Protected: Qi13 – PIMs for older adults

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Operationalisation

Denominator

Population aged 75 or older alive at the end of the year.

Numerator

All defined in the denominator who were dispensed at least one of the following medications during the year (a,b,c,d see “Notes” below):

  • N02AX02 Tramadola,b (opioid, sedative, serotonergic, fall-risk, side-effects)
  • N02AJ Opioids in combination with non-opioid analgesics (opioid risks, risk of double administration of non-opioid analgesics)
  • N02AG Opioids in combination with antispasmodicsb
  • Long-acting benzodiazepines and hypnotics (sedative, fall-risk, side-effects):
    • N05BA01 Diazepama,b,c
    • N05BA12 Alprazolamb
    • N05CD02/03 Nitrazepamb,c, flunitrazepamc
    • N05CM06 Propiomazinea (side-effects, incl. extrapyramidal)
  • R05DA01b/04a/09b Cough suppressants with ethylmorphine (opioid, sedative, fall-risk, side-effects), codeine (opioid, sedative, fall-risk, side-effects), or dextromethorphan (serotonergic, interactions)
  • Medications with potent anticholinergic effects (side-effects, interactions):
    • G04BD Medications for urinary frequency and incontinence excluding G04BD12 mirabegrona,b,c,d
    • M03BC01/51a,b,d Orphenadrine (and combinations)
    • M03BA02/52/72c Carisoprodol (and combinations)
    • M03BB03/53/73d Chlorzoxazone (and combinations)
    • N04AA01/02 Trihexyphenidyla, biperidena,b,c,d
    • N05BB01 Hydroxyzinea,b,c,d
    • N06AA Non-selective monoamine reuptake inhibitorsa,b,c,d, except N06AA09 amitriptylinea
    • First-generation antihistamines
      • R06AA Aminoalkyl ethersa,b,c,d
      • R06AD Phenothiazine derivativesa,c,d
      • R06AE05 Meclozinea,b,c,d

Exclusions (Numerator, denominator)

  • Individuals aged <75 years at the end of the year.
  • Individuals who die or emigrate during the examined year.

Notes

A multitude of tools and lists of potentially inappropriate medications exist in the literature. However, only few of these tools or lists are intended for register-based assessment at population level. Therefore, the list of medications defined here was primarily selected based on (a) the Swedish national indicator (1), which is intended for register-based assessment, i.e., excluding potentially inappropriate medications that are appropriate in specific situations (e.g., palliative care, specialised care), or at specific doses (e.g., amitriptyline).

 

To account for possible differences in the product ranges across countries, the list was complemented with medications with similar characteristics from the following sources:

  • (b) Classified in class D (to be avoided) in the Finnish Medicines Agency’s Meds 75+ database (2)
  • (c) Classified as anticholinergic in the Norwegian Directorate of Health’s indicator regarding anticholinergic medications prescribed by general practitioner dispensed for older people (3) or listed on the Norwegian General Practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients (4)
  • (d) listed on the Danish Health Authority’s deprescribing list Seponeringslisten (5) or list of medications with strong anticholinergic effects (6).

Sources of Data

  • Population register
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Similar or related indicators in Nordic or European quality assessment guidelines or databases

Swedish National Institute for Health and Welfare – guidelines

  • Report on indicators for good pharmacotherapy in older people, including lists of medications to avoid and medications with anticholinergic effects (12)
  • Applied into national quality indicators, modified by working group for primary care quality (1,13)
  • Applied in register-based studies (14–17)

Finnish Medicines Agency (Fimea) Meds75+ database (2)

  • Substances categorised into A–D indicating suitability for adults over 75 years of age.
  • Continuously updated, contains classifications and recommendations for approximately 450–500 substances/combinations
  • Primarily intended as a clinical decision-making tool
  • Has been applied in register-based studies (18–20)
  • Is applied in national quality indicator set to examine the prevalence of PIMs (21)

Norwegian Directorate of Health’s national quality indicators

  • Anticholinergic medications prescribed by general practitioner dispensed for older people (3)

Danish Institute for Rational Pharmacotherapy “Red-yellow-green list”

  • Published in 2011, discontinued in 2017 (22)
  • Applied in register-based studies (23)
  • Recommendations included in deprescribing list (Seponeringsliste), mainly intended as a clinical tool (5)

Similar or related indicators in international scientific literature

Lists or tools to identify or screen potentially inappropriate medications (PIMs) in older adults (validated for or including Europe/Nordic countries):

  • STOPP/START Criteria Version 3 (24)
  • EURO-FORTA (Fit fOR The Aged) Version 2 (25)
  • RASP_CARDIO (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients – cardiovascular segment) (26)
  • STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk) (27)
  • A list of 66 potentially clinically significant drug-drug-interactions in older people (28)
  • GheOP3S (Ghent Older People’s Prescriptions Community Pharmacy Screening) Version 2 (29)
  • Lists of medications deemed often adequate, questionable, or often inadequate for continuation or to be initiated during the last 3 months of life (30)
  • The European Union (EU)(7)-PIM list (31)
  • LUTS-FORTA (Lower urinary tract symptoms – Fit fOR The Aged) (32)
  • NORGEP-NH (The Norwegian General Practice – Nursing Home criteria) (33)
  • NORGEP (The Norwegian General Practice criteria) (4)

Review articles

  • Umbrella review by Anlay et al. (7) identified 23 systematic reviews and guidelines, which included 95 tools (72 explicit, 12 mixed and 11 implicit) and nine guidelines to aid the deprescribing process of potentially inappropriate medications (PIMs). Most tools focused on older adults.
  • Systematic review of validated explicit criteria to identify PIMs in the older adults by Motter et al. (34) identified 36 articles which included criteria concerning 907 different medications/classes, 536 different drug disease interactions involving 84 diseases, and 159 drug-drug interactions.
  • Systematic review by Hyttinen et al. (8) on the impact of PIMs identified 39 articles based on which most found a significant association between PIM exposure and healthcare use among older people, and five found an association between PIM use and higher costs.
  • Systematic review by Kaufmann et al. (35) identified 46 tools to assess inappropriate prescribing (28 explicit, 8 implicit and 10 mixed). Most tools were targeted to older adults.
  • A review by Chang & Chan (36) examined the overlap between seven explicit criteria for potentially inappropriate medications in older adults.

References

  1. PVQ Äldre Äld01: Andel patienter ≥75 år som behandlas med läkemedel som bör undvikas – KIK [Internet]. [cited 2024 May 4]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/8410b66b-8b54-4646-81a9-39407f87ac01
  2. Lääke75+ – Fimea.fi – Fimea [Internet]. [cited 2024 May 4]. Available from: https://fimea.fi/laakehaut_ja_luettelot/laake75-
  3. Helsedirektoratet [Internet]. [cited 2024 May 4]. Legemidler med betydelig antikolinergeffekt til eldre fra allmennlege. Available from: https://www.helsedirektoratet.no/statistikk/kvalitetsindikatorer/allmennlegetjenesten/legemidler-med-betydelig-antikolinergeffekt-til-eldre-fra-allmennlege
  4. Rognstad S, Brekke M, Fetveit A, Spigset O, Wyller TB, Straand J. The norwegian general practice (NORGEP) criteria for assessing potentially inappropriate prescriptions to elderly patients. Scand J Prim Health Care. 2009;27(3):153–9.
  5. Seponerings­listen 2024 [Internet]. [cited 2024 May 4]. Available from: http://www.sst.dk/da/Fagperson/Ansvarlig-medicinering/Rationel-farmakoterapi/Vaerktoejer-til-medicingennemgang/Seponeringslisten
  6. Antikolinerge lægemidler [Internet]. [cited 2024 May 4]. Available from: http://www.sst.dk/da/Fagperson/Ansvarlig-medicinering/Rationel-farmakoterapi/Vaerktoejer-til-medicingennemgang/Antikolinerge-laegemidler
  7. Anlay DZ, Paque K, Van Leeuwen E, Cohen J, Dilles T. Tools and guidelines to assess the appropriateness of medication and aid deprescribing: An umbrella review. Br J Clin Pharmacol. 2024 Jan;90(1):12–106.
  8. Hyttinen V, Jyrkkä J, Valtonen H. A Systematic Review of the Impact of Potentially Inappropriate Medication on Health Care Utilization and Costs Among Older Adults. Med Care. 2016 Oct;54(10):950–64.
  9. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  10. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  11. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  12. Indikatorer för god läkemedelsterapi hos äldre.
  13. PVQ Äldre Äld01: Andel patienter ≥75 år som behandlas med läkemedel som bör undvikas UTGÅR 2023-12-31 – KIK [Internet]. [cited 2024 May 4]. Available from: https://kvalitetsindikatorkatalog.se/#/measure/17d68d90-5941-4c8c-ada7-3db265d345a3
  14. Wallerstedt SM, Belfrage B, Fastbom J. Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study. Pharmacoepidemiol Drug Saf. 2015 Sep;24(9):906–14.
  15. Lesén E, Petzold M, Andersson K, Carlsten A. To what extent does the indicator “concurrent use of three or more psychotropic drugs” capture use of potentially inappropriate psychotropics among the elderly? Eur J Clin Pharmacol. 2009 Jun 1;65(6):635–42.
  16. Parodi López N, Svensson SA, Wallerstedt SM. Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study. Eur J Clin Pharmacol. 2022 Aug;78(8):1331–9.
  17. Wastesson JW, Fritzell J, Burström B, Johnell K, Fastbom J. Regional variations in excessive polypharmacy and potentially inappropriate drug use among older adults in Sweden: Trends from 2006 to 2020. Front Pharmacol [Internet]. 2023 [cited 2023 Sep 18];14. Available from: https://www.frontiersin.org/articles/10.3389/fphar.2023.1030849
  18. Paulamäki J, Jyrkkä J, Hyttinen V, Huhtala H, Jämsen E. Regional variation of potentially inappropriate medication use and associated factors among older adults: A nationwide register study. Res Soc Adm Pharm. 2023 Oct 1;19(10):1372–9.
  19. Saastamoinen L, Verho J. Regional variation in potentially inappropriate medicine use in older adults. – A national register-based cross-sectional study on economic, health system-related and patient-related characteristics. Res Soc Adm Pharm. 2021 Jun 1;17(6):1223–7.
  20. Hyttinen V, Jyrkkä J, Saastamoinen LK, Vartiainen AK, Valtonen H. The association of potentially inappropriate medication use on health outcomes and hospital costs in community-dwelling older persons: a longitudinal 12-year study. Eur J Health Econ. 2019 Mar 1;20(2):233–43.
  21. Sotekuva [Internet]. [cited 2024 May 2]. Available from: https://sotekuva.fi/en/#/chart?regionCategory=HYVINVOINTIALUE&freeze=false&sortByYear=false&absValue=false&munSortOrder=0&showMinAndMaxValues=false&showLowAndHighValues=false&showChartValues=true&previousView=chart
  22. Opdateret liste sætter fokus på gennemgang af medicin [Internet]. [cited 2024 May 4]. Available from: http://www.sst.dk/da/nyheder/2017/IRF-seponeringsliste
  23. Kristensen PK, Johnsen SP, Thomsen RW. Decreasing trends, and geographical variation in outpatient antibiotic use: a population-based study in Central Denmark. BMC Infect Dis. 2019 Apr 24;19(1):337.
  24. O’Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023 Aug 1;14(4):625–32.
  25. Pazan F, Weiss C, Wehling M. The EURO-FORTA (Fit fOR The Aged) List Version 2: Consensus Validation of a Clinical Tool for Improved Pharmacotherapy in Older Adults. Drugs Aging. 2023;40(5):417–26.
  26. De Schutter H, Hias J, Hellemans L, Walgraeve K, Tournoy J, Verhamme P, et al. Consensus validation of a screening tool for cardiovascular pharmacotherapy in geriatric patients: the RASP_CARDIO list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients). Eur Geriatr Med. 2022 Dec;13(6):1467–76.
  27. Seppala LJ, Petrovic M, Ryg J, Bahat G, Topinkova E, Szczerbińska K, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021 Jul;50(4):1189–99.
  28. Anrys P, Petit AE, Thevelin S, Sallevelt B, Drenth C, Soiza RL, et al. An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People. J Am Med Dir Assoc. 2021 Oct 1;22(10):2121-2133.e24.
  29. Foubert K, Capiau A, Mehuys E, De Bolle L, Somers A, Petrovic M, et al. Ghent Older People’s Prescriptions Community Pharmacy Screening (GheOP3S)-Tool Version 2: Update of a Tool to Detect Drug-Related Problems in Older People in Primary Care. Drugs Aging. 2021;38(6):523–33.
  30. Morin L, Laroche ML, Vetrano DL, Fastbom J, Johnell K. Adequate, questionable, and inadequate drug prescribing for older adults at the end of life: a European expert consensus. Eur J Clin Pharmacol. 2018 Oct;74(10):1333–42.
  31. Renom-Guiteras A, Meyer G, Thürmann PA. The EU(7)-PIM list: A list of potentially inappropriate medications for older people consented by experts from seven European countries. Eur J Clin Pharmacol. 2015;71(7):861–75.
  32. OELKE M, BECHER K, CASTRO-DIAZ D, CHARTIER-KASTLER E, KIRBY M, WAGG A, et al. Appropriateness of oral drugs for long-term treatment of lower urinary tract symptoms in older persons: results of a systematic literature review and international consensus validation process (LUTS-FORTA 2014). Age Ageing. 2015;44(5):745–55.
  33. Nyborg G, Straand J, Klovning A, Brekke M. The Norwegian General Practice–Nursing Home criteria (NORGEP-NH) for potentially inappropriate medication use: A web-based Delphi study. Scand J Prim Health Care. 2015 Jun;33(2):134–41.
  34. Motter FR, Fritzen JS, Hilmer SN, Paniz ÉV, Paniz VMV. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol. 2018 Jun;74(6):679–700.
  35. Kaufmann CP, Tremp R, Hersberger KE, Lampert ML. Inappropriate prescribing: a systematic overview of published assessment tools. Eur J Clin Pharmacol. 2014 Jan 1;70(1):1–11.
  36. Chang CB, Chan DC. Comparison of published explicit criteria for potentially inappropriate medications in older adults. Drugs Aging. 2010;27(12):947–57.