The Association Between Potentially Inappropriate Prescribing and Medication-Related Hospital Admissions in Older Patients: A Nested Case Control Study

The Nudging Effect of a Reminder Letter to Reduce Duplicated Medications: A Randomized Controlled Trial

BACKGROUND

The increasing trend of multiple chronic conditions across the world has worsened the problem of medication duplication in health care systems without gatekeeping or referral requirement. Thus, to overcome this problem, a reminder letter has been developed in Taiwan to nudge patients to engage in medication management.

OBJECTIVE

To evaluate the effect of reminder letter on reducing duplicated medications.

RESEARCH DESIGN

A 2-arm randomized controlled trial design.

SUBJECTS

Patients with duplicated medications in the first quarter of 2019.

MEASURES

The Taiwanese single-payer National Health Insurance Administration identified the eligible patients for this study. A postal reminder letter regarding medication duplication was mailed to the patients in the study group, and no information was provided to the comparison group. Generalized estimation equation models with a difference-in-differences analysis were used to estimate the effects of the reminder letters.

RESULTS

Each group included 11,000 patients. Those who had received the reminder letter were less likely to receive duplicated medications in the subsequent 2 quarters (postintervention 1: odds ratio [OR]=0.95, 95% CI=0.87-1.03; postintervention_2: OR=0.99, 95% CI=0.90-1.08) and had fewer days of duplicated medications (postintervention 1: β=-0.115, P =0.015; postintervention 2 (β=-0.091, P =0.089) than those who had not received the reminder letter, showing marginal but significant differences.

CONCLUSIONS

A one-off reminder letter nudge could mildly decrease the occurrence of duplicated medications. Multiple nudges or nudges incorporating behavioral science insights may be further considered to improve medication safety in health systems without gatekeeping.

Types, predictors, and consequences of medicines related problems (MRPs) in frail older adults admitted to hospital from primary care - A retrospective cohort study

Introduction

Medicines related problems (MRPs) can be common in frail older people due to age-compromised body systems and a propensity to be on multiple drugs concurrently. This group of people can also succumb to a rapid deterioration in health. Thus, it is important to investigate MRPs in frail older people. The objectives of the study were to evaluate prevalence of MRPs, types of MRPs, risk factors and deterioration that can be associated with MRPs in frail older people admitted to an English teaching hospital from primary care.

Methods

Included in the sample were frail older adults, aged 65 years and over, admitted from primary care. Data was retrieved from the hospital's electronic patient record system, anonymised, and reviewed for MRPs. MRPs which were retrospectively identified at admission were coded with the WHO-ICD10,2016 (World Health Organisation-International Classification of Diseases version 10, 2016). Descriptive and inferential statistics were performed on the data using SPSS Version 25. Primary outcome was the prevalence of MRPs in frail older patients. Secondary outcome was the association of deterioration indicated as fall, delirium, or NEWs ≥3 with presence of MRPs.

Results

Among the 507 frail older people (≥4 on Rockwood scale) that met criteria for inclusion, 262 (51.8%) were patients with MRPs and 244 (48.2%) without. The Median age of sample as a whole was 85 years (IQR = 80-89). Prevalence of MRPs was 33.28%. Types of MRPs were adverse drug reaction (ADR-20%), non-compliance (9.1%), unintentional poisoning (3.3%) and inappropriate polypharmacy (0.8%). In logistic regression, potentially inappropriate medicines (PIM), social support, number of comorbidities and winter were significant predictors of MRPs. Risk of deteriorating with delirium was two times higher in patients with MRPs than in patients without MRPs, RR 2.613 (95% CI, 1.049 to 6.510).

Conclusion

MRPs and risks of deterioration associated with MRPs in frail older people can be reduced. This is because factors associated with MRPs can be modified.

Predictors for unplanned hospital admissions in community dwelling adults: A dynamic cohort study

BACKGROUND

Polypharmacy and inappropriate medication use are associated with unplanned hospital admissions. Targeted interventions might reduce the hospitalization risk. Yet, it remains unclear which patient profiles derive the largest benefit from such interventions.

OBJECTIVE

The aim of this study was to determine independent risk factors, among which polypharmacy, for unplanned hospital admissions in a cohort of community dwelling adults.

METHODS

A retrospective study was performed using a large general practice registry and an insurance database in Flanders, Belgium. Community dwelling adults aged 40 years or older with data for 2013-2015 were included. The index date was the last general practitioner contact in 2014. Determinants were collected during the preceding year. Unplanned hospital admissions were determined during the year after the index date. Univariable logistic regression models were fitted on each risk factor for an unplanned hospital admission as the primary outcome. Two multivariable models were derived.

RESULTS

In total, 40411 patients were included and 2126 (5.26%) experienced an unplanned hospital admission. Mean age was 58.3 (±12.3) years. The two models identified the following determinants for an unplanned hospital admission: excessive polypharmacy, older age, male sex, number of comorbidities, atrial fibrillation, chronic obstructive pulmonary disease or stroke, low hemoglobin, use of hypnotics, antipsychotics, antidepressants or antiepileptics and prior hospital and general practitioner visits. Prior hospital visits was the largest determinant.

CONCLUSIONS

In our study we identified and confirmed the presence of known determinants for unplanned hospital admissions in community dwelling adults, most of which align with a geriatric phenotype. Our findings can inform the allocation of interventions aiming to reduce unplanned hospital admissions.

Hospitalization and emergency department visits associated with potentially inappropriate medication in older adults: self-controlled case series analysis

Introduction

Potentially inappropriate medications (PIM) and resulting adverse health outcomes in older adults are a common occurrence. However, PIM prescriptions are still frequent for vulnerable older adults. Here, we sought to estimate the risk of hospitalization and emergency department (ED) visits associated with PIM prescriptions over different exposure periods and PIM drug categories.

Methods

We used the National Health Insurance Service-Elderly Cohort Database (NHIS-ECDB) to construct the cohort and implemented a Self-Controlled Case Series (SCCS) method. Hospitalization or ED visits during the exposure and post-exposure periods were compared to those during the non-exposure period, and six PIM drug categories were evaluated. A conditional Poisson regression model was applied, and the risk of outcomes was presented as the incidence rate ratio (IRR). All potential time-varying covariates were adjusted by year. A total of 43,942 older adults aged ≥65 y who had at least one PIM prescription and the events of either hospitalization or ED visits between Jan 2016 and Dec 2019 were selected..

Results

Mean days of each exposure period was 46 d (±123); risk was highest in exposure1 (1-7 d, 37.8%), whereas it was similar during exposure2 (15-28 d), and exposure3 (29-56 d) (16.6%). The mean number of total PIM drugs administered during the study period was 7.34 (±4.60). Both hospitalization and ED visits were significantly higher in both exposure (adjusted IRR 2.14, 95% Confidence Interval (CI):2.11-2.17) and post-exposure periods (adjusted IRR 1.41, 95% CI:1.38-1.44) in comparison to non-exposure period. The risk of adverse health outcomes was highest during the first exposure period (1-14 d), but decreased gradually over time. Among the PIM categories, pain medication was used the most, followed by anticholinergics. All PIM categories significantly increased the risk of hospitalization and ED visits, ranging from 1.18 (other PIM) to 2.85 (pain medication). Sensitivity analyses using the first incidence of PIM exposure demonstrated similar results. All PIM categories significantly increased the risk of hospitalization and ED visits, with the initial period of PIM prescriptions showing the highest risk. In subgroup analysis stratified by the number of medications, PIM effects on the risk of hospitalization and ED visits remained significant but gradually attenuated by the increased number of medications.

Discussion

Therefore, the development of deprescribing strategies to control PIM and polypharmacy collectively is urgent and essential.

It's time to take a sustainable approach to health care in the face of the challenges of the 21st century

Health challenges in the 21st century have become increasingly complex and global. The recent COVID-19 pandemic has only exacerbated the many problems faced by health care systems around the world and sadly, exposed various flaws. With ageing populations, particularly in Canada, as well as unavoidable factors such as globalization and accelerating climate change, it is becoming imperative to implement a new health care approach based on intersectorality and interdisciplinarity. Furthermore, links must be forged between all the stakeholders, i.e. the researchers, the health system and its specialists, the communities and the individuals themselves. It is in this perspective, where everyone concerned must be equally involved in attaining a better quality of life, that the concepts of One Health and sustainable health must be deployed.

Renally inappropriate medications in elderly outpatients and inpatients with an impaired renal function

BACKGROUND AND AIMS

The purpose of this study was to investigate differences in the frequency of renally inappropriate medications (RIMs) in outpatient and inpatient among three institutions.

METHODS

We collected prescription and renal function data for patients over 65 years of age from the drug department system. We selected 50 kinds of the most frequently used medicines which require dose adjustment according to a patient's renal function.

RESULTS

Outpatient RIM was seen in 611 cases (6.17%), and inpatient prescription RIM was seen in 317 cases (5.29%), showing a significant difference between the groups (odds ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.35). However, in a multivariate analysis, when the renal function was included, that difference between outpatients and inpatients became insignificant (OR 1.16, 95% CI 0.98-1.37). The distribution of prescription with or without RIM in outpatient and inpatient settings depended on the CKD stage. Outpatients with a better CKD stage (stage 1-3) had a higher rate of RIM than inpatients, while patients with a worse CKD stage (stage 4 or 5) had a higher rate of RIM than outpatients.

CONCLUSION

The rate of RIM in outpatients tends to be high, and attention should be paid to RIM in inpatients with a severe CKD stage.

Associations between hyper-polypharmacy and potentially inappropriate prescribing with clinical and functional outcomes in older adults

BACKGROUND

: Hyper-polypharmacy and potentially inappropriate prescribing (PIP) are common among older inpatients. This study investigated associations between hyper-polypharmacy and PIP with clinical and functional outcomes in older adults at 3-months after hospital discharge.

RESEARCH DESIGN AND METHOD

: At discharge, prescribed medications were collected and PIPs, comprising potentially inappropriate medications (PIM) and potential prescribing omissions (PPO), were retrospectively identified using STOPP/START version 2. Clinical and functional outcomes were collected prospectively via telephone follow-up and audit.

RESULTS

: Data for 232 patients (mean age 80 years, 51.7 % female) were analysed. PIP prevalence at discharge was 73.7% (PIMs 62.5%, PPOs 36.6%). Exposure to at least 1 PIM was associated with an increased occurrence of unplanned hospital readmission (adjusted odds ratio (AOR) 5.09; 95% CI 2.38─10.85), emergency department presentation (AOR 4.69; 95% CI 1.55─14.21) and the composite outcome (AOR 6.83; 95% CI 3.20─14.57). The number rather than presence of PIMs was significantly associated with increased dependency in at least 1 activity of daily living (ADL) (AOR 2.31; 95% CI 1.08─4.20). Increased PIP use was associated with mortality (AOR 1.45; 95% CI 1.05─1.99).

CONCLUSION

: PIPs overall, and PIMs specifically, were frequent in older adults at hospital discharge, and were associated with increased re-hospitalizations and dependence in ADLs at 3-months post-discharge.

Predicting hospital admissions from individual patient data (IPD): an applied example to explore key elements driving external validity

OBJECTIVE

To explore factors that potentially impact external validation performance while developing and validating a prognostic model for hospital admissions (HAs) in complex older general practice patients.

STUDY DESIGN AND SETTING

Using individual participant data from four cluster-randomised trials conducted in the Netherlands and Germany, we used logistic regression to develop a prognostic model to predict all-cause HAs within a 6-month follow-up period. A stratified intercept was used to account for heterogeneity in baseline risk between the studies. The model was validated both internally and by using internal-external cross-validation (IECV).

RESULTS

Prior HAs, physical components of the health-related quality of life comorbidity index, and medication-related variables were used in the final model. While achieving moderate discriminatory performance, internal bootstrap validation revealed a pronounced risk of overfitting. The results of the IECV, in which calibration was highly variable even after accounting for between-study heterogeneity, agreed with this finding. Heterogeneity was equally reflected in differing baseline risk, predictor effects and absolute risk predictions.

CONCLUSIONS

Predictor effect heterogeneity and differing baseline risk can explain the limited external performance of HA prediction models. With such drivers known, model adjustments in external validation settings (eg, intercept recalibration, complete updating) can be applied more purposefully.

TRIAL REGISTRATION NUMBER

PROSPERO id: CRD42018088129.

Protocol of a tailored educational intervention for general practitioners on potentially inappropriate medications among older patients at community healthcare institutions in Beijing, China: a cluster-randomised controlled trial

INTRODUCTION

Prescribing of potentially inappropriate medications (PIMs) has become a prominent issue of public concern among elderly patients. However, no research has involved interventions on PIMs of Chinese elderly patients seeking care at primary healthcare. This study aims to evaluate the effectiveness of a tailored educational intervention programme for general practitioners (GPs), aiming at reducing the occurrence of PIMs in elderly patients.

METHODS AND ANALYSIS

This is a parallel group, controlled, cluster-randomised trial, with blinded evaluation of outcomes and data analysis, and un-blinded intervention. Twenty primary community healthcare stations (CHSs) in Dongcheng district in Beijing will be randomised to intervention and control arm with an allocation ratio of 1:1. GPs in CHSs randomised to the intervention arm will receive a two-component intervention: general training of PIMs and distribution of PIMs handbook. GPs in the control arm will assess and manage patients according to the institutions' routine practice. The primary outcome is the change in PIMs patient visit rate.

ETHICS AND DISSEMINATION

Ethics committee approval of this study was obtained from Peking University Institution Review Board (IRB00001052-19074). The findings will be published in scientific and conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2100047788.

Medicines Related Problems (MRPs) Originating in Primary Care Settings in Older Adults - A Systematic Review

BACKGROUND

As people age, they become increasingly vulnerable to the untoward effects of medicines due to changes in body systems. These may result in medicines related problems (MRPs) and consequent decline or deterioration in health.

AIM

To identify MRPs, indicators of deterioration associated with these MRPs, and preventative interventions from the literature.

DESIGN AND SETTING

Systematic review of primary studies on MRPs originating in Primary Care in older people.

METHODS

Relevant studies published between 2001 and April 2018 were obtained from Medline (via PubMed), CINAHL, Embase, Psych Info, PASCAL, Scopus, Cochrane Library, Science Direct, and Zetoc. Falls, delirium, pressure ulcer, hospitalization, use of health services and death were agreed indicators of deterioration. The methodological quality of included studies was assessed using the Down and Black tool.

RESULTS

There were 1858 articles retrieved from the data bases. Out of these, 21 full text articles met inclusion criteria for the review. MRPs identified were medication error, potentially inappropriate medicines, adverse drug reaction and non-adherence. These were associated with indicators of deterioration. Interventions that involved doctors, pharmacists and patients in planning and implementation yielded benefits in halting MRPs.

CONCLUSION

This Systematic review summarizes MRPs and associated indicators of deterioration. Appropriate interventions appeared to be effective against certain MRPs and their consequences. Further studies to explore deterioration presented in this systematic review is imperative.

Medication-related hospital readmissions within 30 days of discharge-A retrospective study of risk factors in older adults

Background

Previous studies have shown that approximately 20% of hospital readmissions can be medication-related and 70% of these readmissions are possibly preventable. This retrospective medical records study aimed to find risk factors associated with medication-related readmissions to hospital within 30 days of discharge in older adults (≥65 years).

Methods

30-day readmissions (n = 360) were assessed as being either possibly or unlikely medication-related after which selected variables were used to individually compare the two groups to a comparison group (n = 360). The aim was to find individual risk factors of possibly medication-related readmissions focusing on living arrangements, polypharmacy, potentially inappropriate medication therapy, and changes made to medication regimens at initial discharge.

Results

A total of 143 of the 360 readmissions (40%) were assessed as being possibly medication-related. Charlson Comorbidity Index (OR 1.15, 95%CI 1.5–1.25), excessive polypharmacy (OR 1.74, 95%CI 1.07–2.81), having adjustments made to medication dosages at initial discharge (OR 1.63, 95%CI 1.03–2.58) and living in your own home, alone, were variables identified as risk factors of such readmissions. Living in your own home, alone, increased the odds of a possibly medication-related readmission 1.69 times compared to living in your own home with someone (p-value 0.025) and 2.22 times compared to living in a nursing home (p-value 0.037).

Conclusion

Possibly medication-related readmissions within 30 days of discharge, in patients 65 years and older, are common. The odds of such readmissions increase in comorbid, highly medicated patients living in their own home, alone, and if having medication dosages adjusted at initial discharge. These results indicate that care planning before discharge and the provision of help with, for example, managing medications after discharge, are factors especially important if aiming to reduce the amount of medication-related readmissions among this population. Further research is needed to confirm this hypothesis.

Geriatric emergency department revisits after discharge with Potentially Inappropriate Medications: A retrospective cohort study

OBJECTIVE

To determine whether Potentially Inappropriate Medications (PIMs) prescribed in an academic emergency department (ED) are associated with increased ED revisits in older adults.

METHODS

A retrospective chart review of Medicare beneficiaries 65 years and older, discharged from an academic ED (January 2012 - November 2015) with any PIMs versus no PIMs. PIMs were defined using Category 1 of the 2015 Updated Beers criteria. Primary outcomes, obtained from a Medicare database linked to hospital ED subjects, were ED revisits 3 and 30 days from index ED discharge. Adjusted multiple logistic regression was used with entropy balance weighted covariates: Age in years, Gender, Race, Number of discharge medications, Charlson Comorbidity Index (CCI) score, Emergency Severity Index scores (ESI), Chief Complaint, Medicaid status, and prior 90 Day ED visits.

RESULTS

Over the study period, there were a total of 7,591 Medicare beneficiaries 65+ discharged from the ED with a prescription; 1,383 (18%) received one or more PIMs. ED revisits in 30 days were fewer for the PIMs cohort (12% PIMs vs 16% no PIMs, OR 0.79, 95% CI 0.65 - 0.95, P value <0.005). Hospital admissions in 30 days were fewer for the PIMs cohort (4 PIMs vs 7% no PIMs, OR 0.75, 95% CI 0.56 - 1.00, P value <0.005). In addition to PIMs, covariate risk factors associated with ED revisits in 30 days included comorbidity severity, history of prior ED revisits, chief complaint, and Medicaid status. Risk factors associated with hospitalization in 30 days included those plus age and emergency severity index, but not race nor ethnicity.

CONCLUSIONS

Patients discharged from the ED receiving potentially inappropriate medications as defined by Category 1 of the 2015 updated Beers criteria had lower odds of revisiting the ED within 30 days of index visit. Sociodemographic factors such as gender and race did not predict ED revisits or hospital admissions. Clinical characteristics predicted ED revisits and hospital admissions, the strongest risk being increasing Charlson Comorbidity Index score followed by triage acuity and chief complaint. Future studies are needed to delineate the implications of our findings.

The role of sickness absence diagnosis for the risk of future inpatient- or specialized outpatient care in a Swedish population-based twin sample

Background

Studies of consequences of sickness absence such as health and well-being have been rare whereas risk factors for sickness absence have been studied extensively. This study assumed the consequences of sickness absence would differ by diagnostic group or by patient care type. The aim was to investigate sickness absence due to various diagnosis groups as a predictor for subsequent inpatient- and specialized outpatient care while controlling for familial confounding.

Methods

We utilized the register data of 69,552 twin individuals between 16 and 80years of age (48% women). The first incident sickness absence spell, from baseline year 2005, including diagnosis of sickness absence was our primary exposure of interest and we followed them until the first incident inpatient- and specialized outpatient care episode with main diagnosis code or until 31.12.2013.

Results

A total of 7464 incident sickness absence spells took place (11%), 42% had inpatient care and 83% specialized outpatient care (mean follow-up time 3.2years, SD 3.1years). All the main sickness absence diagnosis groups were associated with increased risk of future care in comparison to no sickness absence. Controlling for confounders attenuated the associations in magnitude but with retaining direction, and we could not confirm an effect of familial factors.

Conclusions

Sickness absence predicts both inpatient- and specialized outpatient care and the association is universal across diagnosis groups. The lower survival time and incidence rates of inpatient than specialized outpatient care point towards severity of diseases assumption. This finding was also universal across sickness absence diagnosis groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10942-2.

Potentially inappropriate prescribing and its associations with health-related and system-related outcomes in hospitalised older adults: A systematic review and meta-analysis

AIMS

To synthesise associations of potentially inappropriate prescribing (PIP) with health-related and system-related outcomes in inpatient hospital settings.

METHODS

Six electronic databases were searched: Medline Complete, EMBASE, CINAHL, PyscInfo, IPA and Cochrane library. Studies published between 1 January 1991 and 31 January 2021 investigating associations between PIP and health-related and system-related outcomes of older adults in hospital settings, were included. A random effects model was employed using the generic inverse variance method to pool risk estimates.

RESULTS

Overall, 63 studies were included. Pooled risk estimates did not show a significant association with all-cause mortality (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 0.90-1.36; adjusted hazard ratio 1.02, 83% CI 0.90-1.16), and hospital readmission (AOR 1.11, 95% CI 0.76-1.63; adjusted hazard ratio 1.02, 95% CI 0.89-1.18). PIP was associated with 91%, 60% and 26% increased odds of adverse drug event-related hospital admissions (AOR 1.91, 95% CI 1.21-3.01), functional decline (AOR 1.60, 95% CI 1.28-2.01), and adverse drug reactions and adverse drug events (AOR 1.26, 95% CI 1.11-1.43), respectively. PIP was associated with falls (2/2 studies). The impact of PIP on emergency department visits, length of stay, and health-related quality of life was inconclusive. Economic cost of PIP reported in 3 studies, comprised various cost estimation methods.

CONCLUSIONS

PIP was significantly associated with a range of health-related and system-related outcomes. It is important to optimise older adults' prescriptions to facilitate improved outcomes of care.

Economic Evaluations of Interventions to Optimize Medication Use in Older Adults with Polypharmacy and Multimorbidity: A Systematic Review

Purpose

To conduct a systematic review of the economic impact of interventions intended at optimizing medication use in older adults with multimorbidity and polypharmacy.

Methods

We searched Ovid-Medline, Embase, CINAHL, Ageline, Cochrane, and Web of Science, for articles published between 2004 and 2020 that studied older adults with multimorbidity and polypharmacy. The intervention studied had to be aimed at optimizing medication use and present results on costs.

Results

Out of 3,871 studies identified by the search strategy, eleven studies were included. The interventions involved different provider types, with a majority described as a multidisciplinary team involving a pharmacist and a general practitioner, in the decision-making process. Interventions were generally associated with a reduction in medication expenditure. The benefits of the intervention in terms of clinical outcomes remain limited. Five studies were cost-benefit analyses, which had a net benefit that was either null or positive. Cost-utility and cost-effectiveness analyses resulted in incremental cost-effectiveness ratios that were generally within the willingness-to-pay thresholds of the countries in which the studies were conducted. However, the quality of the studies was generally low. Omission of key cost elements of economic evaluations, including intervention cost and payer perspective, limited interpretability.

Conclusion

Interventions to optimize medication use may provide benefits that outweigh their implementation costs, but the evidence remains limited. There is a need to identify and address barriers to the scaling-up of such interventions, starting with the current incentive structures for pharmacists, physicians, and patients.

Risk factors for hospital readmission in older adults within 30 days of discharge - a comparative retrospective study

BACKGROUND

The area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population.

METHODS

This comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student's t-test, χ²-test or Fishers' exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission.

RESULTS

The final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001).

CONCLUSION

Patients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.

Impact of Geriatric Pharmacy Specialist Interventions to Reduce Potentially Inappropriate Medication Among Hospitalized Elderly Patients at Medical Wards: A Prospective Quasi-Experimental Study

Background

Elderly patients are at greater risk of receiving potentially inappropriate medications (PIMs) and developing adverse drug events. Identification and correction of PIMs is essential to maximize medication safety.

Objective

To determine the prevalence of PIMs on admission in Thai elderly patients admitted to a medical ward and to compare changes of PIMs on discharge, following comprehensive care by a ward pharmacist with or without a geriatric pharmacy specialist.

Patients and method

A prospective, quasi-experimental study was performed at a tertiary university hospital in Bangkok, Thailand. Patients aged ≥ 60 years who were admitted to the medical ward were recruited and allocated to one of two groups: intervention (IG) and control (CG). The CG received pharmaceutical care from the ward pharmacist. The IG received pharmaceutical care from the geriatric pharmacy specialist along with the ward pharmacist. The 2012 Beers criteria were used to identify PIMs on admission, during hospitalization, and on discharge.

Results

Prevalence of PIMs on admission was 43.3% (N = 187). On discharge, prevalence of PIMs in the IG decreased significantly compared to that on admission (21.3% and 43.3%, p < 0.05) and was significantly lower than in the CG (21.3% and 40.9%, p = 0.036). Moreover, the percentage of patients without PIMs on discharge in the IG was significantly higher than in the CG (78.7% and 59.1%, p < 0.0001).

Conclusion

Use of PIMs was common among hospitalized elderly patients on admission. Pharmaceutical care provided by a geriatric pharmacy specialist in conjunction with a ward pharmacist significantly reduced the prevalence of PIMs on discharge compared with on admission.

Opportunities for changes in the drug product design to enhance medication safety in older people: Evaluation of a national public portal for medication incidents

AIMS

Medication safety requires urgent attention in hospital pharmacy. This study evaluated the medication-related problems/errors as reported to the Dutch medication incident registry and disseminated for information to pharmacists. Through analysis by an expert panel we aimed to better understand which problems could have been mitigated by the drug product design. Additionally, the (wider) implications of the problems for current hospital/clinical practice were discussed.

METHODS

Items were extracted from the public Portal for Patient Safety. Items were included if relevant for older people and connected with the drug product design and excluded if they should reasonably have been intercepted by compliance to routine controls or well-known professional standards in pharmaceutical care. To explore any underreporting of well-known incidents, it was investigated if different medication-related problems could be observed in a regional hospital practise over a 1-month period. For 6 included items (cases), the implications for hospital/clinical practise were discussed in an expert panel.

RESULTS

In total, 307 items were identified in the Portal for Patient Safety; all but 14 were excluded. Six cases were added from daily hospital practice. These 20 cases commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions.

CONCLUSION

Medication registries provide important opportunities to evaluate real-world medication-related problems. However, underreporting of well-known problems should be considered. The product design can be used as an (additional) risk mitigation measure to support medication safety in hospital practice.

A nurse practitioner led protocol to address polypharmacy in long-term care

•

Polypharmacy is common in long term care facilities and frequently associated with poor outcomes.

•

A focus on decreasing polypharmacy as part of 60-day periodic review process in long term care facilities has the potential to improve resident outcomes and assist health care providers in improved medication management.

•

To achieve success in decreasing polypharmacy, an interdisciplinary team with shared goals and communication is needed.

Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. This study sought to determine if a medication management protocol completed at four month intervals by nurse practitioners (NP) could impact polypharmacy and administration times for long term care residents. The data was collected as part of a Centers for Medicare and Medicaid Services (CMS) “Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents” grant. Residents were recruited from participating long-term care facilities. NP completed a medication management protocol on admission to the program and at subsequent 4-month intervals or with an acute change in condition. A total of 2442 non-duplicated individuals were seen for at least 1 visit. Although the protocol did not result in a reduction of regularly scheduled medications, the number of scheduled medication administration times did significantly decrease. NP polypharmacy assessments and recommendations are important but were insufficient to decrease the medication burden.

Potentially inappropriate medications among elderly patients in community healthcare institutions in Beijing, China

PURPOSE

To evaluate potentially inappropriate medications (PIMs) prevalence and predictors in community healthcare institutions (CHIs) for the elderly.

METHODS

We conducted a retrospective observational study, deriving data of patients aged ≥60 from 66 CHIs in Beijing, 2014-2018. The system of Criteria of PIM for Older Adults in China was applied to identify PIMs. The primary outcome was the prevalence of visits with at least one PIM; secondary outcomes were the frequency and rate per thousand visits of specific PIMs. We used descriptive analysis and generalized linear models to analyzed PIMs and the predictors, and marginal effects methods were applied to estimate the mean adjusted PIMs prevalence.

RESULTS

Overall, 4 528 884 elderly patient visits from 2014 to 2018 were eligible for inclusion. A total of 719 757 PIMs were detected, with 14.1% of the visits contained at least one PIM. PIM prevalence was significantly correlated with age, number of prescribed medications and number of diagnoses. Overall, 6.0 per thousand elderly patients in CHIs were exposed to at least one high-risk PIM, while 117.5 per thousand were exposed to at least one low-risk PIM. In 2018, 20% of GPs were responsible for more than half of overall PIM visits.

CONCLUSION

Prescribing of PIMs for older adults is common in CHIs in China, especially for patients who are aged, having multiple medications and diagnostic diseases. Strategies should be developed to enhance prescribing quality for geriatric patients, with special targeting of doctors responsible for a high number of PIMs.

Both New and Chronic Potentially Inappropriate Medications Continued at Hospital Discharge Are Associated With Increased Risk of Adverse Events

BACKGROUND

Admission to hospital provides the opportunity to review patient medications; however, the extent to which the safety of drug regimens changes after hospitalization is unclear.

OBJECTIVE

To estimate the number of potentially inappropriate medications (PIMs) prescribed to patients at hospital discharge and their association with the risk of adverse events 30 days after discharge.

DESIGN

Prospective cohort study.

SETTING

Tertiary care hospitals within the McGill University Health Centre Network in Montreal, Quebec, Canada.

PARTICIPANTS

Patients from internal medicine, cardiac, and thoracic surgery, aged 65 years and older, admitted between October 2014 and November 2016.

MEASURES

Abstracted chart data were linked to provincial health databases. PIMs were identified using AGS (American Geriatrics Society) Beers Criteria®, STOPP, and Choosing Wisely statements. Multivariable logistic regression and Cox models were used to assess the association between PIMs and adverse events.

RESULTS

Of 2,402 included patients, 1,381 (57%) were male; median age was 76 years (interquartile range [IQR] = 70‐82 years); and eight discharge medications were prescribed (IQR = 2‐8). A total of 1,576 (66%) patients were prescribed at least one PIM at discharge; 1,176 (49%) continued a PIM from prior to admission, and 755 (31%) were prescribed at least one new PIM. In the 30 days after discharge, 218 (9%) experienced an adverse drug event (ADE) and 862 (36%) visited the emergency department (ED), were rehospitalized, or died. After adjustment, each additional new PIM and continued community PIM were respectively associated with a 21% (odds ratio [OR] = 1.21; 95% confidence interval [CI] = 1.01‐1.45) and a 10% (OR = 1.10; 95% CI = 1.01‐1.21) increased odds of ADEs. They were also respectively associated with a 13% (hazard ratio [HR] = 1.13; 95% CI = 1.03‐1.26) and a 5% (HR = 1.05; 95% CI = 1.00‐1.10) increased risk of ED visits, rehospitalization, and death.

CONCLUSIONS

Two in three hospitalized patients were prescribed a PIM at discharge, and increasing numbers of PIMs were associated with an increased risk of ADEs and all‐cause adverse events. Improving hospital prescribing practices may reduce the frequency of PIMs and associated adverse events. J Am Geriatr Soc 68:1184–1192, 2020.

See related editorial by Donna M. Fick in this issue.

Development of consumer information leaflets for deprescribing in older hospital inpatients: a mixed-methods study

OBJECTIVE

To develop information leaflets for older inpatients and/or their carers to support deprescribing of antipsychotics, benzodiazepines/Z-drugs and proton pump inhibitors (PPIs).

DESIGN

An iterative mixed-methods approach involving face-to-face user testing and semi-structured interviews was performed over three rounds with consumers and hospital health professionals.

SETTING

Sydney, New South Wales, Australia.

PARTICIPANTS

Thirty-seven consumers (or their carers) aged 65 years or older admitted to hospital in the previous 5 years and taking at least one regular medicine (not the medicine tested) completed user testing. Health professionals included a convenience sample of seven pharmacists and five doctors.

METHODS

The antipsychotic leaflet was tested in round 1 (consumers, n=10) and revised and retested in round 2 (consumers, n=9; health professionals, n=5). Findings from rounds 1 and 2 informed the design of the benzodiazepine/Z-drug and PPI leaflets tested in round 3 (benzodiazepine/Z-drug consumers, n=9; health professionals, n=7; PPI consumers, n=9). Findings from round 3 informed the final design of all leaflets. Consumer user testing involved 12-13 questions to evaluate consumers' ability to locate and understand information in the leaflet. Usability by health professionals was assessed using the System Usability Scale (SUS).

RESULTS

At least 80% of consumers correctly found and understood the deprescribing information in the leaflets (9 of 12 information points in round 1 (antipsychotic); 10 of 12 in round 2; 12 of 13 (benzodiazepine/Z-drug) and 11 of 12 (PPI) in round 3). Consumers perceived the leaflets to be informative, well-designed and useful aids for ongoing medication management. The SUS scores obtained from health professionals were 91.0±3.8 for the antipsychotic leaflet and 86.4±6.6 for the benzodiazepine/Z-drug leaflet, indicating excellent usability.

CONCLUSIONS

Understandable and easy-to-use consumer information leaflets were developed and tested by consumers and health professionals. The feasibility and utility of these leaflets to support deprescribing at transitions of care should be explored in clinical practice.

Potentially Inappropriate Prescribing and Related Hospital Admissions in Geriatric Patients: A Comparative Analysis between the STOPP and START Criteria Versions 1 and 2

BACKGROUND

Older persons are at significant risk of drug-related admissions (DRAs). We previously demonstrated that 27% of hospitalizations in geriatric patients were associated with potentially inappropriate medicines (PIMs) and/or potential prescribing omissions (PPOs) identified by the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 1 (v₁). The updated STOPP/START criteria version 2 (v₂) comprised a 31% increase in prescribing criteria.

OBJECTIVE

As a secondary analysis of our study conducted in 2008, we aimed to compare the prevalence and types of DRAs identified by STOPP/START.v₁ and STOPP/START.v₂.

METHODS

We applied the STOPP/START.v₂ criteria to a subset of 100 consecutively admitted geriatric patients selected from our original cross-sectional study of 302 patients. A geriatrician and a pharmacist adjudicated whether the identified PIMs and PPOs were related to acute hospitalization. Admissions were defined as DRAs if the identified PIM(s) and/or PPO(s) were related to the main cause of admission or played a significant contributory role in the admission.

RESULTS

The median patient age was 83 years and the median number of medications at home was 8. Compared with STOPP/START.v₁, STOPP/START.v₂ not only yielded more instances of inappropriate prescribing but also targeted significantly more PIMs and PPOs associated with preventable DRAs (23% vs. 40% of all admissions, p < 0.001). PIMs of fall-risk-increasing drugs, and PPOs of musculoskeletal and cardiovascular system drugs, were most frequently associated with DRAs.

CONCLUSION

The latter instances of inappropriate prescribing with major clinical relevance warrant particular attention during medication review in older persons.

Do the 2015 Beers Criteria predict medication-related harm in older adults? Analysis from a multicentre prospective study in the United Kingdom

PURPOSE

To investigate whether inappropriate prescribing, defined by the Beers Criteria, is associated with medication-related harm (MRH), hospital admission, and mortality in older adults in England.

METHODS

A multicentre, prospective cohort study recruited 1280 patients (median age 82 years) at hospital discharge. Patients were followed-up in the community by pharmacists for 8 weeks to identify MRH (harm from adverse drug reactions, non-adherence, and medication errors) and hospital admissions. One-year mortality was determined using hospital records. Potentially inappropriate medications (PIMs) were determined using the 2015 version of the Beers criteria. Logistic regression was used to investigate the relationship between patients prescribed PIMs and adverse outcomes.

RESULTS

Two hundred and seventy-six patients (22%) were prescribed one or more PIMs at hospital discharge. The main PIM classes prescribed at hospital discharge were benzodiazepines and related drugs (30%) and antidepressants (27%). 1116 out of 1280 patients completed follow-up and 413 (37%) experienced MRH. In 51 cases (12%), MRH was attributable to a PIM. There was no significant relationship between patients prescribed PIMs and overall MRH, hospital readmission or all-cause one-year mortality. Multiple PIMs at discharge was independently associated with an increased risk of ADR (OR 2.32, 95% CI 1.03-5.23).

CONCLUSION

The prescribing of PIMs is common at hospital discharge of older adults in England. The 2015 Beers criteria have a limited clinical value to predict adverse outcomes following hospital discharge in this setting.

Potential inappropriate prescribing and associated factors among older persons in Nigeria and South Africa

Background Potential inappropriate prescribing (PIP) among older persons is a global public health issue. However, trans-country data that can influence interventions on a global or regional level is scarce. Objectives To compare the prevalence of PIP and to determine the associated factors among older Nigerians and South Africans. Settings Nigerian and South African teaching hospitals. Method A retrospective evaluation of randomly selected medical charts of older persons was carried out in outpatient clinics of one University teaching hospital in both Nigeria and South Africa. Older persons aged ≥ 60 years who attended the hospitals' clinics between 1st January and 31st December 2016 and received medicine prescriptions were included. The PIP was evaluated using the 2015 American Geriatrics Society-Beers Criteria. The prevalence of PIP in both countries was compared and the associated factors for their occurrence determined using a binary logistic regression. Main outcome measure Prevalence of PIP and associated factors among older outpatients. Results A total of 680 participants were evaluated, 352 in Nigeria, mean age 69.03 (7.35) years, and 328 in South Africa, mean age 68.21 (7.42) years (95% CI - 0.28 to 1.94, p = 0.14). The PIP among Nigerian and South African participants were (124/352; 35.2%) versus (97/328; 29.6%) respectively (OR 0.77, 95% CI 0.56-1.06, p = 0.12). Hypertension was significantly associated with PIP among the Nigerians (OR 2.56, 95% CI 1.57-4.17, p = < 0.001) and South Africans (OR 3.11, 95% CI 1.17-8.24, p = 0.02) in a logistic regression. Conclusions The prevalence and pattern of PIP among Nigerian and South African participants were similar. Hypertension was an associated factor for PIP among the participants in both countries.

Qualitative analysis of community pharmacists' opinions on their involvement in reducing potentially inappropriate prescribing

PURPOSE

Older people are at risk of potentially inappropriate prescribing (PIP) due to polypharmacy arising from multi-morbidity. Despite available explicit criteria to reduce PIP, it is highly prevalent. Whilst community pharmacists have the required knowledge to help reduce PIP, they are not currently engaged with the problem. This study explores the views of community pharmacists on their potential involvement in reducing PIP and determines the challenges to its implementation.

METHODS

Semi-structured interviews with pharmacists working in community pharmacies in Ireland. The theoretical domains framework (TDF) was used to develop the topic guide and to analyse the transcripts. Domains of highest relevance for PIP reduction were identified based on their frequency or whether the participants emphasised the impact of constructs within a domain. Local ethical approval was obtained.

RESULTS

Of 18 participants, 12 were female, median age was 30 years (IQR, 27-35) with a median of 6 years (IQR, 3-8) of experience. Seven TDF domains were identified as relevant to PIP reduction. Pharmacists were uncertain about their role in reducing PIP and reluctant to challenge physicians' prescribing decisions. Challenges pertained to the environment, knowledge, social influences, professional role and identity.

CONCLUSIONS

Pharmacists welcomed new responsibilities in reducing PIP as part of their daily practice but expressed a need for removal of social and environmental barriers as well as, provision of relevant guidelines and education about PIP. This study provides useful insights into the target domains for overcoming barriers of pharmacist involvement in reducing PIP.

Potentially inappropriate medication and hospitalization/emergency department visits among the elderly in Korea

Objective

To investigate the association between potentially inappropriate medicine (PIM) use, defined using the American Geriatric Society (AGS) 2012 Beers criteria, and the risk of hospitalization or emergency department (ED) visits in elderly patients, and to examine the most frequently used PIMs among patients with adverse outcomes.

Design/Setting

This was a retrospective study using National Health Insurance claims data from 2010 to 2012.

Intervention(s)

Elderly patients who took PIMs are compared to those who were not taking PIMs.

Study participants

Elderly patients (n = 79 552) who visited medical institutions in Jeju Island during 2011.

Main outcome measure

Hospitalization and ED visits were evaluated according to whether the patients took PIMs during the study period. The most frequent medications used by the PIM group were also investigated.

Results

The likelihood of hospitalization was higher in older patients who took at least one PIM than in those who were not taking PIMs during the study period (odds ratio 2.25, 95% confidence interval 2.09-2.44). Patients taking PIMs were more likely to visit EDs (odds ratio 1.59, 95% confidence interval 1.50-1.67). Among patients who were hospitalized or visited EDs, 45.5% had taken at least one PIM on that day. The most commonly used PIMs included chlorpheniramine maleate, diazepam, metoclopramide HCl and diclofenac sodium.

Conclusion

Our findings indicate that PIM use can lead to negative health consequences, providing further evidence of the inappropriateness of these medications. Thus, pharmaceutical policies regarding PIM use may need to be implemented for elderly adults in Korea.

Medications and Prescribing Patterns as Factors Associated with Hospitalizations from Long-Term Care Facilities: A Systematic Review

BACKGROUND

Residents of long-term care facilities (LTCFs) are at high risk of hospitalization. Medications are a potentially modifiable risk factor for hospitalizations.

OBJECTIVE

Our objective was to systematically review the association between medications or prescribing patterns and hospitalizations from LTCFs.

METHODS

We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and International Pharmaceutical Abstracts (IPA) from inception to August 2017 for longitudinal studies reporting associations between medications or prescribing patterns and hospitalizations. Two independent investigators completed the study selection, data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Tools.

RESULTS

Three randomized controlled trials (RCTs), 22 cohort studies, five case-control studies, one case-time-control study and one case-crossover study, investigating 13 different medication classes and two prescribing patterns were included. An RCT demonstrated that high-dose influenza vaccination reduced all-cause hospitalization compared with standard-dose vaccination (risk ratio [RR] 0.93; 95% confidence interval [CI] 0.88-0.98). Another RCT found no difference in hospitalization rates between oseltamivir as influenza treatment and oseltamivir as treatment plus prophylaxis (treatment = 4.7%, treatment and prophylaxis = 3.5%; p = 0.7). The third RCT found no difference between multivitamin/mineral supplementation and hospitalization (odds ratio [OR] 0.94; 95% CI 0.74-1.20) or emergency department visits (OR 1.05; 95% CI 0.76-1.47). Two cohort studies demonstrated influenza vaccination reduced hospitalization. Four studies suggested polypharmacy and potentially inappropriate medications (PIMs) increased all-cause hospitalization. However, associations between polypharmacy (two studies), PIMs (one study) and fall-related hospitalizations were inconsistent. Inconsistent associations were found between psychotropic medications with all-cause and cause-specific hospitalizations (11 studies). Warfarin, nonsteroidal anti-inflammatory drugs, pantoprazole and vinpocetine but not long-term acetylsalicylic acid (aspirin), statins, trimetazidine, digoxin or β-blockers were associated with all-cause or cause-specific hospitalizations in single studies of specific resident populations. Most cohort studies assessed prevalent rather than incident medication exposure, and no studies considered time-varying medication use.

CONCLUSION

High-quality evidence suggests influenza vaccination reduces hospitalization. Polypharmacy and PIMs are consistently associated with increased all-cause hospitalization.

Hospital readmissions, mortality and potentially inappropriate prescribing: a retrospective study of older adults discharged from hospital

AIMS

Applying version 2 of the STOPP/START criteria to discharge prescriptions of older adults discharged from a general medical unit, the aim of this study is to assess potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) and their association with hospital readmission and mortality.

METHODS

Discharge medications, co-morbidities and patient demographics were recorded over an 8-month period for consecutive emergency admissions of patients aged ≥65 years. PIMs and PPOs were identified using version 2 of the STOPP/START criteria. Multivariate analysis for association of PIMs and PPOs with re-admissions and mortality during the follow-up period were assessed using binary logistic regression.

RESULTS

Data for 259 patients with a mean age of 77 (65-99, 51% female) were analysed. At discharge, the mean number of co-morbidities and medications per patient were 5.4 (SD: 2.1 range: 0-14) and 9.3 (SD: 4.0 range: 1-31) respectively. During the follow-up period (mean 41.5 months, SD: 2.0 range: 38-46 months), 50.2% of patients had died and the median number of readmissions was two (IQR: 1-4 range: 0-33). Prescription of more than five medications was significantly associated with PIMs and PPOs (OR: 2.75, 95% CI: 1.34-5.62 and OR 3.20, 95% CI: 1.57-6.54 respectively). Presence of a PIM was associated with three or more readmissions (OR: 2.43 95% CI: 1.19-4.98) and PPOs with mortality (OR: 1.88, 95% CI: 1.09-3.27).

CONCLUSIONS

Using version 2 of the STOPP/START criteria, the presence of PIMs and/or PPOs in older adults discharged from hospital is significantly associated with repeated hospital admissions and mortality respectively.

Association Between Anticholinergic Drug Use and Health-Related Quality of Life in Community-Dwelling Older Adults

BACKGROUND

The use of drugs with anticholinergic properties (AC drugs) has been associated with decreased functioning and impaired cognition in older adults. Studies assessing the association between AC-drug use and health-related quality of life (HRQoL) show conflicting results.

OBJECTIVE

The aim was to evaluate the association between AC-drug use and HRQoL in community-dwelling older adults.

METHODS

The NuAge cohort study enrolled 1793 men and women aged 68-82 years. The participants were free of disabilities in activities of daily living, not cognitively impaired at recruitment and followed annually for 3 years (December 2003-May 2005). AC-drug exposure was assessed using the Anticholinergic Cognitive Burden Scale (ACBS). HRQoL was assessed using the physical (PCS) and mental (MCS) component summaries of the 36-item Short Form Survey (SF-36) questionnaire. The association between AC drug and HRQoL was determined by a mixed model analysis using four annual time points.

RESULTS

At recruitment the mean age was 74.4 ± 4.2 years, 52% were female and 33% of participants were prescribed at least one AC drug. The mean PCS and MCS (/100) scores were 49.0 ± 8.2 and 54.9 ± 8.1, respectively. In the mixed model analysis, an increase of 1 on the ACBS was associated with a decrease of -0.50 (95% CI -0.68 to -0.31) in the PCS and an increase of 0.19 (95% CI 0.01-0.37) in the MCS.

CONCLUSIONS

In a cohort of generally healthy community-dwelling older adults, AC-drug exposure was associated with a statistically significant decrease in the PCS and increase in the MCS throughout the entire follow-up period. However, the effects on the PCS and MCS were small and likely not clinically relevant.

Are physicians and clinical pharmacists aware and knowledgeable enough about inappropriate prescribing for elderly patients? Findings from Malaysia

OBJECTIVES

To assess the knowledge of physicians and clinical pharmacists about inappropriate prescribing for elderly patients, their confidence in prescribing for elderly patients, and their perceptions of barriers to appropriate prescribing in this population.

METHODS

A cross-sectional study using a validated 20-item questionnaire was conducted among physicians (n=78) and clinical pharmacists (n=45) working in the medical wards of two tertiary hospitals in Malaysia. Knowledge was assessed by six clinical vignettes which were developed based on Beers criteria and the STOPP/START criteria. Other domains of the study were investigated using a four-point or five-point Likert scale.

RESULTS

Of the 82 participants who completed the questionnaire, 65% were physicians, 90.2% had never received training in geriatric medicine, and 70.8% estimated that 25% or more of their patients were elderly. Only six participants (7.3%) had ever used STOPP/START or Beers criteria when prescribing for elderly patients, and 60% of the respondents had never heard of either one of those criteria. The mean score (SD) for the knowledge part was 3.65 (1.46) points, and only 27 participants (22.9%) scored more than four out of a possible six points. Overall, 34% of the participants rated themselves as confident in prescribing for elderly patients, and this was significantly associated with their knowledge score (P=0.02). The mean number (SD) of barriers cited per participant was 6.88 (2.84), with polypharmacy being the most cited barrier.

CONCLUSIONS

The majority of the participants had inadequate knowledge and low confidence regarding recommending medications for elderly patients. Continuing education on geriatric pharmacotherapy may be of value for the hospital physicians and pharmacists.

Preventable ADRs leading to hospitalization - results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients

BACKGROUND

Studies evaluating the impact of age and potentially inappropriate medication (PIM) on avoidable adverse drug reactions (ADRs) are scarce.

METHODS

In this prospective, multi-center, long-term (8.5 years) observational study, we analysed ADRs leading to hospitalization in departments of internal medicine. ADRs causality and preventability were assessed using standardised algorithms. PIM was defined based on the PRISCUS-list. Multivariate analyses and estimation of ADR incidence rates were conducted.

RESULTS

Of all 6,427 ADR patients, a preventable ADR was present in 1,253 (19.5%) patients (elderly patients ≥70 years: 828). Risk factors for preventable ADRs in elderly patients were multimorbidity, two to four ADR-causative drugs, and intake of particular compounds (e.g. spironolactone) but not sex, PIM usage, or the total number of drugs. Regarding particular compounds associated with preventable ADRs, highest incidence rates for preventable ADRs were found for patients aged ≥70 years for spironolactone (3.3 per 1,000 exposed persons (95% CI: 1.4-6.6)) and intermediate-acting insulin (3.3 per 1,000 exposed persons (95% CI: 1.6-6.1)).

CONCLUSION

Avoiding PIM usage seems to be of limited value in increasing safety in elderly patients whereas our results underline the importance of an individualized medication review of the most commonly implicated drugs in preventable ADRs (supported by BfArM FoNr: V-11337/68605/2008-2010).

In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study

BACKGROUND

An increasing number of transitions due to substitution of care of more complex patients urges insight in and improvement of transitional medication safety. While lack of documentation of prescription changes and/or lack of information exchange between settings likely cause adverse drug events, frequency of occurrence of these causes is not clear. Therefore, we aimed at determining the frequency of in-hospital patients’ prescription changes that are not or incorrectly documented in their primary care provider’s (PCP) medical record.

METHODS

A medical record review study was performed in a database linking patients’ medical records of hospital and PCP. A random sample (n = 600) was drawn from all 1399 patients who were registered at a participating primary care practice as well as the gastroenterology or cardiology department in 2013 of the University Medical Center Utrecht, the Netherlands. Outcomes were the number of in-hospital prescription changes that was not or incorrectly documented in the medical record of the PCP, and timeliness of documentation.

RESULTS

Records of 390 patients included one or more primary-secondary care transitions; in total we identified 1511 transitions. During these transitions, 408 in-hospital prescription changes were made, of which 31% was not or incorrectly documented in the medical record of the PCP within the next 3 months. In case changes were documented, the median number of days between hospital visit and documentation was 3 (IQR 0–18).

CONCLUSIONS

One third of in-hospital prescription changes was not or incorrectly documented in the PCP’s record, which likely puts patients at risk of adverse drug events after hospital visits. Such flawed reliability of a routine care process is unacceptable and warrants improvement and close monitoring.

Optimizing medication use in elderly people in primary care: Impact of STOPP criteria on inappropriate prescriptions

BACKGROUND

STOPP (Screening Tool of Older Person's Prescriptions) criteria have been used in acute care and nursing home settings as a screening tool to assess Potentially Inappropriate Medication (PIM) for elderly people. Furthermore, this tool could help General Practitioners (GPs) to lower PIM frequency in primary care.

OBJECTIVE

The aim of the study was to measure the impact of STOPP criteria applied by the GP on prescriptions during a primary care consultation.

SETTING, SUBJECTS AND METHOD

Twenty GPs were involved and trained to use STOPP criteria. GPs were asked to use STOPP criteria for elderly patients (>75years old) who were taking at least five different drugs, seen over a two-month period. The rate of PIM according to STOPP criteria was measured before and after training. Prescription quality was compared using the Medication Appropriateness Index (MAI) score.

RESULTS

Overall, 172 prescriptions were analyzed. A total of 170 PIM were identified according to STOPP criteria before the intervention. Fifty-seven percent of the population (n=98 patients) had at least one PIM. GP's intervention decreased the number of PIM according to STOPP criteria to 106 and was beneficial for 44.9% of the patients (n=44). The mean MAI score of all medications and PIM decreased by 14.3% (p<0.001) and 39.1% (p<0.001) respectively.

DISCUSSION CONCLUSIONS

Application of STOPP criteria by GPs is an effective tool to decrease PIM and MAI score in primary care. The generalization of the use of STOPP criteria during GP consultation should be fostered.

Optimization of drug therapy in elderly individuals admitted to a geriatric unit

Background

A substantial share of adverse drug events involves inappropriate prescribing (IP). Specialized geriatric units are supposed to pay particular attention to prescribing appropriateness and to promoting a higher prescribing quality.

Objective

The objective of this study was to evaluate the reality of such assessment and optimization in real life (usual care) in a population of elderly individuals admitted to a geriatric unit.

Method

This is an observational study including all older patients admitted to an acute geriatric unit over a 6-month period. As part of usual care, the geriatrician is supposed to detect potentially inappropriate medication and potential prescribing omission using validated tools. The primary outcome was the prevalence rate of therapeutic modifications motivated by treatment optimization (stop, switch, or introduction). Multivariate logistic regression analyses were performed to identify the factors associated with therapeutic discontinuation.

Results

A total of 216 patients were included. The mean age was 85.7 years. Included patients had an average of 7.2±3.3 drugs at admission and 5.8±2.7 at discharge. IP was highly prevalent in our study where about 63% of the patients had experienced at least one modification because of overuse. The most commonly discontinued medications were drugs used to treat gastroesophageal reflux disease and peptic ulcer disease and serotonin reuptake inhibitor antidepressants. The most commonly introduced medications were analgesics and warfarin. By using multivariate analysis, we found that patient age and number of drugs on admission were significantly associated with medication discontinuation during hospital stay.

Conclusion

In this real-life study of all patients admitted to a Geriatric Post Emergency Unit, 83% of the patients had a treatment modification during hospital stay. The most original result of our study is the clear reduction in polypharmacy during hospitalization.

The key role of clinical and community health nurses in pharmacovigilance

PURPOSE

The reporting of suspected adverse drug reactions (ADRs) is starting to become routine to nurses. The aim of this review is to underline the role of clinical and community health nurses in pharmacovigilance and to promote their effective participation in ADR reporting in different countries and for patients of different ages.

METHODS

The PubMed, Scopus and ISI Web of Science databases were searched for research articles published between January 1985 and April 2017 using the search items "pharmacovigilance" AND "nurse;" "adverse drug reaction report" AND "nurse;" "community health nurse" AND "adverse drug reaction."

RESULTS

A total of 987 articles were identified using our search strategy, of which 180 articles remained over after the removal of duplicate articles. Of these 180 studies, upon full review we identified 24 which met the inclusion/exclusion criteria and included these in our review. ADR reports by clinical nurses in some countries are comparable in quality and number to those submitted by physicians or pharmacists. Data on ADRs reported by community nurses are currently not available. However, numerous publications emphasized the challenges faced by nurses in reporting ADRs and the need to include pharmacovigilance training in both clinical and community health nurse academic education.

CONCLUSIONS

Nurses are central actors in pharmacovigilance activities, particularly in identifying ADRs which remain outside the reach of other healthcare providers and in being fundamental to the preservation of the health of patients and of the entire community, with attention to the more vulnerable patients, such as children and the elderly.

Potentially Inappropriate Medications in Older Adults: Why the Revised Criteria Matter

The 2 most widely used explicit criteria regarding inappropriate medication use in older adults are the American Geriatrics Society's Beers Criteria and the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START). Both documents were updated recently. They are important educational tools that highlight medications for which risks of use may often exceed benefits in older adults and situations in which potentially appropriate medications should be considered for use. The application of these tools has the potential to significantly affect patient care. Thus, it is important for clinicians to be familiar with both documents.

Potentially inappropriate psychotropic prescription at discharge is associated with lower functioning in the elderly psychiatric inpatients. A cross-sectional study

OBJECTIVE

The objectives are to determine the rate of potentially inappropriate psychotropic (PIP) prescription at discharge in the elderly psychiatric inpatients and to determine whether PIP is associated with lowered functioning outcomes.

METHODS

Sociodemographic, clinical, and treatment data for all inpatients aged ≥ 65 years consecutively hospitalized during 1 year in 13 psychiatry departments was analyzed. PIP+/PIP- groups were defined according to the French-updated Beers criteria. Daily functioning was evaluated by the daily living (ADL) scale. Logistic regression analysis was used to estimate odds ratios for the association between PIP administration at discharge and respectively functioning and potential confounding factors.

RESULTS

Data was obtained for 327 patients. Overall, 124 (37.9 %) patients were males, and the mean age was 73.9 years (SD = 5.6); 163 (49.8 %) patients were diagnosed with affective disorders and 89 (27.2 %) with schizophrenia/schizotypal/delusional disorders. Overall, 249 (76.1 %) had one or more PIP medications, mainly anxiolytics (69.9 %) and hypnotics (17.2 %). In a multivariate analysis, PIP prescription at discharge has been associated with patient lowered personal care functioning, independently of age, gender, and psychiatric or somatic diagnoses (OR = 0.88 (0.79-0.97, p = 0.01).

CONCLUSION

In the current increasingly fragmented health care systems, special attention must be given to PIP prescription in older population suffering from psychiatric disorders. Using the Beers criteria, the present study demonstrates the high prevalence of PIP prescription, which concerns a large panel of drugs but mostly anxiolytics and hypnotics independently of psychiatric or somatic diagnoses and sociodemographic characteristics. Our study has demonstrated for the first time an association between PIP prescription and lowered patient functioning. Further longitudinal studies should confirm a potential causal relation.

Potentially inappropriate prescribing according to STOPP and START and adverse outcomes in community-dwelling older people: a prospective cohort study

AIMS

This study aims to determine if potentially inappropriate prescribing (PIP) is associated with increased healthcare utilization, functional decline and reduced quality of life (QoL) in a community-dwelling older cohort.

METHOD

This prospective cohort study included participants aged ≥65 years from The Irish Longitudinal Study on Ageing (TILDA) with linked administrative pharmacy claims data who were followed up after 2 years. PIP was defined by the Screening Tool for Older Persons Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START). The association with number of emergency department (ED) visits and GP visits reported over 12 months was analyzed using multivariate negative binomial regression adjusting for confounders. Marginal structural models investigated the presence of time-dependent confounding.

RESULTS

Of participants followed up (n = 1753), PIP was detected in 57% by STOPP and 41.8% by START, 21.7% reported an ED visit and 96.1% visited a GP (median 4, IQR 2.5-6). Those with any STOPP criterion had higher rates of ED visits (adjusted incident rate ratio (IRR) 1.30, 95% confidence interval (CI) 1.02, 1.66) and GP visits (IRR 1.15, 95%CI 1.06, 1.24). Patients with two or more START criteria had significantly more ED visits (IRR 1.45, 95%CI 1.03, 2.04) and GP visits (IRR 1.13, 95%CI 1.01, 1.27) than people with no criteria. Adjusting for time-dependent confounding did not affect the findings.

CONCLUSIONS

Both STOPP and START were independently associated with increased healthcare utilization and START was also related to functional decline and QoL. Optimizing prescribing to reduce PIP may provide an improvement in patient outcomes.

Potentially inappropriate medication in the elderly in Germany: an economic appraisal of the PRISCUS list

BACKGROUND

Several lists of potentially inappropriate medication (PIM) for elderly patients have been developed worldwide in recent years. Those lists intend to reduce prescriptions of drugs that carry an unnecessarily high risk of adverse drug events in elderly patients. In 2010, an expert panel published the PRISCUS list for the German drug market. This study calculates the amount of drug reimbursement for PIM in Germany and potential cost effects from the perspective of statutory health insurance when these are replaced by the substitutes recommended by the PRISCUS list.

METHODS

Register-based data for the 30 top-selling drugs on the PRISCUS list in 2009 for patients greater than or equal to 65 years of age were provided by the Scientific Institute of the German Local Health Care Fund. We calculated the percentage of sales and defined daily doses for patients greater than or equal to 65 years of age compared with the total statutory health insurance population. Reimbursement costs for the recommended substitutions were estimated by considering different scenarios.

RESULTS

In 2009, drug reimbursement for the 30 top-selling PIM prescribed to patients greater than or equal to 65 years of age were calculated to be €305.7 million. Prescribing the recommended substitution medication instead of PIM would lead to an increased total reimbursement cost for the German health care system ranging between from €325.9 million to €810.0 million.

CONCLUSIONS

The results show that the substitution of PIM by medication deemed to be more appropriate for the elderly comes along with additional costs. Consequently, there is no short-term incentive for doing so from a payer perspective. Future studies have to consider the long-term effects and other sectors.