Five Ways You Can Reduce

VOL 55, NO 4 / APRIL 2006 305w w w. j f p o n l i n e . c o m

C O R R E S P O N D E N C E

Robert M. Garcia, MD, St.Josephs Hospital andMedical Center, FamilyMedicine ResidencyProgram, 2927 N. 7th Ave,Phoenix, AZ 85013. E-mail:[email protected]

Factors that lead to inappropriate prescribing

Inappropriate prescribing to elderlypatients is increasing. It is not uncommonfor older patients to receive 1 or moremedications from their primary care physi-cian and additional medications from spe-cialty physicians, with each physicianunaware of medications prescribed by theothers.1 As the number of providers fol-lowing the patient increases, so does thenumber of medications.2

One result is that the elderly use a dis-proportionate number of medications.They make up 13% of the US populationbut receive 34% of all prescriptions andconsume 40% of all nonprescription med-ications.3,4 A recent national study of non-institutionalized US adults revealed that90% of persons 65 years or older used atleast 1 medication per week. More than40% used 5 or more medications perweek, and 12% used 10 or more perweek.5 This situation may become morecomplicated as by the year 2030, the elder-ly are expected to make up 20% of the USpopulation.6

Inappropriate prescribing, includingpolypharmacy, is a major contributing fac-tor to adverse drug events in older patients(see Scope of the problem). A recent nest-ed case-controlled study in a large multi-specialty group revealed an associationbetween number of medications, doses ofmedications, and adverse drug events.13

Practice recommendations Obtain pharmacist recommendations

to reduce inappropriate prescribingand adverse drug events (B).

In the inpatient setting, use computer-ized alerts to reduce serious medica-tion errors and help prevent adversedrug events (B).

Review a patients medications toreduce polypharmacy and inappropri-ate prescribing (A).

Educate patients to improve compli-ance with medications, reducepolypharmacy, reduce inappropriateprescribing, and decrease adverseevents (A).

Consider using the Beers criteria foravoiding inappropriate drugs in theelderly.

A round one third of elderly personshospitalized end up there becauseof adverse drug events. Among theambulatory elderly, 35% experience suchevents in a single year. The hopeful outlookis that, depending on the setting, between25% and 95% of these events can be pre-vented by reducing inappropriate prescrib-ing.

In this article we discuss 5 recommen-dations for reducing inappropriate medica-tions, and offer steps to implement theserecommendations.

Five ways you can reduceinappropriate prescribing inthe elderly: A systematic review

Robert M. Garcia, MD,CAQGMSt. Josephs Hospital andMedical Center, FamilyMedicine Residency Program,Phoenix, Arizona; Departmentof Family and CommunityMedicine, University ofArizona College of Medicine

New research findings that are changing clinical practice

APPLIED EVIDENCE

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306 VOL 55, NO 4 / APRIL 2006 THE JOURNAL OF FAMILY PRACTICE

APPLIED EVIDENCE

vention of adverse drug events; and reduc-tion of inappropriate prescribing in theelderly. The search was limited to studiesof patients over 65 years of age.

Fifty-nine articles were identified usingthe above search strategy. In selecting arti-cles on which to base the recommenda-tions in this paper, we gave first priority torandomized controlled trials. When ran-domized controlled trials did not exist, weused cohort studies or meta-analyses. Weexcluded review articles and articles thatdid not specifically address the issue ofreducing inappropriate prescribing for eld-erly patients.

ResultsTABLE W1 (available online at www.jfpon-line.com) describes the results of the sys-tematic review. Of the initial 59 articles,we excluded 26 review articles and 13 thatdid not address inappropriate prescribing.The remaining 19 articles were classifiedinto 5 categories based on the methodsstudied for reducing inappropriate pre-scribing. The methods recommended ineach of the 5 categories were supported byvarying levels of evidence.

Four methods were supported by con-trolled trials, thus providing a higher levelof evidence to support: 1) incorporatingpharmacist recommendations, 2) use ofcomputerized alerts, 3) review of patientsmedication list and 4) patient education(TABLE W2, available online at www.jfpon-line.com). The fifth method, avoidinginappropriate medications, was based onconsensus guidelines and expert opinions.

Method 1: Incorporate pharmacistrecommendationsHaving a pharmacist participate in the careof elderly patients can reduce polypharma-cy and adverse drug events.

A randomized controlled trial of 208patients at a Veterans Administration(VA) medical clinic, aged 65 years of age orolder and taking 5 or more medications,demonstrated that involving a clinicalpharmacist in the patients care reduces

The problem of polypharmacy as it relatesto adverse drug events is so extensive thatit was designated as the principal medica-tion safety issue in the Healthy People2000 report.14

MethodsIn this systematic review, English languagestudies from January 1990 to January2006 were searched on Medline and theCochrane Database of SystematicReviews. Among the specific keywordsand phrases we used: adverse drug eventsin the elderly; inappropriate medications inthe elderly; polypharmacy in the elderly;reduction of polypharmacy in the elderly;drug-drug interactions in the elderly; pre-

Hypertension specialists debate about how to approachtheIn the year 2000, medication-related problemswere responsible for 106,000 deaths at a cost of $85 billionto our healthcare system.7,8

It has been estimated that 30% of hospital admissions in elderly patients are due to drug-related problems.9 Inaddition, approximately two thirds of nursing facility residents will experience an adverse drug event over a 4-year period of time, with 1 in 7 of these residents requiring hospitalization.10,11

Ambulatory patients are also affected. A cohort studyrevealed that approximately 35% of ambulatory elderly experienced an adverse drug event over a 1-yearperiod, 63% of whom required the attention of a physician.9

Another large cohort study, involving 30,347 Medicareenrollees cared for by a multispecialty group practice,demonstrated that adverse drug events are not only com-mon among the elderly, but over 25% of the adverse eventsduring a 12-month period were preventable.12 Other studieshave estimated that up to 95% of adverse drug events arepreventable.3 These figures are particularly troubling whenconsidering our older patient population because 51% of alldeaths caused by adverse reactions to medications occur inpatients over 60 years of age.4

Adverse drug events may occur for several reasons including noncompliance, drug-drug interactions,and physician error.

Scope of the problem


Five ways you can reduce inappropriate prescribing in the elderly

Brown bag evaluations, withattention to nonprescriptionmedications,decreasespolypharmacy


FAST TRACK

inappropriate prescribing and adversedrug effects without adversely affectinghealth-related quality of life.15

In this VA study, patients were ran-domized to an intervention group and acontrol group. In the intervention group,a clinical pharmacist met with patientsduring all scheduled office visits to evalu-ate and make recommendations abouttheir drug regimens. Before each visit, theclinical pharmacist reviewed the patientsmedical record and current medications,and assessed each medication using theMedication Appropriateness Index asa guideline.18,19 Written drug therapy rec-ommendations were then sent to thephysician.

Key outcome measures in this studywere the rate of prescribing inappropriate-ness, medication compliance and knowl-edge, number of medications, adverse drugevents, health-related quality of life,patient satisfaction, and physician recep-tivity to the intervention.

The results show that inappropriateprescribing and the number of drugs pre-scribed decreased by 24% in the interven-tion group but only by 6 % in the controlgroup. In addition, fewer intervention-group patients than control patients expe-rienced adverse drug events (30% vs.40%; P=.19). Physicians were receptiveto the clinical pharmacists interventionsand enacted changes recommended by theclinical pharmacist more frequently thanthey enacted changes independently forcontrol patients (55.1% vs. 19.8%;P=.001).15

Engaging the pharmacist. Encourageyour patients to fill prescriptions by allphysicians at the same pharmacy, therebyenabling the maintenance of a single cur-rent list of medications. Have your officestaff alert the pharmacist whenever a med-ication is discontinued.

When a patient refills medications, thepharmacist routinely reviews the databasefor potential adverse drug events. Thepharmacist should then alert the physicianof potential inappropriate medications oradverse drug events.

Method 2: Use computerized alertsComputerized alerts provide warnings tophysicians using computerized order entrysystems. The system contains informationon patients current medications and drugintolerances and allergies. An alert isgenerated by the system when there is apotential drug allergy, drug intolerance ordrug interaction as defined by the NationalDrug Data File of First Databank Inc. Theuse of computerized alerts for reducingpolypharmacy and inappropriate prescrib-ing has been examined in both outpatientand inpatient settings.

Outpatient. A recent study examinedthe rate at which physicians overrode com-puterized alerts among 3481 consecutivealerts generated at 5 adult primary carepractices that used a common computer-ized physician order entry system for pre-scription writing.20 Of the 3481 consecu-tive alerts, physicians overrode 91.2% ofthe alerts but 8.8% resulted in a change inprescribing.

Although few physicians changed theirprescriptions in response to an alert, therewere few adverse drug events despite thelarge number of alerts that were overrid-den. This may have indicated an alertthreshold that was set too low.21

Inpatient. A randomized comparisonstudy conducted at a large tertiary hospitaldemonstrated that physician computerorder entry decreased the rate of seriousmedication errors by more than half.16 Thisstudy was divided into 2 phases. Phase Iinvolved 2491 admissions and wasdesigned as baseline. Phase II involved4220 admissions that occurred after theintervention was implemented. The inter-vention itself was implementation of acomputerized order entry system thatrequired the ordering physician to com-plete a menu of information includingdrug name, medication dose, route, andfrequency. Computerization ensured legi-bility of all orders. The main outcomemeasured was serious medication errors.

In comparison of the 2 phases, seriousmedication errors decreased 55%, from10.7 events per 1000 patient-days in Phase


Review OTCagents, includingvitamins and minerals, and not just prescriptions

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APPLIED EVIDENCE

I to 4.86 events per thousand in Phase II(P=.1). Preventable adverse drug eventsdeclined 17%, while most significantlypotential adverse drug events declined84%.16

Another study, this one a randomizedcontrolled study of electronic alerts toremind physicians of prescribed measuresto prevent venous thromboembolism inhospitalized patients, also found benefit toan alert system. But the results showed that3 conditions are needed for the success ofthe clinical alerts. First, there must beacceptance by the physicians. Secondly, theelectronic alerts should deliver simple mes-sages that prevent physicians from routine-ly bypassing them. Thirdly, the physicianshould have access to all pertinent infor-mation to make an adequate decision.21

Method 3: Review of medicationsReviewing a patients medications regular-ly can reduce polypharmacy and inappro-priate prescribing. This has been shown inat least 4 studies.

Physicians often unaware of whatpatients are, or are not, taking. Oneprospective observational study of medica-tion review showed a high rate of discrep-ancy between medications the physicianthought a patient was taking and those thepatient actually was taking. This studyinvolved patients 65 years of age or olderwho were taking 4 or more medications.There were 50 physicians-patient pairsblinded at the initial visit. After the initialvisit, physicians were given the patientschart, with a request to complete a ques-tionnaire on all prescription and nonpre-scription medications with dosages andfrequencies of administration. All patientrecords contained a flow sheet for reviewof medications including current, discon-tinued, and over-the-counter medications.

Home visits were conducted 10 daysafter initial visits to gather detailed infor-mation from patients regarding theirunderstanding of medication regimens.Data obtained showed that 74% ofpatients were taking at least 1 medicationthe physician was unaware of, or were not

taking a medication the physician thoughtthey were taking. Moreover, in 12% ofcases, there were discrepancies in under-standing about dose or frequency of med-ication regimens.22

Brown bag assessment useful. In thesecond study, a program promoting med-ication reviews between primary carephysicians and their elderly patients signif-icantly changed prescribing by physicians.In this prospective study, elderly patientstaking 5 or more medications were sent aletter encouraging them to meet with theirprimary care physician for a medicationreview. Interventions included notifyingthe physician that their patients were athigh risk for inappropriate prescribing,providing the physician with a medica-tion management report that listed allprescriptions, doses, and pills dispensedper prescription, and clinical practiceguidelines for effectively preventing andmanaging inappropriate prescribing. Theseguidelines emphasized the brown bagmedication review of both nonprescriptionand prescription medications (ie, havingthe patient bring all their medication to theoffice in a brown bag).

With this intervention, 20% ofpatients reported discontinuation of amedication, 29% reported a change inmedication, and 17% reported a medica-tion that the physician did not know thepatient was taking. Forty-five percent ofphysicians made at least 1 change in apatients medication regimen.23

Include all preparations patients use. Athird study showed that the medicationreview should focus not just on prescrip-tion drugs but also on nonprescriptionagents such as vitamins, laxatives, miner-als, analgesics, and herbal and naturalremedies. This prospective cross-sectionalstudy at 3 university affiliated geriatricclinics involved a room-to-room search ofpatients homes to identify all substances apatient might be taking. The medicationsidentified in the home were compared withthe medication list in the clinic and withmedications found in the brown bag eval-uation and by interview. The physicians

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understanding of medications a patientwas taking matched the patients actual useof medications only 52% of the time;much of the mismatch was attributable tononprescription medications.24

Finally, in a fourth study, a random-ized controlled trial, 133 communitydwelling adults taking 5 or more medica-tions were assessed at baseline by physi-cian exam, symptom review, and objectivetests of physical and cognitive functioning.Sixty-three subjects were randomized tothe intervention group and 77 to the con-trol group.

The primary intervention was a reviewand modification of a patients medicationregimen by a multidisciplinary team con-sisting of a consultant pharmacist, physi-cian, and nurse. This intervention was notavailable to the control group. Medicationusage in both groups was re-evaluated at 6weeks using a brown-bag review.

The control group decreased theirmedication use by an average of 0.04 med-ications per month, while the interventionsubjects decreased their medications by anaverage of 1.5 drugs (although the teamhas actually recommended discontinuationof an average of 4.5 drugs per patient).The difference between recommended dis-continuation and actual discontinuationwas attributed to patients resistance tochanging medications.

Intervention subjects saved an averageof $26.92 per month in wholesale costswhile control subjects saved an average of$6.75 per month. No differences in func-tioning were observed between groups.17

Method 4: Patient educationThe most beneficial intervention may beenhancing communication betweenproviders and patients, and educatingpatients about medication regimens, poten-tial side effects, and adverse drug events.

Encourage reporting of symptoms. Arecent prospective cohort study showedthat 63% of preventable events wereattributed to the physicians failure torespond to medication-related symptoms;37% were due to the patients failure to

inform the physician of the symptoms.25

Intensive counseling reaps big benefits.In a second study, the South DakotaMedication Reduction Project, educationalpresentations by pharmacists and one-on-one sessions between pharmacists andpatients resulted in patients taking fewermedications and reducing dosages in med-ical regimens. This longitudinal studyinvolved over 1000 older adults in ruraland urban southeastern South Dakotacommunities over 6 months.

A pharmacist specializing in geriatricsgave a 30-minute presentation at varioussites on medication-associated problemsand dos and donts of medicationuse. This was followed by a 15-minutequestion-and-answer session.

A one-on-one 20-minute consultationbetween the pharmacist and patients fol-lowed the group presentation. The phar-macist recorded demographic data, med-

T A B L E

MEDICATION POTENTIAL ADVERSE EFFECT

Meperidine (Demerol) Confusion

Propoxyphene (Darvon) CNS effects

Diphenhydramine (Benadryl) Sedation

Long-term use of NSAIDs GI bleeding

Amitriptyline (Elavil) Sedation/anticholinergic effects

Methyldopa (Aldomet) Bradycardia

Diazepam (Valium) Sedation

Cimetidine (Tagamet) Confusion

Nitrofurantoin (Macrodantin) Potential renal insufficiency

Clonidine (Catapres) Hypotension/CNS effects

Disopyramide (Norpace) Heart failure

Ketorolac (Toradol) GI bleeding

Short-acting nifedipine (Procardia) Hypotension

Doxazosin (Cardura) Hypotension

Potentially inappropriate medications in the elderly

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creo

Sending patients a simple letteradvising specificdrug reductionshelps deterpolypharmacy


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FAST TRACK

ical history, medication names, doses,directions, and intended purposes, andobtained feedback about compliance andside effects. The pharmacist also providedoral counseling and written informationabout medications.

If a potentially serious drug-relatedproblem was identified, a letter was sent tothe patients primary care physician, iden-tifying key inappropriate prescribing con-cerns and offering alternative interventionsfor the physicians consideration.

Three months after the educationalintervention, a telephone survey was per-formed. Survey results indicated that olderadults participating in the one-on-onereviews were taking fewer medications,were more likely to take their medications,had dosage reductions, and increased theiruse of nonpharmacologic alternatives.26

But even modest intervention pays off.In another randomized study, a simpleeducation intervention significantlyreduced inappropriate prescribing for eld-erly patients. Participants in the interven-tion group taking more than 10 medica-tions were sent a single letter recommend-ing that medications be reduced. Similarparticipants in the control group did notreceive letters.

The outcome measured was number ofmedications. In the notification group, anaverage reduction of approximately 3 med-ications occurred over a 4-month period.More complex intervention did not reduceinappropriate prescribing any further.2

Value of visual reminders. Anotherstudy showed that a simple visual inter-vention significantly reduced inappropri-ate prescribing. In this controlled trial,physicians were shown a medication gridthat displayed all of their patients medica-tions and times of administration for 1week. In the intervention group, medica-tions decreased by 2.47 per patient. In thecontrol group, medications increased by1.65 per patient and doses increased by3.83 per patient.27

Try a team approach? Yet another ran-domized study showed that compared withusual care, education through an outpa-

tient geriatric evaluation and managementprogram reduced the number of seriousadverse drug events and inappropriate pre-scribing for frail elderly patients. Patientmanagement guideline interventions con-sisted of regular assessments and medica-tion recommendations by pharmacists.There was also a core team comprised of ageriatrician, social worker, and a nurse whoparticipated in evaluation and managementprotocols such as medication reviews. Theprogram reduced the risk of serious adversedrug events by 35%, compared with usualcare of the geriatric patient.28

Method 5: Avoid inappropriate medicationsThe Beers criteria aid in identifying med-ications to be avoided in older persons.They were developed in 1991, then updat-ed in 1997 and again in 2003. In short,these criteria designate as inappropriateany medication that has shown the poten-tial for adverse effects in the elderly.7,29,30

In the 2003 update, a US consensuspanel of experts used a modified Delphimethod to review medications potentiallyineffective or unsafe in the elderly.7,29,30 TheTABLE shows selected examples of com-monly used medications considered inap-propriate.7,2932

Limited research supports use of theBeers criteria. The 1996 MedicalExpenditure Panel Survey controlled for anumber of confounding factors and foundstrong evidence of a sizable and consistentnegative effect of using medications identi-fied as inappropriate by the Beers criteria.32

DiscussionThe key findings of this study are that lit-tle evidence-based literature is available toguide recommendations for reducing inap-propriate prescribing in elderly patients.Only a handful of randomized controlledtrials have been conducted on the topic,and none of those trials involved personsolder than age 85.

However, 4 methods for reducinginappropriate prescribing in the elderly are

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Computerizedalerts in an inpatient setting havereduced medication errorsby 55%


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supported by some evidence: 1) incorpo-rating pharmacist recommendations; 2)using computerized alerts in the inpatientsetting; 3) reviewing medications; and 4)educating patients. No research evidencesupports use of the Beers Criteria, whichare based solely on consensus guidelinesand expert opinions.

Limited evidence suggests that inap-propriate prescribing and polypharmacycan be reduced by up to 24% using phar-macists recommendations based onreview of patients charts and medicationslists. This method of intervention may alsoreduce adverse drug events by 25% with-out adversely affecting health related qual-ity of life.

Though research has shown thatphysicians welcome pharmacists recom-mendations, further study is needed tolook at ways in which physicians andpharmacists may work together effectivelyto decrease inappropriate prescribing inthe elderly. In addition, since the studiesreviewed were conducted before the imple-mentation of Medicare Part D and itschange in pharmacy scope of practice, fur-ther study is needed to help define this newrole of the pharmacist.

The studies reviewed also show thatserious medication errors can be decreasedby 55% and adverse drug events by 84%when physicians use computerized alerts inthe inpatient setting. Considering the sig-nificance of hospital safety and qualitycare issues, this method provides anavenue for hospitals to decrease inappro-priate prescribing in elderly hospitalizedpatients. However, for computerized alertsto work in the inpatient setting, the physi-cian should have access to all pertinentpatient information to make an adequatedecision. Further study is also needed todetermine why physicians routinely bypassor override computerized alerts.

In addition, inappropriate prescribingand polypharmacy can be reduced when amultidisciplinary team consisting of a con-sulting pharmacist, physician, and nursereviews a patients medications through abrown bag review including nonpre-

scription substances such as vitamins andherbal products. This method of interven-tion will not only decrease the number ofmedications used by older patients but alsomedication costs. Further study is neededto see if similar results are achieved inGeriatric Assessment Clinics and also byusing the patients primary care physicianversus a comprehensive team approach formedication review.

Reducing inappropriate prescribing inthe elderly can also be achieved through asimple patient educational interventionsuch as a single letter recommending med-ications be reduced. Patient educationthrough an outpatient evaluation andmanagement program consisting of regu-lar assessments and medication reviewprotocols can reduce serious adverse drugevents by 35%.

The Beers Criteria have been widelyused for well over 10 years and have beenadopted by the Centers for Medicare andMedicaid Services for nursing home regu-lation. They are, however, based on a USConsensus Panel of experts using a modi-fied Delphi Method rather than on anyresearch evidence. The Beers Criteria maybe helpful solely as a guide in assisting thepractitioner to determine whether or not acertain medication may be consideredinappropriate for use in the older patient.However, further evidence-based researchis needed to determine which medicationsare considered inappropriate for use in theolder adult.

LimitationsThis systematic review has several limita-tions. First, there are few randomized con-trolled trials that address inappropriate pre-scribing in patients 65 years of age andolder, thus, limiting the strength of evidence.Secondly, the majority of studies reviewedinvolved healthy elderly and not ill elderly;thus, recommendations for reducing inap-propriate prescribing in the elderly may notapply to ill elderly. Finally, the systematicreview involved studies prior to MedicarePart D and thus do not take into accountthe provision of management programs


A medication gridis a helpful visualreminder ofpatients regimens


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FAST TRACK

under Medicare Part D. With the changingscope of pharmacy practice that MedicarePart D brings, further study will be neededto define the role of the pharmacist in pre-vention of medication errors.

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Five Ways You Can Reduce