Measuring and Evaluating Indicators of Appropriate Prescribing in Older Populations Cahir C., Teeling M., Teljeur C., Bennett K., Fahey T. HRB PhD Scholar Division of Population Health Sciences RCSI Caitriona Cahir HRB PhD Scholar Division of Population Health Sciences RCSI Potentially inappropriate prescribing and cost outcomes for older people: a national population study C Cahir, T Fahey, M Teeling, C Teljeur, J Feely, K 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) BeersSTOPP ONE PIP25.31%24.78% TWO PIP6.39%8.08% THREE PIP1.27%2.28% OVERALL PIP33.22%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 * Linear and quadratic trend p<0.0001

PIP and Gender and Age PIP more likely in females vs males –Beers (1.58, 1.56 to 1.60) –STOPP (1.10, 1.08 to 1.12) PIP more likely in those aged >75yrs vs yrs –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 highest prevalence rates per drug class (n=338,801) BEERS DESCRIPTIONPREV %OR GENDER (F vs M) OR AGE (>75 vs 70-74) CNSLong acting benzodiazepines (risk of falls, fractures) 12.93%1.67 (1.63– 1.70) 0.88 ( ) CardioDoxazosin (hypotension, dry mouth, urinary problems) 5.29%0.99 ( ) 0.82 ( ) CNSDoses of short acting benzodiazepines (smaller doses more effective) 4.96%1.45 ( ) 1.19 ( ) GastroGastrointestinal antispasmodic drugs (highly anticholinergic and uncertain effectiveness) 2.53%1.30 ( ) 0.91 ( ) CNSAmitriptyline (anticholingeric and sedation properties) 2.40%1.42 ( ) 0.74 ( )

STOPP Adjusted Analysis highest prevalence rates per drug class (n=338,801) STOPP DESCRIPTIONPREV %OR GENDER (F vs M) OR AGE (>75 vs 70-74) GastroPPI > 8 weeks full therapeutic dose (dose reduction, discontinuation) 16.69%0.80 ( ) 1.05 ( ) MuscoNSAID >3M (simple analgesics preferable) 8.76%1.25 ( ) 0.78 ( ) CNS>1M Long-acting benzodiazepines (risk of falls, fractures) 5.22%1.72 ( ) 0.89 ( ) DuplicatesNSAIDs, SSRIs, Antidep, ACE, Loop diuretics, opioids (optimisation of monotherapy) 4.78%1.19 ( ) 0.74 ( ) CardioBeta-blocker with COPD (risk of increased bronchospasm) 2.34%0.53 ( ) 0.84 ( )

RESULTS COSTS

Overall Costs Beers maximum costs –Net ingredient cost €10,712,129 –Total expenditure€15,478,526 STOPP maximum costs –Net ingredient cost€38,664,640 –Total expenditure€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 DESCRIPTIONNIC €TOTAL EXP € Doxazosin5,400,793 (50%)6,196,854 (40%) Long-acting benzodiazepines890,252 (8%)2,397,549 (15%) Nifedipine849,995 (8%)1,151,294 (7%) Fluoxetine800,637 (7%)958,362 (6%) Muscle relaxants and antispasmodics738,213 (7%)916,362 (6%) Total of other criteria2,032,239 (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 DESCRIPTIONNIC €TOTAL EXP € PPI > 8 weeks full therapeutic dose22,352,240 (58%)24,715,010 (54%) Neuroleptics >1M Neuroleptics >1M with Parkinsonism Anticholingerics for side-effects 5,612,192* (15%)6,079,905 (13%) Duplicate drugs4,531,160 (12%)5,499,118 (12%) NSAID >3M Warfarin and NSAIDs 3,969,629* (11%)5,050,640* (11%) Long-acting benzodiazepines >1M572,009 (1%)1,352,209 (3%) Total of other criteria1,627,410 (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