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

Evaluating the appropriateness and the factors associated with sodium-glucose co-transporter 2 inhibitors prescribing in a Middle Eastern country: a cross-sectional study

BACKGROUND

Sodium glucose co-transporter 2 inhibitors (SGLT2is) are a novel class of oral antidiabetic drugs (ADDs). Studies evaluating the appropriateness of SGLT2is prescribing, and the factors associated with their initiation in the Middle East region are lacking.

AIM

This study aimed to evaluate the appropriateness of prescribing SGLT2is based on indication, dosing, and contraindication and determine the factors associated with their initial prescribing.

METHOD

In this cross-sectional study, a cohort of 650 patients newly prescribed SGLT2is (n = 400) and/or any other oral ADDs (n = 250) during 2020 were included. Data were extracted from an electronic medical record system. Multivariate logistic regression was conducted to investigate factors associated with prescribing SGLT2is.

RESULTS

SGLT2is were prescribed for appropriate indication in 400 patients (100%), while inappropriately prescribed in relation to contraindication and dosing in 14 patients (3.5%). Male patients were more likely to be prescribed SGLT2is (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.02-2.82). Patients with a baseline glycated hemoglobin (HbA1c) above 7% and atherosclerotic cardiovascular disease (ASCVD) were more likely to be prescribed SGLT2is (OR, 3.22; 95% CI, 1.84-5.64) and (OR, 2.18; 95% CI, 1.05-4.52), respectively. Patients receiving metformin (OR, 7.56; 95% CI, 4.46-12.80), sulfonylureas (OR, 2.30; 95% CI, 1.16-4.56), and dipeptidyl peptidase 4 inhibitors (OR, 3.43; 95% CI, 2.00-5.87) were more likely to be prescribed SGLT2is.

CONCLUSION

SGLT2is were found to be typically prescribed for the appropriate indication. Among the most important factors associated with prescribing SGLT2is are having uncontrolled HbA1c, history of ASCVD, and using other ADDs.

Association between Potentially Inappropriate Medication and Mortality Risk in Older Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

This study aimed to comprehensively assess the association between potentially inappropriate medication (PIM) and mortality risk in older adults through systematic review and meta-analysis.

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Adults aged 60 years and older with PIM use.

METHODS

A systematic search was conducted in PubMed, Web of Science, Cochrane Library, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and China National Knowledge Infrastructure (CNKI) databases up to July 23, 2024. Studies assessing the association between PIM and the risk of death in older adults with sufficient data for meta-analysis were included. Effect sizes were combined using a random-effects model, and heterogeneity was systematically explored.

RESULTS

A total of 44 studies involving 2,191,651 older adults were included. The overall PIM incidence was 45.7% (95% CI, 34.5%-57.0%). Meta-analysis revealed a combined odds ratio (OR) of 1.28 (95% CI, 1.20-1.36) for the association between PIM and increased risk of death. In addition, antipsychotics were associated with a higher risk of death (OR, 2.19; 95% CI, 1.75-2.73), as were anticholinergics (OR, 1.52; 95% CI, 1.23-1.88). Subgroup analyses indicated the association between PIM and death risk was particularly significant in Asia and Oceania, with a weaker association in North America and Europe. The strongest associations were found in individuals aged 70 years and older. The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria had stronger associations than other diagnostic criteria for PIM.

CONCLUSIONS AND IMPLICATIONS

This study confirms a significant association between PIM and mortality risk in older adults, highlighting the need for rational medication use. Clinicians should carefully assess medications in treatment plans. Future research should enhance assessment tools and investigate the impact of PIM on health outcomes to improve medication management.

Potentially Inappropriate Medication Use and Polypharmacy Before and After Admission to Internal Medicine for Older Patients

BACKGROUND

With the aging of the population and the increase in chronic diseases, there is an inherent risk of polypharmacy and inappropriate medication use. This study aimed to determine the prevalence and incidence of potentially inappropriate medication use and its correlation with polypharmacy.

METHODS

This was a retrospective, population-based cohort study among patients ≥ 65 years hospitalized at The National University Hospital of Iceland from 2010-2020. Data on medication usage were retrieved from the National Prescription Medicine Registry. Based on the number of medications filled in the year prior to admission and post-discharge, participants were categorized as non-polypharmacy (<5), polypharmacy (5-9), and hyper-polypharmacy (≥10). The prevalence and incidence of potentially inappropriate medication use was assessed based on the 2019 Beers criteria. Regression models were used to correlate sociodemographic, clinical, and pharmacoepidemiologic variables and the odds of new potentially inappropriate medication use.

RESULTS

The cohort comprised 55,859 patients (48.5% male) with a median [interquartile range] age of 80 [73-86] years. The prevalence of inappropriate medication use in the year preceding admission was 34.0%, 77.7%, and 96.4% for patients with non-polypharmacy, polypharmacy, and hyper-polypharmacy, respectively. The incidence of new potentially inappropriate medication use was 46.7% (95% confidence interval 45.6%-47.6%) among those with no potentially inappropriate medication use pre-admission. Factors associated with higher odds of new potentially inappropriate medication use after discharge were the use of multi-dose dispensing services, dementia, polypharmacy, and hyper-polypharmacy.

CONCLUSIONS

An increased emphasis is needed to review and reevaluate the appropriateness of medication use among the older population in internal medicine.

Adopting STOPP/START Criteria Version 3 in Clinical Practice: A Q&A Guide for Healthcare Professionals

The growing complexity of geriatric pharmacotherapy necessitates effective tools for mitigating the risks associated with polypharmacy. The Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria have been instrumental in optimizing medication management among older adults. Despite their large adoption for improving the reduction of potentially inappropriate medications (PIM) and patient outcomes, the implementation of STOPP/START criteria faces notable challenges. The extensive number of criteria in the latest version and time constraints in primary care pose practical difficulties, particularly in settings with a high number of older patients. This paper critically evaluates the challenges and evolving implications of applying the third version of the STOPP/START criteria across various clinical settings, focusing on the European healthcare context. Utilizing a "Questions & Answers" format, it examines the criteria's implementation and discusses relevant suitability and potential adaptations to address the diverse needs of different clinical environments. By emphasizing these aspects, this paper aims to contribute to the ongoing discourse on enhancing medication safety and efficacy in the geriatric population, and to promote more person-centred care in an aging society.

Continuity of medication information transfer and continuous medication supply during hospital-to-home transitions - nationwide surveys in hospital and community pharmacies after implementing new legal requirements in Germany

BACKGROUND

While successful information transfer and seamless medication supply are fundamental to medication safety during hospital-to-home transitions, disruptions are frequently reported. In Germany, new legal requirements came into force in 2017, strengthening medication lists and discharge summaries as preferred means of information transfer. In addition to previous regulations - such as dispensing medication at discharge by hospital pharmacies - hospital physicians were now allowed to issue discharge prescriptions to be supplied by community pharmacies. The aim of this survey study was to gain first nationwide insights into how these requirements are implemented and how they impact the continuity of medication information transfer and continuous medication supply.

METHODS

Two nationwide self-administered online surveys of all hospital and community pharmacies across Germany were developed and conducted from April 17th to June 30th, 2023.

RESULTS

Overall, 31.0% (n = 111) of all German hospital pharmacies and 4.5% (n = 811) of all community pharmacies participated. The majority of those hospital pharmacies reported that patients who were discharged were typically provided with discharge summaries (89.2%), medication lists (59.5%) and if needed, discharge prescriptions (67.6%) and/or required medication (67.6%). About every second community pharmacy (49.0%) indicated that up to half of the recently discharged patients who came to their pharmacy typically presented medication lists. 34.0% of the community pharmacies stated that they typically received a discharge summary from recently discharged patients at least once per week. About three in four community pharmacies (73.3%) indicated that most discharge prescriptions were dispensed in time. However, one-third (31.0%) estimated that half and more of the patients experienced gaps in medication supply. Community pharmacies reported challenges with the legal requirements - such as patients´ poor comprehensibility of medication lists, medication discrepancies, unmet formal requirements of discharge prescriptions, and poor accessibility of hospital staff in case of queries. In comparison, hospital pharmacies named technical issues, time/personnel resources, and deficits in patient knowledge of medication as difficulties.

CONCLUSION

According to the pharmacies´ perceptions, it can be assumed that discontinuation in medication information transfer and lack of medication supply still occur today during hospital-to-home transitions, despite the new legal requirements. Further research is necessary to supplement these results by the perspectives of other healthcare professionals and patients in order to identify efficient strategies.

Association between continuity of care and inappropriate prescribing in outpatient care in Germany: a cross-sectional analysis conducted as part of the LoChro trial

OBJECTIVES

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are common in multimorbid patients. This study aims to describe PIMs and PPOs in an open-access outpatient setting and to investigate any association between continuity of care (CoC) and PIMs and PPOs in multimorbid older patients.

DESIGN

Cross-sectional study using patient-confirmed outpatient medication plans to describe PIMs and PPOs using the 'Screening Tool of Older Person's Prescription/Screening Tool to Alert to Right Treatment' version 2. Four Poisson regressions modelled the number of PIMs and PPOs using context-adapted versions of the Usual Provider of Care (UPC) and the Modified Modified Continuity Index (MMCI) as measures for CoC.

SETTING

Southern Germany, outpatient setting.

PARTICIPANTS

321 participants of the LoChro-trial at 12-month follow-up (both arms). The LoChro-trial compared healthcare involving an additional care manager with usual care. Inclusion criteria were age over 64, local residence and scoring over one in the Identification of Older patients at Risk Screening Tool.

PRIMARY OUTCOMES

Numbers of PIMs and PPOs.

RESULTS

The mean number of PIMs was 1.5 (SD 1.5), lower than the average number of PPOs at 2.9 (SD 1.7). CoC showed similar results for both indices with a mean of 0.548 (SD 0.279) for MMCI and 0.514 (SD 0.262) for UPC. Both models predicting PPOs indicated more PPOs with higher CoC; statistical significance was only demonstrated for MMCI (MMCI~PPO: Exp(B)=1.42, 95% CI (1.11; 1.81), p=0.004; UPC~PPO: Exp(B)=1.29, 95% CI (0.99; 1.67), p=0.056). No significant association between PIMs and CoC was found (MMCI~PIM: Exp(B)=0.72, 95% CI (0.50; 1.03), p=0.072; UPC~PIM: Exp(B)=0.83, 95% CI (0.57; 1.21), p=0.337).

CONCLUSION

The results did not show a significant association between higher CoC and lesser PIMs. Remarkably, an association between increased CoC, represented through MMCI, and more PPOs was found. Consultation of different care providers in open-access healthcare systems could possibly ameliorate under-prescribing in multimorbid older patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS): DRKS00013904.

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.

Optimizing drug therapy for older adults: shifting away from problematic polypharmacy

INTRODUCTION

The accelerated discovery and production of pharmaceutical products has resulted in many positive outcomes. However, this progress has also contributed to problematic polypharmacy, one of the rapidly growing threats to public health in this century. Problematic polypharmacy results in adverse patient outcomes and imposes increased strain and financial burden on healthcare systems.

AREAS COVERED

A review was conducted on the current body of evidence concerning factors contributing to and consequences of problematic polypharmacy. Recent trials investigating interventions that target polypharmacy and emerging solutions, including incorporation of artificial intelligence, are also examined in this article.

EXPERT OPINION

To shift away from problematic polypharmacy, a multifaceted interdisciplinary approach is necessary. Any potentially successful strategy must be adapted to suit various healthcare settings and must utilize all available resources, including artificial intelligence.

What do primary care providers want to know when caring for patients living with frailty? An analysis of eConsult communications between primary care providers and specialists

BACKGROUND

Frailty is a complex condition that primary care providers (PCPs) are managing in increasing numbers, yet there is no clear guidance or training for frailty care.

OBJECTIVES

The present study examined eConsult questions PCPs asked specialists about patients with frailty, the specialists' responses, and the impact of eConsult on the care of these patients.

DESIGN

Cross-sectional observational study.

SETTING

ChamplainBASE™ eConsult located in Eastern Ontario, Canada.

PARTICIPANTS

Sixty one eConsult cases closed by PCPs in 2019 that use the terms "frail" or "frailty" to describe patients 65 years of age or older.

MEASUREMENTS

The Taxonomy of Generic Clinical Questions (TGCQ) was used to classify PCP questions and the International Classification for Primary Care 3 (ICPC-3) was used to classify the clinical content of each eConsult. The impact of eConsult on patient care was measured by PCP responses to a mandatory survey.

RESULTS

PCPs most frequently directed their questions to cardiology (n = 7; 11%), gastroenterology (n = 7; 11%), and endocrinology (n = 6; 10%). Specialist answers most often pertained to medications (n = 63, 46%), recommendations for clinical investigation (n = 24, 17%), and diagnoses (n = 22, 16%). Specialist responses resulted in PCPs avoiding referral in 57% (n = 35) of cases whereas referrals were still required in 15% (n = 9) of cases. Specialists responded to eConsults in a median 1.11 days (IQR = 0.3-4.7), and 95% (n = 58) of cases received a response within 7 days. Specialists recorded a median of 15 min to respond (IQR = 10-20), with a median cost of $50.00 CAD (IQR = 33.33 - 66.66) per eConsult.

CONCLUSIONS

Through the analysis of questions and responses submitted to eConsult, this study provides novel information on PCP knowledge gaps and approaches to care for patients living with frailty. Furthermore, these analyses provide evidence that eConsult is a feasible and valuable tool for improving care for patients with frailty in primary care settings.

A Digital Health Perspective on Medication Use and Polypharmacy Management for Improving Healthcare Outcomes in Geriatric Patients

The high prevalence of multiple comorbidities poses unique medication-related challenges for geriatric patients. Polypharmacy is a particular concern since taking several medications simultaneously increases the likelihood of adverse drug events and the risk of drug interactions while decreasing patient adherence. These factors are associated with suboptimal health outcomes and a heightened burden on the healthcare system (insurance claims) and the patient (out-of-pocket expenses). These challenges can significantly affect the quality of life of geriatric patients. This chapter critically examines the impact of medication use and polypharmacy on the quality of life of older patients. In addition, the authors discuss how artificial intelligence-based digital tools and precision medicine can address these issues by streamlining medical decision-making, improving the patient experience, and allowing remote monitoring. Finally, they interpret the findings from the lens of ethical considerations associated with the adoption and implementation of digital applications and gadgets.

Potentially inappropriate medications and potential prescribing omissions in hospitalised older adults in New Zealand: A retrospective study

OBJECTIVE

Medication errors can have detrimental effects on patient outcomes, yet there are limited data on the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among older adult inpatients in New Zealand (NZ). This study investigated exposure to PIMs and PPOs in older adults in a New Zealand hospital.

METHODS

Electronic medical records of 846 older adults (≥ 65 years) discharged from the Auckland District Health Board between June 2020 and May 2021 were retrospectively reviewed to extract data on sociodemographic, medication and diagnostic information. STOPP/START version 2 was used to evaluate PIMs and PPOs on admission and discharge.

RESULTS

The mean age was 77.47 ± 8.12 years, and 51% were female. On admission, 48% had ≥1 PIMs and 40% had ≥1 PPOs. On discharge, 45% had ≥1 PIMs and 40% had ≥1 PPOs. Increasing age (adjusted odds ratio [AOR] = 1.02, 95% CI [confidence interval] 1.01, 1.04), number of medicines (AOR = 1.23, CI 1.17, 1.29) and 28-day admission history (AOR = 1.58, CI 1.15, 2.18) were associated with higher odds of PIMs use on admission. At discharge, the number of medicines (AOR = 1.19, CI 1.13, 1.25) and history of readmission (AOR = 1.47, CI 1.08, 2.02) were associated with higher odds of PIMs. Female patients had higher odds of PPOs both on admission (AOR = 1.35, CI 1.02, 1.78) and discharge (AOR = 1.34, CI 1.01, 1.78). Māori, Asian and Pacific patients were more likely to have prescribing omissions compared to NZ Europeans.

CONCLUSIONS

Prescribing omissions and inappropriate medications were common in older inpatients. There were differences observed between different ethnic groups, with NZ Europeans having fewer omissions than other ethnic groups. These findings highlight key opportunities for health-care providers to improve medication use in older adults in NZ.

Prevalence and predictors of inappropriate prescribing in outpatients with severe mental illness

Background

Potentially inappropriate prescribing (PIP) is frequent in geriatrics and results in an increased risk for adverse effects, morbidity, mortality and reduced quality of life. Research on PIP in psychiatry has mainly focused on elderly patients and inpatients.

Objectives

To determine the prevalence and the predictors of PIP of psychotropic medication in outpatients with severe mental illness.

Design

This study is part of the Muva study, a pragmatic open Stepped Wedge Cluster Randomized Trial of a physical activity intervention for patients (age ⩾ 16 years) with severe mental illness.

Methods

A structured medication interview, questionnaires on social functioning, quality of life and psychiatric symptoms, and BMI and waist circumference measurements were performed followed by a structured medication review. Patients were divided into groups: PIP versus no PIP. Between-group differences were calculated and a multivariate binary logistic regression was performed to examine predictors for PIP. A receiver operating characteristics analysis was performed to determine the area under the curve (AUC).

Results

In 75 patients, an average of 5.2 medications of which 2.5 psychotropic medication was used. 35 (46.7%) patients were identified with PIP. Unindicated long-term benzodiazepine use was the most frequently occurring PIP (34.1%). Predictors of PIP were female gender [odds ratio (OR) = 4.88, confidence interval (CI) = 1.16-20.58, p = 0.03], number of medications (OR = 1.41, CI = 1.07-1.86, p = 0.02) and lower social functioning (OR = 1.42, CI = 1.01-2.00, p = 0.05). The AUC was 0.88 for the combined prediction model.

Conclusion

The prevalence of PIP of psychotropic medication in outpatients with severe mental illness is high. It is therefore important to identify, and where possible, resolve PIP by frequently performing a medication review with specific attention to females, patients with a higher number of medications and patients with lower social functioning.

Trial registration

This trial was registered in The Netherlands Trial Register (NTR) as NTR NL9163 on 20 December 2020 (https://trialsearch.who.int/Trial2.aspx?TrialID=NL9163).

Associations between potentially inappropriate prescribing and increased number of medications with postdischarge health outcomes among geriatric rehabilitation inpatients: RESORT study

AIMS

Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes.

METHOD

RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria.

RESULTS

In total, 1890 (mean age 82.6 ± 8.1 years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge.

CONCLUSION

The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality.

Multi-Year Retrospective Analysis of Mortality and Readmissions Correlated with STOPP/START and the American Geriatric Society Beers Criteria Applied to Calgary Hospital Admissions

Introduction: The goals of this retrospective cohort study of 129,443 persons admitted to Calgary acute care hospitals from 2013 to 2021 were to ascertain correlations of "potentially inappropriate medications" (PIMs), "potential prescribing omissions" (PPOs), and other risk factors with readmissions and mortality. Methods: Processing and analysis codes were built in Oracle Database 19c (PL/SQL), R, and Excel. Results: The percentage of patients dying during their hospital stay rose from 3.03% during the first admission to 7.2% during the sixth admission. The percentage of patients dying within 6 months of discharge rose from 9.4% after the first admission to 24.9% after the sixth admission. Odds ratios were adjusted for age, gender, and comorbidities, and for readmission, they were the post-admission number of medications (1.16; 1.12-1.12), STOPP PIMs (1.16; 1.15-1.16), AGS Beers PIMs (1.11; 1.11-1.11), and START omissions not corrected with a prescription (1.39; 1.35-1.42). The odds ratios for readmissions for the second to thirty-ninth admission were consistently higher if START PPOs were not corrected for the second (1.41; 1.36-1.46), third (1.41;1.35-1.48), fourth (1.35; 1.28-1.44), fifth (1.38; 1.28-1.49), sixth (1.47; 1.34-1.62), and seventh admission to thirty-ninth admission (1.23; 1.14-1.34). The odds ratios for mortality were post-admission number of medications (1.04; 1.04-1.05), STOPP PIMs (0.99; 0.96-1.00), AGS Beers PIMs (1.08; 1.07-1.08), and START omissions not corrected with a prescription (1.56; 1.50-1.63). START omissions for all admissions corrected with a prescription by a hospital physician correlated with a dramatic reduction in mortality (0.51; 0.49-0.53) within six months of discharge. This was also true for the second (0.52; 0.50-0.55), fourth (0.56; 0.52-0.61), fifth (0.63; 0.57-0.68), sixth (0.68; 0.61-0.76), and seventh admission to thirty-ninth admission (0.71; 0.65-0.78). Conclusions: "Potential prescribing omissions" (PPOs) consisted mostly of needed cardiac medications. These omissions occurred before the first admission of this cohort, and many persisted through their readmissions and discharges. Therefore, these omissions should be corrected in the community before admission by family physicians, in the hospital by hospital physicians, and if they continue after discharge by teams of family physicians, pharmacists, and nurses. These community teams should also meet with patients and focus on patients' understanding of their illnesses, medications, PPOs, and ability for self-care.

Implementation of clinical medication review in a geriatric ward to reduce potentially inappropriate prescriptions among older adults

PURPOSE

The impact of several pharmaceutical interventions to reduce the use of potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) has been recently studied. We aimed to determine whether clinical medication review (CMR) (i.e. a systematic and patient-centred clinical assessment of all medicines currently taken by a patient) performed by a geriatrician and a pharmacist added to standard pharmaceutical care (SPC) (i.e. medication reconciliation and regular prescription review by the pharmacist) resulted in more appropriate prescribing compared to SPC among older inpatients.

METHODS

A retrospective observational single-centre study was conducted in a French geriatric ward. Six criteria for appropriate prescribing were chosen: the number of PIMs and POMs as defined by the STOPP/STARTv2 list, the total number of drugs prescribed, the number of administrations per day and the number of psychotropic and anticholinergic drugs. These criteria were compared between CMR and SPC group using linear and logistic regression models weighted on propensity scores.

RESULTS

There were 137 patients included, 66 in the CMR group and 71 in the SPC group. The mean age was 87 years, the sex ratio was 0.65, the mean number of drugs prescribed was 9, the mean MMSE was 21 and at admission 242 POMs, and 363 PIMs were prescribed. Clinical medication review did not reduce the number of PIMs at discharge compared to SPC (beta = - 0.13 [- 0.84; 0.57], p = 0.71) nor did it reduce the number of drugs prescribed (p = 0.10), the number of psychotropic drugs (p = 0.17) or the anticholinergic load (p = 0.87). Clinical medication review resulted in more POMs being prescribed than in standard pharmaceutical care (beta = - 0.39 [- 0.72; - 0.06], p = 0.02). Cardiology POMs were more implemented in the medication review group (p = 0.03).

CONCLUSION

Clinical medication review did not reduce the number of PIMs but helped clinicians introduce underused drugs, especially cardiovascular drugs, which are known to be associated with morbidity and mortality risk reduction.

Potentially Inappropriate Medications in Older Adults-Prevalence, Trends and Associated Factors: A Cross-Sectional Study in Saudi Arabia

(1) Background: Potentially inappropriate medications (PIMs) in older adults are associated with drug-related problems, adverse health consequences, repeated hospital admissions and a higher risk of mortality. In Saudi Arabia and some Arab countries, studies of PIMs among large cohorts of older adults are limited. This study aimed to determine the prevalence of PIMs, trends and associated factors among outpatient older adults in Saudi Arabia. (2) Methods: A cross-sectional study was carried out. Over three years (2017-2019), data on 23,417 people (≥65 years) were retrieved from outpatient clinics in a tertiary hospital in Riyadh, Saudi Arabia. PIMs were assessed using the 2019 Beers Criteria. Covariates included sex, age, nationality, number of dispensed medications, and number of diagnoses. A generalized estimating equation model was used to assess trends and factors associated with PIMs. (3) Results: The prevalence of PIMs was high and varied between 57.2% and 63.6% over the study years. Compared with 2017, the prevalence of PIMs increased significantly, with adjusted odds ratios (OR) (95% confidence interval (95% CI)) of 1.23 (1.18-1.29) and 1.15 (1.10-1.21) for 2018 and 2019, respectively. Factors associated with being prescribed PIMs included ≥5 dispensed medications (OR_adjusted = 23.91, 95% CI = 21.47-26.64) and ≥5 diagnoses (OR_adjusted = 3.20, 95% CI = 2.88-3.56). Compared with females, males had a lower risk of being prescribed PIMs (OR_adjusted = 0.90, 95% CI = 0.85-0.94); (4) Conclusions: PIMs were common with an increasing trend among older adults in Saudi Arabia. A higher number of dispensed medications, increased number of diagnoses and female sex were associated with being prescribed PIMs. Recommendations on how to optimize prescriptions and implement de-prescribing strategies are urgently needed.

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: uptake and clinical impact

INTRODUCTION

STOPP/START criteria for potentially inappropriate medications (PIMs, STOPP) and potential prescribing omissions (PPOs, START) have gained considerable interest and traction since they were first published in 2008. This review focuses on their uptake and impact in various clinical settings.

AREAS COVERED

STOPP/START criteria, now in their third iteration, are explicit criteria designed to facilitate detection of common and clinically important PIMs and PPOs during routine medication review in any clinical setting. We examine the influence of the criteria, particularly in clinical trials that focused on their impact on clinically relevant endpoints.

EXPERT OPINION

STOPP/START criteria are widely used in several countries within Europe and beyond for medication review and audit. As a discreet intervention, the criteria have been tested in several single-center and two large-scale multi-center clinical trials. The single-center trials indicate that STOPP/START criteria reduce polypharmacy, inappropriate prescribing, ADRs (adverse drug reactions), medication cost and falls. In contrast, the SENATOR and OPERAM multicentre trials did not demonstrate significant reduction in ADRs, all-cause mortality, drug-related hospital readmissions, nor any improvement in quality-of-life. Further clinical trials are required to examine whether STOPP/START criteria as an intervention can deliver significant clinical benefit in a reproducible manner in various clinical settings.

The Impact of Potentially Inappropriate Medications and Polypharmacy on 3-Month Hospital Readmission among Older Patients: A Retrospective Cohort Study from Malaysia

INTRODUCTION

Potentially inappropriate medications (PIMs) use and polypharmacy are two issues that are commonly encountered among older people. They are associated with several negative outcomes including adverse drug reactions and medication-related hospitalization. There are insufficient studies regarding the impact of both PIMs and polypharmacy on hospital readmission, especially in Malaysia.

AIM

To investigate the possible association between polypharmacy and prescribing PIMs at discharge and 3-month hospital readmission among older patients.

MATERIALS AND METHOD

A retrospective cohort study involved 600 patients ≥60 years discharged from the general medical wards in a Malaysian teaching hospital. The patients were divided into two equal groups: patients with or without PIMs. The main outcome was any readmission during the 3-month follow-up. The discharged medications were assessed for polypharmacy (≥five medications) and PIMs (using 2019 Beers' criteria). Chi-square test, Mann-Whitney test, and a multiple logistic regression were conducted to study the impact of PIMs/polypharmacy on 3-month hospital readmission.

RESULTS

The median number for discharge medications were six and five for PIMs and non-PIMs patients, respectively. The most frequently prescribed PIMs was aspirin as primary prevention of cardiovascular diseases (33.43%) followed by tramadol (13.25%). The number of medications at discharge and polypharmacy status were significantly associated with PIMs use. Overall, 152 (25.3%) patients were re-admitted. Polypharmacy and PIMs at discharge did not significantly impact the hospital readmission. After applying the logistic regression, only male gender was a predictor for 3-month hospital readmission (OR: 2.07, 95% CI: 1.022-4.225).

CONCLUSION

About one-quarter of the patients were admitted again within three months of discharge. PIMs and polypharmacy were not significantly associated with 3-month hospital readmissions while male gender was found to be an independent risk factor for readmission.

Revisiting the inter-rater reliability of drug treatment assessments according to the STOPP/START criteria

AIMS

The aim of this study is to revisit the inter-rater reliability of drug treatment assessments according to the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria.

METHODS

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were independently identified by two physicians in two cohorts of older people (I: 200 hip fracture patients, median age 85 years, STOPP/START version 1; II: 302 primary care patients, median age 74 years, STOPP/START version 2). Kappa statistics were used to evaluate inter-rater agreement.

RESULTS

In cohort I, a total of 782 PIMs/PPOs, related to 68 (78%) out of 87 criteria, were identified by at least one assessor, 500 (64%) of which were discordantly identified by the assessors, that is, by one assessor but not the other. For four STOPP criteria, all PIMs (n = 9) were concordantly identified. In cohort II, 955 PIMs/PPOs, related to 80 (70%) out of 114 criteria, were identified, 614 (64%) of which were discordantly identified. For three STOPP criteria, all PIMs (n = 3) were concordantly identified. For no START criterion, with ≥1 PPO identified, were all assessments concordant. The kappa value for PIM/PPO identification was 0.52 in both cohorts. In cohort II, the kappa was 0.37 when criteria regarding influenza and pneumococcal vaccines were excluded. Further analysis of discordantly identified PIMs/PPOs revealed methodological aspects of importance, including the data source used and criteria wording.

CONCLUSIONS

When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.

The Effectiveness of Family Medicine-Driven Interprofessional Collaboration on the Readmission Rate of Older Patients

Interprofessional collaboration (IPC) for older patient care among family physicians, dentists, therapists, nutritionists, nurses, and pharmacists in the rural hospital care of older patients could improve the hospital readmission rate. However, there is a lack of interventional studies on IPC for improving the readmission rate among Japanese older patients in rural hospitals. This quasi-experimental study was performed on patients >65 years who were discharged from a rural community hospital. The intervention was IPC implementation with effective information sharing and comprehensive management of older patients’ conditions for effective discharge and readmission prevention; implementation started on 1 April 2021. The study lasted 2 years, from 1 April 2021 to 31 March 2022 for the intervention group and from 1 April 2020 to 31 March 2021 for the comparison group. The average participant age was 79.86 (standard deviation = 15.38) years and the proportion of men was 45.0%. The Cox hazard model revealed that IPC intervention could reduce the readmission rate after adjustment for sex, serum albumin, polypharmacy, dependent condition, and Charlson Comorbidity Index score (hazard ratio = 0.66, 95% confidence interval: 0.54−0.81). Rural IPC intervention can improve inpatient care for older patients and decrease readmission rates. Thus, for effective rural IPC interventions, family physicians in hospitals should proactively collaborate with various medical professionals to improve inpatient health outcomes.

Prescribing Practices in Geriatric Patients with Cardiovascular Diseases

Inappropriate prescribing (IP) increases the risk of adverse medication reactions and hospitalizations in elderly patients. Therefore, it is crucial to evaluate prescribing patterns among this population. This study was designed to assess the prevalence of potentially inappropriate medication (PIMs) use and potential prescribing omissions (PPOs) among geriatrics with cardiovascular diseases (CVDs). In addition, it determined the predictors for IP in this population. A multi-center study was performed retrospectively on 605 patients' medical records collected randomly from seven governmental hospitals in Kuwait. Three of these hospitals have specialized cardiac centers (tertiary care). Inclusion criteria were age ≥ 65 years, diagnosed with at least one CVD, and attended the outpatient clinic during the last 6 months before data collection. A total of 383 patients (63.3%; 95% CI: 59.3-67.1%) were found using at least one PIM or having PPO or both, based on STOPP/START criteria. Three hundred and ninety-one patients (64.6%; 95% CI: 60.7-68.4%) were prescribed PIMs categorized as C and/or D medicines according to the Euro-FORTA list. Over one-quarter (28.8%; 95% CI: 25.2-32.6%) of the patients had drug-drug interactions class D that require therapy modification and/or X that should be avoided. Patients taking ≥ five medications had significantly higher PIMs based on STOPP and FORTA criteria, drug-drug interactions (p < 0.001), and significantly higher PPOs based on START criteria (p = 0.041). Patients with three or more chronic diseases had significantly higher PIMs based on STOPP and FORTA criteria and PPOs based on START criteria (p-values: 0.028, 0.035, and 0.005, respectively). Significantly higher PIMs based on STOPP criteria and PPOs based on START criteria were found in general hospitals compared to specialized cardiac centers (p= 0.002, p= 0.01, respectively). These findings highlight the need to develop and implement multifaceted interventions to prevent or minimize inappropriate prescribing among the geriatric population with CVDs in Kuwait.

Prediction of 30-Day Readmission in Hospitalized Older Adults Using Comprehensive Geriatric Assessment and LACE Index and HOSPITAL Score

(1) Background: Elders have higher rates of rehospitalization, especially those with functional decline. We aimed to investigate potential predictors of 30-day readmission risk by comprehensive geriatric assessment (CGA) in hospitalized patients aged 65 years or older and to examine the predictive ability of the LACE index and HOSPITAL score in older patients with a combination of malnutrition and physical dysfunction. (2) Methods: We included patients admitted to a geriatric ward in a tertiary hospital from July 2012 to August 2018. CGA components including cognitive, functional, nutritional, and social parameters were assessed at admission and recorded, as well as clinical information. The association factors with 30-day hospital readmission were analyzed by multivariate logistic regression analysis. The predictive ability of the LACE and HOSPITAL score was assessed using receiver operator characteristic curve analysis. (3) Results: During the study period, 1509 patients admitted to a ward were recorded. Of these patients, 233 (15.4%) were readmitted within 30 days. Those who were readmitted presented with higher comorbidity numbers and poorer performance of CGA, including gait ability, activities of daily living (ADL), and nutritional status. Multivariate regression analysis showed that male gender and moderately impaired gait ability were independently correlated with 30-day hospital readmissions, while other components such as functional impairment (as ADL) and nutritional status were not associated with 30-day rehospitalization. The receiver operating characteristics for the LACE index and HOSPITAL score showed that both predicting scores performed poorly at predicting 30-day hospital readmission (C-statistic = 0.59) and did not perform better in any of the subgroups. (4) Conclusions: Our study showed that only some components of CGA, mobile disability, and gender were independently associated with increased risk of readmission. However, the LACE index and HOSPITAL score had a poor discriminating ability for predicting 30-day hospitalization in all and subgroup patients. Further identifiers are required to better estimate the 30-day readmission rates in this patient population.

Consensus validation of a screening tool for cardiovascular pharmacotherapy in geriatric patients: the RASP_CARDIO list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients)

PURPOSE

Cardiovascular agents commonly used in geriatric patients, are linked to potentially avoidable harm and might hence be a suitable substrate for medication review practices. Therefore, we sought to update and validate the content of the cardiovascular segment of the previously published Rationalization of Home Medication by an Adjusted STOPP list in Older Patients (RASP) List.

METHODS

A three-step study was conducted by the pharmacy department in collaboration with the geriatric medicine and cardiology department at the University Hospitals Leuven, Belgium. First, the cardiovascular segment of the RASP list version 2014 was updated taking into account published research, other screening tools and the input of end-users. Secondly, this draft was reviewed during three panel discussions with five expert cardiologists and three clinical pharmacists, all of whom had relevant expertise in geriatric pharmacotherapy. Thirdly, the content was validated using a modified Delphi Technique by a panel of European hospital pharmacists, cardiologists, geriatricians and an internal medicine physician.

RESULTS

After the first and second step, the RASP_CARDIO list comprised 94 statements. Consensus (≥ 80% agreement) of all statements and one new statement about gliflozins in heart failure was achieved by a panel of seventeen experts across four European countries after two validation rounds. The final construct comprised a list of 95 statements related to potentially inappropriate prescribing of cardiovascular agents.

CONCLUSION

The RASP_CARDIO list is an updated and validated explicit screening tool to optimize cardiovascular pharmacotherapy in geriatric patients.

Evaluating Potentially Inappropriate Medications in Older Kidney Transplant Recipients

OBJECTIVES

Beers Criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) Criteria/Screening Tool to Alert to Right Treatment Criteria are used to assess potentially inappropriate prescribing and medications, which could pose a harm to those of older age. The purpose of this study was to assess and compare the use of Beers and STOPP Criteria in older kidney transplant recipients.

METHODS

This was a dual-center, retrospective chart review from May 1, 2014, to March 1, 2018, including kidney transplant recipients 65 years and older. Those who underwent a dual transplant or had incomplete medical records were excluded. Outcomes included number of potentially inappropriate medications (PIMs) comparing Beers and STOPP Criteria on transplant admission, number of PIMs on admission compared with discharge, and readmissions within 3 months related to these medications.

RESULTS

A total of 121 recipients were evaluated. On admission, 60 medications were listed on the STOPP Criteria compared with 106 medications on the Beers Criteria. When comparing PIMs on admission to discharge, there was a 38% decrease in the number of medications on discharge using the STOPP Criteria, whereas there was a 9% increase using the Beers Criteria.

CONCLUSIONS

Older recipients were more likely to be on a medication listed in the Beers Criteria on admission and have a new medication listed in the Beers Criteria upon discharge compared with the STOPP Criteria.

Frailty and Potentially Inappropriate Prescribing in Older People with Polypharmacy: A Bi-Directional Relationship?

Frail older adults commonly experience multiple co-morbid illnesses and other risk factors for potentially inappropriate prescribing. However, determination of frailty varies depending on the frailty instrument used. Older people’s degree of frailty often influences their care and treatment priorities. Research investigating the association between frailty and potentially inappropriate prescribing is hindered by a wide variety of frailty definitions and measurement tools. We undertook a narrative review of selected articles of PubMed and Google Scholar databases. Articles were selected on the basis of relevance to the core themes of frailty and potentially inappropriate prescribing. We identified observational studies that clearly link potentially inappropriate prescribing, potential prescribing omissions, and adverse drug reactions with frailty in older adults. Equally, the literature illustrates that measured frailty in older adults predisposes to inappropriate polypharmacy and associated adverse drug reactions and events. In essence, there is a bi-directional relationship between frailty and potentially inappropriate prescribing, the underlying substrates being multimorbidity and inappropriate polypharmacy. We conclude that there is a need for consensus on rapid and accurate identification of frailty in older people using appropriate and user-friendly methods for routine clinical practice as a means of identifying older multimorbid patients at risk of potentially inappropriate prescribing. Detection of frailty should, we contend, lead to structured screening for inappropriate prescribing in this high-risk population. Of equal importance, detection of potentially inappropriate prescribing in older people should trigger screening for frailty. All clinicians undertaking a medication review of multimorbid patients with associated polypharmacy should take account of the important interaction between frailty and potentially inappropriate prescribing in the interest of minimizing patient harm.

Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study

PURPOSE

To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment.

METHODS

PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate.

RESULTS

In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment.

CONCLUSION

One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.

[Potentially inappropriate prescribing: Usefulness of STOPP/START criteria version 2 in Catalonian elderly population]

OBJECTIVE

To measure the prevalence of potentially inappropriate prescribing (PIP) among the elderly population in Catalonia using criteria Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) version 2. In addition, to evaluate the association between PIP and several factors (polypharmacy, gender, age and sociodemographic conditions).

MATERIALS AND METHODS

Design: Retrospective cross sectional population study.

SETTINGS

Primary Health Care, Catalonia, Spain.

PARTICIPANTS

The study population comprised of participants 70 years old and over, who attended primary health care centres in Catalonia in 2014 (700.058 patients).

MAIN ANALYSIS

55 STOPP and 19 START criteria are applied to analyse PIP prevalence. Logistic regression models are adjusted to determine PIP association with several factors.

RESULTS

The mean age is 79. 2±6.5. 58.5% being female. 38.7% of patients have 7 or more prescribed drugs, whereas 50% go to a primary care centre 10 or more times during one year. The most frequent PIP among STOPP criteria are related to nonsteroidal anti-inflammatory drug intake, antiplatelet and anticoagulants use, and benzodiazepines. According to START, the most frequent omissions are vitamin D and calcium supplements, antidepressants, and cardiovascular medications. Factors that increase PIP are: female gender, living in a nursing home, receiving home health care, polypharmacy and frequent visits to primary care centres.

CONCLUSIONS

The overall prevalence of PIP is 89.6%. PPI is significantly related to certain drugs and patient's conditions. The knowledge of this association is important for the implementation of security measures for medical prescription.

Number-dependent association of potentially inappropriate medications with clinical outcomes and expenditures among community-dwelling older adults: a population-based cohort study

AIM

To investigate the prevalence of potentially inappropriate medication (PIM) prescribing and its number-dependent association (PIM=1, 2, ≥3) with all-cause hospitalizations, emergency department (ED) visits, and medication expenditures in Beijing, China.

METHOD

A retrospective cohort analysis was conducted to analyze PIM prescribing in community-dwelling older adults aged ≥ 65 years within the Beijing Municipal Medical Insurance Database (data from July to September 2016). The prevalence of PIMs was estimated based on the 2015 Beers Criteria. Logistic models were utilized to investigate the associations between PIM use and all-cause hospitalizations and ED visits. Generalized linear models with the logic link and gamma distribution were used to analyze associations between PIM use and medication expenditures.

RESULTS

Among the 506,214 older adults, the prevalence of PIM was 38.07%. After adjusting for covariables, prescribing 2 and ≥3 PIMs was associated with increased risks of hospitalizations (PIM=2: OR 1.34, 95%CI: 1.22-1.47; PIM≥3: OR=1.47, 95%CI: 1.32-1.63) and ED visits (PIM=2: OR = 1.29, 95%CI 1.12-1.48; PIM≥3: OR=1.23, 95%CI: 1.04-1.44). Exposures of 2 and ≥3 PIMs were associated with higher medication expenditures for inpatient visits (PIM=2: incidence rate ratio IRR = 1.08, 95%CI 1.01-1.16; PIM≥3: IRR=1.18, 95%CI: 1.08-1.28). Vasodilators were the most frequent PIM prescribing group among patients who ended with hospitalizations or ED visits.

CONCLUSIONS

PIMs were prescribed at a high rate among community-dwelling older adults in Beijing. PIMs ≥2 were associated with increased risks of hospitalizations, ED visits, and increased inpatient medication expenditures. Effective interventions are needed to target unnecessary and inappropriate medications in older adults.

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 Readmissions from Health Insurance Claims Data: A Modeling Study Targeting Potentially Inappropriate Prescribing

BACKGROUND

 Numerous prediction models for readmissions are developed from hospital data whose predictor variables are based on specific data fields that are often not transferable to other settings. In contrast, routine data from statutory health insurances (in Germany) are highly standardized, ubiquitously available, and would thus allow for automatic identification of readmission risks.

OBJECTIVES

 To develop and internally validate prediction models for readmissions based on potentially inappropriate prescribing (PIP) in six diseases from routine data.

METHODS

 In a large database of German statutory health insurance claims, we detected disease-specific readmissions after index admissions for acute myocardial infarction (AMI), heart failure (HF), a composite of stroke, transient ischemic attack or atrial fibrillation (S/AF), chronic obstructive pulmonary disease (COPD), type-2 diabetes mellitus (DM), and osteoporosis (OS). PIP at the index admission was determined by the STOPP/START criteria (Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to the Right Treatment) which were candidate variables in regularized prediction models for specific readmission within 90 days. The risks from disease-specific models were combined ("stacked") to predict all-cause readmission within 90 days. Validation performance was measured by the c-statistics.

RESULTS

 While the prevalence of START criteria was higher than for STOPP criteria, more single STOPP criteria were selected into models for specific readmissions. Performance in validation samples was the highest for DM (c-statistics: 0.68 [95% confidence interval (CI): 0.66-0.70]), followed by COPD (c-statistics: 0.65 [95% CI: 0.64-0.67]), S/AF (c-statistics: 0.65 [95% CI: 0.63-0.66]), HF (c-statistics: 0.61 [95% CI: 0.60-0.62]), AMI (c-statistics: 0.58 [95% CI: 0.56-0.60]), and OS (c-statistics: 0.51 [95% CI: 0.47-0.56]). Integrating risks from disease-specific models to a combined model for all-cause readmission yielded a c-statistics of 0.63 [95% CI: 0.63-0.64].

CONCLUSION

 PIP successfully predicted readmissions for most diseases, opening the possibility for interventions to improve these modifiable risk factors. Machine-learning methods appear promising for future modeling of PIP predictors in complex older patients with many underlying diseases.

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.

Factors associated to potentially inappropriate prescribing in older patients according to STOPP/START criteria: MoPIM multicentre cohort study

OBJECTIVES

The objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs).

METHODS

A multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome.

RESULTS

A total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC.

CONCLUSIONS

PIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription.

TRIAL REGISTRATION NUMBER

NCT02830425.

The impact of PIPs on mortality and readmissions in older adults: a retrospective cohort study

PURPOSE

Our aim was to determine the impact of potentially inappropriate prescriptions (PIP), according to "Screening Tool of Older Persons' Prescriptions" criteria version 2 (STOPP-2), on mortality and hospital admissions.

METHODS

Monocentric retrospective cohort study. Patients over 65 years of age and who were consecutively discharged from internal medicine at a Spanish university hospital in 2016 were included. The mortality and hospital admissions of the cohort of patients were analysed using their electronic health records within two years from the time of discharge. Analysis was done based on the type and number of STOPP-2 criteria as well as taking into account the total number of medications. The subdistribution hazard ratios (SHR) were estimated through a competing proportional hazards model.

RESULTS

A total of 270 patients with a median age of 82 years (interquartile range/IQR 76-86 years), and 152 (56.3%) women were studied. It was found out that 28.3% of patients with PIP died compared to 17.2% of patients without it. Digoxin (B1 STOPP-2 criterion) with a subdistribution hazard ratio (SHR) 2.40 (95% CI 0.63-9.18), selective serotonin re-uptake inhibitors/SSRIs (D4) with a SHR 1.76 (95% CI 0.52-5.96) and neuroleptic drugs (K2) with a SHR 2.01 (95% CI 0.82-4.95) non-significantly increased the risk of death. Dementia (SHR 5.45; 95% CI 2.76-10.78) was then the only statistically significant risk factor for death. Sixty percent of patients with a PIP had shown at least one hospital admission compared to 51% of patients without it. The number of drugs at discharge (SHR 1.03; 95% CI 1.01-1.05) and having 1-2 STOPP-2 criteria (SHR 1.17; 95% CI 1.02-1.35) significantly increased the risk of hospital admission.

CONCLUSION

The number of drugs at discharge and having any STOPP criteria significantly increased the risk of hospital admission in this cohort. PIP, only according to some specific STOPP-2 criteria involving digoxin, neuroleptics and SSRIs, might associate with a statistically non-significantly higher risk on mortality.

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

OBJECTIVE

To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.

DESIGN

Cluster randomised controlled trial.

SETTING

110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.

PARTICIPANTS

2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term).

INTERVENTION

Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.

MAIN OUTCOME MEASURE

Primary outcome was first drug related hospital admission within 12 months.

RESULTS

2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).

CONCLUSIONS

Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02986425.

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.

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.

Disease-dependent variations in the timing and causes of readmissions in Germany: A claims data analysis for six different conditions

BACKGROUND

Hospital readmissions place a major burden on patients and health care systems worldwide, but little is known about patterns and timing of readmissions in Germany.

METHODS

We used German health insurance claims (AOK, 2011-2016) of patients ≥ 65 years hospitalized for acute myocardial infarction (AMI), heart failure (HF), a composite of stroke, transient ischemic attack, or atrial fibrillation (S/AF), chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, or osteoporosis to identify hospital readmissions within 30 or 90 days. Readmissions were classified into all-cause, specific, and non-specific and their characteristics were analyzed.

RESULTS

Within 30 and 90 days, about 14-22% and 27-41% index admissions were readmitted for any reason, respectively. HF and S/AF contributed most index cases, and HF and COPD accounted for most all-cause readmissions. Distributions and ratios of specific to non-specific readmissions were disease-specific with highest specific readmissions rates among COPD and AMI.

CONCLUSION

German claims are well-suited to investigate readmission causes if longer periods than 30 days are evaluated. Conditions closely related with the primary disease are the most frequent readmission causes, but multiple comorbidities among readmitted cases suggest that a multidisciplinary care approach should be implemented vigorously addressing comorbidities already during the index hospitalization.

The effects of in-hospital deprescribing on potential prescribing omission in hospitalized elderly patients with polypharmacy

No studies to investigate the effect of a deprescribing intervention on the occurrence of potential prescribing omissions (PPOs) among elderly patients with polypharmacy have been conducted. Therefore, the effect of deprescribing on PPOs among elderly patients with polypharmacy was investigated. All 121 consecutive elderly patients who received in-hospital deprescribing interventions were evaluated. The primary outcome was any occurrence of PPOs based on the 2015 STOPP/START criteria. The proportion of patients who had any PPOs significantly increased after the deprescribing interventions (52.9% vs 77.7%, p < 0.001). In the multivariable analysis, older age was the only independent risk factor associated with an increased risk of any PPOs after the deprescribing interventions (OR 1.08, 95% CI 1.01 to 1.16). In-hospital deprescribing interventions for elderly patients with polypharmacy may increase the occurrence of PPOs. Further study is warranted to investigate the effects on clinical outcomes of the increased occurrence of PPOs due to the deprescribing intervention.

Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis

BACKGROUND

Harm due to medications is common during the transition from hospital to home. Approaches that seek to prevent harm often involve isolated medication-related interventions and show conflicting results. However, until now, no review has focused on the effect of intervention components delivered both in hospital and following discharge from hospital to home.

OBJECTIVE

To examine effects of medication-related interventions on hospital readmissions, medication-related problems (MRPs), medication adherence and mortality.

METHODS

For this systematic review and meta-analysis, we searched the PubMed, Embase, CINAHL and CENTRAL databases without language restrictions. Citations of included articles were checked through Web of Science and Scopus from inception to 20 June 2019. We included prospective studies that examined effects of medication-related interventions delivered both in hospital and following discharge from hospital to home compared with usual care. Three authors independently extracted data and assessed study quality in pairs.

RESULTS

Fourteen original studies were included, comprising 8182 patients. Interventions consisted mainly of patient education and medication reconciliation in the hospital, and patient education following discharge. Nine studies were included in the meta-analysis; compared with usual care (n=3376 patients), medication-related interventions (n=1820 patients) reduced hospital readmissions by 3.8 percentage points within 30 days of discharge (number needed to treat=27, risk ratio (RR) 0.79 (95% CI 0.65 to 0.96)). Meta-regression analysis suggested that readmission rates were reduced by 17% per additional intervention component (RR 0.83 (95% Cl 0.75 to 0.91)). Medication adherence and MRPs may be improved. Effects on mortality were unclear.

CONCLUSIONS

Studied medication-related interventions reduce all-cause hospital readmissions within 30 days. The treatment effect appears to increase with higher intervention intensities. More evidence is needed for recommendations on adherence, mortality and MRPs.

Physician and patient-related factors associated with inappropriate prescribing to older patients within primary care: a cross-sectional study in Brazil

BACKGROUND

Physician and patient-related characteristics can influence prescription of medications to older patients within primary healthcare. Use of Brazilian criteria may indicate the real prevalence of prescription of potentially inappropriate medications to this population.

OBJECTIVES

To evaluate prescription of potentially inappropriate medications to older patients within primary care and identify patient-related and prescribing physician-related factors.

DESIGN AND SETTING

This cross-sectional study was conducted in 22 public primary care facilities in Brazil, among older people (≥ 60 years) who were waiting for medical consultations.

METHODS

Interviews were conducted before and after the medical consultations. If the patient received a medical prescription at the consultation, all the drugs prescribed and the physician's medical council registration number were recorded. Prevalence ratios were estimated to ascertain the magnitude of prescription of potentially inappropriate medications, along with patient and physician-related factors associated with such prescription.

RESULTS

In total, 417 older patients were included; 45.3% had received ≥ 1 potentially inappropriate medication, and 86.8% out of 53 physicians involved had prescribed ≥ 1 potentially inappropriate medication. The strongest patient-related factor associated with higher prevalence of prescription of potentially inappropriate medications was polypharmacy. Among physician-related factors, the number of patients attended, number of prescriptions and length of medical practice < 10 years were positively associated with prescription of potentially inappropriate medications.

CONCLUSIONS

High prevalence of prescription of potentially inappropriate medications was observed. Physician-related characteristics can influence prescription of medications to older people within primary healthcare. This suggests that there is a need for interventions among all physicians, especially younger physicians.

Reducing Inappropriate Outpatient Medication Prescribing in Older Adults across Electronic Health Record Systems

BACKGROUND

The American Geriatrics Society recommends against the use of certain potentially inappropriate medications (PIMs) in older adults. Prescribing of these medications correlates with higher rates of hospital readmissions, morbidity, and mortality. Vanderbilt University Medical Center previously deployed clinical decision support (CDS) to decrease PIM prescribing rates, but recently transitioned to a new electronic health record (EHR).

OBJECTIVE

The goal of this study was to evaluate PIM prescribing rates for older adults before and after migration to the new EHR system.

METHODS

We reviewed prescribing rates of PIMs in adults 65 years and older, normalized per 100 total prescriptions from the legacy and new EHR systems between July 1, 2014 and December 31, 2019. The PIM prescribing rates before and after EHR migration during November 2017 were compared using a U-chart and Poisson regression model. Secondary analysis descriptively evaluated the frequency of prescriber acceptance rates in the new EHR.

RESULTS

Prescribing rates of PIMs decreased 5.2% (13.5 per 100 prescriptions to 12.8 per 100 prescriptions; p < 0.0001) corresponding to the implementation of alternatives CDS in the legacy EHR. After migration of the alternative CDS from the legacy to the new EHR system, PIM prescribing rates dropped an additional 18.8% (10.4 per 100 prescriptions; p < 0.0001). Acceptance rates of the alternative recommendations for PIMs was low overall at 11.1%.

CONCLUSION

The prescribing rate of PIMs in adults aged 65 years and older was successfully decreased with the implementation of prescribing CDS. This decrease was not only maintained but strengthened by the transition to a new EHR system.

Potentially Inappropriate Medications, Drug-Drug Interactions, and Anticholinergic Burden in Elderly Hospitalized Patients: Does an Association Exist with Post-Discharge Health Outcomes?

BACKGROUND

Polypharmacy is very common in elderly patients and is associated with detrimental outcomes.

OBJECTIVE

Our objective was to evaluate the associations between a large panel of therapy quality indicators, including explicit lists of potentially inappropriate medications (PIMs; Beers criteria and Screening Tool of Older Persons' potentially inappropriate Prescriptions [STOPP] criteria), the Anticholinergic Cognitive Burden (ACB) score, and the number of drug-drug interactions (DDIs), with respect to mortality, rehospitalization, and physical function decline within 3 months from hospital discharge in a cohort of hospitalized elderly patients.

METHODS

We studied 2631 individuals aged ≥ 65 years (median age 79.6; males 48.6%) enrolled in the REPOSI registry. The relationships with mortality and rehospitalization were evaluated using Cox regressions, and relationships with functional status change (as percentage variation of Barthel Index [BI]) were evaluated using mixed linear models.

RESULTS

None of the studied indicators was associated with mortality and rehospitalization. Conversely, only ACB was associated with physical function decline, even after correction for confounders (adjusted mean BI variation of - 7.55%; 95% confidence interval [CI] - 12.37 to - 2.47). The number of medications at discharge, particularly polypharmacy (more than five drugs daily), were the only therapy-related factors associated with mortality (adjusted hazard ratio [aHR] 1.05 [95% CI 1.01-1.10] and 1.70 [95% CI 1.12-2.58], respectively) and rehospitalization (aHR 1.05 [95% CI 1.01-1.08] and 1.31 [95% CI 1.01-1.71], respectively).

CONCLUSION

Polypharmacy, a very simple measure, outperformed sophisticated PIM and DDI indicators of quality of therapy as a correlate of primary clinical outcomes, whereas ACB was associated with physical function decline. Thus, innovative approaches to the definition and research of PIMs and DDIs are eagerly awaited from the perspective of averaging the quantitative burden and qualitative interaction of drugs.

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.

Medication management during transitions from hospital to home: a focus group study with hospital and primary healthcare providers in the Netherlands

Background Medication management is jeopardized during a patient's transition from hospital to home. Insight is required from both hospital and primary healthcare providers on how care should be organised to achieve continuity of medication management. Objective This study aimed to identify perspectives of hospital and primary healthcare providers on barriers to the continuity of medication management during a patient's transition from hospital to home and facilitators to overcome these. Setting A qualitative descriptive study was conducted within hospital and primary healthcare settings in the Netherlands. Method Two focus groups were performed with two community care registered nurses, two community pharmacists, four general practitioners, two hospital nurses, two hospital pharmacists, four outpatient pharmacists, two pharmacy technicians, and one physician. A semi-structured interview guide was used to identify perspectives of participants on barriers to continuity of medication management and facilitators to overcome these. Data were analysed following thematic content analysis. Main outcome measure Barriers to the continuity of medication management during a patient's transition from hospital to home would be enumerated, along with facilitators to overcome these barriers. Results Three main themes of barriers and facilitators were identified: (1) healthcare provider collaboration, including the transfer of medication information and effective collaboration; (2) patient's medication use, including information about medication, personalised care, and supervision after discharge; and (3) organisation of healthcare, including the connection between information systems and the supply of medication. Conclusion Barriers and facilitators to continuity of medication management during the transition from hospital to home occur at the provider, patient, and healthcare-system levels. Future interventions should focus on all levels through interprofessional healthcare teams, tailoring care to patient needs, and on the use of a uniform, nationwide patient electronic health record.

Potentially inappropriate medications for the elderly: Incidence and impact on mortality in a cohort ten-year follow-up

INTRODUCTION

Pharmacological therapy plays an important role in disease control in the elderly; unfortunately, this comes with a high prevalence in the use of medications classified as potentially inappropriate.

OBJECTIVE

To analyze the incidence, risk factors, and survival of elderly people using potentially inappropriate medications (PIM).

METHOD

A ten-year follow-up assessment of elderly participants residing in a capital of Central Brazil was conducted. The initial assessment (baseline) included 418 elderly people. Data were collected through home interviews guided by a questionnaire covering socioeconomic, demographic, living conditions, and health variables. The medication information obtained comprised active ingredient, dosage, route, and regimen for the medications. The PIMs were classified according to 2019 Beers Criteria. The analyses were performed using STATA 15.0. For survival analysis, a Cox Regression was performed with the respective Kaplan Meier curve.

RESULTS

The incidence of PIM was 44.1 cases (95% CI: 35.2-54.7) per 1,000 people a year. The most used PIMs were nifedipine, glibenclamide, and sodium diclofenac. The risk factors were polypharmacy (aRR: 3.00; 95% CI: 1.31-6.88) and diabetes mellitus (aRR: 1.57; 95% CI: 1.03-2.39). We identified no statistically significant association between survival and the use of PIM.

CONCLUSION

The study highlights the high consumption of PIM among the elderly causing polypharmacy risks. Health professionals working in drug treatment need to be alert to polypharmacy risks to ensure the rational use of medications to prevent adverse reactions and other health problems.