Quality, Efficiency and Equity in Prescribing in Ireland

Quality, Efficiency and Equity in Prescribing in Ireland

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 persons 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 and age. Establish the association between PIM and gender the associated cost. Relationship and PIM. between the no. of medications taken Methods Retrospective

population based cohort study (aged 70 years) using the HSE-PCRS (n=334,452). Thirty STOPP indicatorsCardiovascular (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 4.50 CNS * p< 0.0001 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 Develop risk modelling. practical prescribing guidelines and clinical decision support systems. Questions

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