Agreement Between Drugs-to-Avoid Criteria and Expert Assessments of Problematic Prescribing

Abstract

Background Drugs-to-avoid criteria are commonly used to evaluate prescribing quality in elders. 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 age 65 and older and taking 5 or more medications. After a comprehensive patient interview, a physician/pharmacist study team 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 and Zhan 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, the Beers criteria flagged 214 drugs (6%) as potentially inappropriate, and the Zhan criteria flagged 91 drugs (2.5%). Kappa statistics for concordance between drugs-to-avoid criteria and expert assessments were 0.10–0.14, 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 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. While these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures of prescribing quality.

Results from a Mailed Promotion of Medication Reviews Among Department of Defense Beneficiaries Receiving 10 or More Chronic Medications

“…Evidence supporting the increased prevalence of adverse outcomes with use of Beers list medications is mixed. [24][25][26] Among most commonly observed, high-risk Beers list medications in our study, only promethazine, cyclobenzaprine, and diazepam are also included in the 2006 Health Plan Employer Data and Information Set list of potentially inappropriate medications for the elderly. 26 It is noteworthy that 31% of the DDI pairs observed among those aged 65 years or older in the present study sample included a Beers list medication considered to be high risk, most commonly oxybutynin, dicyclomine, and hysocyamine.…”

Overview of current and future research and clinical directions for drug discontinuation: psychological, traditional and professional obstacles to deprescribing

“…We still have no consensus as for the best way to de-prescribe. In the author's view and that of others, drugs-to-avoid criteria are less useful as stand-alone measures of prescribing 30 44. Furthermore, the author's view is that stopping one ‘inappropriate’ medication in a patient with problematic polypharmacy does not go far enough.…”

Protecting Patients from Adverse Drug Events: Propoxyphene, PIMs, and Drugs to Avoid in Older Adults

“…As suggested in the 2 reports from Solomon et al in December 2010 and the recent evidence of unexpected harm associated with rosiglitazone and bisphosphonates, studying the relationship between suspected and actual harm associated with drug therapy should be an ongoing, continuous quality improvement process. Steinman et al (2009) assessed the appropriateness of drug use at the Iowa VA Medical Center in 256 elderly outpatients using 5 or more medications, finding little concordance between PIM criteria and actual "problematic" drug use as assessed by a physician-pharmacist team. 36 The team identified 563 of 3,678 drugs (15.3%) received by the 256 elderly outpatients as "problematic;" versus 214 PIMs (5.8%) according to the Beers criteria and 91 (2.5%) by the Zhan criteria.…”

“…Steinman et al (2009) assessed the appropriateness of drug use at the Iowa VA Medical Center in 256 elderly outpatients using 5 or more medications, finding little concordance between PIM criteria and actual "problematic" drug use as assessed by a physician-pharmacist team. 36 The team identified 563 of 3,678 drugs (15.3%) received by the 256 elderly outpatients as "problematic;" versus 214 PIMs (5.8%) according to the Beers criteria and 91 (2.5%) by the Zhan criteria. The expert reviewers rejected as nonproblematic 61% of the Beers criteria PIMs and 49% of the Zhan criteria PIMs.…”