The elderly and drug policy: coming of age.
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Aged↗
Biomedical subjects
J Avorn
Publications and source records attributed to J Avorn.
Medicaid-based pharmacoepidemiology: claims and counterclaims.
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Databases, Factual↗
Use of psychoactive medication and the quality of care in rest homes. Findings and policy implications of a statewide study.
Rest homes have become a major component of the health care system for frail elderly persons and deinstitutionalized psychiatric patients. Although psychoactive medications are frequently used in rest homes, there is little detailed information about the extent of such use, its supervision, or its effects. In a survey of a random sample of 55 rest homes in Massachusetts, we found that 55 percent of the residents were taking at least one psychoactive medication. Antipsychotic medications were being administered to 39 percent; of these, 18 percent were receiving two or more such drugs. In a follow-up investigation, we studied 837 residents in 44 rest homes with particularly high levels of antipsychotic-drug use. About half the residents had no evidence of participation by a physician in decisions about their mental health during the year of the study. A third of the residents had performance deficits on mental-status testing that indicated serious cognitive impairment, although the causal relation of such impairment to medication use could not be determined. Six percent had evidence of moderate or severe tardive dyskinesia, probably as a side effect of medication. An assessment of staff competence revealed a low level of comprehension of the purpose and side effects of commonly used psychoactive drugs. We conclude that psychoactive drugs are widely used in rest homes, with little medical supervision or understanding by staff members of their possible side effects.
Aged↗
Physician motivations for nonscientific drug prescribing.
Although there is increasing concern about inappropriate physician prescribing and how to devise programs to improve drug therapy decisions, little research has been published documenting the reasons for such misprescribing. We analyzed the motivations reported by 141 physicians who were part of a large multi-state randomized controlled trial of 'academic detailing.' The physicians were identified from state Medicaid prescribing records as moderate to high prescribers of cerebral or peripheral vasodilators, propoxyphene, or cephalexin, and were visited by clinical pharmacists serving as outreach educators in a medical school-based prescribing improvement program. Physicians' motivations for their prescribing patterns were discussed in an informal, interactive manner; all responses were recorded in detail by the pharmacists immediately following each visit. Of the 110 responses elicited, the most common reason offered by physicians for use of these medications was patient demand (51 statements, or 46%). Physicians also frequently attributed their prescribing of these drugs to intentional use of placebo effect (24%). An equally common reason was prescribers' assertion that their own clinical experience indicated that these drugs were actually therapies of choice in the conditions presented (26%), despite evidence from the research literature that this was not the case. Such indications included the use of the 'vasodilators' for senile dementia or peripheral vascular disease, cephalexin for viral upper respiratory infections, and propoxyphene instead of acetaminophen or aspirin for mild pain. Greater attention must be paid to physicians' attitudes and motivations concerning suboptimal prescribing if programs are to succeed in replacing these practices with more rational clinical decision-making.
Drug Prescriptions↗
Medicaid data as a resource for epidemiologic studies: strengths and limitations.
Large claims databases from third-party insurance programs such as Medicaid have attracted the interest of epidemiologists because of their enormous size and apparent comprehensiveness. Over 20 million people are covered by the various state Medicaid programs and most states maintain detailed computerized records of all reimbursed health care encounters on a recipient-specific basis. For states covering medication costs, data on drug exposures are particularly complete and accurate. However, Medicaid claims data also have many limitations that can pose major methodological difficulties. Foremost among these is the uneven validity and completeness of the diagnoses appearing on claims. Likewise, the unique identification of specific program participants is not straightforward, although useful approaches can often be developed to track individuals over time. Consideration of the limitations as well as the possible strengths of claims-based data makes it possible to choose appropriate study hypotheses as well as to attempt solutions, where possible, to the biases of this methodology.
Drug Utilization↗
Improving drug prescribing in primary care: a critical analysis of the experimental literature.
Seven percent of all health expenditures in the United States in 1987 was allocated for medications. Accurate prescribing decisions thus have crucial implications for both economic and clinical aspects of health care. A review of 44 empirical studies indicates that different strategies to improve the prescription practices of primary care physicians have proved effective to varying degrees; administrative reminders and feedback systems appear to be suitable for group practices, while one-on-one educational interventions may work well in less-structured office settings. Better-controlled trials and quasi-experimental designs, together with cost-benefit analyses, are still needed to enhance the efficacy and efficiency of prescribing practices.
Ambulatory Care↗
Psychoactive medication use in intermediate-care facility residents.
Despite the large number of elderly patients in nursing homes and the intensity of medication use there, few current data are available on patterns of medication use in this setting. We studied all medication use among 850 residents of 12 representative intermediate-care facilities in Massachusetts. Data on all prescriptions and patterns of actual use were recorded for all patients during one month. On average, residents were prescribed 8.1 medications during the month (interquartile range, 7.4 to 8.8) and actually received 4.7 (range, 4.2 to 5.4) medications during this period. More than half of all residents were receiving a psychoactive medication, with 26% receiving antipsychotic medication. Twenty-eight percent of patients were receiving sedative/hypnotics during the study month, primarily on a scheduled rather than an as-needed basis. Of patients receiving a sedative/hypnotic, 26% (range, 14% to 41%) were taking diphenhydramine hydrochloride, a strongly anticholinergic hypnotic. Of those receiving one of the benzodiazepines, 30% were receiving long-acting drugs, generally not recommended for elderly patients. The typical benzodiazepine dose was equivalent to 7.3 mg per patient per day of diazepam. The most commonly used antidepressant was amitriptyline hydrochloride, the most sedating and anticholinergic antidepressant in common use. These data indicate that despite growing evidence of the risks of psychoactive drug use in elderly patients, the nursing home population studied was exposed to high levels of sedative/hypnotic and antipsychotic drug use. Suboptimal choice of medication within a given class was common, and use of standing vs as-needed orders was often not in keeping with current concepts in geriatric psychopharmacology. Additional research is needed to assess the impact of such drug therapy on cognitive and physical functioning, as well as to determine how best to improve patterns of medication use in this vulnerable population.
Aged↗
Sociodemographic and behavioral characteristics of HIV antibody-positive blood donors.
This paper describes the sociodemographic and behavioral characteristics of 173 blood donors who were confirmed by Western blot tests to have antibodies to human immunodeficiency virus (HIV), the etiologic agent for acquired immunodeficiency syndrome (AIDS). Seropositive donors were predominantly young, unmarried, and male, and major risk factors could be identified for almost all donors. However, more than 20 per cent of the study participants were women, and many participants were not aware that they were at risk of infection. The heterogeneity of the study population, the lack of awareness among many subjects of risk factors and self-exclusion procedures, and the high level of distress among many subjects after notification, emphasize the need for intensive, well-designed education and support programs.
Adult↗
Reduction of incorrect antibiotic dosing through a structured educational order form.
Antibiotics are often used inappropriately in hospitals. We created a structured antibiotic order form designed to guide physicians toward correct therapeutic decisions without restricting their clinical options. Educational messages and graphic reminders were incorporated into a new form required to order parenteral antibiotics at a teaching hospital. Pharmacokinetic considerations were emphasized. The forms were supplemented with brief literature reviews and appropriate references. Before introduction of the form, pharmacokinetically incorrect orders for clindamycin, cefazolin sodium, and metronidazole hydrochloride accounted for 90%, 60%, and 75% of patient-days of therapy for these drugs, respectively. Immediately after implementation of the form, nonrecommended dosing schedules dropped to under 6% of patient-days for all three antibiotics. Savings from these drugs alone accounted for over $76,000 annually. We conclude that in a period of increasing constraints on hospital budgets and proliferating restrictions on physicians' clinical choices, educational intervention at the time orders are written can provide a cost-effective and noncoercive means of improving some forms of acute-care clinical decision making.
Anti-Bacterial Agents↗
Payment restrictions for prescription drugs under Medicaid. Effects on therapy, cost, and equity.
In an attempt to contain costs, 27 Medicaid programs have implemented patient-level payment limits for medications, but the effects of these restrictions on quality of care, costs, and health status remain largely unknown. We measured the effect of one state's limit of three paid prescriptions per month and its replacement a year later by a $1 copayment. Using data on 48 months of claims in the study state (New Hampshire) and a comparison state (New Jersey), we employed time-series analysis to evaluate patient-level changes in the number of prescriptions filled for 16 drugs that varied in their clinical importance and cost. Among 10,734 continuously enrolled patients, the limit of three paid prescriptions per month caused a sudden, sustained drop of 30 percent in the number of prescriptions filled (from 1.10 to 0.77 prescriptions per patient per month); no change was observed in the comparison state. The 860 recipients of multiple drugs, who were predominantly female and elderly or disabled, were most severely affected; the number of prescriptions per month dropped from 5.2 to 2.8 (46 percent). The decrease was greatest for "ineffective drugs" (58 percent), but large drops were also observed for "essential" medications, such as insulin (28 percent), thiazides (28 percent), and furosemide (30 percent). Reductions in Medicaid prescriptions were minimally offset by increases in the size of the prescription or in out-of-pocket payments. When a $1 copayment replaced the three-prescription cap, prescriptions for most medications increased to just below precap levels. Medicaid's savings on drug costs resulting from both policies were comparable ($0.4 to $0.8 million annually), but the copayment policy had less effect on patients receiving multiple drugs. Because the clinical consequences of such policies cannot be assessed from prescription data alone, further study is needed to determine the effects of cost-containment strategies on health status and the use of other services among poor populations.
Cost Control↗
Blood donation by the elderly. Clinical and policy considerations.
At present, healthy potential blood donors older than the age of 66 years often leave the donor pool for reasons of age alone, despite the fact that this demographic group is growing, is a potentially willing source of blood products, and constitutes the cohort with highest per capita use of blood and its derivatives. There is no clinical or physiological rationale for this. We performed a controlled study to measure the feasibility and safety of blood donation by healthy elderly donors aged 66 years and older, compared with a younger cohort aged 55 to 65 years of age. A study group of prior donors aged 66 years and older and a control group of prior donors between the ages of 50 and 65 were sent letters inviting them to donate blood. The volume donated did not differ between the two groups. In the older group, there were eight immediate reactions, seven mild and one moderate. The control population experienced seven immediate reactions, six mild and one severe. We conclude that it is both clinically feasible and efficient to recruit healthy prior donors older than the age of 66 years for blood donation. As a group, this population is potentially able to donate large volumes of blood and do so without any difference in immediate or short-term reactions. Further study of hemodynamic variables as more objective markers of safety is needed.
Adult↗
Pharmacology and geriatric practice: a case study in technology nontransfer.
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Education, Medical↗
Predictors of physician prescribing change in an educational experiment to improve medication use.
In analyzing a university-based program to educate physicians about proper medication use, we sought to measure whether physician background characteristics and the quality or number of educational exposures influenced the rate of relinquishment of inappropriate prescribing. A sample of 435 doctors was randomized to control and experimental groups; interventions consisted of printed educational materials and face-to-face visits by clinical pharmacists. The program sought to reduce inappropriate use of three drug categories: propoxyphene, peripheral/cerebral vasodilators, and cephalexin. Outcome data included the total volume (tablets/capsules) of these drugs prescribed through Medicaid by each study physician 9 months before and after the program. We estimated average changes in prescribing levels by experimental and control physicians within each physician subgroup (e.g., board-certified versus uncertified), adjusting for prescribing level in the same 9 months of the previous year. The results indicated that the rate of prescribing change was independent of most physician background characteristics studied, including age, board certification, specialty, rural versus urban practice, intensity of previous target drug use, and size of Medicaid practice. Experimental effects were highly significant (-9% to -20%, P less than 0.025) in 11 of 14 physician subgroups. The presence of a follow-up reinforcement visit was a strong independent predictor of prescribing change (P less than 0.05). An increase from one visit to two visits was associated with an approximate doubling of the size of the program effect. However, total exposure time was not related to changes in prescribing behavior. These findings document that face to face education can be effective in improving the prescribing practices of a wide variety of physicians, and that brevity, repetition, and reinforcement of recommended practices are important components in the design of such programs.
Drug Prescriptions↗
Cimetidine use in nursing homes: prolonged therapy and excessive doses.
Patterns of cimetidine use were identified in a survey of 3032 patients in 31 nursing homes. Of these, 60 (2%) were receiving cimetidine. For these patients, ages ranged from 63 to 102 years (mean, 81 years). The patients received a range of 1 to 11 regularly scheduled medications (mean, 5.6 medications). Duration of cimetidine treatment averaged 19.6 months for 48 patients (81%) receiving the drug for longer than an eight-week course of therapy. Prescribing indications appeared unjustified in 54 of 60 patients (90%). Doses were rarely appropriately reduced for patient age, despite established reasons to do so and the well-known potential for adverse effects of cimetidine in the elderly. The risks associated with prolonged drug-induced suppression of gastric acid are not known. This study suggests that use of cimetidine without justifiable indication and for extended periods of time is common in nursing home patients. Studies are needed concerning the safety of long-term cimetidine use in elderly patients.
Aged↗
Effect of government and commercial warnings on reducing prescription misuse: the case of propoxyphene.
We analyzed trends in prescribing and overdose deaths related to propoxyphene (e.g., Darvon) before and after a 1978-80 informational campaign carried out by the US Food and Drug Administration and the drug's manufacturer through mailed warnings, face-to-face education of prescribers, press releases, and labeling changes. The goals included a reduction in propoxyphene use with alcohol or other CNS depressants, reduced prescribing of refills, and cessation of prescribing for patients at risk of abuse and misuse (suicide). We conducted time-series analyses of nationwide propoxyphene use data 1974-83 and analyzed data on drug overdose death rates covering a combined population of about 83 million. Segmented regression methods were used to determine if the informational program was associated with changes in trends of prescribing or overdose deaths. Comparison drug series were analyzed to control for other secular trends in prescribing. Nationwide propoxyphene use during the warnings continued a pre-existing decline of about 8 per cent per year, but this decline halted after the warnings. The no-refill recommendation had no impact on refill rates. The risk of overdose death per propoxyphene prescription filled has remained about constant since 1979. Sharper declines in misuse of such drugs will require stronger, more sustained regulatory or educational measures.
Dextropropoxyphene↗
Overmedication of the low-weight elderly.
This study analyzes age, weight, and drug doses using cimetidine hydrochloride, flurazepam hydrochloride, and digoxin as tracers. Data were obtained for 1797 patients (mean age, 72 years) filling consecutive prescriptions from a national pharmacy service. With all three drugs, patients with lower weight received substantially higher doses with correlations of weight vs dose, based on milligrams per kilogram of body weight, ranging from -0.34 to -0.40. Because body weight declines with increasing age, lower-weight patients are also older and at greatest risk for drug toxicity. Patients weighing 50 kg or less (n = 155) received milligram-per-kilogram doses that were 31% to 46% higher than the group mean and 70% to 88% higher than patients weighing more than 90 kg. For all three study drugs, as patient weight declines, the mean milligram-per-kilogram dose rose sharply. There was no trend seen toward reducing doses for older patients. Low body weight, in addition to advanced age, is a major risk factor for overmedication. Physicians must recognize the need to reduce drug doses for their low-weight elderly patients.
Adult↗
Increased antidepressant use in patients prescribed beta-blockers.
Little information exists on the epidemiology of central nervous system side effects in patients taking antihypertensive medications. We examined prevalence rates of tricyclic antidepressant (TCA) use among a random sample (N = 143,253) of Medicaid recipients. The TCA use was compared for patients taking any of seven antihypertensive agents and for those prescribed insulin or oral hypoglycemic agents. Use of TCA was significantly higher in patients taking beta-blockers (23% over two years) than for patients taking hydralazine or hypoglycemics (both 15%) or methyldopa or reserpine (both 10%). Prevalence rate ratios revealed a risk of being prescribed a TCA of 1.5 (95% confidence interval, 1.4 to 1.7) for patients receiving beta-blockers relative to patients receiving hydralazine or hypoglycemics. beta-Blocker use may be an important cause of iatrogenic depression among hypertensive patients.
Adrenergic beta-Antagonists↗
Economic and policy analysis of university-based drug "detailing".
The cost-effectiveness of quality assurance programs is often poorly documented, especially for innovative approaches. The authors analyzed the economic effects of an experimental educational outreach program designed to reduce inappropriate drug prescribing, based on a four-state randomized controlled trial (N = 435 physicians). Primary care physicians randomized into the face-to-face group were offered two individualized educational sessions with clinical pharmacists, lasting an average of 18 minutes each, concerning optimal use of three drug groups that are often used inappropriately. After the program, expenditures for target drugs prescribed by these physicians to Medicaid patients decreased by 13%, compared with controls (P = 0.002); this effect was stable over three quarters. Implementation of this program for 10,000 physicians would lead to projected drug savings (to Medicaid only) of $2,050,000, compared with resource costs of $940,000. Net savings remain high, even after adjustment for use of substitution medications. Although there was a ninefold difference in average preintervention prescribing levels between the highest and lowest thirds of the sample, all groups reduced target drug expenditures at the same rate. Targeting of higher-volume prescribers would thus further raise the observed benefit-to-cost ratio from approximately 1.8 to at least 3.0. Net benefits would also increase further if non-Medicaid savings were added, or if the analysis included quality-of-care considerations. Although print materials alone may be marginally cost-effective, print plus face-to-face approaches offer greater net benefits. The authors conclude that a program of brief, face-to-face "detailing" visits conducted by academic rather than commercial sources can be a highly cost-effective method for improving drug therapy decisions. Such an approach makes possible the enhancement of physicians' clinical expertise without relying on restriction of drug choices.
Arkansas↗