Prevalence of inappropriate prescribing in primary care.

OBJECTIVE: To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved. SETTING: A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen. METHOD: Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients' own GPs. The GPs were asked to provide baseline information regarding the patients' medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded. RESULTS: 212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as 'not indicated', 6% were rated as 'ineffective', 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug-drug interactions, 8.6% had clinically significant drug-disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics. CONCLUSION: The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.

Reliability of a modified medication appropriateness index in primary care.

OBJECTIVE: To evaluate the inter-group and intra-group reliability of a modified Medication Appropriateness Index (MAI) for use in primary care. METHODS: Elderly (>65 years) polypharmacy (> or =5 drugs) patients in Copenhagen County participated in the study. Information concerning their medical history and information regarding each drug taken by them was provided by their own general practitioners. A MAI was scored by two groups of evaluators for every drug. To evaluate inter-group agreement, 211 drugs taken by 30 patients were rated according to the ten criteria making up the MAI. Both evaluator groups provided summaries of comments on the medication of each patient. Intra-group agreement was determined from MAI ratings performed twice at two different times on 86 drugs taken by ten patients. Agreement and chance-adjusted agreement were determined, the latter through kappa statistics. The proportion of positive (ppos) and negative (pneg) agreement was also determined. RESULTS: The overall chance-adjusted inter-group agreement (kappa) was moderate. The agreement was good on the criteria practical directions and drug-disease interaction, moderate on the criteria dosage and duration, fair on the criteria indication, effectiveness, duplication and expense, and poor on the criterion drug-drug interaction. The overall chance-adjusted intra-group agreement was good for all criteria and very good for the criteria indication and practical directions. CONCLUSION: The MAI is used to quantify appropriate and inappropriate prescribing and changes in prescribing quality in intervention studies. However, caution should be used when comparing results across different settings and evaluators. Our study suggests that the index should only be used in intervention studies if the same group rates the appropriateness pre- and post-intervention.