Transcript Slide 1

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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, Thailand
2Department of Pharmacy, Bhuddhachinaraj Hospital, Muang, Phitsanulok, Thailand
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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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
Probability of having
drug-drug interaction
• Risk of drug-drug interactions
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
82%
38%
13%
2 drugs
4 drugs
more than 7
drugs
• Cost of drug-related morbidity and mortality : $76.6 billion annually.
• Incremental healthcare costs related to inappropriate prescribing in
older : $7.2 billion annually.
• 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”
Medications that have no clear evidence-based
indication, carry a substantially higher risk of adverse sideeffect or not cost-effective.
O’Mahony D, Gallagher PF. Inappropriate prescribing in the older population: need for new criteria. Age Aging. 2008 Mar; 37(2):138-41.
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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.
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Background
 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.
•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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Background
 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.
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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Objectives
 To determine the prevalence of PIMs in the Thai elderly
population.
 To identify factors associated with PIMs
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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Methods
Methods
 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
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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
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
– 4 severities classification
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
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.
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Results
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Results
Characteristics
Total
Age mean(SD)
65-74
75-84
≥85
Sex
Male
Female
Status of treatment
Universal Coverage (UC)
Social Security Scheme (SSS)
Civil Servants Medical Benefit Scheme (CSMBS)
Others
Total n (%)
14,994
73 (6.6)
9,360 (62.42)
4,810 (32.08)
824 (5.50)
6,533 (43.57)
8,461 (56.43)
7,532 (50.23)
46 (0.31)
7,347 (49.00)
69 (0.46)
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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

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Table 1. The Most Common Potentially Inappropriate Medications (PIMs) Use among
Elderly Thai Patients
High- risk medication used criteria
Classification*
Prevalence in year 2008 (%)
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)
Medications
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)
*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.
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
Results
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 Factors associated with PIMs
 Individual factors
o 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 factors
o Universal Coverage (UC): OR, 1.77 (1.72 – 1.82) compared with CSMBS
o 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)
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Conclusions &
Implications
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Conclusions
 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.
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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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
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011
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Contact information
Rosarin Sruamsiri, B.Pharm , M.B.A.
Center for Pharmaceutical Outcomes Research (CPOR)
Faculty of Pharmaceutical Sciences
Naresuan University
Muang, Phitsanulok, Thailand 65000
[email protected]
Third International Conference for Improving Use of Medicines, Antalya, Turkey, November 14-18,2011