1
|
Lönnbro J, Holmqvist L, Persson E, Thysell P, Åberg ND, Wallerstedt SM. Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions. Br J Clin Pharmacol 2021; 87:3825-3834. [PMID: 33609324 DOI: 10.1111/bcp.14790] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 02/13/2021] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate inter-rater agreement on the quality of drug treatment, and the relationship between the drug treatment and hospital admission. METHODS Three specialist physicians and two resident physicians determined, independently and in consensus, the quality of drug treatment from an overall medical perspective, and its association with admission, in 30 randomly selected patients (50% female, median age 72 years) admitted to Sahlgrenska University Hospital, Sweden, in April 2018. The inter-rater agreement was evaluated with Gwet's agreement coefficient (AC1 ). RESULTS In all, 200 (95%) out of 210 drugs at admission and 238 (97%) out of 245 drugs at discharge were assessed as reasonable drug treatment by all assessors. Conversely, none of the drugs at admission, and two at discharge, were assessed as unreasonable drug treatment by all assessors (AC1 : 0.88 and 0.94 [all], 0.86 and 0.95 [specialists], 0.92 and 0.92 [residents], respectively). The assessments regarding the association between the drug treatment and the hospital admission (not related or main/contributory reason) were consistent between the assessors for 16 out of 30 patients (AC1 : 0.67 [all], 0.74 [specialists], 0.54 [residents]). In none of the three cases where the hospital admission was considered possibly attributable to a prescribing error did the assessors make consistent assessments. CONCLUSIONS As the inter-rater agreement ranged between weak and almost perfect, the reliability of assessments of drug treatment quality, as well as adverse consequences, appears to be a methodological concern. To yield acceptably reliable results regarding both drug treatment aspects at issue, specialist physicians should be involved.
Collapse
Affiliation(s)
- Johan Lönnbro
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lina Holmqvist
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Persson
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Thysell
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - N David Åberg
- Department of Acute Medicine and Geriatrics, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,HTA Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
2
|
Thorell K, Midlöv P, Fastbom J, Halling A. Use of potentially inappropriate medication and polypharmacy in older adults: a repeated cross-sectional study. BMC Geriatr 2020; 20:73. [PMID: 32075586 PMCID: PMC7032002 DOI: 10.1186/s12877-020-1476-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND With age, the number of chronic conditions increases along with the use of medications. For several years, polypharmacy has been found to be on the increase in western societies. Polypharmacy is associated with an increased risk of adverse drug events (ADE). Medications called potentially inappropriate medications (PIM) have also been found to increase the risk of ADEs in an older population. In this study, which we conducted during a national information campaign to reduce PIM, we analysed the prevalence of PIM in an older adult population and in different strata of the variables age, gender, number of chronic conditions and polypharmacy and how that prevalence changed over time. METHODS This is a registry-based repeated cross-sectional study including two cohorts. Individuals aged 75 or older listed at a primary care centre in Blekinge on the 31st March 2011 (cohort 1, 15,361 individuals) or on the 31st December 2013 (cohort 2, 15,945 individuals) were included in the respective cohorts. Using a chi2 test, the two cohorts were compared on the variables age, gender, number of chronic conditions and polypharmacy. Use of five or more medications at the same time was the definition for polypharmacy. RESULTS Use of PIM decreased from 10.60 to 7.04% (p-value < 0.001) between 2011 and 2013, while prevalence of five to seven chronic conditions increased from 20.55 to 23.66% (p-value < 0.001). Use of PIM decreased in all strata of the variables age, gender number of chronic conditions and polypharmacy. Except for age 80-84 and males, where it increased, prevalence of polypharmacy was stable in all strata of the variables. CONCLUSIONS Use of potentially inappropriate medications had decreased in all variables between 2011 and 2013; this shows the possibility to reduce PIM with a focused effort. Polypharmacy does not increase significantly compared to the rest of the population.
Collapse
Affiliation(s)
- Kristine Thorell
- Department of Quality and Development, Karlskrona, Region Blekinge, Sweden.
- Department of Clinical Sciences, Malmö, General Practice/Family Medicine, Lund University, Box 50332, 202 13, Malmö, Sweden.
| | - Patrik Midlöv
- Department of Clinical Sciences, Malmö, General Practice/Family Medicine, Lund University, Box 50332, 202 13, Malmö, Sweden
| | - Johan Fastbom
- Aging Research Center, Center for Alzheimer Research, Department of Neurobiology, Care Sciences And Society, Karolinska Institute and Stockholm University, Stockholm, Sweden
| | - Anders Halling
- Department of Clinical Sciences, Malmö, General Practice/Family Medicine, Lund University, Box 50332, 202 13, Malmö, Sweden
| |
Collapse
|
3
|
Correa-Pérez A, Delgado-Silveira E, Martín-Aragón S, Rojo-Sanchís AM, Cruz-Jentoft AJ. Fall-risk increasing drugs and prevalence of polypharmacy in older patients discharged from an Orthogeriatric Unit after a hip fracture. Aging Clin Exp Res 2019; 31:969-975. [PMID: 30276631 DOI: 10.1007/s40520-018-1046-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 09/24/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Polypharmacy and fall-risk increasing drugs (FRIDS) have been associated with injurious falls. We aimed to estimate the prevalence of polypharmacy and FRIDS in older patients discharged from an Orthogeriatric Unit after a hip fracture surgery. METHODS This study describes the baseline findings of a 2-year retrospective cohort study. We included patients older than 80 years discharged from an Orthogeriatric Unit who were able to walk before surgery. Patient's baseline variables, total number of drugs, and FRIDS at hospital discharge were collected. RESULTS We included 228 patients. The mean number of drugs and FRIDS prescribed at discharge was 11.6 ± 3.0 and 2.9 ± 1.6, respectively. Polypharmacy was prevalent in all patients except in three: 23.3% (5-9 drugs) and 75.9% (≥ 10 drugs). Only 11 patients had no FRIDS and 35.5% were on > 3 FRIDS. The most prevalent FRIDS were: agents acting on the renin-angiotensin system (43.9%) and anxiolytics (39.9%). The number of FRIDS was higher in patients with extreme polypharmacy (3.4 ± 1.5) than in those on 5-9 drugs (1.5 ± 1.0, p < 0.05). Independent people in performing instrumental activities had lower risk of extreme polypharmacy (≥ 10 drugs) or > 3 FRIDS: OR 0.39 (95% CI 0.18-0.83) and OR 0.41 (95% CI 0.20-0.84), respectively. People living in a nursing home had higher risk of > 3 FRIDS: OR 4.03 (95% CI 1.12-14.53). CONCLUSIONS Polypharmacy and fall-risk increasing drugs are prevalent in patients discharged from orthogeriatric care after surgery for a hip fracture. Interventions on drug use at hospital discharge could have a potential impact on falls in this high-risk population.
Collapse
Affiliation(s)
- Andrea Correa-Pérez
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Crta. Colmenar Km 9.1, 28034, Madrid, Spain.
| | - Eva Delgado-Silveira
- Servicio de Farmacia, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Sagrario Martín-Aragón
- Departamento de Farmacología, Facultad de Farmacia, Universidad Complutense, Madrid, Spain
| | | | - Alfonso J Cruz-Jentoft
- Servicio de Geriatría, Hospital Universitario Ramón y Cajal (IRYCIS), Crta. Colmenar Km 9.1, 28034, Madrid, Spain
| |
Collapse
|
4
|
Parodi López N, Wallerstedt SM. Quality of prescribing in older people from a broad family physician perspective: a descriptive pilot study. BMJ Open 2019; 9:e027290. [PMID: 31160274 PMCID: PMC6549657 DOI: 10.1136/bmjopen-2018-027290] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the quality of drug treatment in older people from a broad family physician perspective, and to provide evidence for power calculations in full-scale studies on prescribing quality. DESIGN Descriptive, retrospective pilot study. SETTING A primary healthcare centre in Sweden. PARTICIPANTS 123 consecutive patients, ≥65 years, with a non-urgent physician consultation in January 2016. MEASURES The drug treatment was assessed by a physician as either appropriate or suboptimal, taking individual factors like morbidity, life expectancy and concurrent drug treatment into account, and preceded by the application of 493 criteria from three screening tools for Potentially Inappropriate Medications (PIMs) and Potential Prescribing Omissions (PPOs). Suboptimal drug treatment was further categorised regarding priority: (1) immediate change suggested or (2) actions suggested in the longer term. Prevalence of the procedure code 'medication review' and the results thereof were also recorded. RESULTS Median age: 76 years; 48% women. When a family physician perspective was applied, and 593 PIMs/PPOs identified in 117 (95%) patients considered, 45 (37%) patients had suboptimal drug treatment. Immediate handling was suggested in 13 (11%) patients, most often concerning withdrawals of drugs for anxiety and insomnia. Handling in the longer term was suggested in 32 (26%) patients, most often concerning overuse of proton pump inhibitors. Over the last year, the procedure code 'medication review' was recorded for 65 (53%) patients. In medication reviews recorded during January 2016 (n=45), 23 (7%) drugs out of 309 were acted on, most often a dosage adjustment. CONCLUSIONS This pilot study shows that when a broad family physician perspective is applied, taking individual factors and medical priorities in the complex clinical situation into account, drug treatment in primary care is appropriate for the majority of older patients. The results may be useful in sample size considerations for future studies on prescribing practices.
Collapse
Affiliation(s)
- Naldy Parodi López
- Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Susanna Maria Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- HTA-centrum, Sahlgrenska universitetssjukhuset, Gothenburg, Sweden
| |
Collapse
|
5
|
Abolhassani N, Marques-Vidal P. Polypharmacy, defined as taking five or more drugs, is inadequate in the cardiovascular setting. J Clin Epidemiol 2018; 101:1-4. [PMID: 29777797 DOI: 10.1016/j.jclinepi.2018.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/10/2018] [Accepted: 05/09/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND By how much polypharmacy (defined by number of drugs) differs from polyactive ingredient use (defined by the number of pharmacologically active ingredients) has not been assessed. OBJECTIVES To compare the extent of polypharmacy vs. polyactive ingredients among patients taking cardiovascular (CV) medicines. METHODS Prospective, 10-year follow-up study conducted among 880 participants of the CoLaus study taking CV drugs at baseline. Polypharmacy was defined as the use of five or more CV medicines; polyactive ingredient use was defined as the use of five or more pharmacologically active CV ingredients. RESULTS The prevalence of polypharmacy increased from 1.4% (0.7-2.4) (prevalence rate [95% confidence interval]) at baseline to 11.9% (9.9-14.3) at follow-up, and the prevalence of polyactive ingredients increased from 2.4% (1.5-3.6) at baseline to almost 17.6% (15.2-20.3) at follow-up. The prevalence of combination drugs increased from 15.7% (13.3-18.3) at baseline to 25.9% (23-28.9) at follow-up, and the prevalence of three-component combination use increased from 0.1% (0.0-0.6) at baseline to 2.3% (1.4-3.5) at follow-up. At baseline, nine of 21 participants on polyactive ingredients were not considered as being on polypharmacy; at follow-up, the rate was 50 of 155 participants. CONCLUSION Among individuals taking CV drugs, polypharmacy as defined by the number of drugs underestimates the prevalence of individuals taking five or more pharmacologically active drugs. Polypharmacy should no longer be based on the number of drugs but on the number of pharmacologically active drugs.
Collapse
Affiliation(s)
- Nazanin Abolhassani
- Lausanne University Hospital (CHUV), Office BH10-642, Rue du Bugnon 46, Lausanne, Switzerland.
| | - Pedro Marques-Vidal
- Lausanne University Hospital (CHUV), Office BH10-642, Rue du Bugnon 46, Lausanne, Switzerland
| |
Collapse
|
6
|
Page A, Clifford R, Potter K, Etherton-Beer C. A concept analysis of deprescribing medications in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1361] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Amy Page
- School of Medicine and Pharmacology; University of Western Australia; Crawley Australia
| | - Rhonda Clifford
- School of Medicine and Pharmacology; University of Western Australia; Crawley Australia
| | | | | |
Collapse
|
7
|
Ong GJ, Page A, Caughey G, Johns S, Reeve E, Shakib S. Clinician agreement and influence of medication-related characteristics on assessment of polypharmacy. Pharmacol Res Perspect 2017; 5:e00321. [PMID: 28603638 PMCID: PMC5464348 DOI: 10.1002/prp2.321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 12/31/2022] Open
Abstract
It is not known how clinicians assess polypharmacy or the medication‐related characteristics that influence their assessment. The aim of this study was to examine the level of agreement between clinicians when assessing polypharmacy and to identify medication‐related characteristics that influence their assessment. Twenty cases of patients with varying levels of comorbidity and polypharmacy were used to examine clinician assessment of polypharmacy. Medicine‐related factors within the cases included Beers and STOPP Criteria medicines, falls‐risk medicines, drug burden index (DBI) medicines, medicines causing postural hypotension, and pharmacokinetic drug–drug interactions. Clinicians were asked to rate cases on the degree of polypharmacy, likelihood of harm, and potential for the medication list to be simplified. Inter‐rater reliability analysis, correlations, and multivariate logistic regression analyses were conducted to identify medicine factors associated with clinicians' assessment. Eighteen expert clinicians were recruited (69.2% response rate). Strong agreement was observed in clinicians' assessment of polypharmacy (intraclass correlation coefficients [ICC] = 0.94), likelihood to cause harm (ICC = 0.89), and ability to simplify medication list (ICC = 0.90). Multivariate analyses demonstrated number of medicines (P < 0.0001) and DBI scores (P = 0.047) were significantly associated with assessment of polypharmacy. Medicines associated with harm were significantly associated with the number of medicines (P = 0.01) and Beers criteria medicines (P = 0.003). Ability to simplify the medication regimen was significantly associated with number of medicines (P = 0.03) and medicines from the STOPP criteria (P = 0.018). Among clinicians, strong consensus exists with regard to assessment of polypharmacy, medication harm, and ability to simplify medications. Definitions of polypharmacy need to take into account not only the numbers of medicines but also potential for medicines to cause harm or be inappropriate, and validate them against clinical outcomes.
Collapse
Affiliation(s)
- Gao-Jing Ong
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Amy Page
- School of Medicine and Pharmacology University of Western Australia Perth Australia
| | - Gillian Caughey
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,School of Pharmacy and Medical Sciences University of South Australia Adelaide South Australia Australia
| | - Sally Johns
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia
| | - Emily Reeve
- Cognitive Decline Partnership Centre Kolling Institute of Medical Research Sydney Medical School The University of Sydney New South Wales Australia.,Geriatric Medicine Research Unit Dalhousie University and Nova Scotia Health Authority 5955 Veterans' Memorial Lane Halifax Nova Scotia Canada
| | - Sepehr Shakib
- Department of Clinical Pharmacology Royal Adelaide Hospital North Terrace Adelaide South Australia Australia.,Discipline of Pharmacology School of Medicine University of Adelaide North Terrace Adelaide South Australia Australia
| |
Collapse
|
8
|
Patterns of drug prescriptions in an orthogeriatric ward as compared to orthopaedic ward: results from the Trondheim Hip Fracture Trial-a randomised clinical trial. Eur J Clin Pharmacol 2017; 73:937-947. [PMID: 28550459 PMCID: PMC5508046 DOI: 10.1007/s00228-017-2263-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/03/2017] [Indexed: 11/09/2022]
Abstract
Purpose In the Trondheim Hip Fracture Trial, 397 home-dwelling patients with hip fractures were randomised to comprehensive geriatric care (CGC) in a geriatric ward or traditional orthopaedic care (OC). Patients in the CGC group had significantly better mobility and function 4 months after discharge. This study explores group differences in drug prescribing and possible associations with the outcomes in the main study. Methods Drugs prescribed at admission and discharge were registered from hospital records. Mobility, function, fear of falling and quality of life were assessed using specific rating scales. Linear regression was used to analyse association between drug changes and outcomes at 4 months. Results The mean age was 83 years, and 74% were females. The mean number (± SD) of drugs in the CGC and OC groups was 3.8 (2.8) and 3.9 (2.8) at inclusion and 7.1 (2.8) and 6.2 (3.0) at discharge, respectively (p = 0.003). The total number of withdrawals was 209 and 82 in the CGC and OC groups, respectively (p < 0.0001), and the number of starts was 844 and 526, respectively (p < 0.0001). A significant negative association was found between the number of drug changes during the hospital stay and mobility and function 4 months later in both groups. However, this association disappeared when adjusting for baseline function and comorbidities. Conclusion These secondary analyses suggest that there are significant differences in the pharmacological treatment between geriatric and orthopaedic wards, but these differences could not explain the beneficial effect of CGC in the Trondheim Hip Fracture Trial. Electronic supplementary material The online version of this article (doi:10.1007/s00228-017-2263-x) contains supplementary material, which is available to authorized users.
Collapse
|
9
|
Is my older cancer patient on too many medications? J Geriatr Oncol 2017; 8:77-81. [DOI: 10.1016/j.jgo.2016.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/03/2016] [Accepted: 10/31/2016] [Indexed: 12/20/2022]
|
10
|
Wirtz VJ, Hogerzeil HV, Gray AL, Bigdeli M, de Joncheere CP, Ewen MA, Gyansa-Lutterodt M, Jing S, Luiza VL, Mbindyo RM, Möller H, Moucheraud C, Pécoul B, Rägo L, Rashidian A, Ross-Degnan D, Stephens PN, Teerawattananon Y, 't Hoen EFM, Wagner AK, Yadav P, Reich MR. Essential medicines for universal health coverage. Lancet 2017; 389:403-476. [PMID: 27832874 PMCID: PMC7159295 DOI: 10.1016/s0140-6736(16)31599-9] [Citation(s) in RCA: 319] [Impact Index Per Article: 45.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 09/05/2016] [Accepted: 09/05/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Veronika J Wirtz
- Department of Global Health/Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.
| | - Hans V Hogerzeil
- Global Health Unit, Department of Health Sciences, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Andrew L Gray
- Division of Pharmacology, Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | | | | | | | | | - Sun Jing
- Peking Union Medical College School of Public Health, Beijing, China
| | - Vera L Luiza
- National School of Public Health Sergio Arouca, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Helene Möller
- United Nations Children's Fund, Supply Division, Copenhagen, Denmark
| | - Corrina Moucheraud
- UCLA Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Bernard Pécoul
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Lembit Rägo
- Regulation of Medicines and other Health Technologies, Geneva, Switzerland
| | - Arash Rashidian
- Department of Information, Evidence and Research, Eastern Mediterranean Region, World Health Organization, Cairo, Egypt; School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Dennis Ross-Degnan
- Research, Eastern Mediterranean Region, World Health Organization, Cairo, Egypt; Harvard Medical School, Boston, MA, USA; Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | | | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Thai Ministry of Public Health Nonthaburi, Thailand
| | - Ellen F M 't Hoen
- Global Health Unit, Department of Health Sciences, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Anita K Wagner
- Research, Eastern Mediterranean Region, World Health Organization, Cairo, Egypt; Harvard Medical School, Boston, MA, USA
| | - Prashant Yadav
- William Davidson Institute at the University of Michigan, Ann Arbor, MI, USA
| | | |
Collapse
|
11
|
Lönnbro J, Wallerstedt SM. Clinical relevance of the STOPP/START criteria in hip fracture patients. Eur J Clin Pharmacol 2017; 73:499-505. [PMID: 28050623 PMCID: PMC5350233 DOI: 10.1007/s00228-016-2188-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 12/20/2016] [Indexed: 01/08/2023]
Abstract
Purpose The aim of this study was to investigate the clinical relevance of potentially inappropriate medications (PIMs), identified by the STOPP criteria, and potential prescribing omissions (PPOs), identified by the START criteria, and to identify predictors for clinically relevant PIMs and PPOs. Methods The STOPP and START criteria were applied on the medication lists of 200 older hip fracture patients, consecutively recruited to a randomized controlled study in 2009. For each identified PIM and/or PPO, the clinical relevance was assessed at the individual level, using medical records from both hospital and primary care as well as data collected in the original study. Results A total of 555 PIMs/PPOs were identified in 170 (85%) patients (median age: 85 years, 67% female), 298 (54%) of which, in 141 (71%) patients, were assessed as clinically relevant. A greater proportion of PIMs than PPOs were clinically relevant: 71% (95% CI: 66%; 76%) vs. 32% (27%; 38%). A greater proportion of PPOs than PIMs could not be assessed with available information: 38% (32%; 44%) vs. 22% (17%; 27%). Number of drugs and multidose drug dispensing, but not age, sex, cognition, or nursing home residence, were associated with ≥1 clinically relevant PIMs/PPOs. Conclusions The present study illustrates that one in two PIMs/PPOs identified by the STOPP/START criteria is clearly clinically relevant, PIMs being clinically relevant to a greater extent than PPOs. Based on available information, the clinical relevance could not be determined in a non-negligible proportion of PIMs/PPOs. Number of drugs and multidose drug dispensing were associated with ≥1 clinically relevant PIMs/PPOs.
Collapse
Affiliation(s)
- Johan Lönnbro
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, SE-413 90, Gothenburg, Sweden.
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| |
Collapse
|
12
|
Parekh N, Page A, Ali K, Davies K, Rajkumar C. A practical approach to the pharmacological management of hypertension in older people. Ther Adv Drug Saf 2016; 8:117-132. [PMID: 28439398 DOI: 10.1177/2042098616682721] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Hypertension is the leading cause of cardiovascular (CV) morbidity and mortality in adults over the age of 65. The first part of this paper is an overview, summarizing the current guidelines on the pharmacological management of hypertension in older adults in Europe and the USA, and evidence from key trials that contributed to the guidelines. In the second part of the paper, we will discuss the major challenges of managing hypertension in the context of multimorbidity, including frailty, orthostatic hypotension (OH), falls and cognitive impairment that are associated with ageing. A novel 'BEGIN' algorithm is proposed for use by prescribers prior to initiating antihypertensive therapy to guide safe medication use in older adults. Practical suggestions are highlighted to aid practitioners in making rational decisions to treat and monitor hypertension, and for considering withdrawal of antihypertensive drugs in the complex older person.
Collapse
Affiliation(s)
| | - Amy Page
- The University of Western Australia, Crawley, Australia
| | - Khalid Ali
- Brighton and Sussex Medical School, Brighton, UK
| | - Kevin Davies
- Brighton and Sussex Medical School, Brighton, UK
| | - Chakravarthi Rajkumar
- Department of Elderly Medicine, Brighton and Sussex Medical School, Audrey Emerton Building, Eastern Road, Brighton BN2 5BE, UK
| |
Collapse
|
13
|
Wallerstedt SM, Fastbom J, Linke J, Vitols S. Long-term use of proton pump inhibitors and prevalence of disease- and drug-related reasons for gastroprotection-a cross-sectional population-based study. Pharmacoepidemiol Drug Saf 2016; 26:9-16. [PMID: 27859947 PMCID: PMC5248645 DOI: 10.1002/pds.4135] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 10/04/2016] [Accepted: 10/18/2016] [Indexed: 12/18/2022]
Abstract
Purpose To analyse the prevalence of long‐term use of proton pump inhibitors (PPI) with respect to underlying diseases and drugs, and to find predictors for such treatment when an evident rationale for the PPI treatment is lacking. Methods The study cohort consisted of individuals, ≥65 years in 2010, residing in the Region Västra Götaland during 2005–2010. For individuals with and without long‐term use of PPI in 2010, we investigated the prevalence of an underlying diagnosis, that is, an acid‐related disease during the five preceding years, as well as concomitant long‐term use of antiplatelet agents or cyclooxygenase inhibitors. Results In all, 278 205 individuals (median age: 74 years; 55% female; median 3 drugs per person; 5% nursing home residents, 11% with multi‐dose drug dispensing) were included in the analyses, 32 421 (12%) of whom were on long‐term treatment with PPI in 2010. For 12 253 individuals (38%) with such treatment, no underlying rationale was found. In individuals without a disease‐ or a drug‐related reason for PPI use, nursing home residence, number of drugs, female sex, but not multi‐dose drug dispensing, were associated with long‐term use of PPI; adjusted odds ratios (95% confidence interval): 1.63 (1.49; 1.78), 1.27 (1.26; 1.28), 1.24 (1.19; 1.29), and 0.94 (0.88; 1.01), respectively. Conclusions Long‐term use of PPI occurs in one out of nine individuals in the older population. For four out of ten of these, no reason for PPI use can be identified. Nursing home residence, female sex, and greater number of drugs predict non‐rational long‐term use of PPI. © 2016 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Sweden.,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Sweden
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet and Stockholm University, Sweden
| | - Johannes Linke
- Department of Geriatrics and Internal Medicine, Södertälje Hospital, Södertälje, Sweden
| | - Sigurd Vitols
- Department of Medicine, Clinical Pharmacology Unit, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
14
|
Abstract
The use of multiple medicines (polypharmacy) is increasingly common in middle-aged and older populations. Ensuring the correct balance between the prescribing of ‘many’ drugs and ‘too many’ drugs is a significant challenge. Clinicians are tasked with ensuring that patients receive the most appropriate combinations of medications based on the best available evidence, and that medication use is optimised according to patients’ clinical needs (appropriate polypharmacy). Historically, polypharmacy has been viewed negatively because of the associated medication safety risks, such as drug interactions and adverse drug events. More recently, polypharmacy has been identified as a risk factor for under-prescribing, such that patients do not receive necessary medications and this can also pose risks to patients’ safety and well-being. The negative connotations that have long been associated with the term polypharmacy could potentially be acting as a driving factor for under-prescribing, whereby clinicians are reluctant to prescribe necessary medicines for patients who are already receiving ‘many’ medicines. It is now recognised that the prescribing of ‘many’ medicines can be entirely appropriate in patients with several chronic conditions and that the risks of adverse drug events that have been associated with polypharmacy may be greatly reduced when patients’ clinical context is taken into consideration. In this article, we outline the current perspectives on polypharmacy and make the case for adopting the term ‘appropriate polypharmacy’ in differentiating between the prescribing of ‘many’ drugs and ‘too many’ drugs. We also outline the inherent challenges in doing so and provide recommendations for future clinical practice and research.
Collapse
Affiliation(s)
- Cathal A Cadogan
- School of Pharmacy, Queen's University Belfast, Belfast, UK. .,RCSI School of Pharmacy, Royal College of Surgeons in Ireland, Ardilaun House, Block B, 111 St Stephen's Green, Dublin 2, Ireland.
| | - Cristín Ryan
- School of Pharmacy, Queen's University Belfast, Belfast, UK.,RCSI School of Pharmacy, Royal College of Surgeons in Ireland, Ardilaun House, Block B, 111 St Stephen's Green, Dublin 2, Ireland
| | | |
Collapse
|
15
|
Wallerstedt SM, Wettermark B, Hoffmann M. The First Decade with the Swedish Prescribed Drug Register - A Systematic Review of the Output in the Scientific Literature. Basic Clin Pharmacol Toxicol 2016; 119:464-469. [PMID: 27112967 DOI: 10.1111/bcpt.12613] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 04/18/2016] [Indexed: 01/15/2023]
Abstract
The aim of this study was to quantify and characterize the scientific output from the Swedish Prescribed Drug Register (SPDR) the first decade after its establishment. A systematic literature search was performed in Medline, EMBASE and PubMed (2005-2014). Additional publications were identified by personal knowledge, reference lists, contact with active authors and a citation search in Web of Sciences. Publications using SPDR data were included in the analysis and characterized regarding study type, presence of patient-level record linkage, target population and topic. A total of 719 publications were identified in the literature search and an additional 148 by other strategies. Three hundred and thirty-eight studies fulfilled the inclusion criteria. The majority were analytic (n = 166; 49.1%) or descriptive (n = 100; 29.5%). The remaining studies focused on validation (n = 20; 5.9%), health economics (n = 16; 4.7%) or miscellaneous (n = 36; 10.7%). The analytic studies investigating effects of drug exposure focused mainly on safety (n = 46) and/or effectiveness (n = 24). The first publications appeared in 2007 (n = 6), and in 2014, 90 articles using SPDR were published. Over the years, linkage with other registers using the personal identity number increased (0-88.9% of the publications). The population was often selected by age (49.7%), condition (45.0%) and/or drug (22.8%) and concerned predominantly psychiatric (29.0%) and cardiovascular (20.4%) diseases. In conclusion, this study illustrates that the establishment of a nationwide individual-based register on dispensed prescription drugs facilitates an encouraging development of pharmacoepidemiological research, both regarding the number of publications and the scientific level of the analyses.
Collapse
Affiliation(s)
- Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Björn Wettermark
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Solna, Sweden.,Department of Healthcare Development, Public Healthcare Services Committee, Stockholm County Council, Stockholm, Sweden
| | - Mikael Hoffmann
- NEPI, Network for Pharmacoepidemiology, Linköping University, Linköping, Sweden
| |
Collapse
|
16
|
Turner JP, Jamsen KM, Shakib S, Singhal N, Prowse R, Bell JS. Polypharmacy cut-points in older people with cancer: how many medications are too many? Support Care Cancer 2015; 24:1831-40. [DOI: 10.1007/s00520-015-2970-8] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 09/28/2015] [Indexed: 01/08/2023]
|
17
|
Wallerstedt SM, Belfrage B, Fastbom J. Association between drug-specific indicators of prescribing quality and quality of drug treatment: a validation study. Pharmacoepidemiol Drug Saf 2015; 24:906-14. [PMID: 26147790 PMCID: PMC4758385 DOI: 10.1002/pds.3827] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 06/02/2015] [Accepted: 06/08/2015] [Indexed: 11/06/2022]
Abstract
Purpose To evaluate the concurrent validity of three European sets of drug‐specific indicators of prescribing quality Methods In 200 hip fracture patients (≥65 years), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to three drug‐specific indicator sets (Swedish National Board of Health and Welfare, French consensus panel list, and German PRISCUS list). As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) and START (Screening Tool to Alert to Right Treatment). Results According to the Swedish, French, and German indicator sets, 82 (41%), 54 (27%), and 43 (22%) patients had potentially inappropriate drug treatment. A total of 141 (71%) patients had suboptimal drug treatment according to the gold standard. The sensitivity for the indicator sets was 0.51 (95% confidence interval: 0.43; 0.59), 0.33 (0.26; 0.41), and 0.29 (0.22; 0.37), respectively. The specificity was 0.83 (0.72; 0.91), 0.88 (0.77; 0.94), and 0.97 (0.88; 0.99). Suboptimal drug treatment was 2.0 (0.8; 5.3), 1.9 (0.7; 5.1), and 6.1 (1.3; 28.6) times as common in patients with potentially inappropriate drug treatment according to the indicator sets, after adjustments for age, sex, cognition, residence, multi‐dose drug dispensing, and number of drugs. Conclusions In this setting, the indicator sets had high specificity and low sensitivity. This needs to be considered upon use and interpretation. Copyright © 2015 The Authors Pharmacoepidemiology and Drug Safety Published by John Wiley & Sons, Ltd.
Collapse
Affiliation(s)
| | | | - Johan Fastbom
- Aging Research Center, Karolinska Institutet and Stockholm University, Sweden
| |
Collapse
|