MEDICINE

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PUBLIC

ISSUES

Inappropriate Medication Prescribing in Skilled-Nursing Facilities Mark H. Beers, MD; Joseph G. Ouslander, MD; Susan F. Fingold, BS; Hal Morgenstern, PhD; David B. Reuben, MD; William Rogers, PhD; Mira J. Zeffren, PharmD; and John C. Beck, MD

• Objective: To quantify the appropriateness of medication prescriptions in nursing home residents. • Design: Prospective, cohort study. • Setting: Twelve nursing homes in the greater Los Angeles area. • Participants: A total of 1106 nursing home residents. • Main Outcome Measures: The appropriateness of medication prescriptions was evaluated using explicit criteria developed through consensus by 13 experts from the United States and Canada. These experts identified 19 drugs that should generally be avoided and 11 doses, frequencies, or durations of use of specific drugs that generally should not be exceeded. • Results: Based on the consensus criteria, 40% of residents received at least one inappropriate medication order, and 10% received two or more inappropriate medication orders concurrently; 7% of all prescriptions were inappropriate. Physicians prescribed a greater number of inappropriate medications for female residents. Regression analysis, corrected for clustering effects within facilities, showed that a greater number of inappropriate medication prescriptions were ordered in larger nursing homes. Inappropriate prescriptions were not related to the proportion of Medicaid (Medical) residents or the number of physicians practicing in the homes. • Conclusions: Inappropriate medication prescribing in nursing homes is common. Female residents and residents of large nursing homes are at the greatest risk for receiving an inappropriate prescription.

Annals of Internal Medicine. 1992;117:684-689. From the UCLA School of Medicine, the UCLA School of Public Health, and Patient Care Pharmacy, Los Angeles, California; and the RAND Corporation, Santa Monica, California. For current author addresses, see end of text. 684

Oeveral studies have raised concerns about the quality of medication prescriptions received by elderly residents of skilled-nursing facilities in the United States (1-3). Although the problem has received substantial attention from the lay public, media, and government, data on the degree to which medications are prescribed inappropriately in this population are scant (4). Our increased knowledge of the pharmacology of aging indicates that many cautions and special considerations are needed when prescribing medications to frail, elderly persons (5-7). Although studies of adverse outcomes related to prescribing medications to elderly persons have addressed only a few types of drugs, recent epidemiologic studies have shown some of the serious consequences of drug use in elderly persons (8-10). Institutionalized elderly persons are often frail (11), usually have several illnesses concurrently, receive more medication than noninstitutionalized older persons (12) and, thus, are probably most at risk for developing serious complications from medications. Less serious complications may also affect quality of life, and even constipation, sedation, and blurred vision may adversely affect the ability of nursing home residents to care for themselves, to participate in decision making, and to enjoy daily activities. In addition, because the cost of care in skilled-nursing facilities is often borne by the government through Medicaid and Medicare and by the insurance industry through Medigap policies, unnecessary prescribing wastes limited resources as well as the limited time available to licensed nursing staff in these facilities. Treating the iatrogenic complications of prescribing further burdens the health care system. Little direct assessment has been made of the quality of medication prescribing in elderly persons, particularly the residents of skilled-nursing facilities. In one review of the subject, Brook and coworkers (4) noted several problems with the few published studies addressing this issue. In most studies of the appropriateness of drug use in elderly persons, implicit reviews of prescribing were used. These implicit reviews relied on the expertise of the investigators themselves in assessing inappropriateness and, thus, cannot be evaluated for validity or duplicated by other investigators. The studies that used explicit criteria focused on narrow therapeutic categories of drugs, such as vaccinations or antibiotics, and therefore could not give an assessment of the overall appropriateness of prescribing. Additionally, the explicit criteria may not have been optimal because the qualifications of the experts creating them were not reported, the number of experts was small, and no explanation was given of the statistical methods used to resolve conflicting opinions. Our study describes the application of explicit criteria

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to medication prescribing in nursing h o m e residents and is the first c o m p r e h e n s i v e review of the a p p r o p r i a t e n e s s of medication prescribing in nursing h o m e s . W e believe that t h e s e data will b e useful for developing health policy and for monitoring t h e effects of efforts to imp r o v e the prescription of m e d i c a t i o n s in nursing h o m e s . Methods The analyses presented in this article are part of an intervention study aimed at improving the quality of prescribing in nursing homes. The intervention consists of providing computer-generated medication reviews, based on the explicit criteria, to doctors at monthly intervals. The homes enrolled in our study were chosen from the 39 skilled-care facilities served by one consulting pharmacy group. We first identified potential homes within a 45-mile radius of the research site in Los Angeles. We approached 14 homes for participation; these nursing homes were selected because they were geographically diverse; represented small-, medium-, and large-sized homes; and ranged (from low to high) in their proportions of Medicaid (MediCal) patients. Two nursing homes declined to participate. For each nursing home, we determined the number of beds, the proportion of Medicaid residents and the number of doctors currently involved in residents' care. We collected pharmacy data in the 12 homes that agreed to participate. We measured drug orders and not drug use; orders and use are equivalent for scheduled drugs but not for drugs given on an as-needed basis. We included all residents who were 65 years of age or more, except those identified by the facility as acute rehabilitation admissions. Data were collected at the time that medication orders were renewed and were recorded from the nursing home's physicians' order forms or supplied by the pharmacy. This data collection system allowed us to detect changes made to medication orders before the physician's signing of the orders. Our results are based on a 1-month assessment of medication orders in each home; for logistic reasons, we collected data for the 12 homes in groups of four, during August 1990, November 1990, and May 1991. The order in which the nursing homes were evaluated was random. We entered our data directly into a computer database. For each resident, we recorded the sex, date of birth, and name of the prescribing physician. For each medication order, we recorded the name of the drug, starting date of the order, dose,

frequency of dosing, route of administration, and the nature of the order (scheduled or given on an as-needed basis). From this information, we computed the total daily dose ordered and the duration of therapy to date. For drugs administered as needed, we computed the maximum total daily dose allowed by the order. We did not measure the actual use of drugs administered on an as-needed basis, and many residents likely received less than the maximal dose. Yet, because our intent was to describe the potential harm presented by prescribing habits, we measured what could have happened had the full dose of the prescription been implemented. The method by which we developed our explicit criteria has been described previously (13). In brief, we surveyed the opinions of 13 experts in geriatric care, geriatric pharmacology, geriatric psychopharmacology, and nursing home care from the United States and Canada. Using a modified Delphi consensus method (14), these experts reached agreement on 30 criteria defining inappropriate drug use in nursing home residents; the criteria related to certain drugs that should not be used and doses and durations of therapy of some drugs that should not be exceeded (Appendix Table 1). We developed a comprehensive list of all the generic and brand name medications identified by the criteria. We used this list to identify all occurrences of inappropriate medication prescribing to the study sample. For each person, we determined his or her total number of drug orders, the number of inappropriate drug orders, and the specific type of inappropriate order. We conducted analyses using both Crunch (Oakland, California) and Stata statistical software (15). The unit of analysis in all computations was the nursing home resident; where needed, however, we corrected for clustering effects within nursing homes (16, 17) by including dummy variables for differences between nursing homes and testing the hypothesis that they were jointly zero using an F-test. Standard errors for regression coefficients in light of clustering were calculated using the formula developed by Huber (18) in which the regression is treated as a maximum-likelihood model in which the nursing home rather than the resident is the unit of observation. These corrections are needed to take into consideration the tendency for prescribing patterns to be more similar among residents of the same nursing home than among residents of different homes. Multiple linear regression and analysis of variance examining the relations between prescribing—both overall prescribing and the prescribing of inappropriate drugs—and the characteristics of nursing homes were done while controlling for clustering effects and were evaluated and corrected

Figure 1. Medication prescriptions per resident in the 12 nursing homes. 15 October 1992 • Annals of Internal Medicine Downloaded from https://annals.org by Tulane University user on 12/19/2018

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Figure 2. Inappropriate medication prescriptions per resident in the 12 nursing homes.

using dummy variables and Huber's method as described above. The institutional characteristics included in the model were size, proportion of medical patients, and the number of doctors prescribing in the institution. Results The study population included 1106 nursing home residents in 12 skilled-nursing facilities in the Los Angeles area. Eighty percent of residents were female, and residents had a mean age of 84 years (range, 65 to 107 years). Women were slightly older than men (85 years compared with 81 years; P < 0.1). The study homes had a mean size of 95 beds (range, 42 to 218 beds), and the mean proportion of residents on Medicaid was 58% (range, 25% to 95%). The average nursing home in California is slightly smaller (87 beds) and has an identical proportion of residents on Medicaid. Residents were prescribed an average of 7.2 medications (95% CI, 7.0 to 7.4). Within nursing homes, the mean number of medication orders per patient ranged from 5.2 to 8.1. The distribution of prescribing is shown by individual nursing homes in Figure 1. Thirty-nine percent of all medications were ordered on an as-needed basis. We found that 40.3% (n = 446) of our study participants were prescribed at least one inappropriate drug; 10.4% (n = 115), two or more inappropriate drugs concurrently; and 1.2% (n = 14), three or more inappropriate drugs concurrently. On average, residents were prescribed 0.52 (95% CI, 0.48 to 0.57) drugs that, based on our criteria, were inappropriate; these inappropriate orders represented 7% of all prescriptions. Within nursing homes, the mean number of inappropriate prescriptions per resident ranged from 0.33 to 0.66. The mean number of inappropriate drug orders among the 12 nursing homes is shown in Figure 2. Fifty-one percent of all inappropriate prescriptions involved the prescription of drugs that our experts 686

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agreed should generally not be prescribed to nursing home residents at all; 34% involved the prescription of drugs for durations of therapy that exceeded the recommended limits; and 15% involved drug doses that exceeded the recommended limits. The types of inappropriate prescribing are summarized in Table 1. The most common types of inappropriate prescriptions in descending order of frequency included orders for overly high doses of iron supplements; orders for long-acting benzodiazepines, persantine, and propoxyphene; orders for overly high doses of histamine-2 blockers; orders for amitriptyline and methyldopa; and orders for overly high doses of short-acting benzodiazepines. Women were prescribed more medications (7.3 drugs compared with 6.6; P < 0.002) than were men, and they were also ordered a greater number of inappropriate drugs than were men (0.54 drugs compared with 0.46, P < 0.1). Although this difference is not highly statistically significant, it does represent a difference of over 15%. Participants 85 years of age and more were ordered fewer medications than those 65 to 84 years of age (6.9 compared with 7.5 drugs, P < 0.01), and they were less frequently ordered inappropriate drugs (0.47 compared with 0.58 drugs, P < 0.02). Regression analysis showed that for each decade of age over 65 years, participants were ordered approximately 0.3 fewer medications and 0.1 fewer inappropriate drugs. Using linear regression, we determined that differences existed among nursing homes in both the total number of inappropriate drug orders and the proportion of drug orders that were inappropriate. Multivariate analysis and analysis of variance showed that these prescribing differences were explainable by the size of the nursing home; that is, residents of larger nursing homes were prescribed greater numbers of inappropriate medications than those in smaller nursing homes. The proportion of patients on Medicaid and the doctor/ patient ratio in the nursing home were not associated

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Table 1. Inappropriate Medication Orders Drug

Orders

%

n Drugs to be avoided Long-acting benzodiazepines Persantine Propoxyphene Antidepressant agents Methyldopa Propranolol Trimethobenzamide Pentazocine Chlorpropamide Muscle relaxants Indomethacin Dementia treatments Gastrointestinal antispasmodic agents Meprobamate Reserpine Total Drugs with duration limitations Histamine blockers Short-acting benzodiazepines Oral antibiotics Total Drugs with dosage limitations Iron supplements Histamine blockers Antipsychotic agents Total

Percent of All Inappropriate Orders

Percent of Inappropriate Orders by Class

73 68 67 29 18 11 7 4 3 3 3 3 2 2 1 293

24.8 23.1 22.8 9.9 6.1 3.7 2.4 1.4 1.0 1.0 1.0 1.0 0.7 0.7 0.3 100

12.7 11.8 11.7 5.0 3.1 1.9 1.2 0.7 0.5 0.5 0.5 0.5 0.3 0.3 0.1 50.8

60 14 12 86

69.8 16.3 14.0 100

10.4 2.4 2.0 14.8

141 36 18 195

72.3 18.5 9.2 100

24.5 6.3 3.0 34.4

with differences in the appropriateness of prescribing (P > 0.2 and P = 0.15, respectively). Discussion Our study estimates the inappropriateness of medication prescribing to nursing home residents. The criteria used to define inappropriate drug use were developed through consensus methods, specifically for elderly nursing home residents, using the opinions of recognized experts in geriatric care from the United States and Canada. The criteria have been explicitly stated and cover medications that should not be used and doses and durations of therapy that should not be exceeded in nursing home residents. These screening criteria may misidentify some cases of appropriate or inappropriate prescribing when complex medical conditions alter the risks and benefits of prescribing, but it is unlikely that such misidentification will occur frequently. Because these criteria are based on a review of pharmacy data rather than on more extensive clinical assessments, we could not determine whether drugs were prescribed without indications or whether clinical conditions might have further contraindicated prescribing. Thus, in some ways, these evaluations may have underestimated inappropriate prescribing if compared to evaluations based on criteria that included clinical indices. On the other hand, our criteria may also have overestimated inappropriate uses of drugs; however, these situations are likely to have been rare, requiring that physicians chose more toxic or less effective drugs or prescribed large doses or long durations of medications because they had system-

atically adjusted their prescribing to symptoms, signs, or laboratory data, or had compulsively considered ways to treat multiple conditions with fewer drugs. In the future, more complex reviews that evaluate extensive clinical information will shed even more light on this subject. We evaluated medication orders and not medication use. Some medications administered on an as-needed basis were certainly used less frequently than their orders would have allowed, thus protecting nursing home residents from some adverse effects. The intent of this study was to evaluate the potential harm produced by doctors' medication orders. The decreased administration of as-needed drugs by nurses does not excuse doctors from the responsibility of writing safe medication orders. It should be noted that of the most commonly encountered inappropriate prescriptions in this study, only the prescription of benzodiazepines and propoxyphene involved drugs that are usually prescribed on an as-needed basis. Previous research has shown that when psychoactive drugs are ordered on an as-needed basis in nursing homes, they are used frequently (1). The findings of our study are disconcerting. Since the 1976 study by the Office of Long Term Care (19) and our previous study in 1988 (1), the overall prescribing rates to nursing home residents have changed little, despite concerns about polypharmacy in frail elderly persons. The findings that more than 40% of nursing home residents have at least one inappropriate prescription, that 10% have two or more inappropriate prescriptions, and that more than 7% of all prescriptions are inappro-

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priate suggest that considerable iatrogenic harm and waste of precious financial and staff resources are occurring. Physicians tended to prescribe less medication and to prescribe inappropriate medication less frequently to the oldest residents of nursing homes. We did not have information on clinical status: It may be that the oldest residents have less illness or, rather, that physicians use more caution when prescribing to very old persons. Despite the older age of women in our study, however, we found that female nursing home residents received more medication and more inappropriate medications than did men. We do not know the reason for this finding. Other studies have shown, however, that physicians tend to prescribe psychoactive drugs more commonly to elderly women than to elderly men (20). Evaluations are needed to determine the reasons that physicians prescribe differently to elderly female nursing home residents. Our criteria were developed to describe inappropriate prescribing according to the risk-benefit definition; that is, the medication orders targeted in this study pose a greater chance of causing harm than of bringing benefit. On the basis of this definition, some of the targeted prescribing practices are potentially more harmful than others. Outcomes may be as serious as falls and fractures, acute confusion, urinary retention, syncope, and, potentially, death. Less dramatic, adverse reactions to medications in elderly persons include sedation, anorexia, mild confusion, dry mouth, constipation, and urinary incontinence. Unnecessarily high doses of iron supplements, for example, do little to improve iron absorption (21) but contribute to constipation (22), a troublesome and sometimes distressing complication in nursing homes. Although not life-threatening, this complication may lead to anorexia, discomfort, the need to prescribe cathartics, and the waste of nursing time. Such reactions are likely to lead to deterioration in residents' ability to perform necessary functions of daily living and in their quality of life. The inappropriate prescribing of medications in nursing homes also wastes financial resources in the form of payments both for the medications themselves and the nursing time required to dispense them. The broad distribution of inappropriate prescribing found in our study suggests that many components of patient's functioning may be adversely affected by medications; further studies should continue to examine effects of inappropriate prescribing on clinical outcomes. Our criteria include three separate but closely related concepts: the prescription of medications that should be avoided in any dose and for any duration because they are ineffective or unsafe; doses of medication that are too high and thus introduce unnecessary risk or are wasteful; and the prescription of medication for too long a duration because overly long treatment is wasteful and dangerous. Although we have described these types of inappropriate prescriptions separately, we believe that it is more important to evaluate the sum of their

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occurrences. In this way, one can better judge the total risk that nursing home residents face from inappropriate drug ordering. Our study shows that some variation exists among nursing homes in the appropriateness of their medication orders, but that even in the best nursing homes studied, inappropriate prescribing is common. Although our sample of nursing homes was small, we found that large nursing homes show the poorest prescribing practices. This finding is consistent with other studies examining the use of psychoactive drugs (1). On the other hand, despite low reimbursement rates for Medicaid residents, nursing homes in our study that cared for a large percentage of Medicaid residents did not show worse prescribing habits. Many other factors may influence prescribing, however, including the training of nurses and physicians, the quality of the nursing and medical directors, characteristics of patients, and facility policies, none of which were analyzed in our study. Our data suggest that despite current safeguards, the quality of prescribing in nursing homes is not good. The reasons are probably multifactorial. Many physicians, nurses, and consultant pharmacists have not yet learned the many caveats in prescribing to frail, elderly persons. In addition, doctors may not take the time to review adequately the medication orders for their patients, maintaining orders and adding new ones without proper consideration of the risks and benefits of therapy. Consulting pharmacists may not have suitable systems for informing doctors about their recommendations. Having better defined the problem and the scope of inappropriate prescribing in nursing homes, we must now examine interventions to improve prescribing. In fact, the data presented in this article are derived from an intervention study in which ways to improve prescribing in nursing homes are being examined. The nursing home industry is often blamed for its inability to provide optimum care for nursing home residents, but rather than attributing blame in the matter of medication prescriptions, we must examine solutions that address education for health care providers and efficient mechanisms for reviewing medication use and offering advice to reduce risk. Grant Support: In part by the John A. Hartford Foundation and by the University of California, Los Angeles, Geriatric Academic Program Award from the National Institutes of Health (Dr. Beers). Requests for Reprints: Mark H. Beers, MD, Merck & Co., Inc., BLA22, POB4, West Point, PA 19486-0004. Current Author Addresses: Dr. Beers: Merck & Co., Inc., BLA-22, POB4, West Point, PA 19486-0004. Drs. Ouslander, Reuben, and Beck, and Ms. Fingold: University of California, Los Angeles, Multicampus Division of Geriatrics and Gerontology, Center for Health Sciences, School of Medicine, Factor A-671, Los Angeles, CA 90024-1687. Dr. Morgenstern: University of California, Los Angeles, School of Public Health, Department of Epidemiology, Los Angeles, CA 900241772. Dr. Rogers: The Rand Corporation, 1800 Main Street, Santa Monica, CA 90403. Dr. Zeffren: Patient Care Pharmacy, 6300 Arizona Circle, Los Angeles, CA 90045.

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Appendix Table 1. Criteria for Inappropriate Medication Orders Medications that should be avoided Sedative or hypnotic agents Long-acting benzodiazepines Meprobamate Short-duration barbiturates Antidepressant agents A i ' UJV Amitnptyline Combination antidepressants-antipsychotics Antihypertensive agents Methyldopa Propranolol Reserpine Nonsteroidal anti-inflammatory drugs Indomethacin Phenylbutazone Oral hypoglycemic agents Chlorpropamide Analgesic agents Propoxyphene Pentazocine Dementia treatments Cyclandelate

Gastrointestinal antispasmodic agents Clidinium Hyoscyamine Dicyclomine Belladonna Antiemetic agents Tnmethobenzamide Medications with dosage limits Antipsychotic agents Haloperidol Thioridazine Digoxin Histamine blockers Cimetidine Ranitidine Iron supplements Short-acting benzodiazepines Oxazepam Thiazides Antihypertensive agents Hydrochlorothiazide w Medications with duration limits Decongestants Oxymetazolme Phenylephrine Pseudoephedrine Histamine blockers Oral antibiotics Short-acting benzodiazepines Oxazepam Triazolam Alprazolam

J T

Isoxsupnne Platelet inhibitors Dipyridamole Muscle relaxants or antispasmodic agents Cyclobenzaprine Orphenidrate Methocarbamol Carisoprodol References 1. Beers M, Avorn J, Soumerai S, Everitt OE, Sherman DS, Salem S. Psychoactive medication use in intermediate-care facility residents. JAMA. 1988;260:3016-24. 2. Ray WA, Federspiel CF, Schaffher W. A study of antipsychotic drug use in nursing homes: epidemiological evidence suggesting misuse. Am J Public Health. 1980;70:485-91. 3. Nolan L, O'Malley K. The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Aging. 1989;18:52-66. 4. Brook RH, Kamberg CJ, Mayer-Oakes A, Beers MH, Raube K, Steiner A. Appropriateness of acute medical care for the elderly: an analysis of the literature. Health Policy. 1990;14:225-42. 5. Beers MH, Ouslander JG. Risk factors in geriatric drug prescribing. A practical guide to avoiding problems. Drugs. 1989;37:105-12. 6. Abrams WB. Drugs and the elderly. Ration Drug Ther. 1985;19:1-6. 7. Albrich JM, Bosker G. Drug therapy in the elderly. Ambulatory Med Lett. 1988:1-32. 8. Ray WA, Griffin MR, Schaffner W, Baugh DK, Melton LJ 3d. Psychotropic drug use and the risk of hip fracture. New Engl J Med. 1987;316:393-406. 9. Ray WA, Griffin MR, Downey W. Benzodiazepines of long and short elimination half-life and the risk of hip fracture. JAMA. 1989; 262:3303-7. 10. Monane M, Avorn J, Everitt D, Fields D, Beers M. Haloperidol use in the nursing home: Frequency of Parkinsonian side effects [Abstract]. J Am Geriatr Soc. 1991;39:A42. 11. Soldo BJ, Manton KG. Demography: characteristics and implications of an aging population. In: Rowe JW, Besdine RW, eds.

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Geriatric Medicine. Boston, Mass: Little, Brown & Company; 1982: 17. Ostrom JR, Hammarlund ER, Christensen DB, Plein JB, Kethley AJ. Medication usage in an elderly population. Med Care. 1985;23:157-64. Beers MH, Ouslander JG, Rollingher I, Reuben DB, Brooks J, Beck JC. Explicit criteria for determining inappropriate medication use in nursing homes. Arch Intern Med. 1991;151:1825-32. Dalkey NC. Delphi. P-3704 RAND. Santa Monica, California: RAND Corporation; 1967. Computing Resource Center. STATA Reference Manual, Santa Monica, CA 1989. Graubard BI, Fears TR, Gail MH. Effects of cluster sampling on epidemiologic analysis in population-based case-control studies. Biometrics. 1989;45:1053-71. Prentice RL. Correlated binary regression with covariates specific of each binary observation. Biometrics. 1988;44:1033-48. Huber PJ. The behavior of maximum likelihood estimates under non-standard conditions. Proceedings of the Fifth Berkeley Symposium on Mathematical Statistics and Probability. 1967;1:221-33. U . S . Public Health Service. Office of Long Term Care. Physicians' Drug Prescribing Patterns in Skilled Nursing Facilities. Rockville, Maryland: U . S . Dept of Health, Education, and Welfare; 1976. Publication no. (OS)76-50050. Hohmann AA. Gender bias in psychotropic drug prescribing in primary care. Med Care. 1989;27:478-90. Crosby WH. Overtreating the deficiency anemias. Arch Intern Med. 1986;146:779. Davies DM. Textbook of Adverse Drug Reactions. New York: Oxford University Press; 1985:241.

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