Inappropriate Prescribing for Elderly Americans in a Large Outpatient Population

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http://archinte.ama-assn.org/cgi/content/full/164/15/1621

 

Inappropriate Prescribing for Elderly Americans in a

Large Outpatient Population

 

Lesley H. Curtis, PhD; Truls Østbye, MD, PhD; Veronica

Sendersky, PharmD; Steve Hutchison, PhD; Peter E.

Dans, MD; Alan Wright, MD, MPH; Raymond L. Woosley,

MD, PhD; Kevin A. Schulman, MD

 

Arch Intern Med. 2004;164:1621-1625.

 

ABSTRACT

 

 

Background We sought to determine the extent of

potentially inappropriate outpatient prescribing for

elderly patients, as defined by the Beers revised list

of drugs to be avoided in elderly populations.

 

Methods We conducted a retrospective cohort study

using the outpatient prescription claims database of a

large, national pharmaceutical benefit manager. The

cohort included 765 423 subjects 65 years or older,

who were covered by a pharmaceutical benefit manager

and filed 1 or more prescription drug claims during

1999. Main outcome measures were the proportion of

subjects who filled a prescription for 1 or more drugs

of concern and the proportion of subjects who filled

prescriptions for 2 or more of the drugs.

 

Results A total of 162 370 subjects (21%) filled a

pre-scription for 1 or more drugs of concern.

Amitriptyline and doxepin accounted for 23% of all

claims for Beers list drugs, and 51% of those claims

were for drugs with the potential for severe adverse

effects. More than 15% of subjects filled

prescriptions for 2 drugs of concern, and 4% filled

prescriptions for 3 or more of the drugs within the

same year. The most commonly prescribed classes were

psychotropic drugs and neuromuscular agents.

 

Conclusions The common use of potentially

inappropriate drugs should serve as a reminder to

monitor their use closely. Pharmaceutical claims

databases can be important tools for accomplishing

this task, though clinical and laboratory data are

needed to improve the sensitivity and specificity of

patient-specific alerts.

 

(snip)

 

Persons 65 years or older make up less than 15% of the

US population but account for nearly one third of

prescription drug consumption.1 Elderly persons are

more likely to have more than 1 chronic disease or

condition, further increasing the likelihood that they

take several drugs concurrently.2 Most prescription

drugs, when dosed and taken appropriately, have

considerable potential to reduce morbidity and

mortality and improve functioning. The potential

benefits must be weighed, however, against the

substantial risk of adverse effects that increases

with age.3-5 The increased risk reflects changes in

metabolism and excretion that occur with aging and is

compounded by the number of prescription drugs taken.6

 

(snip)

 

Seven psychotropic drugs (amitriptyline,

chlordiazepoxide, diazepam, doxepin, flurazepam,

hydroxyzine, and meprobamate) and 5 neuromuscular

agents (carisoprodol, chlorzoxazone, cyclobenzaprine,

metaxalone, and methocarbamol) were included on the

Beers list. More than 210 000 subjects (27.5% of the

study population) filled a prescription for a

psychotropic drug in 1999. Of those, more than 25 000

subjects (12.6%) filled a prescription for

amitriptyline and 17 178 (8.2%) filled a prescription

for diazepam. Nearly 40 000 subjects (5.1%) filled

prescriptions for neuromuscular agents. Of those, 15

690 (14.1%) filled a prescription for cyclobenzaprine.

 

(snip)

 

CONCLUSIONS

 

Using a national sample of prescription drug claims

for elderly patients enrolled with a PBM, we found

that more than 1 in 5 patients filled a prescription

for 1 or more drugs of concern during 1999. Of those,

more than 15% filled prescriptions for 2 different

drugs of concern and 4% filled prescriptions for 3 or

more of such drugs. Psychotropic drugs alone accounted

for more than 45% of the claims for drugs on the Beers

list. Online, computerized systems that support PBM

databases provide an important tool for identifying

potentially dangerous prescribing patterns, but they

require augmentation with clinical and laboratory data

to strengthen the sensitivity and specificity of the

alerts.