The Association of Inappropriate Drug Use with Hospitalisation and Mortality

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.

Contribution of Potentially Inappropriate Medications to Polypharmacy-Associated Risk of Mortality in Middle-Aged Patients: A National Cohort Study

BACKGROUND

The role of potentially inappropriate medications (PIMs) in mortality has been studied among those 65 years or older. While middle-aged individuals are believed to be less susceptible to the harms of polypharmacy, PIMs have not been as carefully studied in this group.

OBJECTIVE

To estimate PIM-associated risk of mortality and evaluate the extent PIMs explain associations between polypharmacy and mortality in middle-aged patients, overall and by sex and race/ethnicity.

DESIGN

Observational cohort study.

SETTING

Department of Veterans Affairs (VA), the largest integrated healthcare system in the US.

PARTICIPANTS

Patients aged 41 to 64 who received a chronic medication (continuous use of ≥ 90 days) between October 1, 2008, and September 30, 2017.

MEASUREMENT

Patients were followed for 5 years until death or end of study period (September 30, 2019). Time-updated polypharmacy and hyperpolypharmacy were defined as 5-9 and ≥ 10 chronic medications, respectively. PIMs were identified using the Beers criteria (2015) and were time-updated. Cox models were adjusted for demographic, behavioral, and clinical characteristics.

RESULTS

Of 733,728 patients, 676,935 (92.3%) were men, 479,377 (65.3%) were White, and 156,092 (21.3%) were Black. By the end of follow-up, 104,361 (14.2%) patients had polypharmacy, 15,485 (2.1%) had hyperpolypharmacy, and 129,992 (17.7%) were dispensed ≥ 1 PIM. PIMs were independently associated with mortality (HR 1.11, 95% CI 1.04-1.18). PIMs also modestly attenuated risk of mortality associated with polypharmacy (HR 1.07, 95% CI 1.03-1.11 before versus HR 1.05, 95% CI 1.01-1.09 after) and hyperpolypharmacy (HR 1.18, 95% CI 1.09-1.28 before versus HR 1.12, 95% CI 1.03-1.22 after). Patterns varied when stratified by sex and race/ethnicity.

LIMITATIONS

The predominantly male VA patient population may not represent the general population.

CONCLUSION

PIMs were independently associated with increased mortality, and partially explained polypharmacy-associated mortality in middle-aged people. Other mechanisms of injury from polypharmacy should also be studied.

Real-world analysis of safety, tolerability, and adherence to nirmatrelvir-ritonavir (paxlovid) in primary care COVID-19 outpatients

This retrospective cross-sectional study aims to evaluate the safety, tolerability, and adherence of patients prescribed Nirmatrelvir-ritonavir (Paxlovid) in outpatient settings, focusing on its use in managing category 2 COVID-19 patients across three primary healthcare clinics in Selangor, Malaysia. Data were collected from the Paxlovid pharmacy registry and medical records at Klinik Kesihatan Seksyen 7, Klinik Kesihatan Seksyen 19, and Klinik Kesihatan Kelana Jaya between April 1, 2022, and November 30, 2022. This study analysed data from 415 category 2 COVID-19 patients aged ≥ 18 years. The primary and secondary outcomes included the assessment of patient demographics, Paxlovid dosing, current medication, changes in drug regimen, adherence, and adverse drug reactions (ADR). Pharmacists follow-ups were conducted on days 3 and 5 post-medication initiation. The majority (79.5%) of the cohort experienced ADR, predominantly dysgeusia, diarrhoea, body ache, vomiting, and nausea. Despite this, the ADRs were generally well-tolerated, with no severe impacts reported. High adherence was observed, with 96.9% of patients completing the 5-day regimen. The primary reasons for non-adherence included adverse effect intolerability, dosing ambiguity, forgetfulness, concerns about ADR, and perceived health improvement. Notable medications interacting with Paxlovid were simvastatin, amlodipine, and atorvastatin, and 21.7% of 23 concurrent medications were found not to comply with the recommended interventions by the University of Liverpool COVID-19 Drug Interaction database. Paxlovid demonstrates a high level of safety and tolerability in outpatient COVID-19 patients, with optimal adherence observed. This study underscores the vital role of healthcare professionals in managing Paxlovid within primary healthcare and highlights the need for broader research and direct patient involvement to enhance treatment strategies against COVID-19.

Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population

Background

Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy.

Aim

To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients.

Methods

We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses.

Results

Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor.

Conclusion

A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Developing a Warning Model of Potentially Inappropriate Medications in Older Chinese Outpatients in Tertiary Hospitals: A Machine-Learning Study

Due to multiple comorbid illnesses, polypharmacy, and age-related changes in pharmacokinetics and pharmacodynamics in older adults, the prevalence of potentially inappropriate medications (PIMs) is high, which affects the quality of life of older adults. Building an effective warning model is necessary for the early identification of PIMs to prevent harm caused by medication in geriatric patients. The purpose of this study was to develop a machine learning-based model for the warning of PIMs in older Chinese outpatients. This retrospective study was conducted among geriatric outpatients in nine tertiary hospitals in Chengdu from January 2018 to December 2018. The Beers criteria 2019 were used to assess PIMs in geriatric outpatients. Three problem transformation methods were used to tackle the multilabel classification problem in prescriptions. After the division of patient prescriptions into the training and test sets (8:2), we adopted six widely used classification algorithms to conduct the classification task and assessed the discriminative performance by the accuracy, precision, recall, F1 scores, subset accuracy (ss Acc), and Hamming loss (hm) of each model. The results showed that among 11,741 older patient prescriptions, 5816 PIMs were identified in 4038 (34.39%) patient prescriptions. A total of 41 types of PIMs were identified in these prescriptions. The three-problem transformation methods included label power set (LP), classifier chains (CC), and binary relevance (BR). Six classification algorithms were used to establish the warning models, including Random Forest (RF), Light Gradient Boosting Machine (LightGBM), eXtreme Gradient Boosting (XGBoost), CatBoost, Deep Forest (DF), and TabNet. The CC + CatBoost model had the highest accuracy value (97.83%), recall value (89.34%), F1 value (90.69%), and ss Acc value (97.79%) with a good precision value (92.18%) and the lowest hm value (0.0006). Therefore, the CC + CatBoost model was selected to predict the occurrence of PIM in geriatric Chinese patients. This study’s novelty establishes a warning model for PIMs in geriatric patients by using machine learning. With the popularity of electronic patient record systems, sophisticated computer algorithms can be implemented at the bedside to improve medication use safety in geriatric patients in the future.

Pharmaceutical intervention in the pharmacological therapy of elderly patients in San Luis-ECUADOR

Population's aging leads to a frequent usage of pharmaceutical medications to treat or control various ailments because of aging, increasing the probability of occurrence of problems related to its usage. The primary objective of this study was to conduct pharmaceutical interventions in elderly patients from San Luis - Riobamba, using surveys to identify the sociodemographic characteristics, diseases, and medicines usage. Once the problems related to pharmacological therapy were identified, pharmaceutical interventions were carried our prior the acceptance of each patient. The study had the participation of 422 elderly patients, with the prevalence of females (59.7%), aged between 60 and 70 years (45.5%); we identified that 82.5% of the elderly patients have diseases, finding that joint pain such as Arthritis/Osteoarthritis has the higher incidence (38.8%), and 50% of the surveyed people consume medication to treat the disease. 40.28% (n=170) of the participants conciliate the treatment review to identify any medication-related problem (MRP), finding interactions (21.2%) and adverse effects probability (21.2%), starting from the PRM identified, 170 pharmaceutical interventions were conducted, considering as priority (67.6%) the education on non-pharmacological measures. The pharmaceutical interventions done through the study benefited the elderly patients and will contribute to reduce the appearance of PRM.

Detectability of Medication Errors With a STOPP/START-Based Medication Review in Older People Prior to a Potentially Preventable Drug-Related Hospital Admission

INTRODUCTION

Multimorbidity and polypharmacy are risk factors for drug-related hospital admissions (DRAs) in the ageing population. DRAs caused by medication errors (MEs) are considered potentially preventable. The STOPP/START criteria were developed to detect potential MEs in older people.

OBJECTIVE

The aim of this study was to assess the detectability of MEs with a STOPP/START-based in-hospital medication review in older people with polypharmacy and multimorbidity prior to a potentially preventable DRA.

METHODS

Hospitalised older patients (n = 963) with polypharmacy and multimorbidity from the intervention arm of the OPERAM trial received a STOPP/START-based in-hospital medication review by a pharmacotherapy team. Readmissions within 1 year after the in-hospital medication review were adjudicated for drug-relatedness. A retrospective assessment was performed to determine whether MEs identified at the first DRA were detectable during the in-hospital medication review.

RESULTS

In total, 84 of 963 OPERAM intervention patients (8.7%) were readmitted with a potentially preventable DRA, of which 72 patients (n = 77 MEs) were eligible for analysis. About half (48%, n = 37/77) of the MEs were not present during the in-hospital medication review and therefore were not detectable at that time. The pharmacotherapy team recommended a change in medication regimen in 50% (n = 20/40) of present MEs, which corresponds to 26% (n = 20/77) of the total identified MEs at readmission. However, these recommendations were not implemented.

CONCLUSION

MEs identified at readmission were not addressed by a prior single in-hospital medication review because either these MEs occurred after the medication review (~50%), or no recommendation was given during the medication review (~25%), or the recommendation was not implemented (~25%). Future research should focus on optimisation of the timing and frequency of medication review and the implementation of proposed medication recommendations.

REGISTRATION

ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.

FUNDING

European Union HORIZON 2020, Swiss State Secretariat for Education, Research and Innovation (SERI), Swiss National Science Foundation (SNSF).

Medication review in multi-morbid geriatric patients: A training program for pharmacy students in Germany

INTRODUCTION

Medication reviews can reduce the geriatric risk of experiencing drug-related problems (DRPs), but medication review training programs in pharmacy education are infrequent and inconsistent. Data on education programs that practice DRP management skills and DRP prioritization should be collected as such training requires a tailored student evaluation at the DRP level.

METHODS

A geriatric patient medication review training was developed and implemented for eighth-semester pharmacy students. Students' DRP management skills were evaluated using audiotaped, 15-min simulated patient scenarios before and after the training using a newly developed algorithm (score 1-9, adequate management defined ≥7). The scenarios included 17 DRPs, five of which were identified as a high priority. Students rated their DRP management and knowledge by self-assessment before and after the training and supplied feedback about the training.

RESULTS

Student comprehension and handling of DRPs improved after the training. The median number of adequately managed DRPs increased from 4 to 7 (P = .001) and the median number of high-priority DRPs identified increased from 4 to 5 (P = .007). Students felt they improved their overall competency, DRP management, and knowledge, and 85% rated the training essential to their university education.

CONCLUSIONS

This training provided students with an objective evaluation algorithm for complex patient simulations in elderly patients. The training improved students' DRP prioritization and management, providing a basic template for future geriatric medication review training programs.

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial

BACKGROUND

The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care.

METHODS/DESIGN

This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient.

POPULATION

Patients aged 65-74 years with multimorbidity (≥ 3 chronic diseases) and polypharmacy (≥ 5 drugs) during the previous 3 months were included.

SAMPLE SIZE

n = 1148 patients (574 per study arm).

INTERVENTION

Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system.

OUTCOMES

The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables.

STATISTICAL ANALYSIS

The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle.

DISCUSSION

It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04147130 . Registered on 22 October 2019.

Potential Drug Interactions Between Psychotropics and Intravenous Chemotherapeutics Used by Patients With Cancer

Introduction: Patients undergoing cancer treatment usually have comorbidities, and psychiatric disorders are commonly seen in these patients. For the treatment of these psychiatric disorders, the use of psychotropic drugs is common, turning these patients susceptible to untoward drug interactions. Therefore, the aim of this study was to estimate the prevalence of clinically relevant drug-drug interactions (DDI) between chemotherapeutic and psychotropic agents in patients with cancer treated at an oncology service in southern Brazil. Methods: An observational epidemiological study with a cross-sectional census-type design was carried out between October and December 2020. The drug-drug interactions were identified through consultation and analysis of the Medscape Drug Interaction Check and Micromedex databases. The interactions were classified as major, when the interaction can be fatal and/or require medical intervention to avoid or minimize serious adverse effects and moderate, when the interaction can exacerbate the patient's condition and/or requires changes in therapy. Results: A total of 74 patients was included in the study among the 194 patients seen in the oncology service during the period studied. A total of 24 (32.4%) DDIs were found, 21 (87.5%) of which were classified as being of major risk and 3 (12.5%) as moderate risk. According to the mechanism of action, 19 (79.1%) were classified as pharmacodynamic interactions and 5 (20.9%) as pharmacokinetic interactions. Conclusion: It was shown that a considerable percentage of patients undergoing intravenous chemotherapy are at risk of pharmacological interaction with psychotropic drugs. Thus, it is essential that the oncologist considers all psychotropic drugs and other drugs used by patients in order to avoid drug-drug interactions.

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

Development of video animations to encourage patient-driven deprescribing: A Team Alice Study

OBJECTIVE

Patient-driven deprescribing initiatives aim to increase patient knowledge and strengthen self-advocacy skills. This article describes the development of three animated videos designed to educate older adults about unsafe prescribing and medication harm, based on the actionable lessons from the death, by polypharmacy, of an older adult in our community.

METHODS

Using a community based participatory research approach (CBPR), members of three senior centers (n = 53) and the Deprescribing Partnership of Western New York (n = 30) were recruited and participated in two rounds of focus groups to guide the video development.

RESULTS

Stakeholder input led to changes in content, wording, and visual presentation. The final versions of the videos emphasize the following messages (1) "New medications and what you should know about the risks", (2) "What you should do when a doctor tells you never to take a certain medication", (3) "What you should know about medications when you are in the hospital."

CONCLUSION

The study highlights the successful process of using CBPR to develop a series of videos designed to provide information on the risks of polypharmacy, and empower older adults to advocate for themselves.

PRACTICE IMPLICATIONS

Animated educational videos are a novel strategy to address medication harm in older adults. This research is a critical first step to increasing patient-led discussions that reduce the incidence of medication harm and inappropriate medication use among older adults.

A comparison of anticholinergic burden in older patients with and without cancer

Aim: To compare anticholinergic burden (ACB) in older patients with and without cancer and evaluate the effects of ACB on geriatric syndromes. Methods: A total of 291 patients from the geriatric clinic and 301 patients from the oncology clinic were evaluated. ACB <2 was categorized as low ACB and ACB ≥2 was categorized as high ACB. A comprehensive geriatric assessment was performed on patients from the geriatric clinic. Results: ACB scores were significantly higher in patients without cancer compared with those with cancer (p < 0.005). Number of falls and Geriatric Depression Scale 15 scores were higher and Mini-Nutritional Assessment and Barthel/Lawton activities of daily living scores were lower in geriatric patients with high ACB scores compared with those with low ACB scores (p < 0.005). Conclusion: It is crucial to understand the potential effects of ACB for rational drug use and optimum cancer management in older patients with cancer.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Potentially inappropriate medications and medication combinations before, during and after hospitalizations: an analysis of pathways and determinants in the Swiss healthcare setting

Background

A hospitalization phase represents a challenge to medication safety especially for multimorbid patients as acute medical needs might interact with pre-existing medications or evoke adverse drug effects. This project aimed to examine the prevalence and risk factors of potentially inappropriate medications (PIMs) and medication combinations (PIMCs) in the context of hospitalizations.

Methods

Analyses are based on claims data of patients (≥65 years) with basic mandatory health insurance at the Helsana Group, and on data from the Hirslanden Swiss Hospital Group. We assessed PIMs and PIMCs of patients who were hospitalized in 2013 at three different time points (quarter prior, during, after hospitalization). PIMs were identified using the PRISCUS list, whereas PIMCs were derived from compendium.ch. Zero-inflated Poisson regression models were applied to determine risk factors of PIMs and PIMCs.

Results

Throughout the observation period, more than 80% of patients had at least one PIM, ranging from 49.7% in the pre-hospitalization, 53.6% in the hospitalization to 48.2% in the post-hospitalization period. PIMCs were found in 46.6% of patients prior to hospitalization, in 21.3% during hospitalization, and in 25.0% of patients after discharge. Additional medication prescriptions compared to the preceding period and increasing age were the main risk factors, whereas managed care was associated with a decrease in PIMs and PIMCs.

Conclusion

We conclude that a patient’s hospitalization offers the possibility to increase medication safety. Nevertheless, the prevalence of PIMs and PIMCs is relatively high in the study population. Therefore, our results indicate a need for interventions to increase medication safety in the Swiss healthcare setting.

Reduction in unplanned hospitalizations associated with a physician focused intervention to reduce potentially inappropriate medication use among older adults: a population-based cohort study

Background

A multimodal general practitioner-focused intervention in the Local Health Authority (LHA) of Parma, Italy, substantially reduced the prevalence of potentially inappropriate medication (PIM) use among older adults. Our objective was to estimate changes in hospitalization rates associated with the Parma LHA quality improvement initiative that reduced PIM use.

Methods

This population-based longitudinal cohort study was conducted among older residents (> 65 years) using the Parma LHA administrative healthcare database. Crude and adjusted unplanned hospitalization rates were estimated in 3 periods (pre-intervention: 2005–2008, intervention: 2009–2010, post-intervention: 2011–2014). Multivariable negative binomial models estimated trends in quarterly hospitalization rates among individuals at risk during each period using a piecewise linear spline for time, adjusted for time-dependent and time-fixed covariates.

Results

The pre-intervention, intervention, and post-intervention periods included 117,061, 107,347, and 121,871 older adults and had crude hospitalization rates of 146.2 (95% CI: 142.2–150.3), 146.8 (95% CI: 143.6–150.0), and 140.8 (95% CI: 136.9–144.7) per 1000 persons per year, respectively. The adjusted pre-intervention hospitalization rate was declining by 0.7% per quarter (IRR = 0.993; 95% CI: 0.991–0.995). The hospitalization rate declined more than twice as fast during the intervention period (1.8% per quarter, IRR = 0.982; 95% CI: 0.979–0.985) and was nearly constant post-intervention (IRR: 0.999; 95% CI: 0.997–1.001). Contrasting model predictions for the intervention period (Q1 2009 to Q4 2010), the intervention was associated with 1481 avoided hospitalizations.

Conclusion

In a large population of older adults, a multimodal general practitioner-focused intervention to decrease PIM use was associated with a decline in the unplanned hospitalization rate. Such interventions to reduce high risk medication use among older adults warrant consideration by health systems seeking to improve health outcomes and reduce high-cost acute care utilization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02172-3.

Developing an Integrated Electronic Medication Reconciliation Platform and Evaluating its Effects on Preventing Potential Duplicated Medications and Reducing 30-Day Medication-Related Hospital Revisits for Inpatients

The aims were to develop an integrated electronic medication reconciliation (ieMR) platform, evaluate its effects on preventing potential duplicated medications, analyze the distribution of the potential duplicated medications by the Anatomical Therapeutic and Chemical (ATC) code for all inpatients, and determine the rate of 30-day medication-related hospital revisits for a geriatric unit. The study was conducted in a tertiary medical center in Taiwan and involved a retrospective quasi pre-intervention (July 1-November 30, 2015) and post-intervention (October 1-December 31, 2016) study design. A multidisciplinary team developed the ieMR platform covering the process from admission to discharge. The ieMR platform included six modules of an enhanced computer physician order entry system (eCPOE), Pharmaceutical-care, Holistic Care, Bedside Display, Personalized Best Possible Medication Discharge Plan, and Pharmaceutical Care Registration System. The ieMR platform prevented the number of potential duplicated medications from pre (25,196 medications, 2.3%) to post (23,413 medications, 3.8%) phases (OR 1.71, 95% CI, 1.68-1.74; p < .001). The most common potential duplicated medications classified by the ATC codes were cardiovascular system (28.4%), alimentary tract and metabolism (26.4%), and nervous system (14.9%), and by chemical substances were sennoside (12.5%), amlodipine (7.5%), and alprazolam (7.4%). The rate of medication-related 30-day hospital revisits for the geriatric unit was significantly decreased in post-intervention compared with that in pre-intervention (OR = 0.12; 95% CI, 0.03-0.53; p < .01). This study indicated that the ieMR platform significantly prevented the number of potential duplicated medications for inpatients and reduced the rate of 30-day medication-related hospital revisits for the patients on the geriatric unit.

Association Between Potentially Inappropriate Medications and Hospital Encounters Among Older Adults: A Meta-Analysis

BACKGROUND

Potentially inappropriate medications (PIMs) are defined by the American Geriatric Society as medications that should be avoided in the elderly in general, or in specific situations. However, PIM use remains high among aging populations and may result in increased utilization of healthcare resources.

OBJECTIVE

The aim of this meta-analysis was to evaluate the impact of PIM use on hospital encounters among older adults.

METHODS

We searched Medline and Scopus from January 1991 to April 2019 using keywords and MeSH terms related to PIMs. Studies were included if they compared the odds of hospital encounters between PIM and non-PIM groups. Hospital encounters could be either hospital admissions or emergency department (ED) visits. Using random-effects meta-analytic methods, we calculated the pooled odds of any hospital encounter in PIM versus non-PIM users.

RESULTS

A total of 21 studies evaluating 3,137,188 patients were included. The proportion of patients on PIMs was > 20% in most (n = 18) studies, median follow up was 12 months, and the mean age of patients ranged from 72 to 86 years. Upon meta-analysis, PIM use was associated with increased odds of both hospital admissions (OR 1.52; 95% CI 1.40-1.65) and ED visits (OR 1.72, 95% CI 1.33-2.24).

CONCLUSION

PIM use among older patients was associated with more hospital encounters. These unnecessary encounters likely cause a substantial burden to the healthcare system and patients.

Use and Deprescribing of Potentially Inappropriate Medications in Frail Nursing Home Residents

BACKGROUND

The STOPPFrail criteria were developed to assist physicians in deprescribing medications among frail patients approaching end of life. We aimed to measure the prevalence of potentially inappropriate medications (PIMs) and to describe changes over time, using STOPPFrail, in frail nursing home residents (NHRs) with limited life expectancy included in a medication review trial.

METHODS

We conducted a post-hoc analysis of the COME-ON study, a cluster-controlled trial that evaluated the effect of a complex intervention on appropriateness of prescribing in Belgian nursing homes. We identified NHRs eligible for the application of STOPPFrail based on functional status, comorbidities, level of care and survival. PIM use was measured at baseline and at 8 months. Changes over time were compared in the control group (CG) and intervention group (IG).

RESULTS

At baseline, 308 NHRs met the STOPPFrail eligibility criteria, of whom 196 (64.1%) had one or more PIM. At 8 months, among the 218 NHRs who were alive, there was an absolute reduction in the prevalence of PIMs of 9.1% in the CG (p < 0.05) and 10.2% in the IG (p < 0.05). We found large reductions for some medications (e.g. proton pump inhibitors) but no reduction for others (e.g. calcium). The percentage of NHRs with one or more PIM discontinued without a new PIM initiated was higher in the IG than the CG but the difference was not significant (35.1% vs 23.6%, p = 0.127).

CONCLUSION

Among frail NHRs with poor survival prognosis, a significant and encouraging decrease in PIM prevalence over time was observed, probably facilitated by medication reviews. The overall prevalence of PIMs remained high, however.

A pharmacist-led medicines review intervention in community-dwelling Māori older adults- a feasibility study protocol

BACKGROUND

Pharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults.

METHOD

This is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12619001070123.

Outcomes of Medication Misadventure Among People With Cognitive Impairment or Dementia: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate mortality and hospitalization outcomes associated with medication misadventure (including medication errors [MEs], such as the use of potentially inappropriate medications [PIMs], and adverse drug events [ADEs]) among people with cognitive impairment or dementia.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials were searched from inception to December 2019.

STUDY SELECTION AND DATA EXTRACTION

Relevant studies using any study design were included. Reviewers independently performed critical appraisal and extracted relevant data.

DATA SYNTHESIS

The systematic review included 10 studies that reported the outcomes of mortality or hospitalization associated with medication misadventure, including PIMs (n=5), ADEs (n=2), a combination of MEs and ADEs (n=2), and drug interactions (n=1). Five studies examining the association between PIMs and mortality/hospitalization were included in the meta-analyses. Exposure to PIMs was not associated with either mortality (odds ratio [OR]=1.36; 95%CI=0.79-2.35) or hospitalization (OR=1.02; 95%CI=0.83-1.26). In contrast, single studies indicated that ADEs with cholinesterase inhibitors were associated with mortality and hospitalization.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Individuals with cognitive impairment or dementia are at increased risk of medication misadventure; based on relatively limited published data, this does not necessarily translate to increased mortality and hospitalization.

CONCLUSIONS

Overall, medication misadventure was not associated with mortality or hospitalization in people with cognitive impairment or dementia, noting the limited number of studies, difficulty in controlling potential confounding variables, and that most studies focus on PIMs.

Potentially Inappropriate Medications Are Associated with Increased Healthcare Utilization and Costs

BACKGROUND/OBJECTIVES

To examine the prevalence of potentially inappropriate medication (PIM) prescribing and its association with healthcare utilization and related expenditures utilizing nationally representative data from the United States.

DESIGN

Retrospective cohort study.

SETTING

The 2011-2015 Medical Expenditure Panel Survey (MEPS).

PARTICIPANTS

Community-dwelling sample of U.S. adults aged 65 and older during the first round of each MEPS cycle.

MEASUREMENTS

A qualified definition operationalized from the 2019 American Geriatrics Society Beers Criteria® was used to estimate the prevalence of PIM prescribing over the study period. Negative binomial models were assembled to examine associations between PIM exposure and healthcare utilization including hospitalizations, emergency department (ED) visits, and outpatient provider visits. Generalized linear models with the log link function and gamma distribution were used to analyze associations between PIM exposure and healthcare expenditures. Sensitivity analyses were conducted utilizing inverse probability treatment weighting using propensity scores for being prescribed a PIM.

RESULTS

The period prevalence of PIM prescribing over the 5-year sample was 34.4%. PIM prescribing was positively associated with hospitalizations (adjusted incidence rate ratio [aIRR] = 1.17; 95 confidence interval [CI] = 1.08-1.26; P < .001), ED visits (aIRR = 1.26; 95% CI = 1.17-1.35; P < .001), and outpatient provider visits (aIRR = 1.18; 95% CI = 1.14-1.21; P < .001). PIM exposure was associated with higher marginal costs within outpatient visits ($116; 95% CI = $105-$243; P < .001), prescription medications ($128; 95% CI = $72-$199; P < .001), and total healthcare expenditures ($458; 95% CI = $295-$664; P < .001). Similar results were found in our propensity score analyses.

CONCLUSION

PIMs continue to be prescribed at a high rate among older adults in the United States. Our results suggest that receipt of PIMs is associated with higher rates of healthcare utilization and increased costs across the healthcare continuum. Further work is needed to implement evidence-based deprescribing interventions that may in turn reduce unnecessary healthcare utilization.

Potentially inappropriate medications in older patients based on Beers criteria: a cross-sectional study of a family medicine practice in Saudi Arabia

BACKGROUND

The use of potentially inappropriate medications (PIMs) is an important issue in older patients who are at risk of adverse drug events.

AIM

To determine the prevalence of PIM use, according to Beers criteria, among an older population (aged ≥65 years) in a large family medicine setting, and to identify the associated risks.

DESIGN & SETTING

A prospective cross-sectional study of patients aged ≥65 years was conducted from June 2017 to June 2018 at the Family and Community Medicine (FCM) clinics of King Saud Medical City (KSMC) in Riyadh, Saudi Arabia.

METHOD

This cross-sectional study included patients aged ≥65 years who were seen at new appointments or followed-up at the FCM clinics of KSMC in Riyadh, Saudi Arabia. Data were collected by extensive face-to-face interviews and from the patients' medical records.

RESULTS

A total of 270 older patients aged 72.41 ±6.23 years (mean ±standard deviation [SD]) were included in the present study. The prevalence of PIMs was 60.7% (n = 164). Multivariate analyses identified three independent variables associated with PIMs: incremental age per 5 years (odds ratio [OR] 1.47, 95% confidence intervals [CI] = 1.15 to 1.88; P = 0.002), female sex (OR 1.95, 95% CI = 1.10 to 3.42; P = 0.021), and polypharmacy (OR 8.21, 95% CI = 4.58 to 14.7; P<0.001). The most common PIMs used were 39.4% related to proton pump inhibitors (PPI), 25.2% to diuretics (other than spironolactone), 10.6% to non-steroidal anti-inflammatory drugs (NSAIDs), and 8.7% to aspirin use.

CONCLUSION

This study showed high prevalence of PIMs. Increasing age, female sex, and polypharmacy were found to be significant risk factors for PIM use. The frequency of morbidities was not significantly different among patients with PIMs compared to those without PIMs, except for hypertension and osteoarthritis, which were more common in the PIMs group. The present study reinforces the importance of comprehensive medication management and reviews.

Symptomatic Events in a Community Palliative Care Population: A Prospective Pilot Study

Background: The palliative care population is prescribed a large number of drugs, increasing as patients deteriorate. The cumulative effects of these medications combined with underlying symptom burden can result in significant morbidity. There is an urgent need to describe possible symptomatic events that could be exacerbated by commonly prescribed drugs in palliative care and their impact. Objectives: To trial the feasibility and acceptability of determining baseline symptomatic event rates for community palliative care patients from which a composite measure of symptomatic events can be developed. Design: This prospective pilot study of patient-reported symptomatic events recruited a convenience cohort of 27 community palliative care patients in a metropolitan specialist palliative care service in Australia. Results: This study has demonstrated a high prevalence rate of symptomatic events (total crude event/participant day rate 0.87) in the study population. Conclusion: Data collection of patient-centered symptomatic events was acceptable and feasible to participants. This pilot supports a fully powered study.

Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Polypharmacy (PP) and potentially inappropriate medications (PIM) are highly prevalent in older adults with cancer. This study systematically reviews the associations of PP and/or PIM with outcomes and, through a meta-analysis, obtains estimates of postoperative outcomes associated with PP in this population.

MATERIALS AND METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Register of Clinical Trials using standardized terms for concepts of PP, PIM, and cancer. Eligible studies included cohort studies, cross-sectional studies, meta-analyses, and clinical trials which examined outcomes associated with PP and/or PIM and included older adults with cancer. A random effects model included studies in which definitions of PP were consistent to examine the association of PP with postoperative complications.

RESULTS

Forty-seven articles met the inclusion criteria. PP was defined as five or more medications in 57% of the studies. Commonly examined outcomes included chemotherapy toxicities, postoperative complications, functional decline, hospitalization, and overall survival. PP was associated with chemotherapy toxicities (4/9 studies), falls (3/3 studies), functional decline (3/3 studies), and overall survival (2/11 studies). A meta-analysis of four studies indicated an association between PP (≥5 medications) and postoperative complications (overall odds ratio, 1.3; 95% confidence interval [1.3-2.8]). PIM was associated with adverse outcomes in 3 of 11 studies.

CONCLUSION

PP is associated with postoperative complications, chemotherapy toxicities, and physical and functional decline. Only three studies showed an association between PIM and outcomes. However, because of inconsistent definitions, heterogeneous populations, and variable study designs, these associations should be further investigated in prospective studies.

IMPLICATIONS FOR PRACTICE

Polypharmacy and potentially inappropriate medications (PIM) are prevalent in older adults with cancer. This systematic review summarizes the associations of polypharmacy and PIM with health outcomes in older patients with cancer. Polypharmacy and PIM have been associated with postoperative complications, frailty, falls, medication nonadherence, chemotherapy toxicity, and mortality. These findings emphasize the prognostic importance of careful medication review and identification of PIM by oncology teams. They also underscore the need to develop and test interventions to address polypharmacy and PIM in older patients with cancer, with the goal of improving outcomes in these patients.

Medication Evaluation in Portuguese Elderly Patients According to Beers, STOPP/START Criteria and EU(7)-PIM List - An Exploratory Study

PURPOSE

The increase in drug prescription for the elderly raises the risk of the occurrence of potentially inappropriate medications (PIMs), thus increasing the incidence of drug-related problems. Likewise, potential prescribing omissions (PPOs) are also highly prevalent in the elderly. This study aimed at assessing the prevalence of PIMs in the elderly by using the EU(7)-PIM list, STOPP criteria version 2 and the Beers criteria version 2015, as well as the prevalence of PPOs by applying the START criteria version 2 in elderly nursing home residents and outpatients of the Eastern Central Region of Portugal.

PATIENTS AND METHODS

A descriptive cross-sectional study was carried out in a sample of 90 Portuguese elderly people. Age, gender, diagnoses and medication history were collected from the patients' clinical records. The prevalence of PIMs and PPOs was measured according to each of the criteria applied.

RESULTS

The patients' ages ranged from 65 to 103 years, with an average age of 84.15 years. In addition, the average number of medications prescribed was 7.6. The STOPP criteria identified 250 PIMs affecting 77 patients (85.5%), the EU(7)-PIM list detected 94 PIMs in 58 patients (64.4%) and the Beers criteria identified 69 PIMs in 51 patients (56.6%). Therefore, the STOPP criteria version 2 identified substantially more PIMs than the other two tools. Furthermore, by applying the START criteria 68 PPOs were detected in 52 patients (57.7%).

CONCLUSION

A high prevalence of PIMs and PPOs was observed, suggesting the need to implement actions aimed at reducing the phenomenon and thus help to improve the quality of care provided in nursing homes. The variations in prevalence with the different tools suggest the need to carefully choose the tool for medication review in the elderly.

Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings

Background

In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing.

Methods

This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill.

Results

In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives.

Conclusions

A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.

Patient Possession of Excess Medication Supply in the VA: A Retrospective Database Study

BACKGROUND

Medication overlap leading to medication excess is a form of therapeutic duplication, itself a type of potentially inappropriate prescribing.

OBJECTIVE

To determine the prevalence of potential medication excess in the Veterans Health Administration (VHA) and identify associated medication-level, patient-level, and system-level factors.

RESEARCH DESIGN

A retrospective database study.

SUBJECTS

All veterans who received ≥1 prescription dispensed by a VHA pharmacy in fiscal year 2014.

MEASURES

The primary outcome of "medication excess" was defined for each patient as the number of excess days' worth of medications for all overlap episodes (concurrently dispensed medications with the same name for >10 d). Predictors included medication-level, patient-level, and system-level factors. Multivariable negative binomial regression analyses estimated the rate ratio of each predictor with medication excess.

RESULTS

Among 4,687,453 veterans, 64% had ≥1 medication overlap episodes. Patients were prescribed a median of 7 [interquartile range (IQR), 3-12] unique medications, had a median of 2 (IQR, 0-5) overlap episodes, and a median of 27 (IQR, 0-96) days of medication excess. In adjusted regression models, factors associated with greater risk of medication excess included having more comorbidities, multiple prescribers, a combination of filling locations (consolidated mail-order pharmacy vs. local pharmacy), and multiple prescription durations (≥90 d vs. less).

CONCLUSIONS

Medication excess was high among VHA users, with nearly two-thirds of patients experiencing at least 1 duplicative medication. As systems such as mail-order pharmacies and 90-day supply are increasingly implemented to reduce costs and improve medication adherence, it is important to recognize the potential for systems-level inefficiencies and potentially inappropriate prescribing.

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review

OBJECTIVES

Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States.

METHODS

PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently.

KEY FINDINGS

Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States.

CONCLUSIONS

Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.

Medication Review and Patient Outcomes in an Orthopedic Department: A Randomized Controlled Study

OBJECTIVE

We investigated the health-related effect of systematic medication review performed by a clinical pharmacist and a clinical pharmacologist on nonelective elderly orthopedic patients.

METHODS

This is a nonblinded randomized controlled study of 108 patients 65 years or older treated with at least 4 drugs. For the intervention, the clinical pharmacist reviewed the participants' medication after completion of the usual medication routine. Information was collected from medical charts, interviews with participants, and database registrations of drug purchase. Results were conferred with the clinical pharmacologist, and recommendations were delivered directly to the ward physicians. The control was usual medication routine, that is, physicians prescribing admitting orders. The primary outcome was time to the first unplanned contact to a physician after discharge (i.e., general practitioner, emergency department visit, or readmission) during 3-month follow-up. Secondary outcomes included other health-related outcomes, for example, length of in-hospital stay, mortality, and quality of life.

RESULTS

Time to the first unplanned contact to a physician was 14.9 days (95% confidence interval, 8.9-21.0) in the intervention group compared with 27.3 days (95% confidence interval, 18.9-35.7) in the controls (P = 0.05). Overall, no statistically significant differences were seen in the secondary outcomes apart from "number of" and "time to first" emergency department visits, which were in favor of the intervention group. A marked hesitation of the ward physicians to comply with recommendations was noted (18%).

CONCLUSIONS

The study showed that the patients receiving usual care had a significantly longer time to the first unplanned contact to a physician after discharge; however, the fact that less than 1 of 5 recommendations was adopted by the physicians raises concerns as to whether this finding could be attributable to the intervention.

Clinical relevance of alerts from a decision support system, PHARAO, for drug safety assessment in the older adults

Background

PHARAO is a decision support system developed to evaluate the risk for a set of either common or serious side-effects resulting from a combination of pharmacodynamic effects from a patient’s medications. The objective of this study was to investigate the validity of the risk scores for the common side-effects generated by PHARAO in older patients.

Methods

Side-effects included were sedation, constipation, orthostatic symptoms, anticholinergic and serotonergic effects. The alerts generated by PHARAO were tested in 745 persons ≥65 years old. Dispensed prescriptions retrieved from the Swedish prescribed drug register were used to generate the pharmacological risk scores of patients’ medications. Symptoms possibly related to side-effects were extracted from medical records data.

Results

The PHARAO system generated 776 alerts, most often for the risk of anticholinergic symptoms. The total specificity estimates of the PHARAO system were 0.95, 0.89 and 0.78 for high, intermediate and low risk alerts, respectively. The corresponding sensitivity estimates were between 0.12 and 0.37. The negative predictive value was 0.90 and the positive predictive value ranged between 0.20–0.25.

Conclusions

The PHARAO system had a high specificity and negative predictive value to detect symptoms possibly associated with the of patients’ medications, while the sensitivity and positive predictive value were low. The PHARAO system has the potential to minimise the risk of over-alerts in combination with a drug-drug interaction alert system, but should be used in connection with a medical evaluation of the patient.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1179-y) contains supplementary material, which is available to authorized users.

Barriers and enablers for deprescribing among older, multimorbid patients with polypharmacy: an explorative study from Switzerland

Background

Polypharmacy is an increasing problem, leading to increased morbidity and mortality, especially in older, multimorbid patients. Consequently, there is a need for reduction of polypharmacy. The aim of this study was to explore attitudes, beliefs, and concerns towards deprescribing among older, multimorbid patients with polypharmacy who chose not to pursue at least one of their GP’s offers to deprescribe.

Methods

Exploratory study using telephone interviews among patients of a cluster-randomized study in Northern Switzerland. The interview included a qualitative part consisting of questions in five pre-defined key areas of attitudes, beliefs, and concerns about deprescribing and an open explorative question. The quantitative part consisted of a rating of pre-defined statements in these areas.

Results

Twenty-two of 87 older, multimorbid patients with polypharmacy, to whom their GP offered a drug change, did not pursue all offers. Nineteen of these 22 were interviewed by telephone. The 19 patients were on average 76.9 (SD 10.0) years old, 74% female, and took 8.9 (SD 2.6) drugs per day. Drugs for acid-related disorders, analgesics and anti-inflammatory drugs were the three most common drug groups where patient involvement and the shared-decision-making (SDM) process led to the joint decision to not pursue the GPs offer. Eighteen of 19 patients fully trusted their GP, 17 of 19 participated in SDM even before this study and 8 of 19 perceived polypharmacy as a substantial burden. Conservatism/inertia and fragmented medical care were the main barriers towards deprescribing. No patient felt devalued as a consequence of the deprescribing offer. Our exploratory findings were supported by patients’ ratings of predefined statements.

Conclusion

We identified patient involvement in deprescribing and coordination of care as key issues for deprescribing among older multimorbid patients with polypharmacy. GPs concerns regarding patients’ devaluation should not prevent them from actively discussing the reduction of drugs.

Trial registration

ISRCTN16560559.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0953-4) contains supplementary material, which is available to authorized users.

Potentially inappropriate medications defined by STOPP criteria in older patients with breast and colorectal cancer

PURPOSE

Screening for potentially inappropriate medications (PIM) is recommended in older patients with cancer receiving chemotherapy, given the concern for adverse drug reactions, drug-drug interactions and non-adherence. Our objective was to determine the impact of PIM on outcomes in patients with breast and colorectal cancers receiving chemotherapy.

METHODS

We used data from the SEER-Medicare database, including patients >/= 66 years old with a diagnosis of Stage II/III breast and colorectal cancer made between 7/1/2007-12/31/2009. We used modified STOPP criteria to define baseline PIM as a dichotomous variable in the 4 months prior to diagnosis. STOPP criteria was used based on its performance as a robust measure of PIM. Outcomes measures included ER visits, hospitalizations, and death within 3 months from the last chemotherapy, and a composite of the three. We used Chi-square or Fisher's exact test to determine associations of PIM with covariates and outcomes, and Cox proportional hazards (PH) model for the time-to-event analysis.

RESULTS

Final analysis included 1,595 patients with breast cancer and 1,528 patients with colorectal cancer. Frequency of baseline PIM by STOPP was 31.5% in the breast and 30.9% in the colorectal cohort. In the breast cohort, associations with the composite outcome in the Cox PH model included disease stage, comorbidity, medication number and baseline ER visits/hospitalization. Age, gender, race, comorbidity and baseline ER visits/hospitalization were associated in the colorectal cohort. PIM was not associated with outcomes in either cohort, aside from hospitalization in the breast.

CONCLUSIONS

We found no consistent association between pre-chemotherapy PIM defined by STOPP and outcomes.

Can screening tools for potentially inappropriate prescriptions in older adults prevent serious adverse drug events?

PURPOSE

The purpose of the study is to identify and explore risk factors of serious adverse drug events (SADE) and SADE-related admissions in acutely hospitalized multimorbid older adults and assess whether these could have been prevented by adherence to the prescription tools Screening Tool of Older Persons' Prescriptions (STOPP) and The Norwegian General Practice (NORGEP) criteria.

METHODS

Cross-sectional study of acutely admitted patients to a medical department in a Norwegian regional hospital. Eligible patients were community-dwelling, receiving home care services, and aged 75+, with ≥ 3 chronic diseases. Medications and information regarding the admission were retrieved from the referral letter and medical records, while an expert panel identified SADE using the Common Terminology Criteria for Adverse Events and SADE-related admissions.

RESULTS

We included 232 patients. Mean (SD) age was 86 (5.7) years, 137 (59%) were female, 121 (52%) used 5-9 drugs whereas 65 (28%) used ≥ 10. We identified SADEs in 72 (31%) of the patients, and in 49 (68%) of these cases, the SADE was considered to cause the hospital admission. A low body mass index (BMI) and a high Cumulative Illness Rating Scale-Geriatrics (CIRS-G) score were independent risk factors for SADEs. Among the SADEs identified, 32 (44%) and 11 (15%) were preventable by adherence to STOPP and NORGEP, respectively.

CONCLUSIONS

We found a high prevalence of SADE leading to hospitalization. Risk factors for SADE were high CIRS-G and low BMI. STOPP identified more SADEs than NORGEP, but adherence to the prescription tools could only to a limited degree prevent SADEs in this patient group.

A systematic review of pharmacist-led medicines review services in New Zealand - is there equity for Māori older adults?

BACKGROUND

Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults.

OBJECTIVE

This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported.

RESULTS

The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori.

CONCLUSION

Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.

Registered nurses' use of computerised decision support in medication reviews

Purpose The purpose of this paper is to explore the implications of registered nurses' (RNs) use of a computerized decision support system (CDSS) in medication reviews. Design/methodology/approach The paper employs a quasi-experimental, one-group pre-test/post-test design with three- and six-month follow-ups subsequent to the introduction of a CDSS. In total, 11 RNs initiated and prepared a total of 54 medication reviews. The outcome measures were the number of drug-related problems (DRPs) as reported by the CDSS and the RNs, respectively, the RNs' views on the CDSS, and changes in the quality of drug treatment. Findings The CDSS significantly indicated more DRPs than the RNs did, such as potential adverse drug reactions (ADRs). The RNs detected additional problems, outside the scope of the CDSS, such as lack of adherence. They considered the CDSS beneficial and wanted to continue using it. Only minor changes were found in the quality of drug treatments, with no significant changes in the drug-specific quality indicators (e.g. inappropriate drugs). However, the use of renally excreted drugs in reduced renal function decreased. Practical implications The RNs' use of a CDSS in medication reviews is of value in detecting potential ADRs and interactions. Yet, in order to have an impact on outcomes in the quality of drug treatment, further measures are needed. These may involve development of inter-professional collaboration, such as established procedures for the implementation of medication reviews, including the use of CDSS. Originality/value This is, to the best of the authors' knowledge, the first study to explore the implications of medication reviews, initiated and prepared by RNs who use a CDSS. The paper adds further insight into the RNs' role in relation to quality of drug treatments.

Building interpretable models for polypharmacy prediction in older chronic patients based on drug prescription records

Background

Multimorbidity presents an increasingly common problem in older population, and is tightly related to polypharmacy, i.e., concurrent use of multiple medications by one individual. Detecting polypharmacy from drug prescription records is not only related to multimorbidity, but can also point at incorrect use of medicines. In this work, we build models for predicting polypharmacy from drug prescription records for newly diagnosed chronic patients. We evaluate the models’ performance with a strong focus on interpretability of the results.

Methods

A centrally collected nationwide dataset of prescription records was used to perform electronic phenotyping of patients for the following two chronic conditions: type 2 diabetes mellitus (T2D) and cardiovascular disease (CVD). In addition, a hospital discharge dataset was linked to the prescription records. A regularized regression model was built for 11 different experimental scenarios on two datasets, and complexity of the model was controlled with a maximum number of dimensions (MND) parameter. Performance and interpretability of the model were evaluated with AUC, AUPRC, calibration plots, and interpretation by a medical doctor.

Results

For the CVD model, AUC and AUPRC values of 0.900 (95% [0.898–0.901]) and 0.640 (0.635–0.645) were reached, respectively, while for the T2D model the values were 0.808 (0.803–0.812) and 0.732 (0.725–0.739). Reducing complexity of the model by 65% and 48% for CVD and T2D, resulted in 3% and 4% lower AUC, and 4% and 5% lower AUPRC values, respectively. Calibration plots for our models showed that we can achieve moderate calibration with reducing the models’ complexity without significant loss of predictive performance.

Discussion

In this study, we found that it is possible to use drug prescription data to build a model for polypharmacy prediction in older population. In addition, the study showed that it is possible to find a balance between good performance and interpretability of the model, and achieve acceptable calibration at the same time.

Factors related to excessive polypharmacy (≥15 medications) in an outpatient population from Colombia

AIMS

To determine the frequency of excessive polypharmacy (≥15 medications) in an outpatient population from Colombia and the variables associated with this condition.

METHODS

A cross-sectional study using a systematised database of 6.2 million affiliates of the Colombian Health System. All patients treated uninterruptedly with 15 or more medications for 3 months (January-March 2017) were included. Sociodemographic, pharmacological, potential drug interactions, and prescribers' variables were identified.

RESULTS

A total of 264 patients with prescriptions of ≥15 medications were identified; with an estimated prevalence of excessive polypharmacy of 108.4 per 100 000 people. The mean age was 67.7 ± 17.8 years and 60.6% were females. The mean number of medications per patient was 20.1 ± 4.5 and 48.9% (n = 129) had 20 or more. The most used were antiulcer medications (89.0%; n = 235), antihypertensives (85.6%; n = 226), analgesic/antipyretic (80.3%; n = 212), psychiatric/neurologic medications (78.5%; n = 207), statins (67.4%; n = 178), acetylsalicylic acid (59.5%; n = 157), and vitamins (57.2%; n = 151). On average, each patient had 21.0 ± 11.4 drug-drug interactions and were attended by 6.2 ± 3.1 physicians. Being treated by seven or more physicians (OR: 5.09; 95% CI: 1.64-15.79) increased the probability of receiving more than 20 medications.

CONCLUSIONS

Drugs for treatment of chronic conditions prevailed, especially in elderly patients with multiple chronic conditions; however, some groups of medications without clear indications, such as antiulcer medications or vitamin supplements, also had extensive use. A main factor that increases the probability of polypharmacy greater than 20 drugs is care by seven or more physicians, which shows a fragmentation in patient care by the country's health system, without achieving co-ordination and integration between the different agents involved in medical care, also influenced by different physicians' practice patterns.

Prescription Changes During Geriatric Care Episodes: A Trend Analysis Conducted in Sweden

BACKGROUND

The number of drugs prescribed for old people has been rising in recent decades. With increasing age and multiple medications, the risk of complications and drug prescription complexity increases. Multiple changes to prescriptions could be a factor that improves treatment quality.

OBJECTIVES

Our objective was to investigate trends in drug prescriptions and factors that contribute to prescription changes. Specific objectives were to find out whether high numbers of prescription changes are significantly correlated with age, sex, comorbidity, length of care episode, and number of drugs.

METHODS

Data were extracted from geriatric clinic records in Stockholm in 2005, 2010, and 2015. Indicators for good drug therapy were used to assess the effects of prescription changes on quality, using an index of inappropriate drug use (IDU). Data were analyzed with Student's t-test, PR test, Wilcoxon's rank sum test, and linear regression.

RESULTS

Patients had more comorbidities and used more drugs but had shorter hospital stays and significantly fewer prescription changes in 2015 than in 2005. Length of care episode was significantly associated with prevalence of prescription changes. Our model showed that, for each day by which the length of care episode decreased, the number of prescription changes decreased by 8%. The number of prescription changes was negatively correlated to the IDU index score.

CONCLUSIONS

The study showed that more prescription changes were associated with longer care episodes and improved drug prescribing quality as per the IDU index. Given prescription changes are regarded as a quality factor in geriatric care, quality may have decreased along with the length of care episodes between 2005 and 2015.

Kidney Function, Polypharmacy, and Potentially Inappropriate Medication Use in a Community-Based Cohort of Older Adults

BACKGROUND

Chronic kidney disease (CKD) afflicts many older adults and increases the risk for medication-related adverse events.

OBJECTIVE

The aim of this study was to assess the prevalence and associated morbidity and mortality of polypharmacy (use of several medications concurrently), and potentially inappropriate medication (PIM) use in older adults, looking for differences by CKD status.

METHODS

We quantified medication and PIM use (from Beers criteria, the Screening Tool of Older People's Prescriptions, and Micromedex®) by level of estimated glomerular filtration rate (eGFR) for participants aged 65 years or older attending a baseline study visit in the Atherosclerosis Risk in Communities study (n =6392). We used zero-inflated negative binomial and Cox proportional hazards regressions to assess the relationship between baseline polypharmacy, PIM use, and subsequent hospitalization and death.

RESULTS

Mean age at baseline was 76 (± 5) years, 59% were female, and 29% had CKD (eGFR < 60 ml/min/1.73 m2). Overall, participants reported 6.1 (± 3.5) medications and 2.3 (± 2.2) vitamins/supplements; 16% reported ≥ 10 medications; 31% reported a PIM based on their age. On average, participants with CKD reported more medications. A PIM based on kidney function was used by 36% of those with eGFR < 30 ml/min/1.73 m2. Over a median of 2.6 years, more concurrent medications were associated with higher risk of hospitalization and death, but PIM use was not. While those with CKD had higher absolute risks, there was no difference in the relative risks associated with greater numbers of medications by CKD status.

CONCLUSION

Polypharmacy and PIM use were common, with greater numbers of medications associated with higher risk of hospitalization and death; relative risks were similar for those with and without CKD.

Community pharmacists' evaluation of potentially inappropriate prescribing in older community-dwelling patients with polypharmacy: observational research based on the GheOP³S tool

Background

In this study, we aimed to (i) determine the prevalence of potentially inappropriate prescribing (PIP) in community-dwelling older polypharmacy patients using the Ghent Older People's Prescriptions community-Pharmacy Screening (GheOP³S) tool, (ii) identify the items that account for the highest proportion of PIP and (iii) identify the patient variables that may influence the occurrence of PIP. Additionally, pharmacist-physician contacts emerging from PIP screening with the GheOP³S tool and feasibility of the GheOP³S tool in daily practice were evaluated.

Methods

A prospective observational study was carried out between December 2013 and July 2014 in 204 community pharmacies in Belgium. Patients were eligible if they were (i) ≥70 years, (ii) community-dwelling, (iii) using ≥5 chronic drugs, (iv) a regular visitor of the pharmacy and (v) understanding Dutch or French. Community pharmacists used a structured interview to obtain demographic data and medication use and subsequently screened for PIP using the GheOP³S tool. A Poisson regression was used to investigate the association between different covariates and the number of PIP.

Results

In 987 (97%) of 1016 included patients, 3721 PIP items were detected (median of 3 per patient; inter quartile range: 2-5). Most frequently involved with PIP are drugs for the central nervous system such as hypnosedatives, antipsychotics and antidepressants. Risk factors for a higher PIP prevalence appeared to be a higher number of drugs (30% extra PIPs per 5 extra drugs), female gender (20% extra PIPs), higher body mass index (BMI, 20% extra PIPs per 10-unit increase in BMI) and poorer functional status (30% extra PIPs with 6-point increase). The feasibility of the GheOP³S tool was acceptable although digitalization of the tool would improve implementation. Despite detecting at least one PIP in 987 patients, only 39 physicians were contacted by the community pharmacists to discuss the items.

Conclusion

A high prevalence of PIP in community-dwelling older polypharmacy patients in Belgium was detected which urges for interventions to reduce PIP.

Potentially inappropriate medication use in older patients with breast and colorectal cancer

BACKGROUND

The objective of this study was to determine patient characteristics associated with potentially inappropriate medication (PIM) use and its impact on outcomes for patients with breast or colorectal cancer receiving adjuvant chemotherapy.

METHODS

The Surveillance, Epidemiology, and End Results database, linked to Medicare claims, was used. The cohort included patients who were 66 years old or older and were diagnosed with stage II or III breast or colorectal cancer between July 1, 2007, and December 31, 2009. The Drugs to Avoid in the Elderly (DAE) list and the Beers criteria were used to identify PIM use. Univariate/multivariate logistic regression determined the association of baseline PIMs with covariates. Event-free survival (EFS) was defined as the time from chemotherapy initiation to the first emergency room (ER) visit, hospitalization, death, or a composite until 3 months after chemotherapy. Cox proportional hazards modeling determined the association of PIMs with EFS.

RESULTS

The analysis included 1595 patients with breast cancer and 1528 patients with colorectal cancer. The baseline PIM frequencies were 22.2% (according to the DAE list) and 27.6% (according to the Beers criteria) in the breast cohort and 15.5% (according to the DAE list) and 24.8% (according to the Beers criteria) in the colorectal cohort. Among patients with breast cancer, 37.5% had at least 1 adverse outcome; associations included the use of ≥5 medications, an advanced stage, higher comorbidity, and prior ER visits/hospitalizations. Baseline PIM use according to the DAE list was associated with an increased risk of death in patients with breast cancer. Among patients with colorectal cancer, 45% had at least 1 adverse outcome, and associations included the use of ≥5 medications, older age, female sex, and higher comorbidity. A time-to-event analysis revealed no association between baseline PIM use and most outcomes.

CONCLUSIONS

These findings require further prospective confirmation, but they support a correlation between polypharmacy and adverse outcomes for cancer patients and call into question the association with PIMs. Cancer 2018;124:3000-7. © 2018 American Cancer Society.

Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria

PURPOSE

Potentially inappropriate medication (PIM) use causes preventable adverse drug reactions in older patients. Several assessment tools have been published to identify and avoid PIM use. In this systematic literature review, we aim to provide summaries and comparisons of validated PIMs lists published between 1991 and 2017 internationally.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA), we performed a systematic review of articles describing the development and validation of criteria for identification of PIMs among older people published between January 1991 and April 2017. The searches were conducted on PUBMED, AgeLine, Academic Search, Academic Search Premier, and CINAHL. We identified the most common medications/classes described as PIM. We also identified the drug-disease interactions and drug-drug interactions reported among criteria.

RESULTS

From 2933 articles screened, 36 met our inclusion criteria. The majority used the Delphi method to validate their criteria. We identified 907 different medications/classes, 536 different drug disease interactions involving 84 diseases/conditions, and 159 drug-drug interactions. Benzodiazepines and nonsteroidal anti-inflammatory drugs were the medications most commonly reported as potentially inappropriate for older people.

CONCLUSION

Although approaches aimed at detecting inappropriate prescribing have intensified in recent years, we observed limited overlap between different PIM lists. Additionally, some PIM lists did not provide special considerations of use and alternative therapies to avoid PIMs. These facts may compromise the use of PIM lists in clinical practice. Future PIM lists should integrate information about alternative therapies and special considerations of use in order to help clinicians in the drug prescription.

Development of eHOME, a Mobile Instrument for Reporting, Monitoring, and Consulting Drug-Related Problems in Home Care: Human-Centered Design Study

Background

Home care patients often use many medications and are prone to drug-related problems (DRPs). For the management of problems related to drug use, home care could add to the multidisciplinary expertise of general practitioners (GPs) and pharmacists. The home care observation of medication-related problems by home care employees (HOME)-instrument is paper-based and assists home care workers in reporting potential DRPs. To facilitate the multiprofessional consultation, a digital report of DRPs from the HOME-instrument and digital monitoring and consulting of DRPs between home care and general practices and pharmacies is desired.

Objective

The objective of this study was to develop an electronic HOME system (eHOME), a mobile version of the HOME-instrument that includes a monitoring and a consulting system for primary care.

Methods

The development phase of the Medical Research Council (MRC) framework was followed in which an iterative human-centered design (HCD) approach was applied. The approach involved a Delphi round for the context of use and user requirements analysis of the digital HOME-instrument and the monitoring and consulting system followed by 2 series of pilots for testing the usability and redesign.

Results

By using an iterative design approach and by involving home care workers, GPs, and pharmacists throughout the process as informants, design partners, and testers, important aspects that were crucial for system realization and user acceptance were revealed. Through the report webpage interface, which includes the adjusted content of the HOME-instrument and added home care practice–based problems, home care workers can digitally report observed DRPs. Furthermore, it was found that the monitoring and consulting webpage interfaces enable digital consultation between home care and general practices and pharmacies. The webpages were considered convenient, clear, easy, and usable.

Conclusions

By employing an HCD approach, the eHOME-instrument was found to be an easy-to-use system. The systematic approach promises a valuable contribution for the future development of digital mobile systems of paper-based tools.

Potentially Inappropriate Antidepressant Prescriptions Among Older Adults in Office-Based Outpatient Settings: National Trends from 2002 to 2012

Using data from 2002 to 2012 National Ambulatory Medical Care Survey, we estimated that the prevalence of overall antidepressant prescriptions increased almost twofold from 5.2% in 2002 to 10.1% in 2012 in office-based outpatient visits made by older adults. In addition, older adults were exposed to the risk of potentially avoidable adverse drug events in approximately one in ten antidepressant-related visits, or 2.2 million visits annually. Amitriptyline and doxepin were the two most frequent disease-independent potentially inappropriate antidepressants. Racial/ethnic minorities, and Medicaid beneficiaries had higher odds of potentially inappropriate antidepressant prescriptions (P < 0.05). Efforts to minimize potentially inappropriate antidepressant prescriptions are needed.

Potential Medication-Related Problems in Older Breast, Colon, and Lung Cancer Patients in the United States

Background: Older adults are often exposed to multiple medications, some of which could be inappropriate or have the potential to interact with each other. Older cancer patients may be at increased risk for medication-related problems due to exposure to cancer-directed treatment.Methods: We described patterns of potentially inappropriate medication (PIM) use and potential drug-chemotherapy interactions among adults age 66+ years diagnosed with stage I-III breast, stage II-III colon, and stage I to II lung cancer. Within the Surveillance, Epidemiology, and End Results-Medicare database, patients had to have Medicare Part D coverage with 1+ prescription in the diagnosis month and Medicare Parts A/B coverage in the prior 12 months. We estimated monthly prevalence of any and cancer-related PIM from 6 months pre- to 23 months postcancer diagnosis and 12-month period prevalence of potential drug-chemotherapy interactions.Results: Overall, 19,318 breast, 7,283 colon, and 7,237 lung cancer patients were evaluated. Monthly PIM prevalence was stable prediagnosis (37%-40%), but increased in the year following a colon or lung cancer diagnosis, and decreased following a breast cancer diagnosis. Changes in PIM prevalence were driven primarily by cancer-related PIM in patients on chemotherapy. Potential drug-chemotherapy interactions were observed in all cohorts, with prevalent interactions involving hydrochlorothiazide, warfarin, and proton-pump inhibitors.Conclusions: There was a high burden of potential medication-related problems among older cancer patients; future research to evaluate outcomes of these exposures is warranted.Impact: Older adults diagnosed with cancer have unique medication management needs. Thus, pharmacy specialists should be integrated into multidisciplinary teams caring for these patients. Cancer Epidemiol Biomarkers Prev; 27(1); 41-49. ©2017 AACR.

The prescription of antiplatelet medication in a very elderly population: An observational study in 15 141 ambulatory subjects

OBJECTIVE

Despite the frequent use of antiplatelet medication (AM) in the elderly patients, very few studies have investigated its prescription. We describe AM prescription through retrospective study in ambulatory elderly patients.

METHOD

All subjects aged over 80 years with a medical prescription delivered in March 2015 and affiliated to the Mutualité Sociale Agricole de Bourgogne. Subjects with prescriptions for AM were compared with those without.

RESULTS

A total of 15 141 ambulatory elderly patients (83-89 years, 61.3% of women) were included and 4412 (29.14%) had a prescription for AM. The latter were more frequently men than those without AM (43% vs 36.93%, P < .0001) and more frequently had chronic comorbidities (77.24% vs 64.65%, P < .0001). Compared with ambulatory subjects without AM, those with AM more frequently had coronary heart disease (35.15% vs 14.49%), severe hypertension (30% vs 25.65%), diabetes (27.42% vs 20.64%), peripheral arterial diseases (16.28% vs 5.96%) and disabling stroke (9% vs 5.56% (all P < .0001). In addition, they had more prescriptions of beta-blockers (45.24% vs 36.90%), angiotensin conversion enzyme inhibitor (31.35% vs 25.44%), calcium channel blockers (33.34% vs 27.90%), nitrate derivatives (10.6% vs 6.03%) or hypolipidemic agents (HA; 49.81% vs 29.72%) (all P < .0001) than those without AM.

CONCLUSION

In this study, which is very interested for its size and the advanced age of the subjects, long-course AM was prescribed in one third of ambulatory elderly patients. Coronary heart disease, severe hypertension and diabetes were more frequent in AM subjects. However, the low percentage of declared strokes was surprising. We provide additional data to doctors following subjects with AM.

[Impact of medium-term outcomes of inappropriate prescribing in older patients discharged from a short stay unit]

Objetivo

Estudiar la asociación entre prescripciones potencialmente inapropiadas (PPI) y eventos adversos a los 30 y 180 días tras el alta de una unidad de corta estancia (UCE).

Material y método

Estudio analítico observacional de cohortes retrospectivo que incluyó pacientes ≥ 75 años al alta de una UCE. Se utilizó la versión 2 de los criterios STOPP-START. La variable resultado fue la presencia de algún evento adverso a 30 y 180 días.

Resultados

Se incluyeron 179 pacientes con una media de 84 (DE: 5) años. La presencia de ≥ 1PPI al alta no se asoció con la aparición de algún evento adverso a los 30 ni a los 180 días de manera global. La presencia de ≥ 1PPI al alta de fármacos del proceso cardiovascular tuvo mayor riesgo de presentar algún evento adverso a los 30 días del alta (OR ajustada 2,1; IC 95%: 1,0-3,2; p = 0,045), los fármacos del proceso «neuropsiquiátrico y riesgo de caídas» se relacionaron con deterioro funcional a los 30 días del alta (OR ajustada 6,3; IC 95%: 1,7-22,5; p = 0,005), y la omisión de fármacos del sistema cardiovascular se asoció con el reingreso a los 180 días (OR ajustada 3,6; IC 95%: 1,5-8,3, p = 0,003).

Conclusiones

La presencia de eventos adversos de pacientes ancianos dados de alta de una UCE podría relacionarse con PPI detectadas por algunos criterios STOPP-START, y concretamente con los fármacos de los procesos cardiovasculares, neuropsiquiátrico y relacionado con las caídas.