1. Controlling “Polypharmacy” in the elderly The “Medication Appropriateness Index” G. Vital-Durand 1, F. Herrmann 2, J-P. Michel 2, V. Rollason 3, N. Vogt 3, P. Dayer 3 Centre Suisse de Pharmacovigilance 1, Berne, Hôpital de Gériatrie 2 and Unité de Gérontopharmacologie Clinique 3, Geneva, Switzerland Contact : gvd@altavista.net 1. Introduction « Polypharmacy » may be defined as drug use that is both inappropriate and excessive 1. Previous researchers have analysed this practice and pointed to its many pitfalls 2-4. Some of the likely causes for such common abuse have been identified and various procedures have been applied to tackle it 5-7. We undertook a controlled study following a randomised, parallel, single-blind design in two groups of elderly hospitalised patients in order to test a quality control (QC)-procedure called Procédure de validation de la prescription (PVP) or Medication Appropriateness Index (MAI) 8. This procedure has been developed as a practical tool intended to help physicians validate their patients’ prescriptions. 2. Study procedure Patients’ drug use was assessed both prior to and following application of the QC-procedure. « Polypharmacy » was defined as the administration of > 5 drugs over a 3 day-period upon hospital admission. In the active group, house-officers were advised of any prescription inappropriateness (on the basis of the MAI score), whereas in the control group, MAI results were not disclosed. Drug prescription data was collected and analysed so as to minimise the observation bias. Variations of prescription patterns were thus identified and measured so as to assess the impact of the QC procedure. Finally interviews were conducted with the house-officers to assess their receptivity to the intervention. We intend to conduct multivariate comparison tests both sequentially within groups and also between groups at similar periods at a later stage. 4. Conclusions « Polypharmacy » is a common occurrence in the context of a reference teaching hospital for elderly patients. The MAI procedure appears to offer a valuable tool to assess the validity of drug prescriptions in elderly hospitalised patients. Furthermore, application of the MAI procedure is feasible by house- officers themselves rather than clinical pharmacology or pharmacy consultants. Further investigations are warranted to validate the application of the procedure by house officers themselves rather than outside observers. Figure - Score items see Figure and Tables 2 & 3 see Table 1 3.2. Impact of the MAI Procedure Two weeks later, patient records were revisited and the same QC procedure was again administered. Those not available for review (drop- outs) fell into such categories as discharge and death (42 %). From those 58 patients who were assessed a second time (Protocol-evaluable category), the following data (average figures) was extracted. Even though the average number of drugs taken in the active group was lower than that in the control group (8.9 vs. 9.5), both the number of inappropriate prescriptions and the MAI score were not significantly different between the two parallel groups. 3. Results 3.1. Extent and nature of “Polypharmacy” 200 newly admitted patients were included in the study, 100 of which in the active group. We present here the results obtained on the basis of an interim analysis of the first 162 patients screened for the study. « Polypharmacy » was identified in 100 patients (62 %) with 9.6 drugs per day on average. These first 100 patients were then randomised into either an active or a control group. Both groups were comparable insofar as age, gender, documented medical history or prescription pattern was concerned. The average number of drugs administered was 9.2 in the active vs. 10.0 in the control group. All patients were administered the QC procedure and the corresponding MAI scores were computed. Of the 10 targets tested in the MAI score, those dealing with cost- effectiveness (once per patient on average [= score 1 ]), efficacy [ score.6 ] and ADR’s* [ score.3 ] were the most commonly missed. As far as the drugs assessed as inappropriate, they mostly fell into the cardio- vascular, CNS and G-I categories. * Adverse drug reactions References 1 - Hanlon JT et al. Amer J Med 1996 ; 100 : 428-37. 2 - Himmel W et al. Eur J Clin Pharmacol 1996 ; 50 : 253-7. 3 - Emeriau JP et al. Bull Acad Nat Méd 1998 ; 182 (7) : 1419-29. 4 - Salles-Montaudon N et al. Rev Méd Int 2000 ; 21 (8) : 664-71. 5 - Beers MH. Arch Int Med 1997 ; 1531-6. 6 - Le Grand A et al. Health Policy Plan 1999 ; 14 (2) : 89-102. 8 - Gurwitz JH et al. J Am Geriatr Soc 1990 ; 542 : 542-52. 8 - Fitzgerald LS et al. Ann Pharmacother 1997 ; 31 (5) : 543-8. see Tables 2 & 3