1. Are Older Women More Likely to Get Inappropriate Drugs? Arlene S. Bierman, MD, MS Ontario Women’s Health Council Chair in Women’s Health Centre for Research in Inner City Health St. Michael’s Hospital June 28, 2005

2. Potentially Inappropriate Prescribing in the Elderly (PIPE) Study Potentially Inappropriate Prescribing in the Elderly (PIPE) Study – Mary Jo V. Pugh PhD, RN 5,6 – B. Graeme Fincke, MD 1,2 – Amy Rosen, PhD 1,2 – Fran Cunningham, PharmD 4 – Bei-Hung Chang, ScD 1,2 – Megan Amuan MPH 1 – Muriel Burke, PharmD 4 – Irfan Dalla 3 – Dan Berlowitz, MD, MPH 1,2 1 Center for Health Quality, Outcomes and Economic Research, Bedford VA; 2 Boston University School of Public Health; 3 University of Toronto; 4 Pharmacy Benefits Management Strategic Healthcare Group, Hines VA and University of Chicago, Illinois 5 Veterans Evidence-based Research, Dissemination, and Implementation Center, 6 South Texas Healthcare System, Audie L. Murphy Division, San Antonio, Texas; University of Texas Health Science Center at San Antonio

3. Inappropriate Prescribing in the Elderly Prescribing of drugs for which potential harms outweigh potential benefits is a major patient safety concern in the elderly. Prescribing of drugs for which potential harms outweigh potential benefits is a major patient safety concern in the elderly. Inappropriate prescribing increases risk for falls, hip fractures, cognitive impairment, diminished independence, and death. Inappropriate prescribing increases risk for falls, hip fractures, cognitive impairment, diminished independence, and death. Studies consistently find that 20-27% of older Americans receive drugs identified as inappropriate, with little to no improvement in nearly two decades. Studies consistently find that 20-27% of older Americans receive drugs identified as inappropriate, with little to no improvement in nearly two decades.

4. Gender Differences in Potentially Inappropriate Prescribing Prior studies of community-dwelling elders have suggested that older women were more likely to receive potentially inappropriate drugs than men. Prior studies of community-dwelling elders have suggested that older women were more likely to receive potentially inappropriate drugs than men. No prior study has examined whether gender differences in potentially appropriate use of these drugs could explain this or the factors associated with gender differences inappropriate prescribing. No prior study has examined whether gender differences in potentially appropriate use of these drugs could explain this or the factors associated with gender differences inappropriate prescribing. Examination of the patterns and correlates of these gender differences can provide evidence to develop and implement effective quality improvement interventions. Examination of the patterns and correlates of these gender differences can provide evidence to develop and implement effective quality improvement interventions.

5. Study Objectives To assess gender differences in rates of inappropriate prescribing To assess gender differences in rates of inappropriate prescribing To assess whether gender differences are explained by gender differences in potentially appropriate indications for these drugs. To assess whether gender differences are explained by gender differences in potentially appropriate indications for these drugs. To examine gender differences in the correlates of inappropriate drug use. To examine gender differences in the correlates of inappropriate drug use.

6. Methods: Data Sources  Multiple Linked US Veterans Administration (VA) Data Sets – Administrative Data: Demographics – Inpatient Records: Diagnoses and Utilization – Outpatient Records: Diagnoses and Utilization – National Ambulatory Pharmacy Data: Drugs, Dose, Duration – Veterans Health Survey: Race/Ethnicity

7. Study Population  Cohort Identification  At least one outpatient visit in Fiscal Year (FY)1999 and FY 2000  > 65 years of age October 1, 1999

8. Potentially Inappropriate Prescribing: Beers Criteria Potentially Inappropriate Prescribing in the Elderly (Beers, 1991,1997 update 2003). Potentially Inappropriate Prescribing in the Elderly (Beers, 1991,1997 update 2003). – Explicit criteria, expert consensus panel – 33 drugs considered inappropriate regardless of diagnosis (disease-independent) – dose limitations – drug-drug/drug-disease interactions Controversial because clinicians argued that some drugs may be appropriate for specific patients in certain circumstances Controversial because clinicians argued that some drugs may be appropriate for specific patients in certain circumstances

9. Outcome Variable: Diagnosis-Adjusted Inappropriate Prescribing AHRQ (US Agency for Healthcare and Quality) expert consensus panel AHRQ (US Agency for Healthcare and Quality) expert consensus panel - Grouped 33 Beers disease-independent drugs into 3 categories using modified Delphi process; Always-avoid: 11 drugs Rarely-appropriate: 8 drugs Some-indications: 14 drugs Diagnosis-adjusted PIPE: Algorithms develop using ICD-9 codes and pharmacy data to adjust for potentially appropriate use. Diagnosis-adjusted PIPE: Algorithms develop using ICD-9 codes and pharmacy data to adjust for potentially appropriate use.

10. Covariates: Patient Characteristics Demographics Demographics - Age, sex, race/ethnicity - 1999 large Health Survey of Veterans provided missing race data Physical and Psychiatric Comorbidity Physical and Psychiatric Comorbidity - Disease burden assessment by Selim’s physical and psychiatric Comorbidity Index - Assessed comorbidity status for 3 years (FY98-00) # psychiatric diagnoses # psychiatric diagnoses # physical diagnoses # physical diagnoses Number of unique medications (FY 00) Number of unique medications (FY 00)

11. Covariates Characteristics of Care Type of Care Received (FY 99) Type of Care Received (FY 99) – Number of Primary Care Visits – Number of Different Specialty Clinics – Geriatric Care – Long-term Care, Medical or Psychiatric Hospitalizations Outpatient visits used to assess continuity of care Outpatient visits used to assess continuity of care number of outpatient visits in primary care (FY 99) Total number of outpatient visits

12. Method - Analysis We determined the prevalence of any use of potentially inappropriate drugs among men and women. Then, we used the VA PIPE study algorithms to examine the proportion of this use that may have been appropriate and whether the proportion that remained inappropriate differed by gender. We determined the prevalence of any use of potentially inappropriate drugs among men and women. Then, we used the VA PIPE study algorithms to examine the proportion of this use that may have been appropriate and whether the proportion that remained inappropriate differed by gender. Using logistic regression we determined the unadjusted and adjusted odds ratios of women receiving diagnosis-adjusted inappropriate drugs compared to men both for individual agents and by drug category (always avoid, rarely appropriate, and rare indication). Patient and care characteristics were included as covariates. Using logistic regression we determined the unadjusted and adjusted odds ratios of women receiving diagnosis-adjusted inappropriate drugs compared to men both for individual agents and by drug category (always avoid, rarely appropriate, and rare indication). Patient and care characteristics were included as covariates. Logistic regressions stratified by gender were conducted to examine gender differences in factors associated with receipt of inappropriate medications. Logistic regressions stratified by gender were conducted to examine gender differences in factors associated with receipt of inappropriate medications.

13. Gender Differences in Use of Inappropriate Drugs Parameter Male (%) (N=946,641) Female (%) (N=19,115)OR (F vs.M) Always avoid 0.91.71.95 Rarely appropriate 10.512.41.31 Some indication 18.122.61.44 At least one drug 25.731.01.45 All comparisons are significant with P< 0.0001

14. Gender Differences Proportion Inappropriate – Some Indication Drug Proportion Inappropriate After Adjusting for Diagnosis/Duration of Use (%) MaleFemale Amitriptyline75.076.1 Doxepin81.680.2 Oxybutynin74.852.6 Chlorpheniramine92.193.1 Diphenhydramine94.295.0

15. Odds of Receiving Inappropriate Drugs: Diagnosis Adjusted OR (F vs. M) *Adjusted for demographics, comorbidities, unique meds & characteristics of care

16. Gender Differences in Diagnosis-Adjusted Use of Individual Agents: Always Avoid DrugUnadjustedAdjusted* OR 95% CI OR Meperidine1.71.2-2.51.51.1-2.2 Belladonna Alkaloids 2.61.3-5.32.21.1-4.4 Dicyclomine2.11.8-2.51.81.6-2.1 Hyoscyamine2.52.0-3.22.51.9-3.1 Propantheline3.22.1-4.72.71.8-4.0 *Adjusted for demographics, comorbidities, unique meds & characteristics of care

17. Gender Differences in Diagnosis-Adjusted Use of Individual Agents: Rare Indication DrugUnadjustedAdjusted* OR 95% CI OR Diazepam1.21.1-1.41.00.9-1.1 Propoxyphene1.31.3-1.41.21.1-1.3 Cyclobenzaprine1.41.2-1.51.41.3-1.6 Methocarbamol1.21.1-1.31.21.1-1.3 *Adjusted for demographics, comorbidities, unique meds & characteristics of care

18. Gender Differences in Diagnosis-Adjusted Use of Individual Agents: Some Indication DrugUnadjustedAdjusted* OR 95% CI OR Amitriptyline1.41.3-1.51.31.2-1.4 Doxepin1.21.0-1.41.00.8-1.1 Disopyramide4.01.6-9.93.01.2-7.4 Oxybutynin2.01.9-2.21.81.6-1.9 Chlorpheniramine1.41.3-1.51.31.2-1.4 Diphenhydramine1.51.4-1.61.41.3-1.5 Promethazine1.71.3-2.11.41.1-1.7 *Adjusted for demographics, comorbidities, unique meds & characteristics of care

19. Drugs less likely to be received by women – Some Indication DrugsUnadjustedAdjusted* OR 95% CI OR Indomethacin0.60.5-0.70.60.5-0.7 Dipyridamole0.80.6-1.00.70.5-0.8 Cyproheptadine0.60.5-0.90.50.4-0.6 *Adjusted for demographics, comorbidities, unique meds & characteristics of care

20. Correlates of Inappropriate Prescribing Parameter Male (N=834,251) Female (N=15,903) ORP-valueORP-Value Hispanic1.08<0.001.360.03 1 mental health diagnosis 1.32<0.000.990.88 2 or more mental health diagnosis 1.61<0.001.080.20 Number of medications 1.17<0.001.18<0.00 Geriatric visit 0.65<0.000.64<0.00 Age, continuity of care, long-term care, medical or psychiatric hospitalizations included in model.

21. Conclusions Older women were more likely to receive inappropriate medications than older men, even after accounting for a liberal set of indications. Older women were more likely to receive inappropriate medications than older men, even after accounting for a liberal set of indications. Analgesic, psychotropic, and anticholinergic medications that should be avoided contribute to higher rates of inappropriate drug use among older women. Analgesic, psychotropic, and anticholinergic medications that should be avoided contribute to higher rates of inappropriate drug use among older women. Psychiatric comorbidity is a predictor of inappropriate drug use in men but not in women. Psychiatric comorbidity is a predictor of inappropriate drug use in men but not in women.

22. Conclusions Receipt of geriatric care was equally protective for men and women, though only a small proportion of the sample received this care. Receipt of geriatric care was equally protective for men and women, though only a small proportion of the sample received this care. Men and women did not differ in proportion of drugs that were inappropriate, inappropriate dosing, or duration. Men and women did not differ in proportion of drugs that were inappropriate, inappropriate dosing, or duration.

23. Limitations While some use is classified as potentially appropriate often safer or more effective options exist. While some use is classified as potentially appropriate often safer or more effective options exist. Data may not capture all drugs received by the cohort, as those who have other drug coverage may have received medications outside the VA. Data may not capture all drugs received by the cohort, as those who have other drug coverage may have received medications outside the VA. VA population may limit generalizability. VA population may limit generalizability. A recent update of the Beers criteria added additional medications to the list of disease-independent drugs. A recent update of the Beers criteria added additional medications to the list of disease-independent drugs.

24. Implications Because of these differences studies on inappropriate prescribing should examine gender differences when possible. Because of these differences studies on inappropriate prescribing should examine gender differences when possible. Efforts to improve the quality of medication management in the elderly should address gender differences in prescribing patterns. Efforts to improve the quality of medication management in the elderly should address gender differences in prescribing patterns. Improved access to geriatric care may decrease rates of inappropriate prescribing. Improved access to geriatric care may decrease rates of inappropriate prescribing.