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Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases.

ABSTRACT: INTRODUCTION:Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to population-wide health administrative data could provide an opportunity to assess the impact of PIP on individual patients as well as on the healthcare system. This would open new possibilities for interventions to monitor and optimise medication management on a broader, population-level scale. METHODS AND ANALYSIS:The aim of this study is to describe the occurrence of PIP in Ontario's older population (aged 65?years and older), and to assess the health outcomes and health system costs associated with PIP-more specifically, the association between PIP and the occurrence of ED visits, hospitalisations and death, and their related costs. This will be done within the framework of a population-based retrospective cohort study using Ontario's large health administrative and population databases. Eligible patients aged 66?years and older who were issued at least 1 prescription between 1 April 2003 and 31 March 2014 (approximately 2 million patients) will be included. ETHICS AND DISSEMINATION:Ethical approval was obtained from the Ottawa Health Services Network Ethical Review Board and from the Bruyère Research Institute Ethics Review Board. Dissemination will occur via publication, presentation at national and international conferences, and ongoing exchanges with regional, provincial and national stakeholders, including the Ontario Drug Policy Research Network and the Ontario Ministry of Health and Long-Term Care. TRIAL REGISTRATION NUMBER:Registered with clinicaltrials.gov (registration number: NCT02555891).

SUBMITTER: Bjerre LM

PROVIDER: S-EPMC4663446 | biostudies-literature | 2015 Nov

REPOSITORIES: biostudies-literature

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Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases.

Bjerre Lise M LM Ramsay Timothy T Cahir Catriona C Ryan Cristín C Halil Roland R Farrell Barbara B Thavorn Kednapa K Catley Christina C Hawken Steven S Gillespie Ulrika U Manuel Douglas G DG

BMJ open 20151125 11

<h4>Introduction</h4>Adverse drug events (ADEs) are common in older people and contribute significantly to emergency department (ED) visits, unplanned hospitalisations, healthcare costs, morbidity and mortality. Many ADEs are avoidable if attention is directed towards identifying and preventing inappropriate drug use and undesirable drug combinations. Tools exist to identify potentially inappropriate prescribing (PIP) in clinical settings, but they are underused. Applying PIP assessment tools to ...[more]

PMID: 26608642

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Project description:BackgroundInappropriate medication use (IMU) by elderly people is a public health problem associated with adverse effects on health. There are a number of methods for identifying IMU, some involving clinical judgment and others, consensually generated lists of drugs to be avoided. This review aims to describe studies that used information from insurance company and social security administrative databases to assess IMU among community-dwelling elderly and to present the risk factors most often associated with IMU.MethodsThe paper search was conducted in Medline and Embase, using descriptors combined with free terms in the title or abstract. The limits applied were: publication date from January 1990 to June 2010, species (human) and publication type (excluding editorials, letters and reviews). Excluded were: case studies; studies in hospitals, nursing homes, or hospital emergency departments; studies of specific drugs or groups of drugs; studies exclusively of subgroups of ill, frail elderly or rural populations. Additional studies were identified from reference lists. Data were selected and extracted after independent reading by two of the authors, with disagreements resolved by a third author. The primary outcome assessed was prevalence of IMU, defined as the proportion of elderly who received at least one inappropriate medication.ResultsOf the 628 studies, 19 met the inclusion criteria, 78.9% of them conducted in the USA. All papers included used explicit criteria of inappropriateness, most commonly Beers criteria (73.7%) in their three versions (1991, 1997 and 2002). Other methods used included Zhan, which is derived from on Beers criteria and was applied in 21% of the papers selected. The study found that prevalence of IMU ranged from 11.5% to 62.5%. Only 68.4% of the studies included examined inappropriate use-related factors, the most important being female sex, advanced age and larger number of drugs.ConclusionsThe results show that the prevalence of IMU among community-dwelling elderly is high and depends partly on the method used to evaluate improper use. Besides the diversity of methods, other factors, such as patient sex, age and number of drugs used concurrently, appear to have influenced the estimates of IMU.

Project description:Potentially inappropriate prescribing (PIP) is one of the major risk factors of adverse drug events in elderly patients. Pharmacotherapy assessment criteria may help reduce the instances of PIP among geriatric patients. This study aimed to verify the applicability of selected tools designed to assess prescribing appropriateness in elderly and to identify PIP in the study population. Based on pharmacist-led medication reviews that were performed among patients attending senior day-care centers based in Poland, aged 65 years and over, the following tools were applied for assessing the appropriateness of pharmacotherapy: PILA (patient-in-focus listing approach): STOPP/START v.2 and Amsterdam tool, DOLA (drug-oriented listing approach): PRISCUS list, and DOLA+: Beers criteria v.2019 and the EU(7)-PIM list-the criteria oriented on medications requiring indications. Fifty patients participated in the study. The prevalence of prescribing issues in the study population was very high and ranged from 28% to 100%, depending on the criteria applied. The highest number of PIP cases was identified based on the PILA criteria: STOPP/START v.2 (171, a mean of 3.4 PIP cases per patient), and the Amsterdam criteria (124, a mean of 2.5 PIP cases per patient). The lack of protective vaccinations against pneumococci identified using the START criterion was found to be the most common PIP (identified in 96% of the patients). Proton-pump inhibitors (PPIs) were identified as the most problematic group of medications. The STOPP, EU(7)-PIM and Beers criteria revealed cases of inappropriate prolonged PPI use, whereas the Amsterdam tool identified cases where PPIs should have been prescribed but were not. The highest number of PIP cases in the study population were identified with the PILA tools, and on this basis the most comprehensive assessment of pharmacotherapy appropriateness in geriatric patients was conducted. Further studies should be designed, covering a larger group of patients across different healthcare settings (inpatient and outpatient), with access to comprehensive patient data.

Project description:ObjectivesThe objectives of the present analyses are to estimate the frequency of potentially inappropriate prescribing (PIP) at admission according to STOPP/START criteria version 2 in older patients hospitalised due to chronic disease exacerbation as well as to identify risk factors associated to the most frequent active principles as potentially inappropriate medications (PIMs).MethodsA multicentre, prospective cohort study including older patients (≥65) hospitalized due to chronic disease exacerbation at the internal medicine or geriatric services of 5 hospitals in Spain between September 2016 and December 2018 was conducted. Demographic and clinical data was collected, and a medication review process using STOPP/START criteria version 2 was performed, considering both PIMs and potential prescribing omissions (PPOs). Primary outcome was defined as the presence of any most frequent principles as PIMs, and secondary outcomes were the frequency of any PIM and PPO. Descriptive and bivariate analyses were conducted on all outcomes and multilevel logistic regression analysis, stratified by participating centre, was performed on the primary outcome.ResultsA total of 740 patients were included (mean age 84.1, 53.2% females), 93.8% of them presenting polypharmacy, with a median of 10 chronic prescriptions. Among all, 603 (81.5%) patients presented at least one PIP, 542 (73.2%) any PIM and 263 (35.5%) any PPO. Drugs prescribed without an evidence-based clinical indication were the most frequent PIM (33.8% of patients); vitamin D supplement in older people who are housebound or experiencing falls or with osteopenia was the most frequent PPO (10.3%). The most frequent active principles as PIMs were proton pump inhibitors (PPIs) and benzodiazepines (BZDs), present in 345 (46.6%) patients. This outcome was found significantly associated with age, polypharmacy and essential tremor in an explanatory model with 71% AUC.ConclusionsPIMs at admission are highly prevalent in these patients, especially those involving PPIs or BZDs, which affected almost half of the patients. Therefore, these drugs may be considered as the starting point for medication review and deprescription.Trial registration numberNCT02830425.

Project description:Inappropriate prescribing is a risk factor for adverse drug reactions and hospitalizations in the elderly and places a considerable burden on the healthcare system. Hence, it is imperative to identify irrational prescribing and implement interventions to improve prescribing appropriateness in geriatric clinical practice. This study aimed to determine: (i) the prevalence of potentially inappropriate medications (PIMs) according to Beers STOPP, FORTA, and the Medication Appropriateness Index (MAI) criteria; (ii) the prevalence of potential prescribing omissions (PPOs) according to START criteria; and (iii) the predictors for PIMs and PPOs. A cross-sectional study was performed among elderly outpatients of 10 primary healthcare centers with specialized geriatric clinics in Kuwait. Four-hundred and seventy-eight patients were selected randomly, 420 (87.9%) agreed to participate. Data about chronic diseases and prescribed medications were obtained from the physicians by accessing the patients' medical records. Descriptive and multivariable logistic regression were used for data analysis. A total of 2645 medications were prescribed to all patients; mean (SD) number of medicines per patient was 6.3 (3.0). PIMs were present in 53.1%, 55.7%, and 44.3% of respondents, according to Beers, STOPP, and FORTA criteria, respectively. Almost 74% of respondents had one or more inappropriate ratings among their medications in the MAI criteria. According to START criteria, 19.8% of patients had at least one PPO. Respondents taking ≥ 5 medications were found to be using more PIMs according to Beers (OR: 6.3), STOPP (OR: 3.3), FORTA (OR: 6.0) and MAI (OR: 3.9) criteria in comparison to those taking ≤ 4 medications (p<0.001). The MAI revealed a significantly higher number of medications with inappropriate ratings compared to the Beers, STOPP and FORTA criteria (p<0.001). Taking the MAI as reference standard, STOPP criteria had the highest sensitivity (68.6%) and measure of agreement (Kappa index = 0.40) to detect PIMs compared with Beers and FORTA criteria. Inappropriate prescribing is common among the elderly in the primary geriatric clinics. This necessitates further evaluation of its impact on clinical outcomes and warrants efforts to implement interventions to improve prescribing practice in these settings.

Dataset Information

Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases.

Publications

Assessing potentially inappropriate prescribing (PIP) and predicting patient outcomes in Ontario's older population: a population-based cohort study applying subsets of the STOPP/START and Beers' criteria in large health administrative databases.

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