Regional Differences in Prescribing Quality Among Elder Veterans and the Impact of Rural Residence

Authors

  • Brian C. Lund PharmD,

    1.  Veterans Rural Health Resource Center-Central Region, VA Iowa City Health Care System, Iowa City, Iowa
    2.  Center for Comprehensive Access & Delivery Research and Evaluation, VA Iowa City Health Care System, Iowa City, Iowa
    3.  Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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  • Mary E. Charlton PhD,

    1.  Veterans Rural Health Resource Center-Central Region, VA Iowa City Health Care System, Iowa City, Iowa
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  • Michael A. Steinman MD,

    1.  Division of Geriatrics, San Francisco VA Medical Center and the University of California, San Francisco, California
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  • Peter J. Kaboli MD

    1.  Veterans Rural Health Resource Center-Central Region, VA Iowa City Health Care System, Iowa City, Iowa
    2.  Center for Comprehensive Access & Delivery Research and Evaluation, VA Iowa City Health Care System, Iowa City, Iowa
    3.  Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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  • Funding: This research was supported by the Veterans Rural Health Resource Center-Central Region (IMV 04-066-1) and the Center for Comprehensive Access & Delivery Research and Evaluation (REA 09-220). This study was also supported in part by an Agency for Healthcare Research and Quality Centers for Education and Research on Therapeutics cooperative agreement #5 U18 HSO16094. Dr. Lund was supported by a Career Development Award from the Health Services Research and Development Service, Department of Veterans Affairs (CDA 10-017). Dr. Steinman was supported by an award from the National Institute on Aging and the American Federation for Aging Research (K23-AG030999).

  • Disclosures: These findings were presented at the VA Health Services Research & Development 28th National Meeting in National Harbor, Maryland, February 16, 2011. None of the research sponsors had any role in the study design, methods, analyses, and interpretation, or in preparation of the manuscript and the decision to submit it for publication. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

  • For further information, contact: Brian C. Lund; PharmD, VA Iowa City Health Care System (Mailstop 152), 601 Hwy 6 West, Iowa City, IA 52246; e-mail: Brian.Lund@va.gov.

Abstract

Purpose: Medication safety is a critical concern for older adults. Regional variation in potentially inappropriate prescribing practices may reflect important differences in health care quality. Therefore, the objectives of this study were to characterize prescribing quality variation among older adults across geographic region, and to compare prescribing quality across rural versus urban residence.

Methods: Cross-sectional study of 1,549,824 older adult veterans with regular Veterans Affairs (VA) primary care and medication use during fiscal year 2007. Prescribing quality was measured by 4 indicators of potentially inappropriate prescribing: Zhan criteria drugs to avoid, Fick criteria drugs to avoid, therapeutic duplication, and drug-drug interactions. Frequency differences across region and rural-urban residence were compared using adjusted odds-ratios.

Findings: Significant regional variation was observed for all indicators. Zhan criteria frequencies ranged from 13.2% in the Northeast to 21.2% in the South. Nationally, rural veterans had a significantly increased risk for inappropriate prescribing according to all quality indicators. However, regional analyses revealed this effect was limited to the South and Northeast, whereas rural residence was neutral in the Midwest and protective in the West.

Conclusions: Significant regional variation in prescribing quality was observed among older adult veterans, mirroring recent findings among Medicare beneficiaries. The association between rurality and prescribing quality is heterogeneous, and relying solely on national estimates may yield misleading conclusions. Although we documented important variations in prescribing quality, the underlying factors driving these trends remain unknown, and they are a vital area for future research affecting older adults in both VA and non-VA health systems.

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