Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review

Abstract

Background: Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized.

Methods: We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data.

Results: Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians.

Conclusions: Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.

Keywords: Overuse; acute care; inappropriate prescribing; long-term care.

Appendix Figure 1

Flow diagram of inclusion and exclusion process. * Reviewers did not need to agree on reason for exclusion