The American Geriatrics Society (AGS) has convened an expert panel, with representatives from the fields of medicine, nursing and pharmacy to update the Beers’ Criteria for Potentially Inappropriate Medication (PIM’s) Use in Older Adults. A preliminary draft document with the update was recently released for public comment. The comment period ended November 28, 2011 so we can expect release of the updated Beers’ List soon.
We’ve done many prior columns on Beers’ List. Most recently, in our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?”, we again noted that the original Beers’ List and subsequent updates were primarily consensus-based rather than truly evidence-based. The new updated version will be much improved in that regard since there has been an extensive review of the evidence in the new work effort.
In our June 21, 2011 Patient Safety Tip of the Week “STOPP Using Beers’ List?” we also noted that the literature has been mixed on the ability of Beers’ List to predict adverse drug events (ADE’s). The STOPP criteria, on the other hand, identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and such ADE’s are extremely common (Hamilton 2011).
In addition to the study demonstrating that the STOPP list is better than Beers’ list at predicting ADE’s related to hospitalization, a study just published (Budnitz 2011) on emergency hospitalizations related to ADE’s concluded that drugs on Beers’ list account for only a small percentage of hospitalizations. In that study, 6.6% of the ADE-related hospitalizations were related to potentially inappropriate medications on Beers’ list and if digoxin is excluded this is reduced to only 3.17%. On the other hand, two thirds of the hospitalizations were related to only four medications or medication categories: warfarin/anticoagulants, antiplatelet agents, insulins, and oral hypoglycemia agents.
While we still feel that Beers’ list is useful, one of the biggest barriers to getting physicians to avoid PIM’s in the elderly is not knowing what alternatives are available. A recent study looking at decision support for CPOE (Hume 2011) found 2 key things that clinicians wanted when viewing alerts: (1) the alerts needed to be “short and sweet” and (2) rather than just telling them they were attempting to prescribe a PIM they wanted alternative choices. So the group developed 15 evidence-based treatment algorithms suggesting alternative therapies. These are actually quite useful. The article also provides valuable insight into how clinicians interact with alerts during CPOE. The editorial accompanying the Hamilton paper (Schnipper 2011) also talks about using tools like STOPP to improve design and implementation of clinical decision support tools to minimize “alert fatigue” that we see so commonly with CPOE systems. And our What’s New in the Patient Safety World column for September 2010 “Beers List and CPOE” noted a study (Mattison 2010) in which researchers were able to demonstrate approximately a 20% reduction in prescribing of flagged drugs by using a carefully chosen subset of potentially inappropriate drug (PIM’s) from Beers’ list drugs to which to attach computerized warnings.
We’ll do a full review of the updated Beers’ List after its official publication.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
· January 15, 2008 “
· October 19, 2010 “ ”
· September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
· June 21, 2011 “STOPP Using Beers’ List?”
What’s New in the Patient Safety World columns:
· September 2010 “Beers List and CPOE”
The American Geriatrics Society (AGS). Public Comment Period for AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults.
Hamilton H, Gallagher P, Ryan C, et al. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med 2011; 171(11): 1013-1019
Budnitz DS, Lovegrove MC, Shehab N, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. NEJM 2011; 365: 2002-2012
Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. BMJ Qual Saf 2011; 20: 875-884 Published Online First: 30 June 2011
Schnipper JL. Medication Safety: Are We There Yet?: Comment
on "Potentially Inappropriate Medications...
Arch Intern Med 2011; 171(11): 1019-1020
Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Preventing Potentially Inappropriate Medication Use in Hospitalized Older Patients With a Computerized Provider Order Entry Warning System. Arch Intern Med. 2010; 170(15): 1331-1336