Abstract
Background: Evidence-practice gaps, adverse medication-related incidents and unplanned medical admissions to hospital are common in elderly Australians. Many prescribing indicator tools designed to address some of these problems have been reported in the literature, the most common of which is the Beers list of inappropriate medications in the elderly. However, many of these tools are not appropriate for the Australian healthcare environment without modification and validation, and there appears to be a need for a tool based on Australian data.
Objective: To develop a list of prescribing indicators for elderly (aged >65 years) Australians based on the most frequent medications prescribed to Australians, and the most frequent medical conditions for which elderly Australians consult medical practitioners.
Method: The most common reasons for elderly Australians to seek or receive healthcare were cross-referenced with the 50 highest-volume Pharmaceutical Benefits Scheme medications prescribed to Australians in 2006 to develop prescribing indicators in the elderly using Australian medication and medical condition information resources.
Results: Forty-eight prescribing indicators were identified, consisting mainly of optimum as well as inappropriate medication choices for a large number of common medical conditions in the elderly.
Conclusion: A prescribing indicators tool was developed. This tool is envisaged as forming an important part of the medication review process, which is aimed at addressing the common problem of adverse medication-related events in elderly Australians.
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References
Commonwealth of Australia. The national strategy for quality use of medicines: plain English edition [online]. Available from URL: http://www.health.gov.au/internet/main/Publishing.nsf/Content/CA777524C860DFF2CA256F1800468B61/$File/natstrateng.pdf [Accessed 2008 Mar 27]
Australian Commission on Safety and Quality in Health Care. Charting the safety and quality of health care in Australia [online]. Available from URL: http://www.safetyandquality.org [Accessed 2008 Mar 27]
Roughead EE, Lexchin J. Adverse drug events: counting is not enough, action is needed. Med J Aust 2006; 184(7): 315–6
Harris MF, Zwar NA. Care of patients with chronic disease: the challenge for general practice. Med J Aust 2007; 187: 104–7
Miller GC, Britt HC, Valenti L. Adverse drug events in general practice patients in Australia. Med J Aust 2006; 184(7): 321–4
Chan M, Nicklason F, Vial JH. Adverse drug events as a cause of hospital admission in the elderly. Int Med J 2001; 31(4): 199–205
Pirmohamed M, James S, Meakin S, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329(7456): 15–9
Routledge PA, O’Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol 2004; 57(2): 121–6
Merle L, Laroche ML, Dantoine T, et al. Predicting and preventing adverse drug reactions in the very old. Drugs Aging 2005; 22(5): 375–92
Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther 2007; 32: 113–21
Elliott RA. Problems with medication use in the elderly: an Australian perspective. J Pharm Pract Res 2006; 36(1): 58–66
Burgess CL, Holman CD, Satti AG. Adverse drug reactions in older Australians, 1981–2002. Med J Aust 2005; 182(6): 267–70
Zhang M, Holman CD, Preen DB, et al. Repeat adverse drug reactions causing hospitalization in older Australians: a population-based longitudinal study 1980–2003. Br J Clin Pharmacol 2007; 63(2): 163–70
Buchan H. Turning knowledge into action. Australian Prescriber 2007; 30(5): 114–5
Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol 1992; 45(10): 1045–51
Lipton HL, Bero LA, Bird JA, et al. The impact of clinical pharmacists’ consultations on physicians’ geriatric drug prescribing: a randomized controlled trial. Med Care 1992; 30(7): 646–58
Lipton HL, Bird JA, Bero LA, et al. Assessing the appropriateness of physician prescribing for geriatric outpatients: development and testing of an instrument. J Pharm Technol 1993; 9(3): 107–13
Tamblyn RM, McLeod PJ, Abrahamowicz M, et al. Questionable prescribing for elderly patients in Quebec. CMAJ 1994; 150(11): 1801–9
Newton PF, Levinson W, Maslen D. The geriatric medication algorithm: a pilot study. J Gen Intern Med 1994; 9(3): 164–7
Oborne CA, Batty GM, Maskrey V, et al. Development of prescribing indicators for elderly medical inpatients. Br J Clin Pharmacol 1997; 43(1): 91–7
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly: an update. Arch Intern Med 1997; 157(14): 1531–6
McLeod PJ, Huang AR, Tamblyn RM, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997; 156(3): 385–91
Parkes AJ, Coper LC. Inappropriate use of medications in the veteran community: how much do doctors and pharmacists contribute? Aust N Z J Public Health. 1997; 21(5): 469–76
Brown NJ, Griffin MR, Ray WA, et al. A model for improving medication use in home health care patients. J Am Pharm Assoc (Wash) 1998; 38(6): 696–702
NSW Therapeutic Assessment Group. Manual of indicators for drug use in Australian hospitals [online]. Available from URL: http://www.ciap.health.nsw.gov.au/nswtag/publications/otherdocs/Manual%20of%20Indicators.pdf [Accessed 2008 Mar 27]
Knight EL, Avorn J. Quality indicators for appropriate medication use in vulnerable elders. Ann Intern Med 2001; 135 (8 Pt 2): 703-10
Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA 2001; 286(22): 2823–9
Mackinnon NJ, Hepler CD. Preventable drug-related morbidity in older adults: 1. Indicator development. J Manag Care Pharm 2002; 8(5): 365–71
Robertson HA, MacKinnon NJ. Development of a list of consensus-approved clinical indicators of preventable drug-related morbidity in older adults. Clin Ther 2002; 24(10): 1595–613
Morris CJ, Cantrill JA, Hepler CD, et al. Preventing drug-related morbidity: determining valid indicators. Int J Qual Health Care 2002; 14(3): 183–98
Morris CJ, Cantrill J. Preventing drug-related morbidity: the development of quality indicators. J Clin Pharm Ther 2003; 28(4): 295–305
Hajjar ER, Hanlon JT, Artz MB, et al. Adverse drug reaction risk factors in older outpatients. Am J Geriatr Pharmacotherapy 2003; 1(2): 82–9
Evidence-practice gaps report. Vol. 1. Melbourne (VIC): National Institute of Clinical Studies, 2003 [online]. Available from URL: http://www.nhmrc.gov.au/nics/asp/index.asp?page=materials/materials_year_article&cid=5212&id=406 [Accessed 2008 Jul 18]
Evidence-practice gaps report. Vol. 2. Melbourne (VIC): National Institute of Clinical Studies, 2005 [online]. Available from URL: http://www.nhmrc.gov.au/nics/asp/index.asp?page=materials/materials_year_article&cid=5212&id=405 [Accessed 2008 Jul 18]
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 Int Med 2003; 163(22): 2716–24
Byles JE, Heinze R, Nair BK, et al. Medication use among older Australian veterans and war widows. Int Med J 2003; 33(8): 388–92
Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med 2004; 140(9): 714–20
Tully MP, Cantrill JA. The validity of explicit indicators of prescribing appropriateness. Int J Qual Health Care 2006; 18(2): 87–94
Okechukwu I, Bennett K, Feely J. General practitioners’ ranking of evidence-based prescribing quality indicators: a comparative study with a prescription database. Br J Clin Pharmacol 2006; 62(2): 218–24
National Prescribing Service. Indicators of quality prescribing in Australian general practice: a manual for users [online]. Available from URL: http://www.nps.org.au/resources/quality_prescribing_indicators/indicators_full.pdf [Accessed 2008 Mar 27]
Allenet B, Bedouch P, Rose FX, et al. Validation of an instrument for the documentation of clinical pharmacists’ interventions. Pharm World Sci 2006; 28(4): 181–8
Laroche ML, Charmes JP, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 2007; 63: 725–31
Naugler CT, Brymer C, Stolee P, et al. Development and validation of an improving prescribing in the elderly tool. Can J Clin Pharmacol 2000; 7(2): 103–7
Elliott RA, Woodward MC, Oborne CA. Indicators of prescribing quality for elderly hospital inpatients. Aust J Hosp Pharm 2001; 31(1): 19–25
Gallagher P, Ryan C, Byrne S, et al. 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 2008; 46(2): 72–83
Beers MH, Ouslander JG, Rollingher I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents: UCLA Division of Geriatric Medicine. Arch Intern Med 1991; 151(9): 1825–32
O’Halloran J, Britt H, Valenti L, et al. Older patients attending general practice in Australia 2000–02: General Practice Series no. 12, General Practice Statistics and Classification Unit [online]. Canberra (ACT): Australian Institute of Health and Welfare, 2003: 1–147. Available from URL: http://www.aihw.gov.au/publications/gep/opagpa/opagpa00-02.pdf [Accessed 2008 Mar 27]
Australian Institute of Health and Welfare. Australia’s health 2006: report no.: AIHW cat. no. AUS 73. Canberra (ACT): AIHW, 2006
Department of Health and Ageing, Australian Government. Expenditure and prescriptions twelve months to 30 June 2006 [online]. Available from URL: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/A58720844CBFCB47CA257218000D91C7/$File/complete.pdf [Accessed 2008 Mar 27]
Rossi S, editor. Australian medicines handbook 2008. Adelaide (SA): Australian Medicines Handbook Pty Ltd, 2008
Australian medicines handbook drug choice companion: aged care. 2nd ed. Adelaide (SA): Australian Medicines Handbook Pty Ltd, 2006
Therapeutic Goods Administration. Australian adverse drug reactions bulletin [online]. Available from URL: http://www.tga.gov.au/adr/aadrb.htm [Accessed 2008 Mar 27]
eTG complete [CD-ROM]. Melbourne (VIC): Therapeutic Guidelines, 2006 Jan
National Prescribing Service Limited. Prescribing practice review [online]. Available from URL: http://www.nps.org.au/site.php?.page=1&content=/html/resource.php&id=8 [Accessed 2008 Mar 27]
National Prescribing Service Limited. National Prescribing Service newsletter [online]. Available from URL: http://www.np-s.org.au/site.php?.page=1&content=/html/resource.php&id=7 [Accessed 2008 Mar 27]
Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet 2007; 370: 185–91
The Australian pharmaceutical formulary and handbook. 20th ed. Canberra (ACT): The Pharmaceutical Society of Australia, 2006
Medicines and older people: an accident waiting to happen? National Prescribing Service newsletter 34, National Prescribing Service Limited; 2004 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/news.php&news=/resources/NPS_News/news34 [Accessed 2008 Jun 12]
Managing dyslipidaemia. Prescribing Practice Review 17, National Prescribing Service Limited; 2002 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr17 [Accessed 2008 Jul 16]
Reducing risk in type 2 diabetes. Prescribing Practice Review 29, National Prescribing Service Limited; 2005 [online]. Available from URL: http://www.nps.org.au/site.php?con-tent=/html/ppr.php&ppr=/resources/Prescribing_Practice_R-eviews/ppr29 [Accessed 2008 Jul 16]
Ischaemic heart disease. Prescribing Practice Review 31, National Prescribing Service Limited; 2005 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr31 [Accessed 2008 Jul 16]
Treating dyslipidaemia. NPS News 20, National Prescribing Service Limited; 2002 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/news.php&news=/re-sources/NPS_News/news20 [Accessed 2008 Jul 16]
Targeting ischaemic heart disease: improving health outcomes with multiple medications. NPS News 41, National Prescribing Service Limited; 2005 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/news.php&news=/resources/NPS_News/news41 [Accessed 2008 Jul 16]
Amabile CM, Spencer AP. Keeping your patients with heart failure safe: a review of potentially dangerous medications. Arch Intern Med 2004; 164: 709–20
Improving outcomes for heart failure patients. Prescribing Practice Review 28, National Prescribing Service Limited; 2004 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr28 [Accessed 2008 Jul 16]
Risk factors for myopathy and rhabdomyolysis with the statins. Australian Adverse Drug Reactions Bulletin 2004; 23(1) [online]. Available from URL: http://www.tga.gov.au/adr/aadrb/aadr0402.htm [Accessed 2008 Jul 16]
Analgesic choices in persistent pain. Prescribing Practice Review 35, National Prescribing Service Limited; 2006 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr35 [Accessed 2008 Jul 16]
Proton pump inhibitors. NPS News 46, National Prescribing Service Limited; 2006 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/news.php&news=/resources/NPS_News/news46 [Accessed 2008 Jul 16]
Maintaining bone health to prevent osteoporotic fractures. NPS News 53, National Prescribing Service Limited; 2007 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/news.php&news=/resources/NPS_News/news53 [Accessed 2008 Jul 16]
Preventing osteoporosis and reducing fracture risk. Prescribing Practice Review 39, National Prescribing Service Limited; 2007 [online]. Available from URL: http://www.nps.org.au/site.php?content=/html/ppr.php&ppr=/resources/Prescribing_Practice_Reviews/ppr39 [Accessed 2008 Jul 16]
Beware the triple whammy! Australian Adverse Medication Reactions Bulletin 2006; 25(5) [online]. Available from URL: http://www.tga.gov.au/adr/aadrb/aadr0610.htm [Accessed 2008 Jul 18]
McGavock H. Prescription-related illness: a scandalous pandemic. J Eval Clin Pract 2004; 10(4): 491–7
Jano E, Aparasu RR. Healthcare outcomes associated with Beers’ criteria: a systematic review. Ann Pharmacother 2007; 41(3): 438–47
Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc 2001; 49(2): 200–9
Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 2007; 370: 173–84
Shelton PS, Fritsch MA, Scott MA. Assessing medication appropriateness in the elderly: a review of available measures. Drugs Aging 2000; 16(6): 437–50
Department of Health and Ageing, Australian Government. Home medicines review [online]. Available from URL: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmr.htm/$FILE/homereview.pdf [Accessed 2008 Mar 27]
Stowasser DA, Allinson YM, O’Leary KM. Understanding the medicines management pathway. J Pharm Pract Res 2004; 34: 293–6
NSW Therapeutic Advisory Group. Indicators for quality use of medicines in Australian hospitals [online]. Available from URL: http://www.ciap.health.nsw.gov.au/nswtag/publications/QUMIndicators/Manual.pdf [Accessed 2008 Mar 28]
King MA, Roberts MS. The influence of the Pharmaceutical Benefits Scheme (PBS) on inappropriate prescribing in Australian nursing homes. Pharm World Sci 2007; 29: 39–42
Sloane PD, Zimmerman S, Brown LC, et al. Inappropriate medication prescribing in residential care/assisted living facilities. J Am Geriatr Soc 2002; 50(6): 1001–11
Gray SL, Hedrick SC, Rhinard EE, et al. Potentially inappropriate medication use in community residential care facilities. Ann Pharmacother 2003; 37(7–8): 988–93
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
O’Mahony D, Gallagher PF. Inappropriate prescribing in the older population: need for new criteria. Age Ageing 2008; 37: 138–41
Sorensen L, King MA, Peck R, et al. In-home medication reviews for war veterans: early experience in Australia. J Pharm Pract Res 2004; 34(2): 122–4
Roughead EE, Anderson B, Gilbert AL. Potentially inappropriate prescribing among Australian veterans and war widows/widowers. Int Med J 2007; 37: 402–5
Elliott RA, Woodward MC, Oborne CA. Antithrombotic prescribing in atrial fibrillation: application of a prescribing indicator and multidisciplinary feedback to improve prescribing. Age Ageing 2002; 31: 391–6
Elliott RA, Woodward MC, Oborne CA. Quality of prescribing for elderly inpatients at nine hospitals in Victoria, Australia. J Pharm Pract Res 2003; 33(2): 101–5
Department of Health and Ageing, Commonwealth of Australia. Australian statistics on medicines 2003 [online]. Available from URL: http://www.health.gov.au/internet/wcms/publishing.nsf/Content/872454E0BDD67CA5CA257110000A95FD/$File/Stats%20on%20Medicines.pdf [Accessed 2008 Mar 27]
Thompson PD, Clarkson P, Karas RH. Statin-associated myopathy. JAMA 2003; 289: 657–9
Hilmer SN. The dilemma of polypharmacy. Australian Prescriber 2008; 31(1): 2–3
Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment): an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing 2007; 36: 632–8
Adverse Drug Reactions Advisory Committee (ADRAC). Evidence-based medicine: pitfalls of overlooking safety. Australian Adverse Drug Reactions Bulletin 2005; 24(2) [online]. Available from URL: http://www.tga.gov.au/adr/aadrb/aadr0504.htm#a4 [Accessed 2008 Jun 12]
Guthrie B, Inkster M, Fahey T. Tackling therapeutic inertia: role of treatment data in quality indicators. BMJ 2007; 335(7619): 542–4
Swagerty D, Brickley R; American Medical Directors Association; American Society of Consultant Pharmacists. American Medical Directors Association and American Society of Consultant Pharmacists joint position statement on the Beers List of Potentially Inappropriate Medications in Older Adults. J Am Med Dir Assoc 2005; 6(1): 80–6
Chutka DS, Takahashi PY, Hoel RW. Inappropriate medications for elderly patients. Mayo Clinic Proc 2004; 79: 122–39
Acknowledgements
Research funds were provided by Medibank Australia Private Health Fund (Medibank). Medibank were not involved in any aspect of the design and conduct of the study; collection, management, analysis or interpretation of the data; or preparation, review or approval of the manuscript.
Timothy Chen has received honoraria from Pfizer, AstraZeneca, Merck, Sharp and Dohme, and Mundipharma. The other authors have no conflicts of interest that are directly relevant to the content of this article.
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Basger, B.J., Chen, T.F. & Moles, R.J. Inappropriate Medication Use and Prescribing Indicators in Elderly Australians. Drugs Aging 25, 777–793 (2008). https://doi.org/10.2165/00002512-200825090-00004
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DOI: https://doi.org/10.2165/00002512-200825090-00004