J Simon Bell
David G Le Couteur
Andrew J McLachlan
Timothy F Chen
Rebekah J Moles
Benjamin J Basger
Sarah N Hilmer
General practitioners manage complex medicine regimens and multiple comorbidities in older people. While medicine use usually leads to benefits for older people, the process of prescribing medicines is becoming increasingly complex.
The quality use of medicines (QUM) is one of the four central objectives of Australia’s National Medicines Policy. The National Strategy for the Quality Use of Medicines, launched in 2002, outlines key approaches and principles to achieve QUM.1 These key principles include appropriate medicine selection, an issue particularly relevant to older people due to their increased susceptibility to adverse drug events (ADEs). There is often limited clinical evidence to guide decisions about which medicines to commence or withdraw in older people. Yet research has continued to identify the widespread and unacceptable economic, clinical and human cost of medicine related harms.2 In Australia, medicine related hospitalisations account for up to 30% of unplanned admissions among people aged 75 years or older, and 32–77% of these may be preventable.3
What is inappropriate medicines use?
Inappropriate medicines use has been defined as that which poses greater risk of harms than benefits, especially when safer alternatives exist.4 The inappropriate use of medicines can be assessed using either explicit (criterion based) or implicit (judgement based) indicators. Ideally, explicit indicators would be evidence based, predictive of ADEs, identify underuse as well as overuse of medicines, include drug disease interactions, be clinically current, not omit any relevant medicines and be easy to use and flexible across health systems. Since the publication of Beers criteria in 1991,5 a set of explicit indicators developed for use in nursing homes in the United States, there has been a proliferation of explicit consensus based lists of ‘drugs to avoid’. Lists of potentially inappropriate medicines have been developed in countries including Canada,6 France,7 Germany,8 Ireland,9 Finland10 and Norway.11 These lists provide guidance about which medicines or doses to avoid. This represents an advantage over using polypharmacy (ie. number of medicines taken by a patient) as an indicator of potentially inappropriate medicines use. This raises the question of whether Australia needs its own classification for potentially inappropriate medicines use.
Defining inappropriate medicines use in the Australian context
Development of an Australian specific classification for inappropriate medicines use would serve to raise awareness among Australian clinicians. This would be particularly true if it were incorporated into prescribing and dispensing software and endorsed by key national medicines policy stakeholder organisations. Such a classification would have applications beyond general practice as a tool for conducting Home Medicines Reviews and Residential Medication Management Reviews,12,13 and to guide prescribing by nonmedical prescribers. Given the increasing number of medicine, pharmacy and nursing students, and the limited number of specialists in geriatric pharmacotherapy, such a list would prove valuable in teaching. The development of an Australian specific classification would also overcome several barriers to implementation of an international classification, such as the differences in medicine availability and prescribing culture.
Nevertheless, traditional explicit classifications are not without their limitations. There is an inconsistent or weak association between traditional ‘drugs to avoid’ criteria and expert assessments of medicine appropriateness.14 Most explicit approaches do not consider the management of comorbid illness, underprescribing of guideline recommended medicines, drugdrug interactions, or provide recommendations for alternative therapeutic options. There is no convincing evidence that use of Beers criteria medicines is associated with an increase rate in mortality or hospitalisation among nursing home residents, and the association with costs and quality of life in community based settings remains inconclusive.15 An Australian specific classification would need to be regularly updated as new medicines and evidence becomes available. Explicit criteria do not replace the importance of appropriate knowledge, skill and judgement.
How could we do better?
We advocate new policy driven approaches in which explicit and implicit criteria are combined. These approaches may incorporate indices of inappropriate medicines use that are predictive of clinically significant outcomes for older people (eg. cognitive impairment and physical function).16 An Australian specific set of indicators combining explicit and implicit criteria has already been proposed.17 Initial development was based on cross-referencing common reasons older Australians seek or receive healthcare with the 50 highest volume Pharmaceutical Benefits Scheme medicines. However, utilisation to date remains low, perhaps due to a lack of awareness or stakeholder endorsement. Stakeholder involvement in QUM initiatives is critical to facilitate local uptake by GPs and encourage further research into the effects on health outcomes. Australia may also seek to develop a list of ‘preferred medicines for older people’ similar to the new World Health Organization list of essential medicines for mothers and children.18 Finally, we advocate for the wider uptake of evidence based services such as Home Medicines Reviews, which are presently offered to only a fraction of those older Australians who stand to benefit.
The high rates of ADEs and potentially preventable medicine related harms represent a major public health issue among older people. Ongoing monitoring and further research is needed to ensure that new policy driven approaches are up-to-date and evidence based. Such approaches should seek to provide GPs with guidance about which medicines to commence or withdraw in older people. We appeal to clinicians, researchers and policy makers to work together to define and address inappropriate medicines use for older people in the Australian context.
- Commonwealth of Australia. National Strategy for the Quality Use of Medicines. 2002. Available at www.health.gov.au/internet/wcms/publishing.nsf/ Content/nmp-pdf-execsumbro-cnt.htm [Accessed 23 October 2011].
- Somers M, Rose E, Simmonds D, Whitelaw C, Calver J, Beer C. Quality use of medicines in residential aged care. Aust Fam Physician 2010;39:413–6.
- Runciman WB, Roughead EE, Semple SJ, Adams RJ. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003;15:i49–59.
- Hamilton HJ, Gallagher PF, O’Mahony D. Inappropriate prescribing and adverse drug events in older people. BMC Geriatr 2009;9:5.
- Beers MH, Ouslander JG, Rollinger I. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991;151:1825–32.
- McLeod PJ, Huang AR, Tamblyn RN, Gayton DC. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. Can Med Assoc J 1997;156:385–91.
- Laroche ML, Charmes JP, Merle L. Potentially inappropriate medications in the elderly: a French consensus panel list. Eur J Clin Pharmacol 2007;63:725–31.
- Holt S, Schmiedl S, Thürmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Dtsch Arztebl Int 2010;107:543–51.
- Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008;46:72–83.
- Finnish Medicines Agency Consensus Working Group. The ABCD classification for drug use among older people in primary care. 2010. Available at www.fimea.fi [Accessed 23 October 2011].
- Rognstad S, Brekke M, Fetveit A, Spigset O, Wyller TB, Straand J. The Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. A modified Delphi study. Scand J Prim Health Care 2009;27:153–9.
- Roughead EE, Barratt JD, Ramsay E, et al. The effectiveness of collaborative medicine reviews in delaying time to next hospitalization for patients with heart failure in the practice setting: results of a cohort study. Circ Health Fail 2009;2:424–8.
- Castelino RL, Hilmer SN, Bajorek BV, Nishtala P, Chen TF. Drug Burden Index and potentially inappropriate medications in community-dwelling older people: the impact of Home Medicines Review. Drugs Aging 2010;27:135–48.
- Steinman MA, Rosenthal GE, Landefeld CS, Bertenthal D, Kaboli PJ. Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing. Arch Intern Med 2009;169:1326–32.
- Jano E, Aparasu RR. Healthcare outcomes associated with Beers Criteria: a systematic review. Ann Pharmacother 2007;41:438–47.
- Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medication in older people. Arch Intern Med 2007;167:781–7.
- Basger BJ, Chen TF, Moles RJ. Inappropriate medication use and prescribing indicators in elderly Australians: development of a prescribing indicators tool. Drugs Aging 2008;25:777–93.
- World Health Organization. Top 30 medicines to save mothers and children. Available at www.who. int/mediacentre/news/notes/2011/mother_child_ medicine_20110321/en/index.html [Accessed 18 August 2011].