Prescribing in Older Populations
- © Photo by Adam Jones adamjones.freeservers.com
Background: Older patients often have multiple conditions requiring multiple drug therapy which increases the risks of iatrogenic polypharmacy. Side effects of drugs may be misinterpreted, prompting prescription of another inappropriate drug- characterised as the “prescribing cascade”.
Quality of care is increasingly evaluated through the use of explicit measures-“quality indicators” which seek to judge the process of care given to patients against specific standards. Quality standards for medication use address several problems: insufficient use of beneficial drugs; poor monitoring of chronic disease and overuse of inappropriate or unnecessary drugs.
Study Aims: The purpose of these observational epidemiological studies is to assess indicators of prescribing quality and efficiency, among older people, in Ireland, Northern Ireland (NI) and the United Kingdom (UK) using pharmacoepidemiological databases and other data sources. This work has now been extended to include indicators of prescribing quality in middle aged adults.
- 1. Republic of Ireland (RoI):To estimate the prevalence of potentially inappropriate prescribing (PIP) in a national Irish population aged ≥70 years, in 2007 using European explicit prescribing criteria (STOPP) and to establish the total cost of PIP drugs and the cost in relation to overall national pharmaceutical expenditure.
- Study Design: A retrospective cross-sectional study of PIP in a national Irish population aged ≥70 years in 2007 using the Irish Primary Care Reimbursement Service (HSE-PCRS) pharmacy claims database.
-Progress to date: This study is complete and has been published (Cahir et al. 2010). Further publications from this study include potential cost savings by reducing potentially inappropriate prescribing of proton pump inhibitors (Cahir et al. 2012) and prescriber variation in PIP (Cahir et al. 2014) .
- 2. Northern Ireland (NI):To the prevalence of PIP in the Northern Irish population aged ≥70 years European explicit prescribing criteria (STOPP), to determine independent correlates of PIP (number of prescribed medications e.g. polypharmacy, gender and age) and to establish the total cost of PIP drugs.
- Study Design: A retrospective cross-sectional study of PIP in the Northern Irish population aged ≥70 years in 2007 using the Enhanced Prescribing Database (EPD).
-Progress to date: This study is complete and has been published (Bradley et al. 2012).
- UK: To estimate and compare the prevalence of PIP in the UK (including NI) and Irish national populations ≥70 using international (Beers) and European (STOPP) explicit prescribing criteria and to determine independent correlates of PIP (number of prescribed medications e.g. polypharmacy, co-morbidity, gender and age) in the UK population ≥70 years in 2007.
- Study Design: A retrospective cross-sectional study using the Irish Primary Care Reimbursement Service (HSE-PCRS), the Enhanced Prescribing Database (EPD) in NI and the UK Clinical Practice Research Datalink (CPRD) for 2007 data.
-Progress to date: This study is complete (STOPP criteria only) and a paper has been published (Bradley et al. 2014). The application of the Beers criteria to the CPRD is now in progress.
- To assess the association between established international (Beers) and European (STOPP) explicit prescribing criteria and health outcomes in a cohort of older GP patients (aged ≥ 70 years) in Ireland in 2009/11 through use of patient questionnaires, HSE-PCRS prescription dispensing data and GP patient clinical information.
- Study Design: A prospective one year cohort study of GP patients aged ≥ 70 years to investigate differences in health outcomes for those prescribed at least one potentially inappropriate medication per STOPP and Beers criteria and those who were not.
-Progress to date: This study is complete and papers have been published on the STOPP criteria only (Cahir et al. 2014) and comparing STOPP and Beers criteria (Cahir et al. 2014).
- Modelling the impact of PIP on adverse events, healthcare utilisation and costs and quality of life to quantify the economic cost of such prescribing
- Study design: Patient-level simulation model incorporating data from multiple sources (i.e. published literature, observational studies) to quantify the economic consequences of PIP and to estimate cost-savings associated with reductions in PIP.
Progress to date: This study is ongoing, study protocol being developed.
- Determining the prevalence of PIP and potential prescribing omissions (according to the STOPP and START criteria respectively) and predictors of PIP/potential prescribing omissions in a nationally representative cohort of community-dwelling older people.
- Study design: A retrospective cross-sectional study of participants aged 65 years and over in the first wave of The Irish Longitudinal Study on Ageing (TILDA).
Progress to date: This study is complete and a paper has been published (Galvin et al. 2014)
- To assess the association between several PIP and PPO (potential prescribing omissions) criteria and change in health outcomes (functional impairment, quality of life and healthcare utilisation) over time in a cohort of community dwelling older people.
– Study design: A longitudinal cohort study of participants from the Irish Longitudinal Study on Ageing (TILDA) with linked medication dispensing history from the HSE-PCRS pharmacy claims database. PIP and PPO will be determined using the STOPP criteria, Beers criteria, START criteria and ACOVE indicators.
Progress to date: This study is ongoing. Analysis of the longitudinal prevalence of PIP and PPO in this cohort is complete and a paper has been submitted for publication. Analysis on the association with health outcomes is underway.
- Development of a set of explicit prescribing criteria, known as the PROMPT (PRescribing Optimally in Middle-aged People’s Treatments) criteria, using a two-round Delphi technique. The PROMPT criteria will be applied to dispensing datasets (in the absence of clinical information) to determine the prevalence of potentially inappropriate prescribing (PIP) in middle-aged adults (aged between 45-64 years) in the Northern Irish and Irish population. This study will also examine the association between PIP and polypharmacy, gender and age group.
Study design: A retrospective cross-sectional study (and a between country comparison) of PIP in middle-aged people in Northern Ireland [using the Enhanced Prescribing Database (EPD)] and in the Republic of Ireland [using the Primary Care Reimbursement Service (PCRS) and The Irish LongituDinal Study on Ageing (TILDA)]. This project is being led by Dr Janine Cooper (QUB).
Progress to date: The first part of this study has been completed, the PROMPT criteria have been identified and validated, and a paper has been published (Cooper et al. 2014 ). Analysis of PIP in middle-aged people in Northern Ireland and the Republic of Ireland (PCRS) is complete and a paper comparing the prevalence in these populations has been drafted. Analysis in TILDA will follow submission of this paper.
- To assess the impact of PIP, as defined by the STOPP criteria, on subsequent health outcomes including adverse drug events, health related quality of life and healthcare utilisation.
-Study design: Prospective cohort study of 931 community dwelling older adults followed up for two years.
Progress to date: Data collection complete. Analysis ongoing.
- To assess trends in prescribing patterns, polypharmacy (being prescribed ≥5 regular medicines) and PIP over a 15 year time period and the relationship between these.
-Study design: Repeated cross-sectional study, using PCRS administrative pharmacy claims data, of all GMS-eligible individuals in the EHB region in the years 1997, 2002, 2007 and 2012.
Progress to date: This study is complete and a paper is being prepared for submission.
Background: Many people with chronic disease have more than one chronic condition, which is referred to as multimorbidity. Research in the area to date has focused mainly on descriptive epidemiology and impact assessment. We are now developing and testing interventions to improve outcomes for individuals with multimorbidity. These interventions will be multi-faceted and contain elements of medicines management, occupational therapy, physiotherapy and psychological support.
The multimorbidity research programme aims to further explore patterns of multimorbidity in primary care patients and determine the links between multimorbidity and health service utilization, particularly in relation to hospital admissions. In addition, we are undertaking exploratory trials to identify an intervention to improve outcomes for individuals with multimorbidity.
Studies Completed and Ongoing:
- We have completed a Cochrane systematic review of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. This review was undertaken with international colleagues from the University of Sherbrook in Canada and was published in the Cochrane Library in April 2012 (Smith et al. 2012). The BMJ also published a shorter version of this review in September 2012 ( Smith et al. 2012). This review is currently being updated.
- Chronic Respiratory Disease and multimorbidity: prevalence and impact in a general practice setting.
Study Design: Cross sectional survey. This study has been completed and a paper published in Respiratory Medicine (O'Kelly et al. 2011 ).
- Multimorbidity in patients with type 2 diabetes.
Design: Secondary data analysis of randomized controlled trial. This paper has been published in the European Journal of General Practice (Teljeur et al. 2013).
- Multimorbidity intervention exploratory trial study 1. This study was completed by Ms Eleanor Wallace for her Research Masters and involved a complex intervention combining GP reports and individual occupational therapy assessments.
- Multimorbidity intervention exploratory trial study 2. This was a study undertaken by Ms Lynn O’Toole for her Research Masters involving a six-week, group based intervention with occupational therapy and medication management components for people with multimorbidity in general practice settings (O'Toole 2013).
- Cohort Study. The Centre for Primary Care Research (CPCR) cohort was established in 2012 with a focus on potentially inappropriate prescribing and adverse drug events. Second wave data has been collected and analyses ill include a focus on the impact of multimorbidity and medicines management on subsequent adverse health outcomes, healthcare utilization and cost in the cohort of 931 elderly community dwelling adults followed up for two years. A US clinical prediction rule for predicting emergency hospital admissions (Probability of Repeated Admissions score) will be validated in this cohort to assess its predictive accuracy in an Irish setting. This project is being led by Dr Emma Wallace who received a HRB Research Training Fellowship to undertake this work and complete her PhD. Dr Wallace has also published a related systematic review of admission risk scores (Wallace 2013). Work is ongoing on a related analysis paper examining the evidence and current policy focus on reducing emergency hospital admissions.
- Occupation based, self-management programme for people with multimorbidity (OPTIMAL): Randomised controlled trial. This trial was undertaken in collaboration with Dr Deirdre Connolly and Ms Jess Garvey in the Department of Occupational Therapy in Trinity College Dublin. The exploratory trial showed statistically significant improvements in a range of primary and secondary outcomes suggesting this intervention is promising. A HRB Research Training Fellowship has been submitted to complete a larger trial of this OPTIMAL intervention.
- Multimorbidity and functional decline in community dwelling adults: a systematic review. The protocol for this review has been published on the PROSPERO database and the review is ongoing.
- Lifestyle risk factors and multimorbidity: a systematic review. The protocol for this review has been published on the PROSPERO database and the review is ongoing.
- Multimorbidity and health behaviours: A systematic review. This systematic review is planned in collaboration with our international collaborator, Prof Martin Fortin in the University of Sherbrooke in Canada.
- Multimorbidity and health behaviours. SPHeRE PhD Scholar, Aine Ryan is undertaking an analysis within TILDA of the impact of health behaviours on the development and progression of multimorbidity.
- Training doctors to manage multimorbidity. We received a HSE Medical Education and Training grant to develop and pilot an educational intervention for doctors managing multimorbidity and are undertaking a related systematic review on this topic. This systematic review is available from here.
We have received funding from the Irish Lung Foundation to support Studies 2 and 4.