Racial-Ethnic Variations in Potentially Inappropriate Psychotropic Medication Use Among the Elderly

Racial and Ethnic Differences in Potentially Inappropriate Medication Use Among Medicare Beneficiaries

Importance

Older Medicare beneficiaries are susceptible to receiving potentially inappropriate medications (PIMs), where the risks outweigh the benefits. Racial and ethnic differences in PIM use may perpetuate health disparities and disproportionately lead to costly adverse drug events for some groups.

Objective

To examine associations of race and ethnicity with PIM use among older Medicare beneficiaries.

Design, Setting, and Participants

This cross-sectional study used nationwide Medicare Part D Event files, fee-for-service claims, and Medicare Advantage (MA) encounter data among Medicare beneficiaries 65 years or older with Part D prescription drug coverage. The study population included random samples of 20% of traditional Medicare (TM) beneficiaries and 50% of MA enrollees from January 1, 2016, to December 31, 2019. Analysis was conducted from May 28 to September 16, 2024.

Exposure

Race and ethnicity.

Main Outcomes and Measures

Linear probability models were estimated for outcomes of (1) high-risk medication use among older adults, (2) potentially harmful drug-disease interactions in patients with dementia, and (3) potentially harmful drug-disease interactions in patients with a history of falls.

Results

The study sample included 21 193 170 patients with 32 199 587 beneficiary-year observations (mean [SD] age, 75.5 [7.3] years; 18 936 697 [58.8%] female; 983 513 [3.1%] Asian or Pacific Islander, 3 190 515 [9.9%] Black, 2 710 930 [8.4%] Hispanic, and 25 314 629 [78.6%] White). Compared with White beneficiaries, the rates of high-risk medication use were 1.7 [95% CI, -1.8 to -1.6] percentage points lower for Asian or Pacific Islander beneficiaries, 3.4 [95% CI, -3.4 to -3.3] percentage points lower for Black beneficiaries, and 0.6 [95% CI, -0.6 to -0.5] percentage points lower for Hispanic beneficiaries. Similarly, White beneficiaries had the highest rates of potentially harmful drug-disease interactions among those with dementia as well as those with a history of falls. The pattern of racial and ethnic differences was similar in analyses stratified by enrollment in TM or MA plans. However, the differences between White individuals and other groups were smaller in MA than in TM plans for all comparisons.

Conclusions and Relevance

In this cross-sectional study of 32 199 587 Medicare beneficiary-years from 2016 to 2019, White Medicare beneficiaries had consistently higher rates of PIM use compared with other racial and ethnic groups. The observed differences may be partially explained by racial and ethnic differences in overall prescription drug use and suggest the need to reduce PIM use in all racial and ethnic groups.

Impact of medication therapy management programs on potentially inappropriate medication use in older adults: A systematic review

BACKGROUND

The use of potentially inappropriate medications (PIMs) is prevalent, costly, and harmful for older adults. These medications are to be avoided among older adults because they generally have (1) a high risk of adverse events in this population and/or (2) limited evidence of benefits in the presence of safer or more effective alternatives. Medication therapy management (MTM) programs can help address PIM use; however, there has not been a synthesis of studies examining the impact of MTM programs on PIM use.

OBJECTIVE

To review published literature evaluating the impact of MTM on PIM use in older adults.

METHODS

A systematic literature review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines using MEDLINE (PubMed) studies were included if they (1) had a Medicare population, (2) were based in the United States, (3) examined an MTM program (ie, used the term "medication therapy management"), (4) focused on the impact of MTM programs on PIM use as the primary outcome, (5) had a randomized controlled trial or an observational study design, and (6) were available in English.

RESULTS

Of 221 articles identified, 31 full-text articles were assessed, and 7 met all inclusion and exclusion criteria. The studies took place in various settings, ranging from single-site tertiary medical centers to multisite outpatient clinics, community pharmacies, and nationwide telehealth MTM providers. Patient populations were majority female sex (ranging from 61% to 71%) and majority White (ranging from 81% to 94%), with a mean age of 73 to 78 years. In 5 of the 7 studies, MTM reduced the use of PIMs; however, 3 did not adjust for confounding or apply a comparator group. Measurement of MTM impacts on PIM use varied across studies. Patient-level and plan-level studies mostly assessed shorter-term PIM usage reduction (4 months or less), whereas studies performed at the provider and institutional level assessed PIM usage reduction trends across consecutive measurement years.

CONCLUSIONS

Based on the current limited evidence, MTM programs in older adults appear to have a positive impact on reducing PIM use. However, evidence was limited by study design, the lack of consistency in outcome measures, and a short follow-up period. Future work should adjust for confounding, apply comparator groups, include longer-term outcomes, and develop a core set of measures that can be consistently applied across studies.

Utilization and Spending on Potentially Inappropriate Medications by US Older Adults with Multiple Chronic Conditions using Multiple Medications

BACKGROUND

The utilization of potentially inappropriate medications (PIMs) in older adults can lead to adverse events and increased healthcare costs. Polypharmacy, the concurrent utilization of multiple medications, is common in older adults with multiple chronic conditions.

OBJECTIVE

To investigate the utilization and costs of PIMs in multimorbid older adults with polypharmacy over time.

METHODS

This retrospective cross-sectional study used linked Medicare claims and electronic health records from seven hospitals/medical centers in Massachusetts (2007-2014). Participants were ≥65 years old, had ≥2 chronic conditions (to define multimorbidity), and used drugs from ≥5 pharmaceutical classes for ≥90 days (to define polypharmacy). Chronic conditions were defined using the Chronic Conditions Indicator from the Agency for Health Research and Quality. PIMs were defined using the American Geriatrics Society 2019 version of the Beers criteria. We calculated the percentage of patients with ≥1 PIMs and the percentages of patients using different types of PIMs. We used logistic regression analyses to test the odds of taking ≥1 PIMs. We calculated mean costs spent on PIMs by dividing the costs spent on PIMs by the total medication cost.

RESULTS

≥69% of patients used ≥1 PIM. After adjusting for healthcare utilization, chronic conditions, medication intake, and demographic factors, female sex (2014: Odds ratio (OR)=1.27, 95%CI 1.25-1.30), age (2014: OR=0.92, 95%CI 0.90-0.93), and Hispanic ethnicity (2014: OR=1.41, 95%CI 1.27-1.56) were associated with PIM use. Gastrointestinal drugs and central nervous system drugs were the most commonly-used PIMs. In patients using ≥1 PIM, >10% of medication costs were spent on PIMs.

CONCLUSION

The utilization of PIMs in US older adults with multimorbidity and polypharmacy is high.