Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review

Abstract

Background Potentially inappropriate medications (PIM) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized. Methods We systematically searched published literature within MEDLINE® and Embase® from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the Emergency Department (ED), or in the hospital. Paired reviewers independently screened abstracts and full text articles, assessed quality and extracted data. Results Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute-care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6 to 92%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians. Conclusions Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.

Discontinuation of medications at the end of life: A population study in Belgium, based on linked administrative databases

“…Chronic medication use was higher in the group for whom at least one PIM was continued. As the number of prescribed medications was found to be the main driver of PIM use in earlier studies, these people were likely to use more PIMs.…”

“…With these strengths and limitations in mind, we can identify dispensing of PIMs during well‐defined time periods, and draw cautious, coarse‐grained conclusions regarding their discontinuation. Research has demonstrated that the main determinant of PIM use is the number of prescribed medications, which is probably confounded by the number and type of co‐morbidities . Adding clinical patient data and data on concomitant use of medications and treatment duration would create extensive opportunities for further research.…”

“…Moreover, if hospitalized on another ward, the treating physician is encouraged to consult a geriatric support team—including a geriatrician—for patients with a positive geriatric risk profile, indicating increased frailty . Research has demonstrated that geriatricians prescribe fewer PIMs compared to other clinicians . Possibly, geriatricians are more aware of existing criteria and tools to identify PIMs and to support deprescribing and clinical practice deprescribing guidelines due to the need to change care goals and treatment targets in severely ill or frail older patients with limited life expectancy.…”

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review†

“…This was done given the substantial changes in the United States healthcare system in the last decade including an increased focus on quality of PIM prescribing following publication of the landmark Institute of Medicine report Crossing the Quality Chasm, revision of the Beers criteria and an increasing focus on quality of care . Studies which exclusively evaluated older adults in the hospital or nursing home were excluded as we have previously published a review of studies in these settings . Studies which used large claims or administrative databases that included inpatient hospital care were included as it was felt that the majority of the included claims were generated by community‐dwelling adults seeking ambulatory care.…”

A Consumer Health Information System to Assist Patients Select Quality Home Health Services

“…The geographic difference by state is common in healthcare. For instance, Gupta et al found a significant difference in patient pain care perception between the states [17], while Nothelle et al reported a difference in potentially inappropriate medication use between US regions [18]. Similarly, Cole, Wilson, and Trivedi reported state variation in quality outcome for community health centers [19].…”