Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
BMC Geriatr. 2021 Mar 6;21(1):163. doi: 10.1186/s12877-021-02089-x.
The use of potentially inappropriate medications (PIMs) is common in older adults and is associated with potential negative consequences, such as falls and cognitive decline. Our objective was to investigate measurable patient factors associated with new outpatient prescribing of potentially inappropriate medications in older multimorbid adults already using multiple medications.
In this retrospective US cohort study, we used linked Medicare pharmacy and medical claims and electronic health record data from a large healthcare system in Massachusetts between 2007 and 2014. We identified patients aged ≥65 years with an office visit who had not been prescribed or used a PIM in the prior 180 days. PIMs were defined using 2019 Beers criteria of the American Geriatrics Society. To specifically evaluate factors in patients with polypharmacy and multimorbidity, we selected those who filled medications for ≥90 days (i.e., chronic use) from ≥5 pharmaceutical classes in the prior 180 days and had ≥2 chronic conditions. Multivariable Cox regression analysis was used to estimate the association between baseline demographic and clinical characteristics on the probability of being prescribed a PIM in the 90-day follow-up period.
In total, we identified 17,912 patients aged ≥65 years with multimorbidity and polypharmacy who were naïve to a PIM in the prior 180 days. Of those, 10,497 (58.6%) were female, and mean age was 78 (SD = 7.5). On average, patients had 5.1 (SD = 2.3) chronic conditions and previously filled 6.1 (SD = 1.4) chronic medications. In total, 447 patients (2.5%) were prescribed a PIM during the 90-day follow-up. Male sex (adjusted hazard ratio (HR) = 1.29; 95%CI: 1.06-1.57), age (≥85 years: HR = 0.75, 95%CI: 0.56-0.99, 75-84 years: HR = 0.87, 95%CI: 0.71-1.07; reference: 65-74 years), ambulatory visits (18-29 visits: HR = 1.42, 95%CI: 1.06-1.92; ≥30 visits: HR = 2.12, 95%CI: 1.53-2.95; reference: ≤9 visits), number of prescribing orders (HR = 1.02, 95%CI: 1.01-1.02 per 1-unit increase), and heart failure (HR = 1.38, 95%CI: 1.07-1.78) were independently associated with being newly prescribed a PIM.
Several demographic and clinical characteristics, including factors suggesting lack of care coordination and increased clinical complexity, were found to be associated with the new prescribing of potentially inappropriate medications. This knowledge could inform the design of interventions and policies to optimize pharmacotherapy for these patients.
在老年人中，使用潜在不适当药物（PIMs）很常见，并且与潜在的负面后果相关，例如跌倒和认知能力下降。我们的目的是研究与已经使用多种药物的多病共存的老年成年人新开出潜在不适当药物处方相关的可衡量患者因素。
在这项回顾性的美国队列研究中，我们使用了马萨诸塞州一家大型医疗保健系统在 2007 年至 2014 年期间的医疗保险药房和医疗索赔以及电子健康记录数据。我们确定了在过去 180 天内没有开出或使用过 PIM 的年龄≥65 岁的门诊患者。使用 2019 年美国老年医学会的 Beers 标准来定义 PIMs。为了专门评估患有多种药物和多病共存的患者的因素，我们选择了在过去 180 天内服用≥90 天（即慢性使用）且≥5 种药物类别的药物并患有≥2 种慢性疾病的患者。多变量 Cox 回归分析用于估计基线人口统计学和临床特征与 90 天随访期间开出 PIM 的概率之间的关联。
我们共确定了 17912 名年龄≥65 岁、过去 180 天内无 PIM 病史的多病共存和多种药物的患者。其中，10497 名（58.6%）为女性，平均年龄为 78（SD=7.5）岁。平均而言，患者有 5.1（SD=2.3）种慢性疾病，此前曾服用 6.1（SD=1.4）种慢性药物。共有 447 名（2.5%）患者在 90 天随访期间开出了 PIM。男性（调整后的危险比（HR）=1.29；95%CI：1.06-1.57）、年龄（≥85 岁：HR=0.75，95%CI：0.56-0.99，75-84 岁：HR=0.87，95%CI：0.71-1.07；参考：65-74 岁）、门诊就诊次数（18-29 次就诊：HR=1.42，95%CI：1.06-1.92；≥30 次就诊：HR=2.12，95%CI：1.53-2.95；参考：≤9 次就诊）、处方医嘱数量（HR=1.02，95%CI：每增加 1 个单位，1.01-1.02）和心力衰竭（HR=1.38，95%CI：1.07-1.78）与新开出 PIM 独立相关。
发现了一些人口统计学和临床特征，包括表明缺乏护理协调和临床复杂性增加的因素，与新开出潜在不适当药物相关。这些知识可以为这些患者的药物治疗优化干预和政策的设计提供信息。
