Transcript PIMs
Improving the Appropriateness of Prescribing in Elderly Patients. Is it feasible? A comprehensive Approach in the Local Health Unit of Parma, Italy Presenting Author: Stefano Del Canale, M.D., Ph.D. Co-authors: Ettore Brianti, M.D. Massimo Fabi, M.D. Scott W. Keith, Ph.D., M.S. Kellie Dudash, PharmD Megan Templin, M.S. Vittorio Maio, PharmD, M.S., MSPH Background Potentially inappropriate medications (PIMs) are those medications whose adverse risks exceed their health benefits1 PIMs use in the community-dwelling elderly is associated with negative patient health outcomes2,3 Using the Beers Criteria, preliminary data in the EmiliaRomagna Region, Italy, showed that 1 out of 5 elderly patients are subject to PIMs in ambulatory settings4 1) Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication nuse in community-residing older persons. Arch Intern Med. 1994;154:21952200. 2) Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in the elderly. J Am Geriatr Soc J. 2004;52:1934-1939. 3) Jano E, Aparasu RR. Healthcare outcomes associated with Beer’s Criteria: a systematic review. Ann Pharmacthero. 2007;41(3):438-447. 4) Maio V, Yuen E, Novielli K, et al. Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy: A Population-Based Cohort Study Drugs & Aging 2006; 23(11):915-924 Objective To enhance physicians’ knowledge of prescribing for the elderly and improve the quality of prescribing in the primary care setting in the Local Health Unit (LHU) of Parma, Italy Methods A 3-year, multi-phase prospective demonstration project targeting all 303 general practitioners (GPs) in the LHU of Parma, Italy, was established in 2007 Key Elements of multi-phase Intervention: 2007 Q1-Q3 2007 Q4 2007 Development of PIMs list Dissemination of PIMs list to GPs & annual review of PIMs prevalence data Q4 2009 2010 Case studies presentation & annual review of PIMs prevalence data Q1-Q3 2009 Development of case studies on PIMs Q1-Q3 2008 Dissemination of alternative list of drugs to GPs Q4 2008 Annual review of PIMs prevalence data PIMs list determined by expert panel category and generic drug name5 Always Avoided Amitriptyline Chlorpropamide Cimetidine Clonidine (oral) Digoxine (>0/125 mg/day) Disopyramide Ferrous sulphate (>325 mg/day) Indomethacin Ketorolac (injectable, >2 days) Methyldopa Nifedipine (short-acting) Nitrofurantoin NSAIDs (oral, >15 days) Oestrogens (oral) Orphenadrine Pentazocine Testosterone Rarely Appropriate Ticlopidine Doxazosin Fluoxetine Clonidine (patch) Atypical antipsychotics* Some Indications Amiodarone *The following selected drugs were included in the analysis: risperidone, clozapine, olanzapine, quetiapine, aripiprazole 5) Maio V, Del Canale S, Abouzaid S, et al. Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther. 2009;34:1-11. Renal effects of NSAIDs and COX-2 inhibitors Arachidonic acid cascade NSAIDs COXIBs COX-2 PGE2 /PGI2 Sodium retention Peripheral oedema Hypertension CHF Renal Failure Acute Prerenal ATN Perazella, M. Expert Opin Drug Saf. 2002;1:53-64. Hyperkalemia Severe ADRs resulting in Hospital Admission showed for Drug Classes (GIFA STUDY) ACEI 7 Insulin 8 Antipsychotics 10 Ca- channel blockers 11 Steroids 12 Antibiotics 13 Antineoplastics 14 Digoxin 14 Diuretics 17 ASA - Antiplatelets 22 NSAIDs 27 0 5 10 15 20 25 30 Onder, JAGS 2002; 50: 1962-8 Methods Study Design Pre-post design to analyze the change in quarterly rates of PIMs. The neighboring Reggio Emilia LHU was evaluated as the comparator population Time Frame Q4 2007 (baseline) to Q4 2009 (end of follow up period) Population Elderly patients aged 65 years and older living in Parma LHU and Reggio Emilia LHU with at least 1 pharmacy claim during the time frame Measurement of Rates of PIMs Percentage of elderly exposed to PIMs by quarter Statistical Tests Differences in overall chi-squared rates of PIMs and for each PIM over time between Parma LHU and Reggio Emilia LHU were evaluated by the Breslow-Day test of homogeneous odds. Results: Parma LHU By Quarter Prevalence of elderly receiving always inappropriate prescribed medications (PIMs) in Parma LHU from Q4 2007 through Q4 2009 Subjects receiving PIMs Subjects receiving any medications Proportion of subjects receiving PIMs (%) Comparison to baseline (% change) Comparison to previous quarter (% change) 2007 Q4 (Baseline) 6416 78506 8.17 - - 2008 Q1 5762 78766 7.32 -10.49 -10.49 2008 Q2 5755 78867 7.30 -10.71 -0.25 2008 Q3 5322 77757 6.84 -16.25 -6.20 2008 Q4 5258 79514 6.61 -19.09 -3.39 2009 Q1 4716 79580 5.93 -27.49 -10.38 2009 Q2 5070 79820 6.35 -22.28 7.18 2009 Q3 4583 78576 5.83 -28.63 -8.17 2009 Q4 (Follow-up) 4575 80250 5.70 -30.24 -2.26 Measurement period Proportion of elderly receiving PIMs in Parma LHU and Reggio LHU by Quarter Breslow-Day test, p=0.004 Summary A quality intervention program looking at improving knowledge in primary care physicians on prescribing for the elderly patients resulted in a substantial reduction of the rate of PIMs The greatest impact was seen in users of digoxin and NSAIDs, with a significant potential benefit for patients Limitations PIMs with a low rate of use at baseline may be impossible to lower any further and may diminish the overall impact of our intervention The study does not measure the impact of the intervention on other healthcare resource use or patient outcomes Future Directions Additional analyses should be performed to further investigate: Which physicians were less prone to change prescribing and use results to design targeted educational interventions Whether the observed change may be retained over time Thank you! 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