Study finds problems in medication prescribing for vulnerable older patients

Older patients at risk of decline and death do not receive recommended medication to treat their chronic health problems about half of the time, according to a study issued by researchers from the RAND Corporation and UCLA.

The vulnerable older patients in the study also frequently were not monitored closely enough by doctors to make sure the drugs were working and did not always receive adequate education about their medications, according to the study in the May 4 edition of the Annals of Internal Medicine.

Researchers say the findings raise questions about the quality of medication care given to the sickest older patients living in the community, as well as the impact of new Medicare programs intended to lower the cost of drugs to more seniors. The study involved 372 Medicare recipients enrolled in health plans that made drugs available for $10 or less per prescription.

"Even for older patients who have access to affordable medications, the quality of drug prescribing just isn't very good," said lead author Dr. Takahiro Higashi, a fellow in the Division of General Internal Medicine and Health Services Research at UCLA's David Geffen School of Medicine. "It may not be enough to extend access to low-cost drugs. We also need to improve the quality of care that seniors receive."

Americans age 65 and older account for nearly one-third of all prescription drug spending in the nation, although they account for just 13 percent of the population. Ninety percent of seniors take at least one prescription medication.

Most research examining the quality of medication care given to seniors has looked at whether older patients are taking too many medications or are prescribed inappropriate or harmful drugs.

The RAND group conducted a comprehensive review of the quality of medication care for older patients as part of a project called Assessing the Care of Vulnerable Elders (ACOVE), an effort to examine the quality of health care provided to vulnerable older Americans living in the community.

Researchers developed a set of quality indicators and applied them to the medication management provided to patients during 1998 to 1999 who were enrolled in two managed care health organizations, one located in the southwest and the other in the northeast.

Among those studied, patients were prescribed recommended medication for common conditions only 50 percent of the time, according to the study. The success varied based on the medical problem, with proper drugs prescribed 94 percent of the time for an irregular heart rhythm called atrial fibrillation and just 11 percent of the time to people at risk of gastrointestinal bleeding.

Researchers also found that patients were adequately monitored for toxicity and to make sure that medication was having the intended effect just 64 percent of the time, while adequate education and documentation occurred in 81 percent of the cases studied.

Inappropriate and harmful medications were avoided in 97 percent of the cases studied.  Dr. Neil Wenger, a RAND researcher and professor of medicine at UCLA who is the study's senior author, said this may be a sign that physicians have responded to previous warnings about prescribing inappropriate medication to older patients.

The patients studied all were identified as having health problems that make them vulnerable to losing their independence and ability to carry out daily activities. About one-third of senior citizens in the United States fall into the vulnerable category.

Other authors of the report are Dr. David H. Solomon, Dr. Roy T. Young, Dr. John T. Chang and Dr. David B. Reuben, all of UCLA's David Geffen School of Medicine; Dr. Paul G. Shekelle of RAND and the Greater Los Angeles Veterans Affairs Healthcare System; Carol Roth, Caren J. Kamberg, Dr. Catherine H. MacLean and Dr. John Adams, all of RAND; and Dr. Jerry Avorn and Dr. Eric L. Knight of the Harvard Medical School.

ACOVE is a six-year collaboration between RAND and Pfizer Inc. that is developing and testing quality indicators to create a comprehensive geriatric-assessment system to inform health care providers and aid consumers.