Facility-level variation in potentially inappropriate prescribing for older veterans

Abstract

Objectives: To describe facility-level variation in two measures of potentially inappropriate prescribing prevalent in Veterans Affairs (VA) facilities-exposure to high-risk medications in elderly adults (HRME) and drug-disease interactions (Rx-DIS)-and to identify facility characteristics associated with high-quality prescribing.

Design: Cross-sectional.

Setting: VA Healthcare System.

Participants: Veterans aged 65 and older with at least one inpatient or outpatient visit in 2005-2006 (N = 2,023,477; HRME exposure) and a subsample with a history of falls or hip fractures, dementia, or chronic renal failure (n = 305,059; Rx-DIS exposure).

Measurements: Incident use of any HRME (iHRME) and incident Rx-DIS (iRx-DIS) and facility-level rates and facility-level predictors of iHRME and iRx-DIS exposure, adjusting for differences in patient characteristics.

Results: Overall, 94,692 (4.7%) veterans had iHRME exposure. At the facility level, iHRME exposure ranged from 1.6% at the lowest facility to 12.8% at the highest (median 4.7%). In the subsample, 9,803 (3.2%) veterans had iRx-DIS exposure, with a facility-level range from 1.3% to 5.8% (median 3.2%). In adjusted analyses, veterans seen in facilities with formal geriatric education had lower odds of iHRME (odds ratio (OR) = 0.86, 95% confidence interval (CI) = 0.77-0.96) and iRx-DIS (OR = 0.95, 95% CI = 0.88-1.01). Patients seen in facilities caring for fewer older veterans had greater odds of iHRME (OR = 1.54, 95% CI = 1.35-1.75) and iRx-DIS exposure (OR = 1.22, 95% CI = 1.11-1.33).

Conclusion: Substantial variation in the quality of prescribing for older adults exists across VA facilities, even after adjusting for patient characteristics. Higher-quality prescribing is found in facilities caring for a larger number of older veterans and facilities with formal geriatric education.

Figure 1

Facility Characteristics Associated with Incident HRME (High Risk Medications in the Elderly) Exposure. Odds ratios and 95% confidence intervals from the random effects logistic regression models are plotted.* *Adjusted for patient-level age, gender, race/ethnicity, presence of mental comorbidity, copayment eligibility, history of emergency room visits and hospitalizations in the prior year, number of medications in the prior year, and receipt of geriatric care.

Figure 2

Facility Characteristics Associated with Incident Rx-DIS (Drug-Disease Interactions) Exposure. Odds ratios and 95% confidence intervals from the random effects logistic regression models are plotted.* *Adjusted for patient-level age, gender, race/ethnicity, presence of mental comorbidity, copayment eligibility, history of emergency room visits and hospitalizations in the prior year, number of medications in the prior year, and receipt of geriatric care.