Metric aims to reduce polypharmacy in older adults


A new measure may help improve rates of polypharmacy in older adults through the identification of low-value prescribing practices.

Using data from 527 low-value prescribing recommendations, researchers developed Evaluating Opportunities to Decrease Low-Value Prescribing (EVOLV-Rx), a metric that aims to improve the detection of low-value prescribing practices, reduce polypharmacy and allow adults to receive low value prescriptions. value care. The results of the qualitative study have been published in JAMA network open.

It is estimated that in the United States more than $100 billion is spent annually on low-value care, with Medicare beneficiaries accounting for up to 43% of that total. However, previous research on low-value care has primarily focused on tests and procedures while excluding the prescription of low-value drugs.

Moreover, about 40% of the elderly are subjected to polypharmacy (taking at least 5 drugs simultaneously), while between 30% and 50% have been prescribed a potentially inappropriate drug.

In the present study, researchers developed EVOLV-Rx by generating criteria to detect candidate low-value prescribing practices. They then used an online modified Delphi approach to bring together a panel of physicians and pharmacists to codify the final components of the model, they explained.

In the first stage of the study, they identified prescribing practices whose costs or harms generally outweighed the benefits for people aged 65 and older. To do this, they assessed the Choosing Wisely Canada recommendations, the Beers Criteria, and Fit for the Aged List, among other compilations.

“We incorporated the results of 3 qualitative studies (which were conducted by some of us and other members of our research team), which used focus groups with patients and caregivers as well as interviews semi-structured with primary care physicians to characterize their perspectives on specific low-value prescription examples,” the authors wrote.

Both sensitive and specific criteria were applied to define each candidate low-value prescribing practice, while a panel of 15 physicians and pharmacists met to build consensus and refine criteria to identify practices most salient low-value prescription for the metric. The panel met 3 times between January 1 and March 31, 2021.

“Candidate low-value prescribing practices were scored as follows: 1 to 3, indicating low validity or utility; 3.5 to 6, validity or usefulness uncertain; and 6.5 to 9, high validity or utility,” they added.

Of the original 527 recommendations identified, 27 were considered for inclusion in the metric. The researchers found:

  • After the first round, 18 candidate practices were evaluated by the panel as having high scientific validity and clinical utility (scores ≥ 6.5)
  • After second-round panel deliberations, the screening criteria for 19 candidate practices were revised
  • After round 3, 18 candidate practices met the inclusion criteria, receiving final median scores of 6.5 or higher for scientific validity and clinical utility
  • Of the practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥ 6.5) but uncertain clinical utility (scores

The researchers believe the tool will help health systems, third-party payers and policymakers reduce low-value prescriptions in a clinically sound and broadly applicable way, they said.

All of the practices included were decided based on the varied perspectives of patients, caregivers, and practicing physicians. Factors assessed included specific medications and their adverse effects, in addition to medical comorbidities that may make older patients susceptible to low-value prescribing. Cumbersome and expensive preparation and administration methods were also considered.

Overall, the tool “contains a set of quality indicators that can be scaled and automated to detect low-value prescriptions in large administrative or clinical datasets for thousands of patients,” noted the authors.

The use of EVOLV-Rx does not preclude the application of more traditional tools and has not been fully operationalized for use in administrative requests or electronic health record data, which is a limitation. Each of the components of the metric may also not apply to all forms of health data or to all populations.


Radomski TR, Decker A, Khodyakov D, et al. Development of a metric to detect and decrease low value prescribing in the elderly. JAMA Netw Open. Published online February 15, 2022. doi:10.1001/jamanetworkopen.2021.48599


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