the prevalence of and factors associated with potentially inappropriate medications use in the...

The Prevalence of and Factors Associated with Potentially Inappropriate Medications Use in The

Elderly Population in Thailand

Rosarin Sruamsiri1, Nathorn Chaiyakunapruk1, Napawan Jeanpeerapong2

1Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences,

Naresuan University, Phitsanulok, Thailand2Department of Pharmacy, Bhuddhachinaraj Hospital, Muang, Phitsanulok, Thailand

The Prevalence of and Factors Associated with Potentially Inappropriate Medications Use in The

Elderly Population in Thailand

Rosarin Sruamsiri1, Nathorn Chaiyakunapruk1, Napawan Jeanpeerapong2

1Center of Pharmaceutical Outcomes Research, Faculty of Pharmaceutical Sciences,

Naresuan University, Phitsanulok, Thailand2Department of Pharmacy, Bhuddhachinaraj Hospital, Muang, Phitsanulok, Thailand

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Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011

Background


• Elderly people are vulnerable to medical misadventures.

• Inappropriate used of medications is considered one of the main causes of adverse drug reactions in the elderly.

• Jano E and Aparasu RR. Healthcare outcomes associated with beers’ criteria: a systematic review. Ann Phamacother. 2007; 41: 438-48• Page et al. Inappropriate prescribing in the hospitalized elderly patient: Defining the problem, evaluation tools, and possible solutions.Clinical Intervention in Aging.2010;5:75-87

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Background


• Risk of drug-drug interactions

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• Cost of drug-related morbidity and mortality : $76.6 billion annually.

• Incremental healthcare costs related to inappropriate prescribing in older : $7.2 billion annually.

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• Goldberg R, Mabee J, Chan L, Wong S. Drug-drug and drug-disease interactions in the ED: analysis of a high risk population. Am J Emerg Med. 1996;14(5):447-450.• Johnson J, Bootman J. Drug-related morbidity and mortality: a cost-of-illness model. Archives of Internal Medicine. 1995;155:1949-1956.• Fu A, Jiang J, Reeves J, Fincham J, Liu G, Perri MI. Potentially inappropriate medication use and healthcare expenditures in the US community dwelling elderly. Medical Care. 2007;45:472–476.

• Goldberg R, Mabee J, Chan L, Wong S. Drug-drug and drug-disease interactions in the ED: analysis of a high risk population. Am J Emerg Med. 1996;14(5):447-450.• Johnson J, Bootman J. Drug-related morbidity and mortality: a cost-of-illness model. Archives of Internal Medicine. 1995;155:1949-1956.• Fu A, Jiang J, Reeves J, Fincham J, Liu G, Perri MI. Potentially inappropriate medication use and healthcare expenditures in the US community dwelling elderly. Medical Care. 2007;45:472–476.

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Background• “Potentially Inappropriate Medications”(PIMs) or

“Potentially Inappropriate Prescriptions”

O’Mahony D, Gallagher PF. Inappropriate prescribing in the older population: need for new criteria. Age Aging. 2008 Mar; 37(2):138-41.

Medications that have no clear evidence-based indication, carry a substantially higher risk of adverse side-effect or not cost-effective.

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Background Prevalence of PIMs ranged from 5.8% to 51.4% in various settings

and countries.

• Aparasu R, Mort J. Inappropriate prescribing for the elderly: Beers criteria-based review. Ann Pharmacother. 2003;34:338-346.•F ialová D, Topinková E, Gambassi G, al e. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293:1348–1358.• Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32:113-121.

• Aparasu R, Mort J. Inappropriate prescribing for the elderly: Beers criteria-based review. Ann Pharmacother. 2003;34:338-346.•F ialová D, Topinková E, Gambassi G, al e. Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293:1348–1358.• Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32:113-121.

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Specific criteria for avoidable PIMs has later been developed in the USA, Canada, France, Ireland and Norway.

A list of PIMs called ‘the criteria for high-risk medications use in Thai older patients’ was developed in 2008.

Background

•Fick D, Cooper J, Wadw W, Waller J, Maclean R, Beers M. Updating the Beers criteria for potentially inappropriate medication use in older adults: result of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724.•McLeod P, Huang A, Tamblyn R, Gayton D. Defining inappropriate practices in prescribing for eldely peoplr: a national consensus panel. Can Med Assoc J. 1997;156:385-391.•Laroche M, Charmes J, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol. 2007;63(725-731).•Gallanher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP(Screening Tool of Older Person's Prescription) and START (Screening Tool to Alert doctors to Right Treatment).Consensus validation. Int J Clin Pharmacol Ther. 2008;46(72-83).•Rognstad S, Brekke M, Fetveit A, Spigset O, Wyller T, Straand J. The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients: A modified Delphi study. Scan J Prim Health Care. 2009;27:153-159.

•Fick D, Cooper J, Wadw W, Waller J, Maclean R, Beers M. Updating the Beers criteria for potentially inappropriate medication use in older adults: result of a US consensus panel of experts. Arch Intern Med. 2003;163:2716-2724.•McLeod P, Huang A, Tamblyn R, Gayton D. Defining inappropriate practices in prescribing for eldely peoplr: a national consensus panel. Can Med Assoc J. 1997;156:385-391.•Laroche M, Charmes J, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol. 2007;63(725-731).•Gallanher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP(Screening Tool of Older Person's Prescription) and START (Screening Tool to Alert doctors to Right Treatment).Consensus validation. Int J Clin Pharmacol Ther. 2008;46(72-83).•Rognstad S, Brekke M, Fetveit A, Spigset O, Wyller T, Straand J. The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients: A modified Delphi study. Scan J Prim Health Care. 2009;27:153-159.

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Understanding the epidemiology of PIMs among elderly population could enable clinicians to properly develop measures to maximize benefits of drug use and minimize adverse drug events

It is important to examine the prevalence of and identify factors associated with PIMs in Thailand.

Background

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To determine the prevalence of PIMs in the Thai elderly population.

To identify factors associated with PIMs

Objectives

MethodsMethods

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Retrospective databases analysis– Databases from a university-affiliated hospital

• Out-patient diagnosis databases• Pharmacy databases

– Inclusion criteria• Patients aged ≥ 65 year-old• Patients visited the outpatient department in 2008

– PIMs evaluation• The criteria for high-risk medication use in Thai older

patients (Winit-Watjana et al 2008)– Analysis

• Descriptive statistics for prevalence of PIMs• Multivariate analysis using generalized estimation

equations (GEE) to determine factors associated with PIMs

Methods

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Methods The criteria for high-risk medication use in Thai older patients (Winit-Watjana et al 2008)

– Categorized into 3 categories

– 4 severities classification

Categories Examples

High-risk medications • Diazepam

Drug-disease interactions • Peptic Ulcer and NSAIDs*

Drug-drugs interactions • Warfarin and NSAIDs*

* NSAIDs : Non-Steroidal anti-inflammatory drug

Winit-Watjana W, Sakulrat P, Kespichayawattana J. Criteria for high-risk medication use in Thai older patients. Arch Gerontol Geriatr2008 Jul-Aug;47(1):35-51.

Severity Description

1 drug or pair should be avoid

2 drug or pair rarely appropriate

3 drug or pair with some indications for elderly patients

UC un-classified

ResultsResults

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Characteristics Total n (%)

Total 14,994Age mean(SD) 73 (6.6) 65-74 9,360 (62.42) 75-84 4,810 (32.08) ≥85 824 (5.50)Sex Male 6,533 (43.57) Female 8,461 (56.43)Status of treatment Universal Coverage (UC) 7,532 (50.23) Social Security Scheme (SSS) 46 (0.31) Civil Servants Medical Benefit Scheme (CSMBS) 7,347 (49.00) Others 69 (0.46)

Results

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Results

58% (8,676/14,994) of included patients were prescribed at least 1 PIMs.

Of 8,676 PIMs users

4 % received drug or pair should be avoid.

8 % received drug or pair rarely appropriate

29 % received drug or pair with some indications for elderly patients

59% unclassified

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Results Table 1. The Most Common Potentially Inappropriate Medications (PIMs) Use among

Elderly Thai Patients

*Classification of high-risk medication use: 1= drug or pair should be avoid; 2= drug or pair rarely appropriate; 3= drug or pair with some indications for elderly patients; UC=un-classified.

High- risk medication used criteria Classification* Prevalence in year 2008 (%)

Medications

NSAIDs 2 1,492/8,676 (17.2)

NSAIDs, COX II inhibitors 2 651/8,676 (7.5)

ACEIs 3 2,605/8,676 (30.0)

Short-acting Benzodiazepines 3 1,732/8,676 (20.0)

Alpha-blockers 3 1,061/8,676 (12.2)

Drug-Disease Interactions

Peptic ulcer-NSAIDs 1 64/8,676 (0.7)

Glaucoma-tricyclic antidepressant 1 30/8,676 (0.3)

Coronary artery disease – testosterone 3 83/8,676 (1.0)

Drug-Drug Interactions

Aspirin-NSAIDs 1 214/8,676 (2.5)

Warfarin-NSAIDs 1 81/8,676 (0.9)

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ResultsFactors associated with PIMs

Individual factorso Polypharmacy

6-9 medications: OR, 3.32 (3.17 – 3.48)≥ 10 medications: OR, 6.94 (6.39– 7.53) compared with patients taking ≤

5 medications. o Higher morbidities:

CCI* score 2-3: OR, 5.04 (4.69 – 5.51) CCI* score >4: OR, 8.78 (8.86 – 8.90) compared with CCI score of 0-1

System factorso Universal Coverage (UC): OR, 1.77 (1.72 – 1.82) compared with CSMBSo Prescribers under training: OR, 1.95 (1.81-2.11)o Prescribers working in the department of psychiatry: OR, 3.46 (3.01-3.98)

Conclusions & Conclusions & ImplicationsImplications

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Conclusions

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Using country’s specific criteria can determine the magnitude of problem in local context.

PIMs used among elderly remains a major public health concern in Thailand.

Both individual characteristics and health system factors were associated with PIMs.

Proper managements are needed especially among those with co-morbidities and receiving muli-medications.


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Implications Further researches are needed to target extended,

clinical practices and policy implementations to reduce PIMs.

Reduction strategies should be implemented from both bottom-up and top-down.

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Acknowledgement Our research team:

• Dr. Nathorn Chiyakunapruk

• Napawan Jeanpeerapong

World Health Organization

Thailand Research Fund through the Royal Golden Jubilee PhD

program


Rosarin Sruamsiri, B.Pharm , M.B.A.Center for Pharmaceutical Outcomes Research (CPOR)

Faculty of Pharmaceutical SciencesNaresuan University

Muang, Phitsanulok, Thailand 65000 [email protected]

Rosarin Sruamsiri, B.Pharm , M.B.A.Center for Pharmaceutical Outcomes Research (CPOR)

Faculty of Pharmaceutical SciencesNaresuan University

Muang, Phitsanulok, Thailand 65000 [email protected]

Contact informationContact information

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