The association between socioeconomic status and use of potentially inappropriate medications in older adults
Jimin Hwang MD, MPH
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Search for more papers by this authorBeini Lyu MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Search for more papers by this authorShoshana Ballew PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorJosef Coresh MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorMorgan E. Grams MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Division of Nephrology, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorDavid Couper PhD
Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Search for more papers by this authorPamela Lutsey PhD
Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
Search for more papers by this authorCorresponding Author
Jung-Im Shin MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Correspondence
Jung-Im Shin, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St, Suite 2-600 (room 2-204), Baltimore, MD 21287, USA.
Email: [email protected]
Search for more papers by this authorJimin Hwang MD, MPH
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Search for more papers by this authorBeini Lyu MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Search for more papers by this authorShoshana Ballew PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorJosef Coresh MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorMorgan E. Grams MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Division of Nephrology, Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland, USA
Search for more papers by this authorDavid Couper PhD
Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
Search for more papers by this authorPamela Lutsey PhD
Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, Minnesota, USA
Search for more papers by this authorCorresponding Author
Jung-Im Shin MD, PhD
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, Maryland, USA
Correspondence
Jung-Im Shin, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument St, Suite 2-600 (room 2-204), Baltimore, MD 21287, USA.
Email: [email protected]
Search for more papers by this authorThis paper was presented as a poster at the American Heart Association EPI|Lifestyle Conference 2022.
Abstract
Background
Potentially inappropriate medication (PIM) use is an important public health problem, particularly among older adults who may need multiple pharmacologic therapies for various chronic conditions. As socioeconomic status (SES) affects the quality of healthcare that individuals receive, SES may be associated with the use of PIM in older adults. This study aimed to determine whether low SES is associated with increased use of PIM.
Methods
We studied 4927 participants (aged 66–90 years) who were on at least one medication at visit five (2011–2013) of the Atherosclerosis Risk in Communities Study. We created a cumulative SES score categorized as high (7–9), middle (3–6), and low (0–2) based on education, income, and area deprivation index. We use multivariable logistic regression to examine the associations between SES and use of two or more PIM for older adults, defined by the 2019 Beers Criteria.
Results
A total of 31.0% and 6.9% of the participants used one or more PIM and two or more PIM, respectively. After adjusting for demographic characteristics and insurance type, low cumulative SES score was associated with significantly greater use of two or more PIM (odds ratio [OR] = 1.83 [95% confidence interval (CI) 1.18–2.86]), as was middle cumulative SES score (OR = 1.40 [95% CI 1.06–1.83]), compared to high cumulative SES score. The results remained significant after further adjusting for comorbidities and medication burden for low cumulative SES score (OR = 1.66 [95%CI 1.02–2.71]).
Conclusions
We found that lower SES was associated with greater use of PIM among older adults independent of their medication burden and comorbidities, suggesting socioeconomic disparities in quality of medication management. Focused efforts targeting older adults with low SES to reduce PIM use may be needed to prevent adverse drug events.
CONFLICT OF INTEREST
The authors declare that there is no conflict of interest.
Supporting Information
| Filename | Description |
|---|---|
| jgs18165-sup-0001-supinfo.pdfPDF document, 659.6 KB | Appendix S1. PIM definitions, population characteristics, and subgroup analysis. Supplementary Table S1: Medication class and generic names of PIM as defined in the AGS Beers Criteria 2019. Supplementary Table S2: Baseline characteristics of the ARIC study population by ADI. Supplementary Table S3: Baseline characteristics of the ARIC study population by education. Supplementary Table S4: Baseline characteristics of the ARIC study population by income. Supplementary Table S5: The number of PIM by the number of comorbidities. Supplementary Table S6: Proportion using PIM by class as defined in the AGS Beers Criteria 2019. Supplementary Table S7: Use of specific appropriate medications by SES in patients with CHD, AF, albuminuria, and HF, respectively. Supplementary Figure S1: Study population. Supplementary Figure S2: Directed acyclic graph (DAG) illustrating the hypothesized causal pathways of SES on PIM use. |
Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Motter FR, Fritzen JS, Hilmer SN, Paniz ÉV, Paniz VMV. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria. Eur J Clin Pharmacol. 2018; 74(6): 679-700. doi:10.1007/s00228-018-2446-0
- 2Milton JC, Hill-Smith I, Jackson SHD. Prescribing for older people. BMJ. 2008; 336(7644): 606-609. doi:10.1136/bmj.39503.424653.80
- 3Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf. 2014; 13(1): 57-65. doi:10.1517/14740338.2013.827660
- 4Akazawa M, Imai H, Igarashi A, Tsutani K. Potentially inappropriate medication use in elderly Japanese patients. Am J Geriatr Pharmacother. 2010; 8(2): 146-160. doi:10.1016/j.amjopharm.2010.03.005
- 5Lin HY, Liao CC, Cheng SH, Wang PC, Hsueh YS. Association of potentially inappropriate medication use with adverse outcomes in ambulatory elderly patients with chronic diseases: experience in a Taiwanese medical setting. Drugs Aging. 2008; 25(1): 49-59. doi:10.2165/00002512-200825010-00006
- 6Koyama A, Steinman M, Ensrud K, Hillier TA, Yaffe K. Long-term cognitive and functional effects of potentially inappropriate medications in older women. J Gerontol A Biol Sci Med Sci. 2014; 69(4): 423-429. doi:10.1093/gerona/glt192
- 7Weir DL, Lee TC, McDonald EG, et al. Both new and chronic potentially inappropriate medications continued at hospital discharge are associated with increased risk of adverse events. J Am Geriatr Soc. 2020; 68(6): 1184-1192. doi:10.1111/jgs.16413
- 8Stockl KM, Le L, Zhang S, Harada AS. Clinical and economic outcomes associated with potentially inappropriate prescribing in the elderly. Am J Manag Care. 2010; 16(1): e1-e10.
- 9Secora A, Alexander GC, Ballew SH, Coresh J, Grams ME. Kidney function, polypharmacy, and potentially inappropriate medication use in a community-based cohort of older adults. Drugs Aging. 2018; 35(8): 735-750. doi:10.1007/s40266-018-0563-1
- 10Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006; 354(11): 1147-1156. doi:10.1056/NEJMsa044464
- 11Begley C, Basu R, Lairson D, et al. Socioeconomic status, health care use, and outcomes: persistence of disparities over time. Epilepsia. 2011; 52(5): 957-964. doi:10.1111/j.1528-1167.2010.02968.x
- 12Shin JI, Wang D, Fernandes G, et al. Trends in receipt of American Diabetes Association guideline-recommended care among U.S. adults with diabetes: NHANES 2005-2018. Diabetes Care. 2021; 44(6): 1300-1308. doi:10.2337/dc20-2541
- 13Ceasar JN, Ayers C, Andrews MR, et al. Unfavorable perceived neighborhood environment associates with less routine healthcare utilization: data from the Dallas heart study. PLoS One. 2020; 15(3):e0230041. doi:10.1371/journal.pone.0230041
- 14Bender AM, Kawachi I, Jørgensen T, Pisinger C. Neighborhood deprivation is strongly associated with participation in a population-based health check. PLoS One. 2015; 10(6):e0129819. doi:10.1371/journal.pone.0129819
- 15Willems S, Peersman W, De Maeyer P, Buylaert W, De Maeseneer J, De Paepe P. The impact of neighborhood deprivation on patients' unscheduled out-of-hours healthcare seeking behavior: a cross-sectional study. BMC Fam Pract. 2013; 14: 136. doi:10.1186/1471-2296-14-136
- 16Sudore RL, Mehta KM, Simonsick EM, et al. Limited literacy in older people and disparities in health and healthcare access. J Am Geriatr Soc. 2006; 54(5): 770-776. doi:10.1111/j.1532-5415.2006.00691.x
- 17Toivo T, Dimitrow M, Puustinen J, et al. Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness. BMC Geriatr. 2018; 18(1): 74. doi:10.1186/s12877-018-0737-z
- 18Aloh HE, Onwujekwe OE, Aloh OG, Okoronkwo IL, Nweke CJ. Impact of socioeconomic status on patient experience on quality of care for ambulatory healthcare services in tertiary hospitals in Southeast Nigeria. BMC Health Serv Res. 2020; 20(1): 473. doi:10.1186/s12913-020-05332-0
- 19Mamdani MM, Tu K, Austin PC, Alter DA. Influence of socioeconomic status on drug selection for the elderly in Canada. Ann Pharmacother. 2002; 36(5): 804-808. doi:10.1345/aph.1A044
- 20Lemmens VEPP, van Halteren AH, Janssen-Heijnen MLG, Vreugdenhil G, Repelaer van Driel OJ, Coebergh JWW. Adjuvant treatment for elderly patients with stage III colon cancer in the southern Netherlands is affected by socioeconomic status, gender, and comorbidity. Ann Oncol. 2005; 16(5): 767-772. doi:10.1093/annonc/mdi159
- 21Neuner JM, Kong A, Blaes A, et al. The association of socioeconomic status with receipt of neoadjuvant chemotherapy. Breast Cancer Res Treat. 2019; 173(1): 179-188. doi:10.1007/s10549-018-4954-0
- 22Odubanjo E, Bennett K, Feely J. Influence of socioeconomic status on the quality of prescribing in the elderly – a population based study. Br J Clin Pharmacol. 2004; 58(5): 496-502. doi:10.1111/j.1365-2125.2004.02179.x
- 23The atherosclerosis risk in communities (ARIC) study: design and objectives. The ARIC investigators. Am J Epidemiol. 1989; 129(4): 687-702.
- 24Singh GK. Area deprivation and widening inequalities in US mortality, 1969-1998. Am J Public Health. 2003; 93(7): 1137-1143. doi:10.2105/ajph.93.7.1137
- 25 By the 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. American geriatrics society 2019 updated AGS beers criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2019; 67(4): 674-694. doi:10.1111/jgs.15767
- 26 American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012; 60(4): 616-631. doi:10.1111/j.1532-5415.2012.03923.x
- 27Hall RK, Blumenthal JB, Doerfler RM, et al. Risk of potentially inappropriate medications in adults with CKD: findings from the chronic renal insufficiency cohort (CRIC) study. Am J Kidney Dis. 2021; 78(6):837-845.e1. doi:10.1053/j.ajkd.2021.03.019
- 28Lip GYH, Nieuwlaat R, Pisters R, Lane DA, Crijns HJGM. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010; 137(2): 263-272. doi:10.1378/chest.09-1584
- 29Disease K, Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group. KDIGO 2012 clinical practice guideline for the evaluation and Management of Chronic Kidney Disease. Off J Int Soc Nephrol. 2013; 3(1):1-163. https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf
- 30Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the Management of Heart Failure. Circulation. 2013; 128(16): e240-e327. doi:10.1161/CIR.0b013e31829e8776
- 31Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977; 1(3): 385-401. doi:10.1177/014662167700100306
10.1177/014662167700100306 Google Scholar
- 32Inker LA, Eneanya ND, Coresh J, et al. New creatinine- and cystatin C-based equations to estimate GFR without race. N Engl J Med. 2021; 385(19): 1737-1749. doi:10.1056/NEJMoa2102953
- 33Morin L, Laroche ML, Texier G, Johnell K. Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review. J Am Med Dir Assoc. 2016; 17(9): 862.e1-862.e9. doi:10.1016/j.jamda.2016.06.011
- 34Fralick M, Bartsch E, Ritchie CS, Sacks CA. Estimating the use of potentially inappropriate medications among older adults in the United States. J Am Geriatr Soc. 2020; 68(12): 2927-2930. doi:10.1111/jgs.16779
- 35White K, Haas JS, Williams DR. Elucidating the role of place in health care disparities: the example of racial/ethnic residential segregation. Health Serv Res. 2012; 47(3 Pt 2): 1278-1299. doi:10.1111/j.1475-6773.2012.01410.x
- 36Monteiro CN, Lima MG, Szwarcwald CL, Bastos TF, Barros MB d A. Use of antihypertensive and antidiabetic medications in Brazil: an analysis of socioeconomic differences. National Health Survey, 2013. Rev Bras Epidemiol. 2019; 22Suppl 02(Suppl 02):E190014.SUPL.2. doi:10.1590/1980-549720190014.supl.2
- 37Roth MT, Esserman DA, Ivey JL, Weinberger M. Racial disparities in the quality of medication use in older adults: baseline findings from a longitudinal study. J Gen Intern Med. 2010; 25(3): 228-234. doi:10.1007/s11606-009-1180-9
- 38Lavizzo-Mourey RJ, Besser RE, Williams DR. Understanding and mitigating health inequities — past, current, and future directions. N Engl J Med. 2021; 384(18): 1681-1684. doi:10.1056/NEJMp2008628
- 39de Boer WIJ, Buskens E, Koning RH, Mierau JO. Neighborhood socioeconomic status and health care costs: a population-wide study in The Netherlands. Am J Public Health. 2019; 109(6): 927-933. doi:10.2105/AJPH.2019.305035
- 40Iwasa H, Yoshida Y. Personality and health literacy among community-dwelling older adults living in Japan. Psychogeriatrics. 2020; 20(6): 824-832. doi:10.1111/psyg.12600
- 41Hoebel J, Rattay P, Prütz F, Rommel A, Lampert T. Socioeconomic status and use of outpatient medical care: the case of Germany. PLoS One. 2016; 11(5):e0155982. doi:10.1371/journal.pone.0155982
- 42Deng Q, Liu W. Physical exercise, social interaction, access to care, and community service: mediators in the relationship between socioeconomic status and health among older patients with diabetes. Front Public Health. 2020; 8: 625. doi:10.3389/fpubh.2020.589742
- 43Kangovi S, Barg FK, Carter T, Long JA, Shannon R, Grande D. Understanding why patients of low socioeconomic status prefer hospitals over ambulatory care. Health Aff (Millwood). 2013; 32(7): 1196-1203. doi:10.1377/hlthaff.2012.0825
- 44Cho HE, Wang L, Chen JS, Liu M, Kuo CF, Chung KC. Investigating the causal effect of socioeconomic status on quality of care under a universal health insurance system - a marginal structural model approach. BMC Health Serv Res. 2019; 19(1): 987. doi:10.1186/s12913-019-4793-7
- 45Meyers DS, Mishori R, McCann J, Delgado J, O'Malley AS, Fryer E. Primary care physicians' perceptions of the effect of insurance status on clinical decision making. Ann Fam Med. 2006; 4(5): 399-402. doi:10.1370/afm.574
- 46Bernheim SM, Ross JS, Krumholz HM, Bradley EH. Influence of patients' socioeconomic status on clinical management decisions: a qualitative study. Ann Fam Med. 2008; 6(1): 53-59. doi:10.1370/afm.749
- 47Wood E, Montaner JSG, Chan K, et al. Socioeconomic status, access to triple therapy, and survival from HIV-disease since 1996. AIDS. 2002; 16(15): 2065-2072. doi:10.1097/00002030-200210180-00012
- 48LeBrón AM, Schulz AJ, Mentz G, Gamboa C, Reyes A. Antihypertensive medication use: implications for inequities in cardiovascular risk and opportunities for intervention. J Health Care Poor Underserved. 2018; 29(1): 192-201. doi:10.1353/hpu.2018.0013
- 49Afulani P, Herman D, Coleman-Jensen A, Harrison GG. Food insecurity and health outcomes among older adults: the role of cost-related medication underuse. J Nutr Gerontol Geriatr. 2015; 34(3): 319-342. doi:10.1080/21551197.2015.1054575
- 50Loyola Filho AI, de Firmo JOA, Mambrini JV d M, et al. Cost-related underuse of medications in older adults: ELSI-Brazil. Rev Saude Publica. 2018; 52Suppl 2(Suppl 2): 8 s. doi:10.11606/S1518-8787.2018052000622
10.11606/s1518-8787.2018052000622 Google Scholar
- 51Piette JD, Wagner TH, Potter MB, Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Med Care. 2004; 42(2): 102-109. doi:10.1097/01.mlr.0000108742.26446.17
- 52Essien UR, Dusetzina SB, Gellad WF. A policy prescription for reducing health disparities-achieving Pharmacoequity. JAMA. 2021; 326(18): 1793-1794. doi:10.1001/jama.2021.17764
- 53Mahajan S, Caraballo C, Lu Y, et al. Trends in differences in health status and health care access and affordability by race and ethnicity in the United States, 1999-2018. JAMA. 2021; 326(7): 637-648. doi:10.1001/jama.2021.9907
- 54Sumarsono A, Lalani H, Segar MW, et al. Association of Medicaid Expansion with Rates of utilization of cardiovascular therapies among Medicaid beneficiaries between 2011 and 2018. Circ Cardiovasc Qual Outcomes. 2021; 14(1):e007492. doi:10.1161/CIRCOUTCOMES.120.007492
- 55Essien UR, Holmes DN, Jackson LR, et al. Association of Race/ethnicity with Oral anticoagulant use in patients with atrial fibrillation: findings from the outcomes registry for better informed treatment of atrial fibrillation II. JAMA Cardiol. 2018; 3(12): 1174-1182. doi:10.1001/jamacardio.2018.3945
- 56Haut ER, Aboagye JK, Shaffer DL, et al. Effect of real-time patient-centered education bundle on Administration of Venous Thromboembolism Prevention in hospitalized patients. JAMA Netw Open. 2018; 1(7):e184741. doi:10.1001/jamanetworkopen.2018.4741
- 57Kripalani S, Robertson R, Love-Ghaffari MH, et al. Development of an illustrated medication schedule as a low-literacy patient education tool. Patient Educ Couns. 2007; 66(3): 368-377. doi:10.1016/j.pec.2007.01.020
- 58Clifford S, Barber N, Elliott R, Hartley E, Horne R. Patient-centred advice is effective in improving adherence to medicines. Pharm World Sci. 2006; 28(3): 165-170. doi:10.1007/s11096-006-9026-6
- 59Smith C, Porter A, Biddle J, Balamurugan A, Smith MR. The Arkansas minority Barber and beauty shop health initiative: meeting people where they are. Prev Chronic Dis. 2020; 17: E153. doi:10.5888/pcd17.200277
- 60Briggs M, Morzinski JA, Ellis J. Influences of a church-based intervention on falls risk among seniors. WMJ. 2017; 116(3): 161-164.
- 61Floyd TD, DuHamel KN, Rao J, Shuk E, Jandorf L. Acceptability of a salon-based intervention to promote colonoscopy screening among African American women. Health Educ Behav. 2017; 44(5): 791-804. doi:10.1177/1090198117726571
