One in 12 older people are prescribed the wrong drug
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《英国医生杂志》
Americans aged over 65 stand an 8% chance of being prescribed inappropriate drugs when they visit their doctor抯 surgery or a hospital outpatient department, a similar rate to that in 1995, a new study has found.
The risk is twice as high for women and may be worse among patients in nursing homes, and the finding probably underestimates the problem, the study抯 author, Dr Margie Rauch Goulding, a health statistician at the National Center for Health Statistics, told the BMJ.
The study, published in the Archives of Internal Medicine (2004;164:305-12), showed that inappropriate prescribing occurred in 16.7 million doctor visits in 2000, with patients getting at least one inappropriate drug.
Dr Goulding抯 study compared trends in inappropriate prescribing in 1995 and 2000. It was based on data from the national ambulatory care medical care survey (which compiles information from patients?visits to doctors?surgeries) and the national hospital ambulatory care survey (which compiles information from patients?visits to hospital outpatient clinics).
Inappropriate drugs were based on two lists. One, developed by an expert panel in 1997, listed 38 drugs or drug groups that should usually be avoided in patients over 65. The second list, developed by another expert panel in 2000, categorised 19 drugs or drug groups from the first list as "always avoid" or "rarely appropriate" in elderly people.
The rate of inappropriate prescribing did not improve. It was 7.8% in both 1995 and 2000, she said. The three drugs that are a "large and persistent part of the problem" are the pain reliever propoxyphene, the antidepressant amitriptyline, and the antianxiety agent diazepam.
Women were almost twice as likely to receive inappropriate drugs. Dr Goulding said that women were more likely to be prescribed drugs than men and more likely to be prescribed drugs affecting the central nervous system (antidepressants, antianxiety agents, and sedative-hypnotic drugs) and painkillers.
Doctors who prescribed inappropriately were more likely to be general and family practitioners than internal medicine specialists or other experts.
Painkillers and drugs affecting the central nervous system were the main problem, Dr Goulding said. She claimed that the risk of patients being given inappropriate drugs could be higher than appeared in the results because the study did not look at dosages that were too high, patients whose medical conditions contraindicated the drug, or interactions between drugs. Because patients in nursing homes are more frail than people in the community, they are at greater risk from inappropriate drugs.
Although inappropriate prescribing for elderly people living in the community has not been linked to increased deaths, prescribing the wrong drug may lead to worsening of symptoms, more pain, a decline in daily functioning, repeat visits to doctors or emergency rooms, and increased health costs.
Dr Goulding said her study looked at the prevalence, not outcomes, of inappropriate prescribing, but she told the BMJ that other studies have shown that inappropriate prescribing leads to oversedation, impaired cognition, confusion, vertigo, and blurred vision, and thus to falls and fractures. It may also lead to constipation, hypoglycaemia, and orthostatic hypotension.
Dr Goulding called for information interventions targeted at both prescribers of inappropriate drugs and those most likely to receive them—women, patients taking several drugs, and patients receiving painkillers or drugs affecting the central nervous system.
The risk is twice as high for women and may be worse among patients in nursing homes, and the finding probably underestimates the problem, the study抯 author, Dr Margie Rauch Goulding, a health statistician at the National Center for Health Statistics, told the BMJ.
The study, published in the Archives of Internal Medicine (2004;164:305-12), showed that inappropriate prescribing occurred in 16.7 million doctor visits in 2000, with patients getting at least one inappropriate drug.
Dr Goulding抯 study compared trends in inappropriate prescribing in 1995 and 2000. It was based on data from the national ambulatory care medical care survey (which compiles information from patients?visits to doctors?surgeries) and the national hospital ambulatory care survey (which compiles information from patients?visits to hospital outpatient clinics).
Inappropriate drugs were based on two lists. One, developed by an expert panel in 1997, listed 38 drugs or drug groups that should usually be avoided in patients over 65. The second list, developed by another expert panel in 2000, categorised 19 drugs or drug groups from the first list as "always avoid" or "rarely appropriate" in elderly people.
The rate of inappropriate prescribing did not improve. It was 7.8% in both 1995 and 2000, she said. The three drugs that are a "large and persistent part of the problem" are the pain reliever propoxyphene, the antidepressant amitriptyline, and the antianxiety agent diazepam.
Women were almost twice as likely to receive inappropriate drugs. Dr Goulding said that women were more likely to be prescribed drugs than men and more likely to be prescribed drugs affecting the central nervous system (antidepressants, antianxiety agents, and sedative-hypnotic drugs) and painkillers.
Doctors who prescribed inappropriately were more likely to be general and family practitioners than internal medicine specialists or other experts.
Painkillers and drugs affecting the central nervous system were the main problem, Dr Goulding said. She claimed that the risk of patients being given inappropriate drugs could be higher than appeared in the results because the study did not look at dosages that were too high, patients whose medical conditions contraindicated the drug, or interactions between drugs. Because patients in nursing homes are more frail than people in the community, they are at greater risk from inappropriate drugs.
Although inappropriate prescribing for elderly people living in the community has not been linked to increased deaths, prescribing the wrong drug may lead to worsening of symptoms, more pain, a decline in daily functioning, repeat visits to doctors or emergency rooms, and increased health costs.
Dr Goulding said her study looked at the prevalence, not outcomes, of inappropriate prescribing, but she told the BMJ that other studies have shown that inappropriate prescribing leads to oversedation, impaired cognition, confusion, vertigo, and blurred vision, and thus to falls and fractures. It may also lead to constipation, hypoglycaemia, and orthostatic hypotension.
Dr Goulding called for information interventions targeted at both prescribers of inappropriate drugs and those most likely to receive them—women, patients taking several drugs, and patients receiving painkillers or drugs affecting the central nervous system.