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.
KeywordsIncidence Rate Digoxin Ketorolac Educational Session Inappropriate Medication
We thank Massimo Fabi, MD, and Ettore Brianti, MD, from the Local Health Authority, Parma, Italy; Roberto Grilli, MD, from Regional Health Care and Social Agency, Regione Emilia-Romagna, Italy; Antonio Brambilla, MD, Eleonora Verdini, BS, and Andrea Donatini, MSc, from the Health Care Authority, Regione Emilia-Romagna, Italy; and all general practitioners in the Parma Local Health Authority who graciously participated in the project. We also thank the GAP (Group for the Appropriateness of Prescribing) for their support in helping with the intervention, which comprises the following: Stefano Baccarini, MD, Anna Bertelè, MD, Alberto Bifani, MD, Alberto Guido Caiazza, MD, Gianluca Boldrocchi, MD, Aderville Cabassi, MD, Mario De Blasi, MD, Stefano Del Canale, MD, PhD, Sigismondo Ferrante, MD, Angelo Franzè, MD, Gianluca Gonzi, MD, Giovanna Negri, PharmD, Paolo Orsi, MD, Giuseppina Paulillo, MD, Giovanni Pedretti, MD, Pietro Pellegrini, MD, Giuseppe Regolisti, MD, Mario Scali, MD, Paolo Tosini, MD and Livio Verti, MD.
Conflict of interest and funding
The authors declare that they have no conflicts of interest relevant to this study. This study was supported through a collaborative agreement between the Parma Local Health Authority, Parma, Italy; the Regional Health Care and Social Agency, Regione Emilia-Romagna, Italy; the Health Care Authority, Regione Emilia-Romagna, Italy; and the Thomas Jefferson University, Philadelphia, USA. The authors’ work was independent of the funders and this paper accurately represents the study results. The study sponsors played no roles in the design or conduct of the study; in the collection, management, analysis, or interpretation of data; in the writing of the manuscript; or in the decision to submit the article for publication.
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