Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly.
OBJECTIVE
To determine if inpatient or outpatient geriatric evaluation and management, as compared with usual care, reduces adverse drug reactions and suboptimal prescribing in frail elderly patients.


METHODS
The study employed a randomized 2 x 2 factorial controlled design. Subjects were patients in 11 Veterans Affairs (VA) hospitals who were > or =65 years old and met criteria for frailty (n = 834). Inpatient geriatric unit and outpatient geriatric clinic teams evaluated and managed patients according to published guidelines and VA standards. Patients were followed for 12 months. Blinded physician-pharmacist pairs rated adverse drug reactions for causality (using Naranjo's algorithm) and seriousness. Suboptimal prescribing measures included unnecessary and inappropriate drug use (Medication Appropriateness Index), inappropriate drug use (Beers criteria), and underuse.


RESULTS
For serious adverse drug reactions, there were no inpatient geriatric unit effects during the inpatient or outpatient follow-up periods. Outpatient geriatric clinic care resulted in a 35% reduction in the risk of a serious adverse drug reaction compared with usual care (adjusted relative risk = 0.65; 95% confidence interval: 0.45 to 0.93). Inpatient geriatric unit care reduced unnecessary and inappropriate drug use and underuse significantly during the inpatient period (P <0.05). Outpatient geriatric clinic care reduced the number of conditions with omitted drugs significantly during the outpatient period (P <0.05).


CONCLUSIONS
Compared with usual care, outpatient geriatric evaluation and management reduces serious adverse drug reactions, and inpatient and outpatient geriatric evaluation and management reduces suboptimal prescribing, in frail elderly patients.
Veterans Affairs Medical Center, Durham, North Carolina, USA. schma001@mc.duke.edu
Kenneth E
KE
Schmader
Joseph T
JT
Hanlon
Carl F
CF
Pieper
Richard
R
Sloane
Christine M
CM
Ruby
Jack
J
Twersky
Susan Dove
SD
Francis
Laurence G
LG
Branch
Catherine I
CI
Lindblad
Margaret
M
Artz
Morris
M
Weinberger
John R
JR
Feussner
Harvey Jay
HJ
Cohen
D000368:Aged; D019090:Case Management; D017723:Drug Utilization Review; D064420:Drug-Related Side Effects and Adverse Reactions; D005260:Female; D016330:Frail Elderly; D015577:Geriatric Assessment; D006300:Health Services Misuse; D006757:Hospital Units / Q000592:standards* / Q000706:statistics & numerical data; D006787:Hospitals, Veterans / Q000592:standards; D006801:Humans; D008297:Male; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010044:Outpatient Clinics, Hospital / Q000592:standards* / Q000706:statistics & numerical data; D012044:Regression Analysis; D014481:United States