Expanded Rationale

National guidelines have been published that identify a number of medications that are potentially inappropriate for use in the elderly (PIMs) because they are either not effective, cause harmful side effects, and/or other more suitable medications are available for treating the same medical conditions¹ While a variety of agents are included in this well accepted list, many share the common pharmacologic property of being "anticholinergic", and contribute to such undesirable effects as delirium, falls, low blood pressure, urinary retention, and cardiac arrhythmias, all of which can be debilitating or contribute to catastrophic events in the frail elderly^2,3. In addition to overt patient harm, adverse effects of the drugs may dramatically affect patient quality of life by diminishing their ability to "age in place".

Efforts to avoid such ineffective yet harmful agents in skilled nursing facilities have successfully improved care but, as of yet, no such effort has been systematically applied to the community dwelling elderly⁴. In fact, the use of some of these agents has perhaps increased in recent years, suggesting that the application of a similar intervention to Medicare Part D beneficiaries will be highly beneficial.

Therefore, to improve the overall quality of prescribing in Medicare Part D beneficiaries, the presence of dispensed prescriptions for specific anticholinergic agents (AAs) will be utilized as the primary quality indicators for this proposed project. An additional indicator, the presence of important drug-drug interactions, will also be assessed. By limiting the focus of the project to a select group of frequently prescribed agents within the broader Beers list, the program will be able to provide specific, evidence-based interventions that have the potential of realizing clinically and socially relevant benefits across a large segment of beneficiaries.

Zhan C, Sangl J, Bierman AS, et al. Potentially inappropriate medication use in the community-dwelling elderly: findings from the 1996 Medical Expenditure Panel Survey. JAMA. Dec 12 2001;286(22):2823-2829.
Feinberg M. The problems of anticholinergic adverse effects in older patients. Drugs Aging. Jul-Aug 1993;3(4):335-348.
Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry. 2001;62 Suppl 21:11-14.
Goulding MR. Inappropriate medication prescribing for elderly ambulatory care patients. Arch Intern Med. Feb 9 2004;164(3):305-312.
Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. Dec 8-22 2003;163(22):2716-2724.