National clinical sentinel audit of evidence-based prescribing for older people.

OBJECTIVES: To audit the performance of hospitals in evidence-based prescribing. SETTING: All hospitals in England were invited to participate. The audit was completed in 62 hospitals. SUBJECTS: Prescribing and clinical data were collected on 100 consecutive medical inpatients aged >/= 65 years at each site, enabling evaluation of eight prescribing indicators before and after intervention. The data were collected using a specifically designed database. INTERVENTIONS: The results of the first audit were available immediately from the software and a national report with locally identifiable information was returned to hospitals. Hospitals were encouraged to design and deliver their own intervention strategy. A questionnaire was sent to all hospitals to document prioritization of indicators. RESULTS: Generic names were used for 36 061 (82.6%) in 1999 and 39 188 (86.4)% in 2000. In 1999, 50% (3074) of patients had documentation of allergy status. This increased to 60% (3684) in 2000. For 21.2% of patients prescribed paracetamol in 1999 and 18.1% in 2000, the prescription was written such that it was possible to exceed the maximum recommended dose of 4 g in 24 hours. Long-acting hypoglycaemic drugs were prescribed to 29 patients in 1999 and 20 patients in 2000. Anti-thrombotics were used appropriately for 54% (520/966) of patients in atrial fibrillation in the first audit and 57% (579/1019) in the second audit. The appropriate use of aspirin increased from 91% (595/651) to 94% (725/772) and the appropriate use of benzodiazepines dropped from 49% (537/1088) to 47% (460/966) between the audits. For three indicators, the allocating of a high priority translated into a bigger improvement between the audits. CONCLUSIONS: Local ownership of data and the quality improvement process, and provision of national benchmarking data did not result in a significant improvement in prescribing in the second audit.

Optimization of drug prescribing.

The hazards of prescribing many drugs, including side-effects, drug interactions, and difficulties of compliance, have long been recognized as particular problems when prescribing for elderly people. The need for appropriate and rational prescribing for elderly patients has been prioritized in the National Service Framework for Older People. This review addresses the research evidence on epidemiology of prescribing in elderly patients, methods of measuring the quality, and the role of the prescriber and the multidisciplinary team in the day-to-day optimization of drug therapy.

National sentinel clinical audit of evidence-based prescribing for older people: methodology and development.

RATIONALE, AIMS AND OBJECTIVES: This national clinical audit aimed to develop and implement a methodology to assess the appropriateness of prescribing for patients over the age of 65 in hospitals, general practice and nursing homes. METHODS: Organizations providing health care in the National Health Service in these three sectors were recruited into multi-disciplinary and inter-organizational local coalition teams. Prescription data and relevant clinical data were collected electronically on a customized database. The appropriateness of prescribing for specific conditions among the patients sampled was assessed by simple computerized algorithms, and users were provided with feedback to stimulate discussion and change. Use of the software tool was demonstrated to be feasible and its data reliable. Participants were re-audited, after a period of nationally guided and locally driven intervention, to evaluate levels of change. Local efforts to stimulate change and barriers to change were collected qualitatively. RESULTS AND CONCLUSIONS: The investigation revealed encouraging results and demonstrated the ability of audit to improve the quality of clinical services in given circumstances, although a multiplicity of questions relating to cost and methodology remain to be addressed.

Development of an indicator to identify inappropriate use of benzodiazepines in elderly medical in-patients.

Studies reporting the quantity of benzodiazepines used are purely descriptive and cannot comment on the quality or appropriateness of prescribing benzodiazepines. An indicator to assess the appropriateness of prescribing benzodiazepines was developed from published literature. The applicability of the indicator was discussed in a multidisciplinary forum. The indicator uses clinical data currently available to the prescriber. The indicator, in the form of an algorithm, was applied to assess the appropriateness of prescribing of benzodiazepines to medical in-patients aged < or =65 years at 17 hospitals in England and Wales. Prescribing data were collected on 1391 patients. Appropriateness of prescribing of 311 benzodiazepines were assessed. Benzodiazepines were prescribed appropriately for 110/311 (35%) prescriptions and inappropriately for 201/311 (65%) prescriptions. Initiation of benzodiazepine for no acceptable indication was the commonest reason for inappropriate prescribing. The instrument identifies the appropriateness of prescribing of benzodiazepines and can be utilised by non-physicians.

Development of prescribing indicators for elderly medical inpatients.

AIMS: To identify and improve suboptimal prescribing for elderly patients 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 unnecessary or potentially harmful prescribing, e.g. duplication; c) assessing the appropriateness of prescribing specific drugs or combinations e.g. digoxin and warfarin/aspirin in atrial fibrillation (AF). Appropriateness was defined on the basis of objective research findings and involved 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 England and Wales. A total of 1686 patients were included, median age 81 years, 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 required' medicines were more consistent, ranging from 76-94% and 52-81% respectively. Little duplication of therapy was seen. Benzodiazepines were prescribed for 22% patients, but were appropriate in only approximately one third of these. Of the 2% patients prescribed an angiotensin converting enzyme inhibitor with a potassium-sparing diuretic or potassium supplement, prescription of the combination was appropriate in 84%. Coprescription of steroids with beta 2-adrenoceptor agonists appeared excessive in 67% patients receiving a beta 2-adrenoceptor agonist, as only 51% had documented evidence of steroid responsiveness or another 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: These prescribing indicators are sensitive to inappropriate prescribing for elderly medical inpatients and cover a wide range of therapeutic areas. They should enable changes in prescribing quality to be measured objectively. Interhospital variation in casemix resulted in substantial differences in the proportion of patients in whom it would have been appropriate to prescribe specific drugs or combinations and prevented derivation of reference ranges of optimal prescribing for four indicators.

The use of over-the-counter medication by elderly medical in-patients.

Use of over-the-counter (OTC) medications by elderly patients is often not identified. This survey was performed to study the use of OTCs by medical in-patients aged 65 and over. Data on the use of OTC medications before and during hospital admission were collected by questioning patients and case notes were examined for documentation of their use of OTC medications. OTC medications were used by 44 of 138 (32%) patients interviewed. Patients used a total of 70 OTC medications before admission and six OTC medications were being used during hospital admission. There was no documentation of pre-admission and in-hospital OTC medicine use in the clinical notes and patients had little knowledge of the potential harm some products can cause. As more products become available over the counter, doctors should record their use in patients' notes and patients should be encouraged to seek professional advice before purchasing OTC medicines and to read the product information leaflets.

Thrombolysis for elderly patients with myocardial infarction: experience in an integrated unit.

The Departments of Medicine and Geriatrics were integrated in the Ogwr Health Unit in 1984. Since then there has been a non-age-related acute admissions policy which has led to early, intensive investigations and appropriate treatment of all patients according to need rather than age. A retrospective analysis of the use of thrombolytic agents over a 12-month period in patients aged 65 or over was undertaken to assess whether our principles extended to care of elderly patients admitted with acute myocardial infarction. High rates of prescription of thrombolytic agents in the elderly were achieved by endorsing the philosophy that age contributes little to the prediction of patient outcome and should not be considered in patient management.

Ulcerative colitis in a husband and wife.

The case histories of a husband and wife who developed ulcerative colitis after 28 years of marriage are described. It is hoped this report will stimulate the systematic study of inflammatory bowel disease occurring in both partners of a marriage and clarify the comparative importance of constitutional and environmental factors in its pathogenesis.

Prolonged pharyngeal impaction of dentures following stroke.

Dysphagia is a well-recognized complication of stroke. We report two cases of dysphagia in stroke patients caused by the pharyngeal impaction of dental prostheses. Radiologic identification of such impaction is unreliable due to the increasing use of radiolucent material in dental prostheses. We recommend direct or indirect laryngoscopy to exclude foreign body impaction in all patients complaining of dysphagia.