Filetype PDF | Posted on 04 Oct 2022 | 4 years ago
Authentication
digital resources
200x Filetype PDF File size 0.08 MB Source: scielo.isciii.es
Pattanaworasate W, Emmerton L, Pulver L, Winckel K. Comparison of prescribing criteria in hospitalised Australian
elderly. Pharmacy Practice (Internet) 2010 Apr-Jun;8(2):132-138.
Original Research
Comparison of prescribing criteria in
hospitalised Australian elderly
Wararat PATTANAWORASATE, Lynne EMMERTON, Lisa PULVER, Karl WINCKEL.
Received (first version): 16-Dec-2009 Accepted: 11-May-2010
ABSTRACT* COMPARACIÓN DE LOS CRITERIOS DE
The Beers criteria (2003) and McLeod criteria PRESCRIPCIÓN EN ANCIANOS
(1997) have been applied internationally to quantify HOSPITALIZADOS EN AUSTRALASIA
inappropriate prescribing in elderly populations.
Similarly, guidelines have been published locally by RESUMEN
the National Prescribing Service (NPS). Los criterios de Beers (2003) y los criterios de
Objective: This study aimed to adapt, evaluate and McLeod (1997) han sido aplicados
compare the utility of these three established criteria internacionalmente para cuantificar la prescripción
in measuring prescribing appropriateness in a inapropiada en las poblaciones de ancianos.
sample of hospitalised elderly patients. Asimismo, el Natioanl Prescribing Service (NPS)
Methods: Initial refinement of the criteria produced ha publicado guías locales.
versions applicable to Australian practice. Inpatient Objetivo: Este estudio trató de adaptar, evaluar y
records of 202 patients aged 65 years or older in six comparar la utilidad de estos tres criterios
wards of the Princess Alexandra Hospital, Brisbane, establecidos para medir la prescripción inapropiada
Australia, were reviewed using the adapted criteria. en una muestra de pacientes ancianos
‘Potentially inappropriate’ prescribing was hospitalizados.
descriptively analysed using relevant denominators. Métodos: Un afinamiento inicial de los criterios
Results: The adapted criteria collectively listed 70 produjo versiones aplicables a la práctica
‘potentially inappropriate’ medicines or drug groups Australiana. Se recogieron los historiales de 202
and 116 ‘potentially inappropriate’ prescribing pacientes hospitalizados de 65 o más años en seis
practices. Patients (mean age 80.0; SD=8.3 years) servicios del Hospital Princess Alexandra de
were prescribed, a median of eight medicines Brisbane, Australia y se utilizaron los criterios
(SD=4.0). At least one ‘potentially inappropriate’ adaptados. Se analizó descriptivamente la
medicine was identified in 110 (55%) patients. prescripción ‘potencialmente inapropiada’
‘Potentially inappropriate’ prescribing practices utilizando denominadores relevantes.
averaged 1.1 per patient (range 1-6). The adapted Resultados: Los criterios adaptados incluían
Beers criteria identified more ‘potentially colectivamente 70 medicamentos o grupos
inappropriate’ medicines/practices (44%, 101/232) ‘potencialmente inapropiados’ y 116 prácticas de
than the McLeod criteria (41%) and NPS criteria prescripción ‘potencialmente inapropiadas’. A los
(16%). Aspirin, benzodiazepines, beta-blockers and pacientes (edad media 80,0; DE=8,3 años) se les
dipyridamole were most commonly identified. prescribió una media de ocho medicamentos
Conclusion: The Beers and McLeod criteria, (DE=4,0). Se identificó al menos un medicamento
developed internationally, required considerable ‘potencialmente inapropiado’ en 110 (55%)
modification for local prescribing. The three criteria pacientes. Las prácticas de prescripción
differed in their focus and approaches, such that ‘potencialmente inapropiadas’ promediaron 1,1 por
development and validation of national criteria, paciente (rango 1-6). Los criterios de Beers
using the key features of these models, is adaptados identificaron más
recommended. There is potential to apply validated medicamentos/prácticas ‘potencialmente
guidelines in clinical practice and review of inapropiadas’ (44%, 101/232) que los de McLeod
prescribing, but only to supplement clinical (41%) y NPS (16%). Los más comúnmente
judgement. identificados fueron aspirina, benzodiacepinas,
beta-bloqueantes y dipiridamol.
Keywords: Drug Utilization Review. Aged. Conclusión: Los criterios de Beers y McLeod,
Australia. desarrollados internacionalmente, requieren una
considerable modificación para la prescripción
local. Los tres criterios diferían en su objetivo y
* abordajes, de modo que se recomienda el desarrollo
Wararat PATTANAWORASATE. MClinPharm. Bangkok y validación de criterios nacionales, utilizando los
Nursing Home Hospital, Bangkok (Thailand). puntos clave de estos modelos. Existe la
Lynne EMMERTON. PhD MPS. School of Pharmacy, The oportunidad de aplicar guías validadas en la
University of Queensland. Queensland (Australia). práctica clínica y revisión de la prescripción, pero
Lisa PULVER. BPharm DipHospPharm MSHPA. School of sólo para suplementar el juicio clínico.
Pharmacy, The University of Queensland. Queensland
(Australia).
Karl WINCKEL. BPharm, DipPharmPrac, CertPsychTher, Palabras clave: Revisión de uso de medicamentos.
MSHPA. Princess Alexandra Hospital, Woolloongabba Ancianos. Australia.
and School of Pharmacy, The University of Queensland.
Queensland (Australia).
www.pharmacypractice.org (ISSN: 1886-3655) 132
Pattanaworasate W, Emmerton L, Pulver L, Winckel K. Comparison of prescribing criteria in hospitalised Australian
elderly. Pharmacy Practice (Internet) 2010 Apr-Jun;8(2):132-138.
18
inappropriate medicines were identified. The
database excluded information about diagnosis,
dosage and duration, requiring exclusion of some
indicators of these criteria.
INTRODUCTION The only nationally-endorsed criteria specific to
The proportion of Australians aged 65 years and Australian prescribing exist in the National
over is estimated to increase from 12% in 1999 to Prescribing Service (NPS) indicators for quality
around 25% by 2051.1 Older patients necessitate prescribing in Australian general practice, published
vigilance in prescribing due to their number of in 2006.19 These evidence-based criteria, designed
medical conditions and medications.2,3 for self-review of prescribing by general
Internationally, ‘inappropriate prescribing’, a practitioners, describe quality prescribing via
recognised problem in the elderly, has been structure, process and outcome indicators, the
modelled to quantify and reduce these issues. process indicators detailing prescribing situations
Beers et al.4 published criteria in the United States requiring caution in older patients. No published
in 1991 to determine potentially inappropriate studies of their application have been located.
prescribing of medication. The revised version The Commonwealth Department of Veterans’
(2003)5 categorises listed 48 medicines or drug Affairs produced a Therapeutic Brief No. 8 -
classes that should generally be avoided in elderly Reducing Adverse Drug Events for your Veteran
patients. Despite acceptance and international Patients for use by general practitioners. Although
application of the Beers criteria, continual updating these guidelines were developed from both the
and international tailoring are required.3,6,7 The Beers and McLeod criteria, details of their
Beers criteria are explicit in nature, being derived development are lacking, and the resulting criteria
from published reviews, expert opinions and listed only four medication groups (long-acting
consensus techniques without clinical judgement benzodiazepines, anticholinergics, non-steroidal
about the presenting patient.8 Studies report 7.8%9 anti-inflammatories and a miscellaneous category)
to over 50%3,10 of patients with at least one to guide patient management.2
potentially inappropriate medication, dependent on Other developments have been reported following
research design (retrospective versus prospective research in Victorian hospitals nearly 10 years ago,
reviews) and characteristics of the reference producing 19 prescribing indicators specific to
patients and setting (primary care, secondary care, hospitalised elderly.20,21 These criteria demonstrated
continuing care). some potential, but they were not adopted more
The McLeod criteria,11 a Canadian initiative, were widely to gain national endorsement. More recently,
developed following the Beers criteria 1991, based researchers in Australia7 have matched the most
on risk-benefit ratios, drug-drug interactions and common reasons for treatment in the elderly with
drug-disease interactions, and describing 38 the most commonly prescribed medicines,
prescribing practices (across four drug/disease incorporating precautions from the Australian
groups: drugs to treat cardiovascular disease, 22
Medicines Handbook. This research produced
psychotropic drugs, non-steroidal anti-inflammatory locally-relevant criteria, although it rejected
drugs, and other analgesics and miscellaneous consensus methodology, and in deriving the list,
drugs), again rated through expert consensus to equated most commonly prescribed medicines with
produce a significance rating up to 4.00, as ‘most appropriate’ prescribing.7
opposed to the ‘high’ and ‘low’ significance In summary, the Beers and McLeod criteria, with
categories of the Beers criteria. their limited applicability to Australian practice,
As with the Beers criteria, the McLeod criteria have appear to be the most established tools for
been criticised for their limited applicability to measurement of prescribing to the elderly. The
geriatric clinical practice.3 A revision, the Improved Australian equivalent in terms of scope and national
3,12
Prescribing in the Elderly Tool (IPET) was trialled endorsement is the NPS criteria, although
in Ireland and compared to the Beers criteria to alternatives have been reported for specific
quantify rates of inappropriate prescribing in purposes. With the increasing elderly population in
hospitals. The Beers criteria demonstrated superior Australia, and the risks associated with multiple
sensitivity via a more exhaustive list of drugs, medicine use in this population, it is timely to
despite some being considered obsolete or rarely investigate the utility of these models in the
used.13 Australian context, recognising that prescribing
Further international research has produced the criteria serve as a guide only and do not replace
START (Screening Tool to Alert doctors to Right clinical judgement.
Treatment) and STOPP (Screening Tool of Older
Persons’ Prescriptions) criteria.3,14 While these METHODS
criteria show promise, their international applicability
has not been established.3 This study aimed to refine, apply and evaluate the
utility of the Beers criteria 2003, the McLeod criteria
Several studies have merged the Beers and 1997 and NPS criteria in a sample of hospitalised
McLeod criteria to determine their combined and elderly patients in Australia. ‘Utility’ was defined as
relative sensitivity.15-17 Australian data applying both relevance of listed medications (or drug groups) to
criteria are limited to analysis of Department of Australian prescribing and the interpretability of the
Veterans’ Affairs pharmacy claims, in which 26 criteria with respect to available patient records.
www.pharmacypractice.org (ISSN: 1886-3655) 133
Pattanaworasate W, Emmerton L, Pulver L, Winckel K. Comparison of prescribing criteria in hospitalised Australian
elderly. Pharmacy Practice (Internet) 2010 Apr-Jun;8(2):132-138.
Refinement of the Prescribing Criteria weekends (19 days). Losses due to inaccessibility,
The Beers, McLeod and NPS criteria were initially ineligibility, early discharge, and admission or
refined by one of the researchers (WP) by removing discharge on non-research days were expected.
drugs unavailable in Australia.19,22 This approach Consequently, 19 data collection days were
has been applied elsewhere.3,22,23 Refinement of the retained (March-April, 2007). The first three days
Beers criteria resulted in retention of 57 medicines comprised pilot testing, which identified minor
(63%). For the McLeod criteria, 33 of the 38 improvements requiring limited retrospective
potentially inappropriate practices were determined supplementation of the pilot data. The data
relevant to Australian practice. The majority of the collection comprised ‘snapshot’ chart reviews by a
NPS criteria were worded as best-practice single researcher (WP) of regular and ‘as needed’
statements, rather than indicators of inappropriate medications, irrespective of the source, date or
medication prescribing; four of the 21 indicators of reason of the prescription. Patients who were either
‘potentially inappropriate’ prescribing were retained present or admitted during the data collection were
for this study. These related to prescribing of included, and those who transferred between wards
antibiotics for upper respiratory tract infections, during the data collection were represented once
prescribing of cephalexin for various conditions, only in the database, with their most current
prescribing of ACE inhibitors with diuretics and non- medications reviewed by the researcher.
steroidal anti-inflammatory drugs (known as the Analysis
‘triple whammy’), and long-term prescribing of Categorical or numerical significance ratings of the
benzodiazepines. significance of inappropriateness were manually
The merged criteria comprised: added to the database from literature describing the
70 medications or drug groups (13 medications Beers, McLeod and NPS criteria. Prescribing of
were common to both the Beers and the McLeod aspirin and benzodiazepines was assumed to be for
criteria), and continuing use. The Beers criteria considered
aspirin as inappropriate at any dose in patients
116 ‘inappropriate’ prescribing practices – receiving anticoagulants, and at doses of at least
medications or drug groups that should generally 325mg as inappropriate in patients with a history of
be avoided in the elderly or are considered gastric ulceration. The McLeod criteria made no
inappropriate in particular conditions – 79 from the distinction regarding aspirin doses.
Beers criteria, 33 from the McLeod criteria and Analysis comprised descriptive comparison and
four from the NPS criteria. critique of the three criteria to determine their
The refined criteria were programmed into an Excel respective ‘utility’, and prevalence data for
spreadsheet designed to also record patient codes, prescribing appropriateness, according to the three
ward, medicines and medical conditions. criteria (using SPSS version 13.0). Denominators
Data Collection were the number of patients and the total number of
prescribed medications.
This study was conducted in the Princess Alexandra
Hospital (PAH), a 727-bed public hospital in RESULTS
Brisbane. Six wards containing a significant Description of the Study Sample
proportion of the hospital’s elderly patients, and
comprising three general medical wards (averaging During the study period, 296 patients were present
two patient admissions per day per ward, total 80 in, or admitted to, the six wards. Eighty-seven were
beds) and three rehabilitation wards (averaging 0.5 excluded due to age (<65 years), and seven
patient admissions per day per ward, total 78 beds), patients’ records were unavailable. The records of
were selected. the 202 patients listed 1794 prescribed medications,
Ethical approval was obtained from the Health and a median of eight medications per patient (SD=4.0,
Research Ethics Committee of the PAH prior to data maximum 22).
collection. Informed consent of the patients was not The mean age was 80.0 (SD=8.3) years (range 65-
required, due to their de-identification and lack of 99 years). The dominant group was females aged
direct involvement. 85-89 years (n=39). The three General Medical
Patients aged 65 years and older, on any regular wards each contributed 37-45 patients to the study,
prescribed medication, were included. Reason for while the three Rehabilitation wards each
admission did not affect their eligibility for inclusion. contributed 23-33 patients, reflecting the higher
The target sample size was determined via initial turnover of the General Medical wards. Some
data collection involving 70 patients, with statistical patients transferred between General Medical and
projection to determine differences between Rehabilitation wards during the study.
preliminary rates of ‘inappropriate’ prescribing (6.2% ‘Inappropriate’ Prescribing (per Patient)
and 4.3%, the two closest proportions, at alpha=0.5 The merged criteria identified 232 ‘potentially
and 95% power). This approach indicated recording inappropriate’ medications prescribed, averaging
of 1478 medications, or 154 patients at 9.6 1.1 potential issues per patient. The Beers criteria
medications per patient. At the rate of data detected a mean of 0.5 potential cases of
collection of one ward per day for data collection inappropriate prescribing per patient, compared to
followed by six admissions per day, a total of 263 0.47 using the McLeod criteria and 0.18 using the
records could be collected over one month less NPS criteria.
www.pharmacypractice.org (ISSN: 1886-3655) 134
Pattanaworasate W, Emmerton L, Pulver L, Winckel K. Comparison of prescribing criteria in hospitalised Australian
elderly. Pharmacy Practice (Internet) 2010 Apr-Jun;8(2):132-138.
Table 1: Instances of ‘Potentially Inappropriate’ Prescribing (202 patient records)
Medicines/Drug Groups Identified Conditions Beers McLeod NPS
Amiodarone 7 0 0
Amitriptyline 2 0 0
Syncope/fall 1 0 0
Anticholinergics Cognitive impairment 3 0 0
Constipation 1 0 0
Incontinence 1 0 0
Antipsychotics Parkinsons 1 0 0
Aspirin Receiving anticoagulants 36 0 0
Aspirin Hypertension 0 47 0
Antibiotics Upper respiratory tract infect. 0 0 3
Benzodiazepines 0 0 26
Angina and COPD 0 1 0
Beta-blockers Angina and heart failure 0 6 0
Hypertension and COPD 0 6 0
Hypertension and heart failure 0 13 0
Calcium channel blockers Constipation 4 0 0
Hypertension and heart failure 0 4 0
Cephalexin 0 0 1
Clopidogrel Receiving anticoagulants 5 0 0
Diazepam 5 0 0
Digoxin >125mcg 1 0 0
Dipyridamole Receiving anticoagulants 2 0 0
Stroke 0 13 0
Doxepin 2 0 0
Imipramine Arrhythmia 2 0 0
Methyldopa 1 0 0
Muscle relaxants Cognitive impairment 1 0 0
Nifedipine 4 0 0
NSAIDs (non-aspirin) Hypertension 0 2 0
Oestrogen only 2 0 0
Oral steroid Diabetes and COPD 0 1 0
Oxazepam >60mg 2 0 0
Oxybutynin 3 0 0
Promethazine 1 0 0
Propanolol COPD 1 0 0
Short-intermediate acting+fall Syncope/Fall 2 0 0
SSRIs SIADH/Hyponatraemia 4 0 0
Constipation 1 0 0
Tricyclic antidepressants Depression 0 1 0
Syncope/Fall 1 0 0
Temazepam >15mg 5 0 0
‘Triple Whammy’ 0 0 7
Total 101 94 37
Table 2: Most Commonly Identified Inappropriate Medications (202 patient records)
Medication McLeod Beers NPS Total
Aspirin 47 36 0 83
Benzodiazepines 0 14 26 40
Beta-blockers 26 0 0 26
Dipyridamole 13 2 0 15
In total, 110 patients (55%) had been prescribed at Beers criteria, 94 issues (41%) by the McLeod
least one ‘potentially inappropriate’ medication criteria and 37 issues (16%) by the NPS criteria
according to the amalgamated criteria, ranging from (Table 1). There was no overlap in the components
one to six instances per patient. of the three criteria, and therefore each of the
There was no significant difference in the issues identified was discrete. The combined criteria
proportions of patients with at least one identified the most common ‘inappropriate’
‘inappropriate’ medication detected by any of the medications as aspirin and benzodiazepines (Table
three criteria between the Rehabilitation and 2).
Medical wards (p>0.05). Of the 101 issues identified using the refined Beers
‘Inappropriate’ Prescribing (by Medicine and Drug criteria, 88 were classified as ‘high’ significance and
Group) 13 as ‘low’ significance issues. Thirty-six of the
issues related to the prescription of aspirin in
Of the 232 potential issues detected (in 110 patients who concurrently received anticoagulant
patients), 101 issues (44%) were identified by the therapy (‘high’ significance). Of the 94 issues
detected using the McLeod criteria, the highest
www.pharmacypractice.org (ISSN: 1886-3655) 135
no reviews yet
Please Login to review.
