【文献Abstract】高齢者への不適切な処方の影響

〈要点〉

・プライマリ・ケアの現場における高齢者への不適切な処方は、死亡率には影響はなかったが、救急外来への受診や薬の副作用、ADLの低下やQOLの低下、入院率の上昇に影響を及ぼす可能性がある

〈雑感〉

・日本の現状をみるとフリーアクセスがであることから患者自身が病院を選択しているため主治医を持たないことが多く、多重受診となっている。そして多重受診であればあるほど多剤になっている。最終的に通院が難しくなり訪問診療となってすべての薬剤を請け負うと本当に多剤となっており「本当に必要なのか？！」と思うことが多い。

・日本の医療システムを改善することもそうだが、医師としても「処方してあげる＝患者のためになる」と思っている人も多い印象がある。私自身はある意味でこれは「責任逃れ」をしているような気がしてならない。患者の訴えを受け止めているのではなく、訴えに対し「やっかいだな」と思って処方に逃げる、という印象を受けるから。そう考えると、医師のプロフェッショナリズムの教育がまだ足りないのかもとも思う。

〈論文〉

Ann Fam Med. 2019 May;17(3):257-266. doi: 10.1370/afm.2373.
Potentially Inappropriate Prescribing Among Older Persons: A Meta-Analysis of Observational Studies.
Liew TM, Lee CS, Goh Shawn KL, Chang ZY.

Abstract
PURPOSE:
Potentially inappropriate prescribing (PIP) is a common yet preventable medical error among older persons in primary care. It is uncertain whether PIP produces adverse outcomes in this population, however. We conducted a systematic review with meta-analysis to pool the adverse outcomes of PIP specific to primary care.

METHOD:
We searched PubMed, Embase, CINAHL, Web of Science, Scopus, PsycINFO, and previous review articles for studies related to "older persons," "primary care," and "inappropriate prescribing." Two reviewers selected eligible articles, extracted data, and evaluated the risk of bias. Meta-analysis was conducted to pool studies with similar PIP criteria and outcome measures.

RESULTS:
Of the 2,804 articles identified, we included 8 articles with a total of 77,624 participants. All included studies had cohort design and low risk of bias. Although PIP did not affect mortality (risk ratio [RR] 0.98; 95% CI, 0.93-1.05), it was significantly associated with the other available outcomes, including emergency room visits (RR 1.63; 95% CI, 1.32-2.00), adverse drug events (RR 1.34; 95% CI, 1.09-1.66), functional decline (RR 1.53; 95% CI, 1.08-2.18), health-related quality of life (standardized mean difference -0.26; 95% CI, -0.36 to -0.16), and hospitalizations (RR 1.25; 95% CI, 1.09-1.44). A majority of the pooled estimates had negligible heterogeneity.

CONCLUSIONS:
This meta-analysis provides consolidated evidence on the wide-ranging impact of PIP among older persons in primary care. It highlights the need to identify PIP in primary care, calls for further research on PIP interventions in primary care, and points to the need to consider potential implications when deciding on the operational criteria of PIP.

© 2019 Annals of Family Medicine, Inc.

KEYWORDS:
adverse outcomes; aged; family physicians; family practice; general practice; general practitioners; inappropriate prescribing; medication errors; meta-analysis; primary health care; systematic review

PMID: 31085530 DOI: 10.1370/afm.2373