Medication use leading to emergency department visits for adverse drug events in older adults.

Emergency department visits by older adults are often due to adverse drug events, but the proportion of these visits that are the result of drugs designated as inappropriate for use in this population is unknown.  Analyses of a national surveillance study of adverse drug events and a national outpatient survey estimate that Americans age 65 years or older have more than 175000 emergency department visits for adverse drug events yearly. Three commonly prescribed drugs accounted for more than one third of visits: warfarin, insulin, and digoxin.  The study was limited to adverse events in the emergency department.  Strategies to decrease adverse drug events among older adults should focus on warfarin, insulin, and digoxin. The Editors Adverse drug events cause clinically significant morbidity and mortality and are associated with large economic costs (15). They are common in older adults, regardless of whether they live in the community, reside in long-term care facilities, or are hospitalized (59). Most physicians recognize that prescribing medications to older patients requires special considerations, but nongeriatricians are typically unfamiliar with the most commonly used measure of medication appropriateness for older patients: the Beers criteria (1012). The Beers criteria are a consensus-based list of medications identified as potentially inappropriate for use in older adults. The criteria were introduced in 1991 to help researchers evaluate prescription quality in nursing homes (10). The Beers criteria were updated in 1997 and 2003 to apply to all persons age 65 years or older, to include new medications judged to be ineffective or to pose unnecessarily high risk, and to rate the severity of adverse outcomes (11, 12). Prescription rates of Beers criteria medications have become a widely used measure of quality of care for older adults in research studies in the United States and elsewhere (1326). The application of the Beers criteria as a measure of health care quality and safety has expanded beyond research studies. The Centers for Medicare & Medicaid Services incorporated the Beers criteria into federal safety regulations for long-term care facilities in 1999 (27). The prescription rate of potentially inappropriate medications is one of the few medication safety measures in the National Healthcare Quality Report (28) and has been introduced as a Health Plan and Employer Data and Information Set quality measure for managed care plans (29). Despite widespread adoption of the Beers criteria to measure prescription quality and safety, as well as proposals to apply these measures to additional settings, such as medication therapy management services under Medicare Part D (30), population-based data on the effect of adverse events from potentially inappropriate medications are sparse and do not compare the risks for adverse events from Beers criteria medications against those from other medications (31, 32). Adverse drug events that lead to emergency department visits are clinically significant adverse events (5) and result in increased health care resource utilization and expense (6). We used nationally representative public health surveillance data to estimate the number of emergency department visits for adverse drug events involving Beers criteria medications and compared the number with that for adverse drug events involving other medications. We also estimated the frequency of outpatient prescription of Beers criteria medications and other medications to calculate and compare the risks for emergency department visits for adverse drug events per outpatient prescription visit.  Data Sources National estimates of emergency department visits for adverse drug events were based on data from the 58 nonpediatric hospitals participating in the National Electronic Injury Surveillance SystemCooperative Adverse Drug Event Surveillance (NEISS-CADES) System, a nationally representative, size-stratified probability sample of hospitals (excluding psychiatric and penal institutions) in the United States and its territories with a minimum of 6 beds and a 24-hour emergency department  (3335). As described elsewhere (5, 34), trained coders at each hospital reviewed clinical records of every emergency department visit to report physician-diagnosed adverse drug events. Coders reported clinical diagnosis, medication implicated in the adverse event, and narrative descriptions of preceding circumstances. Data collection, management, quality assurance, and analyses were determined to be public health surveillance activities by the Centers for Disease Control and Prevention (CDC) and U.S. Food and Drug Administration human subjects oversight bodies and, therefore, did not require human subject review or institutional review board approval.  Data sources and descriptions. NAMCS= National Ambulatory Medical Care Survey (36); NEISS-CADES= National Electronic Injury Surveillance SystemCooperative Adverse Drug Event Surveillance System (5, 3335); NHAMCS = National Hospital Ambulatory Medical Care Survey (37). The NEISS-CADES is a 63-hospital national probability sample, but 5 pediatric hospitals were not included in this analysis. National estimates of outpatient prescription were based on 2 cross-sectional surveys, the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), designed to provide information on outpatient office visits and visits to hospital outpatient clinics and emergency departments  (36, 37). These surveys have been previously used to document the prescription rates of inappropriate medications (17, 3840). Definition of Potentially Inappropriate Medications The most recent iteration of the Beers criteria (12) categorizes 41 medications or medication classes as potentially inappropriate under any circumstances (always potentially inappropriate) and 7 medications or medication classes as potentially inappropriate when used in certain doses, frequencies, or durations (potentially inappropriate in certain circumstances). For example, ferrous sulfate is considered to be potentially inappropriate only when used at dosages greater than 325 mg/d, but not potentially inappropriate if used at lower dosages. For this investigation, we included the Beers criteria medications listed in Table 1. Because medication dose, duration, and frequency were not always available in NEISS-CADES and are not reported in NAMCS and NHAMCS, we included medications regardless of dose, duration, or frequency of use. We excluded 3 medications considered to be potentially inappropriate when used in specific formulations (short-acting nifedipine, short-acting oxybutynin, and desiccated thyroid) because NEISS-CADES, NAMCS, and NHAMCS do not reliably identify these formulations. Table 1. Potentially Inappropriate Medications for Individuals Age 65 Years or Older The updated Beers criteria identify additional medications as potentially inappropriate if they are prescribed to patients who have certain preexisting conditions. We did not include these medications because they have rarely been used in previous studies or safety measures and NEISS-CADES, NAMCS, and NHAMCS do not reliably identify preexisting conditions. Identification of Emergency Department Visits for Adverse Drug Events We defined an adverse drug event case as an incident emergency department visit by a patient age 65 years or older, from 1 January 2004 to 31 December 2005, for a condition that the treating physician explicitly attributed to the use of a drug or for a drug-specific effect (5). Adverse events include allergic reactions (immunologically mediated effects) (41), adverse effects (undesirable pharmacologic or idiosyncratic effects at recommended doses) (41), unintentional overdoses (toxic effects linked to excess dose or impaired excretion) (41), or secondary effects (such as falls and choking). We excluded cases of intentional self-harm, therapeutic failures, therapy withdrawal, drug abuse, adverse drug events that occurred as a result of medical treatment received during the emergency department visit, and follow-up visits for a previously diagnosed adverse drug event. We defined an adverse drug event from Beers criteria medications as an emergency department visit in which a medication from Table 1 was implicated. Identification of Outpatient Prescription Visits We used the NAMCS and NHAMCS public use data files for the most recent year available (2004) to identify outpatient prescription visits. We defined an outpatient prescription visit as any outpatient office, hospital clinic, or emergency department visit at which treatment with a medication of interest was either started or continued. We identified medications by generic name for those with a single active ingredient and by individual active ingredients for combination products. We categorized visits with at least 1 medication identified in Table 1 as involving Beers criteria medications. Statistical Analysis Each NEISS-CADES, NAMCS, and NHAMCS case is assigned a sample weight on the basis of the inverse probability of selection (33, 4244). We calculated national estimates of emergency department visits and prescription visits by summing the corresponding sample weights, and we calculated 95% CIs by using the SURVEYMEANS procedure in SAS, version 9.1 (SAS Institute, Cary, North Carolina), to account for the sampling strata and clustering by site. To obtain annual estimates of visits for adverse events, we divided NEISS-CADES estimates for 20042005 and corresponding 95% CI end points by 2. Estimates based on small numbers of cases (<20 cases for NEISS-CADES and <30 cases for NAMCS and NHAMCS) or with a coefficient of variation greater than 30% are considered statistically unstable and are identified in the tables. To estimate the risk for adverse events relative to outpatient prescription