Inappropriate Prescribing of Medication for Older Veterans
Dan R. Berlowitz MD MPH
Bedford VA Medical Center
Bedford, MA
Funding Period: October 2002 - September 2005

BACKGROUND/RATIONALE:
The explicit, expert consensus-based Beers criteria identified inappropriate medications for the elderly based on information that they had adverse effects that are particularly problematic for the elderly or had questionable efficacy. Despite these risks, studies indicate that 20% of older Americans receive at least one medication that is potentially inappropriate for the elderly (PIPE). The Veterans Health Administration (VHA) serves over one million older veterans, hence it is important to understand the magnitude of this problem. Accordingly, this study addressed three objectives

OBJECTIVE(S):
1: Describe the prevalence and patterns of PIPE in VA ambulatory care taking into consideration appropriate indications for use of PIPE drugs including diagnosis, dose, and duration of use.
2: Identify patients at greatest risk for PIPE in VA ambulatory care.
3: Describe variation of PIPE by facility and VISN and examine facility- and VISN-level characteristics associated with this variation.

METHODS:
The retrospective database study used information from existing VA outpatient, inpatient, and pharmacy databases, the American Hopsital Association database and Pharmacy Benefits Management documents. We also obtained indormation from VISN formulary leaders and clinical pharmacists to help understand findings from quantitative analyses.

Veterans who were 65 years of age October 1, 1999 and who had at least one outpatient visit in FY00 were included. We first identified patienst who received any medication identified by the Beers criteria, and operationalized indications for proper use of these drugs (specific diagnosis, dose, or duration of use) developed by the Agency for Health Research and Quality and criteria for geriatric dose limitations included in the Beers criteria. Older veterans who received a potentially inappropriate medication but who did not have evidence of proper use were classified as having inappropriate use. We determined the prevalence and patterns of inappropriate prescribing in FY00, and conducted multivariable logistic regression analyses to determine if patient characteristics or characteristics of care received were associated with inappropriate prescribing. We developed case-mix adjusted rates of inappropriate prescribing by facilty and used Hierarchical Bayesian Linear Models to determine if facility or VISN characteristics were associated with inappropriate prescribing.

FINDINGS/RESULTS:
Twenty-two percent of older veterans received inappropriate medications, and the duration of use was often prolonged. Patients with greater than or equal 10 medications or psychiatric comorbidities were most likely to receive inappropriate medications. Patients receiving geriatric care were least likely to recive inappropriate medications despite having more comorbidities and receiving more medications. Finally, there was substantial variation by facility (range 15%-48%). Over half of this variation was accounted for by VISN. While qualitative analyses did not reveal specific difference among high and low performers, futher analyses suggested that formulary restrictions account for part of the variation.

IMPACT:
A substanial number of older veterans received inappropriate medications in FY00, and exposure to these medications was long. Findings suggest that geriatric care may be an important component to reducing inappropriate prescribing for older veterans. However, research is needed to quantify the impact of inappropriate prescribing on patient outcomes and to understand the enormous variation that exists among facilities and VISNs.

PUBLICATIONS:

Journal Articles

1. Pugh MJ, Rosen AK, Montez-Rath M, Amuan ME, Fincke BG, Burk M, Bierman A, Cunningham F, Mortensen EM, Berlowitz DR. Potentially inappropriate prescribing for the elderly: effects of geriatric care at the patient and health care system level. Medical Care. 2008; 46(2): 167-73.
2. Bierman AS, Pugh MJ, Dhalla I, Amuan M, Fincke BG, Rosen AK, Berlowitz DR. Sex differences in inappropriate prescribing among elderly veterans. American Journal of Geriatric Pharmacotherapy. 2007; 5(2): 147-61.
3. Pugh MJ, Hanlon JT, Zeber JE, Bierman A, Cornell J, Berlowitz DR. Assessing potentially inappropriate prescribing in the elderly Veterans Affairs population using the HEDIS 2006 quality measure. Journal of Managed Care Pharmacy. 2006; 12(7): 537-45.
4. Pugh MJ, Fincke BG, Bierman AS, Chang BH, Rosen AK, Cunningham FE, Amuan ME, Burk ML, Berlowitz DR. Potentially inappropriate prescribing in elderly veterans: are we using the wrong drug, wrong dose, or wrong duration? Journal of The American Geriatrics Society. 2005; 53(8): 1282-9.
5. Pugh MJ, Cramer J, Knoefel J, Charbonneau A, Mandell A, Kazis L, Berlowitz D. Potentially inappropriate antiepileptic drugs for elderly patients with epilepsy. Journal of The American Geriatrics Society. 2004; 52(3): 417-22.

DRA: Aging and Age-Related Changes, Health Services and Systems
DRE: Quality of Care, Epidemiology
Keywords: Adverse events, Pharmaceuticals, Safety
MeSH Terms: none