Transcript Quality, Efficiency and Equity in Prescribing in Ireland

Caitriona Cahir
HRB PhD Scholar
Division of Population Health Sciences
RCSI
Measuring and Evaluating
Indicators of Appropriate
Prescribing
Older
Potentially in
inappropriate
Populations
prescribing
and cost
outcomes for older people: a
national
population
Cahir
C., Teeling
M., study
Teljeur C., Bennett K., Fahey T.
HRB PhD ScholarC Cahir, T Fahey, M
Division of Population Health Sciences
J
Feely,
K
RCSI
Teeling, C Teljeur,
Bennett
Structure of Presentation
• Brief background to study
• Objectives
• Methods
• Results
• Summary
Background
Prescribing for older people is a challenging process
•
Multi-morbidity
•
Physiological changes
– Pharmacokinetics e.g. digoxin and toxicity
– Pharmacodynamics e.g. benzodiazepines and
falls
– Cognitive impairment e.g. dementia
Background
• How do we measure appropriate prescribing in
older people?
• Appropriateness of prescribing – assessed by
process or outcome measures that are implicit
(judgment based) or explicit (criterion based)
• Explicit process measures of potentially
inappropriate prescribing (PIP)
– Beers criteria (International)
– STOPP screening tool (Irish & UK)
Objectives
1. Estimate the prevalence of PIP in a national
Irish older population in 2007 using Beers
and STOPP criteria
2. Investigate the association between PIP,
number of medications, gender and age
3. Establish the associated cost of PIP
Method
• Retrospective national population study (aged ≥70
years) using the HSE-PCRS for a one year period
(2007) (n=338,801)
• Health Services Executive Primary Care
Reimbursement Services (HSE-PCRS) –
prescription claims, WHO ATC, gender, age
• Beers (independent of diagnosis) and thirty STOPP
indicators applied
RESULTS
OVERALL
PIP Overall Prevalence Rates
(n=338,801)
Beers
STOPP
ONE PIP
25.31%
24.78%
TWO PIP
6.39%
8.08%
THREE PIP
1.27%
2.28%
OVERALL PIP 33.22%
35.84%
PIP and Number of Medications
• Strong association between PIP and the number of
different medications
– Beers (10 drugs vs none) OR=9
– STOPP (10 drugs vs none) OR=50
Association between the number of different
medications and PIP (STOPP) in 2007
60
50
Odds ratio
40
30
20
10
0
1
2
3
4
5
6
7
No of drug classes (vs none)
* Linear and quadratic trend p<0.0001
8
9
10+
PIP and Gender and Age
•
PIP more likely in females vs males
–
–
•
PIP more likely in those aged >75yrs vs. 70-74yrs
–
–
•
Beers (1.58, 1.56 to 1.60)
STOPP (1.10, 1.08 to 1.12)
Beers (1.22, 1.20 to 1.24)
STOPP (1.28, 1.26 to 1.30)
Additionally adjusting for number of medications
–
–
–
–
Beers Gender (1.46, 1.44 to 1.48)
STOPP Gender (0.91, 0.90 to 0.93)
Beers Age (0.98, 0.97 to 1.00)
STOPP Age (0.95, 0.93 to 0.96)
RESULTS
INDIVIDUAL CRITERIA
Beers Adjusted Analysis 2007
5 highest prevalence rates per drug class
(n=338,801)
BEERS DESCRIPTION
PREV %
OR
GENDER
(F vs M)
OR AGE
(>75 vs 70-74)
CNS
Long acting benzodiazepines
(risk of falls, fractures)
12.93%
1.67
(1.63– 1.70)
0.88
(0.87-0.90)
Cardio
Doxazosin
(hypotension, dry mouth, urinary
problems)
5.29%
0.99
(0.96-1.02)
0.82
(0.79- 0.85)
CNS
Doses of short acting
benzodiazepines
(smaller doses more effective)
4.96%
1.45
(1.41- 1.50)
1.19
(1.15-1.23)
Gastro
Gastrointestinal antispasmodic drugs 2.53%
(highly anticholinergic and uncertain
effectiveness)
1.30
(1.24-1.36)
0.91
(0.87-0.95)
CNS
Amitriptyline
(anticholingeric and sedation
properties)
1.42
(1.35-1.49)
0.74
(0.70-0.77)
2.40%
STOPP Adjusted Analysis 2007
5 highest prevalence rates per drug class
(n=338,801)
STOPP DESCRIPTION
PREV %
OR
GENDER
(F vs M)
OR AGE
(>75 vs 70-74)
Gastro
PPI > 8 weeks
full therapeutic dose
(dose reduction, discontinuation)
16.69%
0.80
(0.78-0.81)
1.05
(1.02-1.07)
Musco
NSAID >3M
(simple analgesics preferable)
8.76%
1.25
(1.22-1.28)
0.78
(0.76-0.81)
CNS
>1M Long-acting
benzodiazepines
(risk of falls, fractures)
5.22%
1.72
(1.65- 1.78)
0.89
(0.87-0.92)
Duplicates
NSAIDs, SSRIs, Antidep, ACE,
Loop diuretics, opioids
(optimisation of monotherapy)
4.78%
1.19
(1.15-1.23)
0.74
(0.71-0.76)
Cardio
Beta-blocker with COPD
2.34%
0.53
(0.51-0.56)
0.84
(0.80-0.89)
(risk of increased bronchospasm)
RESULTS
COSTS
Overall Costs
• Beers maximum costs
– Net ingredient cost
– Total expenditure
€10,712,129
€15,478,526
• STOPP maximum costs
– Net ingredient cost
– Total expenditure
€38,664,640
€45,631,319
Beers Cost Analysis 2007
Highest costs as a proportion of overall costs
(NIC= €10,712,129 and Total Exp=€15,478,526)
BEERS DESCRIPTION
NIC €
TOTAL EXP €
Doxazosin
5,400,793 (50%) 6,196,854 (40%)
Long-acting benzodiazepines
890,252 (8%)
2,397,549 (15%)
Nifedipine
849,995 (8%)
1,151,294 (7%)
Fluoxetine
800,637 (7%)
958,362 (6%)
Muscle relaxants and antispasmodics
738,213 (7%)
916,362 (6%)
Total of other criteria
2,032,239 (19%) 3,858,104 (25%)
STOPP Cost Analysis 2007
Highest costs as a proportion of overall costs
(NIC=€38,664,640 and Total Exp= €45,631,319)
STOPP DESCRIPTION
NIC €
TOTAL EXP €
PPI > 8 weeks full therapeutic dose
22,352,240 (58%)
24,715,010 (54%)
Neuroleptics >1M
Neuroleptics >1M with Parkinsonism
Anticholingerics for side-effects
5,612,192* (15%)
6,079,905 (13%)
Duplicate drugs
4,531,160 (12%)
5,499,118 (12%)
NSAID >3M
Warfarin and NSAIDs
3,969,629* (11%)
5,050,640* (11%)
Long-acting benzodiazepines >1M
572,009 (1%)
1,352,209 (3%)
Total of other criteria
1,627,410 (4%)
2,934,437 (6%)
* Adjusted for claimants receiving the same medication per more than one criteria
Summary
• High prevalence of PIP in older populations in
Ireland per Beers and STOPP criteria
• The greater the number of medications the more
likely PIP
• Differences in prevalence rates across gender
and age groups
• Significant costs
Acknowledgements
• Dr Stephen Byrne, School of Pharmacy and Dr
Denis O’Mahony,Department of Medicine, UCC
for developing the STOPP criteria
• Health Services Executive Primary Care
Reimbursement Services (HSE-PCRS)
• The Health Services Research Institute - the Irish
Health Research Board’s (HRB) Cross-Institution
PhD Scholars Programme in Health Services
Research
• HRB Centre for Primary Care Research
Duplicates and PPIs
• Duplicates – 4.78%
– Two concurrent NSAIDs (2.22%)
Diclofenac with glucosamine or nimesulide
– Two concurrent opioids (1.24%)
Tramadol with codeine and morphine
• PPIs
– Co-prescriptions (asp, warfarin, NSAID)
– Duration and dosage