The quality of pharmacologic care for vulnerable older patients
The quality of pharmacologic care for vulnerable older patients
复制标题
DOI：
10.7326/0003-4819-140-9-200405040-00011
复制
发表时间：
2004-05-04
影响因子：
39.2
通讯作者：
Wenger, NS
中科院分区：
文献类型：
--
作者：
Higashi, T;Shekelle, PG;Wenger, NS
背景：虽然药物治疗对老年患者的医疗护理至关重要，但药物在该年龄组中可能具有相当大的毒性。到目前为止，研究集中在不适当的处方和政策努力的目的是访问，但没有全面的测量质量的药理学管理使用明确的标准已经performed.Objective. To评估范围广泛的药理学护理过程中脆弱的老年患者。设计：观察性队列研究。设置：2个管理的护理组织招募老年人。患者：1998年7月1日至1999年7月31日连续参加管理式医疗机构的65岁以上社区高危患者。测量：患者接受药物治疗4个领域43项质量指标所规定的治疗：1）处方指定药物; 2）避免不适当的药物; 3）教育，连续性和文件;和4）药物监测。在475名脆弱的老年患者中，372例（78%）患者同意参与研究，并有可提取的医疗记录。适当的药理学管理百分比范围从10%（记录非甾体抗炎药的风险）到100%心力衰竭患者避免使用短效钙通道阻滞剂，哮喘患者避免使用β受体阻滞剂。“避免不当用药”领域质量指标的通过率（97% [95% CI，96%至98%]）显著高于“处方指定药物”的通过率（50% [CI，45%至55%]）;“教育、连续性和文件”（81% [CI，79%至84%]）;和“药物监测”（64% [Cl，60%至68%]）。局限性：只有不到10名患者符合测量的许多质量指标，并且这些发现在2个管理式护理机构中对一般老年人群的普遍性是不确定的。未能开具指定药物，适当监测药物，记录必要信息，教育患者，和保持连续性是更常见的处方问题比使用不适当的药物在老年患者。
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.