Potentially Inappropriate Prescribing in Hospitalized Older Adult High-Cost Health Care Users: A Pilot Study

Background: High-cost health care users use disproportionate amounts of health care resources relative to the typical patient. It is unclear to what extent poor-quality prescribing, including potentially inappropriate prescribing (PIP), may be contributing to their adverse outcomes and health utilization costs. Objectives: To evaluate the prevalence of PIP and to explore its impact in older adult high-cost health care users. Methods: The charts of older adult high-cost health care users admitted to 2 academic hospitals in Ontario, Canada, in fiscal year 2015/16 were reviewed. Eligible patients were at least 66 years old with at least 5 emergency department visits and 3 hospital admissions in the previous year. A total of 243 patients met these criteria, of whom 100 were randomly selected for review. Cases of PIP were identified using explicit prescribing quality indicators, including the STOPP/START criteria. Types of PIP included potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). Log-linear regression was used to characterize the relationship between PIP and future health care utilization. Medications were reconciled to determine the proportion of PIP addressed by the time of discharge. Results: Eighty-nine of the 100 patients had at least 1 instance of PIP. In total, 276 PIMs and 54 PPOs were identified. Of the 271 instances of PIP identified on admission, only 38 (14%) were resolved by the time of hospital discharge. Each additional PPO was associated with a 1.43-fold increase in the rate of future emergency department visits (p < 0.001). Conclusions: The rate of PIP among older adult high-cost health care users was high. Despite frequent interactions with the health care system, many opportunities to improve the quality of prescribing for this vulnerable population were missed. Greater attention to medication optimization is needed.