Beers Criteria as a Proxy for Inappropriate Prescribing
Beers Criteria as a Proxy for Inappropriate Prescribing
BACKGROUND: The Beers criteria are a compilation of medications deemed potentially inappropriate for older adults, widely used as a prescribing quality indicator.
OBJECTIVE: To determine whether Beers criteria serve as a proxy measure for other forms of inappropriate prescribing, as measured by comprehensive implicit review.
METHODS: Data for patients 65 years and older were obtained from the Veterans Affairs Enhanced Pharmacy Outpatient Clinic (EPOC) and the Iowa Medicaid Pharmaceutical Case Management (PCM) studies. Comprehensive measurement of prescribing quality was conducted using expert clinician review of medical records according to the Medication Appropriateness Index (MAI). MAI scores attributable to non-Beers medications were contrasted between patients who did and did not receive a Beers criteria medication.
RESULTS: Beers criteria medications accounted for 12.9% (EPOC) and 14.0% (PCM) of total MAI scores. Importantly, non-Beers MAI scores were significantly higher in patients receiving a Beers criteria medication in both studies (EPOC: 15.1 vs 12.4, p = 0.02; PCM: 11.1 vs 8.7, p = 0.04), after adjusting for important confounding factors.
CONCLUSIONS: Beers criteria utility extended beyond direct measurement of a limited set of inappropriate prescribing practices by serving as a clinically meaningful proxy for other inappropriate practices. Using prescribing quality indicators to guide interventions should thus identify patients for comprehensive medication review, rather than identifying specific medication targets for discontinuation. Future research should explore both the quality measurement and the intervention targeting applications of the Beers criteria, particularly when integrated with other indicators.
Pharmacotherapy is a crucial component of medical care and the consequences of inappropriate prescribing are significant, with roughly 1.5 million preventable adverse drug events in the US annually, at a cost in excess of $4 billion. Efforts to improve prescribing quality rely on valid measures for initial assessment and ongoing monitoring. Prescribing quality measures are often classified as explicit (criterion based) versus implicit (judgment based). Explicit measures rely on fixed criteria that apply uniformly to all patients and can therefore be computerized and easily determined for large patient samples. In contrast, implicit measures rely on clinical judgment to allow for the needs of individual patients, but are also criticized for lacking structure and reliability. Moreover, implicit measures require access to detailed clinical data and highly trained clinician assessors. For these reasons, explicit measures are usually selected over implicit approaches in real-world applications.
One of the most widely used prescribing quality indicators is an explicit compilation of medications determined by expert consensus to be inappropriate for use in older adults, commonly known as the Beers criteria. One major criticism is that these criteria represent only a small fraction of all possible inappropriate prescribing practices and associated adverse outcomes. In one study, Beers criteria medications accounted for only 13.6% of drugs deemed inappropriate by implicit review and 14.6% of drugs targeted for intervention by a physician-pharmacist team. Similarly, only 3.6% of adverse event-related emergency department visits were due to Beers criteria medications, compared to 17.3% and 13.0% of such visits being due to warfarin and insulin, respectively. While these findings have been used to highlight the limitations of the Beers criteria, it is important to recognize that predicting adverse drug events is a very different application than measuring prescribing quality. While warfarin and insulin exposure may be important when predicting adverse drug events, their use in older adults is not considered potentially inappropriate, and therefore not suitable as prescribing quality measures. In contrast, Beers criteria comprise medications where risk generally outweighs benefit when used in older adults. It is reasonable to require a process measure of prescribing quality, such as Beers criteria, to be a risk factor for adverse drug events to establish validity. However, it is unreasonable to expect them to perform as well as other measures specifically designed for this purpose and does not diminish their value in measuring prescribing quality.
While an infrequent cause at the individual drug level, Beers criteria medications have been frequently associated with adverse event risk when examined at the patient level. For example, one study found only 6.0% of adverse drug events attributable to Beers criteria medications, yet patients who received these drugs were significantly more likely than those who did not to have an adverse drug event (35.0% vs 20.9%). Although Beers criteria medications did not account for many adverse events at the individual drug level, their utility may be higher at the patient level. In addition, the magnitude of association between Beers criteria medication exposure and adverse events is often diminished by adjusting for potential confounders. These observations suggest that Beers criteria may serve as a proxy measure for other forms of inappropriate prescribing. That is, patients receiving a Beers criteria medication may be exposed to other inappropriate prescribing practices at higher rates, which collectively contribute to adverse event risk. While this may be seen as unwanted confounding from a causality perspective, this is an acceptable or even desirable property for a quality indicator. Strong correlations have been observed between quality indicators in related clinical areas, such as myocardial infarction and congestive heart failure. However, these relationships remain unclear for broadly defined prescribing indicators, which are not limited to specific disease states.
Therefore, the objective of this study was to determine whether Beers criteria are a proxy measure for other forms of inappropriate prescribing. We conducted replicate analyses using 2 independently collected patient samples, where inappropriate prescribing was measured by comprehensive implicit review according to the Medication Appropriateness Index (MAI). Total MAI scores attributable to non-Beers medications were compared between patients receiving and those not receiving a Beers criteria medication.
Abstract and Introduction
Abstract
BACKGROUND: The Beers criteria are a compilation of medications deemed potentially inappropriate for older adults, widely used as a prescribing quality indicator.
OBJECTIVE: To determine whether Beers criteria serve as a proxy measure for other forms of inappropriate prescribing, as measured by comprehensive implicit review.
METHODS: Data for patients 65 years and older were obtained from the Veterans Affairs Enhanced Pharmacy Outpatient Clinic (EPOC) and the Iowa Medicaid Pharmaceutical Case Management (PCM) studies. Comprehensive measurement of prescribing quality was conducted using expert clinician review of medical records according to the Medication Appropriateness Index (MAI). MAI scores attributable to non-Beers medications were contrasted between patients who did and did not receive a Beers criteria medication.
RESULTS: Beers criteria medications accounted for 12.9% (EPOC) and 14.0% (PCM) of total MAI scores. Importantly, non-Beers MAI scores were significantly higher in patients receiving a Beers criteria medication in both studies (EPOC: 15.1 vs 12.4, p = 0.02; PCM: 11.1 vs 8.7, p = 0.04), after adjusting for important confounding factors.
CONCLUSIONS: Beers criteria utility extended beyond direct measurement of a limited set of inappropriate prescribing practices by serving as a clinically meaningful proxy for other inappropriate practices. Using prescribing quality indicators to guide interventions should thus identify patients for comprehensive medication review, rather than identifying specific medication targets for discontinuation. Future research should explore both the quality measurement and the intervention targeting applications of the Beers criteria, particularly when integrated with other indicators.
Introduction
Pharmacotherapy is a crucial component of medical care and the consequences of inappropriate prescribing are significant, with roughly 1.5 million preventable adverse drug events in the US annually, at a cost in excess of $4 billion. Efforts to improve prescribing quality rely on valid measures for initial assessment and ongoing monitoring. Prescribing quality measures are often classified as explicit (criterion based) versus implicit (judgment based). Explicit measures rely on fixed criteria that apply uniformly to all patients and can therefore be computerized and easily determined for large patient samples. In contrast, implicit measures rely on clinical judgment to allow for the needs of individual patients, but are also criticized for lacking structure and reliability. Moreover, implicit measures require access to detailed clinical data and highly trained clinician assessors. For these reasons, explicit measures are usually selected over implicit approaches in real-world applications.
One of the most widely used prescribing quality indicators is an explicit compilation of medications determined by expert consensus to be inappropriate for use in older adults, commonly known as the Beers criteria. One major criticism is that these criteria represent only a small fraction of all possible inappropriate prescribing practices and associated adverse outcomes. In one study, Beers criteria medications accounted for only 13.6% of drugs deemed inappropriate by implicit review and 14.6% of drugs targeted for intervention by a physician-pharmacist team. Similarly, only 3.6% of adverse event-related emergency department visits were due to Beers criteria medications, compared to 17.3% and 13.0% of such visits being due to warfarin and insulin, respectively. While these findings have been used to highlight the limitations of the Beers criteria, it is important to recognize that predicting adverse drug events is a very different application than measuring prescribing quality. While warfarin and insulin exposure may be important when predicting adverse drug events, their use in older adults is not considered potentially inappropriate, and therefore not suitable as prescribing quality measures. In contrast, Beers criteria comprise medications where risk generally outweighs benefit when used in older adults. It is reasonable to require a process measure of prescribing quality, such as Beers criteria, to be a risk factor for adverse drug events to establish validity. However, it is unreasonable to expect them to perform as well as other measures specifically designed for this purpose and does not diminish their value in measuring prescribing quality.
While an infrequent cause at the individual drug level, Beers criteria medications have been frequently associated with adverse event risk when examined at the patient level. For example, one study found only 6.0% of adverse drug events attributable to Beers criteria medications, yet patients who received these drugs were significantly more likely than those who did not to have an adverse drug event (35.0% vs 20.9%). Although Beers criteria medications did not account for many adverse events at the individual drug level, their utility may be higher at the patient level. In addition, the magnitude of association between Beers criteria medication exposure and adverse events is often diminished by adjusting for potential confounders. These observations suggest that Beers criteria may serve as a proxy measure for other forms of inappropriate prescribing. That is, patients receiving a Beers criteria medication may be exposed to other inappropriate prescribing practices at higher rates, which collectively contribute to adverse event risk. While this may be seen as unwanted confounding from a causality perspective, this is an acceptable or even desirable property for a quality indicator. Strong correlations have been observed between quality indicators in related clinical areas, such as myocardial infarction and congestive heart failure. However, these relationships remain unclear for broadly defined prescribing indicators, which are not limited to specific disease states.
Therefore, the objective of this study was to determine whether Beers criteria are a proxy measure for other forms of inappropriate prescribing. We conducted replicate analyses using 2 independently collected patient samples, where inappropriate prescribing was measured by comprehensive implicit review according to the Medication Appropriateness Index (MAI). Total MAI scores attributable to non-Beers medications were compared between patients receiving and those not receiving a Beers criteria medication.
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