Facility-level Variation in Potentially Inappropriate Prescribing for Older Veterans

OBJECTIVES: To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs (VA) facilities—exposure to high-risk medications in elderly adults (HRME) and drug–disease interactions (Rx-DIS)—and to identify facility characteristics associated with high-quality prescribing. DESIGN: Cross-sectional. SETTING: VA Healthcare System. PARTICIPANTS: Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005–2006 (N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx-DIS exposure). MEASUREMENTS: Incident use of any HRME (iHRME) and incident Rx-DIS (iRx-DIS) and facility-level rates and facility-level predictors of iHRME and iRx-DIS exposure, adjusting for differences in patient characteristics. RESULTS: Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio (OR) = 0.86, 95% confidence interval (CI) = 0.77–0.96) and iRx-DIS (OR = 0.95, 95% CI = 0.88–1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME (OR = 1.54, 95% CI = 1.35–1.75) and iRx-DIS exposure (OR = 1.22, 95% CI = 1.11–1.33). CONCLUSION: Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education.