Study Suggests Drugs-to-Avoid Criteria for the Elderly have Limited Value
Measuring and improving the quality of drug prescribing for older patients is essential to increasing the overall quality of health for the elderly population. Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. After a comprehensive patient interview, an expert assessment team (physician/pharmacist) recommended that certain drugs be discontinued, substituted, or reduced in dose. Investigators then evaluated the degree to which drugs considered potentially inappropriate by the drugs-to-avoid criteria also were considered problematic by the expert assessment team, and vice versa.
Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. The correspondence between drugs-to-avoid criteria and expert assessment also varied across different types of drugs. For instance, while nearly all of the tricyclic antidepressants were identified as problematic by both the Beers and Zhan criteria and the expert study team, there was almost a complete lack of overlap in assessments of muscle relaxants. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
Steinman M, Rosenthal G, Landefeld C, Bertenthal D, and Kaboli P. Do drugs-to-avoid criteria agree with expert assessments of problem prescribing? Archives of Internal Medicine July 27, 2009;169(14):1326-32.
This study was funded by HSR&D, and Drs. Steinman and Kaboli are supported by HSR&D Career Development Awards. Drs. Rosenthal and Kaboli are part of HSR&D’s Center for Research in the Implementation of Innovative Strategies in Practice (CRIISP) in Iowa City.