outcomes for older people: a national population study. Br J Clin Pharmacol 69:543–552PubMedCrossRefGoogle Scholar
  21. 21.
    Galway KJ, Murphy AW, O'Reilly D, O'Dowd T, O'Neill C, Shryane E, Steele K, Bury G, Gilliland A, Kelly A (2007) Perceived and reported access to the general practitioner: an international comparison of universal access and mixed private/public systems. Ir Med J 100:494–497PubMedGoogle Scholar
  22. 22.
    Davis P (2007) Northern Ireland's electronic prescribing and eligibility system. Br J Health Comp 24:12–14Google Scholar
  23. 23.
    Patterson SM, Hughes C, Kerse N, Cardwell CR (2009) Interventions to improve the appropriate use of polypharmacy for older people (Protocol). Cochrane Database Syst Rev 4:CD008165Google Scholar
  24. 24.
    Davey P, Ferech M, Ansari F, Muller A, Goossens H, ESAC Project Group (2008) Outpatient antibiotic use in the four administrations of the UK: cross-sectional and longitudinal analysis. J Antimicrob Chemother 62:1441–1447PubMedCrossRefGoogle Scholar
  25. 25.
    Hughes JD, Tanpurekul W, Keen NC, Ee HC (2009) Reducing the cost of proton pump inhibitors by adopting best practice. Qual Prim Care 17:15–21PubMedGoogle Scholar
  26. 26.
    Molloy D, Molloy A, O'Loughlin C, Falconer M, Hennessy M (2010) Inppropriate use of proton pump inhibitors. Ir J Med Sci 179:73–75PubMedCrossRefGoogle Scholar
  27. 27.
    Batuwitage BT, Kingham JG, Morgan NE, Bartlett RL (2007) Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 83:66–68PubMedCrossRefGoogle Scholar
  28. 28.
    Forgacs I, Loganayagam A (2008) Overprescribing proton pump inhibitors. Br Med J 336:2–3CrossRefGoogle Scholar
  29. 29.
    McKay AB, Wall D (2008) Overprescribing PPIs: an old problem. Br Med J 19:109CrossRefGoogle Scholar
  30. 30.
    Choudhry MN, Soran H, Ziglam HM (2008) Overuse and inappropriate prescribing of proton pump inhibitors in patients with Clostridium difficile-associated disease. Q J Med 101:445–448CrossRefGoogle Scholar
  31. 31.
    Yang Y-X, Lewis JD, Epstein S, Metz DC (2006) Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA 296:2947–2953PubMedCrossRefGoogle Scholar
  32. 32.
    Coté GA, Howden CW (2008) Potential adverse effects of proton pump inhibitors. Curr Gastroenterol Rep 10:208–214PubMedCrossRefGoogle Scholar
  33. 33.
    Fohl AL, Regal RE (2011) Proton pump inhibitor-associated pneumonia: Not a breath of fresh air after all? World J Gastrointest Pharmacol Ther 6:17–26CrossRefGoogle Scholar
  34. 34.
    Howden CW, Kahrilas PJ (2010) Editorial: just how “difficult” is it to withdraw PPI treatment? Am J Gastroenterol 105:1538–1540PubMedCrossRefGoogle Scholar
  35. 35.
    Inadomi JM, Jamal R, Murata GH, Hoffman RM, Lavezo LA, Vigil JM, Swanson KM, Sonnenberg A (2001) Step-down management of gastroesophageal reflux disease. Gastroenterology 121:1095–1100PubMedCrossRefGoogle Scholar
  36. 36.
    Inadomi JM, McIntyre L, Bernard L, Fendrick AM (2003) Step down from multiple- to single-dose proton pump inhibitors: a prospective study of patients withheartburn or acid regurgitation completely relieved with PPIs. Am J Gastroenterol 98:1940–1944PubMedCrossRefGoogle Scholar
  37. 37.
    Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, Farrar K, Park BK, Breckenridge AM (2004) Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. Br Med J 329:15–19CrossRefGoogle Scholar
  38. 38.
    Barkin RL, Beckerman M, Blum SL, Clark FM, Koh EK, Wu DS (2010) Should nonsteroidal anti-inflammatory drugs (NSAIDs) be prescribed to the older adult? Drugs Aging 27:775–789PubMedCrossRefGoogle Scholar
  39. 39.
    Katz JD, Shah T (2009) Persistent pain in the older adult: what should we do now in light of the 2009 American geriatrics society clinical practice guideline? Pol Arch Med Wewn 119:795–800PubMedGoogle Scholar
  40. 40.
    Lin J, Zhang W, Jones A, Doherty M (2004) Efficacy of topical non-steroidal anti-inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised controlled trials. Br Med J 329:324–329CrossRefGoogle Scholar
  41. 41.
    De Wilde S, Carey IM, Harris T, Richards N, Victor C, Hilton SR, Cook DG (2007) Trends in potentially inappropriate prescribing amongst older UK primary care patients. Pharmacoepidemiol Drug Saf 16:658–667PubMedCrossRefGoogle Scholar
  42. 42.
    Tinetti ME (2003) Preventing falls in elderly persons. N Engl J Med 348:42–49PubMedCrossRefGoogle Scholar
  43. 43.
    Wagner AK, Zhang F, Soumerai SB, Walker AM, Gurwitz JH, Glynn RJ, Ross-Degnan D (2004) Benzodiazepine use and hip fractures in the elderly. Who is at greatest risk? Arch Intern Med 164:1567–1572PubMedCrossRefGoogle Scholar
  44. 44.
    Haumschild MJ, Karfonta TL, Haumschild MS, Phillips SE (2003) Clinical and economic outcomes of a fall-focused pharmaceutical intervention program. Am J Health Syst Pharm 60:1029–1032PubMedGoogle Scholar
  45. 45.
    de Gier NA, Gorgels WJ, Lucassen PL, Oude Voshaar R, Mulder J, Zitman F (2011) Discontinuation of long-term benzodiazepine use: 10-year follow-up. Fam Pract 28:253–259PubMedCrossRefGoogle Scholar
  46. 46.
    Hajar ER, Cafiero AC, Hanlon JT (2007) Polypharmacy in elderly patients. Am J Geriatr Psychiatry 5:345–351Google Scholar
  47. 47.
    Fulton MM, Allen ER (2005) Polypharmacy in the elderly: a literature review. J Am Acad Nurse Pract 17:123–132PubMedCrossRefGoogle Scholar
  48. 48.
    Prybys KM (2002) Polypharmacy in the elderly: clinical challenges in emergency practice. Part 1: Overview, etiology and drug interactions. Emerg Med Reports 23:145–153Google Scholar
  49. 49.
    Gallagher LP (2001) The potential for adverse drug reactions in elderly patients. Appl Nurs Res 14:220–224PubMedCrossRefGoogle Scholar
  50. 50.
    Aparasu RR, Mort JR (2004) Prevalence, correlates, and associated outcomes of potentially inappropriate psychotropic use in the community-dwelling elderly. Am J Geriatr Pharmacother 2:102–111PubMedCrossRefGoogle Scholar
  51. 51.
    Liu GG, Christensen DB (2002) The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc 42:847–857CrossRefGoogle Scholar
  52. 52.
    Homemeds.org. (2011) “Medications management model toolkit—unnecessary therapeutic duplication”. Available at: http://www.homemeds.org/images/medialibrary/Protocol___Therapeutic_Duplication.pdf. Accessed 10 Dec 2011

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Marie C. Bradley
    • 1
    • 2
    Email author
  • Tom Fahey
    • 2
  • Caitriona Cahir
    • 2
  • Kathleen Bennett
    • 3
  • Dermot O’Reilly
    • 4
  • Carole Parsons
    • 1
  • Carmel M. Hughes
    • 1
  1. 1.School of Pharmacy, HRB Centre for Primary Care ResearchQueen’s University BelfastBelfastNorthern Ireland
  2. 2.Division of Population Health Sciences, RCSI Medical School, HRB Centre for Primary Care ResearchRoyal College of Surgeons In IrelandDublinIreland
  3. 3.Department of Pharmacology and Therapeutics, Trinity Centre for Health SciencesSt James’ HospitalDublinIreland
  4. 4.Centre for Public HealthQueen’s University BelfastBelfastNorthern Ireland

Personalised recommendations