1. 17 tools identified composed mostly of (>95%) explicit criteria 4 versions of the Beers Criteria were found The original Beers Criteria (1991) or subsequent versions referenced as points of origin for preliminary lists in 9 of the 13 (69.2%) non-Beers authored explicit criteria tools Only one tool was composed independent of any edition of the Beers Criteria (Prescribing Indicators Tool) 1 tool was non-specific in the summary of literature search methods utilized and incorporation of Beers Criteria is uncertain (High Risk Medications ) Preferred method for compiling criteria was via consensus expert panel and various modifications of the Delphi method Conflicts of interest not disclosed amongst expert panels Few tools provide detailed references and/or rationale for all recommendations (See table) Evaluation of Explicit Tools Used to Assess Medication Appropriateness and Safety in Geriatric Populations Patrick Greene, PharmD Candidate 2013; Marilyn N. Bulloch PharmD, BCPS Title or Author (Country) Year Target Setting & Population Source of ContentContent ProvidedComments Beers (USA) 1991 Nursing home >65 years of age Two round, 13-member consensus expert panel (modified Delphi method); Literature search ( published: 1979-1990) 30 criteria (19 medications/classes to avoid, 11 concerning doses, frequencies, or duration), Recommendations not referenced or explained in detail Beers (USA) 1997 All settings >65 years of age Beers (1991); Two round, 6-member consensus expert panel (modified Delphi method) Literature search (published: 1990-1995) 28 PIMs to avoid in the general geriatric population, 35 PIMs relating to 15 disease states Limited rationale included; specific references pertaining to criteria not provided; Updated recommendations more limited to apply to general geriatric population McLeod (Canada) 1997>65 years of age Beers (1991); Two-round mail survey of 32-member expert panel (modified Delphi method) Primary and Tertiary Literature Search 38 high-risk prescribing practices in 4 groups (incl. recommendations for alternative therapies); 18 drugs generally contraindicated in geriatrics 16 drug-disease interactions, 4 drug-drug interactions Unclear literature search parameters; consensus not required for criteria inclusion; numerical rating of clinical significance of criteria Improving Prescribing in the Elderly Tool (IPET) (Canada) 2000>70 years of age McLeod (1997) as applied to inpatient geriatric study population 14 inappropriate prescribing practices (10 drug-drug interactions, 2 inappropriate medication classes, 2 recommendations regarding duration of drug therapies) Not validated (certain criteria from McLeod validated) Beers (USA) 2003 All settings >65 years of age Beers (1997); Three-round, 12-member consensus expert panel (modified Delphi method) Literature search (published: 1994-2000) 68 criteria of high or low severity (48 PIMS for the general geriatric population, plus 20 disease states with applicable PIM criteria) Loss of anonymity during second round of Delphi method; HEDIS (USA) 2006 Male veterans >65 years of age Beers (2003); Three-round, 12-member consensus expert panel (modified Delphi method); Literature search (published: 1994-2000) Classified Beers Criteria (2003) into 3 categories: always avoid, rarely appropriate drugs (“some indications” rating” not included in final criteria) Excluded several NSAIDs, amitriptyline; overwhelmingly male majority in study population (98%) French Consensus Panel List (France) 2007>75 years of age Beers (2003); McLeod (1997) Guidelines of the French Medicine Agency; Two-round mail survey of 15-member expert panel (modified Delphi method) 36 inappropriate prescribing practices (29 PIMS to avoid in all patients, 5 drug-disease interactions) Provides recommendations for alternative therapies High-Risk Medications (Thailand) 2007"Older Thai patients" Literature search (published: 1990-2006) Three-round mail survey of anonymous 17-member expert panel (Delphi method) 1 drug or drug class designated as “to be avoided’’; 6 as ‘‘drugs rarely appropriate’’; and 9 as ‘‘drugs with some indications for older patients’’ Close-ended survey questions not published; Severely-limited applicability due to lack of consensus (51.5% of drugs or medication classes were not classified, including several severe drug-drug interactions) START (Ireland) 2008 Inpatients on admission >65 years of age Two-round mail survey of 18-member expert panel (Delphi method); evidence-based literature search (not specified); clinical experience of primary geriatrician 22 evidence-based criteria for initiating appropriate therapies for common diseases in geriatric populations Unclear evidence-based literature search parameters STOPP (Ireland) 2008 Inpatients on admission >65 years of age Two-round mail survey of 18-member expert panel (Delphi method); evidence-based literature search (not specified); clinical experience of primary geriatrician 65 criteria (42 criteria concerning drug- disease interactions, 4 related to specific drug combinations, 2 concerning doses, 5 for inappropriate prescribing) Unclear evidence-based literature search parameters Prescribing Indicators (Australia) 2008 Australians >65 years of age Sourced from Australian-published data sources45 explicit criteria (plus 3 implicit criteria) No medications-to-avoid list; no severity ratings; No consensus process; No use of previously published criteria (all Australian data) General Practice Criteria (Norway) 2009 >70 years of age in general practice Beers (2003); clinical experience from three-round mail survey of 47-member expert panel (Delphi method) Literature search (published: 1996-2008) 36 criteria for inappropriate prescribing practices (21 drugs or dosage criteria, 15 drug-drug combination criteria) 36 of 37 suggested criteria rated as clinically relevant; disciplined execution of Delphi method (preservation of anonymity and integrity) PRISCUS (Germany) 2010>65 years of age Beers (1997, 2003), McLeod (1997), French Consensus Panel List (2010); literature search; two-round internet survey (modified Delphi method) 83 drugs identified as potentially inappropriate (2 only due to drug delivery release formulation) Addition of 7 new drugs that are readily available in USA, Canada, and France; Provides detailed rationale and alternative therapies, plus follow-up recommendations Maio et al. (Italy) 2010>65 years of age Beers (2003); recommendations from nominal group technique with 4 rounds. Panel of 9 experts 23 drugs in 3 categories (17 to always avoid, 3 that are rarely appropriate, 3 that may have some indications in geriatric populations) Loss of anonymity due to final face-to-face meeting; Kim et al. (Korea) 2010>65 years of age Beers (2003), McLeod (1997) PRISCUS (2010); literature search; two-round 12 member consensus expert panel (modified Delphi method) 42 drugs to avoided and 13 drugs to be monitored (regardless of disease state 91 PIMs to be avoided or monitored with 29 various disease states Recommendations include use of short-acting BDZs AGS/Beers (USA) 2012 All settings >65 years of age (some criteria only apply to >75 years of age) Beers (2003); Three-round, 11-member consensus expert panel (modified Delphi method) Literature search (published: 2001-2011) 53 medications or medication classes in 3 categories 34 PIMs/classes of medications to avoid 8 to avoid in certain disease states 14 to use with caution Addition of "Guideline-like" recommendation strength; in-depth rationale included; updated with new-to- market drugs; 19 medications or medication classes removed due to lack of or new evidence or market withdrawal Mann et al. (Austria) 2012>65 years of age Beers (1997, 2003), McLeod (1997), French Consensus Panel List (2010), PRISCUS (2010); literature search; two-round 8 member consensus expert panel (modified Delphi method) 73 potentially inappropriate drugs (the majority NSAIDs, TCAs, antipsychotics, BDZs and anti-Parkinson drugs) Dosage, duration, and disease states were not considered Introduction The number of citizens greater than 65 years old is projected to increase to more than 88.5 million in 2050. Also, in 2011, senior citizens received an average of 28.8 prescriptions per patient, a number which does not include prescriptions dispensed via mail-order pharmacies or long-term healthcare facilities. Senior citizens maintain the highest rate of prescription drug usage amongst any demographic segment surveyed and as the proportion of senior citizens in our population continues to grow, appropriate measures must be taken in order to ensure the highest quality of healthcare is delivered to those patients. According to one study, up to 30% of hospital admissions of patients over the age of 65 are due to adverse drug events (ADEs) or drug toxicities, including reactions such as severe depression, constipation, falls, immobility, confusion, and hip fractures. The incidence of serious adverse drug events in all populations is estimated to be high enough that if ranked as a disease by cause of death, if would rank above diabetes and pneumonia as the 5th most common cause of death in the United States. A1997 study that evaluated rates of ADEs in ambulatory adults found that up to 35% of the study population had experienced an ADE, with 29% requiring medical treatment for their ADE. Additionally, up to two-thirds of nursing home residents will experience an ADE over a 4 year period. The systemic issue of inappropriate medication usage and prescribing practices caused total estimated healthcare expenditures related to the use of potentially inappropriate medications (PIMs) in 2000 to rise to $7.2 billion. Given that up to 27% of all ADEs in primary care and up to 42% of ADEs in long-term care settings are preventable, objective vigilance in the monitoring of geriatric medication use is necessary to minimize harm to patient, maximize efficacy and efficiency in the healthcare setting, and increase cost savings in the distribution of care to this population. Explicit criteria are tools that can be used to assess the quality of prescribing practices in geriatric populations. Like any evaluation test, they have limitations in both their sensitivity and specificity and are not a substitute for clinical experience or professional judgment. Explicit criteria-based tools examine and bring attention to clinically important drug-drug, drug-disease, and pharmacodynamic or pharmacokinetic interactions and can be a highly effective tool in the initial evaluation of any medication regimen. Results Conclusion To compare and evaluate various explicit criteria based tools available for the evaluation of prescription and over- the-counter medication use in geriatric patients. Objective Methods A literature search and review using MEDLINE and Google Scholar searches was performed in July of 2012. MEDLINE Search Strategy Search terms included elderly, geriatric, explicit tools, improper medications, medication evaluation, and inappropriate prescribing. Related articles (as identified by MEDLINE) were also used. Google Scholar Search Strategy Query consisted of “explicit tools prescribing elderly” with additional queries using the search terms listed above. Table 1 – Comparison of Explicit Criteria Based Tools AbbreviationDefinition AGSAmerican Geriatrics Society BDZBenzodiazepine CIContraindicated HEDIS Healthcare Effectiveness Data and Information Set NROGRPNorwegian General Practice NSAIDNon-steroidal anti-inflammatory drug PIMPotentially inappropriate medication PRISCUS(Latin) “Old, Ancient” START Screening Tool to Alert doctors to Right Treatment STOPPScreening Tool of Older Peoples’ Prescriptions TCATri-cyclic antidepressant DISCLOSURE: The authors have no financial bias or conflict of interest to disclose. References available on request. Table 2 – Abbreviations and Definitions Summary Vast majority of published tools are based on the Beers Criteria Studies utilizing direct comparison of the most recent AGS/Beers Criteria (2012) and commonly used implicit and explicit criteria is needed to establish clinical validity and evaluate areas of potential improvement Newly-added organizational oversight and increased update frequency to the AGS/Beers Criteria will improve clinical applicability. Further increases in the transparency of the updating process is needed