The quality of pharmacologic care for vulnerable older patients

Background: Although pharmacotherapy is critical to the medical care of older patients, medications can have considerable toxicity in this age group. To date, research has focused on inappropriate prescribing and policy efforts have aimed at access, but no comprehensive measurement of the quality of pharmacologic management using explicit criteria has been performed. Objective: To evaluate the broad range of pharmacologic care processes for vulnerable older patients. Design: Observational cohort study. Setting: 2 managed care organizations enrolling older persons. Patients: community-dwelling high-risk patients 65 years of age or older continuously enrolled in the managed care organizations from 1 July 1998 to 31 July 1999. Measurements: Patients' receipt of care as specified in 43 quality indicators covering 4 domains of pharmacologic care: 1) prescribing indicated medications; 2) avoiding inappropriate medications; 3) education, continuity, and documentation; and 4) medication monitoring. Results: Of 475 vulnerable older patients, 372 (78%) consented to participate and had medical records that could be abstracted.The percentage of appropriate pharmacologic management ranged from 10% for documentation of risks of nonsteroidal anti-inflammatory drugs to 100% for avoiding short-acting calcium-channel blockers in patients with heart failure and avoiding beta-blockers in patients with asthma. Pass rates for quality indicators in the "avoiding inappropriate medications" domain (97% [95% Cl, 96% to 98%]) were significantly higher than pass rates for "prescribing indicated medications" (50% [Cl, 45% to 55%]); "education, continuity, and documentation" (81% [Cl, 79% to 84%]); and "medication monitoring" (64% [Cl, 60% to 68%]). Limitations: Fewer than 10 patients were eligible for many of the quality indicators measured, and the generalizabiIity of these findings in 2 managed care organizations to the general geriatric population is uncertain. Conclusions: Failures to prescribe indicated medications, monitor medications appropriately, document necessary information, educate patients, and maintain continuity are more common prescribing problems than use of inappropriate drugs in older patients.