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Prescribing Quality in Older Veterans: A Multifocal Approach

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ABSTRACT

BACKGROUND AND OBJECTIVE

Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults.

DESIGN AND PARTICIPANTS

Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans Affairs (VA) pharmacies in 2007.

MAIN MEASURES

Using VA pharmacy data linked with encounter, laboratory and other data, we assessed five types of prescribing problems.

KEY RESULTS

Among 462,405 patients age 65 and older, mean age was 75 years, 98 % were male, and patients were prescribed a median of five medications. Half of patients (50 %) had one or more prescribing problems, including 12 % taking one or more medications at an inappropriately high dose, 30 % with drug–drug interactions, 3 % with drug–disease interactions, and 26 % taking one or more Beers criteria drugs. In addition, 16 % were taking a high-risk drug (warfarin, insulin, and/or digoxin). On multivariable analysis, age was not strongly associated with four of the five types of prescribing issues assessed (relative risk < 1.3 across age groups), and comorbid burden conferred substantially increased risk only for drug–disease interactions and use of high-risk drugs. In contrast, the number of drugs used was consistently the strongest predictor of prescribing problems. Patients in the highest quartile of medication use had 6.6-fold to12.5-fold greater risk of each type of prescribing problem compared to patients in the lowest quartile (P < 0.001 for each).

CONCLUSIONS

The number of medications used is by far the strongest risk factor for each of five types of prescribing problems. Efforts to improve prescribing should especially target patients taking multiple medications.

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Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author Contributions

Study conception and design: Steinman, Schwartz, Boscardin

Data acquisition: Miao, Steinman, Boscardin

Analyses: Miao, Steinman, Boscardin, Komaiko

Authorship of manuscript: Steinman, Komaiko

Review for critical intellectual content: Miao, Komaiko, Boscardin, Schwartz

Funding and supervision: Steinman, Schwartz

Sponsorship

Supported by the National Institute of Aging and by the American Federation for Aging Research (RC1-AG036377 and 1 K23-AG030999). The funders had no role in the design, analysis, authorship, or decision to publish the research described in this manuscript.

Support for VA/CMS data is provided by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development, VA Information Resource Center (Project Numbers SDR 02-237 and 98-004).

Prior Presentation at National Meetings

None.

Author information

Authors and Affiliations

  1. Division of Geriatrics, University of California, San Francisco, 4150 Clement St, VA Box 181G, San Francisco, CA, 94141, USA

    Michael A. Steinman MD, Yinghui Miao MPH, W. John Boscardin PhD, Kiya D. R. Komaiko BA & Janice B. Schwartz MD

  2. San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA

    Michael A. Steinman MD, Yinghui Miao MPH, W. John Boscardin PhD & Kiya D. R. Komaiko BA

  3. Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, USA

    W. John Boscardin PhD

  4. The Jewish Home of San Francisco, San Francisco, CA, 94112, USA

    Janice B. Schwartz MD

Authors
  1. Michael A. Steinman MD
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  2. Yinghui Miao MPH
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  3. W. John Boscardin PhD
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  4. Kiya D. R. Komaiko BA
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  5. Janice B. Schwartz MD
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Corresponding author

Correspondence to Michael A. Steinman MD.

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Steinman, M.A., Miao, Y., Boscardin, W.J. et al. Prescribing Quality in Older Veterans: A Multifocal Approach. J GEN INTERN MED 29, 1379–1386 (2014). https://doi.org/10.1007/s11606-014-2924-8

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  • DOI: https://doi.org/10.1007/s11606-014-2924-8

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