Medication use situation and the development of quality indicator for medication use in elderly in Thailand

Abstract

The objectives of this study were to explore the situation of medication use in elderly in tertiary care hospital in Thailand, and to develop and assess the quality indicator for evaluating medication use for elderly in Thailand. The situation presented both the medication use patterns of the elderly and the appropriateness of medication use according to high-risk medication use criteria. The cross-sectional descriptive study was conducted by using the computerized databases of elderly patients who were more than 60 years old, from four tertiary hospitals, during 1st October 2007 to 30th September 2008. To evaluate the appropriateness of medication use, the ATC, 4th level code and the Winit-watjana high-risk medication use criteria were used. Microsoft access 2003 for window was used for database management and all statistical computing was performed using SPSS software version 17.0 (SPSS Co., Ltd, Bangkok, Thailand).. A modified Delphi technique was use for develop the prescribing quality indicators for Thai elderly (PQI-Th), and the RAND appropriateness method also used in this part. The process to develop the PQI-Th was composed of four processes; 6 steps, which are preparation process, selection process, rating process and adjustment process. ACOVE quality indicator and STOPP combine with result from situation study were used as a starting point for develop PQI-Th. The total115, 047 elderly patients were included in the study. Female was 55.74 percent of the elderly The average age of the patients was 70.26 years. Most of the patients (87%) used some kinds of health insurances and 50% were in the Universal Coverage Scheme. The average number of visit was 3.5 times per person per year. Hypertensive disease was the majority of the underlying diseases, and 60% of the patients were diagnosed having two or more diseases. Thirty eight percent of the total prescription was counted as poly-pharmacy (≥ 5 medications in a prescription). More than 70% of medication prescribed was the medication in the National List of Essential Medicines (NLEM). Approximately 50% of the medication was in alimentary and metabolism and in cardiovascular group, particularly simvastatin was the most common prescribed. Duplication medication found in 117 chemical subgroups. Most common duplication found was medication in anti-vertigo preparation. With the Winit-watjana criteria, 14.68% of all the prescriptions were recorded as inappropriate medication prescription (IMP) and 1% of total prescriptions reported drug-drug interactions. The most common medication should be avoided found was NSAIDs group, especially diclofenac sodium. Prescribing NSAIDs together with aspirin was the majority of drug-drug interactions. The PQIs classified into 9 categories according to system of disease. After two round rating, 301 statement of QIs (231 QI from ACOVE, 65 QI from STOPP and 5 QIs from phase 1 analysis), 101 statements and 86 statements were selected in first step and in the second step, respectively. Five PQIs were edited by expert during first round and 3 PQIs were added in this process. After adjusted the PQI with criteria, 42 practice statements were accepted with high priority appropriate both importance and feasibility of implement PQIs. The finding from this study showed the overall picture of medication prescribing for elderly, at ambulatory care clinic. The information, i.e. patient characteristics, number of medication per prescription, type of medications in the prescription, duplication therapy and the level of appropriateness were valuable for presenting the quality of medication use among the elderly in Thailand. The PQI-Th was developed base on well-known indicators and problem of medication use in real practice. Forty two items of indicators were established.