Steinman Michael A, Miao Yinghui, Boscardin W John, Komaiko Kiya D R, Schwartz Janice B
Division of Geriatrics, University of California, San Francisco, 4150 Clement St, VA Box 181G, San Francisco, CA, 94141, USA,
J Gen Intern Med. 2014 Oct;29(10):1379-86. doi: 10.1007/s11606-014-2924-8. Epub 2014 Jul 8.
Quality prescribing for older adults involves multiple considerations. We evaluated multiple aspects of prescribing quality in older veterans to develop an integrated view of prescribing problems and to understand how the prevalence of these problems varies across clinically important subgroups of older adults.
Cross-sectional observational study of veterans age 65 years and older who received medications from Department of Veterans Affairs (VA) pharmacies in 2007.
Using VA pharmacy data linked with encounter, laboratory and other data, we assessed five types of prescribing problems.
Among 462,405 patients age 65 and older, mean age was 75 years, 98 % were male, and patients were prescribed a median of five medications. Half of patients (50 %) had one or more prescribing problems, including 12 % taking one or more medications at an inappropriately high dose, 30 % with drug-drug interactions, 3 % with drug-disease interactions, and 26 % taking one or more Beers criteria drugs. In addition, 16 % were taking a high-risk drug (warfarin, insulin, and/or digoxin). On multivariable analysis, age was not strongly associated with four of the five types of prescribing issues assessed (relative risk < 1.3 across age groups), and comorbid burden conferred substantially increased risk only for drug-disease interactions and use of high-risk drugs. In contrast, the number of drugs used was consistently the strongest predictor of prescribing problems. Patients in the highest quartile of medication use had 6.6-fold to12.5-fold greater risk of each type of prescribing problem compared to patients in the lowest quartile (P < 0.001 for each).
The number of medications used is by far the strongest risk factor for each of five types of prescribing problems. Efforts to improve prescribing should especially target patients taking multiple medications.
老年人合理用药涉及多个方面的考量。我们评估了老年退伍军人用药质量的多个方面，以形成对用药问题的综合认识，并了解这些问题在临床上重要的老年亚组中的患病率如何变化。
对2007年从退伍军人事务部（VA）药房获取药物的65岁及以上退伍军人进行横断面观察性研究。
利用与就诊、实验室及其他数据相关联的VA药房数据，我们评估了五种类型的用药问题。
在462405名65岁及以上的患者中，平均年龄为75岁，98%为男性，患者的药物处方中位数为五种。一半的患者（50%）存在一个或多个用药问题，包括12%的患者服用一种或多种剂量过高的药物，30%的患者存在药物相互作用，3%的患者存在药物与疾病相互作用，26%的患者服用一种或多种符合Beers标准的药物。此外，16%的患者正在服用高风险药物（华法林、胰岛素和/或地高辛）。多变量分析显示，年龄与所评估的五种用药问题中的四种没有密切关联（各年龄组相对风险<1.3），共病负担仅使药物与疾病相互作用和使用高风险药物的风险大幅增加。相比之下，用药数量始终是用药问题的最强预测因素。用药量处于最高四分位数的患者与最低四分位数的患者相比，每种用药问题的风险高6.6倍至12.5倍（每种情况P<0.001）。
用药数量是五种用药问题中每一种的最强风险因素。改善用药的努力应特别针对服用多种药物的患者。
