避免使用药物标准与问题处方专家评估之间的一致性。
Agreement between drugs-to-avoid criteria and expert assessments of problematic prescribing.
作者信息
Steinman Michael A, Rosenthal Gary E, Landefeld C Seth, Bertenthal Daniel, Kaboli Peter J
机构信息
San Francisco VA Medical Center, San Francisco, CA 94121, USA.
出版信息
Arch Intern Med. 2009 Jul 27;169(14):1326-32. doi: 10.1001/archinternmed.2009.206.
BACKGROUND
Drugs-to-avoid criteria are commonly used to evaluate prescribing quality in elderly persons. However, few studies have evaluated the concordance between these criteria and individualized patient assessments as measures of problem prescribing.
METHODS
We used data on 256 outpatients from the Iowa City VA Medical Center who were 65 years or older and taking 5 or more medications. After a comprehensive patient interview, a study team composed of a physician and a pharmacist recommended that certain drugs be discontinued, substituted, or reduced in dose. We evaluated the degree to which drugs considered potentially inappropriate by the drugs-to-avoid criteria of Beers et al and Zhan et al (hereinafter, Beers criteria and Zhan criteria) were also considered problematic by the study team, and vice versa.
RESULTS
In the study cohort, 256 patients were using 3678 medications. The physician-pharmacist team identified 563 drugs (15%) as problematic, while 214 drugs (6%) were flagged as potentially inappropriate by the Beers criteria and 91 drugs (2.5%) were flagged as potentially inappropriate using the Zhan criteria. The kappa statistics for concordance between drugs-to-avoid criteria and expert assessments were 0.10 to 0.14, indicating slight agreement between these measures. Sixty-one percent of drugs identified as potentially inappropriate by the Beers criteria and 49% of drugs flagged by the Zhan criteria were not judged to be problematic by the expert reviewers. Correspondence between drugs-to-avoid criteria and expert assessment varied widely across different types of drugs.
CONCLUSIONS
Drugs-to-avoid criteria have limited power to differentiate between drugs and patients with and without prescribing problems identified on individualized expert review. Although these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures of prescribing quality.
背景
避免用药标准常用于评估老年人的处方质量。然而，很少有研究评估这些标准与作为问题处方衡量指标的个体化患者评估之间的一致性。
方法
我们使用了来自衣阿华市退伍军人医疗中心的256名门诊患者的数据，这些患者年龄在65岁及以上，服用5种或更多药物。在对患者进行全面访谈后，由一名医生和一名药剂师组成的研究团队建议停用、替换某些药物或减少剂量。我们评估了根据比尔斯等人和詹等人的避免用药标准（以下简称比尔斯标准和詹标准）被认为可能不适当的药物，研究团队也认为有问题的程度，反之亦然。
结果
在研究队列中，256名患者使用了3678种药物。医生 - 药剂师团队确定563种药物（15%）有问题，而根据比尔斯标准有214种药物（6%）被标记为可能不适当，根据詹标准有91种药物（2.5%）被标记为可能不适当。避免用药标准与专家评估之间一致性的kappa统计值为0.10至0.14，表明这些指标之间只有轻微一致性。根据比尔斯标准被确定为可能不适当的药物中，61%以及根据詹标准被标记的药物中，49%未被专家评审员判定为有问题。避免用药标准与专家评估之间的对应关系在不同类型的药物中差异很大。
结论
避免用药标准在区分有或没有在个体化专家评审中确定的处方问题的药物和患者方面能力有限。虽然这些标准作为初始处方决策的指南很有用，但它们不够准确，不能作为处方质量的独立衡量标准。
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