Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy: results of application to case histories by general practitioners

Potentially Inappropriate Psychotropic Drugs in Nursing Homes: An Italian Observational Study

BACKGROUND AND OBJECTIVES

Physicians often face difficulties in selecting appropriate medications for older adults with multiple comorbidities. As people age, they are more likely to be living with a number of chronic conditions (multimorbidity) and be prescribed a high number of medications (polypharmacy). Multimorbidity is frequent in nursing home (NH) residents and the use of potentially inappropriate medications, especially psychotropic drugs, is widespread. This retrospective cross-sectional cohort study examined the frequency of potentially inappropriate psychotropic drugs using the Beers, Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) and Fit fOR The Aged (FORTA) criteria, and their association with mortality.

METHODS

This retrospective cross-sectional cohort study was conducted on a sample of long-term care NHs across Italy. Of the 34 NHs with an electronic medical records system, 27 met the inclusion criteria, with complete web-based case report forms (CRFs). Residents under the age of 65 years were excluded. We calculated the prevalence of potentially inappropriate psychotropics drugs (antipsychotics, antidepressants and anxiolytics/hypnotics) according to three criteria for prescriptive appropriateness. Univariate and multivariate correlations were examined, taking into account age, sex, comorbidities, and the number of psychotropic drugs, to analyse the relationship between inappropriate psychotropic use and mortality rates. The rate of inappropriate psychotropic prescriptions was calculated with the prevalence of residents receiving potentially inappropriate psychotropic drugs according to the three criteria. We used a logistic model to check for a possible predictive relationship between inappropriate use of psychotropics and mortality. The study evaluated differences in prescriptive appropriateness among NHs by analysing the proportions of potentially inappropriately treated residents at the last visit. Differences were compared with the overall sample mean using confidence intervals (CIs) calculated using Wald's method.

RESULTS

This study involved 2555 residents, of whom 1908 (74.7% of the total) were treated with psychotropic drugs; 186 (7.3% of the total) were exposed to at least one psychotropic drug considered potentially inappropriate according to the FORTA criteria. Analysis using the Beers criteria showed that 1616 residents (63.2% of the total) received at least one psychotropic drug considered potentially inappropriate. In line with the Beers recommendation, patients receiving at least three psychotropic drugs were also included and 440 were identified (17.2% of the total sample). According to the STOPP criteria, 1451 residents (56.8% of the total sample) were prescribed potentially inappropriate psychotropic drugs. No correlation was found between potentially inappropriate use of psychotropic drugs and mortality, in either univariate analysis or in a multivariate model adjusted for age, sex and comorbidity index.

CONCLUSIONS

Different criteria for appropriate drug prescription identify very different percentages of patients in NHs exposed to psychotropics considered potentially inappropriate. The Beers and STOPP/START criteria identified a larger percentage of patients exposed in NHs than FORTA.

An inter-professional student-run medication review programme. Reducing adverse drug reactions in a memory outpatient clinic: a controlled clinical trial

BACKGROUND

We investigated if the addition of an inter-professional student-led medication review team (ISP-team) to standard care can increase the number of detected ADRs and reduce the number of ADRs 3 months after an outpatient visit.

RESEARCH DESIGN AND METHODS

In this controlled clinical trial, patients were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The ISP team consisted of medical and pharmacy students and student nurse practitioners. The team performed a structured medication review and adjusted medication to reduce the number of ADRs. Three months after the outpatient visit, a clinical pharmacologist who was blinded for allocation performed a follow-up telephone interview to determine whether patients experienced ADRs.

RESULTS

During the outpatient clinic visit, significantly more (p < 0.001) ADRs were detected in the intervention group (n = 48) than in the control group (n = 10). In both groups, 60-63% of all detected ADRs were managed. Three months after the outpatient visit, significantly fewer (predominantly mild and moderately severe) ADRs related to benzodiazepine derivatives and antihypertensive causing dizziness were detected in the patients of the intervention group.

CONCLUSIONS

An ISP team in addition to standard care increases the detection and management of ADRs in elderly patients resulting in fewer mild and moderately severe ADRs.

Medication use problems among older adults at a primary care: A narrative of literature review

Appropriate medication use is one of the most significant challenges among the older population. Although medication use problems are well documented at the secondary and tertiary health care level, the evidence at the primary care level of OECD region is limited. A narrative review of existing literature was conducted through a nonsystematic search for original articles through electronic search databases, Ovid Medline, Google Scholar from 2001 to 2021, and a combination of citation references. Medication use problems are prevalent in older adults at the primary care level. The main issues of medication use identified were as follows; nonadherence, adverse drug events, accessibility, polypharmacy, inappropriate medications, belief about medications, lack of knowledge and awareness, and lack of deprescribing. In addition, the current review has identified the possibilities of the problems: many medications, forgetfulness, lack of deprescribing, lack of communication, poor understanding, and limited awareness of inappropriate medications. This review found that various medication use problems subclusters were identified to impact the health care need among older adults. Therefore, effective interventions targeting these issues need to be developed to reduce medication use problems among older adults at a primary care level.

Balancing Vision With Pragmatism: The Geriatric Emergency Department Guidelines-Realistic Expectations From Emergency Medicine and Geriatric Medicine

BACKGROUND

In 2014, the Geriatric Emergency Department (GED) Guidelines were published and endorsed by four major medical organizations. The multidisciplinary GED Guidelines characterized the complex needs of the older emergency department (ED) patient and current best practices, with the goal of promoting more cost-effective and patient-centered care. The recommendations are extensive and most EDs then and now have neither the resources nor the hospital administrative support to provide this additional service.

DISCUSSION

At the 2021 American Academy of Emergency Medicine's Scientific Assembly, a panel of emergency physicians and geriatricians discussed the GED Guidelines and the current realities of EDs' capacity to provide best practice and guideline-recommended care of GED patients. This article is a synthesis of the panel's presentation and discussion. With the substantial challenges in providing guideline-recommended care in EDs, this article will explore three high-impact GED clinical conditions to highlight guideline recommendations, challenges, and opportunities, and discuss realistically achievable expectations for non-GED-accredited institutions.

CONCLUSIONS

In 2014, the GED Guidelines were published, describing the current best practices for GED patients. Unfortunately, most of the EDs worldwide do not provide the level of service recommended by the GED Guidelines. The GED Guidelines can best be termed aspirational for U.S. EDs at the present time.

Polypharmacy Management in the Older Adults: A Scoping Review of Available Interventions

Background: Polypharmacy paves the way for non-adherence, adverse drug reactions, negative health outcomes, increased use of healthcare services and rising costs. Since it is most prevalent in the older adults, there is an urgent need for introducing effective strategies to prevent and manage the problem in this age group.

Purpose: To perform a scoping review critically analysing the available literature referring to the issue of polypharmacy management in the older adults and provide narrative summary.

Data sources: Articles published between January 2010–March 2018 indexed in CINHAL, EMBASE and PubMed addressing polypharmacy management in the older adults.

Results: Our search identified 49 papers. Among the identified interventions, the most often recommended ones involved various types of drug reviews based on either implicit or explicit criteria. Implicit criteria-based approaches are used infrequently due to their subjectivity, and limited implementability. Most of the publications advocate the use of explicit criteria, such as e.g. STOPP/START, Beers and Medication Appropriateness Index (MAI). However, their applicability is also limited due to long lists of potentially inappropriate medications covered. To overcome this obstacle, such instruments are often embedded in computerised clinical decision support systems.

Conclusion: Multiple approaches towards polypharmacy management are advised in current literature. They vary in terms of their complexity, applicability and usability, and no “gold standard” is identifiable. For practical reasons, explicit criteria-based drug reviews seem to be advisable. Having in mind that in general, polypharmacy management in the older adults is underused, both individual stakeholders, as well as policymakers should strengthen their efforts to promote these activities more strongly.

Optimising prescribing practices in older adults with multimorbidity: a scoping review of guidelines

OBJECTIVE

Inappropriate polypharmacy occurs when multiple medications are prescribed without clear indications or where harms outweigh their benefits. The aims of this scoping review are to (1) identify prescribing guidelines that are available for older adults with multimorbidity and (2) to identify cross-cutting themes used in these guidelines.

DESIGN

Scoping review.

DATA SOURCES

PubMed, Embase, Web of Science, the Cochrane Library databases, Cumulative Index to Nursing and Allied Health Literature, grey literature sources, six key geriatrics journals, and reference lists of identified review papers. The search was conducted in November 2018 and updated in September 2019.

STUDY SELECTION

General prescribing guidelines tailored to or for adults including older adults with multimorbidity.

DATA EXTRACTION

Data for publication description, guideline characteristics, information for users and criteria were extracted. The synthesis contains summarised qualitative descriptions of the studies and guideline characteristics as well as identified cross-cutting themes.

RESULTS

Our search strategy yielded 10 427 unique citations, of which 70 fulfilled the inclusion criteria for synthesis. Among these, there were 61 unique guidelines and tools which used implicit, explicit, mixed or other approaches in the prescriber decision-making process. There are 11 cross-cutting themes identified in the guidelines. Prescriber-related themes are: conduct a comprehensive assessment before prescribing, identify patients' needs, goals and priorities, adopt shared decision-making, consider evidence-based recommendations, use clinical prescribing tools, incorporate multidisciplinary inputs and embrace technology-enabled prescribing. Wider organisation-related and system-related themes related to education, training and the work environment are also identified.

CONCLUSIONS

From guidelines and tools identified, eleven cross-cutting themes provide a usable knowledge base when seeking to optimise prescribing among older adults with multimorbidity. Incorporating these themes in an approach that uses mixed criteria and implementation information could facilitate greater uptake of published prescribing recommendations.

An Interprofessional Student-Run Medication Review Program: The Clinical STOPP/START-Based Outcomes of a Controlled Clinical Trial in a Geriatric Outpatient Clinic

As the population ages, more people will have comorbid disorders and polypharmacy. Medication should be reviewed regularly in order to avoid adverse drug reactions and medication‐related hospital visits, but this is often not done. As part of our student‐run clinic project, we investigated whether an interprofessional student‐run medication review program (ISP) added to standard care at a geriatric outpatient clinic leads to better prescribing. In this controlled clinical trial, patients visiting a memory outpatient clinic were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The medications of all patients were reviewed by a review panel (“gold standard”), resident, and in the intervention arm also by an ISP team consisting of a group of students from the medicine and pharmacy faculties and students from the higher education school of nursing for advanced nursing practice. For both groups, the number of STOPP/START‐based medication changes mentioned in general practitioner (GP) correspondence and the implementation of these changes about 6 weeks after the outpatient visit were investigated. The data of 216 patients were analyzed (control group = 100, intervention group = 116). More recommendations for STOPP/START‐based medication changes were made in the GP correspondence in the intervention group than in the control group (43% vs. 24%, P = < 0.001). After 6 weeks, a significantly higher proportion of these changes were implemented in the intervention group (19% vs. 9%, P = 0.001). The ISP team, in addition to standard care, is an effective intervention for optimizing pharmacotherapy and medication safety in a geriatric outpatient clinic.

Use of antithrombotics at the end of life: an in-depth chart review study

Background

Antithrombotics are frequently prescribed for patients with a limited life expectancy. In the last phase of life, when treatment is primarily focused on optimizing patients’ quality of life, the use of antithrombotics should be reconsidered.

Methods

We performed a secondary analysis of a retrospective review of 180 medical records of patients who had died of a malignant or non-malignant disease, at home, in a hospice or in a hospital, in the Netherlands. All medication prescriptions and clinical notes of patients using antithrombotics in the last three months of life were reviewed manually. We subsequently developed case vignettes based on a purposive sample, with variation in setting, age, gender, type of medication, and underlying disease.

Results

In total 60% (n=108) of patients had used antithrombotics in the last three months of life. Of all patients using antithrombotics 33.3 % died at home, 21.3 % in a hospice and 45.4 % in a hospital. In total, 157 antithrombotic prescriptions were registered; 30 prescriptions of vitamin K antagonists, 60 of heparins, and 66 of platelet aggregation inhibitors. Of 51 patients using heparins, 32 only received a prophylactic dose. In 75.9 % of patients antithrombotics were continued until the last week before death. Case vignettes suggest that inability to swallow, bleeding complications or the dying phase were important factors in making decisions about the use of antithrombotics.

Conclusions

Antithrombotics in patients with a life limiting disease are often continued until shortly before death. Clinical guidance may support physicians to reconsider (dis)continuation of antithrombotics and discuss this with the patient.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00786-3.

REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors (REMEDI[e]S): French implicit and explicit criteria

PURPOSE

To establish a consensus on both explicit and implicit criteria in order to identify potentially inappropriate prescribing (PIP) in French older people aged 75 years and over or 65 years and over with multimorbidity.

METHODS

Fifteen experts in geriatrics, general practice, pharmacy, and clinical pharmacology were involved in a two-round Delphi survey to assess preliminary explicit and implicit criteria based on an extensive literature review and up-to-date evidence data. Experts were asked to rate their level of agreement using a 5-level Likert scale for inclusion of criteria and also for rationale and therapeutic alternatives. A consensus was considered as reached if at least 75% of the experts rated criteria as "strongly agreed" or "agreed."

RESULTS

The new tool included a seven-step algorithm (implicit criteria) encompassing the three main domains that define PIP (i.e. overprescribing, underprescribing, and misprescribing) and 104 explicit criteria. Explicit criteria were divided into 6 tables related to inappropriate drug duplications (n = 7 criteria), omissions of medications and/or medication associations (n = 16), medications with an unfavourable benefit/risk ratio and/or a questionable efficacy (n = 39), medications with an unsuitable dose (n = 4) or duration (n = 6), drug-disease (n = 13), and drug-drug interactions (n = 19).

CONCLUSION

The REMEDI[e]S tool (REview of potentially inappropriate MEDIcation pr[e]scribing in Seniors) is an original mixed tool, adapted to French medical practices, aimed at preventing PIP both at the individual level in clinical practice and the population level in large-scale studies. Therefore, its use could contribute to an improvement in healthcare professionals' prescribing practices and safer care in older adults.

Impact of Medication Reviews Delivered by Community Pharmacist to Elderly Patients on Polypharmacy: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of the study was to assess the impact of medication reviews delivered by community pharmacists to elderly patients on polypharmacy.

METHODS

A systematic literature search was performed in four bibliographic databases/search engine (PubMed, Embase, CENTRAL, and IPA) and three gray literature sources (OpenGrey, ClinicalTrials.gov, and Digital Access to Research Theses - Europe) from inception to January 2018. Randomized controlled trials were selected if they met the following criteria: (a) studied in patients 65 years or older who were taking four or more prescribed medications; (b) the "test" interventions were delivered by community pharmacists; and (c) measured one of these following outcomes: hospitalization, emergency department (ED) visit, quality of life, or adherence. Quality of the included studies was assessed using the Cochrane Effective Practice and Organization of Care Group risk of bias tool. Random-effects model meta-analyses were performed.

RESULTS

Of the 3634 articles screened, four studies with a total of 4633 participants were included. The intervention provided in all included studies was clinical medication review. Three studies were at low risk of bias, and the remaining study had unclear risk of bias. When compared with usual care, medication reviews provided by community pharmacist significantly reduced risk of ED visits (risk ratio = 0.68; 95% confidence interval = 0.48-0.96). There was also a tendency that pharmacist interventions decreased risk of hospitalizations (risk ratio = 0.88; 95% CI = 0.78-1.00), although no statistical significant.

CONCLUSIONS

The current evidence demonstrates that clinical medication reviews for older people with polypharmacy reduces the risk of ED visits. Medication reviews can be considered as another area where community pharmacists can contribute to improve patient safety.

The clinical and educational outcomes of an inter-professional student-led medication review team, a pilot study

Aims

The involvement of an inter-professional healthcare student team in the review of medications used by geriatric patients could not only provide patients with optimized therapy but also provide students with a valuable inter-professional learning experience. We describe and evaluate the clinical and learning outcomes of an inter-professional student-run mediation review program (ISP).

Subject and method

A variable team consisting of students in medicine, pharmacy, master advanced nursing practice, and master physician assistant reviewed the medication lists of patients attending a specialized geriatric outpatient clinic.

Results

During 32 outpatient visits, 188 medications were reviewed. The students identified 14 medication-related problems, of which 4 were not recognized by healthcare professionals. The ISP team advised 95 medication changes, of which 68 (71.6%) were directly implemented. Students evaluated this pilot program positively and considered it educational (median score 4 out of 5) and thought it would contribute to their future inter-professional relationships.

Conclusion

An inter-professional team of healthcare students is an innovative healthcare improvement for (academic) hospitals to increase medication safety. Most formulated advices were directly incorporated in daily practice and could prevent future medication-related harm. The ISP also offers students a first opportunity to work in an inter-professional manner and get insight into the perspectives and qualities of their future colleagues.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02972-3) contains supplementary material, which is available to authorized users.

Generic instruments for drug discontinuation in primary care: A systematic review

Aims

The aim of this systematic review was to identify generic instruments for drug discontinuation in patients with polypharmacy in the primary care setting.

Methods

We systematically searched PubMed and EMBASE, 8 guideline databases (AWMF, NICE, NGC, SIGN, NHMRC, CPG, KCE), the Cochrane Library and grey literature (Google) in 2016 and 2017. Two independent researchers screened and analysed data. The drug discontinuation instruments of the included publications were described and classified.

Results

We identified 16 relevant publications. Here we found complex algorithms as well as instruments composed of distinct sequential steps. Two guidelines are constructed as electronic web‐applications. Instruments revealed diverging emphases on the stages of deprescribing, i.e. preparation, drug evaluation, decision‐making and implementation. Accordingly, 3 types of instruments emerged: general frameworks, detailed drug assessment tools and comprehensive discontinuation guidelines.

Conclusion

Diverse generic instruments exist for different areas of applications in regard to drug discontinuation. However, there is still a need for practical and user‐friendly tools that support physicians in communicational aspects, visualise trade‐offs and also enhance patient involvement.

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system

BACKGROUND

Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm.

METHOD

This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention.

DISCUSSION

The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019.

TRIAL REGISTRATION

Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).

Polypharmacy Is Associated With Accelerated Deterioration of Renal Function in Cardiovascular Outpatients

Background

Polypharmacy is associated with poor prognosis of patients with various diseases. However, it has not been precisely addressed how polypharmacy affects the clinical characteristics of the cardiovascular outpatients. The aim of this study is to search for the clinical characteristics related to the number of prescribed drugs in the cardiovascular outpatients. Also, we examine whether the number of the prescribed drugs affects the worsening of renal function.

Methods

This retrospective study was conducted using the data of 259 continuous cardiovascular outpatients who were examined complete blood count (CBC) and serum creatinine.

Results

In the univariate analysis, the number of prescribed drugs were associated with the number of cardiovascular diseases or their risk factors, age, white blood cells, platelet, body mass index, anemia, and chronic kidney disease stage 3b or higher. In the multivariable analysis, independent variables that significantly correlated with the number of prescribed drugs were the number of cardiovascular diseases or their risk factors, anemia, and chronic kidney disease stage 3b or higher. Among 259 patients, 208 patients received follow-up examination of serum creatinine. The number of prescribed drugs was the only factor that was associated with accelerated deterioration of renal function.

Conclusions

Polypharmacy is associated not only with poor renal function but with accelerated deterioration of renal function. Polypharmacy may be causally related with renal dysfunction.

International Group for Reducing Inappropriate Medication Use & Polypharmacy (IGRIMUP): Position Statement and 10 Recommendations for Action

Globally, the number of drug prescriptions is increasing causing more adverse drug events, which is now a significant cause of mortality, morbidity, and disability that has reached epidemic proportions. The risk of adverse drug events is correlated to very old age, multiple co-morbidities, dementia, frailty, and limited life expectancy, with the major contributor being polypharmacy. Each characteristic alters the risk-benefit balance of medications, typically reducing anticipated benefits and amplifying risk. Current clinical guidelines are based on evidence proven in younger/healthier adult populations using a single disease model and their application to older adults with multimorbidity, in whom testing has not been conducted, yields a different risk-benefit prospect and makes inappropriate medication use and polypharmacy inevitable. Applying inappropriate clinical practice guidelines to older adults is antithetical to good healthcare, is likely to increase health inequity, and is associated with substantial negative clinical, economic, and social implications for health systems. The casualties are on the scale of a war or epidemic, yet are usually invisible in measures of healthcare quality and formal recommendations. Radical and rapid action is required to achieve a better quality of life for older populations and to remain true to the principles of medical professionalism and evidence-based medicine that place patients' interests and autonomy at the fore. This first International Group for Reducing Inappropriate Medication Use & Polypharmacy position statement briefly details the causes, consequences, and extent of inappropriate medication use and polypharmacy. This article outlines current strategies to reduce inappropriate medication use, provides evidence for their effect, and then proposes recommendations for moving forward with 10 recommendations for action and 12 recommendations for research. We conclude that an urgent integrated effort to reduce inappropriate medication use and polypharmacy should be a leading global target of the highest priority. The cornerstone of this position statement from the International Group for Reducing Inappropriate Medication Use & Polypharmacy is the understanding that without evidence of definite relevant benefit, when it comes to prescribing, for many older patients 'less is more'. This approach differs from most other current recommendations and guidance in medical care, as the focus is on what, when, and how to stop, rather than on when to start medications/interventions. Disrupting the framework that indiscriminately applies standard guidelines to older adults requires a new approach that better serves patients with multimorbidity. This transition requires a shift in medical education, research, and diagnostic frameworks, and re-examination of the measures used as quality indicators. In achieving this objective, we promote a return to some of the original concepts of evidence-based medicine: which considers scientific data (where it exists), clinical judgment, patient/family preference, and context. A shift is needed: from the current model that focuses on single conditions to one that simultaneously considers multiple conditions and patient priorities. This approach reframes the clinician's role as a professional providing care, rather than a disease technician.

Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies

Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.

Combating Polypharmacy Through Deprescribing Potentially Inappropriate Medications

Polypharmacy, defined as the use of five or more medications, is becoming increasingly prevalent in older adults throughout the United States. Depre-scribing, along with the use of existing tools, such as the American Geriatrics Society Beers Criteria, can help guide health care providers in reducing the risks associated with polypharmacy such as side effects and drug interactions. The framework of deprescribing and the use of existing guidelines and resources are valuable in guiding health care providers in addressing polypharmacy. [Journal of Gerontological Nursing, 45(1), 9-15.].

Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT

BACKGROUND

Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.

METHODS

The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.

DISCUSSION

So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.

TRIAL REGISTRATION

ISRCTN, ISRCTN18427377 . Registered 11 January 2018.

Tools for Assessment of the Appropriateness of Prescribing and Association with Patient-Related Outcomes: A Systematic Review

BACKGROUND

There are tools and criteria in the literature aimed at distinguishing between appropriate and inappropriate medicines use. However, many have not been externally validated with regard to patient-related outcomes, potentially limiting their use in clinical practice.

OBJECTIVES

The aim of the study was to conduct a systematic review to summarise (1) available prescribing appropriateness assessment tools and criteria, and (2) their associations with patient-related outcomes (external validity).

METHODS

A systematic review was conducted using MEDLINE, EMBASE and Informit (Health Collection) databases to screen for articles in English that examined (1) tools to assess the appropriateness of prescribing and (2) associations of tools with patient-related outcomes, published between 2000 and 2016, without any limits placed on the study design, participant age or setting.

RESULTS

After screening 1710 articles, removing duplicates and shortlisting relevant articles, 42 prescribing assessment tools were identified. Out of the 42 tools, 78.6% (n = 33) provided guidance around stopping inappropriate medications, 28.6% (n = 12) around starting appropriate medications, 61.9% (n = 26) were explicit (criteria based) and 31.0% (n = 13) had been externally validated, with hospitalisation being the most commonly used patient-related outcome (n = 9, 21.4%).

CONCLUSION

The results of this systematic review highlight the need for evidence-based and externally validated tools, which combine the different aspects of medication management to optimise patient-related outcomes. PROSPERO registration number: CRD42017067233.

Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study

BACKGROUND

Polypharmacy is an increasing challenge for primary care. Although sometimes clinically justified, polypharmacy can be inappropriate, leading to undesirable outcomes. Optimising care for polypharmacy necessitates effective targeting and monitoring of interventions. This requires a valid, reliable measure of polypharmacy, relevant for all patients, that considers clinical appropriateness and generic prescribing issues applicable across all medications. Whilst there are several existing measures of potentially inappropriate prescribing, these are not specifically designed with polypharmacy in mind, can require extensive clinical input to complete, and often cover a limited number of drugs. The aim of this study was to identify what experts consider to be the key elements of a measure of prescribing appropriateness in the context of polypharmacy.

METHODS

Firstly, we conducted a systematic review to identify generic (not drug specific) prescribing indicators relevant to polypharmacy appropriateness. Indicators were subject to content analysis to enable categorisation. Secondly, we convened a panel of 10 clinical experts to review the identified indicators and assess their relative clinical importance. For each indicator category, a brief evidence summary was developed, based on relevant clinical and indicator literature, clinical guidance, and opinions obtained from a separate patient discussion panel. A two-stage RAND/UCLA Appropriateness Method was used to reach consensus amongst the panel on a core set of indicators of polypharmacy appropriateness.

RESULTS

We identified 20,879 papers for title/abstract screening, obtaining 273 full papers. We extracted 189 generic indicators, and presented 160 to the panel grouped into 18 classifications (e.g. adherence, dosage, clinical efficacy). After two stages, during which the panel introduced 18 additional indicators, there was consensus that 134 indicators were of clinical importance. Following the application of decision rules and further panel consultation, 12 indicators were placed into the final selection. Panel members particularly valued indicators concerned with adverse drug reactions, contraindications, drug-drug interactions, and the conduct of medication reviews.

CONCLUSIONS

We have identified a set of 12 indicators of clinical importance considered relevant to polypharmacy appropriateness. Use of these indicators in clinical practice and informatics systems is dependent on their operationalisation and their utility (e.g. risk stratification, targeting and monitoring polypharmacy interventions) requires subsequent evaluation.

TRIAL REGISTRATION

Registration number: PROSPERO ( CRD42016049176 ).

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes.

The Effectiveness of a PRoactive Multicomponent Intervention Program on Disability in Independently Living Older People: A Randomized Controlled Trial

BACKGROUND

There is an increase in functional limitations and a decline in physical and mental well-being with age. Very few effective lifestyle interventions are available to prevent adverse outcomes such as disability in (pre-) frail older people. The effectiveness of an interdisciplinary multicomponent intervention program to prevent disability in older people in the community was tested.

METHOD

A randomized controlled trial (RCT) with a one-year follow-up was conducted in the Netherlands. Community-dwelling pre-frail older people aged 65 years and over were invited to participate. Frailty was measured with the Groningen Frailty Indicator (GFI) and categorized into non-frail (GFI=0), pre-frail (GFI = 1-3) and frail (GFI ≥ 4). The intervention program consisted of four components: a medication review, physical fitness, social skills, and nutrition.

OUTCOMES

The primary outcome was activity of daily living (ADL) measured with the Katz-6. Secondary outcomes were quality of life (SF-12) and healthcare consumption such as hospital admission, nursing home admission and primary care visits. Additional outcomes measured in the intervention group were physical fitness, Instrumental Activities of Daily Living (IADL), muscle strength, walking speed, functional capacity, mobility, feelings of depression and loneliness and nutritional status. The data were collected at baseline, after each intervention component and at a 12-month follow-up. An intention to treat analysis was used.

RESULTS

In total, there were 290 participants, and 217 (74.8%) completed the study. The mean age was 74 (SD: 7.2), most were pre-frail (59.9%), the majority were female (55.2%), and the individuals were not living alone (61.4%). After the 12-month follow-up, the median Katz-6 score did not change significantly between the two groups; adjusted Odds Ratio (OR) = 0.96 (95% Confidence Interval (CI): 0.39-2.35, p-value 0.92). No statistically significant differences were observed between the groups for quality of life and healthcare consumption. Among the participants in the intervention group, IADL (Friedman's test p <=0.04, X2 =6.50), walking speed (Friedman's test p <0.001, X2 =19.09) and functional capacity (Friedman's test p <0.001, X2 =33.29) improved significantly after the one-year follow-up. Right-hand grip strength improved immediately after completion of the intervention (Wilcoxon signed-rank test p=0.00, z= -3.39) but not after the 12-month follow-up.

CONCLUSION

The intervention program did not significantly improve daily functioning, quality of life and healthcare consumption among (pre) frail community-dwelling older persons at the one-year follow-up. Participants in the intervention group experienced improvements in walking speed, functional capacity and instrumental activities of daily living. More research is needed to better understand why may benefit and how to identify the target population.

Geriatric Basics for the Neurohospitalist

Due to the increasing age of the population, neurohospitalists are more frequently caring for old and very old people. Fundamental definitions and topics related to geriatric medicine are therefore of particular importance. In this review, common issues encountered in geriatric patients hospitalized on the neurology service are discussed. Focus is put on the geriatric assessment, multiprofessional diagnostic and therapeutic procedures, geriatric syndromes, pharmacotherapy of the aged, delirium, pain, and palliative management as they are relevant for the neurohospitalist. In addition, ethical questions are addressed.

Prevalence of potentially serious drug-drug interactions among South African elderly private health sector patients using the Mimica Matanović/Vlahović-Palčevski protocol

OBJECTIVES

To determine the prevalence of potentially serious drug-drug interactions (DDIs) and their relationship with gender and age, among elderly in South Africa.

METHODS

A cross-sectional study was conducted using pharmaceutical claims data for 2013, for a total of 103 420 medical scheme beneficiaries' ≥65 years. All medications dispensed within one calendar month where the days' supply of medication dispensed overlapped, were grouped as one prescription. DDIs per prescription were then identified using the Mimica Matanović/Vlahović-Palčevski DDI protocol. Results were interpreted using effect sizes, that is Cramér's V, Cohen's d and Cohen's ƒ² .

KEY FINDINGS

A total of 331 659 DDIs were identified on 235 870 (25.8%, N = 912 713) prescriptions (mean 0.36 (SD 0.7) (95% CI, 0.36 to 0.37)). Women encountered 63.5% of all DDIs. Effect sizes for the association between DDIs and age group (Cramér's V = 0.06), and gender (Cramér's V = 0.05) was negligible. There was no difference between men and women regarding the mean number of DDIs identified per prescription (Cohen's d = 0.10). The number of medicine per prescription (ƒ² = 0.51) was the biggest predictor of the DDIs. The most frequent interacting drug combinations were between central nervous system medicines (30.6%).

CONCLUSION

Our study is the first to report the prevalence of potentially serious DDIs among an elderly population in the South African private health sector utilising the Mimica Matanović/Vlahović-Palčevski DDI protocol. Overall, we identified DDIs in approximately 26% of the prescriptions in our study. Age and gender were not found to be predictors of potentially serious DDIs.

Polypharmacy Reduction Strategies: Tips on Incorporating American Geriatrics Society Beers and Screening Tool of Older People's Prescriptions Criteria

There is no single definition of polypharmacy. Use of 5 or more medications commonly is used. An alternative, quantitative definition, such as use of more medications than clinically indicated or use of unnecessary or harmful prescribing, has been proposed. Protocols or algorithms to improve polypharmacy and prescribing in older adults have been developed. The American Geriatrics Society (AGS) Beers Criteria and Screening Tool of Older People's Prescriptions (STOPP) explicit criteria reflect elements that are common across protocols and algorithms. Concepts in AGS Beers and STOPP can be incorporated into polypharmacy reduction strategies to improve outcomes of care for older adults.

Review of structured guides for deprescribing

Avoiding inappropriate polypharmacy has become increasingly recognised as a safety imperative for older patient care. Deprescribing is an active process of reviewing all medications being used by individual patients that prompts clinicians to consider which medications have unfavourable risk-benefit trade-offs in the context of illness severity, advanced age, multi-morbidity, physical and emotional capacity, life expectancy, care goals and personal preferences. Structured guides to deprescribing include algorithms, flow charts or tables which are patient-directed and aim to guide the clinician through sequential steps in deciding which medications should be targeted for discontinuation. In this narrative review, we describe seven structured deprescribing guides whose stated purpose included the reduction of polypharmacy, their use was not restricted to a single drug or drug class and they had undergone some form of efficacy testing. There was considerable heterogeneity in guide design and content, with some guides constituting little more than a set of principles while others entail detailed processes and sub-steps which addressed multiple determinants of drug appropriateness. Evidence of effectiveness for each guide was limited in that none have been evaluated in randomised controlled trials, that pilot or feasibility studies have involved relatively small patient samples, that intra-rater and inter-rater reliabilities have not been determined and that most have been studied in hospital settings. Which is most useful to clinicians is unknown in the absence of head-to-head comparisons. While most guides have face validity, more research is needed for determining effectiveness and ease of use in routine clinical practice, especially in primary care settings.

A New Computer-Based Tool to Reduce Potentially Inappropriate Prescriptions in Hospitalized Geriatric Patients

BACKGROUND

Potentially inappropriate prescriptions (PIPs), associated with adverse drug reactions, hospitalization, and wasteful healthcare spending, are common in elderly patients with comorbidities and multiple drugs.

OBJECTIVE

Our objective was to develop and validate a new tool to reduce PIPs in a hospitalized geriatric population.

METHODS

This was an observational cohort study of two cohorts (development [n = 100 subjects] and validation [n = 449 subjects]) of consecutive patients aged ≥65 years admitted to geriatric wards from April to December 2012. In the development phase, data on clinical and demographic characteristics, Multidimensional Prognostic Index (MPI), and prescribed drugs before hospital admission were collected and processed using a tool that integrates the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) criteria and the Micromedex™ Drug-Reax System, a drug-management platform. This tool generated a report that was provided to the treating physicians. The weight of the PIPs, as defined by the Medication Appropriateness Index (MAI), was assessed on admission and on discharge. Similar procedures were followed in the validation cohort.

RESULTS

PIPs were independently associated with polypharmacy and with prescribing of antithrombotics, sedatives and antidepressants in both cohorts. The use of the tool led to a significant reduction of the MAI score, both in the development (median score 4 [interquartile range; IQR 1-5] vs. 2 [IQR 0-4], p < 0.001) and in the validation cohorts (median 3 [IQR 1-5] vs. 2 [IQR 0-4], p < 0.001).

CONCLUSION

This tool significantly reduced PIPs, as defined by the MAI score, in a hospitalized geriatric population. This strategy might be useful to minimize inappropriate medication exposure in this group.

Optimization of Geriatric Pharmacotherapy: Role of Multifaceted Cooperation in the Hospital Setting

Because older patients are more vulnerable to adverse drug-related events, there is a need to ensure appropriate pharmacotherapy in these patients. This narrative review describes approaches to improve pharmacotherapy in older people in the hospital setting. Screening to identify older patients at risk of drug-related problems and adverse drug reactions (ADRs) is the first critical step within a multistep approach to geriatric pharmacotherapy. Two methods that have been developed are the GerontoNet ADR risk score and the Brighton Adverse Drug Reactions Risk (BADRI) model, which take into account a number of factors, the most important of which is the number of medicines. In order to reduce potentially inappropriate prescribing in older patients, different types of interventions exist, such as pharmacist-led medication reviews, educational interventions, computerized decision support systems, and comprehensive geriatric assessment. The effects of these interventions have been studied, sometimes in a multifaceted approach, by combining different techniques. None of the existing interventions shows a clear beneficial effect on patients' health outcomes if applied in isolation; however, when these interventions are combined within the context of a multidisciplinary team, positive effects on patients' health outcomes can be expected. Appropriate geriatric pharmacotherapy, global assessment of patients' clinical and functional parameters, and integration of skills from different healthcare professionals are needed to address medical complexity of older adults.

Drug-drug interactions in the intensive care unit: Do they really matter?

PURPOSE

To describe prevalence and patterns of potential drug-drug interactions (pDDIs) in the intensive care unit (ICU), occurrence of adverse drug events (ADEs), and agreement between different compendia and intensivists' perceptions.

METHODS

A cross-sectional study. Drug profiles of all adult patients from 2 academic ICUs were screened on day 3 upon admission. We identified pDDIs using 3 compendia (Stockley's, Micromedex, and Epocrates) and documented their mechanism of action, clinical consequences, severity, level of evidence, and management. Medical records were searched to identify ADEs potentially related to major pDDIs. Agreement between information sources (compendia, intensivists) was evaluated.

RESULTS

We identified 1120 pDDIs among 275 patients. Median number of pDDIs per patient was 3.0 (interquartile range, 1-6), with 79% of patients presenting with at least 1 pDDI. Major pDDIs were detected in 18% of patients, with potentially related to ADEs in 4% of patients. Only 13% of all pDDIs were documented simultaneously in all 3 compendia. Different information sources (compendia, clinicians) showed "no" to "fair" agreement.

CONCLUSIONS

Potential drug-drug interactions occurred in most ICU patients, contrasting with low rates of potentially related ADEs, which may have been underestimated. Sources of information are inconsistent, challenging the identification of pDDIs.

Efficiency of Clinical Decision Support Systems Improves with Experience

Efficiency, or the resources spent while performing a specific task, is widely regarded as one the determinants of usability. In this study, the authors hypothesize that having a group of users perform a similar task over a prolonged period of time will lead to improvements in efficiency of that task. This study was performed in the domain of decision-supported medication reviews. Data was gathered during a randomized controlled trial. Three expert teams consisting of an independent physician and an independent pharmacist conducted 150 computerized medication reviews on patients in 13 general practices located in Amsterdam, the Netherlands. Results were analyzed with a linear mixed model. A fixed effects test on the linear mixed model showed a significant difference in the time required to conduct medication reviews over time; F(31.145) = 14.043, p < .001. The average time in minutes required to conduct medication reviews up to the first quartile was M = 20.42 (SD = 9.00), while the time from the third quartile up was M = 9.81 (SD = 6.13). This leads the authors to conclude that the amount of time users needed to perform similar tasks decreased significantly as they gained experience over time.

Usually Available Clinical and Laboratory Data Are Insufficient for a Valid Medication Review: A Crossover Study

OBJECTIVES

To establish the quality of medication reviews performed by nursing home physicians, general practitioners and pharmacists.

DESIGN AND SETTING

15 Pharmacists, 13 general practitioners and 18 nursing home physicians performed a medication review for three cases (A, B and C), at three evaluation moments. First, they received the medication list. Secondly, they also received laboratory results and reason for admission and finally, we added medical history. Remarks were divided into 6 categories, i.e. indication without medication, medication without indication, contraindications/ interactions, dosage problems, double medication and wrong medication. Remarks were compared to the remarks made by our expert panel and scored according to our grading model as appropriate (0 to +3) or missed or potentially harmful (-1). For each medication error category, the percentage of participants who made this error was computed.

RESULTS

After the first evaluation moment, the overall estimated mean percentage score was -1.7% for case A, 3.9% for case B, and 8.7% for case C. After the second review, this score was 15.0% for case A, 19.8% for case B, and 22.2% for case C. This further increased to 30.0% for case A, 36.7% for case B and 44% for case C at the final evaluation. The absence of medication where there was an indication (indication without medication) was frequently missed and did not improve after adding the extra information regarding laboratory results, reason for admission and finally medical history.

CONCLUSION

Increasing clinical information helps physicians and pharmacists to improve their medication reviews, however, additional information was still related with a high margin of error. Detection of certain errors becomes easier with additional information, whereas other errors remain undetected. To achieve a high standard of medication review, we have to change the way medication reviews should be performed.

Routine deprescribing of chronic medications to combat polypharmacy

The positive benefit-risk ratio of most drugs is decreasing in correlation to very old age, the extent of comorbidity, dementia, frailty and limited life expectancy (VOCODFLEX). First, we review the extent of inappropriate medication use and polypharmacy (IMUP) globally and highlight its negative medical, nursing, social and economic consequences. Second, we expose the main clinical/practical and perceptual obstacles that combine to create the negative vicious circle that eventually makes us feel frustrated and hopeless in treating VOCODFLEX in general, and in our 'war against IMUP' in particular. Third, we summarize the main international approaches/methods suggested and tried in different countries in an attempt to improve the ominous clinical and economic outcomes of IMUP; these include a variety of clinical, pharmacological, computer-assisted and educational programs. Lastly, we suggest a new comprehensive perception for providing good medical practice to VOCODFLEX in the 21st century. This includes new principles for research, education and clinical practice guidelines completely different from the 'single disease model' research and clinical rules we were raised upon and somehow 'fanatically' adopted in the 20th century. This new perception, based on palliative, geriatric and ethical principle, may provide fresh tools for treating VOCODFLEX in general and reducing IMUP in particular.

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant's Usability

Background

Polypharmacy poses threats to patients’ health. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) is a drug optimization process for conducting medication reviews in primary care. To effectively and efficiently incorporate this method into daily practice, the STRIP Assistant—a decision support system that aims to assist physicians with the pharmacotherapeutic analysis of patients’ medical records—has been developed. It generates context-specific advice based on clinical guidelines.

Objective

The aim of this study was to validate the STRIP Assistant’s usability as a tool for physicians to optimize medical records for polypharmacy patients.

Methods

In an online experiment, 42 physicians were asked to optimize medical records for two comparable polypharmacy patients, one in their usual manner and one using the STRIP Assistant. Changes in effectiveness were measured by comparing respondents’ optimized medicine prescriptions with medication prepared by an expert panel of two geriatrician-pharmacologists. Efficiency was operationalized by recording the time the respondents took to optimize the two cases. User satisfaction was measured with the System Usability Scale (SUS). Independent and paired t tests were used for analysis.

Results

Medication optimization significantly improved with the STRIP Assistant. Appropriate decisions increased from 58 % without the STRIP Assistant to 76 % with it (p < 0.0001). Inappropriate decisions decreased from 42 % without the STRIP Assistant to 24 % with it (p < 0.0001). Participants spent significantly more time optimizing medication with the STRIP Assistant (24 min) than without it (13 min; p < 0.0001). They assigned it a below-average SUS score of 63.25.

Conclusion

The STRIP Assistant improves the effectiveness of medication reviews for polypharmacy patients.

Effect of a patient-centered drug review on polypharmacy in primary care patients: study protocol for a cluster-randomized controlled trial

BACKGROUND

Managing patients with polypharmacy is a challenging issue in primary care. The aim of this study is to determine whether a patient-centered systematic review leads to more appropriate medication use in patients without negatively affecting quality of life and the course of the disease.

METHODS/DESIGN

The trial is a two-armed, double blinded cluster-randomized controlled trial. Primary care physicians (PCPs) will be randomly assigned to the intervention or control group. Physicians in the intervention group undergo training with instruction of the algorithm. The control group is given a lecture on multimorbidity and instructions for collecting data in a usual care manner. PCPs will approach patients aged 60 years or older who are taking 5 or more drugs. The study period is 1 year. The primary outcome measure is the change in the number of drugs 12 months after the algorithm was applied by the PCP during consultation with the patient. Secondary outcomes are: change in the number of drugs immediately after the encounter and 6 months later, reason for a change of the medication, discrepancy in the decision to change between PCP and patient, number of drugs for which the patient is suggesting a change, number of drugs the patient is taking that are not known to the PCP, time consumption of the intervention, disease-specific variables to evaluate the course of the disease(s) for which the patient is being treated , quality of life, barriers against using the algorithm, numbers of drugs readopted due to an unfavorable course of the disease, and numbers of drugs which have been started.

DISCUSSION

Answering the four questions of the algorithm requires a weighing-up of risks and benefits and contains a shared-decision-making approach: a prioritization of the treatment goals is necessary. This can only be done in collaboration with the patient. The majority of patients with multimorbidity are treated in the primary care setting. This underlines the significance of our study carried out in this setting: given the high prevalence of adverse drug events in patients with multimorbidity an intervention like ours has a large potential to reduce drug-related morbidity.

TRIAL REGISTRATION

ISRCTN16560559 13 November 2014.

Does increased use of generic medicines by elders in Belgium help to contain escalating health care budgets?

This study explored the use of generic medicines among elders in Belgium. The generic market share by volume for elders in 2010 was 23.1%, while this was 23.7% for the total Belgian population in 2009. Pharmaceutical expenditure in Belgium was €649.74 per capita for elders in 2010. Calculations of possible savings through an increased use of generic medicines showed that these savings were rather limited (4.48% when the generic market share by volume increased to 95%). The full potential of generic medicines in the elder population has not yet been realized in Belgium, due to the limited use of generic medicines and their relatively high prices. The Belgian government should implement additional incentives for physicians, pharmacists, and patients to increase the use of generics and combine these with policies to lower prices of generic medicines and policies to decrease the volume of medicines used by elders and rationalize the prescribing of medicines for elders.

Structured pharmaceutical analysis of the Systematic Tool to Reduce Inappropriate Prescribing is an effective method for final-year medical students to improve polypharmacy skills: a randomized controlled trial

Medical students may not be adequately trained to prescribe appropriately to older adults with polypharmacy. This study addressed how to teach students to minimize inappropriate polypharmacy. Final-year medical students (N = 106) from two Dutch schools of medicine participated in this randomized controlled trial with a pre/posttest design. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) was used as the intervention. This medication review tool consists of five steps and is part of the Dutch multidisciplinary guideline on polypharmacy. Step two is a structured pharmaceutical analysis of drug use, assessed using six questions regarding undertreatment, ineffective treatment, overtreatment, potential adverse effects, contraindications or interactions, and dose adjustments. It is used in combination with the Screening Tool to Alert doctors to Right Treatment and the Screening Tool of Older Person's Prescriptions checklists. Students were asked to optimize the medication lists of real people, making use, or not, of the STRIP. The number of correct or potentially harmful decisions that the students made when revising the lists was determined by comparison with expert consensus. Students who used the STRIP had better scores than control students; they made more correct decisions (9.3 vs 7.0, 34%; P < .001, correlation coefficient (r) = 0.365) and fewer potentially harmful decisions (3.9 vs 5.6, -30%; P < .001, r = 0.386). E-learning did not have a different effect from that of non-E-learning methods. Students were satisfied with the method. The STRIP method is effective in helping final-year medical students improve their prescribing skills.

Development of a computer system to support medication reviews in nursing homes

The frail elderly populations of nursing homes frequently use drugs and suffer from considerable comorbidities. Medication reviews are intended to support evidence based prescribing and optimise therapy. However, literature is still ambiguous regarding the optimal method and the effects of medication reviews. Innovative computerised systems may support the medication reviews in the future. We are developing a clinical decision support system (CDSS) that, independently of the prescribing software, continuously monitors all prescribed drugs while taking into account co-medication, laboratory-data and co-morbidities. The CDSS will be developed in five phases: (1) development of the computerised system, (2) development of the clinical rules, (3) validation of the CDSS, (4) randomised controlled trial, and (5) feasibility for implementation in different nursing homes. The clinical decision support system aims at supporting the traditional medication review.

Identification of drug-related problems of elderly patients discharged from hospital

BACKGROUND

Drug-related problems (DRP) following hospital discharge are common among elderly patients using multiple drugs for the treatment of chronic diseases. The aim of this study was to investigate the occurrence of DRP in these patients using a specific tool for the identification of DRP by community pharmacists.

METHODS

An observational study involving 340 patients aged over 60 years using at least five prescription drugs and discharged from hospital. The occurrence of DRP was assessed by means of an identification tool specifically developed for use by community pharmacists, including a semistructured patient interview and a checklist of common DRP.

RESULTS

In total, 992 potential DRP were observed in the 340 patients (mean 2.9 ± 1.7). No drug prescribed but clear indication, an unnecessarily long duration of treatment, dose too low, and incorrect drug selection were the DRP most commonly observed. Ten percent of DRP occurring in 71 patients were drug-drug interactions. The number of DRP was related to the number of drugs prescribed. Frequently occurring DRP found using the patient interview were fear of side effects and no or insufficient knowledge of drug use. Medication of patients discharged from the pulmonary department and of those with type 2 diabetes was particularly associated with occurrence of DRP.

CONCLUSION

Following hospital discharge, DRP occur frequently among elderly patients using five or more drugs for the treatment of chronic disease. The number of DRP increased with the number of drugs used. An important task for community pharmacists is to identify, resolve, and prevent the occurrence of DRP among this patient group. Since DRP are associated with an increased risk of hospital readmissions, morbidity, and mortality, it is very important to develop intervention strategies to resolve and prevent DRP.

General practitioners’ attitudes towards decision-supported prescribing: An analysis of the Dutch primary care sector

The use of multiple drugs by patients increases the risk of medical problems. Clinical decision support could assist general practitioners with prescribing but is underused. This article aims to investigate the attitudes of general practitioners towards using decision support systems. A survey was distributed among 500 Dutch general practitioners. Virtually all 184 respondents indicated having a clinical information system, while only 21 percent indicated having a decision support plug-in; this correlated with their use of medical formularies. Only use of one of the medical formularies correlated with the number of recognized underprescription problems. General practitioners’ attitudes toward a newly proposed system aiding them with polypharmacy prescribing were mainly positive (57%); the perceived usefulness correlated with output quality (p = .000), time investment (p = .000), and financial stimuli (payability: p = .000 and reimbursement: p = .015) but not with job relevance. Dutch general practitioners are thus likely to adopt the proposed system under the conditions that it improves prescription quality and does not require extensive investments of time or money.