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Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy

A Population-Based Cohort Study

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Abstract

Background

In the US, a growing body of epidemiological studies has documented widespread potentially inappropriate medication prescribing among the elderly in outpatient settings. However, only limited information exists in Europe.

Objective

To evaluate the prevalence of potentially inappropriate medication prescribing among elderly outpatients in Emilia Romagna, Italy and to investigate factors associated with potentially inappropriate medication prescribing in that setting.

Methods

Retrospective cohort study using the Emilia Romagna outpatient prescription claims database from 1 January 2001 to 31 December 2001 linked with information (age, sex and other variables) available from a demographic file of approximately 1 million Emilia Romagna residents aged ≥65 years. The cohort comprised 849 425 elderly patients who had at least one drug prescription during the study period. The prevalence of potentially inappropriate medication prescribing, as defined by the 2002 Beers’ criteria, was measured together with predictors associated with potentially inappropriate medication prescribing.

Results

A total of 152 641 (18%) elderly Emilia Romagna outpatients had one or more occurrences of potentially inappropriate medication prescribing. Of these, 11.5% received prescriptions for two medications of concern and 1.7% for three or more. Doxazosin (prescribed to 23% of subjects) was the most frequently occurring potentially inappropriate prescribed medication, followed by ketorolac (20.5%), ticlopidine (18.3%) and amiodarone (12.6%). Factors associated with greater likelihood of potentially inappropriate medication prescribing were older age, overall number of drugs prescribed and greater number of chronic conditions. The odds of receiving potentially inappropriate prescribed medications were lower for females, subjects living in more urban areas and subjects with a higher income level.

Conclusions

This study provides strong evidence that potentially inappropriate medication prescribing for elderly outpatients is a substantial problem in Emilia Romagna. Focusing on the prevalence of potentially inappropriate medication prescribing and associated predictors can help in the development of educational programmes targeting outpatient practitioners to influence prescribing behaviour and, therefore, reduce potentially inappropriate medication prescribing.

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Notes

  1. As defined in the Beers’ criteria, ferrous sulphate should not exceed a dosage of 325 mg/day because constipation is likely to occur in the elderly with a higher dose. Ferrous sulphate is sold in Italy as Ferrograd® (the use of trade names is for product identification purposes only and does not imply endorsement) [Abbott S.p.A], which contains 40 tablets of 525mg (the tablets are not divisible). Although no specific information on the daily dose taken by a patient was available in the database, each tablet of ferrous sulphate itself potentially exceeds Beers’ criterion for this drug. We felt, therefore, that for purpose of this study, ferrous sulphate should be considered as a drug to be avoided in the elderly, especially because safer iron supplements are available through the Italian National Formulary.

  2. The following medications were excluded because they were not reimbursed by the Italian National Formulary in 2001: propoxyphene, oxybutynin, flurazepam, meprobamate, lorazepam, oxazepam, alprazolam, temazepam, triazolam, dipyridamole, reserpine, clinidium-chlordiazepoxide, chlorpheniramine, diphenhydramine, hydroxyzine, cyproheptadine, promethazine, ergot mesyloids, cyclandelate, meperidine (pethidine), laxatives and mineral oil.

  3. In Emilia Romagna, plain locations are more likely to be associated with urban areas, whereas hill or mountain locations are more likely to be associated with rural areas.

  4. A commune is the smallest administrative district.

  5. Our analysis confirmed that the two measures do indeed measure somewhat different independent effects (see Results section and the table for the multivariable logistical regression analysis in that section) and that there is no evidence of multicollinearity. Multicollinearity leads to inflated variance estimates. If multicollinearity were a problem, we would have seen unusually large coefficient standard errors and removing one of the two variables would have lowered the size of the remaining standard errors. This did not happen in our regressions. Moreover, the fact that in our most comprehensive logistical regression model the CCDG score was still statistically significant after controlling for the number of medications suggests that the individual’s severity of disease — at least as measured by the CCDG score — was associated with inappropriate medication prescribing.

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Acknowledgements

This research was supported through a collaborative agreement between the Regional Health Care Agency, Assessorato alla Sanità, Emilia Romagna, Italy and Jefferson Medical College, Philadelphia, PA, USA. Dr Maio had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

We thank Carol Rabinowitz for assistance with data management and analysis. We thank Francesco Taroni, MD, Andrea Donatini, MS, Lucia Nobilio, BS, and Sabine Mall, BS, from the Regional Health Care Agency, Emilia Romagna, Bologna, Italy for providing the data and for assistance with data management.

The authors have no conflicts of interest of direct relevance to the contents of this study.

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Authors and Affiliations

  1. Jefferson Medical College, Philadelphia, Pennsylvania, USA

    Vittorio Maio, Elaine J. Yuen, Karen Novielli, Kenneth D. Smith & Daniel Z. Louis

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  1. Vittorio Maio
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  2. Elaine J. Yuen
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  3. Karen Novielli
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  5. Daniel Z. Louis
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Correspondence to Vittorio Maio.

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Maio, V., Yuen, E.J., Novielli, K. et al. Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy. Drugs Aging 23, 915–924 (2006). https://doi.org/10.2165/00002512-200623110-00006

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