Factors Associated With PIM use in the Frail Elderly: A Cross-sectional Study

Background: The use of potentially inappropriate medications (PIM) by the elderly is commonly studied, but studies evaluating the use of PIM by frail elderly covered by prepaid health plans are still lacking. Objective: To identify the prevalence of use and the factors associated with the use of PIM by the elderly patients with high and moderate risk of clinical-functional vulnerability, according to the Beers criteria 2019. Methods: A cross-sectional study was developed with elderly people from a private health plan in Vitória-ES, Brazil. Socioeconomic, demographic and clinical data were collected through a digital platform and a structured questionnaire through an interview, from October 2018 to June 2019. The association between the use of PIM and independent variables was verified by univariate logistic regression with their respective confidence intervals (CI) 95%. The Multiple Model included the variables with P ≤ .20. Results: 332 elderly patients were interviewed (mean age 81.5 years, gender 237 female, 95 male). A 65% prevalence of PIM use was identified. In the multiple logistic regression model, the variables associated with the use of PIM were self-medication (P = .004), high risk of clinical-functional vulnerability (P = .022), use of psychotropic medications (P = .000001), musculoskeletal medications (P = .04) and alimentary tract medications (P = .03). Physical exercises were considered a protection factor (P = .02). Conclusion: The high prevalence of PIM use indicates the need for improvement in elderly private health care, to increase pharmacotherapy safety for this population.

Pharmacological treatments and medication-related problems in nursing homes in Catalonia: a multidisciplinary approach

Background: Aging correlates with increased frailty, multi-morbidity, and chronic diseases. Furthermore, treating the aged often entails polypharmacy to achieve optimal disease management, augmenting medication-related problems (MRPs). Few guidelines and tools address the problem of polypharmacy and MRPs, mainly within the institutionalized elderly population. Routine pharmacological review is needed among institutionalized patients. This pharmacological review may improve with a multidisciplinary approach of a collaboration of multiple health professionals. This study aimed to describe institutionalized patients, systematically review their medication plans, and then give recommendations and identify MRPs. Methods: A cross-sectional study was performed using data obtained from patients living in five nursing homes in the northern area of Barcelona, Spain. The inclusion criteria comprised institutionalized patients with public health coverage provided by the Health Department of Catalonia. A detailed description of the clinical characteristics, chronic diseases, pharmacological treatments, recommendations, incomplete data, and MRPs, such as potential drug-drug interactions, therapeutic duplications, contraindications, and drugs deemed inappropriate or of doubtful efficacy, was made. The clinical pharmacologist was the medical doctor specialist who acted as the coordinator of the multidisciplinary team and actively reviewed all the prescribed medications to make recommendations and detect MRPs. Results: A total of 483 patients were included. Patients had a mean age of 86.3 (SD 8.8) years, and 72.0% were female individuals. All patients had at least three health-related problems, with a mean of 17.4 (SD 5.6). All patients, except one, had a minimum of one prescription, with a mean of 8.22 drugs prescribed (SD 3.5) per patient. Recommendations were made for 82.4% of the patients. Of these recommendations, verification of adequate use was made for 69.3% and withdrawal of a drug for 49.5%. Conclusion: This study demonstrates a high prevalence of health-related problems and several prescribed drugs in nursing homes in Catalonia. Many recommendations were made, confirming the increased proportion of polypharmacy, MRPs, and the need for standardized interventions. A multidisciplinary team approach, including general practitioners, geriatric assessments, a clinical pharmacist, and a clinical pharmacologist, should address this problem.

Prevalence of potentially inappropriate medications among newly treated patients with type 2 diabetes in UK primary care

AIMS

The aim of this study was to estimate the prevalence of potentially inappropriate prescriptions (PIPs) in patients starting their first noninsulin antidiabetic treatment (NIAD) using two explicit process measures of the appropriateness of prescribing in UK primary care, stratified by age and polypharmacy status.

METHODS

A descriptive cohort study between 2016 and 2019 was conducted to assess PIPs in patients aged ≥45 years at the start of their first NIAD, stratified by age and polypharmacy status. The American Geriatrics Society Beers criteria 2015 was used for older (≥65 years) patients and the Prescribing Optimally in Middle-age People's Treatments criteria was used for middle-aged (45-64 years) patients. Prevalence of overall PIPs and individual PIPs criteria was reported using the IQVIA Medical Research Data incorporating THIN, a Cegedim Database of anonymized electronic health records in the UK.

RESULTS

Among 28 604 patients initiating NIADs, 18 494 (64.7%) received polypharmacy. In older and middle-aged patients with polypharmacy, 39.6% and 22.7%, respectively, received ≥1 PIP. At the individual PIP level, long-term proton pump inhibitors (PPI) use was the most frequent PIP among older adults, and strong opioid without laxatives was the most frequent PIP in middle-aged patients with polypharmacy (11.1% and 4.1%, respectively).

CONCLUSIONS

This study revealed that patients starting NIAD treatment receiving polypharmacy have the potential for pharmacotherapy optimization.

Evaluation of KIDs List Compliance at a Children's Hospital Within a Large Academic Medical Center

OBJECTIVES

In 2020, a list of Key Potentially Inappropriate Drugs in Pediatrics, known as the "KIDs List," was published. The objective of this analysis was to evaluate institutional compliance with the -recommendations in this publication and identify areas for improvement.

METHODS

Medications in the KIDs List were compared to the institutional formulary at a large academic medical center caring for pediatric and adult patients. Medications listed in the formulary were then -evaluated for order comments and restrictions related to their use in pediatric patients. Oral liquid products and a group of commonly used intravenous (IV) medications were reviewed for potentially inappropriate excipients through available manufacturer information. The pediatric clinical specialists were then solicited to review and make recommendations for medications that had not been addressed.

RESULTS

Of the 67 medications or classes listed in the KIDs List, 47 (70.1%) of the medications are listed in our formulary and available for use. Of these 47 medications, 4 (8.5%) included warnings related to their use in pediatric patients. Of the 270 oral liquid medications reviewed, 206 (76.3%) contained at least 1 -potentially inappropriate excipient. Of the 20 commonly used IV medications, 3 (15%) contained at least 1 potentially inappropriate excipient.

CONCLUSIONS

This review found that many medications listed in the KIDs List are included in our -institution's formulary and that few have warnings for pediatric patients built into the institutional electronic health record. Further review of medications in the formulary will be conducted to determine the next steps to implementing KIDs List recommendations.

Development of a list of Australian potentially inappropriate medicines using the Delphi technique

BACKGROUND

Older people are at high risk of medicines-related harms. otentially inappropriate medicines (PIMs) list has been developed to assist clinicians and researchers to identify medicines with risks that may potentially outweigh their benefits in order to improve medication management and safety.

AIM

To develop a list of PIMs for older people specific to Australia.

METHODS

The study obtained expert consensus through the utilisation of the Delphi technique in Australia. A total of 33 experts partook in the initial round, while 32 experts engaged in the subsequent round. The primary outcomes encompass medicines assessed as potentially inappropriate, the specific contexts in which their inappropriateness arises and potentially safer alternatives.

RESULTS

A total of 16 medicines or medicine classes had one or more medicines deemed as potentially inappropriate in older people. Up to 19 medicines or medicine classes had specific conditions that make them more potentially inappropriate, while alternatives were suggested for 16 medicines or classes.

CONCLUSION

An explicit PIMs list for older people living in Australia has been developed containing 19 drugs/drug classes. The PIMs list is intended to be used as a guide for clinicians when assessing medication appropriateness in older people in Australian clinical settings and does not substitute individualised treatment advice from clinicians.

Scaling the EQUIPPED medication safety program: Traditional and hub-and-spoke implementation models

BACKGROUND

The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement.

METHODS

We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation.

RESULTS

The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites.

CONCLUSIONS

EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

Polypharmacy, potentially inappropriate medications and associated factors among older adults with hypertension in primary care

OBJECTIVE

to identify the prevalence and associations of polypharmacy and potentially inappropriate medication use among older adults with hypertension treated in primary care.

METHODS

a cross-sectional study carried out with older adults with hypertension treated at a Family Health Strategy unit. Data collection included analysis of medical records, interviews and multidimensional assessment of older adults. Socio-demographic information and clinical variables were collected. Statistical analysis was performed by multiple logistic regression.

RESULTS

polypharmacy prevalence was 38.09%, and potentially inappropriate medication (PIM), 28.57%. There was a significant association between polypharmacy and PIM use, altered sleep and ethnicity. PIM use was associated with polypharmacy, worse family functioning, and absence of a caregiver. Cognitive decline reduces the prevalence of these medications.

CONCLUSIONS

polypharmacy and PIM use among older adults with hypertension represent a problem in this population, especially among the most vulnerable.

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSION

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

Impact of the publication of the Finnish Meds75+ database on the use of potentially inappropriate medications in older persons

AIMS

To evaluate the impact of the updated nationwide Meds75+ database and its linkage to the Finnish health portal on the use of potentially inappropriate medications (PIMs) among older persons. We also aimed to evaluate whether there is regional variation in trend changes of PIM use.

METHODS

Meds75+ was implemented at the population level in 2015, so randomization is unfeasible. We used a quasi-experimental interrupted time series analysis to evaluate the changes in levels and trends of PIM use. The data included all Finnish community-dwelling persons aged ≥75 years (N = 920 163) who had medication purchases in the Prescription Register during 2009-2020. Data were linked with the Care Registers for Health and Social Care and the cause of death register.

RESULTS

The prevalence of PIMs decreased from 20.2% in 2009 to 11.7% in 2020. The change of level of the monthly PIM users was negative (β -0.036, 95% confidence interval [CI] -0.202 to 0.131), but not statistically significant (P = .673) after the publication of the database. We found a small decrease (β -0.018, 95% CI -0.083 to 0.047, P = .593) in the slope of PIM users, but it was not statistically significant. The regional results were similar to the main findings.

CONCLUSIONS

Publication of the updated Meds75+ database did not decrease the level or trend of PIM users. In addition, this study did not show any significant regional variation in PIM use trends. Further research should focus on determining barriers and facilitators to the utilization of PIM criteria in clinical practice.

Potentially inappropriate medications with older people in intensive care and associated factors: a historic cohort study

BACKGROUND

The epidemiology of potentially inappropriate medications (PIMs) in critical care units remains limited, especially in terms of the factors associated with their use.

OBJECTIVE

To estimate the incidence and factors associated with PIMs use in intensive care units.

DESIGN AND SETTING

Historical cohort study was conducted in a high-complexity hospital in Brazil.

METHODS

A retrospective chart review was conducted on 314 patients aged ≥ 60 years who were admitted to intensive care units (ICUs) at a high-complexity hospital in Brazil. The dates were extracted from a "Patient Safety Project" database. A Chi-square test, Student's t-test, and multivariable logistic regression analyses were performed to assess which factors were associated with PIMs. The statistical significance was set at 5%.

RESULTS

According to Beers' criteria, 12.8% of the identified drugs were considered inappropriate for the elderly population. The incidence rate of PIMs use was 45.8%. The most frequently used PIMs were metoclopramide, insulin, antipsychotics, non-steroidal anti-inflammatory drugs, and benzodiazepines. Factors associated with PIMs use were the number of medications (odds ratio [OR] = 1.17), length of hospital stay (OR = 1.07), and excessive potential drug interactions (OR = 2.43).

CONCLUSIONS

Approximately half of the older adults in ICUs received PIM. Patients taking PIMs had a longer length of stay in the ICU, higher numbers of medications, and higher numbers of potential drug interactions. In ICUs, the use of explicit methods combined with clinical judgment can contribute to the safety and quality of medication prescriptions.

Personal Continuity and Appropriate Prescribing in Primary Care

PURPOSE

Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients.

METHODS

We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex.

RESULTS

The patients' mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions.

CONCLUSIONS

A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Development of REDCap-based architecture for a clinical decision support tool linked to the electronic health record for assessment of medication appropriateness

Objective

To develop the architecture for a clinical decision support system (CDSS) linked to the electronic health record (EHR) using the tools provided by Research Electronic Data Capture (REDCap) to assess medication appropriateness in older adults with polypharmacy.

Materials and Methods

The tools available in REDCap were used to create the architecture for replicating a previously developed stand-alone system while overcoming its limitations.

Results

The architecture consists of data input forms, drug- and disease-mapper, rules engine, and report generator. The input forms integrate medication and health condition data from the EHR with patient assessment data. The rules engine evaluates medication appropriateness through rules built through a series of drop-down menus. The rules generate output, which are a set of recommendations to the clinician.

Discussion and conclusion

This architecture successfully replicates the stand-alone CDSS while addressing its limitations. It is compatible with several EHRs, easily shared among the large community using REDCap, and readily modifiable.

Potentially inappropriate medications according to Marc, STOPP and PRISCUS criteria in a cohort of elderly HIV+ patients. The COMMPI project

OBJECTIVE

The objective is to determine the prevalence of potentially inappropriate drugs according to the Marc, STOPP, and PRISCUS lists in elderly HIV patients.

METHODS

It was an observational, retrospective, and multicenter study. People living with HIV 65 years or older who underwent chronic concomitant treatment were included. Descriptive and multivariate analyzes were performed to study the association between polypharmacy and potentially inappropriate medication compliance.

RESULTS

A total of 55 patients were included, 81.8% men and a median age of 69 years (IQR: 67-73). The median number of comorbidities was 3 (IQR: 2-5) and the most frequent pattern of multimorbidity was cardiometabolic (62.9%). The predominant antiretroviral treatment was triple therapy (65.5%). Polypharmacy was present in 70.9% of the patients and 25.5% had major polypharmacy. The most frequent polypharmacy pattern was cardiovascular (69.2%). The percentage of potentially inappropriate medications according to the Marc, STOPP and PRISCUS lists was 65.5%, 30.9% and 14.5%, respectively (p<0.001). Adjusted for age and sex, polypharmacy was not independently associated with potentially inappropriate medication compliance in any of the lists.

CONCLUSIONS

Polypharmacy and potentially inappropriate medications have a high prevalence. There is great variability in the percentage according to the list applied. Age, sex, and presence of polypharmacy are not predisposing factors to the presence of potentially inappropriate medications.

A comprehensive look at explicit screening tools for potentially inappropriate medication: A systematic scoping review

OBJECTIVE

To map explicit screening tools to identify potentially inappropriate medication (PIMs), and the characteristics and limitations of these tools. Including PIMs-interactions, therapeutic alternatives and the clinical management of PIMs.

METHODS

A systematic scoping review was conducted in PubMed and Scopus (until May 2021). The number of PIMs listed as essential drugs was identified in Model List of Essential Medicines by the World Health Organization (WHO) and National List of Essential Medicines (Brazil). In addition to reporting the therapeutic alternatives and clinical management proposed by explicit screening tools to identify PIMs, we suggested our own alternatives for the PIMs most frequently reported.

RESULTS

Fifty-eight tools reported 614 PIMs and 747 PIMs-interactions. Limited overlap between the tools was observed: 123 (69.1%) of 178 therapeutic alternatives proposed by the tools were considered inappropriate by other tools, and 222 (36.1%) of the 614 PIMs identified were named as being inappropriate only once. Only 21 tools were developed by a Delphi panel technique associated with systematic review. The PIMs listed as essential medication in Brazil and by the WHO were 30.6% and 23.3% of the total reported, respectively. For the most-cited PIMs, such as non-steroidal anti-inflammatory drugs, tricyclic antidepressants and benzodiazepines, we suggested the use of non-opioid and opioid analgesics; agomelatine, bupropion or moclobemide; and melatonin, respectively.

CONCLUSIONS

The next stages in the development of explicit screening tools to identify PIMs include achieving more consensus between them and improving their applicability across countries. Further, it is recommended that tools include PIMs risks and advice on therapeutic alternatives.

Applicability of explicit potentially inappropriate medication lists to the Australian context: A systematic review

OBJECTIVES

To determine i) the similarity of potentially inappropriate medications specified in and between existing explicit lists and ii) the availability in Australia of medications included on existing lists to determine their applicability to the Australian context.

METHODS

This systematic review identified explicit potentially inappropriate medication lists that were published on EMBASE (1974 - April 2021), MEDLINE (1946 - April 2021) and Elsevier Scopus (2004 - April 2021). The reference lists of seven previously published systematic reviews were also manually reviewed. Lists were included if they were explicit, and the most recent version and the complete list were published in English. Lists based on existing lists were excluded if no new items were added. Potentially inappropriate medications identified on each list were extracted and compared to the medications available on the Australian Register of Therapeutic Goods and Australian Pharmaceutical Benefits Schemes.

RESULTS

Thirty-five explicit published lists were identified. A total of 645 unique potentially inappropriate medications were extracted, of which 416 (64%) were available in Australia and 262 (41%) were subsided by the general Pharmaceutical Benefits Scheme. Applicability of each explicit list ranged from 50-96% according to medications available in Australia and 25-83% according to medications available under subsidy.

CONCLUSIONS

Pooling data from different lists may help to identify potentially inappropriate medications that may be applicable to local settings. However, if selecting a list for use in the Australian context, consideration should also be given to the intended purpose and setting for application.

Impact of Pharmaceutical Interventions in Hospitalized Patients: A Comparative Study Between Clinical Pharmacists and an Explicit Criteria-Based Tool

Background

It has been well recognized that pharmaceutical interventions (PIs) can prevent patient harm related to prescribing errors. Various tools have been developed to facilitate the detection and the reduction of inappropriate prescriptions and some have shown benefit on clinical outcomes.

Objective

The objective of this study was to evaluate the clinical, economical, and organizational impact of interventions generated by clinical pharmacists in hospitalized patients, and to evaluate the performance of an explicit tool, the Potentially Inappropriate Medication Checklist for Patients in Internal Medicine (PIM-Check), in detecting each pharmacist's intervention.

Methods

A cohort retrospective study was conducted on hospitalized patients. The impact of PIs based on pharmacists’ standard examination was evaluated using the Clinical, Economic, and Organizational (CLEO) tool. The performance of PIM-Check in detecting each intervention was assessed by conducting a retrospective medication review based on available information collected from patients’ records. A qualitative analysis was also conducted to identify the types of PIs that PIM-Check failed to detect.

Results

The study was performed on 162 patients with a median age of 68 years (interquartile range = 46–77 years) and a median hospital stay of 5 days (interquartile range = 4–7 days). The pharmacists generated 1.9 PIs per patient (n = 304) of which 31% were detected by PIM-Check. The acceptance rate of the interventions by physicians was 84% (n = 255). Among the accepted interventions, 53% (n = 136) had a clinical impact graded CL ≥ 2C (moderate or major), whereas the majority of them were not detected by PIM-Check (63%; 86 out of 136). In addition, 46% of accepted interventions (n = 117) were associated with a cost decrease, among which 62% were not detected by PIM-Check (73 out of 117). The qualitative analysis shows that PIM-Check mostly failed to detect PIs related to dose adjustment, overprescribing, and therapy monitoring.

Conclusions

According to the CLEO tool evaluation of PIs, our results show that clinical pharmacists’ interventions are associated with improved clinical outcomes. In comparison with pharmacists’ interventions, PIM-Check failed in detecting the majority of interventions associated with a moderate or major impact.

Assessment of Prescriptions in Elderly Patients Hospitalized in Medicine Departments

Drug-related iatrogenesis is an important issue in the elderly population, and preventing iatrogenic accidents helps to reduce hospitalizations. Our study’s objective was to evaluate prescriptions in the geriatric population of our establishment. The study conducted is a targeted clinical audit. Ten criteria were tested on the hospital prescriptions of people over 75 years old in 11 medical departments, before and after improvement actions. The non-compliance threshold was set at 10% of prescriptions for each criterion. In each phase, 165 patients were included. Four criteria were non-compliant (NC) in the first phase: the presence of Potentially Inappropriate Medications for the Elderly (PIMs) (NC = 57.6%), the adaptation of the medication to renal clearance (NC = 24.9%), the presence of illogical combination (NC = 9.7%), and the total anti-cholinergic score of the prescription (NC = 12.1%). After the implementation of improvement actions, the number of non-compliant criteria decreased between the two phases, from four to two. We obtained a significant improvement for three of the four criteria found to be non-compliant in the first phase. The criterion adaptation to renal function is close to compliance (NC = 10.1%) and the PIMs criterion remained non-compliant after reassessment (NC = 32.1%). Vigilance must be ongoing in order to limit drug iatrogeny, particularly in frail elderly patients.

Characterization of potentially inappropriate medication prescriptions for the elderly in primary care and hospital settings

Background

Polypharmacy cannot be defined numerically due to its varied definitions, and inclusion of comorbidities aggravates the dilemma, creating challenges for the healthcare system and the patients' course of treatment. The introduction of the potentially inappropriate medication (PIM) list developed by the American Geriatrics Society (AGS) (AGS Beers Criteria®; updated in 2019) was deemed a solution. However, several risk factors are associated with PIMs, including increased emergency room visits, hospitalization and mortality, and a decline in daily activity. Differences in PIM prescription rates have been reported; however, with the recent Beers criteria update, the number of patients exposed to PIMs is expected to increase significantly due to the addition of new medications to the list.

Objectives

This study aimed to describe the characteristics of PIM prescriptions for the elderly in primary care and hospital settings.

Methods

Medications for elderly patients prescribed in our hospital between 2016 and 2019 were reviewed and sorted based on Beers criteria to identify patients with the most PIMs. Correlations were made between gender and facility.

Results

This study included 40,168 patients (51% males). The total and average numbers of PIM per elderly patient were 260,753 and 6.5, respectively. Proton pump inhibitors were prescribed the most, followed by nonsteroidal anti-inflammatory drugs.

Conclusions

We found that increasing numbers of PIMs are prescribed to the elderly in our healthcare facilities. Therefore, further recommendations from local geriatric communities and the implementation of reminders for physicians through electronic prescription systems are needed to decrease the rate of prescribed PIMs.

Potentially Inappropriate Medication Use in the Elderly

It is estimated that approximately half of adults, older than 65 years of age, have been prescribed potentially inappropriate medications (PIMs). This study's objective was to determine the prevalence of PIM use among older patients. Two retrospective chart reviews were performed on 200 and 164 older patients who underwent comprehensive geriatric assessments (CGAs) at outpatient geriatrics clinics at the Glenrose Rehabilitation Hospital (Glenrose) in 2012-13 and at the Misericordia Community Hospital (Misericordia) in 2016-17, respectively. Outcome measures included demographics; prevalence of PIM use; common PIMs used; whether PIM use was addressed, and if so, how; and total number of oral medications. At the Glenrose, the prevalence of PIM use was 45 per cent (90/200). Of the 90 patients who had used PIMs, 46.7 per cent (42/90) had at least one of their medications stopped or modified. At the Misericordia, the prevalence of PIM use was 57.3 per cent (94/164). Of the 94 patients who used PIMs, 47.9 per cent (45/94) had at least one of their medications stopped or modified. These results suggest that an increased awareness of PIM among physicians is needed to further decrease PIM use.

A narrative review of updates in deprescribing research

BACKGROUND/OBJECTIVES

Deprescribing is a strategy intended to reduce harms associated with potentially inappropriate medications. Reflective of the growing interest in deprescribing, there has been an increase in related research to better understand the landscape, opportunities for improvement, how best to develop and implement interventions, and remaining knowledge gaps that can be addressed with additional study.

DESIGN

We conducted a narrative review of recent deprescribing literature.

SETTING

As part of the US Deprescribing Network's inaugural conference in October 2020, we presented a narrative review of recent deprescribing literature to an audience with a range of clinical and research expertise.

PARTICIPANTS

We searched four databases for English-language articles published between January 1, 2019 and August 31, 2020.

MEASUREMENTS

We evaluated titles, abstracts, and full-length manuscripts for relevance, novelty, rigor and variety of methods; we also aimed for broad representation of authors, institutions, and nations.

RESULTS

The initial search returned 199 citations, from which we reviewed 18 full-length manuscripts, selecting 10 articles to present. Salient themes included missed opportunities to deprescribe in potentially eligible patients, with variable impact of medication- and patient-level factors, along with differing perspectives and behaviors between geriatricians, internists, and cardiologists. Clinical, financial, and economic drivers were also evaluated. Finally, attention was given to issues applicable to deprescribing research, including difficulty recruiting trial participants, perspectives of investigators, and integration of findings into clinical practice.

CONCLUSION

This narrative review summarizes key advances in the field while also identifying priority areas for additional research.

Potentially inappropriate prescriptions to Brazilian older people with Alzheimer disease: A cross-sectional study

Older adults are the leading users of medications, where this can be associated with a high number of potentially inappropriate medications (PIMs) and of potentially inappropriate prescribing (PIP) and consequent harm to health. No Brazilian study evaluating potentially inappropriate prescribing in older patients with Alzheimer's disease (AD) was found. This study determined and analyzed the prevalence of PIP and PIM prescribed for older people with AD.A cross-sectional study was carried out at the Specialty Drugs Pharmacy in the city of Sorocaba, São Paulo State, Brazil. The MEDEX system provided the register in older people with AD and data were collected during interviews with patients and/or caregivers between June and September 2017. The PIMs were identified according to the 2019 Beers Criteria. The association between PIMs and independent variables was analyzed by Poisson regression.This study included 234 older patients with AD. The prevalence of PIP prescribed was 66.7% (n = 156). Of the 1073 medications prescribed, 30.5% (n = 327) were inappropriate with most affecting the central nervous system or cardiovascular, particularly quetiapine (12.8%) and acetylsalicylic acid (11.6%), respectively. Around 45.2% of the PIMs should be avoided in older people, especially sertraline (14.2%) and clonazepam (7.4%). After adjusted analysis, the PIMs were associated with the diagnosis of depression (P = 0.010) and the number of comorbidities (P = 0.005).There was a high number of PIMs among older people, a substantial number of which should have been avoided in this population. Health care professionals can apply these findings to improve safety in the use of medications for treating patients with AD.

Clinical and economic impacts of explicit tools detecting prescribing errors: A systematic review

WHAT IS KNOWN AND OBJECTIVE

Many explicit tools have been developed to reduce prescribing errors and ensure patients' safety. The impact of explicit tools is not well studied. The objective of this study was (a) to conduct a systematic review of systematic reviews listing explicit tools developed to detect prescribing errors and (b) to assess their impact on clinical and economic outcomes.

METHODS

This project includes two related parts. First, a systematic review of systematic reviews listing explicit tools dedicated to geriatrics or internal medicine was performed to develop an exhaustive list of explicit tools. Then, using the list compiled in the first step, a systematic review of randomized controlled trials (RCT) assessing clinical or economic impacts of tools was performed to evaluate their usefulness.

RESULTS AND DISCUSSION

The systematic review of systematic reviews identified 49 explicit tools. The systematic review of RCT, using one or more of the 49 explicit tools, identified 5 RCT using explicit tools as intervention (3 STOPP/START and 2 FORTA RCT). The 5 studies evaluated clinical impacts with 3 RCT identifying significant clinical impacts (falls, activities of daily living and/or adverse drug reactions) and 2 STOPP/START RCT identifying significant economic impacts.

WHAT IS NEW AND CONCLUSION

The systematic review of RCT showed that explicit tools can have some effect in improving patients' safety. Further studies are warranted to better characterize their clinical and economic impact.

A cross-sectional study of psychotropic drug use in the elderly: Consuming patterns, risk factors and potentially inappropriate use

OBJECTIVES

The aims of the present study were: (1) to describe psychotropic drug consumption patterns in an outpatient population aged 65 years and older; (2) to determine the impact of a number of demographic and clinical factors on psychotropic consumption; and (3) to determine the ratio of potentially inappropriate psychotropic agents prescribed to the above population.

METHODS

Cross-sectional, observational study of outpatients aged 65 years and older. Data on sociodemographic and clinical variables were collected. Psychotropic drugs were classified into three categories: anxiolytics-hypnotics, antidepressants, and antipsychotics. To determine the risk factors for psychotropic drug use among these patients, a multivariate logistic regression model was developed and subsequently validated using bootstrap resampling techniques. To identify the psychotropic drugs to be avoided, a review of treatments received by the patients was performed based on the 2015 version of the Beers criteria.

RESULTS

The study included 225 outpatients of whom 30.7% were on psychotropic drugs for chronic treatment. The highest likelihood of psychotropic utilisation corresponded to the following profile: female, living in a nursing home, having two or more prescribing physicians, and having received six or more different diagnoses. According to Beers criteria, 51 patients (22.7% of the sample and 73.9% of patients on psychotropic drugs) had been prescribed at least one potentially inappropriate psychotropic drug.

CONCLUSION

Elderly patients commonly use psychotropic medications and are the most vulnerable to the adverse effects of these drugs. It is necessary to re-evaluate the pertinence and accuracy of these medical prescriptions.

Annual Prevalence of Use of Potentially Inappropriate Medications for Treatment of Affective Disorders in Parkinson's Disease

OBJECTIVE

To examine the national prevalence of pharmacological treatment of affective disorders in older adults with Parkinson's disease (PD), and determine the prevalence and risk factors for receipt of an American Geriatrics Society Beers Criteria® defined potentially inappropriate medication (PIM) for affective disorder treatment.

DESIGN

Cross-sectional analysis of 2014 Medicare data.

SETTING

Research Identifiable File data from the Centers for Medicare and Medicaid Services.

PARTICIPANTS

Individuals ≥65 years of age with PD whose inpatient, outpatient, and prescription care is administered through the U.S. Medicare Program.

MEASUREMENTS

The 2014 prevalence of affective (i.e., depressive and anxiety) disorders was calculated. We assessed prescription fills for affective disorder treatment and classified prescriptions according to PIM status. Patient and clinician factors associated with PIM prescriptions were determined.

RESULTS

Of 84,323 beneficiaries with PD, 15.1% had prevalent depression only, 7.5% had anxiety only, and 8.5% had comorbid depression and anxiety. Among those with depression only, 80.7% were treated in 2014 (12.8% of treated received at least one PIM). The annual treatment prevalence was 62.9% (75.9% PIM) and 93.1% (63.9% PIM) in the anxiety only and comorbid group, respectively. In most groups, PIM use was less likely among men and those with dementia; geriatricians were less likely to prescribe PIMs.

CONCLUSION

Treatment of affective disorders in persons diagnosed with PD is high. PIM use is also common, particularly in persons with anxiety. Future research will quantify the potential effects of these PIMs on clinical and patient outcomes.

Evidence of association between the use of drugs and community-dwelling older people frailty: a cross-sectional study

BACKGROUND

The scientific literature has shown that an association between polypharmacy and frailty exists. However, few studies have also considered drug interactions and the use of potentially inappropriate medications.

OBJECTIVE

To evaluate the association between the use of drugs and frailty among community-dwelling older people.

DESIGN AND SETTING

Cross-sectional study carried out among 580 older people in Uberaba (MG).

METHODS

Data were collected at these older people's homes using instruments validated in Brazil. Descriptive, bivariate and binary logistic regression analyses were performed (P < 0.05).

RESULTS

Most of these individuals were classified as pre-frail (55.7%), while 13.1% were frail. It was found that 31.7% of them presented polypharmacy, 41.7% had drug interactions and 43.8% were using potentially inappropriate medications. In the initial model, polypharmacy (odds ratio, OR = 1.91; confidence interval, CI = 1.27-2.86) and use of potentially inappropriate medications (OR = 2.45; CI = 1.68-3.57) increased the chance that these older people would be pre-frail or frail. In the final adjusted model, use of potentially inappropriate drugs remained associated with the outcome (OR = 2.26; CI = 1.43-3.57).

CONCLUSION

Use of potentially inappropriate medications was the independent variable that explained the occurrence of frailty in a representative sample of community-dwelling older adults.

Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system

OBJECTIVES

To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up.

DESIGN

Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package.

SETTING

Three academic emergency departments that each implemented EQUIPPED over three successive years.

PARTICIPANTS

Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects.

INTERVENTION(S)

EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge.

MAIN OUTCOME MEASURE(S)

Implementation process components assembled through successive implementation.

RESULTS

Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model.

CONCLUSIONS

Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.

Frequency of and risk factors for potentially inappropriate medication use in Parkinson's disease

BACKGROUND

impairments in neurotransmitter pathways put Parkinson's disease (PD) patients at risk for drug-disease interactions and adverse medication events.

OBJECTIVE

to determine the prevalence and risk factors for potentially inappropriate medication (PIM) prescriptions, as defined by the 2015 Beers List, in PD.

METHODS

cross-sectional analysis was conducted on 2014 Medicare beneficiaries with PD who had parts A, B and D coverage. The prevalence of PIM prescriptions for older adults was determined overall, and specifically for medications that can exacerbate motor symptoms or cognitive impairment in PD. Logistic regression models were constructed to determine the association between age, sex, race, geography and poverty with PIM prescriptions.

RESULTS

the final sample included 458,086 beneficiaries. In 2014, 35.8% of beneficiaries with PD filled a prescription for at least one PIM for older adults. In total, 8.7% of beneficiaries received a PIM that could exacerbate motor symptoms and 29.0% received a PIM that could worsen cognitive impairment. After adjustment, in all models, beneficiaries who were younger, female, white, urban-dwelling and eligible for Medicaid benefits were more likely to receive a PIM.

CONCLUSION

PIM prescriptions are not uncommon in PD, particularly for medications that can exacerbate cognitive impairment. Future research will examine underlying drivers of sex and other disparities in PIM prescribing. Additional studies are needed to understand the impact of PIMs on disease symptoms, healthcare utilisation and patient outcomes.

Prescribing for geriatrics in Tehran; is it appropriate and rational?

Background: The world’s population is growing older. Inappropriate and irrational use of drugs in the elderly is a considerable health concern due to consequences such as increased morbidity and adverse drug events. This study aimed to evaluate the rationality of prescribing and determining the extent of inappropriate prescribing in a sample of geriatric patients in Tehran.

Methods: This cross sectional study was performed on 1512 prescriptions of patients aged ≥ 65 years from 5 pharmacies affiliated to Tehran University of Medical Sciences in 2014. Prescription of potentially inappropriate medications (PIMs) was investigated using the Beers Criteria along with WHO prescribing indices. Date were analyzed using SPSS software, and significance level was set at less than 0.05.

Results: Mean (SD) age of patients was 73.9(6.7) years. A total of 472 (31.2%) patients received at least 1 PIM. Benzodiazepines were the most frequent drug class and general practitioners (GPs) were the most frequent prescriber of PIMs. The highest and the lowest percentage of prescriptions containing brand-names were prescribed by subspecialists (62.5%) and GPs (42.2%), respectively. Antibiotics and injectable medications were prescribed for 26.8% and 28.5% of patients by GPs. Mean (SD) number of drugs per prescription was 3.57 (1.92). Prescriptions containing systemic antibiotics and PIMs had significantly higher mean number of drugs compared to those without these items (both P < 0.001).

Conclusion: There is a need for interventions to improve the quality of prescribing for elderly patients, especially by GPs. Also, there are still some problems in rational use of drugs based on prescribing indices, especially, prescribing brand-names and injectable medications.

Use of an Electronic Clinical Decision Support System in Primary Care to Assess Inappropriate Polypharmacy in Young Seniors With Multimorbidity: Observational, Descriptive, Cross-Sectional Study

Background

Multimorbidity is a global health problem that is usually associated with polypharmacy, which increases the risk of potentially inappropriate prescribing (PIP). PIP entails higher hospitalization rates and mortality and increased usage of services provided by the health system. Tools exist to improve prescription practices and decrease PIP, including screening tools and explicit criteria that can be applied in an automated manner.

Objective

This study aimed to describe the prevalence of PIP in primary care consultations among patients aged 65-75 years with multimorbidity and polypharmacy, detected by an electronic clinical decision support system (ECDSS) following the 2015 American Geriatrics Society Beers Criteria, the European Screening Tool of Older Person’s Prescription (STOPP), and the Screening Tool to Alert doctors to Right Treatment (START).

Methods

This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling adults aged 65-75 years (henceforth called young seniors), with multimorbidity (≥3 diseases) and polypharmacy (≥5 medications), who had visited their primary care doctor at least once over the last year at 1 of the 38 health care centers participating in the Multimorbidity and Polypharmacy in Primary Care (Multi-PAP) trial. Sociodemographic data, clinical and pharmacological treatment variables, and PIP, as detected by 1 ECDSS, were recorded. A multivariate logistic regression model with robust estimators was built to assess the factors affecting PIP according to the STOPP criteria.

Results

PIP was detected in 57.0% (338/593; 95% CI 53-61) and 72.8% (432/593; 95% CI 69.3-76.4) of the patients according to the STOPP criteria and the Beers Criteria, respectively, whereas 42.8% (254/593; 95% CI 38.9-46.8) of the patients partially met the START criteria. The most frequently detected PIPs were benzodiazepines (BZD) intake for more than 4 weeks (217/593, 36.6%) using the STOPP version 2 and the prolonged use of proton pump inhibitors (269/593, 45.4%) using the 2015 Beers Criteria. Being a woman (odds ratio [OR] 1.43, 95% CI 1.01-2.01; P=.04), taking a greater number of medicines (OR 1.25, 95% CI 1.14-1.37; P<.04), working in the primary sector (OR 1.91, 95% CI 1.25-2.93; P=.003), and being prescribed drugs for the central nervous system (OR 3.75, 95% CI 2.45-5.76; P<.001) were related to a higher frequency of PIP.

Conclusions

There is a high prevalence of PIP in primary care as detected by an ECDSS in community-dwelling young seniors with comorbidity and polypharmacy. The specific PIP criteria defined by this study are consistent with the current literature. This ECDSS can be useful for supervising prescriptions in primary health care consultations.

Academic Detailing with Provider Audit and Feedback Improve Prescribing Quality for Older Veterans

Suboptimal prescribing persists as a driver of poor quality care of older veterans and is associated with risk of hospitalization and emergency department visits. We adapted a successful medication management model, Integrated Management and Polypharmacy Review of Vulnerable Elders (IMPROVE), from an urban geriatric specialty clinic to rural community-based clinics that deliver primary care. The goals were to promote prescribing quality and safety for older adults, including reduced prescribing of potentially inappropriate medications (PIMs). We augmented the original model, which involved a pharmacist-led, one-on-one medication review with high-risk older veterans, to provide rural primary care providers (PCPs) and pharmacists with educational outreach through academic detailing and tools to support safe geriatric prescribing practices, as well as individual audit and feedback on prescribing practice and confidential peer benchmarking. Twenty PCPs and 4 pharmacists at 4 rural Georgia community-based outpatient clinics participated. More than 7,000 older veterans were seen in more than 20,000 PCP encounters during the 14-month intervention period. Implementation of the IMPROVE intervention reduced PIM prescribing incidence from 9.6 new medications per 100 encounters during baseline to 8.7 after the intervention (P = .009). IMPROVE reduced PIM prevalence (proportion of encounters involving veterans who were taking at least 1 PIM) from 22.6% to 16.7% (P < .001). These approaches were effective in reducing PIMs prescribed to older veterans in a rural setting and constitute a feasible model for disseminating geriatric best practices to the primary care setting.

Polypharmacy and Potentially Inappropriate Medication in People with Dementia: A Nationwide Study

BACKGROUND

Polypharmacy (use of ≥5 different medications) and potentially inappropriate medication (PIM) are well-known risk factors for numerous negative health outcomes. However, the use of polypharmacy and PIM in people with dementia is not well-described.

OBJECTIVE

To examine the prevalence of polypharmacy and PIM in older people with and without dementia in a nationwide population.

METHODS

Cross-sectional study of the Danish population aged ≥65 in 2014 (n = 1,032,120) based on register data, including information on diagnoses and dispensed prescriptions. Polypharmacy and PIM use among people with (n = 35,476) and without dementia (n = 994,231) were compared, stratified by living situation and adjusted for age, sex, and comorbidity. The red-yellow-green list from the Danish Institute for Rational Pharmacotherapy and the German PRISCUS list were used to define PIM.

RESULTS

People with dementia were more frequently exposed to polypharmacy (dementia: 62.6% versus no-dementia: 35.1%, p < 0.001) and likewise PIM (red-yellow-green: 45.0% versus 29.7%, p < 0.001; PRISCUS: 24.4% versus 13.2%, p < 0.001). After adjustments for age, sex, and comorbidity, the likelihood of polypharmacy and PIM was higher for community-dwelling people with dementia than without dementia (odds ratio (OR); [95% confidence interval (CI)] polypharmacy: 1.50 [1.45-1.55]; red-yellow-green: 1.27 [1.23-1.31]; PRISCUS: 1.25 [1.20-1.30]). In contrast, dementia slightly decreased the odds of polypharmacy and PIM in nursing home residents.

CONCLUSION

Use of polypharmacy and PIM were widespread in the older population and more so in people with dementia. This could have negative implications for patient-safety and demonstrates the need for interventions to improve drug therapy in people with dementia.

History and Future of KALIS: Towards Computer-assisted Decision Making in Prescriptive Medicine

With an increasing older population in Germany and the need for polypharmacy to treat multimorbid patients computer-assisted decision making on an individual level is increasingly important to reduce prescription errors and adverse drug reactions. While current systems focus on guidelines and prescribing information, molecular information is equally important for explanation and discovery of drug-related problems. Based on the existing KALIS system and newer projects like PIMBase, a new concept for the KALIS-2 system is presented. Improvements to the modularisation of components enable future extension and greater maintainability. Interoperability with available electronic health records standards and protocols allows the integration and communication with existing workflows for healthcare professionals. Finally, new visualisation modes empower the user to explore and analyze the patient situation in an individual patient subgraph. For offline use and dialogue between patient and general practitioner, the results can be printed out using a new reporting tool. The adherence to findings from previous decision support systems and reasons for their failed adoption is an important task in the development of KALIS-2.

Legacy Drug-Prescribing Patterns in Primary Care

PURPOSE

Polypharmacy is a key clinical challenge for primary care. Drugs that should be prescribed for an intermediate term (longer than 3 months, but not indefinitely) that are not appropriately discontinued could contribute to polypharmacy. We named this type of prescribing legacy prescribing. Commonly prescribed drugs with legacy prescribing potential include antidepressants, bisphosphonates, and proton pump inhibitors (PPIs). We evaluated the proportion of legacy prescribing within these drug classes.

METHODS

We conducted a population-based retrospective cohort study using prospectively collected data from the McMaster University Sentinel and Information Collaboration (MUSIC) Primary Care Practice Based Research Network, located in Hamilton, Ontario. All adult patients (aged 18 or older) in the MUSIC data set during 2010-2016 were included (N = 50,813). We calculated rates of legacy prescribing of antidepressants (prescription longer than 15 months), bisphosphonates (longer than 5.5 years), and PPIs (longer than 15 months).

RESULTS

The proportion of patients having a legacy prescription at some time during the study period was 46% (3,766 of 8,119) for antidepressants, 14% (228 of 1,592) for bisphosphonates, and 45% (2,885 of 6,414) for PPIs. Many of these patients held current prescriptions. The mean duration of prescribing for all legacy prescriptions was significantly longer than that for non-legacy prescriptions (P <.001). Concurrent legacy prescriptions for both antidepressants and PPIs was common, signaling a potential prescribing cascade.

CONCLUSIONS

The phenomenon of legacy prescribing appears prevalent. These data demonstrate the potential of legacy prescribing to contribute to unnecessary polypharmacy, providing an opportunity for system-level intervention in primary care with enormous potential benefit for patients.

Potentially inappropriate medication among people with dementia in eight European countries

Objectives

to evaluate the frequency of potentially inappropriate medication (PIM) prescription among older people with dementia (PwD) from eight countries participating in the European study 'RightTimePlaceCare', and to evaluate factors and adverse outcomes associated with PIM prescription.

Methods

survey of 2,004 PwD including a baseline assessment and follow-up after 3 months. Interviewers gathered data on age, sex, prescription of medication, cognitive status, functional status, comorbidity, setting and admission to hospital, fall-related injuries and mortality in the time between baseline and follow-up. The European Union(7)-PIM list was used to evaluate PIM prescription. Multivariate regression analysis was used to investigate factors and adverse outcomes associated with PIM prescription.

Results

overall, 60% of the participants had at least one PIM prescription and 26.4% at least two. The PIM therapeutic subgroups most frequently prescribed were psycholeptics (26% of all PIM prescriptions) and 'drugs for acid-related disorders' (21%). PwD who were 80 years and older, lived in institutional long-term care settings, had higher comorbidity and were more functionally impaired were at higher risk of being prescribed two PIM or more. The prescription of two or more PIM was associated with higher chance of suffering from at least one fall-related injury and at least one episode of hospitalisation in the time between baseline and follow-up.

Conclusions

PIM use among PwD is frequent and is associated with institutional long-term care, age, advanced morbidity and functional impairment. It also appears to be associated with adverse outcomes. Special attention should be paid to psycholeptics and drugs for acid-related disorders.

Data-Driven Assessment of Potentially Inappropriate Medication in the Elderly

Multimorbid patients taking polypharmacy represent a growing population at high risk for inappropriate prescribing. Various lists for identifying potentially inappropriate medication are spread across scientific journals and difficult to access. To address this ongoing need, a new database named PIMBase is developed which integrates these well-known lists and unifies their rating scales. The analysis of the pharmacovigilance data reveals the benefits of combining the lists. PIMBase is meant to be a web-based system and starting point for the data-driven assessment of polypharmacy to identify inappropriate medication and to improve the quality of prescribing. PIMBase is available at https://pimbase.kalis-amts.de.

Pay for performance associated with increased volume of medication reviews but not with less inappropriate use of medications among the elderly - an observational study

OBJECTIVE

A pay for performance programme was introduced in 2009 by a Swedish county with 1.6 million inhabitants. A process measure with payment linked to coding for medication reviews among the elderly was adopted. We assessed the association with inappropriate medication for five years after baseline.

DESIGN AND SETTING

Observational study that compared medication for elderly patients enrolled at primary care units that coded for a high or low volume of medication reviews.

PATIENTS

144,222 individuals at 196 primary care centres, age 75 or older.

MAIN OUTCOME MEASURES

Percentage of patients receiving inappropriate drugs or polypharmacy during five years at primary care units with various levels of reported medication reviews.

RESULTS

The proportion of patients with a registered medication review had increased from 3.2% to 44.1% after five years. The high-coding units performed better for most indicators but had already done so at baseline. Primary care units with the lowest payment for coding for medication reviews improved just as well in terms of inappropriate drugs as units with the highest payment - from 13.0 to 8.5%, compared to 11.6 to 7.4% and from 13.6 to 7.2% vs 11.8 to 6.5% for polypharmacy.

CONCLUSIONS

Payment linked to coding for medication reviews was associated with an increase in the percentage of patients for whom a medication review had been registered. However, the impact of payment on quality improvement is uncertain, given that units with the lowest payment for medication reviews improved equally well as units with the highest payment.

Exploring the enablers and barriers to implementing the Medication Appropriateness Tool for Comorbid Health conditions during Dementia (MATCH-D) criteria in Australia: a qualitative study

OBJECTIVES

The Medication Appropriateness Tool for Comorbid Health conditions in Dementia (MATCH-D) criteria provide expert consensus guidance about medication use for people with dementia. This study aimed to identify enablers and barriers to implementing the criteria in practice.

SETTING

Participants came from both rural and metropolitan communities in two Australian states.

PARTICIPANTS

Focus groups were held with consumers, general practitioners, nurses and pharmacists.

OUTCOMES

data were analysed thematically.

RESULTS

Nine focus groups were conducted. Fifty-five participants validated the content of MATCH-D, appraising them as providing patient-centred principles of care. Participants identified potential applications (including the use of MATCH-D as a discussion aid or educational tool for consumers about medicines) and suggested supporting resources.

CONCLUSION

Participants provided insights into applying MATCH-D in practice and suggested resources to be included in an accompanying toolkit. These data provide external validation of MATCH-D and an empiric basis for their translation to practice. Following resource development, we plan to evaluate the feasibility and efficacy of implementation in practice.

Application of the STOPP/START criteria to a medical record database

PURPOSE

The STOPP/START criteria are increasingly used to assess prescribing quality in elderly patients at practice level. Our aim was to test computerized algorithms for applying these criteria to a medical record database.

METHODS

STOPP/START criteria-based computerized algorithms were defined using Anatomical-Therapeutic-Chemical (ATC) codes for medication and International Classification of Primary Care (ICPC) codes for diagnoses. The algorithms were applied to a Dutch primary care database, including patients aged ≥65 years using ≥5 chronic drugs. We tested for associations with patient characteristics that have previously shown a relationship with the original STOPP/START criteria, using multivariate logistic regression models.

RESULTS

Included were 1187 patients with a median age of 75 years. In total, 39 of the 62 STOPP and 18 of the 26 START criteria could be converted to a computerized algorithm. The main reasons for inapplicability were lack of information on the severity of a condition and insufficient covering of ICPC-codes. We confirmed a positive association between the occurrence of both the STOPP and the START criteria and the number of chronic drugs (adjusted OR ranging from 1.37, 95% CI 1.04-1.82 to 3.19, 95% CI 2.33-4.36) as well as the patient's age (adjusted OR for STOPP 1.30, 95% CI 1.01-1.67; for START 1.73, 95% CI 1.35-2.21), and also between female gender and the occurrence of STOPP criteria (adjusted OR 1.41, 95% CI 1.09-1.82).

CONCLUSION

Sixty-five percent of the STOPP/START criteria could be applied with computerized algorithms to a medical record database with ATC-coded medication and ICPC-coded diagnoses.

Implementation of guideline-based therapy for chronic obstructive pulmonary disease: Differences between men and women veterans

Chronic obstructive pulmonary disease (COPD) is common among both men and women, and guidelines recommend the same therapy for both sexes. While previous studies have identified gender differences in other chronic disease management, few studies have examined how implementation of COPD guidelines differs between men and women. We performed a cross-sectional study of veterans admitted to Veterans Affairs (VA) hospitals for COPD during October 1, 2008, to September 30, 2011. We collected information on baseline COPD medications during the 6 months prior to hospitalization and categorized therapies as “appropriate” or “inappropriate” based on current guidelines. We used multivariable logistic regression to examine the differences in COPD medications between men and women, after controlling for baseline patient characteristics. We also examined the differences in hospital outcomes, including length of stay and hospital readmission. We identified 33,558 veterans, including 1149 women and 32,409 men who were admitted to 130 VA hospitals. Women were significantly less likely to have received inhaler therapies prior to admission, with lower rates of short-acting beta agonists, short-acting muscarinic antagonists, long-acting beta agonists, and long-acting muscarinic antagonists compared to men. Women also received fewer appropriate inhaler combinations (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.74–0.93) and more inappropriate combinations (OR = 1.33, 95% CI 1.17–1.51). Women and men were prescribed similar rates of inhaled steroid and oral steroids. Hospital outcomes were also similar between the two groups. These findings highlight a potential gender disparity in appropriate outpatient COPD therapy. Improving the quality of care for patients with COPD should include equitable implementation of guideline-based COPD management.