High risk prescribing in older adults: prevalence, clinical and economic implications and potential for intervention at the population level

BMC Public Health

Emily Banks²  Grace Joshy⁴  Fiona M Blyth¹  Sarah N Hilmer¹  Rosalie Viney⁵  Andrew J McLachlan⁶  Sallie-Anne Pearson⁷  David G Le Couteur³  Danijela Gnjidic¹ 

[1] Sydney Medical School, University of Sydney, Sydney, NSW, Australia;Sax Institute, Sydney, NSW, Australia;ANZAC Institute, Concord Hospital, Sydney, NSW, Australia;National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia;Centre for Health Economics Research & Evaluation, University of Technology, Sydney, NSW, Australia;Centre for Education and Research on Ageing and Concord RG Hospital, Sydney, NSW, Australia;Faculty of Pharmacy, University of Sydney, Bank Building A15, Science Rd, Sydney, NSW, Australia

关键词: Older adults;    Costs;    Clinical outcomes;    Prevalence;    High-risk prescribing;   

Others  :  1162564
DOI  :  10.1186/1471-2458-13-115

 received in 2013-01-07, accepted in 2013-02-01,  发布年份 2013

【 摘 要 】

Background

High risk prescribing can compromise independent wellbeing and quality of life in older adults. The aims of this project are to determine the prevalence, risk factors, clinical consequences, and costs of high risk prescribing, and to assess the impact of interventions on high risk prescribing in older people.

Methods

The proposed project will utilise data from the 45 and Up Study, a large scale cohort of 267,153 men and women aged 45 and over recruited during 2006–2009 from the state of New South Wales, Australia linked to a range of administrative health datasets. High risk prescribing will be assessed using three indicators: polypharmacy (use of five or more medicines); Beers Criteria (an explicit measure of potentially inappropriate medication use); and Drug Burden Index (a pharmacologic dose-dependent measure of cumulative exposure to anticholinergic and sedative medicines). Individual risk factors from the 45 and Up Study questionnaire, and health system characteristics from health datasets that are associated with the likelihood of high risk prescribing will be identified. The main outcome measures will include hospitalisation (first admission to hospital, total days in hospital, cause-specific hospitalisation); admission to institutionalised care; all-cause mortality, and, where possible, cause-specific mortality. Economic costs to the health care system and implications of high risk prescribing will be also investigated. In addition, changes in high risk prescribing will be evaluated in relation to certain routine medicines-related interventions. The statistical analysis will be conducted using standard pharmaco-epidemiological methods including descriptive analysis, univariate and multivariate regression analysis, controlling for relevant confounding factors, using a number of different approaches.

Discussion

The availability of large-scale data is useful to identify opportunities for improving prescribing, and health in older adults. The size of the 45 and Up Study, along with linkage to health databases provides an important opportunity to investigate the relationship between high risk prescribing and adverse outcomes in a real-world population of older adults.

【 授权许可】

   
2013 Gnjidic et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Hilmer SN, Gnjidic D: The effects of polypharmacy in older adults. Clin Pharmacol Ther 2009, 85(1):86-88.
• [2]Hilmer SN, Gnjidic D, Abernethy DR: Pharmacoepidemiology in the postmarketing assessment of the safety and efficacy of drugs in older adults. J Gerontol A Biol Sci Med Sci 2012, 67(2):181-188.
• [3]McLean AJ, Le Couteur DG: Aging biology and geriatric clinical pharmacology. Pharmacol Rev 2004, 56(2):163-184.
• [4]Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J: A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012, 196(1):50-53.
• [5]Gnjidic D, Hilmer SN, Blyth F, Naganathan V, Cumming RG, Handelsman D, McLachlan AJ, Abernethy DR, Banks E, Le Couteur DG: High risk prescribing and incidence of frailty among older community-dwelling men. Clin Pharmacol Ther 2012, 91:521-528.
• [6]Jyrkka J, Enlund H, Lavikainen P, Sulkava R, Hartikainen S: Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf 2011, 20(5):514-522.
• [7]Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH: Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med 2003, 163(22):2716-2724.
• [8]American geriatrics society updated beers criteria for potentially inappropriate medication use in older adults J Am Geriatr Soc 2012, 60(4):616-631.
• [9]Aparasu RR, Mort JR: Inappropriate prescribing for the elderly: beers criteria-based review. Ann Pharmacother 2000, 34(3):338-346.
• [10]Opondo D, Eslami S, Visscher S, de Rooij SE, Verheij R, Korevaar JC, Abu-Hanna A: Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review. PLoS One 2012, 7(8):e43617.
• [11]Hilmer SN, Mager DE, Simonsick EM, Cao Y, Ling SM, Windham BG, Harris TB, Hanlon JT, Rubin SM, Shorr RI, et al.: A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007, 167(8):781-787.
• [12]Gnjidic D, Cumming RG, Le Couteur DG, Handelsman DJ, Naganathan V, Abernethy DR, Hilmer SN: Drug burden index and physical function in older Australian men. Br J Clin Pharmacol 2009, 68(1):97-105.
• [13]Wilson NM, Hilmer SN, March LM, Cameron ID, Lord SR, Seibel MJ, Mason RS, Chen JS, Cumming RG, Sambrook PN: Associations between Drug Burden Index and falls in older people in residential aged care. J Am Geriatr Soc 2011, 59(5):875-880.
• [14]Hilmer SN, Mager DE, Simonsick EM, Ling SM, Windham BG, Harris TB, Shorr RI, Bauer DC, Abernethy DR: Drug burden index score and functional decline in older people. Am J Med 2009, 122(12):1142-1149. e1142
• [15]Gnjidic D, Le Couteur DG, Abernethy DR, Hilmer SN: Drug burden index and beers criteria: impact on functional outcomes in older people living in self-care retirement villages. J Clin Pharm 2012, 52:258-265.
• [16]Gnjidic D, Bell JS, Hilmer SN, Lonnroos E, Sulkava R, Hartikainen S: Drug burden index associated with function in community dwelling older people living in finland: a cross-sectional study. Ann Med 2012, 44:458-467.
• [17]Gnjidic D, Hilmer S, Le Couteur D: High risk prescribing in older adults: more harm than good? Aging Health 2012, 8(4):325-327.
• [18]Lonnroos E, Gnjidic D, Hilmer SN, Bell JS, Kautiainen H, Sulkava R, Hartikainen S: Drug burden index and hospitalization among community-dwelling older people. Drugs Aging 2012, 29(5):395-404.
• [19]Lowry E, Woodman RJ, Soiza RL, Hilmer SN, Mangoni AA: Drug burden index, physical function, and adverse outcomes in older hospitalized patients. J Clin Pharmacol 2012, 52(10):1584-1591.
• [20]Nishtala PS, McLachlan AJ, Bell JS, Chen TF: Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions. Am J Geriatr Psychiatry 2008, 16(8):621-632.
• [21]Crotty M, Halbert J, Rowett D, Giles L, Birks R, Williams H, Whitehead C: An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing 2004, 33(6):612-617.
• [22]Patterson SM, Hughes C, Kerse N, Cardwell CR, Bradley MC: Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev 2012, 5:CD008165.
• [23]Iyer S, Naganathan V, McLachlan AJ, Le Couteur DG: Medication withdrawal trials in people aged 65 years and older: a systematic review. Drugs Aging 2008, 25(12):1021-1031.
• [24]Gnjidic D, Le Couteur DG, Kouladjian L, Hilmer SN: Deprescribing trials: methods to reduce polypharmacy and the impact on prescribing and clinical outcomes. Clin Geriatr Med 2012, 28:237-253.
• [25]Banks E, Redman S, Jorm L, Armstrong B, Bauman A, Beard J, Beral V, Byles J, Corbett S, Cumming R, et al.: Cohort profile: the 45 and up study. Int J Epidemiol 2008, 37(5):941-947.
• [26]Medicare Australia. http://www.medicareaustralia.gov.au/ webcite
• [27]Australian Bureau of Statistics: National Health Survey 2004–05: Summary of results, cat. no. 4364.0. Canberra: ABS; 2006.
• [28]Aged Care and Community Care Management Information System. http://www.abs.gov.au/AUSSTATS/abs@.nsf/7d12b0f6763c78caca257061001cc588/618db0ee74d3d00cca2573b4001188ad!OpenDocument webcite
• [29]National Death Index. http://www.aihw.gov.au/national-death-index/ webcite
• [30]Admitted Patient Data Collection. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/1368.1Explanatory%20Notes1452007?opendocument&tabname = Notes&prodno = 1368.1&issue = 2007&num = &view= webcite
• [31]Choicemaker (software) ChoiceMaker Technologies. USA: New York; 2006.
• [32]Gnjidic D, Hilmer SN, Blyth F, Naganathan V, Waite L, Seibel MJ, McLachlan AJ, Cumming RG, Handelsman D, Le Couteur DG: Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiology 2012, 65:989-995.
• [33]Pearson SA, Ringland C, Kelman C, Mant A, Lowinger J, Stark H, Nichol G, Day R, Henry D: Patterns of analgesic and anti-inflammatory medicine use by Australian veterans. Intern Med J 2007, 37(12):798-805.
• [34]WHO Collaborating Centre for Drug Statistics Methodology: The Anatomical Therapeutic Chemical Classification System. Norwegian Institute of Public Health; Available at: http://www.whocc.no/atcddd/ webcite
• [35]Home Medicines Review. http://www.medicareaustralia.gov.au/provider/pbs/fourth-agreement/hmr.jsp webcite
• [36]Chronic Disease Managament Medicare Item. http://www.health.gov.au/internet/main/publishing.nsf/content/mbsprimarycare-chronicdiseasemanagement webcite
• [37]Ponsonby AL, Dwyer T, Couper D: Is this finding relevant? Generalisation and epidemiology. Aust N Z J Public Health 1996, 20(1):54-56.
• [38]Manolio TA, Collins R: Enhancing the feasibility of large cohort studies. JAMA 2010, 304(20):2290-2291.
• [39]Mealing NM, Banks E, Jorm LR, Steel DG, Clements MS, Rogers KD: Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs. BMC Med Res Methodol 2010, 10:26. BioMed Central Full Text
• [40]Doll R, Peto R, Wheatley K, Gray R, Sutherland I: Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994, 309(6959):901-911.