Potentially Inappropriate Medication: Have We Gotten Better?
Potentially Inappropriate Medication: Have We Gotten Better?
Objectives To evaluate the use of medications classified as inappropriate according to the Health Plan Employer Data and Information Set (HEDIS) in elderly veterans residing in Department of Veterans Affairs (VA) nursing homes from 2004 to 2009 and to identify participant-specific correlates of use.
Design Retrospective, cross-sectional study using VA administrative data merged with participant-specific data from the Minimum Data Set.
Setting VA nursing homes (community living centers (CLCs)).
Participants Veterans aged 65 and older residing in CLCs at the time of the prescribed medication use (N = 176,168).
Measurements The number of exposed veterans aged 65 and older per facility receiving at least one HEDIS high-risk medication was determined.
Results Between 2004 and 2009, 28,970 of 176,168 (mean 16.4 ± 9.5%) veterans received at least one HEDIS high-risk medication. Over the period, the number of veterans receiving high-risk medications decreased steadily from 23.9 ± 10.0% in 2004 to 10.0 ± 6.6% in 2009. Nevertheless, large facility variations remained in 2009, with rates from 0% to 44.4%. Certain characteristics were also associated with HEDIS high-risk medication use, including female sex (odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.25–2.04), cancer (OR = 1.19, 95% CI = 1.08–1.32), renal disease (OR = 1.16, 95% CI = 1.01–1.33), chronic obstructive pulmonary disease (OR = 1.16, 95% CI = 1.05–1.28), and diabetes mellitus (OR = 1.11, 95% CI = 1.02–1.22). Protective characteristics included age 75 and older (OR = 0.81, 95% CI = 0.73–0.90) and having a diagnosis of moderate (OR = 0.72, 95% CI = 0.64–0.82) or severe (OR = 0.72, 95% CI = 0.61–0.85) cognitive impairment.
Conclusion The use of HEDIS medications among elderly veterans residing in VA nursing homes has markedly improved. Nevertheless, significant variations between facilities and certain subpopulations remain. A low percentage of women at VA CLCs make comparisons with community nursing homes difficult.
The use of potentially inappropriate medications (PIMs) is well documented in people aged 65 and older, in whom their use is a safety concern. Negative consequences of PIMs include adverse drug events, falls, hospitalizations, and healthcare costs. Previous studies of community dwellers have found that as many as one in five older adults are exposed to PIMs according to varying criteria (e.g., Beers Criteria, Zhan criteria) established by different organizations. For example, 21.3% of community-dwelling elderly adults received at least one PIM using data from the 1996 Medical Expenditure Survey. A European study of home care recipients in eight countries during 2002 identified inappropriate prescribing in 19.8% of more than 2,700 individuals. One study found that 19.6% of community-dwelling veterans aged 65 and older in 2000 were exposed to at least one PIM as defined according to criteria established using the Health Plan Employer Data and Information Set (HEDIS). Another study examining trends in the use of high-risk medications by older outpatient veterans revealed a modest decline from 13.1% in 2004 to 12.3% in 2006.
Studies conducted in frail populations suggest even higher rates of PIM in institutionalized populations such as those in nursing homes. Nursing home populations are at the highest risk of adverse drug events because of high medication burden, renal and liver impairments, and functional and cognitive impairment. As many as 50% of long-stay residents aged 65 and older received at least one PIM in 1996. A second nursing home study using slightly different criteria noted a prevalence upon nursing home admission of more than 25%.
These studies all suggest that the problem of PIMs was rampant a decade ago, particularly in the nursing home setting. There is reason to believe that geriatric prescribing has improved over the last 10 to 15 years in part because of the publication of these studies, the 1999 adoption of Centers for Medicare and Medicaid Services criteria for nursing home drug use review protocols, the landmark Institute of Medicine report spotlighting medication errors, and a greater emphasis on quality of care. In 2006, the National Committee on Quality Assurance began publishing the Healthcare Effectiveness Data and Information Set (HEDIS), which included potentially inappropriate prescribing as a quality measure, annually. The current study therefore used the HEDIS criteria to assess whether the incidence of PIM prescribing decreased over a 6-year period (2004–2009) in veterans residing in Veterans Administration nursing homes (hereafter referred to as Community Living Centers (CLCs)). Secondary goals of this analysis included an evaluation of geographic prescribing differences between VA CLCs and an evaluation of any patient-specific predictors of inappropriate medication use.
Abstract and Introduction
Abstract
Objectives To evaluate the use of medications classified as inappropriate according to the Health Plan Employer Data and Information Set (HEDIS) in elderly veterans residing in Department of Veterans Affairs (VA) nursing homes from 2004 to 2009 and to identify participant-specific correlates of use.
Design Retrospective, cross-sectional study using VA administrative data merged with participant-specific data from the Minimum Data Set.
Setting VA nursing homes (community living centers (CLCs)).
Participants Veterans aged 65 and older residing in CLCs at the time of the prescribed medication use (N = 176,168).
Measurements The number of exposed veterans aged 65 and older per facility receiving at least one HEDIS high-risk medication was determined.
Results Between 2004 and 2009, 28,970 of 176,168 (mean 16.4 ± 9.5%) veterans received at least one HEDIS high-risk medication. Over the period, the number of veterans receiving high-risk medications decreased steadily from 23.9 ± 10.0% in 2004 to 10.0 ± 6.6% in 2009. Nevertheless, large facility variations remained in 2009, with rates from 0% to 44.4%. Certain characteristics were also associated with HEDIS high-risk medication use, including female sex (odds ratio (OR) = 1.6; 95% confidence interval (CI) = 1.25–2.04), cancer (OR = 1.19, 95% CI = 1.08–1.32), renal disease (OR = 1.16, 95% CI = 1.01–1.33), chronic obstructive pulmonary disease (OR = 1.16, 95% CI = 1.05–1.28), and diabetes mellitus (OR = 1.11, 95% CI = 1.02–1.22). Protective characteristics included age 75 and older (OR = 0.81, 95% CI = 0.73–0.90) and having a diagnosis of moderate (OR = 0.72, 95% CI = 0.64–0.82) or severe (OR = 0.72, 95% CI = 0.61–0.85) cognitive impairment.
Conclusion The use of HEDIS medications among elderly veterans residing in VA nursing homes has markedly improved. Nevertheless, significant variations between facilities and certain subpopulations remain. A low percentage of women at VA CLCs make comparisons with community nursing homes difficult.
Introduction
The use of potentially inappropriate medications (PIMs) is well documented in people aged 65 and older, in whom their use is a safety concern. Negative consequences of PIMs include adverse drug events, falls, hospitalizations, and healthcare costs. Previous studies of community dwellers have found that as many as one in five older adults are exposed to PIMs according to varying criteria (e.g., Beers Criteria, Zhan criteria) established by different organizations. For example, 21.3% of community-dwelling elderly adults received at least one PIM using data from the 1996 Medical Expenditure Survey. A European study of home care recipients in eight countries during 2002 identified inappropriate prescribing in 19.8% of more than 2,700 individuals. One study found that 19.6% of community-dwelling veterans aged 65 and older in 2000 were exposed to at least one PIM as defined according to criteria established using the Health Plan Employer Data and Information Set (HEDIS). Another study examining trends in the use of high-risk medications by older outpatient veterans revealed a modest decline from 13.1% in 2004 to 12.3% in 2006.
Studies conducted in frail populations suggest even higher rates of PIM in institutionalized populations such as those in nursing homes. Nursing home populations are at the highest risk of adverse drug events because of high medication burden, renal and liver impairments, and functional and cognitive impairment. As many as 50% of long-stay residents aged 65 and older received at least one PIM in 1996. A second nursing home study using slightly different criteria noted a prevalence upon nursing home admission of more than 25%.
These studies all suggest that the problem of PIMs was rampant a decade ago, particularly in the nursing home setting. There is reason to believe that geriatric prescribing has improved over the last 10 to 15 years in part because of the publication of these studies, the 1999 adoption of Centers for Medicare and Medicaid Services criteria for nursing home drug use review protocols, the landmark Institute of Medicine report spotlighting medication errors, and a greater emphasis on quality of care. In 2006, the National Committee on Quality Assurance began publishing the Healthcare Effectiveness Data and Information Set (HEDIS), which included potentially inappropriate prescribing as a quality measure, annually. The current study therefore used the HEDIS criteria to assess whether the incidence of PIM prescribing decreased over a 6-year period (2004–2009) in veterans residing in Veterans Administration nursing homes (hereafter referred to as Community Living Centers (CLCs)). Secondary goals of this analysis included an evaluation of geographic prescribing differences between VA CLCs and an evaluation of any patient-specific predictors of inappropriate medication use.
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