Inappropriate Medication in Older Adults Undergoing Surgery
OBJECTIVES: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery.
DESIGN: Retrospective cohort study.
SETTING: Three hundred seventy-nine acute care hospitals participating in the nationally representative Perspective database (2006–2008).
PARTICIPANTS: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N=272,351).
MEASUREMENTS: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period.
RESULTS: One-quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)=0.98 per year of age, 95% confidence interval (CI)=0.97–0.98) and in men (AOR=0.83, 95% CI=0.81–0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR=1.22, 95% CI=1.08–1.40). Participants undergoing surgery in the West (AOR=1.79, 95% CI=1.02–3.16) and South (AOR=2.24, 95% CI=1.38–3.64) were more likely to receive a PIM than those in the Northeast.
CONCLUSION: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts.
As the population ages, an increasing number of older adults will be candidates for major surgery. Currently, more than 50% of orthopedic, urological, and general surgery procedures are performed in individuals aged 65 and older. Numerous studies have documented that morbidity and mortality after major surgery increase dramatically with age. For this reason, there is increasing interest in identifying potential processes of care that can improve surgical care in the growing population of older adults.
Although there is great enthusiasm for improving surgical care in older adults, there is little agreement about where to start. A recent review of potential quality indicators for older adults undergoing surgery identified more than 90 candidate measures. One potential quality indicator—the avoidance of high-risk medications—is easily measured and is an attractive target for quality improvement. Beers and colleagues initially proposed an explicit list of potentially inappropriate medications (PIMs) in older adults that Zhan and colleagues subsequently refined. Zhan criteria medications include 33 agents considered inappropriate for use in individuals aged 65 and older. PIM use has been associated with adverse drug reactions in older adults such as delirium, falls, and urinary retention. This list contains several types of medications—including sedatives and pain medications—that are commonly used in people undergoing surgery. Although PIM use has been studied in older adults hospitalized with medical diagnoses, it has not been studied in older adults undergoing surgery.
Currently, the prevalence and risk factors for perioperative PIM use in older adults undergoing surgery is unknown. For this reason, data from a nationally representative sample of U.S. hospitals (Perspective database) were used to study PIM use in individuals aged 65 and older undergoing major gastrointestinal, urological, gynecological, and orthopedic surgery. To better understand risk factors for receipt of a PIM in the perioperative period, participant and provider characteristics associated the PIM use were examined.
Abstract and Introduction
Abstract
OBJECTIVES: To determine the prevalence and factors associated with use of potentially inappropriate medications (PIMs) in older adults undergoing surgery.
DESIGN: Retrospective cohort study.
SETTING: Three hundred seventy-nine acute care hospitals participating in the nationally representative Perspective database (2006–2008).
PARTICIPANTS: Individuals aged 65 and older undergoing major inpatient gastrointestinal, gynecological, urological, and orthopedic surgery (N=272,351).
MEASUREMENTS: Medications were classified as PIMs using previously published criteria defining 33 medications deemed potentially inappropriate in people aged 65 and older. Information about participant and provider characteristics and administration of PIMs was obtained from hospital discharge file data. Logistic regression techniques were used to examine factors associated with use of PIMs in the perioperative period.
RESULTS: One-quarter of participants received at least one PIM during their surgical admission. Meperidine was the most frequently prescribed PIM (37,855, 14% of participants). In adjusted analysis, PIM use was less likely as age advanced (adjusted odds ratio (AOR)=0.98 per year of age, 95% confidence interval (CI)=0.97–0.98) and in men (AOR=0.83, 95% CI=0.81–0.85). PIMs were more likely to be prescribed to participants cared for by orthopedic surgeons than for those cared for by general surgeons (AOR=1.22, 95% CI=1.08–1.40). Participants undergoing surgery in the West (AOR=1.79, 95% CI=1.02–3.16) and South (AOR=2.24, 95% CI=1.38–3.64) were more likely to receive a PIM than those in the Northeast.
CONCLUSION: Receipt of PIMs in older adults undergoing surgery is common and varies widely between providers and geographic regions and according to participant characteristics. Interventions aimed at reducing the use of PIMs in the perioperative period should be considered in quality improvement efforts.
Introduction
As the population ages, an increasing number of older adults will be candidates for major surgery. Currently, more than 50% of orthopedic, urological, and general surgery procedures are performed in individuals aged 65 and older. Numerous studies have documented that morbidity and mortality after major surgery increase dramatically with age. For this reason, there is increasing interest in identifying potential processes of care that can improve surgical care in the growing population of older adults.
Although there is great enthusiasm for improving surgical care in older adults, there is little agreement about where to start. A recent review of potential quality indicators for older adults undergoing surgery identified more than 90 candidate measures. One potential quality indicator—the avoidance of high-risk medications—is easily measured and is an attractive target for quality improvement. Beers and colleagues initially proposed an explicit list of potentially inappropriate medications (PIMs) in older adults that Zhan and colleagues subsequently refined. Zhan criteria medications include 33 agents considered inappropriate for use in individuals aged 65 and older. PIM use has been associated with adverse drug reactions in older adults such as delirium, falls, and urinary retention. This list contains several types of medications—including sedatives and pain medications—that are commonly used in people undergoing surgery. Although PIM use has been studied in older adults hospitalized with medical diagnoses, it has not been studied in older adults undergoing surgery.
Currently, the prevalence and risk factors for perioperative PIM use in older adults undergoing surgery is unknown. For this reason, data from a nationally representative sample of U.S. hospitals (Perspective database) were used to study PIM use in individuals aged 65 and older undergoing major gastrointestinal, urological, gynecological, and orthopedic surgery. To better understand risk factors for receipt of a PIM in the perioperative period, participant and provider characteristics associated the PIM use were examined.