Effect of Prescriber Education on the Use of Medications Contraindicated in Older Adults in a Managed Medicare Population

OBJECTIVES: To measure the effect of pharmacy intervention programs on the percentage of older adult members filling prescriptions for one or more contraindicated medications in a managed Medicare population. METHODS: Prescribers of potentially inappropriate (i.e., contraindicated) medications in a managed Medicare + Choice (now known as Medicare Advantage) health maintenance organization (HMO) were identified from drug claims each calendar quarter for letter and telephone contact. The initial study population was composed of members in the Medicare + Choice HMO who were aged 65 years or older and who utilized their managed care pharmacy benefit during the 4-year measurement period from 1999 fourth quarter (Q4) through 2003 Q4. The study population was expanded in 2003 Q1 to include all patients aged 65 years or older, including commercial HMO members and Medicare + Choice members. The prescribers of target (contraindicated) drugs were contacted by a letter that described the program and included a prescriber-specific list of patients who had received a potentially inappropriate drug. Each prescriber was requested to review the report and change the contraindicated drug to a more appropriate agent, lower the medication dose, or carefully monitor those patients who could not discontinue the drug. A clinical pharmacist contacted high-volume prescribers of target drugs (4 or more patients in a given quarter) by telephone to discuss the identified patients. RESULTS: The incidence of inappropriate use of the target medications in older adults declined by 19%, from an absolute 5.3% of prescriptions in the base period (1999 Q4) to 4.3% at the end of the first 2-year period, in 2001 Q4. A change in the target drugs in 2002 Q1 from a list based upon the Beers' criteria to a list based in part on the Zhan et al. criteria was associated with a 45% reduction in the percentage (2.4%) of older adult members who received target drugs; this proportion remained essentially unchanged at 2.2% through 2003 Q4, the end of the second half of the 4-year intervention period. CONCLUSIONS: A clinical intervention program targeting prescribers of drugs judged to be contraindicated in older adults was associated with a decline in the percentage of HMO members receiving one or more target contraindicated drugs. After a 4-year intervention period, 2.2% of older adult HMO members continued to receive one or more target contraindicated drugs.

s people age, they develop medical conditions that are often treated with pharmaceuticals. Additionally, as people age, pharmacokinetic and pharmacodynamic changes occur that can affect the disposition of medications in the body 1 ; this combination of pharmacokinetic and pharmacodynamic changes as well as an increase in medical conditions requiring drug treatment can lead to increased risks of drug interactions, noncompliance, and adverse outcomes in older adult patients. There are numerous case reports and review articles in the medical literature that document serious dru gre l a t e d morbidity and/or deaths related to medication use in older adults. [2][3][4][5][6][7][8] Some of these drug effects are direct extensions of the drug' s own pharmacologic effect, such as increased sedation from a sedative-hypnotic agent or hypotension from antihypertensive agents, while other effects can be due to adverse outcomes resulting from a particular agent or class of agents (e.g., falls related to use of long-acting benzodiazepines). 3 -5 In the early 1990s, Beers identified medications that were deemed inappropriate to use for nursing home residents. Subsequently, Beers developed explicit criteria to determine potentially inappropriate medication use in noninstitutionalized older adults (65 years or older). 9 Beers defined inappro p r i a t e medications as those agents where the potential risk of use outweighs the potential benefit. Subsequently, Zhan et al. addressed the limitations of Beers' s research by identifying criteria for 33 drugs/drug classes based on whether the drug should always be avoided in older adults or whether use of the drug may be appropriate in older adult patients under certain circumstances. 2 The agents that were identified were placed into 3 categories: (1) drugs that should generally be avoided in ambulatory older adult patients, (2) doses or frequencies of drug administration that generally should not be exceeded, and (3) medications that should be avoided in older people known to have any of several medical conditions. The compete list of d rugs identified by Zhan et al. can be found in their publication. 2 Willcox et al. examined the amount of inappropriate drug prescribing in community-dwelling patients older than 65 years from the 1987 National Medical Expenditure Survey. 10 Criteria for inappropriate medications were developed through a modified Delphi consensus technique by a panel of 13 experts in pharmacology and geriatrics. The consensus panel defined as inappropriate any medications that should be entirely avoided, excessive dosage of medicines, and excessive duration of treatment. The list of medications used by the consensus panel was limited to 23. Using a subset of these d rugs (n= 20, excluding the a n t i h y p e rtensives propranolol, methyldopa, and reserpine), they ABSTRACT OBJECTIVE: To measure the effect of pharmacy intervention programs on the percentage of older adult members filling prescriptions for one or more contraindicated medications in a managed Medicare population.
METHODS: Prescribers of potentially inappropriate (i.e., contraindicated) medications in a managed Medicare + Choice (now known as Medicare Advantage) health maintenance organization (HMO) were identified from drug claims each calendar quarter for letter and telephone contact. The initial study population was composed of members in the Medicare + Choice HMO who were aged 65 years or older and who utilized their managed care pharmacy benefit during the 4-year measurement period from 1999 fourth quarter (Q4) through 2003 Q4. The study population was expanded in 2003 Q1 to include all patients aged 65 years or older, including commercial HMO members and Medicare + Choice members. The prescribers of target (contraindicated) drugs were contacted by a letter that described the program and included a prescriber-specific list of patients who had received a potentially inappropriate drug. Each prescriber was requested to review the report and change the contraindicated drug to a more appropriate agent, lower the medication dose, or carefully monitor those patients who could not discontinue the drug. A clinical pharmacist contacted high-volume prescribers of target drugs (4 or more patients in a given quarter) by telephone to discuss the identified patients.
RESULTS: The incidence of inappropriate use of the target medications in older adults declined by 19%, from an absolute 5.3% of prescriptions in the base period (1999 Q4) to 4.3% at the end of the first 2-year period, in 2001 Q4. A change in the target drugs in 2002 Q1 from a list based upon the Beers' criteria to a list based in part on the Zhan et al. criteria was associated with a 45% reduction in the percentage (2.4%) of older adult members who received target drugs; this proportion remained essentially unchanged at 2.2% through 2003 Q4, the end of the second half of the 4-year intervention period.
CONCLUSIONS: A clinical intervention program targeting prescribers of drugs judged to be contraindicated in older adults was associated with a decline in the percentage of HMO members receiving one or more target contraindicated drugs. After a 4-year intervention period, 2.2% of older adult HMO members continued to receive one or more target contraindicated drugs.
found that 23.5% of all community-dwelling seniors, or 6.64 million people, received at least 1 potentially inappropriate medication during 1987. When they evaluated the entire list of 23 drugs, they found that 32% of all elderly people, or 9.04 million community-dwelling seniors, received at least 1 potentially inappropriate medication. They also found that the rare instances where some of the contraindicated medications "may be appropriate" accounted for almost none of their use. Additionally, they did not consider drug dosage, duration, or medication interactions. Although their data were consistent with other studies of inappropriate prescribing for nursing home residents and the incidence of self-reported adverse drug effects in community-dwelling seniors, the authors felt that the numbers of community-dwelling seniors who received at least 1 inappropriate medication was disturbingly high.
Stuck et al. investigated the prevalence of inappropriate medication use in community-dwelling older persons (75 years and older) by using in-home interviews with study subjects regarding medication use. 11 Inappropriate medication use was evaluated using explicit criteria developed through the modified Delphi consensus process. A total of 414 community-dwelling persons participated in the study, and the mean patient age was 80.5 years in a range of 75 to 95 years. Overall, they found that 6.9% (n = 69) of all reported prescription medications were i n a p p ropriate according to their criteria. These 69 inappro p r i a t e medications were used by 58 (14%) of the 414 subjects, with 49 (11.8%) reporting the use of 1 medication, and 9 (2.1%) reporting the use of 2 or more inappropriate medications. The most commonly used medications included the long-acting benzodiazepines, dipyridamole, amitriptyline, or chlorpropamide. The authors noted that since older individuals may underreport the number of medications that they are actually taking by as much as 20% to 30%, the amount of medication actually taken may also be significantly underestimated. Thus, the 14% prevalence of inappropriate medication use reported here is likely much lower than the actual percentage.
Goulding studied trends in inappropriate prescribing in ambulatory older adult patients using data from 1995 through 2000. 12 Data were reviewed from office-based physician visits in the National Ambulatory Medical Care Survey and the hospital outpatient departments of the National Hospital Ambulatory Medical Survey. Drugs were identified from Beers' s and Zhan' s criteria. 2,9 She concluded that, in the time frame studied, at least 1 potentially inappropriate medication (by the Beers criteria) was prescribed 7.8% of the time, and at least 1 potentially inappropriate medication (by the Zhan et al. criteria) was prescribed 3.7% to 3.8% of the time. Pain relievers (propoxyphene) and central nervous system drugs (anxiolytics, sedative/hypnotics, and antidepressants) were the most commonly prescribed drugs. She also observed that (1) women were at higher risk than men to receive a potentially inappropriate medication, possibly due to more inappropriate prescribing at physician' s office visits for central nervous system agents and pain relievers or because studies show that women are prescribed more p s y c h o t ropic medications compared with men and (2) pre s c r i b i n g of potentially inappropriate medications was mostly done by general practitioners rather than specialists. The author noted that use of these medications in this patient population still occurs and is still inappropriate and that quality improvement e ff o rts should be perf o rmed to correct prescribing of inappropriate medications in this patient population. She also noted that more comprehensive drug and diagnosis data would assist in truly determining the inappropriateness of drug prescribing in this patient population.
In 2004, Curtis et al. concluded that 21.2% of patients 65 years or older in a large outpatient pharmacy benefit management population received one or more "drugs of c o n c e rn" using updated Beers criteria. 1 3 This analysis was limited to 18 medications from a retrospective claim review performed during 1999. They noted that psychotropic drugs alone accounted for more than 45% of the claims for medications on the Beers list. They concluded that since these potentially inappropriate medications continue to be prescribed, patients should be closely monitored.
Prescribing potentially inappropriate (i.e., contraindicated) medications represents an area of concern in the delivery of medical care, especially in older individuals. It can lead to mortality, morbidity, and increased costs of care. As the medical literature continues to expand on this topic, there is still a need to evaluate specific populations of older patients. We reported our intervention project for prescribers of potentially inappro p r i a t e drugs in older adults to the Centers for Medicare and Medicaid Services at the time of their 2000 site visit to our health maintenance organization (HMO). The Centers for Medicare and Medicaid Services encourages the conduct of perf o rm a n c e i m p rovement projects that achieve, through ongoing measure m e n t and interventions, demonstrable and sustained impro v e m e n t s in important aspects of patient care. This intervention is also one of the many examples of "Patient Safety" reported by HIP Health Plan of New York (HIP-NY) to the National Committee for Quality Assurance as part of the accreditation survey in 2001 and again in 2004. Therefore, evaluation of our Medicare and/or older adult members appeared to be a warranted and necessary activity. Our goal was to reduce the percentage of older adult members filling prescriptions for one or more contraindicated medications to as low a level as possible.

■ ■ Methods Study Population and Design
This analysis was performed using a large database of paid e l e c t ronic pharmacy claims from HIP-NY. This is a not-for-p ro f i t , mixed-model HMO serving more than 1.4 million members. Approximately 110,000 members were Medicare beneficiaries in 2004, up from approximately 91,000 Medicare risk members in 2000 quarter (Q) 1. The Pharmacy Services Department of the HMO functions as its own pharmacy benefit manager (PBM). For this study, pharm a c y claims that were reversed were identified and excluded from analysis to prevent false-positive letters to prescribers.
The study population consisted of Medicare beneficiaries who utilized their HMO pharmacy benefit to obtain medications during the measurement periods. The target population was expanded in 2003 Q1 to include commercial HMO members aged 65 years and older. In other words, the pool of patients subject to the intervention program was expanded from members with a Medicare + Choice (now known as Medicare Advantage) drug benefit rider to include members aged 65 years or older enrolled in commercial HMO plans.
A prospective study approach was used to identify older adult members who received one or more prescriptions for potentially inappropriate medications. At the beginning of the program (1999), an initial list of 8 target (contraindicated) medications was identified from the literature. 8,9,14 Two of the HIP-NY clinical pharmacists determined the initial list of medications based on actual pharmacy claims and review of the literature (the Beers list and that of the U.S. General Accounting Office [July 1995] report on Prescription Drugs and the Elderly, which identified the following drugs as potentially harmful in older adults: amitriptyline, indomethacin, cyclobenzaprine, p ropoxyphene, diazepam, meprobamate, methocarbamol, methyldopa, hyoscyamine, dicyclomine, and disopyramide). 1 4 The recommendations were reviewed and approved by our p h a rm a c y and therapeutics committee. Additionally, due to decreased utilization and attempts to revise the HMO' s drug f o rm u l a ry to reflect more appropriate medications for use in older adults, the following changes were implemented: deletion of flurazepam, meprobamate, chlorpropamide, and methyldopa, and addition of oxazepam.
In 2002 Q1, we updated our target medication list based on our actual pharmacy claims and information published by Zhan et al. At that time, the target list of drugs was expanded from 8 to 10 with the addition of dicyclomine, hyoscyamine, and disopyramide and the removal of propoxyphene (Table 1). Other program modifications at this time included targeting only (1) chronic users (patients who had more than 1 claim in a quarter) of indomethacin and (2) patients who received more than 50 mg of amitriptyline per day. These modifications were based on new medical literature (Zhan et al. 2 ) and physician input. According to Zhan et al., amitriptyline may be appro p r i a t e for some indications in older adults, and provider feedback from interventions suggested that lower doses of amitriptyline were not being used for depression but for such conditions as pain management and diabetic neuropathy with appropriate follow-up and monitoring. 2 We therefore modified the report to target amitriptyline in doses greater than 50 mg daily. Zhan et al. also stated that indomethacin may be appropriate for short courses (e.g., acute gouty arthritis) and implied that chronic use is not recommended. Therefore, we chose to target chronic users of indomethacin, defined as more than 1 pharmacy claim for indomethacin during each intervention quarter.

List of Contraindicated (Target) Drugs in This HMO Intervention Program
R e g a rding the anticholinergic agents disopyramide, cyclobenzaprine, dicyclomine, and methocarbamol, it is generally felt that these agents should be avoided in older adults due to their potential adverse effects. 2 We also decided to target disopyramide based on our pharmacy utilization and the choices of alternate antiarrhythmic agents. We added dicyclomine and hyoscyamine to our list of targeted medications based on pharmacy utilization and the individual agent' s potential for adverse effects in this patient population. We decided to no longer target propoxyphene due to decreased pharmacy utilization of this agent. Since methyldopa was listed in the Beers criteria, has the potential to cause bradycardia and exacerbate depression in older adults, and was highly utilized in our patient population, we chose to include it as one of our targeted medications. A d d i t i o n a l l y, there are many alternate treatments for hypert e n s i o n that have less serious side effects.
We calculated quarterly measurements of the proportion of older adult members who filled a prescription for a contraindicated drug. We also calculated the proportion of older adult members who filled a prescription for 1 or more of the subset of 7 targ e t e d contraindicated drugs that was consistent throughout the entire 4-year intervention period.
This intervention program with prescribers of target contraindicated drugs for older adult members in this health plan is ongoing. The base period for assessing the impact of the intervention program was the fourth calendar quarter (Q4) of 1999. The measurement period for this study included 16 calendar quarters from 2001 Q1 through the 2003 Q4. Letters were mailed to prescribers of medications contraindicated in older patients after the end of each calendar quarter. The letter described the program and included a provider pro f i l e (Appendix). In some cases, the prescriber was not the primary care provider (PCP) for the particular patient (the p rescriber may have been another PCP or a specialist).
T h e re f o re, each prescriber and PCP received a profile containing their names, the full name and HMO identification number of each patient who received contraindicated drugs in that specific quarter, the generic name of the contraindicated drug(s) that each patient received in that quarter as well as the reason for the contraindication, any formulary alternatives (if available), and identification of the physician prescribing each drug. In addition to sending a prescriber-specific profile, a clinical pharmacist contacted some prescribers by telephone.
Each calendar quarter, prescribers with the highest volume of patients receiving the target contraindicated drugs were contacted by telephone. A clinical pharmacist called prescribers to discuss the target patients' drug use and treatment plan. Alternative therapeutic options were generally discussed with the prescriber during these telephone contacts, as were the risks and benefits of the options and age-related pharmacokinetic and pharmacodynamic changes in older patients. The telephone contact also generally included a discussion of the individual p a t i e n t ' s other medications if the clinical pharmacy case manager identified any other potential medication-related problems upon reviewing the patient' s medication pro f i l e . D rug form u l a ry questions or pharmacy benefit questions were also answered at this time.
A third intervention included publication of an article titled " I n a p p ropriate Prescribing in the Elderly" in the HMO' s pharm a c y and therapeutics newsletter distributed to each physician and pharmacist provider in the HMO network. 15 In all, physicians in this HMO were contacted by means of 3 approaches: (1) a physician-specific report card of individual older patients with d rugs defined as contraindicated, (2) telephone contact with some of the prescribers of these target contraindicated drugs, and (3) general distribution of written materials to all prescribers. Approximately 45 hours of a clinical pharmacist' s time was devoted to this intervention program each calendar quarter. An additional 5 to 10 hours of clerical time is also committed to this project each quarter. Costs of supplies and postage are approximately $230 per quarter, not including printer cartridges. This project is conducted in-house at HIP-NY. If a project such as this were to be undertaken with outsourced vendors, administrative costs may be higher.
The proportion of older adult patients prescribed one or more inappropriate drugs (number of prescriptions for one or more inappropriate drugs divided by the total number of older adult members with drug utilization) was calculated for the overall plan and re p o rted annually to appropriate committees within HIP-NY. Physicians identified as prescribing the same drugs in 2 consecutive quarters for the same patient ("repeat p rescribers") were re p o rted to the HMO Peer Review Committee in the Quality Risk Management Department. The Peer Review Committee (comprising 5 physicians and a nurse) contacts repeat prescribers to identify the rationale for continued contraindicated drug use. At any intervention point that the prescriber provided appropriate rationale for continued use of the medication to either the Peer Review Committee or pharm a c y case manager (e.g., was unable to change the medication or lower the dose of medication, had no safer alternatives available, the patient tolerated the medication well and was being continuously monitored), then the name of the patient and the contraindicated drug were logged into a database. Subsequent quarterly evaluations excluded those patients and their respective contraindicated drug(s).

Measurement and Analysis
Our goal was to have as few as possible older adult patients receiving any of the targeted contraindicated drugs. We were not able, through a literature review, to ascertain an industry standard or benchmark that could be applied to this study. Quarterly measurements of the proportion of Medicare + Choice patients receiving one or more contraindicated drugs were calculated; they were expanded in the fourth year of the intervention to include all patients aged 65 years or older. A time series analysis quantified the number of patients who received the targeted contraindicated drugs over time.

■ ■ Results
Quarterly data on the percentage of older adult members who received the target contraindicated medications and the perc e n t a g e of older adult members who received one or more of the subset of 7 contraindicated medications (consistent through the 4-year period) were analyzed using StatGraphics. Based on a time series analysis of the quarterly data, a linear model was determined to be the best-fitting model for both sets of data. Compared with other models, the linear model minimizes the root mean squared error, the mean absolute error, the mean absolute percentage error, the mean error, and the mean percentage error for these sets of data. Data were forecasted for 4 additional quarters using a linear forecasting model, and statistically significant downward trends were detected for both "the percentage of older adult members who received pre s c r i p t i o n s for contraindicated medications," (slope = -0.23 percentage points, P<0.001), and the percentage of older adult members who received one or more of 7 contraindicated medications, (slope = -0.14 percentage points, P<0.001). Table 2 presents the number and percentage of older adult members who received a prescription for one or more contraindicated medications during each quart e r. Figure 1 graphically presents the number of older adult members, prescribers and PCPs targeted (by quarter). Figure 2 presents the percentage of older adult members who filled contraindicated medications by quarter. Table 3 presents the percentage of older adult members who received one or more of the subset of 7 targeted contraindicated drugs that were consistent throughout the 4-year study period. Figure 3 graphically represents the data in Table 3.

■ ■ Discussion
Several researchers have evaluated the use of explicit criteria for identifying potentially inappropriate medication use in older adult patients in many different settings. 2,[6][7][8][9] Other researchers have chosen to develop clinical indicators of preventable drugrelated morbidity. 1 6 , 1 7 We chose to focus on specific "inappro p r i a t e " drug use that may produce preventable drug-related morbidity in our population of older patients. Using the Beers criteria, Fick et al. showed that patients with potentially inappropriate medications in 1997-1998 had higher costs and utilization. 18 Our evaluation used modified Beers and Zhan et al. criteria to d e t e rmine inappropriate medication use in our older adult o u t p a t i e n t population.

Number of Older Adult Members, Prescribers, and Primary Care Providers
Targeted by Quarter     (Table 4). Throughout the first 2 years of the intervention program, propoxyphene use was declining. We therefore removed it from the target drug list and added dicyclomine and disopyramide. During the interventions, it appeared that, for drug classes w h e re there are a lot of choices without the potential for significant side effects in the older adult population, changing therapy is e a s i e r. In classes where there are limited choices, such as skeletal muscle relaxants or gastrointestinal anticholinerg i c s / a n t i s p a s m o d i c s , it is much more difficult for prescribers to change therapy. Since all skeletal muscle relaxants can cause sedation, older patients p rescribed this class of medications should be carefully monitore d to prevent adverse events if the drug(s) cannot be changed.

Percentage of Older Adult Members Who Received One or More of Subset (7) Target Contraindicated Drugs
The main program barrier was access to physicians, which hindered physician education. During pharmacy case management, it became apparent that, although the program letter described and referenced medical literature citations on the explicit criteria used for determining potentially inappropriate medications in older patients, prescribers were not cognizant of this information. Additionally, some prescribers were reluctant to believe that criteria even existed. Through pharmacy case management, prescriber education was conducted regarding age-related pharmacokinetic and pharmacodynamic changes in older patients. Some prescribers were resistant to the HMO or a clinical pharmacist assessing the care provided to their patients. Additionally, there appeared to be some association between the reluctance to change therapy and the number of years a physician had been practicing. This may be due to prescriber familiarity and experience with the older drugs. Provider satisfaction with this intervention program has not been measured.
This intervention program, operated primarily by the pharm a c y department, enjoyed some benefit from collaborating with the Peer Review Committee in the Quality Risk Department. The collaboration appeared to motivate some prescribers to discuss their patients' medications with the pharmacy case manager in order to avoid interaction with the Peer Review Committee (in the Quality Risk Department).
A secondary outcome of this intervention program was review of the complete medication profile for some patients, potentially uncovering other opportunities for quality impro v e m e n t in medication management. We did not measure the magnitude of this secondary benefit, but anecdotal comments from physicians suggested that the interventions precipitated reevaluation of the patient' s entire drug use.

Limitations
Our study was a before-after comparison and involved no control group. Our trend analyses in the reduction of older adult patients who received contraindicated drugs were affected by 2 important changes. First, the list of target drugs was revised at the midpoint of the measurement period in 2002 Q1 to delete propoxyphene and its combinations, add dicyclomine and disopyramide, and change the screen for amitriptyline use to only those doses above 50 mg per day. Second, the denominator for our primary measure was changed in the last year of the 4-year measurement period to include commercial HMO members as well as Medicare + Choice members. This was associated with a small but noticeable increase in our primary measure from 0.6% of patients who received 1 or more of the 7 target drugs to 0.7% of patients (Table 3).
Although the interventions were aimed at decreasing i n a p p ropriate prescribing of one or more contraindicated medications in our patient population, we did not measure the impact of the interventions on health care resource utilization or patient outcomes. We assumed that decreasing inappropriate medication use in an older adult population may have a favorable effect on patient outcomes. This intervention involved collaboration between the Pharm a c y S e rvices Department and the Quality Risk Department where P h a rmacy Services provided the list of target prescribers and patients to the Quality Risk Department after the end of each calendar quart e r. Once the Quality Risk Department received this i n f o rmation, prescribers were not always immediately contacted by letter within the next calendar quart e r. In other words, a given p rescriber may not have been contacted by the Quality Risk D e p a rtment re g a rding the target drug and patient within weeks of the close of the previous calendar quart e r. Prescriber contact became timelier in the latter years of the interv e n t i o n .

■ ■ Conclusions
Over a 4-year measurement period, our quality improvement intervention with prescribers of target drugs contraindicated in older adults demonstrated that the percentage of target p rescriptions and the percentage of patients who receive target drugs can both be reduced. While the incidence of use of contraindicated drugs can be reduced, a goal of zero incidence of prescribing of drugs judged to be inappropriate in older adults may be unattainable.

A P P E N D I X
<<MD NAME>>, MD <<DATE>> <<MD ADDRESS 1>> <<MD ADDRESS 1>> <<MD CITY, STATE, ZIP>> Dear Primary Care Provider, Trends from the NCHS (1985)(1986)(1987)(1988)(1989)(1990)(1991)(1992)(1993)(1994)(1995)(1996)(1997)(1998)(1999) show that there was a 22% increase in the rate of office visits for patients over 65 years of age. Four or more drugs were provided or prescribed more often for patients > 65 years of age, compared to office visits for all other age groups. Patients > 65 years of age were 558% more likely to have an NME (new molecular entity) mentioned at their office visit compared to the youngest age group. This is disturbing considering many NMEs are not studied in this older patient population. 1 Prescribing certain medications represents an area of concern in the delivery of medical care, especially regarding elderly patients. Studies indicate that geriatric patients are at high risk for developing complications due to inappropriate medication prescribing which may result in serious drug-related morbidity or may lead to drug-related mortality. Explicit criteria have been developed through literature and consensus methodology for delineating what constitutes inappropriate use of medications in the elderly. These criteria target medications that should always be avoided, are rarely appropriate, may have some indications for use, as well as recommendations concerning dosages and duration of drug therapies that should not be exceeded. [2][3][4][5] In 2002, we revised our list of medications which may be potentially inappropriate to use in the elderly.
We have enclosed a list of your patients who received or continue to receive these "potentially inappropriate" medications. Physicians who continue to p rescribe these "potentially inappropriate" drugs will be evaluated by our Quality Risk Management Department. We encourage you to evaluate the enclosed m e m b e r ' s medications and prescribe an alternative from our form u l a ry.