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
Structure of presentation
 Brief background to study.
 Outline of study objectives.
 Methods.
 Results.
 Items for discussion and further research.
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).
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).
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.
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.
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.
30%
25%
20%
15%
10%
5%
0%
 0.71% (n=2,374) were
prescribed four.
1
2
3
4
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.
STOPP Adjusted Analysis 2007
5 highest prevalence rates (n=334,452)
System
STOPP
Description
Prev
%
Male
%
Female
%
OR
Gender
(F vs M)
70-74
years
%
>75
OR
years Age
%
(> 75 vs
70-74)
Gastro
Musco
PPI > 8 weeks
full therapeutic
dose.
20.18
NSAID >3M
7.80
19.94
20.36
1.00
16.87
22.17
(0.99-1.02)
6.49
8.77
1.39*
(1.38-1.43)
7.97
7.69
(1.35-1.43)
Cardio
Digoxin
>125ug/day
7.18
>1M Long-acting
benzodiazepines
5.52
Duplicates NSAIDs, SSRIs,
Antidep, ACE,
Loop diuretics,
opioids
* p< 0.0001
4.50
CNS
7.96
6.60
0.77*
6.85
1.89*
3.64
9.31
5.02
1.34*
(1.30-1.39)
2.78*
(2.69-2.87)
5.09
5.78
(1.83- 1.96)
3.81
0.94*
(0.92-0.97)
(0.75-0.79)
3.72
1.40*
1.10*
(1.06-1.13)
4.72
4.37
0.90*
(0.87-0.93)
STOPP Adjusted Cost Analysis 2007
(NIC= €39,204,062 )
System
STOPP Description
NIC
Total Cost
Gastro
PPI > 8 weeks full therapeutic
dose.
24,510,624
27,263,003
CNS
Neuroleptics >1M, (also with
Parkinsonism),
anticholingerics for side
effects.
5,815,282*
6,557,863*
Duplicates
NSAIDs, SSRIs, Antidep,
ACE, Loop diuretics, Opioids
4,544,244
5,509,161
Musco
NSAID >3M
Warfarin and NSAIDs
3,056,281*
3,918,678*
* Adjusted for claimants receiving the same medication per more than one criteria
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.
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.
Questions