Potentially inappropriate medications in the elderly: a French consensus panel list

Management of potentially inappropriate medication use among older adult's patients in primary care settings: description of an interventional prospective non-randomized study

BACKGROUND

The management of inappropriate medication use in older patients suffering from multimorbidity and polymedication is a major healthcare challenge. In a primary care setting, a medication review is an effective tool through which a pharmacist can collaborate with a practitioner to detect inappropriate drug use.

AIM

This project described the implementation of a systematic process for the management of potentially inappropriate medication use among Lebanese older adults. Its aim was to involve pharmacists in geriatric care and to suggest treatment optimization through the analysis of prescriptions using explicit and implicit criteria.

METHOD

This study evaluated the medications of patients over 65 years taking a minimum of five chronic medications a day in different regions of Lebanon. Descriptive statistics for all the included variables using mean and standard deviation (Mean (SD)) for continuous variables and frequency and percentage (n, (%)) for multinomial variables were then performed.

RESULTS

A total of 850 patients (50.7% women, 28.6% frail, 75.7 (8.01) mean age (SD)) were included in this study. The mean number of drugs per prescription was 7.10 (2.45). Roughly 88% of patients (n = 748) had at least one potentially inappropriate drug prescription: 66.4% and 64.4% of the patients had at least 1 drug with an unfavorable benefit-to-risk ratio according to Beers and EU(7)-PIM respectively. Nearly 50.4% of patients took at least one medication with no indication. The pharmacists recommended discontinuing medication for 76.5% of the cases of drug related problems. 26.6% of the overall proposed interventions were implemented.

DISCUSSION

The rate of potentially inappropriate drug prescribing (PIDP) (88%) was higher than the rates previously reported in Europe, US, and Canada. It was also higher than studies conducted in Lebanon where it varied from 22.4 to 80% depending on the explicit criteria used, the settings, and the medical conditions of the patients. We used both implicit and explicit criteria with five different lists to improve the detection of all types of inappropriate medication use since Lebanon obtains drugs from many different sources. Another potential source for variation is the lack of a standardized process for the assessment of outpatient medication use in the elderly.

CONCLUSION

The prevalence PIDP detected in the sample was higher than the percentages reported in previous literature. Systematic review of prescriptions has the capacity to identify and resolve pharmaceutical care issues thus improving geriatric care.

One Hundred Explicit Definitions of Potentially Inappropriate Prescriptions of Antibiotics in Hospitalized Older Patients: The Results of an Expert Consensus Study

BACKGROUND

In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use.

OBJECTIVE

To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients.

METHODS

We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round.

RESULTS

Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2).

CONCLUSIONS

The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.

Do Proton Pump Inhibitors Reduce Upper Gastrointestinal Bleeding in Older Patients with Atrial Fibrillation Treated with Oral Anticoagulants? A Nationwide Cohort Study in France

BACKGROUND

Proton pump inhibitors (PPIs) are largely used in older adults and data are needed in off-label indications, such as the prevention of upper gastrointestinal bleeding (UGIB) in patients receiving oral anticoagulants (OACs). This study aimed to assess whether PPIs reduce the risk of UGIB in patients initiating oral anticoagulation.

METHODS

We conducted a longitudinal study based on the French national health database. The study population included 109,693 patients aged 75-110 years with a diagnosis of atrial fibrillation who initiated OACs [vitamin K antagonist (VKA) or direct OAC (DOAC)] between 2012 and 2016. We used multivariable Cox models weighted by inverse of probability of treatment to estimate the adjusted hazard ratio (aHR) of UGIB between PPI users and nonusers over a 6- and 12-month follow-up.

RESULTS

PPI users represented 23% of the study population (28% among VKA initiators and 17% among DOAC initiators). The mean age (83 ± 5.3 years) and proportion of women (near 60%) were similar between groups. The risk of UGIB in the first 6 months after initiation of OAC decreased by 20% in PPI users compared with PPI nonusers [aHR6 months = 0.80, 95% confidence interval (CI) 0.65-0.98], but was not significantly modified when the follow-up was extended to 12 months (aHR12 months = 0.90, 95% CI 0.76-1.07), with a stronger effect among patients treated with vitamin K antagonists (aHR6 months = 0.73, 95% CI 0.58-0.93; aHR12 months = 0.81, 95% CI 0.67-0.99).

CONCLUSIONS

This study suggests that PPIs were associated with reduced risk of gastrointestinal bleeding after initiation of oral anticoagulation in older patients with atrial fibrillation, particularly within 6 months after initiation of an antivitamin K antagonist.

Potentially Inappropriate Medication Dispensing in Outpatients: Comparison of Different Measurement Approaches

Purpose of the Research

This paper aims at comparing different approaches to measure potentially inappropriate medication (PIM) with routinely collected data on prescriptions, patient age institutionalization status (ie in nursing home or in the community). A secondary objective is to measure the rate and prevalence of PIM dispensing and to identify problematic practices in Switzerland.

Material and Methods

The studied population includes about 90,000 insured over 17 years old from a Swiss health maintenance organization in 2019 and 2020. We computed and compared the number of PIM per patient for Beers criteria, Priscus list, Laroche, NORGEP and Prescrire approaches. We also created a composite indicator that accounts for the specificities of the Swiss context (adaptation to the Swiss drugs' market, recommendations in force related to sleeping pills, anxiolytics and NSAIDs). We also stratified the analysis per physician, including initiation and cessation of PIM prescription.

Results

Our comparison revealed similarities between the approaches, but also that each of them had specific gaps that provides further motivation for the development of a composite approach. PIM rate was particularly high for sleeping pills, anxiolytics, NSAIDs, even when analyses were limited to chronic use. Drugs with anticholinergic effect were also frequently prescribed. Based on our composite indicator, 27% of insured over 64 years old received at least one PIM in 2020, and 8% received more than one. Our analyses also reveal that for sleeping pills and anxiolytics, half of the volume (or prevalence?) occurs in the <65 population. We observed strong variations between physicians and a significant proportion of new users among patients with PIM.

Conclusion

Our results show that PIMs prescribing is very frequent in Switzerland and is driven mostly by a few drug categories. There is important physician variation in PIM prescribing that warrants the development of intervention targeted at high PIM-prescribers.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study

INTRODUCTION

Polypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source.

AIM

To develop a list of medications to facilitate appropriate prescribing among older adults.

METHODS

A preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians.

RESULTS

The preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains.

CONCLUSIONS

The newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Assessment of potentially inappropriate medication use among geriatric outpatients in the Slovak Republic

BACKGROUND

Potentially inappropriate medication (PIM) use is a highly prevalent problem among older people, making it challenging to improve patient safety. The aim of this study was to assess the use of PIMs among geriatric outpatients (OUTs) in the Slovak Republic according to the EU(7) PIM list and to identify the differences in PIM prescriptions among general practitioners (GPs), internists (INTs) and geriatricians (GERs).

METHODS

In total, 449 patients (65 years and older) from 4 medical centres who were in the care of GPs (32.5%), INTs (22.7%) or GERs (44.8%) were included in this retrospective analysis. Data were collected from 1.12.2019-31.3.2020. PIMs were identified according to the EU(7) PIM list from patients' records. PIM prescriptions by GPs, INTs and GERs were assessed. All obtained data were statistically analysed.

RESULTS

Polypharmacy (68.8% of patients), and PIM use (73% of patients) were observed. The mean number of all prescribed drugs was 6.7 ± 0.2 drugs per day/patient. The mean number of prescribed PIMs was 1.7 ± 0.1 PIMs per day/patient. Drugs from Anatomical Therapeutic Chemical (ATC) classes C, N and A accounted for the greatest number of PIMs. Significantly higher numbers of prescribed drugs as well as PIMs were prescribed by GPs than INTs or GERs. There were 4.2 times higher odds of being prescribed PIMs by GPs than by GERs (p < 0.001).

CONCLUSIONS

Polypharmacy and overprescription of PIMs were identified among geriatric patients in our study. We found a positive relationship between the number of prescribed drugs and PIMs. The lowest odds of being prescribed PIMs were observed among those who were in the care of a geriatrician. The absence of geriatricians and lack of information about PIMs among general practitioners leads to high rates of polypharmacy and overuse of potentially inappropriate medications in geriatric patients in the Slovak Republic.

Sex-specific medication trajectories in older adults newly diagnosed with diabetes

Background

People with diabetes tend to use many medications to treat diabetes and comorbidities. Nevertheless, the evolution of polypharmacy in newly diagnosed males and females has been little studied.

Objective

The objective of this paper was to identify and describe medication trajectories in incident diabetes cases according to sex.

Methods

Data were obtained from the Quebec Integrated Chronic Disease Surveillance System. We built a population-based cohort of community-dwelling individuals aged >65 years diagnosed with diabetes in 2014 who were alive and covered with the public drug plan until March 31, 2019. Latent class models were used to identify medication trajectory groups in males and females separately.

Results

Of the 10,363 included individuals, 51.4% were males. Females were older and more likely to have more medication claims than males. Four trajectory groups were identified for males and five for females. Most trajectories showed sustained and stable number of medications over time. For each sex, only one of the trajectory groups included a mean annual number of medications lesser than five. Slight increasing trends of medication use were detected in the trajectories composed of very high users, which included older, more comorbid individuals frequently exposed to potentially inappropriate medications.

Conclusions

Most males and females with incident diabetes had a high burden of medication following the year of diagnosis and were classified in a group of sustained medication use over time. The largest increase in medication was among those who had higher level of polypharmacy of questionable quality at baseline, raising concerns about the innocuity of such medication trajectories.

Outcomes in deprescribing implementation trials and compliance with expert recommendations: a systematic review

BACKGROUND

Deprescribing, defined as discontinuing or reducing the dose of medications that are no longer needed or for which the risks outweigh the benefits is a way to reduce polypharmacy. In 2022, the US Deprescribing Research Network (USDeN) published recommendations concerning the measurement of outcomes for deprescribing intervention studies. The objectives of this systematic review were to identify the outcome categories used in deprescribing intervention trials and to relate them to the previously published recommendations.

METHODS

We searched MEDLINE, Embase, PsychInfo, and the Cochrane library from January 2012 through January 2022. Studies were included if they were randomized controlled trials evaluating a deprescribing intervention. After data extraction, outcomes were categorized by type: medication outcomes, clinical outcomes, system outcomes, implementation outcomes, and other outcomes based on the previously published recommendations.

RESULTS

Thirty-six studies were included. The majority of studies focused on older adults in nursing homes and targeted inappropriate medications or polypharmacy. In 20 studies, the intervention was a medication review; in seven studies, the intervention was educational or informative; and three studies based their intervention on motivational interviewing or patient empowerment. Thirty-one studies presented a medication outcome (primary outcome in 26 studies), 25 a clinical outcome, 18 a system outcome, and seven an implementation outcome. Only three studies presented all four types of outcomes, and 10 studies presented three types of outcomes.

CONCLUSIONS

This review provides an update on the implementation of gold standard deprescribing studies in clinical practice. Implementation outcomes need to be developed and specified to facilitate the implementation of these practices on a larger scale and clinical outcome need to be prioritized. Finally, this review provides new elements for future real-life deprescribing studies.

Explicit potentially inappropriate medications criteria for older population in Asian countries: A systematic review

BACKGROUND

Explicit potentially inappropriate medications (PIM) criteria are commonly used to identify and deprescribe potentially inappropriate prescriptions among older patients. Most of these criteria were developed specifically for the Western population, which might not be applicable in an Asian setting. The current study summarizes the methods and drug lists to identify PIM in older Asian people.

METHODS

A systematic review of published and unpublished studies were carried out. Included studies described the development of explicit criteria for PIM use in older adults and provided a list of medications that should be considered inappropriate. PubMed, Medline, EMBASE, Cochrane CENTRAL, CINAHL, PsycINFO, and Scopus searches were conducted. The PIMs were analyzed according to the general conditions, disease-specific conditions, and drug-drug interaction classes. The qualities of the included studies were assessed using a nine-point evaluation tool. The kappa agreement index was used to evaluate the level of agreement between the identified explicit PIM tools.

RESULTS

The search yielded 1206 articles, and 15 studies were included in our analysis. Thirteen criteria were identified in East Asia and two in South Asia. Twelve out of the 15 criteria were developed using the Delphi method. We identified 283 PIMs independent of medical conditions and 465 disease-specific PIMs. Antipsychotics were included in most of the criteria (14/15), followed by tricyclic antidepressants (TCAs) (13/15), antihistamines (13/15), sulfonylureas (12/15), benzodiazepines (11/15), and nonsteroidal anti-inflammatory drug (NSAIDs) (11/15). Only one study fulfilled all the quality components. There was a low kappa agreement (k = 0.230) between the included studies.

CONCLUSION

This review included 15 explicit PIM criteria, which most listed antipsychotics, antidepressants, and antihistamines as potentially inappropriate. Healthcare professionals should exercise more caution when dealing with these medications among older patients. These results may help healthcare professionals in Asian nations to create regional standards for the discontinuation of potentially harmful drugs for elderly patients.

Pharmaceutical care for the patients admitted to a multidisciplinary complex chronic patient unit

OBJECTIVE

To assess the pharmacist's contributions by analyzing potentially inappropriate prescription and home treatment reconciliation in the complex chronic patient unit of a tertiary hospital.

METHOD

Observational, prospective, multidisciplinary study of patients in the complex chronic patient unit of a hospital during February 2019-June 2020. Multidisciplinary team of the complex chronic developed a checklist with a selection of non-recommended drugs based on STOPP/START, Beers and Priscus criteria, and drugs susceptible to deprescription according to LESS-CHRON criteria. The pharmacist applied the checklist daily in patients admitted to the unit, in addition to reconciling home treatment by reviewing the prescribed treatment with that detailed in the electronic home prescription. Therefore, the following variables were collected: age, sex and number of drugs on admission as independent variables, and dependent variables: number of drugs at discharge, type of potentially inappropriate prescription, reasons for reconciliation, drugs involved and degree of acceptance of the recommendation by the prescribing physician to assess the pharmaceutical contribution. The statistical analysis was performed with IBM® SPSS® Statistics22.

RESULTS

We reviewed 621 patients with a median age of 84 years (56.4% women), and intervention was performed in 218 (35.1%). The median number of drugs was 11 (2-26) at admission and 10 (0-25) at discharge. 373 interventions were performed: 235 for medication reconciliation (78.3% accepted), 71 for non-recommended drugs (57.7% accepted), 42 for deprescription (61.9% accepted) and 25 for other reasons. Statistically significant differences were observed between the number of drugs at discharge and at admission in both intervention patients (n = 218) and complex chronic patients (n = 114) (p < 0.001 in both cases). Moreover, statistically significant differences were observed in the number of drugs at admission between patients included in the complex chronic programme and those not included (p = 0.001), and in the number of drugs at discharge (p = 0.006).

CONCLUSIONS

The integration of the pharmacist in the multidisciplinary team of the complex chronic patient unit improves patient safety and quality of care. The selected criteria were useful for detecting inappropriate drugs in this population and favored deprescription.

Pharmaceutical care for the patients admitted to a multidisciplinary complex chronic patient unit

OBJECTIVE

To assess the pharmacist's contributions by analysing potentially inappropriate prescription and home treatment reconciliation in the complex chronic patient unit of a tertiary hospital.

METHOD

Observational, prospective, multidisciplinary study of patients in the complex chronic patient unit of a hospital during February 2019 - June 2020. Multidisciplinary team of the complex chronic developed a checklist with a selection of non-recommended drugs based on STOPP/START, Beers and PRISCUS criteria, and drugs susceptible to deprescription according to LESS-CHRON criteria. The pharmacist applied the checklist daily in patients admitted to the unit, in addition to reconciling home treatment by reviewing the prescribed treatment with that detailed in the electronic home prescription. Therefore, the following variables were collected: age, sex and number of drugs on admission as independent variables, and dependent variables: number of drugs at discharge, type of potentially inappropriate prescription, reasons for reconciliation, drugs involved and degree of acceptance of the recommendation by the prescribing physician to assess the pharmaceutical contribution. The statistical analysis was performed with IBM® SPSS® Statistics22.

RESULTS

We reviewed 621 patients with a median age of 84 years (56.4% women), and intervention was performed in 218 (35.1%). The median number of drugs was 11 (2-26) at admission and 10 (0-25) at discharge 373 interventions were performed: 235 for medication reconciliation (78.3% accepted), 71 for non-recommended drugs (57.7% accepted), 42 for deprescription (61.9% accepted) and 25 for other reasons. Statistically significant differences were observed between the number of drugs at discharge and at admission in both intervention patients (n = 218) and complex chronic patients (n = 114) (p < 0.001 in both cases). Moreover, statistically significant differences were observed in the number of drugs at admission between patients included in the complex chronic programme and those not included (p = 0.001), and in the number of drugs at discharge (p = 0.006).

CONCLUSIONS

The integration of the pharmacist in the multidisciplinary team of the complex chronic patient unit improves patient safety and quality of care. The selected criteria were useful for detecting inappropriate drugs in this population and favoured deprescription.

Artificial intelligence-supported web application design and development for reducing polypharmacy side effects and supporting rational drug use in geriatric patients

Introduction

The main complications of polypharmacy, which is known as the simultaneous use of more than five drugs, are potentially inappropriate medicines(PIMs), drug–drug, and drug-disease interaction. It is aimed to prepare an auxiliary tool to reduce the complications of polypharmacy and to support rational drug use(RDU), by evaluating the patient with age, drugs, and chronic diseases in this study.

Materials and methods

In the first phase of this study, as methodological research, an up-to-date and comprehensive auxiliary tool as a reference method was generated with a database containing interaction information of 430 most commonly used drug agents and chronic diseases in geriatrics in the light of current and valid 6 PIM criteria for geriatric patients, and medication prospectuses, relevant current articles, and guidelines. Then, an artificial intelligence(AI) supported web application was designed and developed to facilitate the practical use of the tool. Afterward, the data of a cross-sectional observational single-center study were used for the rate and time of PIM and drug interaction detection with the web application. The proposed web application is publicly available at https://fastrational.com/.

Results

While the PIM coverage rate with the proposed tool was 75.3%, the PIM coverage rate of EU(7)-PIM, US-FORTA, TIME-to-STOPP, Beers 2019, STOPP, Priscus criteria in the web application database respectively(63.5%–19.5%) from the highest to the lowest. The proposed tool includes all PIMs, drug–drug, and drug-disease interaction information detected with other criteria. A general practitioner detects interactions for a patient without the web application in 2278 s on average, while the time with the web application is decreased to 33.8 s on average, and this situation is statistically significant.

Discussion

In the literature and this study, the PIM criteria alone are insufficient to include actively used medicines and it shows heterogeneity. In addition, many studies showed that the biggest obstacle to drug regulation in practice is “time constraints.” The proposed comprehensive auxiliary tool analyzes age, drugs, and diseases specifically for the patient 60 times faster than the manual method, and it provides quick access to the relevant references, and ultimately supports RDU for the clinician, with the first and only AI-supported web application.

Comparison of the 22nd World Health Organization Model List of Essential Medicines with the explicit criteria for the treatment of chronicity in elderly patients

OBJECTIVES

This study analysed whether the Model List of Essential Medicines is suitable for elderly patients. Furthermore, it investigated the specific issues that should be considered when prescribing a drug and which drugs should be added to improve the list according to the explicit criteria guidelines.

METHODS

A qualitative descriptive review was performed comparing the explicit criteria guidelines of Beers 2019, Laroche, McLeod, NORGEP, PRISCUS, STOPP/START 2014 and Winit-Watjana with the 22nd edition of the Model List of Essential Medicines.

RESULTS

The Model List of Essential Medicines has 458 drugs. Depending on the explicit criteria considered, there were different numbers of potentially inappropriate medications and potential prescribing omissions. When all explicit criteria were combined, a total of 73 medicines were classified as potentially inappropriate. Using the STOPP/START criteria, 46 potential prescribing omissions were detected. According to these explicit criteria, the Model List of Essential Medicines appeared to lack some medicines.

CONCLUSIONS

Explicit criteria guidelines have different potential for detecting potentially inappropriate medications. Our findings suggest that some drugs should be added to the next edition of the Model List of Essential Medicines to cover some therapeutic gaps.

The MGPIDP-L project: Potentially inappropriate drug prescribing and its associated factors

OBJECTIVE

The aim of this study was to identify the prevalence of potentially inappropriate drug prescribing¹ (PIDP) using a combination of explicit and implicit criteria in a sample of Lebanese older adults taking 5 or more chronic medications per day in ambulatory care settings and to identify which factors were associated with PIDP. The explicit criteria included five different lists: Beers, Laroche, European Union (EU(7)-PIM list), STOPP/ START, STOPP Frail, and Alert and Mastering of Iatrogenesis issued by the French High Authority of Health. We also performed a sensitivity analysis to compare the potentially inappropriate medications according to each criterion.

METHODS

Data were collected from each patient via a face-to-face interview. Logistic regressions were conducted to evaluate both objectives.

RESULTS

Many factors were positively associated with PIDP. The risk of PIDP was positively associated with age (OR =4.692, 95% CI [1.889-11.655]). Treatment for insomnia doubled the odds of PIDP (P<0.05). Participants who picked their medications from the pharmacy and had excess stock of drugs were at higher risk of having PIDP by 2.042 (95% CI [1.199-3.478]) and 2.965(95% CI [1.133-7.762]) respectively. However, patients with a perception of being heavily medicated and patients with a missed dose in the last two weeks had lower odds of PIDP.

CONCLUSION

Our study showed a high prevalence of PIDP in Lebanon, which is associated with various correlates. Selecting the appropriate tools to assess PIDP and providing patient education regarding the risks associated with potentially inappropriate medications are issues to be addressed among older adults.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients.

OBJECTIVES

We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life.

SEARCH METHODS

In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts.

SELECTION CRITERIA

We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence.

MAIN RESULTS

In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.

Potential Risk Factors of Drug-Related Problems in Hospital-Based Mental Health Units: A Systematic Review

INTRODUCTION

Reducing the occurrence of drug-related problems is a global health concern. In mental health hospitals, drug-related problems are common, leading to patient harm, and therefore understanding their potential risk factors is key for guiding future interventions designed to minimise their frequency.

OBJECTIVE

The aim of this systematic review was to explore the potential risk factors of drug-related problems in mental health inpatient units.

METHODS

Six databases were searched between 2000 and 2021 to identify studies that investigated the potential risk factors of drug-related problems in adults hospitalised in mental health inpatient units. Data extraction was performed by two authors independently and Allan and Barker's criteria were used for study quality assessment. Studies were categorised based on drug-related problem types and potential risk factors were stratified as patient, medication, and hospital related.

RESULTS

A total of 22 studies were included. Studies mostly originated in Europe (n = 19/22, 86.4%), and used a multivariable logistic regression to identify potential risk factors (n = 13, 59%). Frequently investigated factors were patient age (n = 14/22), sex (n = 14/22) and the number of prescribed medications (n = 14/22). Of these, increasing the number of prescribed medications was the only factor consistently reported to be significantly associated with the occurrence of most types of drug-related problems (n = 11/14).

CONCLUSIONS

A variety of patient, medication and hospital-related potential risk factors of drug-related problems in mental health inpatient units were identified. These factors could guide the development of interventions to reduce drug-related problems such as pharmaceutical screening tools to identify high-risk patients for timely interventions. Future studies could test a wider range of possible factors associated with drug-related problems using standardised approaches.

CLINICAL TRIAL REGISTRATION

PROSPERO: CRD42021279946.

A High Postoperative Atropinic Burden is Associated with Postoperative Delirium in Elderly Patients with Hip Fracture: Results of the Prospective, Observational, ATROPAGE Trial

Background

Postoperative delirium frequently occurs in the elderly after hip fracture surgery and is associated with poor outcomes. Our aim was to identify a correlation between the atropinic burden (AB) due to drugs with clinical antimuscarinic effect and the occurrence of postoperative delirium.

Methods

We carried out a prospective, monocentric, observational study including 67 patients over 65 years of age who underwent hip fracture surgery. The addition of the anticholinergic weight of each drug was calculated at different time points to distinguish the prehospital, intra- and postoperative part of the AB. A multivariate analysis was carried out to identify the explanatory variables associated with postoperative delirium.

Results

Patients were 78 [71-86] years old. The time from admission to surgery was 12 [12-24] hours. The ADL and CIRS scores were 6 [5.5-6] and 6 [4-9], respectively. The total (prehospital plus intraoperative plus postoperative) AB was 5 [3-9]. The incidence of postoperative delirium was 54% (36/67). The demographic characteristics were comparable between delirium and no delirium groups. Univariate analysis showed statistically significant differences between no delirium and delirium groups concerning the number of prehospital atropinic drugs, prehospital AB, the number of postoperative atropinic drugs, postoperative AB, in-hospital AB and the MMSE calculated on postoperative day 5. Using multivariate analysis, postoperative AB, but not pre- and in-hospital ABs, was associated with postoperative delirium with an odds ratio of 1.84 (95% CI: 1.25-2.72; p = 0.002). A postoperative AB > 2 was associated with a postoperative delirium with an area under ROC curve of 0.73 (95% CI: 0.61-0.83; p = 0.0001).

Conclusion

Contrary to a prior exposure to atropinic drugs, a postoperative atropinic burden >2 was associated with postoperative delirium in elderly patients with hip fracture. Postoperative administration of (new) antimuscarinic drugs is a precipitating factor of delirium that could be avoided.

Potentially inappropriate medication use in the elderly: physicians' and hospital pharmacists knowledge, practice, confidence, and barriers

BACKGROUND

Inappropriate medication prescribing and dispensing by physicians and pharmacists is a preventable cause of morbidity and mortality in the elderly. Signifying the importance of healthcare professionals' knowledge of potentially inappropriate prescribing tools/ guidelines which would improve overall health outcomes. Beers Criteria is one of the most used guidelines that list specific potentially inappropriate medications (PIMs). This study aimed to investigate physicians' and hospital pharmacists' awareness, knowledge, practice, confidence, and barriers to the use of Beers criteria.

METHODS

A cross-sectional survey was carried out among 66 hospital pharmacists and 31 family medicine physicians working in a teaching hospital in Nigeria, between May and September 2021 using a self-administered questionnaire. Knowledge of PIMs was assessed using 11 clinical vignettes based on the 2019 Beers Criteria. Practice behavior towards elderly patients was assessed using a 5-item statement with a 5-point Likert scale. Perceived barriers to the appropriate use of Beers Criteria were assessed using a 15-item statement. Descriptive and inferential statistics were used to analyze the data.

RESULTS

A total of 66 hospital pharmacists and 31 family medicine physicians participated in the study. Only (24; 36.4%) pharmacists and (4; 12.9%) physicians knew guidelines that listed specific PIMs. In all (21; 31.8%) pharmacists and (11; 35.4%) physicians demonstrated good knowledge of Beers Criteria, while most pharmacists (55; 83.3%) and physicians (29; 93.5%) reported good practice when dealing with elderly patients in terms of asking relevant questions and considering their ages while dispensing medications. Knowledge scores were not significantly associated with hospital pharmacists' socio-demographics. Most of the physicians and pharmacists were confident in the care provided for geriatric patients. The majority (66; 100.0%) pharmacists and (28; 93.5%) physicians suggested training through seminar presentations as a measure to improve the use of Beers' criteria. Lack of time to counsel patients was a major barrier recounted by both physicians and pharmacists.

CONCLUSION

Healthcare professionals that participated in this study had satisfactory practice, although a gap in the knowledge of hospital pharmacists and family medicine physicians was noted. In addition to creating awareness among healthcare professionals and training on PIMs and Beers' criteria, a multidisciplinary approach to reduce potentially inappropriate prescribing and dispensing would greatly help reduce the incidence of potentially inappropriate medication use among elderly patients.

Prescription of benzodiazepines and Z-drugs among older patients in primary care: a French, national, cohort study

BACKGROUND

In France, general practitioners (GPs) prescribe benzodiazepines and Z-drugs (BZD/ZDs) widely, and especially to older adults. Several characteristics of patients and/or GPs linked to BZD/ZD overprescription have been described in the general population but not among older patients in primary care.

OBJECTIVES

To estimate the proportion of GP consultations by patients aged 65 and over that resulted in a BZD/ZD prescription, and determine whether any GP-related factors predicted BZD/ZD overprescription in this setting.

METHODS

We analyzed sociodemographic and practice-related GP characteristics, and aggregated data on consultations recorded prospectively by 117 GPs in a database between 2000 and 2010. Next, we used logistic regression models to look for factors potentially associated with BZD/ZD overprescription (defined as an above-median prescription rate).

RESULTS

The GPs' mean age at inclusion was 47.4 (7.1), and 87.9% were male. During the study period, the median (95% confidence interval) proportion of consultations with patients aged 65 and over resulting in a BZD/ZD prescription was 21.8% (18.1-26.1) (range per GP: 5-34.1%). In a multivariable analysis, a greater number of chronic disease (OR [95% CI] = 2.10 [1.22-3.64]), a greater number of drugs prescribed per consultation (5.29 [2.72-10.28]), and shorter study participation were independently associated with BZD/ZD overprescription.

CONCLUSIONS

BZD/ZD overprescription was associated with a greater chronic disease burden and the number of drugs prescribed per consultation but not with any sociodemographic or practice-related GP characteristics. Targeted actions are needed to help GPs limit their prescription of BZD/ZDs to older patients with multiple comorbidities and polypharmacy.

Prevalence of potentially inappropriate prescribing in older adults in Central and Eastern Europe: a systematic review and synthesis without meta-analysis

We aimed to systematically review the prevalence of potentially inappropriate prescribing (PIP) in older adults in Central and Eastern Europe (CEE) in all care settings. We searched Embase and MEDLINE (up to June 2019) and checked the reference lists of the included studies and relevant reviews. Eligible studies used validated explicit or implicit tools to assess the PIP prevalence in older adults in CEE. All study designs were considered, except case‒control studies and case series. We assessed the risk of bias using the Joanna Briggs Institute Prevalence Critical Appraisal Tool and the certainty of evidence using the GRADE approach. Meta-analysis was inappropriate due to heterogeneity in the outcome measurements. Therefore, we used the synthesis without meta-analysis approach-summarizing effect estimates method. This review included twenty-seven studies with 139,693 participants. Most studies were cross-sectional and conducted in high-income countries. The data synthesis across 26 studies revealed the PIP prevalence: the median was 34.6%, the interquartile range was 25.9-63.2%, and the range was 6.5-95.8%. The certainty of this evidence was very low due to the risk of bias, imprecision, and inconsistency. These findings show that PIP is a prevalent issue in the CEE region. Further well-designed studies conducted across countries are needed to strengthen the existing evidence and increase the generalizability of findings.

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

IMPORTANCE

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes.

OBJECTIVE

To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients.

DESIGN, SETTING, AND PARTICIPANTS

This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022.

EXPOSURES

The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study.

MAIN OUTCOMES AND MEASURES

Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit.

RESULTS

A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list.

CONCLUSIONS AND RELEVANCE

In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

Potentially inappropriate medication use by level of polypharmacy among US Veterans 49-64 and 65-70 years old

BACKGROUND

Potentially inappropriate medications (PIMs) are medications contra-indicated in particular circumstances. We sought to characterize PIMs by level of polypharmacy by age, sex, and race/ethnicity.

METHODS

We performed a cross-sectional drug dispensing study using electronic health records available through the US Department of Veterans Affairs. We extracted pharmacy fill and refill records during fiscal year 2016 (i.e., October 1, 2015-September 30, 2016) for all patients aged 49-70 who accessed care in the preceding fiscal year. PIMs were defined by the combined Beers and Laroche (henceforth Beers Laroche) criteria used for older patients and the PROMPT criteria used for middle-aged.

RESULTS

In the 1 499 586 patients aged 49-64, PIMs prevalence by PROMPT in patients with 0-4, 5-9, and ≥10 medications was 14.0%, 62.2%, and 86.1%, respectively, and by Beers Laroche was 14.3%, 63.4%, and 85.7%, respectively. In the 1 249 119 patients aged 65-70, PIMs prevalence by Beers Laroche was 14.8%, 59.9%, and 83.3%, and by PROMPT was 13.9%, 57.4%, and 82.0%, respectively. Meaningful differences in prevalence were shown by sex and race/ethnicity according to both set of criteria (e.g. PROMPT in patients with 5-9 medications: 66.1% women vs. 59.3% men; standardized-mean-differences [SMD] = 0.14; 61.7% of White vs. 54.5% of non-White; SMD = 0.15). The most common PIMs were digestive, analgesic, antidiabetic, and psychotropic medications.

CONCLUSION

Prevalence of PIMs was high and increased with polypharmacy. Beers Laroche and PROMPT provided similar estimations inside and outside their target age, suggesting that PIMs are common among those with polypharmacy regardless of age.

Efficacy and safety of adrenergic alpha-1 receptor antagonists in older adults: a systematic review and meta-analysis supporting the development of recommendations to reduce potentially inappropriate prescribing

Background

Adrenergic alpha-1 receptor antagonists (alpha-1 antagonists) are frequently used medications in the management of lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) and in the management of therapy-resistant arterial hypertension, two conditions frequently found in older adults. This systematic review aims at presenting a complete overview of evidence over the benefits and risks of alpha-1 antagonist treatment in people ≥ 65 years, and at deriving recommendations for a safe application of alpha-1 antagonists in older adults from the evidence found.

Methods

A comprehensive literature search was performed (last update March 25^th 2022) including multiple databases (Medline/Pubmed, Embase, the Cochrane Library) and using the PICOS framework to define search terms. The selection of the studies was done by two independent reviewers in a two-step approach, followed by a systematic data extraction. Quality appraisal was performed for each study included using standardised appraisal tools. The studies retrieved and additional literature were used for the development of recommendations, which were rated for strength and quality according to the GRADE methodology.

Results

Eighteen studies were included: 3 meta-analyses, 6 randomised controlled trials and 9 observational trials. Doxazosin in the management of arterial hypertension was associated with a higher risk of cardiovascular disease, particularly heart failure, than chlorthalidone. Regarding treatment of LUTS suggestive of BPH, alpha-1 antagonists appeared to be effective in the relief of urinary symptoms and improvement of quality of life. They seemed to be less effective in preventing disease progression. Analyses of the risk profile indicated an increase in vasodilation related adverse events and sexual adverse events for some agents. The risk of falls and fractures as well as the effects of long-term treatment remained unclear. All meta-analyses and 5 out of 6 interventional studies were downgraded in the quality appraisal. 7 out of 9 observational studies were of good quality.

Conclusions

It cannot be recommended to use doxazosin as first-line antihypertensive agent neither in older adults nor in younger patients. In the management of BPH alpha-1 antagonists promise to effectively relieve urinary symptoms with uncertainty regarding their efficacy in preventing long-term progression events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03415-7.

Strategies and Tools for Supporting the Appropriateness of Drug Use in Older People

Through this structured review of the published literature, we aimed to provide an up-to-date description of strategies (human-related) and tools (mainly from the digital field) facilitating the appropriateness of drug use in older adults. The evidence of each strategy and tool’s effectiveness and sustainability largely derives from local and heterogeneous experiences, with contrasting results. As a general framework, three main steps should be considered in implementing measures to improve appropriateness: prescription, acceptance by the patient, and continuous monitoring of adherence and risk-benefit profile. Each step needs efforts from specific actors (physicians, patients, caregivers, healthcare professionals) and dedicated supporting tools. Moreover, how to support the appropriateness also strictly depends on the particular setting of care (hospital, ambulatory or primary care, nursing home, long-term care) and available economic resources. Therefore, it is urgent assigning to each approach proposed in the literature the following characteristics: level of effectiveness, strength of evidence, setting of implementation, needed resources, and issues for its sustainability.

Assessment of Potentially Inappropriate Medications Using the EU (7)-PIM List, in a Sample of Portuguese Older Adults' Residents in Nursing Homes

Abstract

Prescription of potentially inappropriate medication (PIM) in older adults is associated with poor clinical outcomes. The EU (7)-PIM list was created for the European market to improve pharmacotherapy in older adults.

Purpose

This work aims to characterize the medication profile and assess the presence of PIM, using the EU (7)-PIM list in older adults’ residents at nursing homes.

Methods

Retrospective data were collected from the anonymized nursing home records. After PIM identification, a descriptive analysis was performed, and a generalized linear model for dependent negative binomial-type variables was constructed to assess the risk of PIM.

Results

Of the 210 participants (mean age 85.10), 82.40% were polymedicated. PIM was observed in 86.4% participants (mean per patient = 2.30± 0.10). The most common PIM were proton pump inhibitors (n = 121, 57.62%), followed by anxiolytics (n = 96, 45.71%). 64.30% of all patients take 2–4 PIM and 5.80% take five or more PIM. The occurrence of PIM is influenced by the number of prescribed medicines (RR 1.14; 95% CI 1.1.-1.17) and the presence of digestive system diseases (RR 1.05; 95% CI 1.0–1.09).

Conclusion

The high prevalence of PIM observations highlights the necessity of the implementation of guidelines to prevent PIM.

Prevalence of potentially inappropriate medications among old people with major neurocognitive disorder in 2012 and 2017

Background

The increased risk of adverse drug reactions due to age-related altered pharmacokinetics and pharmacodynamics is a challenge when prescribing medications to older people, and especially among older people with major neurocognitive disorder who are particularly sensitive to drug effects. The aim of this study was to investigate the use of potential inappropriate medications (PIMs) in 2012 and 2017 among old people with major neurocognitive disorder. A secondary aim was to investigate factors associated with PIM use.

Methods

This register-study was based on the Swedish registry for cognitive/dementia disorders and the Swedish prescribed drug register. Criteria from the National Board of Health and Welfare were used to identify PIMs between 1 July–31 December 2012 and 1 July-–31 December 2017 among people ≥ 65 years. Drug use was defined as one or more filled prescriptions during each timeframe.

Results

The total use of PIMs declined significantly between 2012 (28.7%) and 2017 (21.7%). All PIMs and PIM groups declined between these years, except for antipsychotic drugs, which increased from 11.6% to 12.3%. The results from the multiple regression model found that PIM use was associated with younger age (OR: 0.97 CI: 0.96–0.97), a lower Mini Mental State Examination score (OR: 0.99 CI: 0.99–1.00), the use of multi-dispensed drugs (OR: 2.05 CI: 1.93–2.18), and compared to Alzheimer’s disease, with the subtypes dementia with Lewy bodies and Parkinson’s disease dementia (OR: 1.57 CI: 1.40–1.75), frontotemporal dementia (OR: 1.29 CI: 1.08–1.54) and vascular dementia (OR: 1.10 CI: 1.03–1.16).

Conclusions

Overall, the use of PIMs decreased between the years 2012 and 2017. The increase of antipsychotic drugs and the association between PIM use and multi-dispensed drugs warrant concern.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03240-y.

Potentially Inappropriate Prescribing for Prostatic Hyperplasia in Older Persons

OBJECTIVES

In the context of improved medication management of older patients, we wished to evaluate the overprescription of potentially inappropriate drugs [α1-blockers and 5α-reductase inhibitors (5-ARI)] for benign prostate hyperplasia (BPH). These drugs are considered by geriatricians to increase the risk of falls and pharmacodynamic interactions, but these properties have not yet been proven.

DESIGN

This was a descriptive study of drug prescriptions in a geriatric academic center.

SETTING AND PARTICIPANTS

We included all patients older than 75 years who received a prescription for α1-blockers or 5-ARIs for 2 weeks in our hospital.

METHODS

We evaluated the prevalence of the potentially inappropriate prescription of α1-blockers and 5-ARI in older people during hospitalization using a new tool consisting of an 8-item list of explicit indicators developed using the most recent summary of product characteristics (SmPC) and latest European Association of Urology (EAU) guidelines.

RESULTS

A population of 117 patients (≥75 years) was included in the study. The median age was 84.5 (±6.3) years. The average time since urological medication prescription was 1.2 ± 1.6 years. According to explicit criteria, 84 patients (71.8%) received at least 1 potentially inappropriate urologic medication, 77 (91.7%) related to α1-blockers. Patients with a potentially inappropriate prescription for α1-blockers and/or 5-ARIs more frequently had urological assessments (P = .026), more frequently showed pharmacological interactions, with the risk of orthostatic hypotension (P = .005) or arrhythmia (P = .028), and experienced more falls in their history (P = .043). The misuse group was associated with an increased risk of falls, with an odds ratio of 3.22 (P = .039, 95% confidence interval 1.08-10.2).

CONCLUSIONS AND IMPLICATIONS

In our study, potentially inappropriate prescriptions for older individuals for BPH was close to 72% and mainly involved α1-blockers. Potentially inappropriate prescriptions for BPH were associated with a threefold higher frequency of falls.

What Is the Medication Iatrogenic Risk in Elderly Outpatients for Chronic Pain?

PURPOSE

Medication iatrogeny is a major public health problem that increases as the population ages. Therapeutic escalation to control pain and associated disorders could increase polypharmacy and iatrogeny. This study aimed to characterize the medication iatrogenic risk of elderly outpatients with chronic pain.

METHODS

This was a prospective cohort study recruiting patients 65 years or older with chronic pain. A medication iatrogenic assessment was performed based on the best possible medication history to record risk of adverse drug events (Trivalle score), STOPP (Screening Tool of Older Person's Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria, and potentially inappropriate medications.

RESULTS

We recruited 100 patients with an average age of 71 years. The median number of medications before pain consultation was 8 (interquartile range = [7;11]). Trivalle score showed that 43% of patients were at moderate or high medication iatrogenic risk. Before consultation, 79% and 75% of patients had at least 1 STOPP or START criterion on their orders, respectively. One-third of orders mentioned benzodiazepine prescribed for more than 4 weeks. At least 1 potentially inappropriate medication was prescribed for 54% of the patients, with a median of 1 per patient (interquartile range = [0;1]). A combination of several anticholinergics was prescribed in 23% of patients.

CONCLUSION

Elderly patients with chronic pain are at risk of medication iatrogeny. Preventive measures as multidisciplinary medication review could reduce the iatrogenic risk in these outpatients.This study is registered at clinicaltrials.gov as NCT04006444 on July 3, 2019.

Development of a decision tree for the pharmacy-led consultation of elderly patients with haematological malignancies

INTRODUCTION

Elderly patients with haematological malignancies are a population at risk of iatrogenic for whom these activities could optimize therapeutic management. However, the limitation of human resources requires optimization of the process in order to improve the efficiency of pharmaceutical activities. The objective was to build a decision tree to optimize the pharmaceutical consultation in these population within a multidisciplinary team in haematology.

METHOD

Pharmaceutical consultations were proposed to elderly subjects with haematological malignancies followed up in a haematology day hospitalization at the University Hospital of Limoges. Risk factors for prescribing risky drugs in this population were determined by logistic regression models. A decision tree was constructed based on these results and by agreement between pharmacist, geriatrician and hematologist.

RESULTS

Female gender (aOR[CI95%] = 1.71 [1.14-2.57]), polypharmacy (aOR[CI95%] = 1.89 [1.14-3.13]), hyper-polypharmacy (aOR[CI95%] = 5.73 [3.03-10.84]) and moderate cholinergic load (aOR[CI95%] = 2.15 [1.04-4.45]) were risk factors for the prescription of inappropriate medicine. Female gender (aOR[CI95%] = 1.55 [1.02-2.35]) and hyper-polypharmacy (aOR[CI95%] = 6.19 [1-1.28]) were risk factors for prescribing anticholinergic drugs or anticoagulants; in contrast, frailty status was a protective factor for prescribing anticholinergics (aOR[CI95%] = 0.51 [0.33-0.81]). Prioritization of pharmaceutical consultations is based on frailty status, prescription of a target drug and polypharmacy.

DISCUSSION

Pharmaceutical consultations during the day hospitalization of elderly subjects with hematological diseases allow to propose therapeutic optimizations. The prioritization proposed in our study would increase the efficiency of pharmaceutical activities in order to improve quality and safety throughout the care pathway of these patients.

Implementation assessment of a patient personalized clinical pharmacy programme (5P project) into orthogeriatric care pathway

WHAT IS KNOWN AND OBJECTIVE

The orthogeriatric path (hip-fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload.

METHODS

Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals.

RESULTS AND DISCUSSION

Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview.

CONCLUSION

The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high-performance computing tools are needed.

Explicit definitions of potentially inappropriate prescriptions of antibiotics in hospitalized older patients

CONTEXT

The use of explicit definitions of potentially inappropriate prescriptions of antibiotics (antibiotic PIPs) might constitute an innovative means to fight against antimicrobial resistance. Explicit definitions of PIPs can reduce the rate of inappropriate prescriptions, but explicit definitions of antibiotic PIPs in geriatric medicine are currently lacking. The objective of the study was to develop explicit definitions of antibiotic PIPs for hospitalized older patients.

METHOD

We performed a qualitative study of focus groups involving geriatricians and infectious disease specialists. The study complied with the Consolidated Criteria for Reporting Qualitative Research. Transcripts of audio recordings were analyzed in a two-step independent reviewing process. The exact wording of the definitions was validated by a steering committee, an independent expert group, and the focus group participants.

RESULTS

The four focus groups comprised 28 stakeholders. Our analysis identified 65 explicit definitions of antibiotic PIPs: 47 (73%) concerned misuse, 15 (23%) concerned overuse and three (5%) concerned underuse. Most definitions were related to critically important antibiotics: 11 (17%) for fluoroquinolones, eight (12%) for amoxicillin-clavulanic acid, eight (12%) for cephalosporins, seven (11%) for aminoglycosides, and five (8%) for carbapenems.

CONCLUSION

To address the public health challenge of antimicrobial resistance, our study generated explicit definitions for antibiotic PIPs in older patients. We intend to refine and to validate these definitions through a national Delphi survey; the resulting consensus might provide key messages for prescribers and open up perspectives for reducing the incidence of antibiotic PIPs.

Which Potentially Inappropriate Medications List Can Detect Patients At Risk of Readmissions in the Older Adult Population Admitted for Falls? An Observational Multicentre Study Using a Clinical Data Warehouse

BACKGROUND AND OBJECTIVE

Hospital readmissions are common in the older adult population and potentially inappropriate medications are known to be involved in these readmissions. Several lists of potentially inappropriate medications have been published in diverse countries in order to adapt the lists to local specificities. Among them, the Beers Criteria^® were first published in 1991 in the USA, followed by the French Laroche list, the Norwegian NORGEP criteria, the German PRISCUS list, the Austrian consensus panel list and the European list, EU-7. The main objective was to detect which potentially inappropriate medications list can better detect hospital readmissions within 30 days in the older adult population hospitalised for fall-related injuries.

METHODS

We conducted a multicentre, observational, retrospective cohort study. Data from older patients initially hospitalised for falls in 2019 and discharged home were retrieved from the Clinical Data Warehouse. Exposure to potentially inappropriate medications was classified according to the six lists mentioned above. The local ethics committee approved the study protocol (number CER-2020-79).

RESULTS

After adjustments using propensity score matching, taking a potentially inappropriate medication as per the Laroche and PRISCUS lists was associated with a 30-day hospital readmission with an odds ratio of 1.58 (95% confidence interval 1.06-2.37) and 1.68 (95% confidence interval 1.13-2.50), respectively, while the other four studied lists showed no associations with readmissions.

CONCLUSIONS

Our study evidenced that not all lists published allow the accurate prediction of hospital readmissions to the same extent. We found that the Laroche and PRISCUS lists were associated with increased 30-day all-cause hospital readmissions after an index admission with a fall-related injury.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Potentially inappropriate medication prescribing among elderly patients with cardiovascular diseases

Background/Aim. The growing number of older adults means higher medicine utilization. The aim of the study was to determine the frequency and identify risk factors of potentially inappropriate medication (PIM) in the elderly population with cardiovascular diseases. Methods. The retrospective, cross-sectional study was performed in 2018, and the relevant data were collected during the period from January 2016 to December 2017. The study sample included 1,500 patients over 65 years with cardiovascular disease who had medical records at the Institute for Gerontology and Palliative Care, Belgrade. Assessment of PIM was done by standard international criteria such as the American Geriatrics Society 2015 updated Beers Criteria for PIM use in older adults. Results. PIM frequency in the elderly population was 70.3%. In relation to gender, it was more frequent in female elders. The mean number of prescribed drugs was similar for 2016 and 2017, 7.2 and 7.3, respectively. The most common were: medium-acting benzodiazepines (70.9%), central ? blockers (23.98%), and antipsychotics (typical and atypical) (20.94%). The most common comorbidity was noted in a group labeled with the International Disease Classification I00-I99, which includes heart and blood vessel diseases [n = 2,658 (36.9%)]. The most common diagnoses belonged to the subgroups I10-I15 [hypertensive diseases, n = 1,298 (18%)], I20-I25 [ischemic heart diseases n = 542 (7.5%)], I30-I52 [other forms of heart disease, n = 705 (9.8%)], I60-I69 [cerebrovascular diseases, n = 94 (1.3%)], and I80- I89 [diseases of veins, lymph vessels, and lymph nodes n = 12 (0.17%)]. The risk factors for PIM were: polypharmacy, gender, nicotine use, cognitive status, nutrition state, and the number of diseases registered in the study sample. Conclusion. Cardiovascular diseases in the elderly population are associated with a high prevalence of PIM. Creating health recommendations for prescribing drugs to the elderly that would emphasize these factors could reduce the prevalence of PIM in this population.

Risk Indicators Improve the Prescription Quality of Drugs with Anticholinergic Properties in Nursing Homes

AIM

The objective of this study was to assess the impact of a collaborative therapeutic optimization program on the rate of potentially inappropriate prescription of drugs with anticholinergic properties in nursing homes.

METHODS

Quasi-experimental study in 37 nursing homes in France. The intervention included the use of quality indicators for prescriptions combined with educational sessions and dedicated materials for nursing home staff (unlimited access to study material for staff, including nurses, general practitioners, pharmacists). Indicators were calculated based on routine data collected from an electronic pill dispenser system. The primary outcome was the presence of at least one prescription containing ≥1 drug from a list of 12 drugs with anticholinergic properties. A difference-in-differences analysis was conducted at 18 months as well as propensity score weighting to minimize any potential indication bias. A generalized estimating equation model estimated the probability of being prescribed at least one target drug at any time during a 9-month period for each resident.

RESULTS

In total, 33 nursing homes (intervention group: n = 10; control group: n = 23) were included, totalling 8137 residents. There was a decrease in the use of drugs with anticholinergic properties over time in both groups, as well as a decline in the intervention group compared to the control group (Odds Ratio: 0.685, 95% CI: 0.533, 0.880; p < 0.01) that was attributable to the intervention. An estimated 49 anticholinergic properties drug prescriptions were avoided by the intervention.

CONCLUSION

This study found that an intervention based on indicators derived from routine prescription data was effective in reducing use of drugs with anticholinergic properties prescriptions in nursing homes.

Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines

OBJECTIVE

Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019.

STUDY SELECTION

General prescribing guidelines tailored to or for adults including older adults with multimorbidity.

DATA EXTRACTION

Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes.

RESULTS

Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified.

CONCLUSIONS

From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.

Health Impacts and Characteristics of Deprescribing Interventions in Older Adults: Protocol for a Systematic Review and Meta-analysis

Background

Deprescribing, a relatively recent concept, has been proposed as a promising solution to the growing issues of polypharmacy and use of medications of questionable benefit among older adults. However, little is known about the health outcomes of deprescribing interventions.

Objective

This paper presents the protocol of a study that aims to contribute to the knowledge on deprescribing by addressing two specific objectives: (1) describe the impact of deprescribing in adults ≥60 years on health outcomes or quality of life; and (2) determine the characteristics of effective interventions in deprescribing.

Methods

Primary studies targeting three concepts (older adults, deprescribing, and health or quality of life outcomes) will be included in the review. The search will be performed using key international databases (MEDLINE, EMBASE, CINAHL, Ageline, PsycInfo), and a special effort will be made to identify gray literature. Two reviewers will independently screen the articles, extract the information, and evaluate the quality of the selected studies. If methodologically feasible, meta-analyses will be performed for groups of intervention studies reporting on deprescribing interventions for similar medications, used for similar or identical indications, and reporting on similar outcomes (eg, benzodiazepines used against insomnia and studies reporting on quality of sleep or quality of life). Alternatively, the results will be presented in bottom-line statements (objective 1) and a matrix outlining effective interventions (objective 2).

Results

The knowledge synthesis may be limited by the availability of high-quality clinical trials on deprescribing and their outcomes in older adults. Additionally, analyses will likely be affected by studies on the deprescribing of different types of molecules within the same indication (eg, different pharmacological classes and medications to treat hypertension) and different measures of health and quality of life outcomes for the same indication. Nevertheless, we expect the review to identify which deprescribing interventions lead to improved health outcomes among seniors and which of their characteristics contribute to these outcomes.

Conclusions

This systematic review will contribute to a better understanding of the health outcomes of deprescribing interventions among seniors.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42015020866; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42015020866

International Registered Report Identifier (IRRID)

PRR1-10.2196/25200

Prescribing-Assessment Tools for Long-Term Care Pharmacy Practice: Reaching Consensus through a Modified RAND/UCLA Appropriateness Method

Medicines are the most used health technology in Long-Term Care. The prevalence of potentially inappropriate medicines amongst Long-Term Care patients is high. Pharmacists, assisted by prescribing-assessment tools, can play an important role in optimizing medication use at this level of care. Through a modified RAND/UCLA Appropriateness Method, 13 long-term care and hospital pharmacists assessed as 'appropriate', 'uncertain', or 'inappropriate' a collection of commonly used prescribing-assessment tools as to its suitability in assisting pharmacy practice in institutional long-term care settings. A qualitative analysis of written or transcribed comments of participants was pursued to identify relevant characteristics of prescribing-assessment tools and potential hinders in their use. From 24 different tools, pharmacists classified 9 as 'appropriate' for pharmacy practice targeted to long-term care patients, while 3 were classified as 'inappropriate'. The tools feature most appreciated by study participants was the indication of alternatives to potentially inappropriate medication. Lack of time and/or pharmacists and limited access to clinical information seems to be the most relevant hinders for prescribing-assessment tools used in daily practice.

Potentially inappropriate medication use in elderly patients treated in intensive care units: A cross-sectional study using 2019 Beers, STOPP/v2 Criteria and EU(7)-PIM List

OBJECTIVE

To determine the prevalence of and the risk factors for Potentially Inappropriate Medication (PIM), the drug groups most commonly evaluated as PIMs in elderly patients in the ICUs by using 2019 Beers Criteria, STOPP version 2 (v2) Criteria and EU(7)-PIM List. The relation between mortality rate and length of ICU stay with PIMs was also examined.

METHODS

This was a cross sectional study conducted on patients aged ≥65 years, treated in ICUs (n = 139) between June 8, 2020, and January 11, 2021. Patients' demographic characteristics, clinical data and laboratory findings about the drugs used were collected prospectively. PIMs were evaluated according to each of the criteria applied. Relationship of dependent and independent variables was evaluated using chi-square analysis, t-test and logistic regression analysis. P < .05 was considered statistically significant.

RESULTS

The number of patients with at least 1 PIM according to three criteria was 118 (84.9%) (80.6%, 59.7%, 48.2%, Beers, STOPP/v2 and EU(7)-PIM List, respectively). In the univariate analysis, receiving renal replacement therapy and high number of drugs were the covariates that significantly affected the presence of PIM according to all three criteria (P < .05). Combined use of anxiolytics and opioids in Beers Criteria (58.3%), antipsychotics (26.6%) in STOPP/v2 Criteria, and antiarrhythmics (23.7%) in EU(7)-PIM List were the drugs that caused PIM at most. No relationship was found between the presence of PIM and mortality. The length of ICU stay was determined significantly longer in the presence of PIM according to Beers Criteria (P = .028).

CONCLUSIONS

In this study, the prevalence of PIM was determined higher in elderly patients in ICU. Our results supported that 2019 Beers Criteria for ICU patients seems to be more directive in detecting PIMs and determining the prognosis. Reducing the number of drugs administered may be the first step to decrease PIMs in elderly patients in ICU and to maintain the treatment safely.

How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

Background

A new model was developed for integrating a personalised clinical pharmacy programme (5P project) into the orthogeriatric care pathway.

Objective

To secure the therapeutic care of orthogeriatric patients.

Design and Setting

Prospective descriptive study in a multisite teaching hospital from June 2019 to January 2020.

Subjects

Patients aged ≥75 years admitted for hip fracture.

Methods

A prescription review was performed for all patients at inclusion. Other clinical pharmacy activities (additional prescription review, pharmaceutical interviews, medication reconciliation) were dedicated to “high-risk” patients. Potential medication errors (ME), either pharmaceutical interventions (PI) or unintentional discrepancies (UID), were recorded. The potential clinical impact of PI was evaluated by a pluriprofessional expert panel using a validated tool.

Results

In the 455 patients included, 955 potential ME were detected, that is ≥1 potential ME for 324/455 (71%) patients. In acute care, 561 PI were formulated during prescription review for 440/455 (97%) patients and 348/561 (62%) were accepted by physicians. Medication reconciliation was performed for 213 patients, 316 UID were identified. In rehabilitation units, a second prescription review was performed for 112/122 (92%) “high-risk” patients, leading to 61 PI. The clinical impact was evaluated for 519/622 (83%) PI. A consensus was obtained for 310/519 (60%) PI: 147/310 (47%) were rated as having minor clinical impact, 138/310 (45%) moderate, 22/310 (7%) major, 2/310 (0.6%) vital, and 1/310 (0.3%) null.

Conclusion

The 5P project secured the orthogeriatric care pathway by detecting a great number of potential ME, including PI mostly considered as having a significant clinical impact.

[Development of a tool to help optimizing drug prescriptions in pediatric units in Côte d'Ivoire: GOPP tool]

OBJECTIVE

This study aims to develop a tool for optimizing drug management related to clinical and therapeutic contexts of pediatric units in Côte d'Ivoire.

METHODOLOGY

A list of Inappropriate prescribings (IPs) was developed from prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at 4 Teaching Hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0-5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of>70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained. Each IP of final list associated with "rationale", (justifying the inappropriateness of prescribing), and "recommendations and/or therapeutic alternative", used to elaborate items of a tool for helping to optimize drug prescriptions in pediatrics (GOPP tool).

RESULTS

A qualitative list of 54 IPs was drawn up from 267 Drug related problems detected after prescription review of 4992 prescription lines for 881 patients. Twenty-three (23) experts rated IPs on this list during two-round Delphi survey. At the end of survey, final list of 52 IPs was retained for development GOPP tool items. Malaria (15%), rhinitis (12%) and bacterial infectious (8%) are mainly pathologies concerned by these items.

CONCLUSION

GOPP tool developed in this study should help to improve drug management of patients in pediatric units in Côte d'Ivoire.

Prevalence and direct costs of potentially inappropriate prescriptions in France: a population-based study

BACKGROUND

Potentially inappropriate prescriptions (PIPs) in the older population remain a growing public health concern due to the many associated adverse events increasing healthcare service use and health costs. This study aimed to assess the prevalence and direct costs of PIPs in older adults aged ≥65 years in France.

METHODS

A population-based cross-sectional study was conducted in 2017 using a representative sample of the French national healthcare reimbursement system database. PIPs were defined using the French REMEDI[e]S tool. Overall reimbursed direct costs and by PIP category were extrapolated to the French older population.

RESULTS

The overall PIP prevalence was estimated at 56.7% (95% CI: 56.4-57.0). Medications with an unfavorable benefit/risk ratio had the highest prevalence (34.0%, 95% CI: 33.7-34.3). Direct costs associated with PIPs represented 6.3% of the total reimbursed medication costs in 2017 (€507 million). Drug duplications were the main contributors to these costs (39.2% of the total reimbursed PIP costs, €199 million) and among all PIPs, proton pump inhibitors (>8 weeks) were the most expensive PIPs (€152 million).

CONCLUSIONS

PIP prevalence is still high among French older adults, with substantial direct costs. Large-scale interventions targeting the most prevalent and/or costly PIPs are needed to reduce their clinical and economic impacts.

Expert Consensus on a List of Inappropriate Prescribing after Prescription Review in Pediatric Units in Abidjan, Côte d'Ivoire

Introduction

Inappropriate prescribing (IP) includes inappropriate prescription and omission of prescription. IP can adversely affect the quality of health care in pediatric units. A list of IP taking into account frequently encountered drug-related problems (DRPs) can be useful to optimize prescriptions in pediatrics. The aim of this study was to validate by expert consensus a list of IP after a prescription review in pediatric units in Abidjan.

Materials and Methods

A list of IPs was developed from a prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at teaching hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0–5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of >70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained.

Results

A qualitative list of 54 IPs was drawn up from 267 DRPs detected after prescription review of 4,992 prescription lines for 881 patients. Our panel comprised 22 pediatricians (96%) and one clinical pharmacist (4%). Mean agreement ratings were 4.43/5 (95% CI 4.39–4.48) and 4.6/5 (95% CI 4.56–4.64), respectively, during the first Delphi round and the second (p<0.001). At the end of the first round, all items submitted (54) were retained, including 13 items that had been reworded. In the second round, 20 experts participated and two IPs (4%) were not retained for the final list. This list comprised 52 IPs (44 inappropriate prescriptions and eight omissions of prescription).

Conclusion

The list of IP validated in this study should help in the detection of DRPs and optimize prescriptions in pediatric units in Côte d’Ivoire.

Development of clinical pharmacy programs integrated into patient care pathways using adverse event risks

BACKGROUND

In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the "5P project" (Patient personalized clinical pharmacy program integrated into care pathway).

OBJECTIVE

To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods.

METHOD

Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd^, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway.

RESULTS

The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required.

CONCLUSIONS

The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

[What academic training for pharmacy students for clinical pharmacy? Example of shared medication report]

OBJECTIVES

In 2018, the implementation of shared medication reports in pharmacy encourages pharmacists to cooperate with other healthcare professionals. This job allows a decrease of medication errors in elderly. This requires a reorganization of the training offered by universities (initial and continuing training). The aim is to present the results of this pedagogical experimentation.

METHODS

The experimentation (years 2017-2018 and 2018-2019) required the creation of a course to allow students to carry out a pharmaceutical analysis suitable to elderly people, to set up and carry out a shared medication report in pharmacy. Then, during their 6th year internship, students had to carry out at least one shared medication report per month. A monthly follow-up was organized with a database online.

RESULTS

Sixty-four students and 35 internship supervisors participated in the experimentation. All the students improved their ease in using clinical pharmacy tools (pharmaceutical analysis, pharmaceutical interventions, assessment of adherence, etc.). They carried out 345 shared medication reports. In 24.3% of cases, an improvement in the prescription was proposed to the doctor (general practitioner or specialist). For 80% of the internship supervisors, the initial training of the students helped to set up this new pharmacy activity.

CONCLUSIONS

This teaching is appreciated by students and internship supervisors. It enabled the adoption of the various tools essential for carrying out shared medication reports in pharmacy. Shared medication reports reinforce the multidisciplinary work of pharmacists, especially with general practitioners.

Prevalence and determinants of potentially inappropriate medication use in Hong Kong older patients: a cross-sectional study

OBJECTIVES

To assess the prevalence of potentially inappropriate medication (PIM) use in Hong Kong older patients visiting general outpatient clinics (GOPCs) between 2006 and 2014 and to identify factors associated with PIM use among older adults visiting GOPCs in 2014.

DESIGN

Cross-sectional study.

SETTING

GOPC.

PARTICIPANTS

Two study samples were constructed including a total of 844 910 patients aged 65 and above from 2006 to 2014 and a cohort of 489 301 older patients in 2014.

MEASUREMENTS

Two subsets of the 2015 American Geriatrics Society Beers criteria-PIMs independent of diagnosis and PIMs due to drug-disease interactions-were used to estimate the prevalence of PIM use over 12 months. PIMs that were not included in the Hospital Authority drug formulary or with any specific restriction or exception in terms of indication, dose or therapy duration were excluded. Characteristics of PIM users and non-PIM users visiting GOPCs in 2014 were compared. Independent associations between patient variables and PIM use were assessed by stepwise multivariable logistic regression analysis.

RESULTS

The 12-month period prevalence of PIM use decreased from 55.56% (95% CI 55.39% to 55.72%) in 2006 to 47.51% (95% CI 47.37% to 47.65%) in 2014. In the multivariable regression analysis, the strongest factor associated with PIM use was the number of different drugs prescribed (adjusted OR, AOR 23.01, 95% CI 22.36 to 23.67). Being female (AOR 0.89, 95% CI 0.85 to 0.87 for males vs females) and having a greater number of GOPC visits (AOR 1.83, 95% CI 1.78 to 1.88) as well as more than six diagnoses (AOR 1.43, 95% CI 1.36 to 1.52) were associated with PIM use.

CONCLUSIONS

The overall prevalence of PIM use in older adults visiting GOPCs decreased from 2006 to 2014 in Hong Kong although the prevalence of PIM use was still high in 2014. Patients with female gender, a larger number of medications prescribed, more frequent visits to GOPCs, and more than six diagnoses were at higher risk for PIM use.

Development and validation of explicit criteria to identify potentially inappropriate prescribing for adults with type 2 diabetes mellitus

BACKGROUND

Early detection and timely resolution of potentially inappropriate prescribing (PIP) prevents adverse outcomes and improves patient care. An explicit tool specifically designed to detect PIP among people with Type 2 Diabetes Mellitus (T2DM) has not been published.

OBJECTIVES

This study aims to develop and validate the Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus (IMPACT2DM); an explicit tool that can be used to identify PIP for adults with T2DM.

METHODS

Current national and international guidelines for the management of T2DM and drug information software programs were used to generate potential items. The content of the IMPACT2DM was validated by 2 consecutive rounds of Delphi method. Physicians and clinical pharmacists experienced in providing care for people with diabetes and authors of selected diabetes guidelines were invited to participate in the Delphi panel. Consensus was assumed if 90% (first round) and 85% (second round) of expert panelists showed agreement to include or exclude an item.

RESULTS

A total of 95 potential items were generated from selected diabetes guidelines and drug information software programs. After the first Delphi round 27 items had ≥90% agreement and were included in the tool; 19 items were considered not PIP and were excluded from the tool. The second round contained 49 items; of these 43 were included and 6 were excluded from the tool. The final IMPACT2DM contains 70 items categorized by type of PIP and arranged in terms of medical conditions and medication classes. IMPACT2DM can be applied using information on medical charts and requires minimal or no clinical knowledge to assess quality of diabetes care and improve medication selection.

CONCLUSIONS

IMPACT2DM has been developed from current quality evidence and undergone content validation. It is the first explicit tool specifically designed to identify PIP for adults with T2DM.

Potentially inappropriate prescriptions: Associations with the health insurance contract and the quality of the patient-physician relationship?

CONTEXT

Potentially Inappropriate Prescriptions (PIP) are often used as an indicator of potential drug overuse or misuse to limit adverse drug events in older people.

OBJECTIVE

To determine whether PIP exposure differs as a function of the patient's health insurance scheme and the patient-physician relationship.

METHODS

Our dataset was collected from two surveys delivered to two cohorts of the Swiss Lc65+ study, together with a stratified random sample of older people in the Swiss canton of Vaud. The study sample consisted of 1,595 people aged 68 years and older living in the community and reporting at least one prescription drug. Logit regression models of PIP risk were run for various categories of variables: health related, socioeconomic, health insurance scheme and patient-physician relationship.

RESULTS

17% of our respondents had at least one PIP. Our results suggested that being enrolled in a health plan with restriction in the patient's choice of providers and having higher deductibles were associated with lower PIP risk. PIP risk did not differ as a function of the quality of the patient-physician relationship.

CONCLUSION

Our study helps to raise awareness about the organizational risk factors of PIP and, more specifically, how health insurance contracts could play a role in improving the management of drug consumption among community-dwelling older people.