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.

[The national drug interactions database]. / Den nationale Interaktionsdatabase.

Among health professionals, a national drug interactions database including all relevant information, conclusions and recommendations has been in demand for a long time. A project group was established in 2001, and the database became a reality at the end of 2003. It contains about 2,000 descriptions of drug interactions for pharmaceuticals, herbal drugs and vitamins/minerals. The Danish Medicines Agency is responsible for the updating of the database in cooperation with a scientific board.

[Lack of consensus on drug interactions: a descriptive analysis of information on interactions in the Laegemiddelkatalog, Medicinfortegnelse and product descriptions]. / Manglende konsensus på interaktionsområdet. En deskriptiv analyse af information om interaktioner i Laegemiddelkataloger, Medicinfortegnelsen og produktresumeerne.

INTRODUCTION: Practitioners' experience with inconsistencies between two Danish handbooks and the SPCs have lead to this comparative analysis of information on drug interactions in these publications. On the same background, a Danish database with drug interactions based on evidence and transparency is established. MATERIALS AND METHOD: The material comprises information on 62 randomly selected drugs marketed in Denmark and described in the Laegemiddelkatalog, Medicinfortegnelse and 62 SPCs. A total of 586 drug interactions was analysed. This is a comparative analysis of the discrepancies of the information, the exactness of the name of the interacting drug, and applicability for health care personnel. RESULTS: The comparison of the three sources shows inconsistency for 78% of the interactions. Fifty-nine percent of the interactions are mentioned in one source only. The distribution among the categories in the exactness of the name of the interacting drug (p=0.02), and applicability for health care personnel (p=0.0001) is not uniform for the three sources. The SPCs are less exact in mentioning the interacting drug and more often recommend actions to be taken to ameliorate drug interactions. DISCUSSION: The consistency among the sources is relatively low. The inconsistency may contribute to patients' exposure to potentially severe drug interactions, first and foremost because of the omission of potentially severe drug interactions in the sources. It may also contribute to confusion on the part of health care personnel and drug users, which once again may lead to inadequate drug utilisation. There is a need for information on drug interactions and a consensus nationally in Denmark and probably internationally as well.