Metric Aims to Decrease Polypharmacy in Older Adults

A new metric may help improve polypharmacy rates in older adults through 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 enhance detection of low-value prescribing practices, reduce polypharmacy, and enable adults to receive high-value care. Findings of the qualitative study were published in JAMA Network Open.

It is estimated that in the United States, over $100 billion is spent on the delivery of low-value care per year, with Medicare beneficiaries accounting for up to 43% of this total. However, previous research on low-value care has mainly focused on tests and procedures while excluding low-value prescribing of medications.

Furthermore, approximately 40% of older individuals are subjected to polypharmacy (taking at least 5 medications concurrently), while between 30% and 50% have been prescribed a potentially inappropriate medication.

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

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

“We integrated the findings from 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 semistructured interviews with primary care physicians to characterize their perspectives on and specific examples of low-value prescribing,” 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 convened to establish consensus on and refine the criteria to identify the most salient low-value prescribing practices for the metric. The panel met 3 times between January 1 and March 31, 2021.

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

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

  • After round 1, 18 candidate practices were rated by the panel as having high scientific validity and clinical usefulness (scores of ≥ 6.5)
  • After round 2 panel deliberations, the criteria to detect 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 both scientific validity and clinical usefulness
  • Of those practices that were not included in the final version of EVOLV-Rx, 3 received high scientific validity (scores ≥ 6.5) but uncertain clinical usefulness (scores < 6.5) ratings, whereas 6 received uncertain scientific validity rating (scores < 6.5)

The investigators believe the tool will help enable health systems, third-party payers, and policy makers to reduce low-value prescribing in clinically sound and broadly applicable ways, they said.

All included practices were decided upon based on varying perspectives from 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. Burdensome and costly preparation and methods of administration were also weighed.

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

Use of EVOLV-Rx does not preclude the application of more traditional tools and has not been fully operationalized for use in administrative claims or electronic health record data, marking a limitation. Each of the metric’s components may also not be applicable to all forms of health data or in all populations.


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

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