Number-dependent association of potentially inappropriate medications with clinical outcomes and expenditures among community-dwelling older adults: a population-based cohort study

Understanding potentially inappropriate medication: A focus group study with general practitioners

INTRODUCTION

Polypharmacy and Potentially Inappropriate Medication (PIM) pose significant challenges for older adults, frequently leading to adverse health outcomes. While digital health tools offer promise solutions to improve medication management for this population, their integration into primary care settings remains slow. This study aims to explore the perspectives of Portuguese general practitioners (GPs) regarding polypharmacy, PIM, and the adoption of digital health-related tools for medication appropriateness in older adults.

METHODS

Five qualitative focus group sessions were conducted with 37 GPs working in Portuguese primary healthcare facilities of the north. The sessions were recorded, and a thematic analysis was performed.

RESULTS

The following five themes emerged: factors associated with polypharmacy, challenges in deprescribing, problems related to PIM, strategies to handle polypharmacy, and barriers and facilitators adopting digital health-related tools for medication appropriateness. Eight barriers and nine facilitators were identified.

CONCLUSION

This study underscores the complexity of medication management in older adults and highlights the potential of digital health tools to optimize medication use. Tailored interventions and collaborative efforts among all healthcare stakeholders are essential to enhance medication management and improve health outcomes in older adults.

Impact of Chinese criteria on potentially inappropriate medication use in China

Background

In 2018, China issued a set of criteria for effectively identifying and managing potentially inappropriate medication (PIM) use in older adults. However, there is currently a lack of evidence regarding the impact of these criteria on PIM use among older Chinese adults.

Methods

We used interrupted time series analysis on the prescription data of older outpatients from 59 hospitals in six major geographic regions of China to compare changes in the overall prevalence of PIM use, the prevalence of PIM use stratified by different numbers of PIMs, and the prevalence of top five PIMs (i.e. clopidogrel, estazolam, zolpidem, sliding-scale insulin, and alprazolam) from 2015 (before) to 2021 (after) the release of criteria in 2018.

Results

We included 982 605 older outpatients. Compared with trends prior to the publication of the criteria, there were significant decreases in the coefficient for change in the slope of the overall prevalence of PIM use (β = -0.607; 95% confidence interval (CI) = -0.881, -0.482; P < 0.001), the prevalence of single PIM use (β = -0.368; 95% CI = -0.465, -0.272; P < 0.001), the prevalence of multiple PIM use (β = -0.104; 95% CI = -0.173, -0.080; P = 0.019), the prevalence of clopidogrel (β = -0.342; 95% CI = -0.463, -0.227; P = 0.006), and the prevalence of estazolam (β = -0.077; 95% CI = -0.124, -0.037; P = 0.009) post-publication. Conversely, there was a significant increase in the prevalence of zolpidem, after the criteria were released (β = 0.030; 95% CI = 0.002, 0.057; P = 0.036).

Conclusions

We found that the release of criteria for effectively identifying and managing PIM use has had a positive effect on its prevalence among older outpatients in China.

Association of polypharmacy with clinical outcomes and healthcare utilization in older adults with cardiometabolic diseases: a retrospective cohort study

BACKGROUND

Limited knowledge exists on the association between polypharmacy among older patients diagnosed with cardiometabolic diseases and the risk of clinical outcomes and healthcare utilization.

AIM

This study aimed to estimate the impact of polypharmacy on clinical outcomes and healthcare utilization in older adults with cardiometabolic diseases.

METHOD

A retrospective cohort analysis was performed using data from the Beijing Municipal Medical Insurance Database. The study focused on polypharmacy prescribing patterns in community-dwelling adults 65 years and older with cardiometabolic diseases. Polypharmacy was defined as the use of five or more medications on the index date. The primary outcome included clinical outcomes, including hospitalizations and emergency department visits. The secondary outcome focuses on hospital utilization, specifically medication costs and length of stay.

RESULTS

The study included a cohort of 405,608 patients. Among these, the most frequently used drug classes in the polypharmacy and non-polypharmacy groups were HMG-CoA reductase inhibitors and dihydropyridines, respectively. After adjustment for covariates, polypharmacy was not associated with an increased risk of hospitalization (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.95-1.26, p = 0.23) or ED visits (OR 1.28, 95% CI 0.97-1.68, p = 0.08). Similarly, no significant association was found with an increase in inpatient medication costs ($2,620.5, 95% CI $2387.3-$2894.3, p = 0.97) or length of stay (3.98 days, 95% CI 3.68-4.30 days, p = 0.79). However, polypharmacy was associated with higher medication costs in outpatient settings ($73.07, 95% CI $72-$74, p < 0.05) and ED visits ($51.2, 95% CI $44.5-$59.1, p < 0.05).

CONCLUSION

Although polypharmacy is associated with increased healthcare costs in outpatient settings and ED visits, it does not significantly increase the risk of hospitalization or ED visits when properly managed.

Variability in the prevalence of inappropriate medication use among older adults: A review highlighting the importance of screening methods and database types

AIMS

The global older population is growing rapidly, and the rise in polypharmacy has increased potentially inappropriate medication (PIM) encounters. PIMs pose health risks, but detecting them automatically in large medical databases is complex. This review aimed to uncover PIM prevalence in individuals aged 65 years or older using health databases and emphasized the risk of underestimating PIM prevalence due to underutilization of detection tools.

METHODS

This study conducted a broad search on the Medline database to identify articles about the prevalence of PIMs in older adults using various databases. Articles published between January 2010 and June 2023 were included, and specific criteria were applied for study selection. Two literature reviews conducted before our study period were integrated to obtain a perspective from the 1990s to the present day. The selected papers were analysed for variables including database type, screening method, adaptations and PIM prevalence. The study categorized databases and original screening tools for clarity, examined adaptations and assessed concordance among different screening methods.

RESULTS

This study encompassed 48 manuscripts, covering 58 sample evaluations. The mean prevalence of PIMs within the general population aged over 65 years was 27.8%. Relevant heterogeneity emerged in both the utilized databases and the detection methods. Adaptation of original screening tools was observed in 86.2% (50/58) of cases. Half of the original screening tools used for assessing PIMs belonged to the simple category. About a third of the studies employed less than half of the original criteria after adaptation. Only three studies used over 75% of the original criteria and more than 50 criteria.

CONCLUSIONS

This extensive review highlights PIM prevalence among the older adults, emphasizing method intricacies and the potential for underestimation due to data limitations and algorithm adjustments. The findings call for enhanced methodologies, transparent algorithms and a deeper understanding of intricate rules' impact on public health implications.

Association between changes in potentially inappropriate medication use and adverse outcomes during hospitalization in older adults: A retrospective study

PURPOSE

To evaluate the association between the change in the number of PIMs in older adults during hospitalization and adverse outcomes.

METHODS

This retrospective cohort study was conducted in the internal medicine wards of a tertiary teaching hospital between May and December 2017. 3,460 patients (77.5±8.4 years, 60.4% male) were enrolled, and 206 patients died during hospitalization. PIMs were defined using the Beers Criteria as suggested by the American Geriatrics Society. Adverse outcomes studied were functional decline (a loss in 1 or more activities of daily living from admission to discharge), prolonged length of stay (LOS) (≥14 days), and mortality.

RESULTS

2258 patients (65.3%) had increasing PIMs during hospitalization. They tended to be younger (77.0±8.3 versus 78.5±8.5 years, p<0.001) and had lower numbers of PIMs at admission (0.4±0.8 versus 0.8±1.1, p<0.001). Increasing PIM use was strongly associated with greater functional decline (aOR 1.36, 95%CI 1.01-1.67, p=0.005), prolonged LOS (aOR 3.47, 95%CI 2.71-4.44, p<0.001) and higher mortality rate (aOR 2.68, 95%CI 1.75-4.12, p<0.001), even after adjusting for all covariates. We observed a strong association between adverse outcomes and increasing PIMs in older adults during hospitalization (p for trend <0.001).

CONCLUSIONS

Older adults with increasing PIMs during hospitalization were at greater risk for functional decline, prolonged LOS, and mortality, especially in those with three or more PIMs. Further studies are needed to better understand the complex interactions and to evaluate the effectiveness of intervention programs to lower PIM number and improve discharge outcomes for patients who had increasing PIM use during hospitalization.

Associated adverse health outcomes of polypharmacy and potentially inappropriate medications in community-dwelling older adults with diabetes

Aim: This study aimed to identify the association of chronic polypharmacy and potentially inappropriate medications (PIMs) with adverse health outcomes (AHOs) in community-dwelling older adults with diabetes in China. Methods: A 2-year retrospective cohort study was conducted using 11,829 community-followed older adults with diabetes and medical records from 83 hospitals and 702 primary care centers in Shenzhen, China. Chronic polypharmacy and PIMs were identified from prescription records using Beers' criteria, and their associated AHO was analyzed using multivariable logistic regression analysis. Results: The prevalence of chronic polypharmacy and at least one PIM exposure was 46.37% and 55.09%, respectively. The top five PIMs were diuretics, benzodiazepines, first-generation antihistamines, sulfonylureas, and insulin (sliding scale). Chronic polypharmacy was positively associated with all-cause hospital admission, admission for coronary heart disease, admission for stroke, admission for dementia, and emergency department visits. Exposure to PIMs was positively associated with all-cause hospital admission, admission for heart failure (PIMs ≥2), admission for stroke (PIMs ≥3), emergency department visits, bone fracture, constipation, and diarrhea. Conclusion: Chronic polypharmacy and PIMs were prevalent in older adults with diabetes in Chinese communities. Iatrogenic exposure to chronic polypharmacy and PIMs is associated with a higher incidence of different AHOs. This observational evidence highlights the necessity of patient-centered medication reviews for chronic polypharmacy and PIMs use in older patients with diabetes in primary care facilities in China and draws attention to the caution of polypharmacy, especially PIM use in older adults with diabetes in clinical practice.

Potentially Inappropriate Medication Use Among Older Patients with Diabetes in a Chinese Community

BACKGROUND

Potentially inappropriate medications (PIMs) are frequently prescribed to older people with diabetes. This study aimed to assess the prevalence of PIM use in older people with diabetes and identify potential risk factors influencing the development of PIM use.

METHODS

This was a cross-sectional study conducted in an outpatient setting in Beijing, China, using Chinese criteria. The prevalence of PIM use, polypharmacy, and comorbidities in older adults with diabetes in an outpatient setting was measured. Logistic models were employed to investigate the association among polypharmacy, comorbidities, and PIM use.

RESULTS

The prevalence of PIM use and polypharmacy was 50.1% and 70.8%, respectively. The most common comorbidities were hypertension (68.0%), hyperlipemia (56.6%), and stroke (36.3%), and the top three inappropriately used medications were insulin (22.0%), clopidogrel (11.9%), and eszopiclone (9.81%). Age (OR 1.025; 95% CI 1.009, 1.042), the number of diagnoses (OR 1.172; 95% CI 1.114, 1.232), coronary heart disease (OR 1.557; 95% CI 1.207, 2.009), and polypharmacy (OR 1.697; 95% CI 1.252, 2.301) were associated with PIM use.

CONCLUSIONS

Given the higher rate of PIM use among older adults with diabetes, strategies and interventions targeting this population are needed to minimize PIM use.

Prevalence of potentially inappropriate medications and association with comorbidities in older adults with diabetes in an outpatient visitation setting

AIMS

Potentially inappropriate medications had been found associated with adverse drug events such as falls, emergency department admissions and hospital readmissions. There is lack of information about the prevalence of potentially inappropriate medications and associated chronic conditions in older patients with diabetes in China. This study aimed to assess the prevalence of potentially inappropriate medications in older adults with diabetes in an outpatient visitation setting and the association with polypharmacy due to comorbidities.

MATERIALS AND METHODS

This was a 3-year repeated cross-sectional study which conducted in outpatient setting of 52 hospitals in Shenzhen, China, using 2019 Beers criteria. The prevalence of potentially inappropriate medications, polypharmacy and comorbidities in older adults with diabetes in an outpatient setting was expressed as percentages. Logistic models were used to investigate the association between potentially inappropriate medication exposure and age, sex, polypharmacy and comorbidities.

RESULTS

Among the 28,484 older adults with diabetes in 2015, 31,757 in 2016 and 24,675 in 2017, the prevalence of potentially inappropriate medications was 43.2%, 44.88% and 42.40%, respectively. The top five potentially inappropriate medications were diuretics (20.56%), benzodiazepines (13.85%), androgens (13.18%), non-steroidal anti-inflammatory drugs (12.94%) and sulfonylureas (6.23%). After adjustment for age and polypharmacy, the probability of potentially inappropriate medication exposure was associated with chronic gastrointestinal diseases, followed by osteoarthritis and rheumatoid arthritis, chronic pulmonary disease, chronic kidney disease, tumor, dementia, chronic liver disease, hypertension, cardiovascular disease, cerebrovascular disease and hyperlipemia.

CONCLUSION

Potentially inappropriate medications were common in older patients with diabetes in an outpatient visitation setting. Higher probability of potentially inappropriate medication exposure was associated with the comorbidity chronic gastrointestinal diseases as well as osteoarthritis and rheumatoid arthritis. To ensure that iatrogenic risks remain minimal for older adults with diabetes, the clinical comorbidities should be considered.