The Quality of Pharmacologic Care for Vulnerable Older Patients

Higashi, Takahiro; Shekelle, Paul G; Solomon, David H.; Knight, Eric L.; Roth, Carol P.; Chang, John T.; Kamberg, Caren; MacLean, Catherine H.; Young, Roy T.; Adams, John; Reuben, David B.; Avorn, Jerry; Wenger, Neil S.

doi:10.7326/0003-4819-140-9-200405040-00011

Cited by 200 publications

(165 citation statements)

References 36 publications

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“…Of these, 142 quality indicators pertained to pharmacologic care. Following the methodology used in other studies [18], the pharmacologic indicators were stratified into 4 domains: "prescribing indicated medications" with 68 indicators, "avoiding inappropriate medications" with 19 indicators, "education, continuity, and documentation" with 43 indicators and "monitoring" with 12 indicators. Finally, 11 out of the total 26 conditions, and their corresponding 37 quality indicators from the prescribing indicated medications domain were selected for the study (see Appendix 2 on the online material only).…”

Section: Methodsmentioning

confidence: 99%

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Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

San-José

Agustí

Vidal

et al. 2014

European Journal of Internal Medicine

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Methods: An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75 years and older were randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess Potentially Prescribing Omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed.Results: 672 patients [median age (Q1_Q3) 82 (79-86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1-Q3 7-13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p<.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p<.001) was observed. Polypharmacy (≥10 medicines) was the strongest Conclusions: A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different.

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Section: Methodsmentioning

confidence: 99%

“…The ACOVE project approach is more comprehensive as it includes pharmacologic care indicators [16,17]. Studies in the United States, focusing on the ACOVE pharmacologic care indicators, show that underprescribing indicators get the worst results, affecting 50% of patients [18].…”

Section: Introductionmentioning

confidence: 99%

Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

San-José

Agustí

Vidal

et al. 2014

European Journal of Internal Medicine

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“…1,2 These findings have highlighted the need for improved physician adherence to clinical practice guidelines and better methods to measure guideline adherence. 3 However, both clinicians and researchers have expressed concern that widespread application of clinical practice guidelines may have unintended negative consequences for complex patients.…”

Section: Introductionmentioning

confidence: 99%

The Impact of Concordant and Discordant Conditions on the Quality of Care for Hyperlipidemia

et al. 2008

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BACKGROUND: Physician treatment of cardiovascular risk factors may be affected by specific types of patient comorbidities.OBJECTIVES: To examine the relationship between discordant comorbidities and LDL-cholesterol management in hypertensive patients not previously treated with lipid-lowering therapy; to determine whether the presence of cardiovascular (concordant) conditions mediates this relationship. DESIGN:We performed a retrospective cohort study of 1,935 hypertensive primary care patients (men >45 years of age, women >55 years of age) with documented elevated low-density lipoprotein (LDL) cholesterol and no lipid-lowering therapy at baseline. The outcome was guideline-consistent hyperlipidemia management defined as optimal value on repeat LDL cholesterol testing or initiation of lipid-lowering therapy. Using generalized estimating equations (GEE), we examined the association of concordant and discordant comorbidities with guideline-consistent hyperlipidemia management over a 2-year follow-up period, adjusting for patient characteristics.RESULTS: Guideline-consistent hyperlipidemia management was achieved in 1,236 patients (64%). In the fully adjusted model, each additional discordant condition resulted in a 19% lower adjusted odds ratio of guideline-consistent hyperlipidemia management (p< 0.001) when compared with no discordant conditions. The dampening effect of discordant conditions on guideline-consistent management persisted even in the presence of concordant conditions, but each additional concordant condition was associated with a 37% increase in the adjusted odds of guideline-consistent hyperlipidemia management (p<0.001).CONCLUSIONS: In this cohort of hypertensive primary care patients, the number of conditions discordant with cardiovascular risk was strongly negatively associated with guideline-consistent hyperlipidemia management even in patients at the highest risk for cardiovascular events and cardiac death.KEY WORDS: hyperlipidemia; quality of care; comorbidity.

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“…20 Moreover, recent studies demonstrate that older patients are both overprescribed contraindicated drugs 21 and underprescribed ACE inhibitors for hypertensive and diabetic renal disease. 22 We hypothesized that 4 years after publication of the NKF guidelines and initiation of the National Kidney Disease Education Project (NKDEP) aimed at raising awareness among primary care providers, 23 renal disease would still be underdiagnosed in the primary care setting, especially for older patients with near normal serum creatinine, and that failure to recognize kidney disease would lead to underprescribing of renal protective medicines and inappropriate prescribing of other, harmful medications.…”

Section: Introductionmentioning

confidence: 99%

Recognition and Management of Chronic Kidney Disease in an Elderly Ambulatory Population

et al. 2008

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BACKGROUND: Chronic kidney disease (CKD) is a growing problem among the elderly. Early detection is considered essential to ensure proper treatment and to avoid drug toxicity, but detection is challenging because elderly patients with CKD often have normal serum creatinine levels. We hypothesized that most cases of CKD in the elderly would go undetected, resulting in inappropriate prescribing. OBJECTIVE:To determine whether recognition of CKD is associated with more appropriate treatment DESIGN: Retrospective chart review PARTICIPANTS: All patients aged ≥65 years with a measured serum creatinine in the past 3 years at 2 inner city academic health centers.MEASUREMENTS: Estimated glomerular filtration rate (eGFR) calculated using the Modified Diet in Renal Disease equation, and for patients with eGFR<60, documentation of CKD by the provider, diagnostic testing, nephrology referral and prescription of appropriate or contraindicated medications. RESULTS:Of 814 patients with sufficient information to estimate eGFR, 192 (33%) had moderate (eGFR< 60 mL/min) and 5% had severe (eGFR<30 mL/min) CKD. Providers identified 38% of moderate and 87% of severe CKD. Compared to patients without recognized CKD, recognized patients were more likely to receive an ACE/ARB (80% vs 61%, p=.001), a nephrology referral (58% vs 2%, p<.0001), or urine testing (75% vs 47%, p<.0001), and less likely to receive contraindicated medications (26% vs 40%, p=.013). CONCLUSIONS:Physicians frequently fail to diagnose CKD in the elderly, leading to inappropriate treatment. Efforts should focus on helping physicians better identify patients with low GFR.

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The Quality of Pharmacologic Care for Vulnerable Older Patients

Abstract: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.

Cited by 200 publications

References 36 publications

Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

The Impact of Concordant and Discordant Conditions on the Quality of Care for Hyperlipidemia

Recognition and Management of Chronic Kidney Disease in an Elderly Ambulatory Population

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