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Presenting Author: Stefano Del Canale, M.D., Ph.D. Co-authors: Ettore Brianti, M.D.

Improving the Appropriateness of Prescribing in Elderly Patients. Is it feasible? A comprehensive Approach in the Local Health Unit of Parma, Italy. Presenting Author: Stefano Del Canale, M.D., Ph.D. Co-authors: Ettore Brianti, M.D. Massimo Fabi, M.D. Scott W. Keith, Ph.D., M.S.

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Presenting Author: Stefano Del Canale, M.D., Ph.D. Co-authors: Ettore Brianti, M.D.

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  1. Improving the Appropriateness of Prescribing in Elderly Patients. Is it feasible? A comprehensive Approach in the Local Health Unit of Parma, Italy Presenting Author: Stefano Del Canale, M.D., Ph.D. Co-authors: Ettore Brianti, M.D. Massimo Fabi, M.D. Scott W. Keith, Ph.D., M.S. Kellie Dudash, PharmD Megan Templin, M.S. Vittorio Maio, PharmD, M.S., MSPH

  2. Background • Potentially inappropriate medications (PIMs) are those medications whose adverse risks exceed their health benefits1 • PIMs use in the community-dwelling elderly is associated with negative patient health outcomes2,3 • Using the Beers Criteria, preliminary data in the Emilia-Romagna Region, Italy, showed that 1 out of 5 elderly patients are subject to PIMs in ambulatory settings4 1) Stuck AE, Beers MH, Steiner A, et al. Inappropriate medication nuse in community-residing older persons. Arch Intern Med. 1994;154:2195-2200. 2) Fu AZ, Liu GG, Christensen DB. Inappropriate medication use and health outcomes in the elderly. J Am Geriatr Soc J. 2004;52:1934-1939. 3) Jano E, Aparasu RR. Healthcare outcomes associated with Beer’s Criteria: a systematic review. Ann Pharmacthero. 2007;41(3):438-447. 4) Maio V, Yuen E, Novielli K, et al. Potentially Inappropriate Medication Prescribing for Elderly Outpatients in Emilia Romagna, Italy: A Population-Based Cohort Study Drugs & Aging 2006; 23(11):915-924

  3. Objective • To enhance physicians’ knowledge of prescribing for the elderly and improve the quality of prescribing in the primary care setting in the Local Health Unit (LHU) of Parma, Italy

  4. Methods • A 3-year, multi-phase prospective demonstration project targeting all 303 general practitioners (GPs) in the LHU of Parma, Italy, was established in 2007 Key Elements of multi-phase Intervention: Q1-Q3 2007 Q4 2007 Q1-Q3 2008 Development of PIMs list Dissemination of PIMs list to GPs & annual review of PIMs prevalence data Dissemination of alternative list of drugs to GPs 2007 Q4 2009 Q1-Q3 2009 Q4 2008 Case studies presentation & annual review of PIMs prevalence data Development of case studies on PIMs Annual review of PIMs prevalence data 2010

  5. *The following selected drugs were included in the analysis: risperidone, clozapine, olanzapine, quetiapine, aripiprazole 5) Maio V, Del Canale S, Abouzaid S, et al. Using explicit criteria to evaluate the quality of prescribing in elderly Italian outpatients: a cohort study. J Clin Pharm Ther. 2009;34:1-11.

  6. Renal effectsof NSAIDs and COX-2 inhibitors Arachidonic acid cascade NSAIDs COXIBs COX-2 PGE2 /PGI2 • Sodium retention • Peripheral oedema • Hypertension • CHF • Renal Failure • Acute • Prerenal • ATN Hyperkalemia Perazella, M. Expert Opin Drug Saf. 2002;1:53-64.

  7. Severe ADRs resulting in Hospital Admission showed for Drug Classes (GIFA STUDY) ACEI 7 Insulin 8 Antipsychotics 10 Ca- channel blockers 11 Steroids 12 Antibiotics 13 Antineoplastics 14 Digoxin 14 Diuretics 17 ASA - Antiplatelets 22 NSAIDs 27 0 5 10 15 20 25 30 Onder, JAGS 2002; 50: 1962-8

  8. Methods

  9. Results: Parma LHU By Quarter aThe number of subjects does not equal the total because some subjects received more than one PIP. NE= not eligible; NSAIDS= non-steroidal anti-inflammatory drugs *p<0.05; **p<0.01

  10. Proportion of elderly receiving PIMs in Parma LHU and Reggio LHU by Quarter Breslow-Day test, p=0.004

  11. Summary • A quality intervention program looking at improving knowledge in primary care physicians on prescribing for the elderly patients resulted in a substantial reduction of the rate of PIMs  • The greatest impact was seen in users of digoxin and NSAIDs, with a significant potential benefit for patients

  12. Limitations • PIMs with a low rate of use at baseline may be impossible to lower any further and may diminish the overall impact of our intervention • The study does not measure the impact of the intervention on other healthcare resource use or patient outcomes

  13. Future Directions • Additional analyses should be performed to further investigate: • Which physicians were less prone to change prescribing and use results to design targeted educational interventions • Whether the observed change may be retained over time

  14. Thank you!Any questions?

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