Trends in Use of High-Risk Medications for Older Veterans: 2004 to 2006

Authors

  • Mary Jo V. Pugh PhD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • ab Joseph T. Hanlon PharmD, MS,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • cd Chen-Pin Wang PhD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • ab Todd Semla PharmD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • efg Muriel Burk PharmD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • efg Megan E. Amuan MPH,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • h Ashlei Lowery MD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • i Chester B. Good MD,

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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  • and dj Dan R. Berlowitz MD, MPH gk

    1. From the aSouth Texas Veterans Health Care System, Veterans Evidence-based Research and Implementation Center, San Antonio, Texas; bDepartment of Epidemiology and Biostatistics and iDivision of Geriatrics, Gerontology and Palliative Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas; cDivision of Geriatric Medicine, Departments of Pharmacy and Therapeutics and Epidemiology and jDivision of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; dGeriatric Research Education and Clinical Center and Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; ePharmacy Benefits Management Services, Department of Veterans Affairs, Hines, Illinois; Departments offMedicine and gPsychiatry and Behavioral Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; hCenter for Health Quality, Outcomes, and Economic Research, Department of Veterans Affairs, Bedford, Massachusetts; and kSchool of Public Health, Boston University, Boston, Massachusetts.
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Address correspondence to Mary Jo Pugh, VERDICT REAP, South Texas Veterans Health Care System (11C6), 7400 Merton Minter, San Antonio, TX 78023. E-mail: maryjo.pugh2@va.gov or pughm@uthscsa.edu

Abstract

OBJECTIVES: To examine the change in use of high-risk medications for the elderly (HRME), as defined by the National Committee on Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) quality measure (HEDIS HRME), by older outpatient veterans over a 3-year period and to identify risk factors for HEDIS HRME exposure overall and for the most commonly used drug classes.

DESIGN: Longitudinal retrospective database analysis.

SETTING: Outpatient clinics within the Department of Veterans Affairs (VA).

PARTICIPANTS: Veterans aged 65 by October 1, 2003, and who received VA care at least once each year until September 30, 2006.

MEASUREMENTS: Rates of use of HEDIS HRME overall and according to specific drug classes each year from fiscal year 2004 (FY04) to FY06.

RESULTS: In a cohort of 1,567,467, high-risk medication exposure fell from 13.1% to 12.3% between FY04 and FY06 (P<.001). High-risk antihistamines (e.g., diphenhydramine), opioid analgesics (e.g., propoxyphene), skeletal muscle relaxants (e.g., cyclobenzaprine), psychotropics (e.g., long half-life benzodiazepines), endocrine (e.g., estrogen), and cardiac medications (e.g., short-acting nifedipine) had modest but statistically significant (P<.001) reductions (range −3.8% to −16.0%); nitrofurantoin demonstrated a statistically significant increase (+36.5%; P<.001). Overall HEDIS HRME exposure was more likely for men, Hispanics, those receiving more medications, those with psychiatric comorbidity, and those without prior geriatric care. Exposure was lower for individuals exempt from copayment. Similar associations were seen between ethnicity, polypharmacy, psychiatric comorbidity, access-to-care factors, and use of individual HEDIS HRME classes.

CONCLUSION: HEDIS HRME drug exposure decreased slightly in an integrated healthcare system. Risk factors for exposure were not consistent across drug groups. Future studies should examine whether interventions to further reduce HEDIS HRME use improve health outcomes.

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