Quality Indicators for Medication Use in Vulnerable Elders

Medications play a critical role in maintaining the health of vulnerable elders (VEs), who often contend with a great burden of acute and chronic illness. Older patients disproportionately use prescription drugs, with seniors filling an average of 20 prescriptions annually, and aging can be associated with decreased metabolism and excretion of prescription drugs and their metabolites, placing elderly patients at greater risk of side effects and complicating appropriate dosing. Additionally, patients, caregivers, and even physicians often mistake medication side effects for the onset of new illnesses or aging itself. The underrepresentation of elderly patients in clinical trials and the resulting deficiencies of useful data to guide practice create additional challenges for prescribers. A careful review of existing evidence can inform clinical practice and can be used to create quality indicators (QIs), with a goal of benchmarking the quality of care provided. In the first iteration of Assessing Care of Vulnerable Elders (ACOVE), indicators were created to measure the quality of care across multiple domains to represent the full continuum of pharmacological care. The attention given to the full continuum of care differentiates ACOVE indicators from other lists that focus on identification of medications that should be avoided in elderly people. A chart-based review of pharmacological care of community-dwelling elderly people in a managed care setting applying indicators from the first ACOVE process found substantial underuse of appropriate medications (50% indicator pass rate). In addition, shortfalls were seen in medication monitoring (64% pass rate) and education (81% pass rate). Overuse of inappropriate medications occurred infrequently (97% pass rate), although the measurement set had limited ability to identify deficits in this area. This updated set of QIs reevaluates QIs to assess pharmacological care provided to community-dwelling VEs. The indicators have been updated to reflect recent literature, and new indicators were added in accordance with evidence-based standards. METHODS: A total of 153 articles and guidelines were considered in this review. These articles were selected from Medline searches identifying 8,125 titles or abstracts. RESULTS: Of the 22 potential QIs, the expert panel process judged 19 to be valid; three indicators were rejected. The literature summaries that support each of the indicators judged to be valid in the expert panel process are described. Additionally, five indicators related to prescribing of nonsteroidal antiinflammatory drugs (NSAIDs), aspirin, and acetaminophen are listed here for indexing purposes, and the justification is provided in the Osteoarthritis section.