Comparison of tools for the assessment of inappropriate prescribing in hospitalized older people

Performance of potentially inappropriate medications assessment tools in older Indian patients with cancer

BACKGROUND

Polypharmacy and potentially inappropriate medication (PIM) use are common problems in older adults. Safe prescription practices are a necessity. The tools employed for the identification of PIM sometimes do not concur with each other.

METHODS

A retrospective analysis of patients ≥60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India from 2018 to 2021 was performed. Beer's-2015, STOPP/START criteria v2, PRISCUS-2010, Fit fOR The Aged (FORTA)-2018, and the EU(7)-PIM list-2015 were the tools used to assess PIM. Every patient was assigned a standardized PIM value (SPV) for each scale, which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all five tools was considered the reference standard for each patient. Bland-Altman plots were utilized to determine agreement between each scale and the reference. Association between baseline variables and PIM use was determined using multiple logistic regression analysis.

RESULTS

Of the 467 patients included in this analysis, there were 372 (79.66%) males and 95 (20.34%) females with an average age of 70 ± 5.91 years. The EU(7)-PIM list was found to have the highest level of agreement given by a bias estimate of 0.010, the lowest compared to any other scale. The 95% CI of the bias was in the narrow range of -0.001 to 0.022, demonstrating the precision of the estimate. In comparison, the bias (95%) CI of Beer's criteria, STOPP/START criteria, PRISCUS list, and FORTA list were -0.039 (-0.053 to -0.025), 0.076 (0.060 to 0.092), 0.035 (0.021 to 0.049), and -0.148 (-0.165 to -0.130), respectively. Patients on polypharmacy had significantly higher PIM use compared to those without (OR = 1.47 (1.33-1.63), p = <0.001).

CONCLUSIONS

The EU(7)-PIM list was found to have the least bias and hence can be considered the most reliable among all other tools studied.

Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP: A cross-sectional study

Background

Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria.

Objective

To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria^® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care.

Methods

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model.

Results

A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores.

Conclusions

The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.

A Collaborative Medication Review Including Deprescribing for Older Patients in an Emergency Department: A Longitudinal Feasibility Study

Medication review for older patients with polypharmacy in the emergency department (ED) is crucial to prevent inappropriate prescribing. Our objective was to assess the feasibility of a collaborative medication review in older medical patients (≥65 years) using polypharmacy (≥5 long-term medications). A pharmacist performed the medication review using the tools: Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, a drug–drug interaction database (SFINX), and Renbase^® (renal dosing database). A geriatrician received the medication review and decided which recommendations should be implemented. The outcomes were: differences in Medication Appropriateness Index (MAI) and Assessment of Underutilization Index (AOU) scores between admission and 30 days after discharge and the percentage of patients for which the intervention was completed before discharge. Sixty patients were included from the ED, the intervention was completed before discharge for 50 patients (83%), and 39 (61.5% male; median age 80 years) completed the follow-up 30 days after discharge. The median MAI score decreased from 14 (IQR 8-20) at admission to 8 (IQR 2-13) 30 days after discharge (p < 0.001). The number of patients with an AOU score ≥1 was reduced from 36% to 10% (p < 0.001). Thirty days after discharge, 83% of the changes were sustained and for 28 patients (72%), 1≥ medication had been deprescribed. In conclusion, a collaborative medication review and deprescribing intervention is feasible to perform in the ED.

The effect of hospitalization on potentially inappropriate medication use in older adults with chronic kidney disease

OBJECTIVES

Potentially inappropriate medication (PIM) use is associated with increased morbidity and mortality in chronic kidney disease (CKD). However, there is a paucity of data on how hospitalization affects PIM use in older adults with CKD. Therefore, we aimed to measure the impact of hospitalization on PIM use in older CKD patients, and identify factors predicting PIM use.

METHODS

A retrospective cohort study was conducted in older adults (≥65 years) with CKD admitted to an Australian tertiary care hospital over a 6 month period. PIM use was measured, upon admission and at discharge, using the Medication Appropriateness Index (MAI) and Beers criteria (2015 version) for medications recommended to be avoided in older adults and under certain conditions.

RESULTS

The median age of the 204 patients was 83 years (interquartile range (IQR): 76-87 years) and most were men (61%). Overall, the level of PIM use (MAI) decreased from admission to discharge (median [IQR]: 6 [3-12] to 5 [2-9]; p < .01]). More than half of the participants (55%) had at least one PIM per Beers criterion on admission, which was reduced by discharge (48%; p < .01). People admitted with a higher number of medications (β 0.72, 95% CI 0.56-0.88) and lower eGFR values (β - 0.11, 95% CI -0.18 to -0.04) had higher MAI scores after adjusting for age, sex and Charlson's comorbidity index.

CONCLUSIONS

PIMs were commonly used in older CKD patients. Hospitalization was associated with a reduction in PIM use, but there was considerable scope for improvement in these susceptible individuals.

Impact of medication reviews on inappropriate prescribing in aged care

BACKGROUND

Inappropriate prescribing (IP) is prevalent among elderly people in aged care facilities. Little has been published on the effect of pharmacists performing residential medication management reviews (RMMRs) in aged care on the appropriateness of prescribing. RMMRs represents a key strategy for achieving quality use of medicines, by assisting residents in aged care facilities and their carers to better manage their medicines. However, the structure of RMMR has moved from annual to every two years for each resident.

OBJECTIVES

The primary objective of this study was to investigate the impact of pharmacists performing RMMRs on medication use appropriateness, as measured by the Medication Appropriateness Index (MAI).

METHODS

Retrospective analysis of RMMRs pertaining to 223 aged care residents aged ≥65 years in Sydney, Australia. The MAI was applied on two RMMR cohorts; newer cohort (n = 111, 2015) i.e. following the recent changes to the RMMR funding and older cohort (n = 112, 2012) at baseline, after pharmacists' recommendations (assuming all pharmacists' recommendations were accepted by the General Practitioner [GP]), and after the actual uptake of pharmacists' recommendations by the GP. Differences in inappropriate prescribing were measured using the Wilcoxon sign rank test.

RESULTS

Overall, all patients in the study (n = 223) had at least one inappropriate rating at baseline (median MAI score of 26 for the old cohort and 27 for the newer cohort). The median cumulative MAI scores were significantly lower after the RMMRs by pharmacists (15.5 and 20 for the old and new cohort respectively, p < .001) and following the uptake of recommendations by the GP, indicating an increased appropriateness of drug regimen after the medication review (20 and 22 for the old and new cohort respectively, p < .001).

CONCLUSION

This study shows that pharmacist-led medication reviews are effective in reducing inappropriate prescribing among aged care residents, as demonstrated by the reduction in MAI scores. Future studies should focus on the impact of such a decrease on patient outcomes.

Predictive Validity of the Beers and Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) Criteria to Detect Adverse Drug Events, Hospitalizations, and Emergency Department Visits in the United States

OBJECTIVES

To compare the predictive validity of the 2003 Beers, 2012 American Geriatrics Society (AGS) Beers, and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria.

DESIGN

Retrospective cohort.

SETTING

Managed care administrative claims data from 2006 to 2009.

PARTICIPANTS

Commercially insured persons aged 65 and older in the United States (N=174,275).

MEASUREMENTS

Association between adverse drug events (ADEs), emergency department (ED) visits, and hospitalization outcomes and inappropriate medication use using time-varying Cox proportional hazard models. Measures of model discrimination (c-index) and hazard ratios (HRs) were calculated to compare unadjusted and adjusted models for associations.

RESULTS

The prevalence of inappropriate prescribing was 34.1% for the 2012 AGS Beers criteria, 32.2% for the 2003 Beers criteria, and 27.6% for the STOPP criteria. Each set of criteria modestly discriminated ADEs in unadjusted analyses (STOPP criteria: hazard ratio (HR)=2.89, 95% confidence interval (CI)=2.68-3.12, C-index=0.607; 2012 AGS Beers criteria: HR=2.51, 95% CI=2.33-2.70, C-index=0.603; 2003 Beers criteria: HR=2.65, 95% CI=2.46-2.85, C-index=0.605). Similar results were observed for ED visits and hospitalizations. The c-indices increased to between 0.65 and 0.70 in adjusted analyses. The kappa for agreement between criteria was 0.80 for the 2003 and 2012 AGS Beers criteria, 0.58 for the 2012 AGS Beers and STOPP criteria, and 0.59 for the 2003 Beers and STOPP criteria. For the three outcomes, the 2012 AGS Beers criteria had the highest sensitivity (61.2-71.2%) and the lowest specificity (41.2-70.7%), and the STOPP criteria had the lowest sensitivity (53.8-64.7%) but the highest specificity (47.8-78.1%).

CONCLUSION

All three criteria were modestly prognostic for ADEs, EDs, and hospitalizations, with the STOPP criteria slightly outperforming both Beers criteria. With low sensitivity, low specificity, and low agreement between the criteria, they can be used in a complementary fashion to enhance sensitivity in detecting ADEs.

Potentially inappropriate prescribing (PIP) in long-term care (LTC) patients: validation of the 2014 STOPP-START and 2012 Beers criteria in a LTC population--a protocol for a cross-sectional comparison of clinical and health administrative data

INTRODUCTION

Potentially inappropriate prescribing (PIP) is frequent and problematic in older patients. Identifying PIP is necessary to improve prescribing quality; ideally, this should be performed at the population level. Screening Tool of Older Persons' potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Beers criteria were developed to identify PIP in clinical settings and are useful at the individual patient level; however, they are time-consuming and costly to apply. Only a subset of these criteria is applicable to routinely collected population-level health administrative data (HAD) because the clinical information necessary to implement these tools is often missing from databases. The performance of subsets of STOPP/START and Beers criteria in HAD compared with clinical data from the same patients is unknown; furthermore, the performance of the updated 2014 STOPP-START and 2012 Beers criteria compared with one another is also unknown.

METHODS AND ANALYSIS

A cross-sectional study of linked HAD and clinical data will be conducted to validate the subsets of STOPP/START and Beers criteria applicable to HAD by comparing their performance when applied to clinical and HAD for the same patients. Eligible patients will be 66 years and over and recently admitted to 1 of 6 long-term care facilities in Ottawa, Ontario. The target sample size is 275, but may be less if statistical significance can be achieved sooner. Medication, diagnostic and clinical data will be collected by a consultant pharmacist. The main outcome measure is the proportion of PIP missed by the subset of STOPP/START and Beers criteria applied to HAD when compared with clinical data.

ETHICS AND DISSEMINATION

The study was approved by the Ottawa Health Services Network Research Ethics Board, the Bruyère Continuing Care Research Ethics Board and the ethics board of the City of Ottawa Long Term Care Homes. Dissemination will occur via publication, national and international conference presentations, and exchanges with regional, provincial and national stakeholders.

TRIAL REGISTRATION NUMBER

NCT02523482.

Evaluating medication-related quality of care in residential aged care: a systematic review

Given the growing aged care population, the complexity of their medication-related needs and increased risk of adverse drug events, there is a necessity to systematically monitor and manage medication-related quality of care. The aim of this systematic review was to identify and synthesise medication-related quality of care indicators with respect to application to residential aged care. MEDLINE (Ovid), Psychinfo, CINAHL, Embase and Google® were searched from 2001 to 2013 for studies that were in English, focused on older people aged 65+ years and discussed the development, application or validation of original medication-related quality of care indicators. The quality of selected articles was appraised using the Critical Appraisal Skills Program and psychometric qualities extracted and synthesised using content analysis. Indicators were mapped to six medication-related quality of care attributes and a minimum indicator set derived. Thirty three articles describing 25 indicator sets met the inclusion criteria. Thirteen (52%) contained prescribing quality indicators only. Eight (32%) were developed specifically for aged care. Twenty three (92%) were validated and seven (28%) assessed for reliability. The most common attribute addressed was medication appropriateness (n = 24). There were no indicators for evaluating medication use in those with limited life expectancy, which resulted in only five of the six attributes being addressed. The developed minimum indicator set contains 28 indicators representing 22 of 25 identified indicator sets. Whilst a wide variety of validated indicator sets exist, none addressed all aspects of medication-related quality of care pertinent to residential aged care. The minimum indicator set is intended as a foundation for comprehensively evaluating medication-related quality of care in this setting. Future work should focus on bridging identified gaps.

Conceptualizing and measuring potentially inappropriate drug therapy

WHAT IS KNOWN AND OBJECTIVE

Elderly people are the principal consumers of prescription drugs. The more the medication used by the patient, the greater the likelihood there is of the patient being subjected to potentially inappropriate drug therapy (PIDT). PIDT has been measured in the literature with both implicit and explicit tools. The purpose of this review was to assess the use of tools to detect PIDT in various studies and to determine which terms are used to refer to PIDT in practice.

METHODS

A systematic review was conducted according to the following steps: the first was identification. In this step, studies were selected from different combinations of the descriptors 'aged', 'elderly', 'inappropriate prescribing' and 'drug utilization' in three different languages, using the Embase, Medline, Scielo, Scopus and Web of Science databases. Second, the papers that satisfied the inclusion criteria for data extraction were carefully examined by three evaluators to determine the tools used and terms that referred to PIDT.

RESULTS AND DISCUSSION

From the combinations of keywords, 8610 articles were found. At the end of the selection process, 119 of the articles complied with the specified criteria. The degree of agreement among evaluators was moderate for the study titles (κ1  = 0·479) and substantial for abstracts (κ2  = 0·647). With respect to the PIDT evaluation criteria used by the studies, 27·7% used two criteria. Of the 27 evaluation criteria identified, the Beers criteria were used by 82·3% of the studies. More than 50 different terms to identify PIDT were found in the literature.

WHAT IS NEW AND CONCLUSION

This review is the first study to conceptualize and discuss terms that refer to PIDT. At present, there is no consensus regarding terms used to refer to PIDT, with over 50 different terms currently in use. This review shows an increase in the number of articles aimed at evaluating PIDT using implicit and explicit tools.

Potentially Inappropriate Prescribing in Older Patients Discharged From Acute Care Hospitals to Residential Aged Care Facilities

Background: The frequency of prescribing potentially inappropriate medications (PIMs) in older patients remains high despite evidence of adverse outcomes from their use. Little is known about whether admission to hospital has any effect on appropriateness of prescribing. Objectives: This study aimed to identify the prevalence and nature of PIMs and explore the association of risk factors for receiving a PIM. Methods: This was a prospective study of 206 patients discharged to residential aged care facilities from acute care. All patients were at least 70 years old and were admitted between July 2005 and May 2010; their admission and discharge medications were evaluated. Results: Mean patient age was 84.8 ± 6.7 years; the majority (57%) were older than 85 years, and mean (SD) Frailty Index was 0.42 (0.15). At least 1 PIM was identified in 112 (54.4%) patients on admission and 102 (49.5%) patients on discharge. Of all medications prescribed at admission (1728), 10.8% were PIMs, and at discharge, of 1759 medications, 9.6% were PIMs. Of the total 187 PIMs on admission, 56 (30%) were stopped and 131 were continued; 32 new PIMs were introduced. Of the potential risk factors considered, in-hospital cognitive decline and frailty status were the only significant predictors of PIMs. Conclusions: Although admission to hospital is an opportunity to review the indications for specific medications, a high prevalence of inappropriate drug use was observed. The only associations with PIM use were the frailty status and in-hospital cognitive decline. Additional studies are needed to further evaluate this association.

Potentially inappropriate prescribing in patients on admission and discharge from an older peoples' unit of an acute UK hospital

BACKGROUND

The Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) classifies 65 common drug issues found to contribute to inappropriate prescribing in the elderly. International studies using STOPP criteria indicate high potentially inappropriate medication (PIM) prevalence rates; however, no studies have been conducted in older patients in UK hospitals. Published literature has not assessed whether prescribers attempt to minimise the potential risk of PIMs by putting in place follow-up or review plans.

OBJECTIVES

The objectives of this study were (1) to determine prevalence and types of PIMs in older people admitted to and discharged from a UK hospital; and (2) to determine how often PIMs prescribed on discharge are accompanied by a plan for follow-up.

METHODS

This was a retrospective, non-randomised study conducted in the Specialist Health and Ageing Unit (HAU) of a 950-bed acute hospital trust in England, UK. The subjects were patients aged ≥65 years admitted to the HAU in June and July 2011. Data were obtained by applying STOPP criteria to electronic admission and discharge medication lists. Parametric and non-parametric tests were performed to assess variables and to detect differences between groups. A PIM index was calculated by dividing the total number of PIMs by the total number of medications.

RESULTS

Medication lists for 195 patients were assessed. Median age was 85.5 years. The median number of admission medicines was nine. A total of 66 patients (34 %) were prescribed more than ten medications. The median number of discharge medicines was ten, with 80 patients (41 %) prescribed more than ten medicines. Admission PIM prevalence was 26.7 % (95 % CI 20.5-32.9; 52 patients, 74 PIMs). The most common PIM categories on admission were central nervous system (CNS) and psychotropic drugs, drugs adversely affecting patients at risk of falls and drugs acting on the urogenital system. The likelihood of having a PIM on admission was doubled in patients receiving more than ten medications compared with those taking fewer (odds ratio 2.3 [95 % CI 1.2-4.4]; p = 0.01). Discharge PIM prevalence was 22.6 % (95 % CI 16.7-28.5; 44 patients, 51 PIMs). PIMs reduced significantly on discharge (p = 0.005). The most common discharge PIMs were drugs adversely affecting patients at risk of falls, CNS and psychotropics, urogenital drugs and cardiovascular agents. Advice for general practitioners to monitor medication was documented on the discharge summary of three patients. An index was developed, based on the ratio of PIMs to medication totals. The PIM index complements the assessment of PIM prevalence and allows comparison of prescribing appropriateness between populations and between studies by taking into account the total amount of prescribed medication. Despite an increase in medication prescribed, the PIM index (rate) decreased from 0.043 on admission to 0.027 at discharge.

CONCLUSIONS

Admission to a specialist HAU was associated with a significant reduction in PIMS. Very few patients discharged with a PIM had a documented follow-up plan. PIM prevalence was lower than published rates found internationally. Similar studies in settings of varying types across the UK are needed.

The medication appropriateness index at 20: where it started, where it has been, and where it may be going

Potentially inappropriate prescribing for older adults is a major public health concern. While there are multiple measures of potentially inappropriate prescribing, the medication appropriateness index (MAI) is one of the most common implicit approaches published in the scientific literature. The objective of this narrative review is to describe findings regarding the MAI's reliability, comparison of the MAI with other quality measures of potentially inappropriate prescribing, its predictive validity with important health outcomes, and its responsiveness to change within the framework of randomized controlled trials. A search restricted to English-language literature involving humans aged 65+ years from January 1992 to June 2013 was conducted using MEDLINE and EMBASE databases using the search term 'medication appropriateness index'. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. A total of 26 articles were identified for inclusion in this narrative review. The main findings were that the MAI has acceptable inter- and intra-rater reliability, it more frequently detects potentially inappropriate prescribing than a commonly used set of explicit criteria, it predicts adverse health outcomes, and it is able to demonstrate the positive impact of interventions to improve this public health problem. We conclude that the MAI may serve as a valuable tool for measuring potentially inappropriate prescribing in older adults.

PROPER I: frequency and appropriateness of psychotropic drugs use in nursing home patients and its associations: a study protocol

BACKGROUND

Nursing home patients with dementia use psychotropic drugs longer and more frequently than recommended by guidelines implying psychotropic drugs are not always prescribed appropriately. These drugs can have many side effects and effectiveness is limited. Psychotropic drug use between nursing home units varies and is not solely related to the severity of neuropsychiatric symptoms. There is growing evidence indicating that psychotropic drug use is associated with environmental factors, suggesting that the prescription of psychotropic drugs is not only related to (objective) patient factors. However, other factors related to the patient, elderly care physician, nurse and the physical environment are only partially identified. Using a mixed method of qualitative and quantitative research, this study aims to understand the nature of psychotropic drug use and its underlying factors by identifying: 1) frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms in nursing home patients with dementia, 2) factors associated with (appropriateness of) psychotropic drug use.

METHODS

A cross-sectional mixed methods study. For the quantitative study, patients with dementia (n = 540), nursing staff and elderly care physicians of 36 Dementia Special Care Units of 12 nursing homes throughout the Netherlands will be recruited. Six nursing homes with high average rates and six with low average rates of psychotropic drug use, based on a national survey about frequency of psychotropic drug use on units, will be included. Psychotropic drugs include antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants and anti-dementia drugs. Appropriateness will be measured by an instrument based on the Medication Appropriateness Index and current guidelines for treatment of neuropsychiatric symptoms. Factors associated to psychotropic drug use, related to the patient, elderly care physician, nurse and physical environment, will be explored using multilevel regression analyses. For the qualitative study, in depth interviews with staff will be held and analyzed to identify and explore other unknown factors.

DISCUSSION

This study will provide insight into factors that are associated with the frequency and appropriateness of psychotropic drug use for neuropsychiatric symptoms. Understanding psychotropic drug use and its associations may contribute to better dementia care.

Effects of pharmacists' interventions on appropriateness of prescribing and evaluation of the instruments' (MAI, STOPP and STARTs') ability to predict hospitalization--analyses from a randomized controlled trial

BACKGROUND

Appropriateness of prescribing can be assessed by various measures and screening instruments. The aims of this study were to investigate the effects of pharmacists' interventions on appropriateness of prescribing in elderly patients, and to explore the relationship between these results and hospital care utilization during a 12-month follow-up period.

METHODS

The study population from a previous randomized controlled study, in which the effects of a comprehensive pharmacist intervention on re-hospitalization was investigated, was used. The criteria from the instruments MAI, STOPP and START were applied retrospectively to the 368 study patients (intervention group (I) n = 182, control group (C) n = 186). The assessments were done on admission and at discharge to detect differences over time and between the groups. Hospital care consumption was recorded and the association between scores for appropriateness, and hospitalization was analysed.

RESULTS

The number of Potentially Inappropriate Medicines (PIMs) per patient as identified by STOPP was reduced for I but not for C (1.42 to 0.93 vs. 1.46 to 1.66 respectively, p<0.01). The number of Potential Prescription Omissions (PPOs) per patient as identified by START was reduced for I but not for C (0.36 to 0.09 vs. 0.42 to 0.45 respectively, p<0.001). The summated score for MAI was reduced for I but not for C (8.5 to 5.0 and 8.7 to 10.0 respectively, p<0.001). There was a positive association between scores for MAI and STOPP and drug-related readmissions (RR 8-9% and 30-34% respectively). No association was detected between the scores of the tools and total re-visits to hospital.

CONCLUSION

The interventions significantly improved the appropriateness of prescribing for patients in the intervention group as evaluated by the instruments MAI, STOPP and START. High scores in MAI and STOPP were associated with a higher number of drug-related readmissions.

[Suitability of pharmacological treatment in patients with multiple chronic conditions]

OBJECTIVE

To identify tools for measuring the appropriateness of drug therapy useful in patients with multiple chronic conditions.

DESIGN

We performed a literature review.

DATA SOURCES

The following database were consulted (December 2009): Pubmed, EMBASE, CINAHL, PsycINFO and Spanish Medical Index (IME) to detect tools for measuring the appropriateness of treatment in patients with multiple chronic conditions, or otherwise elderly or polypharmacy.

STUDY SELECTION

Studies were identified both qualitative and quantitative methodology, both theoretical and field work, both original and revised work and included work from all areas of the health system. 108 articles were retrieved, of which we selected 59. The consultation of their references include 20 jobs allowed, resulting in a total of 59 articles.

DATA EXTRACTION

Of all the tools identified, the researchers performed a selection of those with possible utility for classified PP. The articles were classified into implicit and explicit methods and the characteristics of the field works were tabulated.

RESULTS

We identified two implicit methods (MAI and Hamdy) and 6 explicit methods (Beers criteria, IPET, STOPP/START, ACOVE, CRIME and NORGEP). None was specific to patients with multiple chronic conditions. The questionnaire MAI, the Beers criteria and its modifications are most often used in literature. The advantages of explicit criteria means that many of them have been developed recently.

CONCLUSION

There are several tools to measure the appropriateness and none of them has been designed for a population of patients with multiple chronic conditions yet, which by its nature requires a specific approach spreads.