Potentially Inappropriate Medication: Have We Gotten Better?
Potentially Inappropriate Medication: Have We Gotten Better?
The rate of high-risk medication use in veterans residing in VA CLCs over a 6-year period between 2004 and 2009 declined steadily from 23.9% to 10.0%. This rate is significantly lower than the rates previously identified in community-based VA populations based on data from 2000, which showed HEDIS rates of 19.6% overall, and than rates found in nursing home studies using data from more than a decade ago that found prevalence rates as high as 50%. Similar to previously published studies, the current analysis also shows that high-risk medications remain more common in women and less common in older individuals and those with moderate to significant cognitive impairment.
Despite the positive trends identified in this study, significant variability of high-risk medication use remains between facilities, with rates ranging from 0% use at one facility in 2009 to another with almost 45% use. These findings are complementary to a previous study that evaluated the variation of PIMs in a community setting and described a range of inappropriate prescribing from 0.6% at the lowest facility to 12.8% at the highest (median 4.7%). Given these profound interfacility variations, the notion of using PIM rates at the facility level as a quality indicator to drive improvement seems appropriate. Many of the drugs classified as HEDIS high-risk medications are associated with significant risks of confusion, falls, hospitalization, and death. As such, their continued use represents a serious threat to safety in a susceptible population given numerous comorbidities and baseline cognitive and functional impairment.
Further work is required to elucidate why elderly women receive high-risk medications with far greater frequency. Work is also required to identify why certain facilities have failed to reduce high-risk medication use as rapidly as others. For example, this analysis identified the same healthcare facility with the highest rate of high-risk medication use in both years studied. In contrast, another VA facility reduced rates from 43% to <9% over the same time period. Qualitative research is probably required to determine whether and how policies deviate between contrasting facilities and might help identify best practices that could be subsequently disseminated to VA and non-VA long-term care facilities.
Important contributions of this study include the length of the analysis period. Previously published studies in the community and in long-term care facilities evaluated data from more than a decade ago—often auditing older records against medication standards that were not yet widely distributed or acknowledged. With the final development of the HEDIS criteria in 2006, it is plausible that the publication of these criteria and their broader dissemination inside and outside the VA has in part driven at least some of the improvement identified during the study period. One study noted a decline in inappropriate medication use in Medicare beneficiaries in nursing homes from 28.8% to 23.4% between 1997 and 2000 after the Centers for Medicare and Medicaid Services mandated expansion to their drug use review policy in 1999.
The findings of the current study also serve as potential benchmarks for future quality improvement efforts that might seek to further limit PIMs in elderly adults—particularly in high-risk populations such as those seen in long-term care facilities. With Medicare Part D data now available, comparisons of the findings of the current study with those in community-based nursing homes may soon be possible in long-stay nursing home populations where such data are available. A particular strength of this VA-based study was the inclusion of all VA CLC residents, including those admitted for postrehabilitation, for whom data on medication use is often difficult to obtain in the community because of the bundling of services under Medicare. Further work will need to be conducted to separate long-stay residents in the panel from those receiving skilled nursing home care to establish whether rates are higher or lower in the latter population.
There are several limitations in this research that deserve mention. First, the medication data used in this study were based on prescription claims within the VA healthcare system only. Although data were available on the names, dosages, and frequencies of the medications and the number of pills dispensed, it was not possible to determine whether actual dosing occurred at the bedside. It was also not possible to know whether medications were available from external sources such as those obtained over the counter, although given the highly monitored environment of a VA long-term care facility, it is significantly less likely that medications from outside VA sources were allowed into the building and that dosing did not occur as directed.
Second, this study included a small proportion of women, so it is likely that the rates of high-risk medication use at community nursing homes, where women predominate, will be different. Given the greater use of high-risk medications identified in this and other studies in women, it is likely that community levels of use are significantly higher than those observed in VA-based facilities. Additional resources, such as the electronic medical record, the availability of pharmacy services, and culture change initiatives within the VA probably play a role in reducing high-risk medication rates. Further study will be needed to determine the degree to which these factors play a role at various facilities.
Third, this study did not consider veterans in hospice or those admitted for end-of-life care. In certain cases, the use of HEDIS medications such as certain antihistamines might be appropriate for symptom relief in terminal conditions, although based on the evaluation of individual medications over time, it is doubtful that the drugs most commonly used in such situations (e.g., scopolamine) played a significant role in the analyses. Finally, the data did not consider the total number of medications prescribed. It is plausible that there was a general trend toward less medication use overall during the study period. As such, the use of fewer HEDIS medications might in part be a reflection of that. Still, it is doubtful that medication use overall was reduced by the same percentage (23.9% in 2004–10% in 2009) as the evaluation of HEDIS medication use suggests.
Discussion
The rate of high-risk medication use in veterans residing in VA CLCs over a 6-year period between 2004 and 2009 declined steadily from 23.9% to 10.0%. This rate is significantly lower than the rates previously identified in community-based VA populations based on data from 2000, which showed HEDIS rates of 19.6% overall, and than rates found in nursing home studies using data from more than a decade ago that found prevalence rates as high as 50%. Similar to previously published studies, the current analysis also shows that high-risk medications remain more common in women and less common in older individuals and those with moderate to significant cognitive impairment.
Despite the positive trends identified in this study, significant variability of high-risk medication use remains between facilities, with rates ranging from 0% use at one facility in 2009 to another with almost 45% use. These findings are complementary to a previous study that evaluated the variation of PIMs in a community setting and described a range of inappropriate prescribing from 0.6% at the lowest facility to 12.8% at the highest (median 4.7%). Given these profound interfacility variations, the notion of using PIM rates at the facility level as a quality indicator to drive improvement seems appropriate. Many of the drugs classified as HEDIS high-risk medications are associated with significant risks of confusion, falls, hospitalization, and death. As such, their continued use represents a serious threat to safety in a susceptible population given numerous comorbidities and baseline cognitive and functional impairment.
Further work is required to elucidate why elderly women receive high-risk medications with far greater frequency. Work is also required to identify why certain facilities have failed to reduce high-risk medication use as rapidly as others. For example, this analysis identified the same healthcare facility with the highest rate of high-risk medication use in both years studied. In contrast, another VA facility reduced rates from 43% to <9% over the same time period. Qualitative research is probably required to determine whether and how policies deviate between contrasting facilities and might help identify best practices that could be subsequently disseminated to VA and non-VA long-term care facilities.
Important contributions of this study include the length of the analysis period. Previously published studies in the community and in long-term care facilities evaluated data from more than a decade ago—often auditing older records against medication standards that were not yet widely distributed or acknowledged. With the final development of the HEDIS criteria in 2006, it is plausible that the publication of these criteria and their broader dissemination inside and outside the VA has in part driven at least some of the improvement identified during the study period. One study noted a decline in inappropriate medication use in Medicare beneficiaries in nursing homes from 28.8% to 23.4% between 1997 and 2000 after the Centers for Medicare and Medicaid Services mandated expansion to their drug use review policy in 1999.
The findings of the current study also serve as potential benchmarks for future quality improvement efforts that might seek to further limit PIMs in elderly adults—particularly in high-risk populations such as those seen in long-term care facilities. With Medicare Part D data now available, comparisons of the findings of the current study with those in community-based nursing homes may soon be possible in long-stay nursing home populations where such data are available. A particular strength of this VA-based study was the inclusion of all VA CLC residents, including those admitted for postrehabilitation, for whom data on medication use is often difficult to obtain in the community because of the bundling of services under Medicare. Further work will need to be conducted to separate long-stay residents in the panel from those receiving skilled nursing home care to establish whether rates are higher or lower in the latter population.
Limitations
There are several limitations in this research that deserve mention. First, the medication data used in this study were based on prescription claims within the VA healthcare system only. Although data were available on the names, dosages, and frequencies of the medications and the number of pills dispensed, it was not possible to determine whether actual dosing occurred at the bedside. It was also not possible to know whether medications were available from external sources such as those obtained over the counter, although given the highly monitored environment of a VA long-term care facility, it is significantly less likely that medications from outside VA sources were allowed into the building and that dosing did not occur as directed.
Second, this study included a small proportion of women, so it is likely that the rates of high-risk medication use at community nursing homes, where women predominate, will be different. Given the greater use of high-risk medications identified in this and other studies in women, it is likely that community levels of use are significantly higher than those observed in VA-based facilities. Additional resources, such as the electronic medical record, the availability of pharmacy services, and culture change initiatives within the VA probably play a role in reducing high-risk medication rates. Further study will be needed to determine the degree to which these factors play a role at various facilities.
Third, this study did not consider veterans in hospice or those admitted for end-of-life care. In certain cases, the use of HEDIS medications such as certain antihistamines might be appropriate for symptom relief in terminal conditions, although based on the evaluation of individual medications over time, it is doubtful that the drugs most commonly used in such situations (e.g., scopolamine) played a significant role in the analyses. Finally, the data did not consider the total number of medications prescribed. It is plausible that there was a general trend toward less medication use overall during the study period. As such, the use of fewer HEDIS medications might in part be a reflection of that. Still, it is doubtful that medication use overall was reduced by the same percentage (23.9% in 2004–10% in 2009) as the evaluation of HEDIS medication use suggests.
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