Potentially inappropriate medications in hospitalized senior patients

Patient safety has become a high priority for hospitals, various national health care advocacy organizations, and health care-accrediting bodies. Suggestions for handling medical errors proposed in 1999 offer guidelines from the Institute of Medicine for a safer health system.1 “With adequate leadership, attention, and resources, improvements can be made.”2 Seniors (persons 65 years of age or older) are of particular interest because of their potential comorbid disease states, the numerous medications they are prescribed, and their altered pharmacokinetic and pharmacodynamic profiles—all factors requiring careful selection of appropriate pharmacotherapy. Factors that contribute to these altered profiles include reduced protein binding, reduced biotransformation, diminished renal elimination, impairment of responding organs resulting from the pathological state, reduction in the reactivity of homeostatic mechanisms, and the aging process.3 Inappropriate prescribing of medications in this population may lead to adverse effects associated with increases in morbidity and mortality.4 In 1991, Beers et al.5 developed criteria identifying inappropriate use of medications in seniors residing in nursing homes, based on the risk–benefit definition of appropriateness (i.e., the potential risks outweigh the potential benefits). The criteria, known as the Beers criteria, included two aspects of medication use: (1) drugs to generally avoid in seniors and (2) dosages, frequencies, or durations that should not be exceeded. As more experience was gained and new drugs were approved, the Beers criteria were updated in 1997 and again in 2003. The updates sought to generalize the criteria to senior patients regardless of their place of residence, assign a relative rating of severity to each criterion, and identify alerts that apply when clinical information on diagnoses is available.6,7 The updated Beers criteria grouped these drugs into two categories: (1) drugs to generally avoid in seniors and (2) drugs that should be avoided in patients who have a certain condition or diagnosis.7 In addition, the adverse effects of these medications were analyzed and rated (high or low severity) based on the probability of the event occurring and the significance of the outcome.6,7 In an inpatient setting, these adverse effects may be reflected by excessive lengths of stay and increases in morbidity and mortality. Previous applications and publications of the Beers criteria have focused mainly on ambulatory care and nursing home settings.4,8,–13 There has been little study on the application of these criteria in an acute care, inpatient setting. In our analysis, we sought to document the use of the Beers medications at participating hospital members of the University HealthSystem Consortium (UHC) using the Clinical Data Base (CDB)—Pharmacy. UHC is a nonprofit, member-driven alliance of over 90 academic health centers (AHCs) in the United States. UHC offers tools and services that support members’ clinical resource management and quality improvement initiatives. UHC’s CDB—Pharmacy is an electronic repository that combines data from an institution’s administrative, clinical, and financial systems. The data gathered were generated from participant hospitals’ Health Care Financing Administration Uniform Bill of 1992 data, discharge summaries, charge masters, and patient-level transaction billing files. The primary objective of this analysis was to determine how often drugs or drug classes named in the updated Beers criteria were prescribed for senior inpatients at AHCs. Secondary objectives were to compare the average length of stay, the length of stay in an intensive care unit (ICU), and the inpatient hospital mortality for patients who did or did not receive a Beers medication.