Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients - 12/03/24

Doi : 10.1016/j.annemergmed.2024.01.033

Rachel M. Skains, MD, MSPH ^a,^b, Jennifer L. Koehl, PharmD, BCPS ^c, Amer Aldeen, MD ^d, Christopher R. Carpenter, MD, MSc ^e, Cameron J. Gettel, MD, MHS ^f, Elizabeth M. Goldberg, MD, ScM ^g, Ula Hwang, MD, MPH ^f,^h, Keith E. Kocher, MD, MPH ⁱ, Lauren T. Southerland, MD, MPH ^j, Pawan Goyal, MD ^k, Carl T. Berdahl, MD, MS ^l, Arjun K. Venkatesh, MD, MBA ^f, Michelle P. Lin, MD, MPH ^m,^⁎
^a Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
^b Geriatric Research, Education and Clinical Center, Birmingham VAMC, Birmingham, AL
^c Department of Pharmacy, Massachusetts General Hospital, Boston, MA
^d US Acute Care Solutions, Canton, OH
^e Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
^f Department of Emergency Medicine, Yale University, New Haven, CT
^g Department of Emergency Medicine, University of Colorado, Aurora, CO
^h Geriatric Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY
ⁱ Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
^j Department of Emergency Medicine, The Ohio State University, Columbus, OH
^k Quality Division, American College of Emergency Physicians, Irving, TX
^l Department of Emergency Medicine, Cedars Sinai Medical Center, Los Angeles, CA
^m Department of Emergency Medicine, Stanford University, Palo Alto, CA

^∗Corresponding Author.

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Tuesday 12 March 2024

Abstract

Study objective

Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.

Methods

We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).

Results

For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic “Z” drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.

Conclusion

We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

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Plan

Introduction

Materials and Methods

Selection of Expert Panel

Initial Medication List

Modified Delphi Method

Finalization of the Geriatric Prescription List

Final Geriatric Prescription List

Limitations

Discussion

	Supervising editor: Timothy F. Platts-Mills, MD, MSc. Specific detailed information about possible conflict of interest for individual editors is available at editors.
	Author contributions: MPL, AKV, and PG conceived and designed the study and obtained research funding. MPL and AKV supervised data collection. RS collected, managed, and analyzed the data. RMS and MPL drafted the manuscript, and all authors contributed substantially to its revision. MPL takes responsibility for the paper as a whole.
	Data sharing statement: Data access will be considered on a case-by-case basis by email request to Dr. Michelle P. Lin at mplin@stanford.edu.
	Authorship: All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
	Funding and support: By Annals’ policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). RMS was supported by the National Institute on Aging (NIA) (R33AG058926) and the West Health Institute (WHI). CRC was supported by the NIA (R33AG058926, R61AG069822), the John A Hartford Foundation (JAHF), and the WHI. CJG was a Pepper Scholar with support from the Claude D. Pepper Older Americans Independence Center at Yale School of Medicine (P30AG021342) and the NIA (R03AG073988). EMG was supported by the NIA (K76AG059983). UH was supported by the NIA (R33AG058926, R33AG069822), the JAHF, and the WHI. KEK was supported by the Blue Cross Blue Shield of Michigan and Blue Care Network for a quality network in ED care, as well as the Agency for Healthcare Research and Quality, the National Heart, Lung, and Blood Institute (NHLBI), and the Department of Defense for other projects. LTS was supported by the NIA (K23AG061284). MPL was supported by the NHLBI (K23HL143042). This work was also supported by the American College of Emergency Physicians (ACEP). None of the funders played any role in the collection, analysis, interpretation of the data; preparation of the manuscript; and decision to submit the manuscript for publication. AKV reported support from the Centers for Medicare and Medicaid Services and Moore Foundation to develop hospital, health system and emergency care quality measures and rating systems. AKV and CJG also reported support from the JAHF to examine emergency care quality outside of this work. RMS, JLK, AA, CRC, EMG, UH, KEK, LTS, PG, CTB, and MPL had no financial conflicts of interest to disclose. CJG, KEK, AKV, CRC, and MPL reported leadership positions on ACEP Committees, including Quality and Patient Safety (CJG, KEK, AKV, MPL), Clinical Emergency Data Registry (AKV, MPL, CTB), Clinical Policy Committee (CRC) and Emergency Medicine Data Institute Board of Governors (AKV, MPL). AA and KEK also reported leadership positions on the Emergency Care Quality Measures Consortium. CRC also reported leadership positions with the Geriatric Emergency care Applied Research (GEAR) Network, Clinician-Scientists in Transdisciplinary Aging Research (Clin-STAR) Coordinating Center, ACEP Geriatric Emergency Department Accreditation Advisory Board, Journal of the American Geriatrics Society Editorial Board and Academic Emergency Medicine Editorial Board, and American Board of Emergency Medicine MyEMCert Key Advances editorial team.
	Presentation information: This work was presented as an Oral Abstract at the Society of Academic Emergency Medicine (SAEM) 2023 Annual Meeting, May 16-19, 2023, Austin, TX.
	Please see page XX for the Editor’s Capsule Summary of this article.