LAUSR

Physicians know how easy it is to start a medication for a chronic condition in older adults. Often, these medications have marginal benefits and substantial potential harms and can be difficult to stop once started. Many older patients receive multiple medications with potential interactions and harms, which can be costly and is sometimes referred to as financial toxicity from treatment. Yet the problems of polypharmacy and overprescribing in older adults remain stubbornly difficult to address despite the many well-meaning attempts at a solution that targets prescribers and patients. The article by Radomski et al1 proposes a new metric for identifying low-value prescribing in older adults: Evaluating Opportunities to Decrease Low-Value Prescribing (EVOLV-Rx). The authors reviewed medication guidelines, including existing lists of high-risk drugs in older adults and the Beers Criteria,2 peer-reviewed literature, and studies of patient and caregiver perspectives to develop a list of 27 common prescribing practices that were considered low value. The authors used the following criteria to assess practices for inclusion in the EVOLV-Rx metric: lack of effectiveness because of inappropriately prolonged use, potential harm because of the risk of an adverse drug event or drug interaction, excessive cost because of the use of brand-name medication, and use of a medication to treat the adverse effect of another drug.1 The authors also reviewed the 100 most frequently prescribed medications among Medicare beneficiaries to identify the most frequently prescribed drugs. Radomski et al. formed a panel of experts composed of physicians, pharmacist, and health system leaders and through a modified Delphi process refined the criteria for the practices included in EVOLV-Rx. Using the RAND/UCLA (University of California, Los Angeles) Appropriateness Method,3 the authors narrowed the list of 27 to 18 common practices that are low value and therefore good targets for intervention to decrease their use. The resulting metric (EVOLV-Rx) is an important addition to the existing tools for improving prescribing practices. A few clinical examples can illustrate the clinical significance of this metric. One of the low-value medications identified was thyroid hormone, a commonly overprescribed and ineffective medication for subclinical hypothyroidism. For each medication, the tool provides specific criteria for identifying patients who are particularly at risk for receiving the medication. In this case, patients older than 80 years or those with a new prescription but with a thyrotropin (previously thyroid-stimulating hormone) dose of less than 10 mIU/L are at risk for receiving a thyroid hormone prescription. In addition, the tool identifies patients who use a brand-name thyroid medication instead of a less expensive generic equivalent. Another example is the use of a benzodiazepine for a period of more than 4 weeks. Long-term use of this medication class is associated with increased risk of falls and fractures in older patients. The tool identifies patients who have a concurrent prescription for any other psychoactive medication that could further increase risk, and it flags the brand-name products. In short, EVOLV-Rx is a practical list of low-value drugs and prescribing practices that should not be started or should be stopped. It also helps identify at-risk patients. There is a large body of evidence from higher-income countries that signals a need for this tool. In spite of the known overprescribing and harms of low-value medications for older adults, these drugs remain commonly prescribed. For example, despite a recommendation from Choosing Wisely Canada to avoid prescribing benzodiazepines for patients who are older than 65 years, national data show that 10% of Canadians aged 65 years or older receive benzodiazepines and other sedative hypnotics on a regular basis, with considerable variation in use nationally.4 In the eastern Canadian province of New Brunswick, nearly 25% of older adults regularly receive such drugs.4 Similarly, the Organisation for Economic Co-operation and Development reported that, across multiple European + Related article