Hospital admission as a deprescribing triage point for patients discharged to Residential Aged Care Facilities

Effects of the Nudge Theory-Based Multifaceted Intervention on Reducing Inappropriate Proton Pump Inhibitors Use for Prophylaxis in Hospitalized Patients: A Non-Randomized Controlled Study

BACKGROUND

Inappropriate use of proton pump inhibitors (PPIs) for prophylaxis among hospitalized patients continues to be a significant issue. Previous interventions have often been ineffective and lack evaluation of their longer-term impacts.

AIM

This study aims to assess the clinical and economic effects of a nudge theory-based multifaceted intervention on reducing inappropriate PPI prophylaxis in hospitalized patients.

METHODS

This non-randomized controlled study was carried out in a teaching hospital's wards from January 2021 to June 2023, with a 12-month pre-intervention period, a 12-month intervention period (including the first and second stages of intervention), and a post-intervention period with 6-month follow-up. The intervention, based on nudge theory, was implemented among 114 doctors across 10 wards, sequentially involved peer comparison, information provision, and face-to-face feedback. The outcomes were assessed by randomly selecting cases of adult patients who received at least one PPI treatment during hospitalization, and the statistical analysis included univariate analysis, and multivariate and subgroup analyses.

RESULTS

The study included 1782 patients, with a median age of 61 years. During and after intervention, the rate of appropriate PPI use significantly increased by 2.83- to 5.47-fold, rising from 23.82% (147/617) to 46.96% (139/296) after the first stage, to 63.13% (202/320) after the second stage, and remained at 53.01% (291/549) later on. The rate of PPI injections decreased from 92.54 to 74.13-84.12%, the median defined daily doses from 16 to 7-12, and PPI-related expenditures from 484.80 to 156.00-262.99 CNY per-patient. The cost associated with inappropriate PPI use dropped from 161.60 to 0-45.58 CNY per-patient. Subgroup analyses supported these findings.

CONCLUSION

A nudge theory-based multifaceted intervention led to increased appropriate PPI use, decreased PPI injections, and cost savings, with benefits lasting at least 6 months post-intervention.

Deprescribing in Australian residential aged care facilities: A scoping review

OBJECTIVES

Older adults residing in residential aged care facilities (RACFs) are particularly vulnerable to negative health outcomes from polypharmacy and suboptimal prescribing in the context of frailty and multimorbidity. Deprescribing, the intentional withdrawal of inappropriate medications, has been proposed as a promising approach to reduce polypharmacy-related harms. Examining current deprescribing interventions in RACFs would help identify gaps in research knowledge. The aim of this scoping review was to synthesise the current literature, describe the current knowledge gaps and future research priorities that the authors identified.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO and AgeLine were searched according to the Joanna Briggs Institute (JBI) guidelines for scoping reviews from inception until February 2024 to identify relevant studies published in the English language.

RESULTS

Of the 2244 articles screened, 13 studies (total of 133,150 RACF residents across Australia) were identified examining deprescribing interventions. Six studies were controlled trials and seven studies were observational studies. There were six pharmacist-led interventions, five multidisciplinary team-led interventions and two physician-led interventions. Main themes discussed included as follows: multidisciplinary care, education for health-care professionals, refining outcome measures, overcoming system issues and research logistics. The most commonly targeted medications in the included studies were psychotropics.

CONCLUSIONS

Deprescribing is an important intervention for RACF residents but more research into translating evidence into clinically meaningful outcomes is needed. Successful studies typically involved multidisciplinary interventions, had an educational component, followed-up longitudinally with residents and carers and involved stakeholders, such as nurses. The economic impacts of deprescribing in this cohort are poorly understood.

Proton pump inhibitors associated with an increased risk of mortality in elderly: a systematic review and meta-analysis

PURPOSE

The increased use of proton pump inhibitors (PPIs) in the elderly has raised concerns about potential severe adverse effects. Our systematic review investigated the mortality associated with PPI use in elderly populations.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for relevant publications until August 2022. We included randomized controlled trials (RCTs), quasi-RCTs, and observational studies on the association between proton pump inhibitors and mortality in the elderly. To estimate the pooled relative risk (RR) and 95% confidence interval (CI), the inverse-variance random effect model was used. Heterogeneity was assessed using the I2 test. Subgroup analyses were performed by follow-up period, population, and study design.

RESULTS

A total of 4 RCTs and 36 cohort studies were included in the meta-analysis. Four RCTs showed that there was no significant association between PPIs and the risk of death. From 23 observational studies (26 cohorts), the use of proton pump inhibitors was not significantly associated with increased mortality in the elderly (RR 1.14; 95% CI, 0.90-1.45). However, when controlling for covariates from 33 observational studies (41 cohorts), proton pump inhibitors in older adults aged 50 years or more were significantly associated with a 15% higher risk of mortality compared to nonusers (RR 1.15; 95% CI, 1.10-1.20).

CONCLUSIONS

Our meta-analysis of RCTs found that PPIs did not show a significant association with increased mortality risk in older adults. However, the meta-analysis of cohort studies and long-term follow-up studies showed a higher increased risk of death with PPI use in older adults. The prescription of PPIs in patients aged 50 years or older should be carefully considered.

Using electronic admission data to monitor temporal trends in local medication use: Experience from an Australian tertiary teaching hospital

Background and aims: Medication usage varies according to prescribing behavior, professional recommendations, and the introduction of new drugs. Local surveillance of medication usage may be useful for understanding and comparing prescribing practices by healthcare providers, particularly in countries such as Australia that are in the process of enhancing nationwide data linkage programs. We sought to investigate the utility of electronic hospital admission data to investigate local trends in medication use, to determine similarities and differences with other Australian studies, and to identify areas for targeted interventions.

Methods: We performed a retrospective longitudinal analysis using combined data from a hospital admissions administrative dataset from a large tertiary teaching hospital in Adelaide, South Australia and a hospital administrative database documenting medication usage matched for the same set of patients. All adult admissions over a 12-year period, between 1 January 2007 and 31st December 2018, were included in the study population. Medications were categorized into 21 pre-defined drug classes of interest according to the ATC code list 2021.

Results: Of the 692,522 total admissions, 300,498 (43.4%) had at least one recorded medication. The overall mean number of medications for patients that were medicated increased steadily from a mean (SD) of 5.93 (4.04) in 2007 to 7.21 (4.98) in 2018. Results varied considerably between age groups, with the older groups increasing more rapidly. Increased medication usage was partly due to increased case-complexity with the mean (SD) Charlson comorbidity index increasing from 0.97 (1.66) in 2007-to-2012 to 1.17 (1.72) in 2013-to-2018 for medicated patients. Of the 21 medication classes, 15 increased (p < 0.005), including antithrombotic agents; OR = 1.18 [1.16–1.21], proton pump inhibitors; OR = 1.14 [1.12–1.17], statins; OR = 1.12; [1.09–1.14], and renin-angiotensin system agents; OR = 1.06 [1.04–1.08], whilst 3 decreased (p < 0.005) including anti-inflammatory drugs (OR = 0.55; 99.5% CI = 0.53–0.58), cardiac glycosides (OR = 0.81; 99.5% CI = 0.78–0.86) and opioids (OR = 0.82; 99.5% CI = 0.79–0.83). The mean number of medications for all admissions increased between 2007 and 2011 and then declined until 2018 for each age group, except for the 18-to-35-year-olds.

Conclusion: Increased medication use occurred in most age groups between 2007 and 2011 before declining slightly even after accounting for increased comorbidity burden. The use of electronic hospital admission data can assist with monitoring local medication trends and the effects of initiatives to enhance the quality use of medicines in Australia.

Antipsychotic treatment in elderly patients on polypharmacy with schizophrenia

PURPOSE OF REVIEW

Elderly patients with schizophrenia (SCH) are treated with antipsychotics and are often on different comedications, including polypharmacy (five or more medications). Evidence-based guidelines and randomized controlled trials do not include patients on polypharmacy, something that represents a 'gap' between evidence-based recommendations and clinical prescribing patterns. In this context, narrative reviews are needed to help clinicians in daily practice.

RECENT FINDINGS

Antipsychotic treatment efficacies in meta-analyses are similar in the elderly with SCH compared with the general population (medium effect size). Long-term cohort studies show that antipsychotic treatment reduces overall mortality, hospitalizations, and cardiovascular death. These studies are limited because polypharmacy was not studied. The prevalence of antipsychotic use as potentially inappropriate medications was very high in nursing homes (25%). The prevalence of antipsychotic polypharmacy was 40%. Different strategies to manage these problems are available, including collaboration with clinical pharmacists, leading to reduced polypharmacy and better adherence to treatment guidelines.

SUMMARY

Elderly patients with SCH on polypharmacy are less frequently studied, although they represent many patients with SCH. Different potentially inappropriate medication lists and collaboration with clinical pharmacists represent effective strategies for medication optimization. More studies are needed on this topic (e.g., prospective nonrandomized studies).

Prospective cohort study of nonspecific deprescribing in older medical inpatients being discharged to a nursing home

Background:

Older patients from nursing homes are commonly exposed to polypharmacy before a hospital admission. Deprescribing has been promoted as a solution to this problem, though systematic reviews have not found benefit. The aim of this study was to understand if in-hospital deprescribing of certain classes of medications is associated with certain benefits or risks.

Methods:

We conducted a prospective, multicentre, cohort study in 239 medical inpatients ⩾75 years (mean age 87.4 years) who were exposed to polypharmacy (⩾5 medications) prior to admission and discharged to a nursing home for permanent placement. Patients were categorised by whether deprescribing occurred, mortality and readmissions were assessed 30 and 90 days after hospital discharge. The EQ-5D-5 L health survey assessed changes in health-related quality of life (HRQOL) at 90 days, with comparison to EQ-5D-5 L results at day 30. Latent class analysis (LCA) was used to investigate associations between patterns of prescribed and deprescribed medications and mortality.

Results:

Patients for whom deprescribing occurred had a higher Charlson Index; there were no differences between the groups in principal diagnosis, total or Beers list number of medications on admission. The number of Beers list medications increased in both groups before discharge. Patients who had medications deprescribed had nonsignificantly greater odds of dying within 90 days [odds ration (OR) = 3.23 (95% confidence interval (CI): 0.68, 14.92; p = 0.136]. Deprescribing of certain classes was associated with higher 90-day mortality: antihypertensives (OR = 2.27, 95% CI: 1.004, 5; p = 0.049) and statins (OR = 5, 95% CI: 1.61, 14.28; p = 0.005). Readmissions and 1-year mortality rates were similar. There was no deterioration in HRQOL when medications were deprescribed. LCA showed that patients with the least medication changes had the lowest mortality.

Conclusion:

Deprescribing certain classes of medications during hospitalisation was associated with worse mortality, but not readmissions or overall HRQOL. Larger controlled deprescribing studies targeting specific medications are warranted to further investigate these findings.

This study was registered with the Australian and New Zealand Clinical Trials Registry, ACTRN1 2616001336471.

Plain language summary

Background: When an older person living in a nursing home is admitted to hospital, does stopping long-term medications help them?

Many older people from nursing homes take a large number of medications each day to treat symptoms and prevent adverse events. “Polypharmacy” is a term used to describe taking multiple long-term medications, and it is associated with many negative outcomes such as increased number of falls, cognitive decline, hospital readmission, even death. Deprescribing of nonessential medications – whether stopping or reducing the dose – is promoted as good hospital practice and is assumed to help older frail people live longer and feel better. However, we often don’t fully understand what is and is not essential.

We wanted to better understand the effect of deprescribing long-term medications for older frail patients during an unplanned hospital admission as they were going to a nursing home to live.

Methods: While admitted to hospital, medications are often reviewed by a clinical pharmacist and specialist physician. Sometimes medications are ceased; sometimes they are not. This gave us the opportunity to study two groups of older frail people from nursing homes: those who had regular, long-term medications ceased or reduced and those who did not. We wanted to see if one group did better. For example, did they feel worse if we stopped certain medications? Did they suffer other bad events compared with those patients for whom no medications were ceased? Were they readmitted to hospital earlier or more often?

Results and conclusion: Despite the assumption that stopping medications for this type of patient is good practice, we found no benefit. We were also surprised to find stopping or reducing certain drug classes (e.g. antihypertensives and cholesterol-lowering drugs) was associated with greater mortality. Larger, randomised studies will better answer these important questions.