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      Potentially Inappropriate Medication Use in Older Patients in Swiss Managed Care Plans: Prevalence, Determinants and Association with Hospitalization

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          Abstract

          Objectives

          To describe the prevalence and determinants of potentially inappropriate medication (PIM) use and association with hospitalizations in an elderly managed care population in Switzerland.

          Methods

          Using health care claims data of four health insurers for a sample of managed care patients 65 years of age and older to compare persons on PIM with persons not on PIM. Beers' 2012 and PRISCUS criteria were used to determine the potential inappropriateness of prescribed medications. The sample included 16′490 elderly patients on PIM and 33′178 patients not on PIM in the time period of January 1, 2008 through December 31, 2012. Prevalence estimates are standardized to the population of Switzerland. Associations between PIM and hospitalizations were examined by multivariate Cox regression analyses controlling for possible confounding variables.

          Results

          The estimated prevalence of PIM use in our managed care sample was 22.5%. Logistic regression analysis showed that number of different medications used in the previous year, total costs in the previous year and hospitalization in the previous year all significantly increased the likelihood of receiving PIM. Multiple Cox regression analysis revealed that those on cumulative levels of PIM use acted significantly as a factor related to greater hospitalization rates: the adjusted HR was 1.13 (95% CI 1.07–1.19) for 1 PIM, 1.27 (95% CI 1.19–1.35) for 2 PIM, 1.35 (95% CI 1.22–1.50) for 3 PIM, and 1.63 (95% CI 1.40–1.90) for more than 3 PIM compared to no PIM use.

          Conclusions

          The prevalence of PIM in managed care health plans are widely found but seem to be much lower than rates of non-managed care plans. Furthermore, our study revealed a significant association with adverse outcomes in terms of hospitalizations. These findings stress the need for further development of interventions to decrease drug-related problems and manage patients with multiple chronic conditions.

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          Most cited references37

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          Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts.

          Donna M Fick, James W. Cooper, William Wade … (2003)
          Medication toxic effects and drug-related problems can have profound medical and safety consequences for older adults and economically affect the health care system. The purpose of this initiative was to revise and update the Beers criteria for potentially inappropriate medication use in adults 65 years and older in the United States. This study used a modified Delphi method, a set of procedures and methods for formulating a group judgment for a subject matter in which precise information is lacking. The criteria reviewed covered 2 types of statements: (1) medications or medication classes that should generally be avoided in persons 65 years or older because they are either ineffective or they pose unnecessarily high risk for older persons and a safer alternative is available and (2) medications that should not be used in older persons known to have specific medical conditions. This study identified 48 individual medications or classes of medications to avoid in older adults and their potential concerns and 20 diseases/conditions and medications to be avoided in older adults with these conditions. Of these potentially inappropriate drugs, 66 were considered by the panel to have adverse outcomes of high severity. This study is an important update of previously established criteria that have been widely used and cited. The application of the Beers criteria and other tools for identifying potentially inappropriate medication use will continue to enable providers to plan interventions for decreasing both drug-related costs and overall costs and thus minimize drug-related problems.
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            Aging biology and geriatric clinical pharmacology.

            Allan J McLean, David Le Couteur (2004)
            Population aging evokes doomsday economic and sociological prognostication, despite a minority of older people suffering significant dependency and the potential for advances in therapeutics of age-related disease and primary aging. Biological aging processes are linked mechanistically to altered drug handling, altered physiological reserve, and pharmacodynamic responses. Parenteral loading doses need only be adjusted for body weight as volumes of distribution are little changed, whereas oral loading doses in some cases may require reduction to account for age-related increases in bioavailability. Age-related reduction of hepatic blood flow and hepatocyte mass and primary aging changes in hepatic sinusoidal endothelium with effects on drug transfer and oxygen delivery reduce hepatic drug clearance. Primary renal aging is evident, although renal clearance reduction in older people is predominantly disease-related and is poorly estimated by standard methods. The geriatric dosing axiom, "start low and go slow" is based on pharmacokinetic considerations and concern for adverse drug reactions, not from clinical trial data. In the absence of generalizable dosage guidelines, individualization via effect titration is required. Altered pharmacodynamics are well documented in the cardiovascular system, with changes in the autonomic system, autacoid receptors, drug receptors, and endothelial function to modify baseline cardiovascular tone and responses to stimuli such as postural change and feeding. Adverse drug reactions and polypharmacy represent major linkages to avoidable morbidity and mortality. This, combined with a deficient therapeutic evidence base, suggests that extrapolation of risk-benefit ratios from younger adults to geriatric populations is not necessarily valid. Even so, therapeutic advances generally may convert healthy longevity from an asset of fortunate individuals into a general social benefit.
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              Potentially inappropriate prescribing and cost outcomes for older people: a national population study.

              Kathleen Bennett, J Feely, Tom Fahey … (2010)
              Optimization of drug prescribing in older populations is a priority due to the significant clinical and economic costs of drug-related illness. This study aimed to: (i) estimate the prevalence of potentially inappropriate prescribing (PIP) in a national Irish older population using European specific explicit prescribing criteria; (ii) investigate the association between PIP, number of drug classes, gender and age and; (iii) establish the total cost of PIP. This was a retrospective national population study (n= 338 801) using the Health Service Executive Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database. The HSE-PCRS uses the WHO Anatomical Therapeutic Chemical (ATC) classification system and details of every drug dispensed and claimants' demographic data are available. Thirty PIP indicators (STOPP) were applied to prescription claims for those >or=70 years in Ireland in 2007. STOPP is a physiological system based screening tool of older persons' potentially inappropriate prescriptions assessing drug-drug and drug-disease interactions, dose and duration. In our study population PIP prevalence was 36% (121 454 claimants). The main contributors to this were: 56 560 (17%) prescribed proton pump inhibitors at maximum therapeutic dose for >8 weeks, 29 691 (9%) prescribed non-steroidal anti-inflammatories for >3 months, 17 676 (5%) prescribed long-acting benzodiazepines for >1 month and 16 201 (5%) prescribed duplicate drugs. The main determinant of PIP was polypharmacy. The likelihood of PIP increased with a significant linear and quadratic trend (P or=70 years in 2007. The findings identify a high prevalence of PIP in Ireland with significant cost consequences.
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                Author and article information

                Contributors
                Terence J. Quinn: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2014
                Publication date (Electronic): 19 August 2014
                Volume: 9
                Issue: 8
                Electronic Location Identifier: e105425
                Affiliations
                [1 ]Department of Health Sciences, Helsana Group, Zurich, Switzerland
                [2 ]Institute of General Practice and Health Services Research, University Hospital, Zurich, Switzerland
                [3 ]Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
                University of Glasgow, United Kingdom
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: OR TR OS. Performed the experiments: RR. Analyzed the data: RR OR. Contributed reagents/materials/analysis tools: EB OR RR. Wrote the paper: OR TR OS.

                Article
                Publisher ID: PONE-D-14-06233
                DOI: 10.1371/journal.pone.0105425
                PMC ID: 4138178
                PubMed ID: 25136981
                SO-VID: 3ecc000c-6af0-45dc-b60e-cee289e42ec0
                Copyright statement: Copyright @ 2014
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 12 February 2014
                Date accepted : 23 July 2014
                Page count
                Pages: 9
                Funding
                This work was supported by an unconditional grant from the Swiss Academy of Medical Sciences (SAMS), Basel, Switzerland. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Epidemiology
                Subject: Pharmacoepidemiology
                Subject: Health Care
                Subject: Health Services Research
                Subject: Clinical Medicine
                Subject: Pharmacology
                Subject: Adverse Reactions

                ScienceOpen disciplines: Uncategorized
                Data availability:
                ScienceOpen disciplines: Uncategorized

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