DEVELOPMENT OF PRESCRIBING INDICATORS FOR ELDERLY MEDICAL INPATIENTS

Aims To identify and improve suboptimal prescribing for elderly patien ts we have developed a number of prescribing indicators which focus on areas of concern and allow evaluation of the benefit of interventions . We report here on fourteen indicators. Methods The indicators are of three types: a) purely descriptive with no attempt to define optimal values, e.g. number of items prescribed per patient; b) based on unnec essary or potentially harmful prescribing, e.g. duplication; c) assess ing the appropriateness of prescribing specific drugs or combinations e.g. digoxin and warfarin/aspirin in atrial fibrillation (AF). Appropr iateness was defined on the basis of objective research findings and i nvolved comparing individual patient clinical records to criteria for appropriate prescribing. Prescribing and personal data were collected for medical inpatients aged 65 years or over in 19 hospitals in Englan d and Wales. A total of 1686 patients were included, median age 81 yea rs, 41% were male. Results Patients were prescribed 11475 items, mean 4.6 regular items per patient. Completion of drug allergy/sensitivity statements varied from 3 to 93% between units. Use of generic name and specification of a maximum frequency of administration for 'as requir ed' medicines were more consistent, ranging from 76-94% and 52-81% res pectively. Little duplication of therapy was seen. Benzodiazepines wer e prescribed for 22% patients, but were appropriate in only approximat ely one third of these. Of the 2% patients prescribed an angiotensin c onverting enzyme inhibitor with a potassium-sparing diuretic or potass ium supplement, prescription of the combination was appropriate in 84% . Coprescription of steroids with beta(2)-adrenoceptor agonists appear ed excessive in 67% patients receiving a beta(2)-adrenoceptor agonist, as only 51% had documented evidence of steroid responsiveness or anot her indication for steroids. Stroke prophylaxis in AF was inadequate: 22% patients prescribed digoxin also received warfarin or aspirin 300 mg whereas 64% should have received the coprescription. Conclusions Th ese prescribing indicators are sensitive to inappropriate prescribing for elderly medical inpatients and cover a nide range of therapeutic a reas. They should enable changes in prescribing quality to be measured objectively. Interhospital variation in casemix resulted in substanti al differences in the proportion of patients in whom it would have bee n appropriate to prescribe specific drugs or combinations and prevente d derivation of reference ranges of optimal prescribing for four indic ators.