Medication Underuse in Aging Outpatients with Cardiovascular Disease: Prevalence, Determinants, and Outcomes in a Prospective Cohort Study

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Abstract

Background

Cardiovascular disease is a leading cause of death in older people, and the impact of being exposed or not exposed to preventive cardiovascular medicines is accordingly high. Underutilization of beneficial drugs is common, but prevalence estimates differ across settings, knowledge on predictors is limited, and clinical consequences are rarely investigated.

Methods

Using data from a prospective population-based cohort study, we assessed the prevalence, determinants, and outcomes of medication underuse based on cardiovascular criteria from Screening Tool To Alert to Right Treatment (START).

Results

Medication underuse was present in 69.1% of 1454 included participants (mean age 71.1 ± 6.1 years) and was significantly associated with frailty (odds ratio: 2.11 [95% confidence interval: 1.24–3.63]), body mass index (1.03 [1.01–1.07] per kg/m ²), and inversely with the number of prescribed drugs (0.84 [0.79–0.88] per drug). Using this information for adjustment in a follow-up evaluation (mean follow-up time 2.24 years) on cardiovascular and competing outcomes, we found no association of medication underuse with cardiovascular events (fatal and non-fatal) (hazard ratio: 1.00 [0.65–1.56]), but observed a significant association of medication underuse with competing deaths from non-cardiovascular causes (2.52 [1.01–6.30]).

Conclusion

Medication underuse was associated with frailty and adverse non-cardiovascular clinical outcomes. This may suggest that cardiovascular drugs were withheld because of serious co-morbidity or that concurrent illness can preclude benefit from cardiovascular prevention. In the latter case, adapted prescribing criteria should be developed and evaluated in those patients.

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Most cited references 23

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STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.

P. Gallagher, C. Ryan, S Byrne … (2008)

Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment). A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets. STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START. STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses.

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Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals.

Paul Gallagher, Beatriz Montero Errasquin, Beatrice Gasperini … (2011)

Potentially inappropriate prescribing is common in older people presenting to hospital with acute illness in Ireland. The aim of this study was to determine if this phenomenon is unique to Ireland or whether it is a more widespread problem in hospitals across Europe. Prospective data were collected from 900 consecutive older patients admitted to six university teaching hospitals (150 patients per centre) in Geneva (Switzerland), Madrid (Spain), Oostende (Belgium), Perugia (Italy), Prague (Czech Republic) and Cork (Ireland). Age, gender, comorbidity, cognitive status, prescription medicines taken before admission and baseline haematological, biochemical and electrocardiographic data were recorded. STOPP and Beers' criteria were applied to detect potentially inappropriate medicines (PIMs). START criteria were applied to detect potentially inappropriate prescribing omissions (PPOs). The overall PIM prevalence rate was 51.3% using STOPP criteria, varying from 34.7% in Prague to 77.3% in Geneva, and 30.4% using Beer's criteria, varying from 22.7% in Prague to 43.3% in Geneva. Using START criteria, the overall PPO prevalence rate was 59.4%, ranging from 51.3% in Cork to 72.7% in Perugia. Polypharmacy predicted the presence of PIMs using STOPP criteria [with >10 medications: odds ratio (OR) 7.22, 95% confidence interval (CI) 4.30-12.12, p 10 medications: OR 4.87, 95% CI 3.00-7.90, p < 0.001). Increasing co-morbidity (Charlson Index ≥2) and age ≥85 years significantly predicted PPOs. Potentially inappropriate drug prescribing and the omission of beneficial drugs are highly prevalent in acutely ill hospitalized older people in six European centres.

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Polypharmacy and prescribing quality in older people.

Michael A Steinman, C. Seth Landefeld, Gary Rosenthal … (2006)

To evaluate the relationship between inappropriate prescribing, medication underuse, and the total number of medications used by patients. Cross-sectional study. Veterans Affairs Medical Center. One hundred ninety-six outpatients aged 65 and older who were taking five or more medications. Inappropriate prescribing was assessed using a combination of the Beers drugs-to-avoid criteria (2003 update) and subscales of the Medication Appropriateness Index that assess whether a drug is ineffective, not indicated, or unnecessary duplication of therapy. Underuse was assessed using the Assessment of Underutilization of Medications instrument. All vitamins and minerals, topical and herbal medications, and medications taken as needed were excluded from the analyses. Mean age was 74.6, and patients used a mean+/-standard deviation of 8.1+/-2.5 medications (range 5-17). Use of one or more inappropriate medications was documented in 128 patients (65%), including 73 (37%) taking a medication in violation of the Beers drugs-to-avoid criteria and 112 (57%) taking a medication that was ineffective, not indicated, or duplicative. Medication underuse was observed in 125 patients (64%). Together, inappropriate use and underuse were simultaneously present in 82 patients (42%), whereas 25 (13%) had neither inappropriate use nor underuse. When assessed by the total number of medications taken, the frequency of inappropriate medication use rose sharply from a mean of 0.4 inappropriate medications in patients taking five to six drugs, to 1.1 inappropriate medications in patients taking seven to nine drugs, to 1.9 inappropriate medications in patients taking 10 or more drugs (P<.001). In contrast, the frequency of underuse averaged 1.0 underused medications per patient and did not vary with the total number of medications taken (P=.26). Overall, patients using fewer than eight medications were more likely to be missing a potentially beneficial drug than to be taking a medication considered inappropriate. Inappropriate medication use and underuse were common in older people taking five or more medications, with both simultaneously present in more than 40% of patients. Inappropriate medication use is most frequent in patients taking many medications, but underuse is also common and merits attention regardless of the total number of medications taken.

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Author and article information

Contributors

Hemachandra Reddy: 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, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 19 August 2015

Publication date Collection: 2015

Volume: 10

Issue: 8

Electronic Location Identifier: e0136339

Affiliations

[1 ]Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, Germany

[2 ]Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany

[3 ]Saarland Cancer Registry, Saarbrücken, Germany

[4 ]Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Germany

Texas Tech University Health Science Centers, UNITED STATES

Author notes

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

Conceived and designed the experiments: ADM HB HK WEH. Performed the experiments: ADM RQ JF KS BS BH DH. Analyzed the data: ADM. Contributed reagents/materials/analysis tools: ADM RQ JF KS BS DH. Wrote the paper: ADM RQ JF KS BS BH DH HK HB WEH.

* E-mail: walter.emil.haefeli@ 123456med.uni-heidelberg.de

Article

Publisher ID: PONE-D-15-24148

DOI: 10.1371/journal.pone.0136339

PMC ID: 4544845

PubMed ID: 26288222

SO-VID: 8eddc3e8-d97d-4548-8b0a-b48f3f08905b

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 : 5 June 2015

Date accepted : 1 August 2015

Page count

Figures: 2, Tables: 3, Pages: 12

Funding

This work was supported in part by institutional funding and ADM, RQ, and JF received funding from the German Federal Ministry of Education and Research (BMBF, Berlin, Germany) under Grant Numbers 01ET0717, 01ET1004B, and 01GY1320B. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Data Availability Due to ethical restrictions related to protecting patient confidentiality imposed by the Ethics Committees of the Medical Faculty of the University of Heidelberg and the Medical Board of the State of Saarland, anonymized data are available upon request to Dr. Andreas Daniel Meid ( andreas.meid@ 123456med.uni-heidelberg.de ).

Medication Underuse in Aging Outpatients with Cardiovascular Disease: Prevalence, Determinants, and Outcomes in a Prospective Cohort Study

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Abstract

Background

Methods

Results

Conclusion

Related collections

PLOS Climate

Most cited references 23

STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.

Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals.

Polypharmacy and prescribing quality in older people.

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