1. Measuring and Evaluating Indicators of Appropriate Prescribing in Older Populations Cahir C., Teeling M., Feely J, Byrne S., Fahey T., Bennett K. Caitriona Cahir HRB PhD Scholar Division of Population Health Sciences RCSI

2. Structure of presentation Brief background to study. Outline of study objectives. Methods. Results. Items for discussion and further research.

3. Appropriate prescribing in older people “Good prescribing” should encompass the appropriate choice of medicine not only from the perspective of the physician but also that of the patient, while at the same time aiming to maximise effectiveness, minimise risk and minimise cost (Barber, 1995). Appropriateness of prescribing – assessed by process or outcome measures that are explicit (criterion based) or implicit (judgment based) (Spinewine et al., 2007).

4. Appropriate prescribing in older people Explicit and implicit measures -US Beers criteria, DUR, ACOVE, IPET, MAI. Beers criteria- US and Canadian studies- 14% to 37%. European cross-sectional study -19.8%. Process measures should have links to health outcomes. Evidence is mixed and contradictory. UCC STOPP/START screening tool of older person’s potentially inappropriate prescriptions (Gallagher et al., 2007).

5. Objectives Estimate the prevalence of potentially inappropriate prescribing (PIM) in older populations in Ireland in 2007 using STOPP criteria. Investigate the association between PIM and gender and age. Establish the associated cost. Relationship between the no. of medications taken and PIM.

6. Methods Retrospective population based cohort study (aged ≥70 years) using the HSE-PCRS (n=334,452). Thirty STOPP indicators–Cardiovascular (7), CNS (9),Gastrointestinal (2), Respiratory (2), Muscoskeletal (2), Urogential (2), Endocrine (1) and duplicate classes of medicines (5). Logistic regression- gender and age.

7. Results (n=334,452) 27% (n=91,740) of the population aged ≥ 70 years were prescribed one PIM. 10% (n=32,877) were prescribed two. 3% (n=9,665) were prescribed three. 0.71% (n=2,374) were prescribed four.

8. Results Total NIC of STOPP medication in 2007 was €39,204,062. Total expenditure was €47,730,089. 9% were recipients of ≥ 5 medications per month and a PIM.

9. STOPP Adjusted Analysis 2007 5 highest prevalence rates (n=334,452) SystemSTOPP Description Prev % Male % Female % OR Gender (F vs M) 70-74 years % >75 years % OR Age (> 75 vs 70-74 ) GastroPPI > 8 weeks full therapeutic dose. 20.1819.9420.361.00 (0.99-1.02) 16.8722.171.40* (1.38-1.43) MuscoNSAID >3M7.806.498.771.39* (1.35-1.43) 7.977.690.94* (0.92-0.97) CardioDigoxin >125ug/day 7.187.966.600.77* (0.75-0.79) 3.649.312.78* (2.69-2.87) CNS>1M Long-acting benzodiazepines 5.523.726.851.89* (1.83- 1.96) 5.095.781.10* (1.06-1.13) DuplicatesNSAIDs, SSRIs, Antidep, ACE, Loop diuretics, opioids 4.503.815.021.34* (1.30-1.39) 4.724.370.90* (0.87-0.93) * p< 0.0001

10. STOPP Adjusted Cost Analysis 2007 (NIC= €39,204,062 ) SystemSTOPP DescriptionNICTotal Cost GastroPPI > 8 weeks full therapeutic dose. 24,510,62427,263,003 CNSNeuroleptics >1M, (also with Parkinsonism), anticholingerics for side effects. 5,815,282*6,557,863* DuplicatesNSAIDs, SSRIs, Antidep, ACE, Loop diuretics, Opioids 4,544,2445,509,161 MuscoNSAID >3M Warfarin and NSAIDs 3,056,281*3,918,678* * Adjusted for claimants receiving the same medication per more than one criteria

11. Items for discussion and further research PPIs- further analysis  Co-prescriptions.  Duration of PPI prescribing and dosage. Duplicates  Two concurrent NSAIDs (2.09%) –Diclofenac with glucosamine or nimesulide.  Two concurrent opioids (1.13%)- Tramadol with codeine and morphine.

12. Items for discussion and further research Comparison- Beers versus STOPP. Linkage studies- to assess health outcomes and explore reasons behind prescribing patterns. Predictive risk modelling. Develop practical prescribing guidelines and clinical decision support systems.

13. Questions