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The Medication Appropriateness Index at 20: Where It Started, Where It Has Been, and Where It May Be Going

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Abstract

Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI’s reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term ‘medication appropriateness index’. A manual search of the reference lists from identified articles and the authors’ article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.

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References

  1. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane K, Swine C, et al. Appropriate prescribing in elderly people: how can it be measured and optimized? Lancet. 2007;370:173–84.

    Article  PubMed  Google Scholar 

  2. Nelson EA, Dannefer D. Aged heterogeneity: fact or fiction? The fate of diversity in gerontological research. Gerontologist. 1992;32:17–23.

    Article  CAS  PubMed  Google Scholar 

  3. Mangoni AA, Jackson SH. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol. 2004;57:6–14.

    Article  CAS  PubMed  Google Scholar 

  4. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in elderly inpatients and outpatients. J Am Geriatr Soc. 2001;49:200–9.

    Article  CAS  PubMed  Google Scholar 

  5. Knapp DA. Development of criteria for drug utilization review. Clin Pharmacol Ther. 1991;5:600–2.

    Article  Google Scholar 

  6. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med. 1991;151:1825–32.

    Article  CAS  PubMed  Google Scholar 

  7. Dimitrov MS, Airaksinen MS, Kivelä SL, Lyles A, Leikola SN. Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: a systematic review. J Am Geriatr Soc. 2011;59:1521–30.

    Article  Google Scholar 

  8. O’Connor MN, Gallagher P, O’Mahony D. Inappropriate prescribing: criteria, detection and prevention. Drugs Aging. 2012;29:437–52.

    Article  PubMed  Google Scholar 

  9. Hanlon JT, Schmader K, Lewis I. Adverse drug reactions. In: Delafuente JC, Stewart RB, editors. Therapeutics in the elderly. 2nd ed. Cincinnati: Harvey Whitney Books; 1995. p. 212–27.

    Google Scholar 

  10. Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45:1045–51.

    Article  CAS  PubMed  Google Scholar 

  11. Samsa G, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech K, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994;47:891–6.

    Article  CAS  PubMed  Google Scholar 

  12. Hanlon JT, Weinberger M, Samsa GP, Schmader K, Lewis I, Uttech K, et al. A randomized controlled trial of a clinical pharmacist intervention with elderly outpatients with polypharmacy. Am J Med. 1996;100:428–37.

    Article  CAS  PubMed  Google Scholar 

  13. Fitzgerald LS, Hanlon JT, Shelton PS, Landsman PB, Schmader KE, Pulliam CC, Williams ME. Reliability of a modified medication appropriateness index in ambulatory older persons. Ann Pharmacother. 1997;31:543–8.

    CAS  PubMed  Google Scholar 

  14. Kassam R, Martin LG, Farris KB. Reliability of a modified medication appropriateness index in community pharmacies. Ann Pharmacother. 2003;37:40–6.

    Article  PubMed  Google Scholar 

  15. Bregnhøj L, Thirstrup S, Kristensen MB, Sonne J. Reliability of a modified medication appropriateness index in primary care. Eur J Clin Pharmacol. 2005;61:769–73.

    Article  PubMed  Google Scholar 

  16. Spinewine A, Dumont C, Mallet L, Swine C. Medication appropriateness index: reliability and recommendations for future use. J Am Geriatr Soc. 2006;54:720–2.

    Article  PubMed  Google Scholar 

  17. Stuijt CC, Franssen EJ, Egberts AC, Hudson SA. Reliability of the medication appropriateness index in Dutch residential home. Pharm World Sci. 2009;31:380–6.

    Article  PubMed  Google Scholar 

  18. Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89:845–54.

    Article  CAS  PubMed  Google Scholar 

  19. Steinman MA, Rosenthal GE, Landefeld CS, Bertenthal D, Sen S, Kaboli PJ. Conflicts and concordance between measures of medication prescribing quality. Med Care. 2007;45:95–9.

    Article  PubMed  Google Scholar 

  20. Lund BC, Steinman MA, Chrischilles EA, Kaboli PJ. Beers criteria as a proxy for inappropriate prescribing of other medications among older adults. Ann Pharmacother. 2011;45:1363–70.

    Article  PubMed  Google Scholar 

  21. Luo R, Scullin C, Mullan AM, Scott MG, McElnay JC. Comparison of tools for the assessment of inappropriate prescribing in hospitalized older people. J Eval Clin Pract. 2012;18:1196–202.

    Article  PubMed  Google Scholar 

  22. Schmader KE, Hanlon JT, Landsman PB, Samsa GP, Lewis IK, Weinberger M. Inappropriate prescribing and health outcomes in elderly veteran outpatients. Ann Pharmacother. 1997;31:529–33.

    CAS  PubMed  Google Scholar 

  23. Lund BC, Carnahan RM, Egge JA, Chrischilles EA, Kaboli PJ. Inappropriate prescribing predicts adverse drug events in older adults. Ann Pharmacother. 2010;44:957–63.

    Article  PubMed  Google Scholar 

  24. Hanlon JT, Sloane RJ, Pieper CF, Schmader KE. Association of adverse drug reactions with drug–drug and drug–disease interactions in frail older outpatients. Age Ageing. 2011;40:274–7.

    Article  PubMed  Google Scholar 

  25. Olsson IN, Runnamo R, Engfeldt P. Medication quality and quality of life in the elderly, a cohort study. Health Qual Life Outcomes. 2011;9:95.

    Article  PubMed  Google Scholar 

  26. Hellström LM, Bondesson A, Höglund P, Midlöv P, Holmdahl L, et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011;67:741–52.

    Article  PubMed  Google Scholar 

  27. Somers A, Mallet L, van der Cammen T, Robays H, Petrovic M. Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients. Am J Geriatr Pharmacother. 2012;10:101–9.

    Article  PubMed  Google Scholar 

  28. Gillespie UM, Alassaad A, Hammarlund-Udenaes M, Mörlin C, Henrohn D, Bertilsson M, et al. Effects of pharmacists’ interventions on appropriateness of prescribing and evaluation of the instruments’ (MAI, STOPP and STARTs’) ability to predict hospitalization: analyses from a randomized controlled trial. Plos One. 2013;8:e62401.

    Article  CAS  PubMed  Google Scholar 

  29. Bregnhøj L, Thirstrup S, Kristensen MB, Bjerrum L, Sonne J. Combined intervention programme reduces inappropriate prescribing in elderly patients exposed to polypharmacy in primary care. Eur J Clin Pharmacol. 2009;65:199–207.

    Article  PubMed  Google Scholar 

  30. Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2:257–64.

    Article  PubMed  Google Scholar 

  31. Bryant LJ, Coster G, Gamble GD, McCormick RN. The General Practitioner–Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews. Int J of Pharm Pract. 2011;19(2):94–105.

    Article  Google Scholar 

  32. Burnett KM, Scott MG, Fleming GF, Clark CM, McElnay JC. Effects of an integrated medicines management program on medication appropriateness in hospitalized patients. Am J Health Syst Pharm. 2009;66:854–9.

    Article  PubMed  Google Scholar 

  33. Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33:612–7.

    Article  PubMed  Google Scholar 

  34. Schmader KE, Hanlon JT, Pieper CF, Sloane R, Ruby CM, Twersky J, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med. 2004;116:394–401.

    Article  PubMed  Google Scholar 

  35. Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized controlled trial. J Am Geriatr Soc. 2007;55:658–65.

    Article  PubMed  Google Scholar 

  36. Hanlon JT, Schmader KE. What types of inappropriate prescribing predict adverse drug reactions in older adults? Ann Pharmacother. 2010;44:1110–1.

    Article  PubMed  Google Scholar 

  37. Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse drug events in older people. BMC Geriatr. 2009;9:5.

    Article  PubMed  Google Scholar 

  38. Hamilton H, Gallagher P, Ryan C, Byrne S, O’Mahony D. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171:1013–9.

    Article  PubMed  Google Scholar 

  39. Hajjar ER, Hanlon JT, Sloane RJ, Lindblad CI, Pieper CF, Ruby CM, et al. Unnecessary drug use in the frail elderly at hospital discharge. J Am Geriatr Soc. 2005;53:1518–23.

    Article  PubMed  Google Scholar 

  40. Wright RM, Sloane RJ, Pieper CF, Ruby-Scelsi CM, Twersky J, Schmader KE, et al. Underuse of indicated medications among physically frail older US veterans at the time of hospital discharge. Am J Geriatr Pharmacother. 2009;7:271–80.

    Article  PubMed  Google Scholar 

  41. Volume CI, Burback LM, Farris KB. Reassessing the MAI: elderly persons opinions about medication appropriateness. Int J Pharm Pract. 1997;3:129–37.

    Google Scholar 

  42. Barber N, Bradley C, Barry C, Stevenson F, Britten N, Jenkins L. Measuring the appropriateness of prescribing in primary care: are current measures complete? J Clin Pharm Ther. 2005;30:533–9.

    Article  CAS  PubMed  Google Scholar 

  43. The American Geriatrics Society. Beers Criteria Update Expert Panel: American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;2012(60):616–31.

    Article  Google Scholar 

  44. Gallagher P, Ryan C, Byrne S, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert Doctors to Right Treatment): consensus validation. Int J Clin Pharm Ther. 2008;46:72–83.

    Article  CAS  Google Scholar 

  45. Holmes HM, Sachs GA, Shega JW, et al. Integrating palliative medicine into the care of persons with advanced dementia: identifying appropriate medication use. J Am Geriatr Soc. 2008;56:1306–11.

    Article  PubMed  Google Scholar 

  46. Suhrie EM, Hanlon JT, Jaffe EJ, Sevick MA, Ruby CM, Aspinall SL. Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. Am J Geriatr Pharmacother. 2009;7(1):20–5.

    Article  PubMed  Google Scholar 

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Acknowledgments

Supported in part by the National Institute on Aging Grants (R01-AG 027017, P30-AG024827, K07-AG033174, P30-AG028716), and an Agency for Healthcare Research and Quality Grant (R01-HS018721). The authors report no potential conflicts of interest.

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Correspondence to Joseph T. Hanlon.

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Hanlon, J.T., Schmader, K.E. The Medication Appropriateness Index at 20: Where It Started, Where It Has Been, and Where It May Be Going. Drugs Aging 30, 893–900 (2013). https://doi.org/10.1007/s40266-013-0118-4

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