The Quality of Pharmacologic Care for Vulnerable Older Patients

4 May 2004 | Volume 140 Issue 9 | Pages 714-720

Background: Although pharmacotherapy is critical to the medical care of older patients, medications can have considerable toxicity in this age group. To date, research has focused on inappropriate prescribing and policy efforts have aimed at access, but no comprehensive measurement of the quality of pharmacologic management using explicit criteria has been performed.

Objective: To evaluate the broad range of pharmacologic care processes for vulnerable older patients.

Design: Observational cohort study.

Setting: 2 managed care organizations enrolling older persons.

Patients: Community-dwelling high-risk patients 65 years of age or older continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999.

Measurements: Patients' receipt of care as specified in 43 quality indicators covering 4 domains of pharmacologic care: 1) prescribing indicated medications; 2) avoiding inappropriate medications; 3) education, continuity, and documentation; and 4) medication monitoring.

Results: Of 475 vulnerable older patients, 372 (78%) consented to participate and had medical records that could be abstracted. The percentage of appropriate pharmacologic management ranged from 10% for documentation of risks of nonsteroidal anti-inflammatory drugs to 100% for avoiding short-acting calcium-channel blockers in patients with heart failure and avoiding ß-blockers in patients with asthma. Pass rates for quality indicators in the "avoiding inappropriate medications" domain (97% [95% CI, 96% to 98%]) were significantly higher than pass rates for "prescribing indicated medications" (50% [CI, 45% to 55%]); "education, continuity, and documentation" (81% [CI, 79% to 84%]); and "medication monitoring" (64% [CI, 60% to 68%]).

Limitations: Fewer than 10 patients were eligible for many of the quality indicators measured, and the generalizability of these findings in 2 managed care organizations to the general geriatric population is uncertain.

Conclusions: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.

Editors' Notes Context Prescription and management of medications are important issues for older adults. Contribution Among elders enrolled in two managed care organizations, most quality problems were related to failure to prescribe indicated medications; failure to monitor medications; and failure to provide medication along with proper documentation and education in concert with other physicians. Implications Prescribing inappropriate medications for older adults is less of an issue than other aspects of drug therapy. Quality improvement efforts should focus on avoiding errors of omission in prescribing indicated medications, monitoring, patient education, and follow-up. –The Editors

 

Author and Article Information

From the University of California, Los Angeles, and the Greater Los Angeles Veterans Affairs Healthcare System, Los Angeles, California; RAND Health, Santa Monica, California and Washington, DC; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.

Acknowledgments: The authors thank Robert Brook, MD, ScD, for his guidance and Patricia Smith and Victor Gonzalez for technical assistance.

Grant Support: By a contract from Pfizer Inc. to RAND. Dr. Shekelle is a Senior Research Associate of the Veterans Affairs Health Services Research and Development Service. Dr. Chang is supported by a National Research Service Award (PE-19001) and the University of California, Los Angeles, Specialty Training and Advanced Research (STAR) Program.

Potential Financial Conflicts of Interest:Stock ownership or options (other than mutual funds): Roy T. Young (Pfizer Inc.); Grants received: J. Avorn (Pfizer Inc., Bristol-Myers Squibb, Novo Nordisk, Pharmacia).

Requests for Single Reprints: Takahiro Higashi, MD, Division of General Internal Medicine, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095.

Current Author Addresses: Drs. Higashi and Chang: Division of General Internal Medicine, University of California, Los Angeles, 911 Broxton Plaza, Los Angeles, CA 90095-1736.

Dr. Shekelle: Greater Los Angeles Veterans Affairs Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA 90073.

Drs. Solomon, MacLean, Adams, and Wenger and Ms. Roth: RAND, 1700 Main Street, M-26, Santa Monica, CA 90407-2138.

Drs. Knight and Avorn: Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, 221 Longwood Avenue, Suite 341, Boston, MA 02115.

Ms. Kamberg: RAND, 1200 South Hayes Street, Arlington, VA 22202.

Dr. Young: Division of General Internal Medicine, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.

Dr. Reuben: Division of Geriatrics, University of California, Los Angeles, 200 Medical Plaza, Los Angeles, CA 90095-1736.