Prescribing Rates of Drugs
to be Avoided in the Elderly
in Managed Care
Lok Wong, MHS; Russell Mardon, PhD; Phil Renner,
MBA - National Committee for Quality Assurance
Arlene Bierman, MD, MS - University of Toronto
Academy Health June 2005
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Session:
Quality and Safety for All –
Caring for Vulnerable Populations
Acknowledgements
NCQA Geriatric Measurement Advisory Panel (GMAP)
Medication Management Technical Subgroup
Arlene Bierman, MD, MS ;
Emerald Foster, Pharm.D., CGP;
Jerry Gurwitz, MD;
Joseph T. Hanlon, Pharm.D. ;
Mark E. Lehman, Pharm.D. FASCP;
Edward Westrick, MD, PhD
This study was supported by the Centers for Medicaid
and Medicare Services (CMS) under a HEDIS contract
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Study Objective
•
•
•
To evaluate to what extent Medicare
managed care enrollees 65+ receiving
potentially harmful drugs to be avoided in
the elderly
To develop a patient safety HEDIS measure
to highlight and reduce use of high-risk
medications
Harms from drugs in the elderly include:
–
–
–
–
neurological side effects: antipsychotics and antiemitics
central nervous system effects: anticholinergic drugs
increased risk of falls: anti-anxiety drugs
cardiac and renal effects: amphetamines and other drugs
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Drugs to be Avoided
• Potentially harmful drugs identified by consensus
panels of geriatric physicians and pharmacists
• Zahn criteria (2001):
– Never appropriate
– Rarely appropriate
• Beers updated criteria (2003):
– High severity
– Low severity
• Never or rarely appropriate drugs selected by NCQA
expert panel for patient safety measure
– Harmful drugs regardless of drug dose, frequency, or
patient’s underlying health status
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Study Population
• Over 824,000 Medicare enrollees in 2002
and over 803,000 in 2003
• Ages 65 and older
• 9 health plans across the United States
• Average number of enrollees per plan
from 7,500 to 187,000.
• Continuously enrolled during the year
• Pharmacy benefits
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Study Design
• Retrospective pharmacy claims data analysis
• Percentages of Medicare elderly enrolled
throughout the year who received:
– at least one drug to be avoided in the elderly
– at least two drugs from different therapeutic
classes to be avoided in the elderly
Rates calculated by plan, age, gender and across
the total study population.
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Findings – Potentially Harmful Drugs
•
•
Nearly a million elderly enrollees
received more than 3 million
prescriptions of potentially harmful
drugs (Zahn/Beers)
Average 3-6 prescriptions per member
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Rates of Drugs Never or Rarely
Appropriate in the Elderly
At least 1
Min %
Avg %
Max %
At least 2
2002
13.2
20.5
29.9
2003
12.3
20.1
29.2
Min %
Avg %
Max %
2002
1.5
3.2
5.1
2003
1.1
3.1
4.3
• 165,000 enrollees received about 500,000 never or
rarely appropriate drug prescriptions
• About 1 in 5 Medicare enrollees (20%, range 12-30%)
received at least 1 drug to be avoided in the elderly
– Never appropriate: 4.4% (2.4% - 5.6%)
– Rarely appropriate: 16.1% (9.2% - 25.7%)
• Multiple risk exposure: 3% (1% - 5%) received at least
2 drugs from different classes
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HEDIS Measure: Drugs to be Avoided
• For the final HEDIS measure, NCQA expert panel
added drugs from the updated Beers list they
considered “never or rarely appropriate” in the elderly
• Total 59 drugs in 18 therapeutic classes selected
HEDIS 2006 Measure Definition:
• Percentages of Medicare enrollees 65+ with:
– at least one drug to be avoided in the elderly
– at least two different drugs to be avoided in the
elderly
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Top Prescribed Drugs to be Avoided
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Estrogen (19%, 619,000)
Anti-anxiety, sedative hypnotics and benzos (18%, 593,000)
Narcotic analgesics and propoxyphene (7%, 244,000)
Skeletal muscle relaxants (4.3%, 141,000)
Antihistamines (3.8%, 125,000)
Nitrofurantoin (2%, 70,000)
GI antispasmodic – dicylcomine, propantheline (1.6%, 35,000)
Belladonna Alkaloids (1%, 28,000)
Thyroid hormones (0.78%, 26,000)
Vasodilators - dipyridamole (0.6%, 20,000)
Barbiturates (0.35%, 11,500)
Antiemitics (0.34%, 11,000)
Oral hypoglycemics – chlorpropamide (0.13%, 4300)
(Percentage and Number of Prescriptions in Medicare enrollees)
Underlined are additional Beers drugs added to the measure
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Conclusions
• Results shows high rates of harmful prescribing
in the elderly managed care population
• Higher prescribing rates than other studies
• Additional patient safety concern: patients with
multiple drug-risk exposure
• A HEDIS patient safety measure can highlight and monitor
extent of harmful drug prescribing in managed care
• QI interventions needed to reduce harmful prescribing
– Plans: review drug utilization in elderly, pharmacy-based
interventions, formulary restrictions
– Clinicians: drug alerts, education on safer alternatives
– Elderly patients: medications review, patient education
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References
1.
Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating
the Beers criteria for potentially inappropriate medication use in older adults.
Arch Intern Med. 2003; 163: 2716-2724.
2.
Beers MH. Explicit criteria for determining potentially inappropriate medication
use by the elderly. Arch Intern Med 1997; 157: 1531-1536.
3.
Zhan C, Sangl J, Bierman AS, Miller MR, Friedman B, Wickizer SW, Meyer
GS. 2001. Potentially inappropriate medication use in the community-dwelling
elderly. JAMA 286(22): 2823-2868.
4.
Kaufman MB, Brodin KA, Sarafian A, Effect of Prescriber Education on the
Use of Medications Contraindicated in Older Adults in a Managed Medicare
Population. J Manag Care Pharm. 2005 April/May;11(3):211-219
5.
Steven R. Simon, MD, MPH, K. Arnold Chan, MD, ScD, Stephen B. Soumerai,
ScD, Anita K. Wagner, PharmD, DPH, Susan E. Andrade, ScD, Adrianne C.
Feldstein, MD, MS, Jennifer Elston Lafata, PhD, Robert L. Davis, MD, MPH,
Jerry H. Gurwitz, MD, Potentially Inappropriate Medication Use by Elderly
Persons in U.S. Health Maintenance Organizations, 2000-200, Journal of the
American Geriatrics Society, 2005, Volume 53, Issue 2, page 227-232
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Contact Information
Corresponding author:
Lok Wong, MHS
Senior Health Care Analyst
Quality Measurement
National Committee for Quality Assurance
2000 L Street, NW, Suite 500
Washington D.C. 20036
wong@ncqa.org
Tel: 202 – 955 – 1784
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