Office of Inspector General

REVIEW OF PRESCRIBING PRACTICES

FOR ELDERLY OUTPATIENTS

Report No. 7R1-A28-008

Date: November 22, 1996

Office of Inspector General

Washington, DC 20420

VHA’s medication management of four drugs

prescribed to elderly outpatients compared

favorably to the private sector. VHA can help

optimize medication management for specific

drugs and patient populations by providing

data on drug specific prescribing practices to

VHA managers and clinicians.
Memorandum to the Under Secretary for Health (10)

Review of Prescribing Practices for Elderly Outpatients

1. The Office of Inspector General (OIG) conducted a review of the Department of

Veterans Affairs (VA) Veterans Health Administration's (VHA) prescribing practices for

selected drugs issued to outpatients aged 65 or older. The purpose of the review was to

help VHA:

· assess how well it manages certain medications for the elderly; and

· develop management tools for health care providers to monitor and optimize

medication management for the elderly.

2. The management of prescription drugs is an issue that has drawn a significant amount

of attention especially for elderly patients aged 65 and older. Health care providers

report that the elderly use more prescription drugs than any other age group and are more

likely to be taking multiple prescription drugs, which increases the probability of adverse

drug reactions. Additionally, the elderly are more susceptible to adverse drug reactions

because of the aging process. Studies published in The Journal of the American Medical

Association (JAMA) in 1994 and by the General Accounting Office (GAO) in 1995

concluded that between 25 and 17.5 percent of non institutionalized elderly patients were

taking 1 or more of 20 prescription drugs that many experts regard as generally unsuitable

for their age group. Experts believe that there has been insufficient research specifically

involving drug usage by the elderly. As a result, there is a need for more knowledge and

information in an effort for clinicians to appropriately manage medications for the

elderly.

3. Our review focused on 4 of the 20 drugs reported in JAMA and by the GAO. The

four drugs reviewed (Amitriptyline, Chlorpropamide, Dipyridamole, and Propoxyphene)

were selected based on discussions with VA geriatric experts, who believed there was

greater agreement among clinicians that the four drugs generally should not be prescribed

for the elderly. The scope of the review covered the period October 1, 1995 through

March 31, 1996. The review included analyses of all prescriptions of these four drugs to

VA outpatients aged 65 and older.
ii

4. Based on a nationwide review of prescribing practices for these four drugs, we found

that, during the first 6 months of Fiscal Year 1996, VHA providers prescribed these four

drugs to elderly outpatients substantially less frequently than non-VA providers as

reported in both the 1994 JAMA article and the 1995 GAO report. We also found that by

providing VHA managers and clinicians information regarding their prescribing practices

for these drugs, prescribing practices changed to further improve medication management

for elderly patients. Specifically, our review of prescribing practices at VA Medical

Center Bedford, MA showed that after prescription data was provided and educational

programs were initiated for clinicians, the use of the four drugs was reduced by 60

percent among elderly outpatients. We believe managers at other VHA facilities should

also be furnished information regarding use of the four drugs at their facilities so that they

have the opportunity to optimize medication management. Additionally, we believe that

by using the Automated Data Processing (ADP) application developed for this review, the

scope of facility reviews could be expanded to other drugs or other patient populations

(e.g., Proscar for the treatment of prostate conditions).

5. We recommended that you (1) have VISN Directors forward OIG furnished

information regarding prescribing practices for the four drugs to the individual VHA

facilities, (2) incorporate the ADP application into the national DHCP system, and (3)

encourage VISN Directors to utilize the ADP application to help optimize medication

management for specific drugs and patient populations as warranted.

6. You concurred with the findings and recommendations and provided acceptable

implementation plans. We consider all issues resolved. However, we will follow up on

implementation of planned actions until they have been completed.

For the Assistant Inspector General for Auditing

THOMAS L. CARGILL, JR.

Director, Bedford Audit Operations Division
TABLE OF CONTENTS

Page

Memorandum to the Under Secretary for Health (10)......................................... i

RESULTS AND RECOMMENDATIONS

Medication Management for Elderly Outpatients Can Be Enhanced

by Monitoring Prescribing Practices for Selected Drugs ................................. 1

Conclusion........................................................................................................... 4

Recommendations ......................................................................................... 4

APPENDIXES

I PURPOSE, SCOPE AND METHODOLOGY .............................................. 6

II BACKGROUND .......................................................................................... 7

III SUMMARY SCHEDULE BY VETERANS INTEGRATED SERVICE

NETWORK .................................................................................................... 9

IV MEMORANDUM FROM THE UNDER SECRETARY FOR HEALTH......... 10

V FINAL REPORT DISTRIBUTION................................................................. 13
1

RESULTS AND RECOMMENDATIONS

Medication Management For Elderly Outpatients Can Be Enhanced By Monitoring

Prescribing Practices For Selected Drugs

VHA clinicians prescribed Amitriptyline, Chlorpropamide, Dipyridamole, and

Propoxyphene, drugs geriatric experts regard as generally unsuitable for elderly

outpatients, less frequently than non-VHA clinicians. During the first 6 months of Fiscal

Year (FY) 1996, analyses of all prescriptions of these four drugs to VHA outpatients aged

65 and older showed 6.67 percent of the patients were prescribed one or more of the four

drugs. The percentage of VHA patients receiving one or more of the four drugs was

lower than the percentage of elderly patients reported in recent studies published in The

Journal of the American Medical Association (JAMA) and by the General Accounting

Office (GAO) which found 16.46 percent and 13.72 percent respectively of patients were

receiving these drugs. We also found that by providing VHA managers and clinicians

information regarding their prescribing practices for these drugs, medication management

for elderly patients was further enhanced. Our review of VA Medical Center (VAMC)

Bedford’s prescribing practices showed that after prescription data was provided and

educational programs were initiated for clinicians, the use of the four drugs was reduced

by 60 percent among elderly patients. We believe that by routinely extracting and

providing drug specific prescribing practice information, VHA could establish an

effective quality assurance monitor to help facilities optimize management of medications

prescribed to elderly patients. Additionally, by adopting and modifying the Automated

Data Processing (ADP) application used for this review such management monitors could

be expanded to other drugs or patient populations (e.g., Proscar for the treatment of

prostate conditions).

Management of Prescription Drugs for the Elderly

The potentially inappropriate use of prescription drugs is an issue that has drawn a

significant amount of attention especially for elderly patients aged 65 and older. The

elderly take more prescription drugs than any other age group and more often take several

drugs at once, which increases the probability of adverse drug reactions. The elderly are

also more vulnerable to adverse drug reactions as they often do not eliminate drugs from

their systems as efficiently as younger patients because of decreased liver and kidney

function.

In 1991, geriatric experts identified 20 drugs which they believe are generally

inappropriate for use by elderly patients, because alternative drugs provide equivalent

therapeutic benefits with fewer side effects. For example, some drugs, because of

decreased liver and kidney functions, can impair physical or mental function in the

elderly or even cause hospitalization, or death1. The medical community has only

 

1

 Many clinicians maintain that use of these drugs is not always inappropriate. For example, if a patient was doing

well on the drug and was being closely monitored, it would be appropriate to continue its use.
2

recently started to emphasize the study of geriatrics and elderly clinical pharmacology.

For example, board certification in geriatrics was offered for the first time in 1988.

Medical experts believe that there has been insufficient research specifically involving

drug usage by the elderly. As a result, there is a need for more knowledge and

information in an effort for clinicians to appropriately manage medications for the

elderly.

Many Elderly Patients Were Using Potentially Unsuitable Drugs

Recent studies have reported that many non institutionalized patients were using 1 or

more of these 20 drugs identified by geriatric experts as generally unsuitable for elderly

patients. JAMA in 1994 published an article showing nearly 25 percent of non

institutionalized elderly patients were using at least 1 drug identified as generally

unsuitable2. A 1995 report by GAO found that about 17.5 percent of non institutionalized

Medicare patients 65 or older used at least 1 of the 20 drugs3.

Based on discussions with VHA geriatric experts, we focused our review on 4

(Amitriptyline, Chlorpropamide, Dipyridamole, and Propoxyphene) of the 20 drugs

included in the JAMA article and GAO report. The VHA geriatric experts believed there

was greater agreement among clinicians that the four drugs generally should not be

prescribed for the elderly. The review included analysis of all prescriptions of these four

drugs to VHA outpatients aged 65 and older during the period October 1, 1995 through

March 31, 1996.

VHA Providers Prescribed Potentially Unsuitable Drugs Less Frequently

We found that during the first 6 months of FY 1996, VHA providers prescribed

Amitriptyline, Chlorpropamide, Dipyridamole, and Propoxyphene to elderly outpatients

less frequently than as compared to non-VHA providers, as reported in both the 1994

JAMA article and the 1995 GAO report.

As illustrated in the following chart, 6.67 percent of VHA patients were using one or

more of the four drugs compared with 16.46 percent of patients in the JAMA article and

13.72 percent of patients in the GAO report.

 

2

 The Journal of the American Medical Association, July 24, 1994, “Inappropriate Drug Prescribing for the

Community-Dwelling Elderly” by Willcox, et. al.

3

 The General Accounting Office (GAO/HEHS-95-152), July 1995, “Prescription Drugs and the Elderly”.
3

COMPARISONS OF VA DRUG USAGE RATES

Percentage of Patients in Study Receiving One or More of the Four Drugs

NAME OF DRUG

1994 JAMA

ARTICLE

1995 GAO

REPORT

VA 10/1/95 -

3/31/96

Amitriptyline 3.13% 2.63% 2.72%

Chlorpropamide 2.06% .87% .23%

Dipyridamole 6.44% 4.09% .70%

Propoxyphene 4.83% 5.63% 3.02%

Percentage of Elderly Receiving

One or More of the Four Drugs 16.46% 13.22% 6.67%

Providing Information Can Further Improve Medication Management

By providing VHA managers and clinicians information regarding their prescribing

practices for the four drugs, medication management for elderly patients can be further

enhanced. Our review of prescribing practices at VAMC Bedford, showed that after

prescription data was provided and educational programs were initiated for clinicians, the

use of the four drugs was reduced by 60 percent among elderly patients as illustrated

below:

COMPARISON OF CHANGES IN

PRESCRIBING PRACTICES AT VAMC BEDFORD

NAME OF DRUG

NO. 65

& >

1/1/95 -

6/30/95

NO. RECV

DRUG

%

NO.

65 & >

10/1/95 - 3/31/96

NO. RECV.

DRUG %

Amitriptyline 1,947 45 2.31 2,243 20 .89

Chlorpropamide 1,947 6 .31 2,243 2 .09

Dipyridamole 1,947 13 .67 2,243 5 .22

Propoxyphene 1,947 17 .87 2,243 5 .22

Total Number of

Pts. Using One or

More of the Four

Drugs 81 4.16 32 1.43
4

Other VHA Facilities Should Be Furnished Drug Utilization Information

More detailed information on the prescribing practices of each of the four drugs is

summarized by VISN in Appendix III. The table in Appendix III shows the average, high

and low percent ranges of elderly patients who received each drug. For example, in

VISN 18 the percent of elderly patients who received Amitriptyline ranged from a low of

1.17 percent to a high of 6.81 percent; while the average for VISN 18 of 3.06 percent is

comparable to the nationwide average of 2.72 percent.

A copy of the ADP application used to obtain information regarding use of the four drugs

during the first 6 months of FY 1996 was transmitted to each VHA facility. In addition,

each VISN Director will be furnished listings detailing prescribing practices for each

VHA facility for each of the four drugs.

We believe managers at other VHA facilities should also be furnished information

regarding use of the four drugs at their facilities so that they have the opportunity to

optimize medication management for their elderly patients. Additionally, the scope of

facility reviews could be expanded to other drugs or other patient populations (e.g.,

Proscar for the treatment of prostate conditions) by using the ADP application developed

for this review.

Conclusion

VHA’s medication management of four drugs prescribed to elderly outpatients compared

favorably to the private sector. VHA can help optimize medication management for

specific drugs and patient populations by providing data on drug specific prescribing

practices to VHA managers and clinicians.

Recommendations

We recommend that the Under Secretary for Health (1) have VISN Directors forward

OIG furnished information regarding prescribing practices for the four drugs to the

individual VHA facilities, (2) incorporate the ADP application into the national DHCP

system, and (3) encourage VISN Directors to utilize the ADP application to help optimize

medication management for specific drugs and patient populations as warranted.

Under Secretary for Health Comments

The Under Secretary concurred with the findings and recommendations.
5

Implementation Plan

The Under Secretary provided an implementation plan which stated that

recommendations 1 and 3 were implemented October 15, 1996. Recommendation 2, to

incorporate the ADP application into the national DHCP system, would be accomplished,

but final implementation would be dependent upon completion of higher priority projects.

The Under Secretary also stated the Pharmacy Benefits Management Strategic Healthcare

Group will be taking the lead in coordinating steps to assure that data extract needs are

assessed and that VISNs and headquarters offices get the assistance they need in

establishing relevant and effective mechanisms for review and analysis of pharmaceutical

utilization information. (See Appendix IV on page 10 for the full text of the Under

Secretary’s comments.)

Office of Inspector General Comments

The implementation plan is acceptable and we consider all issues resolved. However, we

will follow up on implementation of planned actions until they have been completed.
6

APPENDIX I

PURPOSE, SCOPE AND METHODOLOGY

Purpose

The purpose of the review was to help VHA:

• assess how well it manages certain medications for the elderly; and

• develop management tools to enable care providers to monitor and optimize

medication management for the elderly.

Scope and Methodology

To review VHA’s prescribing practices for the elderly, we:

• Conducted a medical literature review.

• Interviewed knowledgeable VHA physicians, pharmacists, and quality management

specialists.

• Attended “Optimizing Medication Management of the Older Adults” workshop, which

was co-sponsored by VA and the Health Care Financing Administration and designed

to produce quality indicators for optimizing medication management of the older

adult.

• Developed computer software to acquire relevant data regarding prescribing practices

at VHA medical facilities.

• Identified all veterans among the 933,060 outpatients aged 65 and over receiving

Amitriptyline, Chlorpropamide, Dipyridamole, and Propoxyphene from all VHA

facilities (except Manila) during the period October 1, 1995 to March 31, 1996.

• Verified the accuracy of the information extracted at three VAMCs.

• Analyzed the data.

• Reviewed changes in drug utilization at a VAMC.

• Discussed results of our review with VHA managers.

The review was conducted in accordance with government auditing standards for

qualifications, independence and due professional care.
7

APPENDIX II

Page 1 of 2

BACKGROUND

The management of prescription drugs is an issue that has drawn a significant amount of

attention especially for elderly patients aged 65 and older. The elderly take more

prescription drugs than any other age group and more often take several drugs at once,

which increases the probability of adverse drug reactions. Health care providers report

that the elderly are also more vulnerable to adverse drug reactions as they often do not

eliminate drugs from their systems as efficiently as younger patients because of decreased

liver and kidney function. For example, because the elderly have decreased liver and

kidney functions, some drugs can impair their physical or mental functions or even cause

hospitalization or death.

The medical community has only recently started to emphasize the study of geriatrics and

elderly clinical pharmacology. For example, board certification in geriatrics was offered

to physicians for the first time in 1988. Medical experts believe that there has been

insufficient research specifically involving drug usage by the elderly. As a result, there is

a need for more knowledge and information in an effort for clinicians to appropriately

manage medications for the elderly. VHA management has been actively working to

develop additional knowledge and information regarding drug usage by the elderly. In

March 1995, VHA and the Health Care Financing Administration co-sponsored a

workshop, “Optimizing Medication Management of the Older Adults”, designed to

produce quality indicators for medication management.

In 1991, geriatric experts identified 20 drugs which they believe are generally

inappropriate for use by elderly patients, because alternative drugs provide equivalent

therapeutic benefits with fewer side effects. The 20 drugs were:

Diazepam Chlordiazepoxide Flurazepam

Meprobamate Pentobarbital Secobarbital

Amitriptyline Indomethacin Phenylbutazone

Chlorpropamide Propoxyphene Pentazocine

Isoxsuprine Cyclandelate Dipyridamole

Cyclobenzaprine Methocarbamol Carisoprodol

Orphenadrine Trimethobenzamide

On July 27, 1994, the Journal of the American Medical Association published an article

entitled “Inappropriate Drug Prescribing for the Community-Dwelling Elderly”. The

article reported that 23.5 percent of people aged 65 or older living in the community

received at least 1 of the 20 potentially inappropriate drugs. In July 1995, the General

Accounting Office (GAO) published the results of their review of the same 20 drugs
8

APPENDIX II

Page 2 of 2

among Medicare patients. In Prescription Drugs and the Elderly, GAO reported 17

percent of elderly outpatients still receive 1 or more of the 20 drugs despite recent

improvement. Based on discussions with VHA geriatrics experts, we selected

Amitriptyline, Chlorpropamide, Dipyridamole, and Propoxyphene for further study. The

four drugs, their use and reason why they may be inappropriate for elderly are shown

below:

Prescription Drug Use Comment

Amitriptyline To treat depression Other antidepressant medications cause

fewer side effects, such as cognitive

impairment and loss of balance.

Chlorpropamide To treat diabetes Other oral hypoglycemic medications

have shorter half-lives and do not cause

inappropriate antidiuretic hormone

secretion which leads to dehydration.

Dipyridamole To reduce blood-clot Effectiveness at low dosage is at doubt.

formation Toxic reaction is high at higher dosages.

Safer alternatives exist.

Propoxyphene To moderate pain Other analgesic medications are more

effective and safer.
9

APPENDIX III

SUMMARY SCHEDULE BY VETERANS INTEGRATED SERVICE NETWORK

Percentage Range of Elderly Patients Receiving Each Drug

AMITRIPTYLINE CHLORPROPAMIDE DIPYRIDAMOLE PROPOXYPHENE

VISN AVG HIGH LOW AVG HIGH LOW AVG HIGH LOW AVG HIGH LOW

1 2.31% 3.34% 0.89% 0.45% 1.65% 0.06% 0.48% 0.69% 0.22% 2.07% 6.47% 0.22%

2 2.15% 2.50% 1.95% 0.26% 0.53% 0.00% 1.20% 2.57% 0.43% 3.41% 8.07% 0.00%

3 1.31% 1.99% 0.51% 0.40% 0.86% 0.05% 1.25% 2.90% 0.00% 0.15% 0.59% 0.00%

4 2.00% 3.55% 0.51% 0.20% 0.56% 0.00% 0.68% 1.55% 0.00% 3.64% 13.41% 1.07%

5 2.45% 3.51% 1.92% 0.36% 0.75% 0.10% 0.26% 0.54% 0.17% 1.36% 2.63% 0.05%

6 2.91% 4.59% 0.46% 0.24% 0.60% 0.00% 0.85% 3.50% 0.11% 2.92% 17.74% 0.00%

7 3.63% 5.26% 1.72% 0.35% 1.51% 0.08% 0.67% 2.89% 0.00% 4.81% 10.73% 0.00%

8 1.84% 2.72% 0.24% 0.33% 0.75% 0.08% 0.60% 1.80% 0.06% 4.85% 19.46% 0.01%

9 4.56% 6.74% 2.67% 0.27% 0.64% 0.12% 0.49% 1.13% 0.00% 2.81% 7.41% 0.00%

10 2.84% 3.98% 1.93% 0.15% 0.56% 0.00% 1.46% 2.94% 0.12% 3.54% 19.86% 0.08%

11 2.37% 3.77% 0.89% 0.17% 0.28% 0.05% 1.09% 2.60% 0.44% 6.57% 16.61% 0.02%

12 2.07% 2.55% 1.23% 0.07% 0.25% 0.00% 0.44% 0.85% 0.03% 2.80% 7.37% 0.00%

13 2.17% 5.09% 1.13% 0.04% 0.13% 0.00% 0.30% 0.78% 0.00% 2.90% 11.51% 0.36%

14 3.70% 4.56% 1.67% 0.19% 0.46% 0.09% 0.70% 1.23% 0.00% 3.96% 11.88% 0.00%

15 3.58% 6.42% 2.24% 0.18% 0.65% 0.00% 0.74% 3.66% 0.03% 2.84% 10.07% 0.00%

16 3.96% 5.66% 2.57% 0.11% 0.27% 0.00% 0.82% 1.92% 0.07% 3.75% 14.14% 0.00%

17 3.41% 4.17% 2.95% 0.21% 0.42% 0.00% 1.54% 4.64% 0.63% 2.03% 9.31% 0.07%

18 3.06% 6.01% 1.17% 0.16% 0.34% 0.00% 0.52% 3.05% 0.08% 2.41% 8.73% 0.02%

19 3.12% 4.15% 2.09% 0.06% 0.40% 0.00% 0.25% 0.60% 0.00% 3.88% 12.85% 0.00%

20 1.94% 2.35% 1.61% 0.08% 0.21% 0.00% 0.30% 0.58% 0.12% 1.40% 6.01% 0.00%

21 2.34% 3.28% 1.05% 0.09% 0.25% 0.00% 0.26% 0.42% 0.05% 1.04% 4.88% 0.00%

22 2.40% 3.07% 1.50% 0.46% 1.52% 0.02% 0.27% 0.73% 0.03% 1.95% 5.84% 0.00%
APPENDIX IV

10

Page 1 of 3

MEMORANDUM FROM THE UNDER SECRETARY FOR HEALTH

DATED NOVEMBER 8, 1996

Department of

Veterans Affairs Memorandum

Date: November 8, 1996

From: Under Secretary for Health (10/105E)

Subj: OIG Draft Report, Review of Prescribing Practices for Elderly Outpatients

To: Assistant Inspector General for Auditing (52)

1. The draft report was reviewed by the appropriate Veterans Health Administration

(VHA) program offices and we concur with the report findings and recommendations. VHA

has put great emphasis on discontinuing or modifying the use of the drugs studied by OIG (as

well as many others) in the elderly, especially in VA nursing home care units. Strong

programs in geriatrics (especially research and education), the availability of consulting

clinical pharmacists and active P&T Committees with facility Drug Usage Evaluation

programs have greatly assisted VHA efforts in this area. Your report findings reflect the

effectiveness of these processes and other quality assurance monitors that are used by most

facilities to enhance medication management. As you recommended, the facility specific

information you prepared has already been provided to each Veterans Integrated Service

Network (VISN) Director for distribution to each facility to use in these processes. In

addition, copies of your final report will be distributed to each of VA’s Geriatric Research,

Education and Clinical Care programs for use in the development of educational presentations

to VA and non-VA clinicians, and your findings and recommendations will be presented for

discussion on one or more of the systemwide monthly Geriatrics and Extended Care

conference calls.

2. The issues you raise in your report regarding access to pharmaceutical utilization

information and management of pharmaceutical utilization at the VISN, while addressed in

the recommendations, extend beyond them. In addition to the activities outlined in our

attached corrective action plan (which meet the immediate requirements of the

recommendations), the Pharmacy Benefits Management Strategic Healthcare Group will be

taking the lead in coordinating steps to assure that data extract needs are assessed and that

VISNs and headquarters offices get the assistance they need in establishing relevant and

effective mechanisms for review and analysis of this information.

3. Thank you for the opportunity to review the draft report. If you have any questions or

require further information, please contact Paul C. Gibert, Jr., Director, Management Review

Service (105E), Office of Policy, Planning and Performance, at 273.8355.

[Signed by Tomas L. Garthwaite, M.D., for:]

Kenneth W. Kizer, M.D., M.P.H.

Attachment

VA Form 2105

Mar 1989
APPENDIX IV

11

Page 2 of 3

Action Plan in Response to OIG/GAO/MI Audits/Program Evaluations/Reviews

Name of Report: Review of Prescribing Practices for Elderly Outpatients

Project No.: None

Date of Report: Draft report, dated September 20, 1996

______________________________________________________________________________

Recommendations/ Status Completion

Actions Date

______________________________________________________________________________

Recommendation 1.: Have VISN Directors forward OIG furnished information regarding

prescribing practices for the 4 drugs to the individual VHA facilities.

Concur

The information was forwarded to the VISN Directors by the Chief Network Officer on October 15,

1996, for dissemination to all VHA facilities. (See attached memorandum)

Completed 10/15/96

Recommendation 2.: Incorporate the ADP application into the national DHCP system.

Concur

This will be accomplished, however, final implementation is dependent upon completion of higher

priority projects.

In process 12/31/97

Recommendation 3.: Encourage VISN Directors to utilize the ADP application to help optimize

medication management for specific drugs and patient population as warranted.

Concur

The Chief Network Officer encouraged all VISN Directors to use the ADP application once it is

incorporated into the national DHCP system in a memorandum to all VISN Directors, dated October 15,

1996.

Completed 10/15/96
APPENDIX IV

12

Page 3 of 3

Department of

Veterans Affairs Memorandum

Date: October 15, 1996

From: Chief Network Officer (10N)

Subj: OIG Draft Report, Review of Prescribing Practices for Elderly Outpatients

To: Network Directors (10N1-22)

1. The OIG recently issued a draft report on the prescribing practices for selected

drugs (Amitriptyline, Chlorpropamida, Dipyridamole, and Propoxphene) issued to

outpatients aged 65 or older. The review was done to assist VHA in:

a. assessing how well it manages certain medications for the elderly

b. developing management tools for health care providers to monitor and

optimize medication management for the elderly.

2. The OIG concluded that VHA providers prescribed these 4 drugs to elderly

outpatients less frequently than non-VA providers. A review of prescribing

practices at one VA Medical Center revealed that after the prescription data was

provided and educational programs were initialed for clinicians, the use of the 4

drugs was reduced by 60% among elderly outpatients. Consequently, the OIG

believes that the attached information should be shared with your facilities so that

they have the opportunity to optimize medication management.

3. The OIG also recommended that the ADP application developed for this

review be incorporated into the national DHCP system. Once this is done, I

would encourage you to utilize the ADP application to help optimize medication

management for specific drugs and patient populations as warranted.

[Signed]

Jule D. Moravec, Ph.D.

Attachment

VA Form 2105

Mar 1989
APPENDIX V

13

FINAL REPORT DISTRIBUTION

VA DISTRIBUTION

Secretary (00)

Under Secretary for Health (105E)

General Counsel (02)

Assistant Secretary for Management (004)

Assistant Secretary for Policy and Planning (008)

Deputy Assistant Secretary for Congressional Affairs (60)

Deputy Assistant Secretary for Public Affairs (80)

Director, Office of Management Controls (004B)

Chief Network Officer (10N)

Associate Chief Medical Director for Quality Management (15)

Assistant Chief Medical Director for Geriatrics and Extended Care (114)

Director, Pharmacy Service (111)

Directors, VISNs 1-22

Director, VAMC Bedford, MA (518/00)

NON-VA DISTRIBUTION

Office of Management and Budget

U.S. General Accounting Office

Congressional Committees:

Chairman, Senate Committee on Governmental Affairs

Ranking Member, Senate Committee on Governmental Affairs

Chairman, Senate Committee on Veterans’ Affairs

Ranking Member, Senate Committee on Veterans’ Affairs

Chairman, Subcommittee on VA, HUD, and Independent Agencies, Senate Committee on

Appropriation

Ranking Member, Subcommittee on VA, HUD, and Independent Agencies, Senate

Committee on Appropriations

Chairman, Subcommittee on VA, HUD, and Independent Agencies, House Committee on

Appropriations

Ranking Member, Subcommittee on VA, HUD, and Independent Agencies, House Committee

on Appropriations

Chairman, House Committee on Veterans’ Affairs

Ranking Member, House Committee on Veterans’ Affairs

Chairman, House Committee on Veterans’ Affairs, Subcommittee on Hospitals and Health

Care

Ranking Member, House Committee on Veterans’ Affairs, Subcommittee on Hospitals and

Health Care