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Improving the Appropriateness of Prescribing in Elderly Patients. Is it feasible? A comprehensive Approach in the Local Health Unit of Parma, Italy Presenting.

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Presentation on theme: "Improving the Appropriateness of Prescribing in Elderly Patients. Is it feasible? A comprehensive Approach in the Local Health Unit of Parma, Italy Presenting."— Presentation transcript:

1 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

2 Background Potentially inappropriate medications (PIMs) are those medications whose adverse risks exceed their health benefits 1 Potentially inappropriate medications (PIMs) are those medications whose adverse risks exceed their health benefits 1 PIMs use in the community-dwelling elderly is associated with negative patient health outcomes 2,3 PIMs use in the community-dwelling elderly is associated with negative patient health outcomes 2,3 Using the Beers Criteria, preliminary data in the Emilia- Romagna Region, Italy, showed that 1 out of 5 elderly patients are subject to PIMs in ambulatory settings 4 Using the Beers Criteria, preliminary data in the Emilia- Romagna Region, Italy, showed that 1 out of 5 elderly patients are subject to PIMs in ambulatory settings 4 1) Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication nuse in community-residing older persons. Arch Intern Med. 1994;154:2195- 2200. 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

3 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 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

4 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 A 3-year, multi-phase prospective demonstration project targeting all 303 general practitioners (GPs) in the LHU of Parma, Italy, was established in 2007 Q1-Q3 2007 Key Elements of multi-phase Intervention: Development of PIMs list Q4 2007 Dissemination of PIMs list to GPs & annual review of PIMs prevalence data Dissemination of alternative list of drugs to GPs Q1-Q3 2008 Annual review of PIMs prevalence data Development of case studies on PIMs Case studies presentation & annual review of PIMs prevalence data Q4 2009Q4 2008Q1-Q3 2009 2007 2010

5 PIMs list determined by expert panel category and generic drug name 5 Always Avoided AmitriptylineChlorpropamideCimetidine 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 PentazocineTestosterone Rarely Appropriate TiclopidineDoxazosinFluoxetine Some Indications Amiodarone Clonidine (patch) Atypical antipsychotics* *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.

6 Renal effects of NSAIDs and COX-2 inhibitors HyperkalemiaRenal Failure Acute  Prerenal  ATN PGE 2 /PGI 2 Sodium retention  Peripheral oedema  Hypertension  CHF Arachidonic acid cascade COX-2 NSAIDs COXIBs Perazella, M. Expert Opin Drug Saf. 2002;1:53-64.

7 Severe ADRs resulting in Hospital Admission showed for Drug Classes (GIFA STUDY) Onder, JAGS 2002; 50: 1962-8 27 22 17 14 13 12 11 10 8 7 05 15202530 NSAIDs ASA - Antiplatelets Diuretics Digoxin Antineoplastics Antibiotics Steroids Ca- channel blockers Antipsychotics Insulin ACEI

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.

9 Results: Parma LHU By Quarter Table 1. Prevalence of elderly receiving potentially inappropriate prescribed medications (PIP) in Parma LHA from 2007 through 2009 Measurement period Subjects rec eivi ng PIP Subjects receivin g any medicat ions Proportion of subjects receiving PIP (%) Compariso n to baseli ne (% change) Compariso n to previ ous quarte r (% change) 2007 Q4 6416 785068.17 -- 2008 Q1 5762 787667.32-10.49-10.49 2008 Q2 5755 788677.30-10.71-0.25 2008 Q3 5322 777576.84-16.25-6.20 2008 Q4 5258 795146.61-19.09-3.39 2009 Q1 4716 795805.93-27.49-10.38 2009 Q2 5070 798206.35-22.287.18 2009 Q3 4583 785765.83-28.63-8.17 2009 Q4 4575 802505.70-30.24-2.26 a The number of subjects does not equal the total because some subjects received more than one PIP. NE= not eligible; NSAIDS= non-steroidal anti-inflammatory drugs *p<0.05; **p<0.01 Prevalence of elderly receiving always inappropriate prescribed medications (PIMs) in Parma LHU from Q4 2007 through Q4 2009 Measurement period Subjects receiving PIMs Subjects receiving any medications Proportion of subjects receiving PIMs (%) Comparison to baseline (% change) Comparison to previous quarter (% change) 2007 Q4 (Baseline) 6416785068.17-- 2008 Q1 5762787667.32-10.49-10.49 2008 Q2 5755788677.30-10.71-0.25 2008 Q3 5322777576.84-16.25-6.20 2008 Q4 5258795146.61-19.09-3.39 2009 Q1 4716795805.93-27.49-10.38 2009 Q2 5070798206.35-22.287.18 2009 Q3 4583785765.83-28.63-8.17 2009 Q4 (Follow-up)4575 802505.70-30.24-2.26

10 Proportion of elderly receiving PIMs in Parma LHU and Reggio LHU by Quarter Breslow-Day test, p=0.004

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12 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 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 The greatest impact was seen in users of digoxin and NSAIDs, with a significant potential benefit for patients

13 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 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 The study does not measure the impact of the intervention on other healthcare resource use or patient outcomes

14 Future Directions Additional analyses should be performed to further investigate: Additional analyses should be performed to further investigate: Which physicians were less prone to change prescribing and use results to design targeted educational interventions 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 Whether the observed change may be retained over time

15 Thank you! Any questions?


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