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Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use
Research in Social and Administrative Pharmacy xxx (2017) 1e8
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Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use Vanida Prasert a, *, Manabu Akazawa b, Aiko Shono b, Farsai Chanjaruporn c, Chanuttha Ploylearmsang d, Kamolnut Muangyim a, Thanased Wattanapongsatit e, Uthen Sutin f a
Department of Pharmacy, Sirindhorn College of Public Health, 20000, Thailand Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 204-8588, Japan c Social and Administrative Pharmacy Excellence Research Unit, Faculty of Pharmacy, Mahidol University, 10400, Thailand d Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, 44150, Thailand e Health Strategy Development, Public Health Office, 20000, Thailand f Community and Family Medicine Unit, Bothong Hospital, 20270, Thailand b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 May 2017 Accepted 22 May 2017
Background: Potential inappropriate medication (PIM) prescribing is a medication that puts patients at risk rather than having benefits. PIM use has been associated with hospitalization, morbidity, and mortality resulting from ADRs in elderly patients. The Lists of Risk Drugs for Thai Elderly (LRDTE) was developed as the new screening tool to identify PIMs use. The prevalence of PIM use using the LRDTE has not been determined in Thailand. Purpose: The main purpose of this study was to examine the prevalence of PIM use based on the LRDTE. In addition, this aimed to address the PIM problem by identifying factors that influenced PIM use among elderly patients in Thailand. Methods: A retrospective cross-sectional descriptive study was conducted using the computerized database at four community hospitals in Thailand during fiscal year 2014. The LRDTE criteria were used as a screening tool for identifying the medicine items of PIM use. Descriptive statistics and multivariate logistic regression were used to identify common and Thai region-specific predictors of PIM use. Results: Of a total of 13274 elderly patients, 79% were prescribed at least one PIM, as indicated by the LRDTE criteria. Amlodipine (32%), omeprazole (30%), and tramadol (18%) were the most commonly prescribed PIMs in elderly patients aged 60 years and older. Hospital and physician characteristics were identified as independent predictors after adjustment for patient and utilization factors. Conclusion: PIM use in Thai elderly patients was highly prevalent in community hospitals because the LRDTE criteria reflected clinical practice in Thailand. Hospital and physician factors were identified as region-specific factors that were highly associated with PIM use. Revision of hospital formularies and educational programs for physicians are needed to improve prescribing and avoid PIM use. © 2017 Elsevier Inc. All rights reserved.
Keywords: Potentially inappropriate medication Lists of Risk Drugs for Thai Elderly Elderly patients
1. Introduction Thailand is an upper-middle income country in South East Asia, whose population is quickly aging.1 In 2016, approximately 10
* Corresponding author. Department of Pharmacy, Sirindhorn College of Public Health, 29 M 4, Chonburi Province, Thailand. E-mail address: [email protected] (V. Prasert).
million people were aged over 60 years and this number is expected to double within the next three decades.2 In addition, the burden of disease in elderly people increasingly shifts to noncommunicable diseases.3 Four out of five older Thai citizens have at least one chronic disease and have been continuously prescribed multiple medicines. Polypharmacy increases the risk of adverse drug reaction (ADRs). These problems are related to potentially inappropriate medication (PIM) use in the elderly.4
http://dx.doi.org/10.1016/j.sapharm.2017.05.012 1551-7411/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
PIM has been defined as a medication that puts patients at risk rather than having benefits and includes prescription medications with drugedrug and drugedisease interactions.5 PIM use has been associated with hospitalization, morbidity, and mortality resulting from ADRs in elderly patients6,7 and is a problem in high income countries,8,9 including those in Asia. Presently, several screening tools can be used to identify PIMs in older adults. The original tool was the Beers Criteria, which was published in 1991 in the United States. An expert panel identified medicines that should be avoided in the elderly owing to drug-disease interactions, drug-drug interactions, the need for caution in this population, and effects on kidney function.10 The screening tool of older people's prescriptions (STOPP) was explicit criteria published in Europe in which the medication lists were organized by physiological organ systems.11 In Thailand, the Winit-Watjana criteria were developed in 2009 and included the use of high-risk medications with potential ADRs, drug-disease interactions, and drug-drug interactions.12 As for PIM studies in Asian countries, the prevalence of PIM use determined from the Beers Criteria in Indonesia was 87% in geriatric patients,13 whereas, in Malaysia, the reported prevalence of PIM use determined using the STOPP was 33%.14 For Thailand, PIM use was identified using the Winit-Watjana criteria and the prevalence was 58% in elderly patients.15 In addition, a 32% and 28% prevalence was determined using the STOPP and Beers Criteria, respectively.16 Irrational prescribing is a problem in the Thai health care system, especially PIM prescribing to elderly patients.17,18 These patients frequently receive medicines without knowing the indication and follow a polypharmacy pattern of use. In 2011, the Ministry of Public Health launched the rational drug use (RDU) policy to enhance the quality of health services for all people.19 Reducing PIM use is the one of the missions of the RDU policy aimed at improving drug safety in the elderly.17,18 For this purpose, in 2012, the Lists of Risk Drugs for Thai Elderly (LRDTE) were developed from the 2012 Beers Criteria and 2008 STOPP. The advantage of the LRDTE was that the medication lists considered the age group in elderly aged over 60 years and the severity of medication risk. Furthermore, this is the currently covered standard treatment guideline and hospital formulary for Thai elderly.19 The prevalence of PIM use using the LRDTE has not been determined in Thailand. Therefore, the main purpose of this study was to examine the prevalence of PIM use based on the LRDTE. In addition, this aimed to address the PIM problem by identifying factors that influenced PIM use among elderly patients in Thailand.
2. Methods 2.1. Study design and population This was a retrospective, cross-sectional descriptive study of PIM use among elderly patients in community hospitals in Chonburi Province, Thailand. Chonburi Province is located in Eastern Thailand and has the highest population density.20 Four of nine hospitals in the province participated in the study after they agreed to provide the required information. Three hospitals were small hospitals in rural areas and the other was a medium hospital in an urban area. Each had a different number of beds, number of medicines, medicine list, and types of specializations (Appendix 1).21 The population studied included elderly patients aged 60 years and older who had at least 2 pharmacy claims and visited as an outpatient over a 1-year period during fiscal year 2014 (FY 2014). Missing or irretrievable medication data were excluded.
2.2. Data source and variables The secondary data were collected from four hospitals using medical and pharmacy claims from the Health Data Center (HDC) database between April 1, 2014 and March 31, 2015 (FY 2014). The HDC database included all claims data of patient characteristics, health service utilization, and Thai region-specific characteristics. According to a literature review, patient characteristics, age category (60e74 or 75 years) based on the LRDTE criteria,19 gender (male or female), and comorbidities were identified from International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD-10) code22 and the Elixhauser classification system.23 For health service utilization characteristics, the number of outpatient visits was classified as 1e3 or 4 visits; the number of hospitalizations was categorized 0 or 1; and the number of diagnoses was utilized as a categorical variable (1e2, 3e4, or 5), as described in a previous Thai study.16 Medication dispensed, including generic or brand name, strength, form, number of medicines, and dispensing date, was determined. Prescription and nonprescription medications were coded according to the Anatomical Therapeutic Chemical (ATC) classification system recommended by the World Health Organization.24 Each patient's total number of medications was categorized as < 5 or 5, based on prior studies.25 As for the Thai region-specific characteristics, the study considered health insurance schemes, hospital characteristics, and prescribers. Health insurance schemes consisted of the civil servants medical benefit scheme (CSMBS) for government employees, the universal coverage scheme (UCS) for the remaining population, the social security scheme (SSS) for private employees, and out-ofpocket. The beneficiaries for each health insurance were different. CSMBS and out-of-pocket allowed the use of both essential and non-essential medicines, whereas SSS and UCS allowed the use of only essential medicine.26 Hospital characteristics were classified by community hospital levels. The hospital formulary in each hospital was different based on the hospital level. In addition, the hospitals were described by the number of beds and doctors (F1: medium level hospital having 60 beds or more and specialists or F2: small level hospital having 30 beds or more and no specialists) using the geographic information system in Thailand.21 Prescribers were general practitioners, specialists, or other health personnel (including dentists and nurses). Each prescriber has a different role in prescribing: specialists have more authority than other prescribers in that they can prescribe specialized medicines, general practitioners can prescribe common medicines, and other health personnel can prescribe only limited medicines.27 The study was approved by the Research Ethic Committee of Sirindhorn College of Public Health, Chonburi Province, Thailand on July 21, 2016. In addition, the data use was officially approved by each hospital.
2.3. Measurement of potentially inappropriate medicines PIMs were defined using the LRDTE; the new explicit criteria consisted of 76 medications or 8 medication classes that should generally be avoided in all elderly patients. The LRDTE is categorized by age and severity of medicine. Age was separated into two categories: 60e74 years and 75 years and over. Medicine was categorized into 3 severity levels: level 1 (mild) is used within condition or over the short term or with intensive monitoring, level 2 (moderate) is avoid by using alternative choices, and level 3 (severe) is not recommended and no benefit,19 as indicated in Appendix 2.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
2.4. Data analysis The main objective of this study was to examine the prevalence of PIM use among elderly patients based on the LRDTE. The prevalence of PIM use was calculated as the number of elderly patients who used at least one PIM during FY 2014 divided by the number of elderly patients who received any service at the four hospitals during FY 2014. Risk factors predicting PIM use were identified using multivariate logistic regression models. In model 1, common risk factors were patient and health service utilization factors. In model 2, Thai region-specific factors, including health insurance schemes, hospitals, and physicians, were added. Each health insurance scheme was different for its beneficiaries; therefore, the PIM prescribing rate was compared between the different health insurance schemes. For hospitals were reported the results for each hospital individually to account for potential biases from differences in the proportions of older adults. A physician factor was included if a general practitioner or others prescribed PIM to patients at least one time during the one year period.
3
The results from the two models were compared to determine whether the Thai region-specific characteristics were independent risk factors after adjustment for the common factors and described as unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). A p-value < 0.05 was considered statistically significant. All analyses were carried out using STATA software version 13 (Stata, College Station, TX, USA). 3. Results 3.1. Basic characteristics A total of 13274 elderly patients aged 60 years were included during FY 2014. The basic characteristics of these patients are presented in Table 1. The top five comorbidities were hypertension, diabetes mellitus, musculoskeletal conditions, dyslipidemia, and gastrointestinal disease. For health service utilization, the average number of outpatient visits was 4.9 ± 4.5 (range 1e88), whereas the average number of hospitalizations was 0.2 ± 0.7 (range 0e11). In addition, the average
Table 1 Basic characteristics among elderly patients and PIM prevalence. Characteristic Patient characteristics Age, Mean ± SD (Range) 60e74 years 75 years Gender Female Male x Comorbidities Hypertension Diabetic Mellitus Musculoskeletal conditions Dyslipidemia Gastrointestinal disease Acute respiratory disease COPD/Asthma Cardiovascular disease Health service utilization characteristics (Per year) Number of outpatient visits, Mean ± SD (Range) 1e3 4 Number of hospitalizations Mean ± SD (Range) 0 1 Number of diagnoses, Mean ± SD (Range) 1e2 3e4 5 Characteristic Number of medications, Mean ± SD (Range) 1e5 >5 Health insurance scheme Civil Servants Medical Benefit Scheme Universal Coverage Scheme Social Security Scheme Out-of-Pocket Hospital characteristics Hospital A Hospital B Hospital C Hospital D *Prescriber characteristics General practitioner Specialist Other health personnel (Dentist, Nurse) * x
Total n ¼ 13,274
(%)
PIM prevalence (%) 10,536 (79.3)
9599 3675
(72.3) (27.7)
69.80 ± 8.07 (60e114) 78.4 81.9
7881 5393
(59.4) (40.6)
81.6 76.1
2705 2561 2063 1904 1825 1807 478 343
(20.4) (19.3) (15.5) (14.3) (13.8) (13.6) (3.6) (2.6)
94.7 90.8 96.4 90.4 96.6 86.1 71.3 87.8
6157 7117
(38.3) (61.7)
11,602 1672
(86.4) (13.6)
7685 2701 2888
(57.9) (20.4) (21.8)
4.86 ± 4.52 (1e88) 65.5 87.6 0.20 ± 0.68 (0e11) 78.4 85.9 3.49 ± 4.00 (1e43) 72.8 83. 8 92.7
Total n ¼ 13,274
(%)
PIM prevalence (%) 10,536 (79.37)
6710 6564
(50.5) (49.5)
7.17 ± 5.89 (1e43) 64.2 94.9
1863 10,275 280 856
(14.0) (77.4) (2.1) (6.5)
80.6 80.3 77.9 65.9
6480 2733 1339 2722
(48.8) (20.6) (10.1) (20.5)
80.5 76.3 77.6 81.0
11,542 822 6025
(86.9) (6.2) (45.4)
84.91 87.10 74.84
Elderly patients visited the physician more than once, total was more than 100%. Elderly patients had more than one comorbidity, total was more than 100%.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
number of diagnoses and medications used was 3.5 ± 4.0 (range 1e43) and 7.2 ± 5.9 (range 1e43), respectively. As for Thai regional factors, most patients were covered under the UCS (77.4%), visited hospital A (48.8%), and were prescribed medicines by general practitioners (86.9%). 3.2. Prevalence of PIM use identified using the LRDTE The prevalence of PIM use was 79.3% (10536/13274) in elderly patients during FY 2014 (Table 1). More elderly patients aged 75 years and older were prescribed PIMs than those aged 60e74 years. Female patients received more PIMs than male patients. Moreover, the highest prevalence of PIM use was in relation to gastrointestinal disease and musculoskeletal conditions. PIM was frequently prescribed for those with multiple outpatient visits (4 visits), at least one hospitalization, multiple comorbidities (5 diagnoses), and polypharmacy (5 medicines). The majority of PIM users received CSMBS and UCS. PIM was prescribed most often in hospital D. Additionally, PIMs were commonly prescribed by general practitioners and specialists. Fig. 1 presents the prevalence of the 10 most frequently prescribed PIMs for those aged 60e74 years and 75 years. The results indicated that elderly patients aged 75 years received more PIMs than those aged 60e74 years. The most common PIMs identified by LRDTE criteria were amlodipine (60e74 years: 31% vs 75 years: 35%), omeprazole (27% vs 36%), tramadol (17% vs 22%), lorazepam (11% vs 15%), hyoscine (10% vs 12%), amitriptyline (9% vs 11%), and hydroxyzine (6% vs 8%). 3.3. Factors influencing PIM use in elderly patients for drug policy perspective After adjustment for patient and utilization factors (model 1), positive associations were identified between female gender, all comorbidities except COPD/asthma, 4 or more outpatient visits, 5
or more diagnoses, and 5 or more medications (Table 2). By adding Thai region-specific factors (model 2), most factors remained statistically significant predictors (excluding female and outpatient visits). Moreover, Hospital D [OR 1.24; 95% CI 1.07e1.43] and general practitioner prescribers [OR 2.80; 95%CI 2.44e3.21] were independent predictors for PIM use as Thai region-specific factors. Health insurance schemes were not independent predictors after adjustment for common factors.
4. Discussion This was the first study evaluating PIM use using the LRDTE criteria in Thailand. The result found that 79% of elderly Thai patients were at risk of PIM use. The prevalence of PIM use was higher than that found in previous Thai PIM use studies: 32% using STOPP,28 28% using 2012 Beers Criteria,16 and 58% using WinitWatjana criteria.15 The prevalence of PIM may not be directly comparable to other studies because of health setting and methodological differences. The medicine lists in the LRDTE criteria covered current standard treatment guidelines and hospital formularies.19 Therefore, the high PIM prevalence in this study suggested the importance of using the new LRDTE criteria to fulfill the RDU policy to reduce irrational drug use for Thai elderly.17 The top three most common PIMs prescribed to elderly patients aged 60 years were amlodipine (32%), omeprazole (30%), and tramadol (18%). Amlodipine has been commonly prescribed for hypertension in Thai elderly patients aged 75 years.29 The previous Thai PIM study that used the Beers Criteria did not report the prevalence of amlodipine use because this medicine was not listed in the criteria.30 Amlodipine was added to the LRDTE criteria to avoid ADRs, including an increased risk of edema, falls, and fractures.31 In addition, constipation was a common ADR in elderly patients.32 Meanwhile, a PIM use study in the Netherlands revealed a lower prevalence of amlodipine use from the use of STOPP because this medicine was not widely prescribed among elderly
Fig. 1. Prevalence of the most frequently used potentially inappropriate medications in the elderly (60e74 years old and 75 years old). *1 ¼ mild, 2 ¼ moderate, 3 ¼ severe. (2,2) ¼ (first digit ¼ PIM level for those aged 60e75 years, second digit ¼ PIM level for those aged 75 years).
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
5
Table 2 Factors that influenced potentially inappropriate medication use in Thai elderly. Variable
Unadjusted OR (95%CI)
Adjusted OR (95%CI) Model 1
Patient factors Age 60e74 years 75 years Gender Female Comorbidities Gastrointestinal disease Musculoskeletal conditions Hypertension Dyslipidemia Diabetic Mellitus Acute respiratory disease COPD/Asthma Cardiovascular disease Health service utilization factors Number of outpatient visits 1-3 4 Number of hospitalizations 0 1 Number of diagnoses 1e2 3e4 5 Health service utilization factors Number of medications 1e5 >5 Region-specific factors Health insurance scheme CSMBS UCS SSS Out-of-pocket Hospitals Hospital A Hospital B Hospital C Hospital D Prescriber General practitioner
Model 2
1.00 1.25
(1.13e1.37)
1.00 1.02
(0.92e1.17)
1.00 1.01
(0.89e1.14)
1.39
(1.28e1.52)
1.13
(1.02e1.26)
1.10
(0.99e1.22)
8.53 8.38 5.78 2.72 3.02 1.72 0.64 1.89
(6.61e11.00) (6.62e10.61) (4.86e6.88) (2.32e3.19) (2.62e3.48) (1.49e1.98) (0.52e0.78) (1.36e2.61)
9.80 9.91 6.01 2.37 1.94 1.39 0.34 1.64
(7.43e12.73) (7.72e12.72) (4.96e7.29) (1.96e2.86) (1.62e2.32) (1.16e1.65) (0.26e0.44) (1.12e2.41)
9.79 8.56 4.99 1.87 1.62 1.14 0.30 1.60
(7.44e12.88) (6.65e11.03) (4.11e6.08) (1.54e2.26) (1.35e1.94) (0.95e1.36) (0.23e0.39) (1.07e2.36)
1.00 5.6
(5.08e6.18)
1.00 1.23
(1.06e1.42)
1.00 1.13
(0.98e1.31)
1.00 1.67
(1.45e1.93)
1.00 1.12
(0.93e1.34)
1.00 1.09
(0.91e1.31)
1.00 1.93 4.73
(1.72e2.16) (4.08e5.50)
1.00 0.93 3.72
(0.81e1.08) (3.10e4.46)
1.00 1.03 4.22
(0.87e1.22) (3.28e5.42)
1.00 10.45
(9.26e11.80)
1.00 8.26
(7.08e9.64)
1.00 7.50
(6.38e8.82)
1.00 1.02 0.86 0.47
(0.90e1.15) (0.65e1.15) (0.41e0.55)
e e e e
e e e e
1.00 1.01 1.24 1.25
(0.86e1.18) (0.85e1.81) (0.99e1.56)
1.00 0.78 0.84 1.02
(0.70e0.87) (0.73e0.97) (0.91e1.14)
e e e e
e e e e
1.00 0.96 0.93 1.24
(0.79e1.18) (0.78e1.13) (1.07e1.43)
7.61
(6.83e8.48)
e
e
2.80
(2.44e3.21)
CSMBS: Civil Servants Medical Benefit Scheme, UCS: Universal Coverage Scheme. SSS: Social Security Scheme.
patients in this country.33 A prior study conducted in Thai elderly did not report the prevalence of omeprazole because it was not listed in the WinitWatjana criteria.15 Omeprazole was included in LRDTE criteria because it reduces calcium absorption over the long term.19 Omeprazole was continuously prescribed for peptic ulcer and preventing NSAID-induced ulceration, particularly in Thai elderly patients who were concurrently using aspirin, corticosteroids, or anticoagulants.34 This was consistent with a study performed in Ireland using STOPP, which indicated that omeprazole was commonly prescribed to prevent potential ADRs from continuous aspirin use.35 Therefore, elderly patients should be continuously monitored. Tramadol was frequently prescribed for chronic pain in elderly patients because elderly patients are at risk of developing peptic ulcers from chronic NSAID use.36 Conversely, a study performed in Taiwan using the Beers Criteria indicated that tramadol was prescribed less often because it was indicated for the treatment of moderate or severe pain in those who have not responded to other
analgesic medications or NSAIDS. Therefore, this medicine was not prescribed as a first line treatment.37 According to the adjusted logistic regression models, the factors positively associated with PIM use in this study were multiple comorbidities, increased number of diagnoses, frequency of outpatient visits, and polypharmacy. This was similar to most previous studies, in which those factors showed a strong effect on PIM use in Ireland, Utah, and Japan.38e40 After including the Thai region-specific factors in the model, the hospital factor was an important predictor of PIM use. Hospital D was associated with an increased likelihood of PIM use compared to other hospitals because it was a relatively new hospital and its formulary was restricted (Appendix 1). All hospitals have their own formularies, which include medications on the National List of Essential Medicines (NLEM), a list of medications used in the hospitals in Thailand (NLEM: 70e90%), and those not on the NLEM (10e30%).41 Most medications on the NLEM were included in LRDTE criteria as PIM (Appendix 2). In fact, medicine selection in hospitals is claimed to be based on need, safety, efficacy, and cost-
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
effectiveness for all patients, but it might not be focused specifically on elderly patients.35 Consistently, the study by Gallagher et al., which used the Beers Criteria and STOPP in Europe, concluded that differences in hospital characteristics was a key factor in PIM use based on the hospital formulary and policy.42 Therefore, hospital formularies should be revised by recognizing potential risks for elderly patients. For the prescriber factor, prescription from a general practitioner affected the increase in PIM use. The restriction of the hospital formulary and RDU policy affected the physician's prescribing decisions. The policy requires the use of medication listed on the NLEM; therefore, general practitioners must choose medications listed in the NLEM as first line medicines. Similarly, the study of Barnett et al.,43 which used the Beers Criteria in Canada, indicated that general practitioners were the biggest predictors of PIM use in elderly patients.43 Furthermore, the PIM issue was not widely known by physicians, so they might not have been familiar with PIM criteria.16 Consistently, in the prior studies, physicians focused on drug duplication and compliance more than considering PIM risk.44 To improve rational drug use, continuing medical training for physicians should focus on PIM prescribing. The three health insurance schemes differed with respect to prescribing and reimbursement conditions.45 Therefore, these factors might be associated with PIM use. In the unadjusted model, those covered by the out-of-pocket scheme had decreased PIM use compared with those covered by the CSMBS. Those covered by the out-of-pocket scheme could receive medications regardless of whether they were listed in the NLEM, so elderly patients had more choices than those covered by CSMBS and thereby, could avoid PIM use. The previous Thai PIM study that applied the Winit-Watjana criteria indicated that the UCS was associated with increased PIM use compared with the CSMBS.15 The adjusted models found no statistically significant association. This might have been caused by differences in the numbers of elderly people covered by each health insurance. Most used UCS and a few used SSS. Consistently, RDU policy tries to promote the use of medications listed on the NLEM for all health insurance schemes as first line treatment.24,45 Therefore, there were no significant differences between the health insurance schemes regarding PIM prescriptions. According to the study by Donohue et al., which used the Beers Criteria in the United States, drug coverage limitations influenced elderly patients' likelihood of PIM use.46
4.1. Limitations There were several limitations to this study. First, this study was conducted in only four community hospitals in Thailand. Therefore, the study results might not be able to be completely extrapolated to all community hospitals in Thailand. Second, the study was limited by the study database because the data were not sufficient to identify other patient conditions, such as constipation or history of falls and fracture. Therefore, the results might be overestimated or underestimated.
5. Conclusions The prevalence of PIM use in this study, identified using LRDTE criteria, was 79% in Thai elderly patients. The hospital and general practitioners were Thai region-specific factors associated with PIM use. The revision of hospital formularies and educational programs for physicians are needed to improve prescribing habits. Therefore, in further study, because evaluation of drug use using the LRDTE criteria high potential detected PIM prescriptions in Thai elderly, these criteria should be applied in the computer alert system to prevent PIM prescription in Thai health care system.
Funding sources This research supported by the funds made available under Japan Society for the Promotion of Science (Grant no. R11617) and Meiji Pharmaceutical University, Japan.
Acknowledgements The authors are sincerely grateful to supervisor and advisor for their untried supports and staffs at community hospital and Public health office for all help and their willingness of retrieving data.
Appendix 1. Community hospital characteristics in Chonburi Province in fiscal year 2014.
Characteristic
Hospital A
Hospital B
Hospital C
Hospital D
Hospital level Number of doctors
F1 SP 4 (þ3) GP 7 Dentist 8 64 247,703 6956 287 33 12
F2 GP 6 Dentist 3
F2 GP 4 Dentist 4
F2 GP 4 Dentist 2
60 95,185 4466 262 29 11
30 74,947 1641 224 27 12
30 47,120 628 208 28 14
Number of Number of Number of Number of Number of % of PIMc
beds outpatient visit/year inpatients visit/year medicines in the hospitala PIM lists in the hospitalb
PIM ¼ Potential inappropriate medication. F1 ¼ The medium community hospital where was comprised 60 beds and there was specialist. F2 ¼ The small community hospital where is comprised 30 beds and there was not specialist. GP: General practitioner and SP: Specialist. a Number of medicine in the hospital is the number of all modern medicines in the hospital (excluding duplicated medication). b Number of PIM list in the hospital is PIM list in the hospital was identified from Lists of risk medicines for Thai elderly. c % of PIM ¼ (Number of PIM list in the hospital 100)/Number of medicine in the hospital.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
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Appendix 2. Most frequently encountered potentially inappropriate medications according to the Lists of Risk Drugs for Thai Elderly.
Medicatione
PIM user Non PIM user Pain management Tramadol Diclofenac Ibuprofen Naproxen Colchicine Aspirin >325 mg/day Pethidine Etoricoxib Celecoxib Gastrointestinal Omeprazole Hyoscine Metoclopramide Loperamide Medicatione
ATC code
Total n ¼ 13,274 (%)
Thai NLEM
PIM level
60-74 years
75 years
N02AX02 S01BC0 M01AE01 M01AE02 M04AC01 N02BA01 N02AB02 M01AH05 M01AH05
ED ED ED ED ED ED ED NED NED
L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 2 (Moderate) L 1 (Mild) L1 (Mild)
A02BC01 A03BB01 A03FA01 A07DA03
ED ED ED ED
L 1 (Mild) L 3 (Severe) L 2 (Moderate) L1 (Mild)
ATC code
Thai NLEM
Cardiovascular system Amlodipine C08CA01 Prazosin C02CA01 Nifedipine C08CA05 Digoxin C01AA05 Spironolactone C03DA01 Doxazosin C02CA04 Methyldopa C02AB01 Verapamil C08DA01 Amiodarone C01BD01 Diltiazem C08DB01 Central Nervous System Lorazepam N05BA06 Amitriptyline N06AA09 Diazepam N05BA01 Phenobarbital N03AA02 Anticholinergics (excluded TCAs) Chlorpheniramine R06AB04 Hydroxyzine N05BB01 Central Nervous System Cyproheptadine R06AX02 Diphenhydramine R06AA02 Endocrine System Pioglitazone A10BG03 Glibenclamide A10BB01 Other Codeine R05DA04 Trihexyphenidyl N04AA01
(79.4) (20.6) (53.8) (18.3) (12.7) (12.1) (5.0) (3.5) (1.4) (0.4) (0.3) (0.14) (43.3) (29.8) (10.9) (2.5) (0.1)
Total n ¼ 13,274 (%)
PIM level 60-74 years
10,536 2738 7140 2432 1679 1610 665 466 190 47 33 18 5755 3958 1448 337 12
75 years
ED ED ED ED ED ED ED ED ED ED
L L L L L L L L L L
2 2 2 2 2 2 2 2 2 2
(Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate)
ED ED ED ED
L L L L
1 2 1 2
(Mild) (Moderate) (Mild) (Moderate)
ED ED
L 1 (Mild) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
ED ED
L 1 (Mild) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
ED ED
L 2 (Moderate) L 2 (Moderate)
ED ED
L 2 (Moderate) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
L 2 (Moderate)
5451 4259 446 337 151 96 73 42 24 18 5 3626 1574 1280 760 12 3053 1622 887 3626 508 36 803 530 273 186 110 76
(41.0) (32.1) (3.4) (2.5) (1.1) (0.7) (0.5) (0.3) (0.2) (0.1) (0.1) (27.3) (11.9) (9.6) (5.7) (0.1) (23.0) (12.2) (6.7) (27.3) (3.8) (0.3) (6.1) (4.0) (2.1) (1.4) (0.8) (0.6)
% Most frequently PIM ¼ (Number of patients who received PIM x 100)/total patient. ATC ¼ Anatomical Therapeutic Chemical Classification System. NLEM ¼ National list Essential medicine, ED ¼ Essential drug, NED ¼ Non-essential drug. Level 1(Mild): use within condition or short term use or with intensive monitoring. Level 2 (Moderate): not recommend, avoid by using alternative choices. Level 3 (Severe): Not recommend, no benefit, L ¼ level. e Elderly patients receive PIM more than one.
References 1. Knodel J, Prachuabmoh V, Chayovan N. The Changing Well-being of Thai Elderly. first ed. Chiang mai: Help Age International publishers; 2013. 2. Social and quality of life database system. Population Structure. http://social. nesdb.go.th/Social Stat/StatReport _Final.aspx?reportid¼697&template¼ 2R1C&yeartype¼M&subcatid¼1 ; Accessed 30 January 2016. [in Thai].
3. Kaufman ND, Chasombat S, Tanomsingh S, Rajataramya B, Potempa K. Public health in Thailand: emerging focus on non-communicable diseases. Int J Health Plann Mgmt. 2011;26(3):197e212 [in Thai]. 4. Institute of geriatric medicine. Survey the Quality of Elderly Life in 2011. Bangkok: Ministry of public health; 2011 [in Thai]. 5. Spinewine Anne, Schmader Kenneth E, Barber Nick, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173e184. 6. Lu WH, Wen YW, Chen LK, et al. Effect of polypharmacy, potentially inappropriate medications and anticholinergic burden on clinical outcomes: a
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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retrospective cohort study. CMAJ. 2015;187:130e137. 7. Montastruc François, Duguet Cannelle, Rousseau Vanessa, Bagheri Haleh, Montastruc Jean-Louis. Potentially inappropriate medications and adverse drug reactions in the elderly: a study in a PharmacoVigilance database. Eur J Clin Pharmacol. 2014;70(9):1123e1127. 8. Guaraldo L, Cano FG, Damasceno GS, Rozenfeld S. Inappropriate medication use among the elderly: a systematic review of administrative databases. BMC Geriatr. 2011:11e79. D, Topinkova E, Gambassi G, et al. Potentially inappropriate medication 9. Fialova use among elderly home care patients in Europe. JAMA. 2005;11:1348e1358. 10. The American geriatrics society 2015. Beers criteria update expert panel. American geriatrics society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11): 2227e2246. 11. Farrell B, Bjerre LM, Ramsay T, et al. Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases. BMJ Open. 2015;5(11):1e12. 12. Winit-Watjana W, Sakulrat P, Kespichayawattana J. Criteria for high-risk medication use in Thai older patients. Arch Gerontol Geriatr. 2008;47(1): 35e51 [in Thai]. 13. Azizah RN, Andrajati R, Supardi S. Identification of potential inappropriate prescribing (PIP) for the geriatric patients used Beers criteria in IbnuSina hospital Makassar Indonesia. Der Pharma Chem. 2016;8:101e104. 14. Chen Li Li, Tangiisuran Balamurugan, Shafie Asrul Akmal, Hassali Mohamed Azmi Ahmad. Evaluation of potentially inappropriate medications among older residents of Malaysian nursing homes. Int J Clin Pharm. 2012;34(4):596e603. 15. Sruamsiri R, Chaiyakunapruk N, Jeanpeerapong N. Prevalence of and factors Associated with potentially inappropriate medications use in the elderly population in Thailand. In: Third International Conference for Improving Use of Medicines. 2011 Nov 14-18:355e356. Antalya, Turkey[in Thai]. 16. Pannoi T, Sedgwick Chapman R, Panza A. Prevalence of potentially inappropriate medication (PIM) and factors associated with PIM in elderly outpatient prescriptions at a district hospital in the Southern region of Thailand. J Health Res. 2014;28(2):101e108 [in Thai]. 17. Chongtrakul P. RDU hospital: the pathway to rational drug use. Thai J Pharmacol. 2015;37(1):41e62 [in Thai]. 18. Sudchada P, Umnuaypornlert A, Kitikannakorn NA. Survey of practical policies to promote rational drug use (RDU) of pharmacy and therapeutics committee (PTC) in Thailand. Srinagarind Med J. 2012;27(2):157e166 [in Thai]. 19. Ployluermsang C, Tieankanitikul K, ChobPradit J, Suntorn S, Suwankasawong W. Development of medicine list for screening and reducing medication-related problems in Thai elderly. J Health Syst Res. 2015:77e95 [in Thai]. 20. Health data center in Chonburi province. Health Information. http://data.cbo. moph.go.th/; Accessed 25 March 2016). [in Thai]. 21. Asia pacific observatory on health system and policies. Public Hospital Governance in Thailand. http://www.wpro.who.int/asia_pacific_observatory/ country_comparative_studies/ccs_public_hospital_5_tha.pdf?ua¼; Accessed 20 April 2016. 22. World Health Organization. International Statistical Classification of Diseases and Related Health Problems 10th Revision Version for 2016. Geneva; 2016. http:// apps.who.int/Classificationsicd10/browse/2016/en#! /IX. Accessed 25 March 2016. 23. Elixhauser Anne, Steiner Claudia, Harris D Robert, Coffey Rosanna M. Comorbidity measures for use with administrative data. Med Care. 1998;36(1):8e27. 24. WHO Collaborating Centre for Drug Satistics Methodology. ATC/DDD Index; 2016. Geneva http://www.whocc.no/atc_ddd_index/. Accessed 20 April 2006. 25. Gnjidic Danijela, Hilmer Sarah N, Blyth Fiona M, et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012;65(9): 989e995. 26. Jitramontree N, Thayansin S. Social welfare for older persons in Thailand: policy and recommendation. J Pub Health Dev. 2013;11(3):39e47 [in Thai]. 27. World Health Organization. Medicines in Health Care Delivery, Thailand: Situational Analysis. New Delhi, India: The WHO/SEARO Workbook Tool for Undertaking a Situational Analysis of Medicines in Health Care Delivery in Low and Middle
Income Countries. 2016. 28. Limpawattana P, Kamolchai N, Theeranut A, Pimporm J. Potentially inappropriate prescribing of Thai older adults in an internal medicine outpatient clinic of a tertiary care hospital. Afr J Pharm Pharmacol. 2013;7(34):2417e2422 [in Thai]. 29. The committee of rational drug use. Rational Drug Use Hospital Manual. first ed. Bangkok: Thai agricultural cooperative printing; 2015 [in Thai]. 30. Ploylearmsang C, Kerdchantuk P, SoonKang K, Worasin P, Kedhareon P. Drugrelated problems and factors affecting on medicine use problems in elderly of Banmakok, Kantharawichai, MahaSarakham province. J Sci Technol Mahasarakham Univ. 2014:804e812 [in Thai]. 31. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/ START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015;44(2):213e218. 32. Gallagher P, Ryan C, Byrne S, Kennedy J, O'Mahony D. STOPP (screening tool of older Person's prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72e83. 33. Frankenthal Dvora, Lerman Yaffa, Kalendaryev Edward, Lerman Yehuda. Intervention with the screening tool of older persons potentially inappropriate prescriptions/screening tool to alert doctors to right treatment criteria in elderly residents of a chronic geriatric facility: a randomized clinical trial. J Am Geriatrics Soc. 2014;62(9):1658e1665. 34. Thongbai T, Thanapirom K, Ridtitid W, et al. Factors predicting mortality of elderly patients with acute upper gastrointestinal bleeding. Asian Biomed. 2016;10(2):115e122 [in Thai]. 35. Holloway KA. Drug Policy and Use of Pharmaceuticals in Health Care Delivery. Thailand: World Health Organization; 2012:17e31. July 2012. [in Thai]. 36. Kittiboonyakun P, Paktipat W. Prescribing patterns and medication problems related to the use of pain medication and adjuvant drugs in patients with osteoarthritis. Thai J Pharm Pract. 2015;7(2):278e287 [in Thai]. 37. Chang CB, Yang SY, Lai HY, et al. Application of three different sets of explicit criteria for assessing inappropriate prescribing in older patients: a nationwide prevalence study of ambulatory care visits in Taiwan. BMJ. 2015;5(11):1e9. 38. O'Dwyer M, Peklar J, Mccallion P, Mccarron, Henman CM. Factors associated with polypharmacy and excessive polypharmacy in older people with intellectual disability differ from the general population: a cross-sectional observational nationwide study. BMJ. 2016:1e11. 39. Buck M, Atreja A, Brunker CP, et al. Potentially inappropriate medication prescribing in outpatient practices: prevalence and patient characteristics based on electronic health record. Am J Geriatr Pharmacother. 2009;7:4e92. 40. Onda M, Imai H, Takada Y, Fujii S, Shono T, Nanaumi Y. Identification and prevalence of adverse drug events caused by potentially inappropriate medication in homebound elderly patients: a retrospective study using a nationwide survey in Japan. BMJ. 2015;5(8):1e9. 41. Yoongthong W, Hu S, Whitty JA, et al. National drug policies to local formulary decisions in Thailand, China, and Australia: drug listing changes and opportunities. Value Health. 2012;15(1):126e131 [in Thai]. 42. Gallagher P, Lang PO, Cherubini A, et al. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol. 2011;67(11):1175e1188. 43. Barnett K, McCowan C, Evans JMM, Gillespie ND, Davey PG, Fahey T. Prevalence and outcomes of use of potentially inappropriate medicines in older people: cohort study stratified by residence in nursing home or in the community. BMJ Qual Saf. 2011;20(3):275e281. 44. Alagiakrishnan K, Wilson P, Sadowski CA, et al. Physicians' use of computerized clinical decision supports to improve medication management in the elderly the Seniors Medication Alert and Review Technology intervention. Clin Interv Aging. 2016;11:73e81. 45. Limwattananon S, Limwattananon C, Cheawchanwattana A, Tangcharoensathien V, Silkavute P. Forecasted expenditure due to use of expensive drugs in Civil servant medical benefit scheme: a comparison with Universal health coverage scheme. J Health Syst Res. 2011;5(2):170e180 [in Thai]. 46. Donohue JM, Marcum ZA, Gellad WF, Lave JR, Men A, Hanlon JT. Medicare part D and potentially inappropriate medication use in the elderly. Am J Manag Care. 2012;18(9):315e322.
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Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use Vanida Prasert a, *, Manabu Akazawa b, Aiko Shono b, Farsai Chanjaruporn c, Chanuttha Ploylearmsang d, Kamolnut Muangyim a, Thanased Wattanapongsatit e, Uthen Sutin f a
Department of Pharmacy, Sirindhorn College of Public Health, 20000, Thailand Department of Public Health and Epidemiology, Meiji Pharmaceutical University, 204-8588, Japan c Social and Administrative Pharmacy Excellence Research Unit, Faculty of Pharmacy, Mahidol University, 10400, Thailand d Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, 44150, Thailand e Health Strategy Development, Public Health Office, 20000, Thailand f Community and Family Medicine Unit, Bothong Hospital, 20270, Thailand b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 21 May 2017 Accepted 22 May 2017
Background: Potential inappropriate medication (PIM) prescribing is a medication that puts patients at risk rather than having benefits. PIM use has been associated with hospitalization, morbidity, and mortality resulting from ADRs in elderly patients. The Lists of Risk Drugs for Thai Elderly (LRDTE) was developed as the new screening tool to identify PIMs use. The prevalence of PIM use using the LRDTE has not been determined in Thailand. Purpose: The main purpose of this study was to examine the prevalence of PIM use based on the LRDTE. In addition, this aimed to address the PIM problem by identifying factors that influenced PIM use among elderly patients in Thailand. Methods: A retrospective cross-sectional descriptive study was conducted using the computerized database at four community hospitals in Thailand during fiscal year 2014. The LRDTE criteria were used as a screening tool for identifying the medicine items of PIM use. Descriptive statistics and multivariate logistic regression were used to identify common and Thai region-specific predictors of PIM use. Results: Of a total of 13274 elderly patients, 79% were prescribed at least one PIM, as indicated by the LRDTE criteria. Amlodipine (32%), omeprazole (30%), and tramadol (18%) were the most commonly prescribed PIMs in elderly patients aged 60 years and older. Hospital and physician characteristics were identified as independent predictors after adjustment for patient and utilization factors. Conclusion: PIM use in Thai elderly patients was highly prevalent in community hospitals because the LRDTE criteria reflected clinical practice in Thailand. Hospital and physician factors were identified as region-specific factors that were highly associated with PIM use. Revision of hospital formularies and educational programs for physicians are needed to improve prescribing and avoid PIM use. © 2017 Elsevier Inc. All rights reserved.
Keywords: Potentially inappropriate medication Lists of Risk Drugs for Thai Elderly Elderly patients
1. Introduction Thailand is an upper-middle income country in South East Asia, whose population is quickly aging.1 In 2016, approximately 10
* Corresponding author. Department of Pharmacy, Sirindhorn College of Public Health, 29 M 4, Chonburi Province, Thailand. E-mail address: [email protected] (V. Prasert).
million people were aged over 60 years and this number is expected to double within the next three decades.2 In addition, the burden of disease in elderly people increasingly shifts to noncommunicable diseases.3 Four out of five older Thai citizens have at least one chronic disease and have been continuously prescribed multiple medicines. Polypharmacy increases the risk of adverse drug reaction (ADRs). These problems are related to potentially inappropriate medication (PIM) use in the elderly.4
http://dx.doi.org/10.1016/j.sapharm.2017.05.012 1551-7411/© 2017 Elsevier Inc. All rights reserved.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
PIM has been defined as a medication that puts patients at risk rather than having benefits and includes prescription medications with drugedrug and drugedisease interactions.5 PIM use has been associated with hospitalization, morbidity, and mortality resulting from ADRs in elderly patients6,7 and is a problem in high income countries,8,9 including those in Asia. Presently, several screening tools can be used to identify PIMs in older adults. The original tool was the Beers Criteria, which was published in 1991 in the United States. An expert panel identified medicines that should be avoided in the elderly owing to drug-disease interactions, drug-drug interactions, the need for caution in this population, and effects on kidney function.10 The screening tool of older people's prescriptions (STOPP) was explicit criteria published in Europe in which the medication lists were organized by physiological organ systems.11 In Thailand, the Winit-Watjana criteria were developed in 2009 and included the use of high-risk medications with potential ADRs, drug-disease interactions, and drug-drug interactions.12 As for PIM studies in Asian countries, the prevalence of PIM use determined from the Beers Criteria in Indonesia was 87% in geriatric patients,13 whereas, in Malaysia, the reported prevalence of PIM use determined using the STOPP was 33%.14 For Thailand, PIM use was identified using the Winit-Watjana criteria and the prevalence was 58% in elderly patients.15 In addition, a 32% and 28% prevalence was determined using the STOPP and Beers Criteria, respectively.16 Irrational prescribing is a problem in the Thai health care system, especially PIM prescribing to elderly patients.17,18 These patients frequently receive medicines without knowing the indication and follow a polypharmacy pattern of use. In 2011, the Ministry of Public Health launched the rational drug use (RDU) policy to enhance the quality of health services for all people.19 Reducing PIM use is the one of the missions of the RDU policy aimed at improving drug safety in the elderly.17,18 For this purpose, in 2012, the Lists of Risk Drugs for Thai Elderly (LRDTE) were developed from the 2012 Beers Criteria and 2008 STOPP. The advantage of the LRDTE was that the medication lists considered the age group in elderly aged over 60 years and the severity of medication risk. Furthermore, this is the currently covered standard treatment guideline and hospital formulary for Thai elderly.19 The prevalence of PIM use using the LRDTE has not been determined in Thailand. Therefore, the main purpose of this study was to examine the prevalence of PIM use based on the LRDTE. In addition, this aimed to address the PIM problem by identifying factors that influenced PIM use among elderly patients in Thailand.
2. Methods 2.1. Study design and population This was a retrospective, cross-sectional descriptive study of PIM use among elderly patients in community hospitals in Chonburi Province, Thailand. Chonburi Province is located in Eastern Thailand and has the highest population density.20 Four of nine hospitals in the province participated in the study after they agreed to provide the required information. Three hospitals were small hospitals in rural areas and the other was a medium hospital in an urban area. Each had a different number of beds, number of medicines, medicine list, and types of specializations (Appendix 1).21 The population studied included elderly patients aged 60 years and older who had at least 2 pharmacy claims and visited as an outpatient over a 1-year period during fiscal year 2014 (FY 2014). Missing or irretrievable medication data were excluded.
2.2. Data source and variables The secondary data were collected from four hospitals using medical and pharmacy claims from the Health Data Center (HDC) database between April 1, 2014 and March 31, 2015 (FY 2014). The HDC database included all claims data of patient characteristics, health service utilization, and Thai region-specific characteristics. According to a literature review, patient characteristics, age category (60e74 or 75 years) based on the LRDTE criteria,19 gender (male or female), and comorbidities were identified from International Statistical Classification of Disease and Related Health Problems 10th Revision (ICD-10) code22 and the Elixhauser classification system.23 For health service utilization characteristics, the number of outpatient visits was classified as 1e3 or 4 visits; the number of hospitalizations was categorized 0 or 1; and the number of diagnoses was utilized as a categorical variable (1e2, 3e4, or 5), as described in a previous Thai study.16 Medication dispensed, including generic or brand name, strength, form, number of medicines, and dispensing date, was determined. Prescription and nonprescription medications were coded according to the Anatomical Therapeutic Chemical (ATC) classification system recommended by the World Health Organization.24 Each patient's total number of medications was categorized as < 5 or 5, based on prior studies.25 As for the Thai region-specific characteristics, the study considered health insurance schemes, hospital characteristics, and prescribers. Health insurance schemes consisted of the civil servants medical benefit scheme (CSMBS) for government employees, the universal coverage scheme (UCS) for the remaining population, the social security scheme (SSS) for private employees, and out-ofpocket. The beneficiaries for each health insurance were different. CSMBS and out-of-pocket allowed the use of both essential and non-essential medicines, whereas SSS and UCS allowed the use of only essential medicine.26 Hospital characteristics were classified by community hospital levels. The hospital formulary in each hospital was different based on the hospital level. In addition, the hospitals were described by the number of beds and doctors (F1: medium level hospital having 60 beds or more and specialists or F2: small level hospital having 30 beds or more and no specialists) using the geographic information system in Thailand.21 Prescribers were general practitioners, specialists, or other health personnel (including dentists and nurses). Each prescriber has a different role in prescribing: specialists have more authority than other prescribers in that they can prescribe specialized medicines, general practitioners can prescribe common medicines, and other health personnel can prescribe only limited medicines.27 The study was approved by the Research Ethic Committee of Sirindhorn College of Public Health, Chonburi Province, Thailand on July 21, 2016. In addition, the data use was officially approved by each hospital.
2.3. Measurement of potentially inappropriate medicines PIMs were defined using the LRDTE; the new explicit criteria consisted of 76 medications or 8 medication classes that should generally be avoided in all elderly patients. The LRDTE is categorized by age and severity of medicine. Age was separated into two categories: 60e74 years and 75 years and over. Medicine was categorized into 3 severity levels: level 1 (mild) is used within condition or over the short term or with intensive monitoring, level 2 (moderate) is avoid by using alternative choices, and level 3 (severe) is not recommended and no benefit,19 as indicated in Appendix 2.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
2.4. Data analysis The main objective of this study was to examine the prevalence of PIM use among elderly patients based on the LRDTE. The prevalence of PIM use was calculated as the number of elderly patients who used at least one PIM during FY 2014 divided by the number of elderly patients who received any service at the four hospitals during FY 2014. Risk factors predicting PIM use were identified using multivariate logistic regression models. In model 1, common risk factors were patient and health service utilization factors. In model 2, Thai region-specific factors, including health insurance schemes, hospitals, and physicians, were added. Each health insurance scheme was different for its beneficiaries; therefore, the PIM prescribing rate was compared between the different health insurance schemes. For hospitals were reported the results for each hospital individually to account for potential biases from differences in the proportions of older adults. A physician factor was included if a general practitioner or others prescribed PIM to patients at least one time during the one year period.
3
The results from the two models were compared to determine whether the Thai region-specific characteristics were independent risk factors after adjustment for the common factors and described as unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). A p-value < 0.05 was considered statistically significant. All analyses were carried out using STATA software version 13 (Stata, College Station, TX, USA). 3. Results 3.1. Basic characteristics A total of 13274 elderly patients aged 60 years were included during FY 2014. The basic characteristics of these patients are presented in Table 1. The top five comorbidities were hypertension, diabetes mellitus, musculoskeletal conditions, dyslipidemia, and gastrointestinal disease. For health service utilization, the average number of outpatient visits was 4.9 ± 4.5 (range 1e88), whereas the average number of hospitalizations was 0.2 ± 0.7 (range 0e11). In addition, the average
Table 1 Basic characteristics among elderly patients and PIM prevalence. Characteristic Patient characteristics Age, Mean ± SD (Range) 60e74 years 75 years Gender Female Male x Comorbidities Hypertension Diabetic Mellitus Musculoskeletal conditions Dyslipidemia Gastrointestinal disease Acute respiratory disease COPD/Asthma Cardiovascular disease Health service utilization characteristics (Per year) Number of outpatient visits, Mean ± SD (Range) 1e3 4 Number of hospitalizations Mean ± SD (Range) 0 1 Number of diagnoses, Mean ± SD (Range) 1e2 3e4 5 Characteristic Number of medications, Mean ± SD (Range) 1e5 >5 Health insurance scheme Civil Servants Medical Benefit Scheme Universal Coverage Scheme Social Security Scheme Out-of-Pocket Hospital characteristics Hospital A Hospital B Hospital C Hospital D *Prescriber characteristics General practitioner Specialist Other health personnel (Dentist, Nurse) * x
Total n ¼ 13,274
(%)
PIM prevalence (%) 10,536 (79.3)
9599 3675
(72.3) (27.7)
69.80 ± 8.07 (60e114) 78.4 81.9
7881 5393
(59.4) (40.6)
81.6 76.1
2705 2561 2063 1904 1825 1807 478 343
(20.4) (19.3) (15.5) (14.3) (13.8) (13.6) (3.6) (2.6)
94.7 90.8 96.4 90.4 96.6 86.1 71.3 87.8
6157 7117
(38.3) (61.7)
11,602 1672
(86.4) (13.6)
7685 2701 2888
(57.9) (20.4) (21.8)
4.86 ± 4.52 (1e88) 65.5 87.6 0.20 ± 0.68 (0e11) 78.4 85.9 3.49 ± 4.00 (1e43) 72.8 83. 8 92.7
Total n ¼ 13,274
(%)
PIM prevalence (%) 10,536 (79.37)
6710 6564
(50.5) (49.5)
7.17 ± 5.89 (1e43) 64.2 94.9
1863 10,275 280 856
(14.0) (77.4) (2.1) (6.5)
80.6 80.3 77.9 65.9
6480 2733 1339 2722
(48.8) (20.6) (10.1) (20.5)
80.5 76.3 77.6 81.0
11,542 822 6025
(86.9) (6.2) (45.4)
84.91 87.10 74.84
Elderly patients visited the physician more than once, total was more than 100%. Elderly patients had more than one comorbidity, total was more than 100%.
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
number of diagnoses and medications used was 3.5 ± 4.0 (range 1e43) and 7.2 ± 5.9 (range 1e43), respectively. As for Thai regional factors, most patients were covered under the UCS (77.4%), visited hospital A (48.8%), and were prescribed medicines by general practitioners (86.9%). 3.2. Prevalence of PIM use identified using the LRDTE The prevalence of PIM use was 79.3% (10536/13274) in elderly patients during FY 2014 (Table 1). More elderly patients aged 75 years and older were prescribed PIMs than those aged 60e74 years. Female patients received more PIMs than male patients. Moreover, the highest prevalence of PIM use was in relation to gastrointestinal disease and musculoskeletal conditions. PIM was frequently prescribed for those with multiple outpatient visits (4 visits), at least one hospitalization, multiple comorbidities (5 diagnoses), and polypharmacy (5 medicines). The majority of PIM users received CSMBS and UCS. PIM was prescribed most often in hospital D. Additionally, PIMs were commonly prescribed by general practitioners and specialists. Fig. 1 presents the prevalence of the 10 most frequently prescribed PIMs for those aged 60e74 years and 75 years. The results indicated that elderly patients aged 75 years received more PIMs than those aged 60e74 years. The most common PIMs identified by LRDTE criteria were amlodipine (60e74 years: 31% vs 75 years: 35%), omeprazole (27% vs 36%), tramadol (17% vs 22%), lorazepam (11% vs 15%), hyoscine (10% vs 12%), amitriptyline (9% vs 11%), and hydroxyzine (6% vs 8%). 3.3. Factors influencing PIM use in elderly patients for drug policy perspective After adjustment for patient and utilization factors (model 1), positive associations were identified between female gender, all comorbidities except COPD/asthma, 4 or more outpatient visits, 5
or more diagnoses, and 5 or more medications (Table 2). By adding Thai region-specific factors (model 2), most factors remained statistically significant predictors (excluding female and outpatient visits). Moreover, Hospital D [OR 1.24; 95% CI 1.07e1.43] and general practitioner prescribers [OR 2.80; 95%CI 2.44e3.21] were independent predictors for PIM use as Thai region-specific factors. Health insurance schemes were not independent predictors after adjustment for common factors.
4. Discussion This was the first study evaluating PIM use using the LRDTE criteria in Thailand. The result found that 79% of elderly Thai patients were at risk of PIM use. The prevalence of PIM use was higher than that found in previous Thai PIM use studies: 32% using STOPP,28 28% using 2012 Beers Criteria,16 and 58% using WinitWatjana criteria.15 The prevalence of PIM may not be directly comparable to other studies because of health setting and methodological differences. The medicine lists in the LRDTE criteria covered current standard treatment guidelines and hospital formularies.19 Therefore, the high PIM prevalence in this study suggested the importance of using the new LRDTE criteria to fulfill the RDU policy to reduce irrational drug use for Thai elderly.17 The top three most common PIMs prescribed to elderly patients aged 60 years were amlodipine (32%), omeprazole (30%), and tramadol (18%). Amlodipine has been commonly prescribed for hypertension in Thai elderly patients aged 75 years.29 The previous Thai PIM study that used the Beers Criteria did not report the prevalence of amlodipine use because this medicine was not listed in the criteria.30 Amlodipine was added to the LRDTE criteria to avoid ADRs, including an increased risk of edema, falls, and fractures.31 In addition, constipation was a common ADR in elderly patients.32 Meanwhile, a PIM use study in the Netherlands revealed a lower prevalence of amlodipine use from the use of STOPP because this medicine was not widely prescribed among elderly
Fig. 1. Prevalence of the most frequently used potentially inappropriate medications in the elderly (60e74 years old and 75 years old). *1 ¼ mild, 2 ¼ moderate, 3 ¼ severe. (2,2) ¼ (first digit ¼ PIM level for those aged 60e75 years, second digit ¼ PIM level for those aged 75 years).
Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012
V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
5
Table 2 Factors that influenced potentially inappropriate medication use in Thai elderly. Variable
Unadjusted OR (95%CI)
Adjusted OR (95%CI) Model 1
Patient factors Age 60e74 years 75 years Gender Female Comorbidities Gastrointestinal disease Musculoskeletal conditions Hypertension Dyslipidemia Diabetic Mellitus Acute respiratory disease COPD/Asthma Cardiovascular disease Health service utilization factors Number of outpatient visits 1-3 4 Number of hospitalizations 0 1 Number of diagnoses 1e2 3e4 5 Health service utilization factors Number of medications 1e5 >5 Region-specific factors Health insurance scheme CSMBS UCS SSS Out-of-pocket Hospitals Hospital A Hospital B Hospital C Hospital D Prescriber General practitioner
Model 2
1.00 1.25
(1.13e1.37)
1.00 1.02
(0.92e1.17)
1.00 1.01
(0.89e1.14)
1.39
(1.28e1.52)
1.13
(1.02e1.26)
1.10
(0.99e1.22)
8.53 8.38 5.78 2.72 3.02 1.72 0.64 1.89
(6.61e11.00) (6.62e10.61) (4.86e6.88) (2.32e3.19) (2.62e3.48) (1.49e1.98) (0.52e0.78) (1.36e2.61)
9.80 9.91 6.01 2.37 1.94 1.39 0.34 1.64
(7.43e12.73) (7.72e12.72) (4.96e7.29) (1.96e2.86) (1.62e2.32) (1.16e1.65) (0.26e0.44) (1.12e2.41)
9.79 8.56 4.99 1.87 1.62 1.14 0.30 1.60
(7.44e12.88) (6.65e11.03) (4.11e6.08) (1.54e2.26) (1.35e1.94) (0.95e1.36) (0.23e0.39) (1.07e2.36)
1.00 5.6
(5.08e6.18)
1.00 1.23
(1.06e1.42)
1.00 1.13
(0.98e1.31)
1.00 1.67
(1.45e1.93)
1.00 1.12
(0.93e1.34)
1.00 1.09
(0.91e1.31)
1.00 1.93 4.73
(1.72e2.16) (4.08e5.50)
1.00 0.93 3.72
(0.81e1.08) (3.10e4.46)
1.00 1.03 4.22
(0.87e1.22) (3.28e5.42)
1.00 10.45
(9.26e11.80)
1.00 8.26
(7.08e9.64)
1.00 7.50
(6.38e8.82)
1.00 1.02 0.86 0.47
(0.90e1.15) (0.65e1.15) (0.41e0.55)
e e e e
e e e e
1.00 1.01 1.24 1.25
(0.86e1.18) (0.85e1.81) (0.99e1.56)
1.00 0.78 0.84 1.02
(0.70e0.87) (0.73e0.97) (0.91e1.14)
e e e e
e e e e
1.00 0.96 0.93 1.24
(0.79e1.18) (0.78e1.13) (1.07e1.43)
7.61
(6.83e8.48)
e
e
2.80
(2.44e3.21)
CSMBS: Civil Servants Medical Benefit Scheme, UCS: Universal Coverage Scheme. SSS: Social Security Scheme.
patients in this country.33 A prior study conducted in Thai elderly did not report the prevalence of omeprazole because it was not listed in the WinitWatjana criteria.15 Omeprazole was included in LRDTE criteria because it reduces calcium absorption over the long term.19 Omeprazole was continuously prescribed for peptic ulcer and preventing NSAID-induced ulceration, particularly in Thai elderly patients who were concurrently using aspirin, corticosteroids, or anticoagulants.34 This was consistent with a study performed in Ireland using STOPP, which indicated that omeprazole was commonly prescribed to prevent potential ADRs from continuous aspirin use.35 Therefore, elderly patients should be continuously monitored. Tramadol was frequently prescribed for chronic pain in elderly patients because elderly patients are at risk of developing peptic ulcers from chronic NSAID use.36 Conversely, a study performed in Taiwan using the Beers Criteria indicated that tramadol was prescribed less often because it was indicated for the treatment of moderate or severe pain in those who have not responded to other
analgesic medications or NSAIDS. Therefore, this medicine was not prescribed as a first line treatment.37 According to the adjusted logistic regression models, the factors positively associated with PIM use in this study were multiple comorbidities, increased number of diagnoses, frequency of outpatient visits, and polypharmacy. This was similar to most previous studies, in which those factors showed a strong effect on PIM use in Ireland, Utah, and Japan.38e40 After including the Thai region-specific factors in the model, the hospital factor was an important predictor of PIM use. Hospital D was associated with an increased likelihood of PIM use compared to other hospitals because it was a relatively new hospital and its formulary was restricted (Appendix 1). All hospitals have their own formularies, which include medications on the National List of Essential Medicines (NLEM), a list of medications used in the hospitals in Thailand (NLEM: 70e90%), and those not on the NLEM (10e30%).41 Most medications on the NLEM were included in LRDTE criteria as PIM (Appendix 2). In fact, medicine selection in hospitals is claimed to be based on need, safety, efficacy, and cost-
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
effectiveness for all patients, but it might not be focused specifically on elderly patients.35 Consistently, the study by Gallagher et al., which used the Beers Criteria and STOPP in Europe, concluded that differences in hospital characteristics was a key factor in PIM use based on the hospital formulary and policy.42 Therefore, hospital formularies should be revised by recognizing potential risks for elderly patients. For the prescriber factor, prescription from a general practitioner affected the increase in PIM use. The restriction of the hospital formulary and RDU policy affected the physician's prescribing decisions. The policy requires the use of medication listed on the NLEM; therefore, general practitioners must choose medications listed in the NLEM as first line medicines. Similarly, the study of Barnett et al.,43 which used the Beers Criteria in Canada, indicated that general practitioners were the biggest predictors of PIM use in elderly patients.43 Furthermore, the PIM issue was not widely known by physicians, so they might not have been familiar with PIM criteria.16 Consistently, in the prior studies, physicians focused on drug duplication and compliance more than considering PIM risk.44 To improve rational drug use, continuing medical training for physicians should focus on PIM prescribing. The three health insurance schemes differed with respect to prescribing and reimbursement conditions.45 Therefore, these factors might be associated with PIM use. In the unadjusted model, those covered by the out-of-pocket scheme had decreased PIM use compared with those covered by the CSMBS. Those covered by the out-of-pocket scheme could receive medications regardless of whether they were listed in the NLEM, so elderly patients had more choices than those covered by CSMBS and thereby, could avoid PIM use. The previous Thai PIM study that applied the Winit-Watjana criteria indicated that the UCS was associated with increased PIM use compared with the CSMBS.15 The adjusted models found no statistically significant association. This might have been caused by differences in the numbers of elderly people covered by each health insurance. Most used UCS and a few used SSS. Consistently, RDU policy tries to promote the use of medications listed on the NLEM for all health insurance schemes as first line treatment.24,45 Therefore, there were no significant differences between the health insurance schemes regarding PIM prescriptions. According to the study by Donohue et al., which used the Beers Criteria in the United States, drug coverage limitations influenced elderly patients' likelihood of PIM use.46
4.1. Limitations There were several limitations to this study. First, this study was conducted in only four community hospitals in Thailand. Therefore, the study results might not be able to be completely extrapolated to all community hospitals in Thailand. Second, the study was limited by the study database because the data were not sufficient to identify other patient conditions, such as constipation or history of falls and fracture. Therefore, the results might be overestimated or underestimated.
5. Conclusions The prevalence of PIM use in this study, identified using LRDTE criteria, was 79% in Thai elderly patients. The hospital and general practitioners were Thai region-specific factors associated with PIM use. The revision of hospital formularies and educational programs for physicians are needed to improve prescribing habits. Therefore, in further study, because evaluation of drug use using the LRDTE criteria high potential detected PIM prescriptions in Thai elderly, these criteria should be applied in the computer alert system to prevent PIM prescription in Thai health care system.
Funding sources This research supported by the funds made available under Japan Society for the Promotion of Science (Grant no. R11617) and Meiji Pharmaceutical University, Japan.
Acknowledgements The authors are sincerely grateful to supervisor and advisor for their untried supports and staffs at community hospital and Public health office for all help and their willingness of retrieving data.
Appendix 1. Community hospital characteristics in Chonburi Province in fiscal year 2014.
Characteristic
Hospital A
Hospital B
Hospital C
Hospital D
Hospital level Number of doctors
F1 SP 4 (þ3) GP 7 Dentist 8 64 247,703 6956 287 33 12
F2 GP 6 Dentist 3
F2 GP 4 Dentist 4
F2 GP 4 Dentist 2
60 95,185 4466 262 29 11
30 74,947 1641 224 27 12
30 47,120 628 208 28 14
Number of Number of Number of Number of Number of % of PIMc
beds outpatient visit/year inpatients visit/year medicines in the hospitala PIM lists in the hospitalb
PIM ¼ Potential inappropriate medication. F1 ¼ The medium community hospital where was comprised 60 beds and there was specialist. F2 ¼ The small community hospital where is comprised 30 beds and there was not specialist. GP: General practitioner and SP: Specialist. a Number of medicine in the hospital is the number of all modern medicines in the hospital (excluding duplicated medication). b Number of PIM list in the hospital is PIM list in the hospital was identified from Lists of risk medicines for Thai elderly. c % of PIM ¼ (Number of PIM list in the hospital 100)/Number of medicine in the hospital.
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V. Prasert et al. / Research in Social and Administrative Pharmacy xxx (2017) 1e8
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Appendix 2. Most frequently encountered potentially inappropriate medications according to the Lists of Risk Drugs for Thai Elderly.
Medicatione
PIM user Non PIM user Pain management Tramadol Diclofenac Ibuprofen Naproxen Colchicine Aspirin >325 mg/day Pethidine Etoricoxib Celecoxib Gastrointestinal Omeprazole Hyoscine Metoclopramide Loperamide Medicatione
ATC code
Total n ¼ 13,274 (%)
Thai NLEM
PIM level
60-74 years
75 years
N02AX02 S01BC0 M01AE01 M01AE02 M04AC01 N02BA01 N02AB02 M01AH05 M01AH05
ED ED ED ED ED ED ED NED NED
L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 1 (Mild) L 2 (Moderate) L 1 (Mild) L1 (Mild)
A02BC01 A03BB01 A03FA01 A07DA03
ED ED ED ED
L 1 (Mild) L 3 (Severe) L 2 (Moderate) L1 (Mild)
ATC code
Thai NLEM
Cardiovascular system Amlodipine C08CA01 Prazosin C02CA01 Nifedipine C08CA05 Digoxin C01AA05 Spironolactone C03DA01 Doxazosin C02CA04 Methyldopa C02AB01 Verapamil C08DA01 Amiodarone C01BD01 Diltiazem C08DB01 Central Nervous System Lorazepam N05BA06 Amitriptyline N06AA09 Diazepam N05BA01 Phenobarbital N03AA02 Anticholinergics (excluded TCAs) Chlorpheniramine R06AB04 Hydroxyzine N05BB01 Central Nervous System Cyproheptadine R06AX02 Diphenhydramine R06AA02 Endocrine System Pioglitazone A10BG03 Glibenclamide A10BB01 Other Codeine R05DA04 Trihexyphenidyl N04AA01
(79.4) (20.6) (53.8) (18.3) (12.7) (12.1) (5.0) (3.5) (1.4) (0.4) (0.3) (0.14) (43.3) (29.8) (10.9) (2.5) (0.1)
Total n ¼ 13,274 (%)
PIM level 60-74 years
10,536 2738 7140 2432 1679 1610 665 466 190 47 33 18 5755 3958 1448 337 12
75 years
ED ED ED ED ED ED ED ED ED ED
L L L L L L L L L L
2 2 2 2 2 2 2 2 2 2
(Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate) (Moderate)
ED ED ED ED
L L L L
1 2 1 2
(Mild) (Moderate) (Mild) (Moderate)
ED ED
L 1 (Mild) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
ED ED
L 1 (Mild) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
ED ED
L 2 (Moderate) L 2 (Moderate)
ED ED
L 2 (Moderate) L 1 (Mild)
L 2 (Moderate) L 2 (Moderate)
L 2 (Moderate)
5451 4259 446 337 151 96 73 42 24 18 5 3626 1574 1280 760 12 3053 1622 887 3626 508 36 803 530 273 186 110 76
(41.0) (32.1) (3.4) (2.5) (1.1) (0.7) (0.5) (0.3) (0.2) (0.1) (0.1) (27.3) (11.9) (9.6) (5.7) (0.1) (23.0) (12.2) (6.7) (27.3) (3.8) (0.3) (6.1) (4.0) (2.1) (1.4) (0.8) (0.6)
% Most frequently PIM ¼ (Number of patients who received PIM x 100)/total patient. ATC ¼ Anatomical Therapeutic Chemical Classification System. NLEM ¼ National list Essential medicine, ED ¼ Essential drug, NED ¼ Non-essential drug. Level 1(Mild): use within condition or short term use or with intensive monitoring. Level 2 (Moderate): not recommend, avoid by using alternative choices. Level 3 (Severe): Not recommend, no benefit, L ¼ level. e Elderly patients receive PIM more than one.
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Please cite this article in press as: Prasert V, et al., Applying the Lists of Risk Drugs for Thai Elderly (LRDTE) as a mechanism to account for patient age and medicine severity in assessing potentially inappropriate medication use, Research in Social and Administrative Pharmacy (2017), http:// dx.doi.org/10.1016/j.sapharm.2017.05.012