American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

American Geriatrics Society 2012 Beers Criteria Update Expert Panel

Disclosures

J Am Geriatr Soc. 2012;60(4):616-631. 

In This Article

Methods

For this new update, the AGS employed a well-tested framework that has long been used for development of clinical practice guidelines.[6,21–23] Specifically, the framework involved the appointment of an 11-member interdisciplinary expert panel with relevant clinical expertise and experience and an understanding of how the criteria have been previously used. To ensure that potential conflicts of interest are disclosed and addressed appropriately, panelists disclosed potential conflicts of interest with the panel at the beginning. Each panelist's potential conflict of interests are provided toward the end of this article. This framework also involved a development process that included a systematic literature review and evaluation of the evidence base by the expert panel. Finally, the Institute of Medicine's 2011 report on developing practice guidelines,[23] which included a period for public comments, guided the framework. These three framework principles are described in greater detail below.

Literature Search

The literature from December 1, 2001 (the end of the previous panel's search) to March 30, 2011, was searched to identify published systematic reviews and meta-analyses that were relevant to the project. Search terms included adverse drug reactions, adverse drug events, medication problems, polypharmacy, inappropriate drug use, suboptimal drug therapy, drug monitoring, pharmacokinetics, drug interactions, and medication errors. Terms were searched alone and in combination. Search limits included human subjects, English language, and aged 65 and older. Data sources for the initial search included Medline, the Cochrane Library (Cochrane Database of Systematic Reviews), International Pharmaceutical abstracts, and references lists of selected articles that the panel co-chairs identified.

The initial search identified 25,549 citations, of which 6,505 were selected for preliminary review. The panel cochairs reviewed 2,267 citations, of which 844 were excluded for not meeting the study purpose or not containing primary data. An additional search was conducted with the additional terms drug–drug and drug–disease interactions, pharmacoepidemiology, drug safety, geriatrics, and elderly prescribing. An additional search for randomized clinical trials and postmarketing and observational studies published between 2009 and 2011 was conducted using terms related to major drug classes and conditions, delimited by more-general topics (e.g., adverse drug reactions, Beers Criteria, suboptimal prescribing, and interventions). Previous searches were used to develop additional terms to be included in subsequent searches, such as a list of authors whose work was relevant to the goals of the project. When evidence was sparse on older medications, searches were conducted on drug class and individual medication names and included older search dates for these drugs. The co-chairs continually reviewed the updated search results for articles that might be relevant to the project. Panelists were also asked to forward pertinent citations that might be useful for revising the previous Beers Criteria or supporting additions to them.

At the time of the panel's face-to-face meeting, the cochairs had selected 2,169 unduplicated citations for the full panel review. This total included 446 systematic reviews or meta-analyses, 629 randomized controlled trials, and 1,094 observational studies. Additional articles were found in a manual search of the reference lists of identified articles and the panelist's files, book chapter, and recent review articles, with 258 citations selected for the final evidence tables to support the list of drugs to avoid.

Panel Selection

After consultation with the AGS, the co-chairs identified prospective panel members with recognized expertise in geriatric medicine, nursing, pharmacy practice, research, and quality measures. Other factors that influenced selection were the desire to have interdisciplinary representation, a range of medical specialties, and representation from different practice settings (e.g., long-term care, ambulatory care, geriatric mental health, palliative care and hospice). In addition to the 11-member panel, representatives from CMS, NCQA, and PQA were invited to serve as ex-officio members.

Each expert panel member completed a disclosure form that was shared with the entire panel before the process began. Potential conflicts of interest were resolved by the panel co-chairs and were available during the open comment period. Panel members who disclosed affiliations or financial interests with commercial entities are listed under the disclosures section of this article.

Development Process

The co-chairs and AGS staff edited the survey used in the previous Beers Criteria development process, excluding products no longer marketed. The resulting survey had three parts: medications currently listed as potentially inappropriate for older adults independent of diseases or conditions, medications currently listed as potentially inappropriate when used in older adults with certain diseases or conditions, and new submissions from the panel. Each panelist was asked to complete the survey using a 5-point Likert scale ranging from strongly agree to strongly disagree (or no opinion). Ratings were tallied and returned to the panel along with each panelist's original ratings. Two conference calls allowed for review of survey ratings, discussion, and consensus building.

The panel convened for a 2-day in-person meeting on August 2 and 3, 2011, to review the second draft of the survey and the results of the literature search. Panel discussions were used to define terms and to address questions of consistency, the inclusion of infrequently used drugs, the best strategies for evaluating the evidence, and the consolidation or expansion of individual criterion. The panel then split into four groups, with each assigned a specific set of criteria for evaluation. Groups were assigned as closely as possible according to specific area of clinical expertise (e.g., cardiovascular, central nervous system). Groups reviewed the literature search, selected citations relevant to their assigned criteria, and determined which citations should be included in an evidence table. During this process, panelists were provided copies of abstracts and full-text articles. The groups then presented their findings to the full panel for comment and consensus. After the meeting, each group met in a conference call to resolve any questions or to include additional supporting literature.

An independent researcher prepared evidence tables, which were distributed to the four criteria-specific groups. Each panelist independently rated the quality of evidence and strength of recommendation for each criterion using the American College of Physicians' Guideline Grading System[24] (Table 1), which is based on the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) scheme developed previously.[25] AGS staff compiled the panelist ratings for each group and returned them to that group, which then reached consensus in conference call. Additional literature was obtained and included as needed. When group consensus could not be reached, the full panel reviewed the ratings and worked through any differences until they reached consensus. For some criteria, the panel provided a "strong" recommendation even though the quality of evidence was low or moderate. In such cases, the strength of recommendation was based on potential severity of harm and the availability of treatment alternatives.

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