[Potentially inappropriate medications in geriatrics: Which tools to detect them?]

[Development of a tool to help optimizing drug prescriptions in pediatric units in Côte d'Ivoire: GOPP tool]

OBJECTIVE

This study aims to develop a tool for optimizing drug management related to clinical and therapeutic contexts of pediatric units in Côte d'Ivoire.

METHODOLOGY

A list of Inappropriate prescribings (IPs) was developed from prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at 4 Teaching Hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0-5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of>70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained. Each IP of final list associated with "rationale", (justifying the inappropriateness of prescribing), and "recommendations and/or therapeutic alternative", used to elaborate items of a tool for helping to optimize drug prescriptions in pediatrics (GOPP tool).

RESULTS

A qualitative list of 54 IPs was drawn up from 267 Drug related problems detected after prescription review of 4992 prescription lines for 881 patients. Twenty-three (23) experts rated IPs on this list during two-round Delphi survey. At the end of survey, final list of 52 IPs was retained for development GOPP tool items. Malaria (15%), rhinitis (12%) and bacterial infectious (8%) are mainly pathologies concerned by these items.

CONCLUSION

GOPP tool developed in this study should help to improve drug management of patients in pediatric units in Côte d'Ivoire.

Expert Consensus on a List of Inappropriate Prescribing after Prescription Review in Pediatric Units in Abidjan, Côte d'Ivoire

Introduction

Inappropriate prescribing (IP) includes inappropriate prescription and omission of prescription. IP can adversely affect the quality of health care in pediatric units. A list of IP taking into account frequently encountered drug-related problems (DRPs) can be useful to optimize prescriptions in pediatrics. The aim of this study was to validate by expert consensus a list of IP after a prescription review in pediatric units in Abidjan.

Materials and Methods

A list of IPs was developed from a prescription review of inpatients and outpatients aged 1 month to 15 years and followed in pediatric units at teaching hospitals of Abidjan during 16 months. A two-round Delphi method was used to validate a qualitative list of IPs by experts according to their level of agreement on a six-point Likert scale of 0–5 (0, no opinion; 5, strongly agree). Only propositions obtaining the agreement (rating 4 or 5) of >70% of experts who gave a non-zero rating for the first round and 80% for the second round were retained.

Results

A qualitative list of 54 IPs was drawn up from 267 DRPs detected after prescription review of 4,992 prescription lines for 881 patients. Our panel comprised 22 pediatricians (96%) and one clinical pharmacist (4%). Mean agreement ratings were 4.43/5 (95% CI 4.39–4.48) and 4.6/5 (95% CI 4.56–4.64), respectively, during the first Delphi round and the second (p<0.001). At the end of the first round, all items submitted (54) were retained, including 13 items that had been reworded. In the second round, 20 experts participated and two IPs (4%) were not retained for the final list. This list comprised 52 IPs (44 inappropriate prescriptions and eight omissions of prescription).

Conclusion

The list of IP validated in this study should help in the detection of DRPs and optimize prescriptions in pediatric units in Côte d’Ivoire.

Ability to detect potentially inappropriate prescribing in older patients: comparative analysis between PIM-Check and STOPP/STARTv2

Purpose

Potentially inappropriate prescribing (PIP) is a source of preventable adverse drug events. The objective of this study was a comparative analysis (quantitative and qualitative) between two tools used to detect PIP, PIM-Check and STOPP/START.

Methods

First, a qualitative analysis (QAC) was conducted to evaluate the concordance between the criteria, which constitute PIM-Check and the gold standard STOPP/START. Second, a retrospective comparative and observational study was performed on the list of treatment at the admission of 50 older patients hospitalized in an acute geriatric ward of a university hospital in Switzerland in 2016 using both tools.

Results

The QAC has shown that 50% (57 criteria) of STOPP/START criteria are fully or partially concordant with those of PIM-Check. The retrospective study was performed on 50 patients aged 87 years, suffering from 5 co-morbidities (min–max 1–11) and treated by of 8 drugs (min–max 2–16), as medians. The prevalence of the detected PIP was 80% by PIM-Check and 90% by STOPP/START. Medication review shows that 4.2 PIP per patient were detected by PIM-Check and 3.5 PIP by STOPP/START among which 1.9 PIP was commonly detected by both tools, as means. PIM-Check detected more PIP related to cardiology, angiology, nephrology, and endocrinology in older patients but missed the PIP related to geriatric syndromes (e.g., fall, dementia, Alzheimer) detected by STOPP/START.

Conclusions

By using PIM-Check in geriatric settings, some PIP will not be detected. It is considered as a limitation for this tool in this frail population but brings a certain complementarity in other areas of therapy not covered by STOPP/START.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A survey on what pharmacists and physicians caring for nursing home residents expect of user-friendly lists of potentially inappropriate prescribing (PIP lists)

INTRODUCTION

Potentially inappropriate prescribing (PIP, including potentially inappropriate medication, PIM) is frequent. In research and practice, the use of PIP lists could optimize a patient's medication. However, they are barely used, possibly because of their limited user-friendliness. This study aimed at evaluating the opinions of pharmacists and physicians caring for nursing home residents on user-friendliness as well as knowledge and current use of PIP lists.

METHODS

Semi-structured telephone interviews and paper-based surveys were conducted with physicians and pharmacists who care for nursing home residents. Descriptive analysis and Fisher's exact test were performed.

RESULTS

A total of 30 practitioners participated in the survey, eight of whom were interviewed by phone. 43 % (13/30) of the participants had already heard of PIP lists, and 46 % (6/13) of them made use of a PIP list. Less experienced professionals had more often heard of PIP lists than more experienced ones. The most important aspects of user-friendliness were: time required to use the list, electronic availability, clear structure and provision of reasons why a medication is potentially inappropriate. Physicians preferred a PIP list adapted to the Swiss drug market more often than pharmacists.

DISCUSSION

Knowledge and current use of PIP lists are limited, which is partially consistent with the results of other studies. Participants with less professional experience have heard of PIP lists more frequently, opinions on user-friendliness differ between professions, and preferences seem to be, overall, highly individual.

CONCLUSION

In order for PIP lists to be used more frequently, the aspects of user-friendliness should be taken into account. Personalizable PIP lists could be an interesting development.

Impact of medication review via tele-expertise on unplanned hospitalizations at 3 months of nursing homes patients (TEM-EHPAD): study protocol for a randomized controlled trial

Background

Inappropriate drug prescribing causes preventable drug-related adverse events that result in increased morbidity and mortality, additional costs and diminished quality of life. Numerous initiatives have been launched to improve the quality of drug prescribing and safeguard the security of drug administration processes in nursing homes. Against the backdrop of implementation of telemedicine services, the focus of the present work is to evaluate the impact of a telemedication review carried out by a hospital physician and pharmacist as part of the telemedicine offer.

Methods

The present study is a randomized controlled clinical trial. A total of 364 patients will be randomized into two groups: (1) an experimental group (182 patients) benefiting from a telemedication review using tele-expertise and (2) a control group (182 patients) receiving standard care. The primary endpoint will be rate of all-cause unplanned hospital admissions occurring within 3 months of randomization. The secondary endpoints will be rate of unplanned admissions at 6 months, patient quality of life, incidence of behavioral disturbances, number of falls, number of residents prescribed at least one inappropriate medication, nursing staff satisfaction, proposed medication reviews and their acceptability rate, characteristics of patients whose general practitioners have taken account of tele-expertise, efficacy of tele-expertise as compared to standard prescription and acceptability and satisfaction surveys of participating caregivers.

Discussion

In the literature, various studies have investigated the utility of structured medication review processes, but outcome measures are heterogeneous, and results vary widely. Medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Incremental cost-effectiveness ratios will be used to compare the cost and effectiveness of the experimental strategy and that of standard care. Our approach, involving the combination of an acceptability survey and a mixed-method (qualitative and quantitative) satisfaction survey, is particularly innovative. The results of this randomized trial are expected to confirm that medication review using tele-expertise has potential as a worthwhile care management strategy for nursing home residents.

Trial registration

Clinicaltrials.gov NCT03640845; registered August 21, 2018 (Clinicaltrials.gov NCT03640845).

[Telemedicine and drug iatrogenesis in nursing homes]

Inappropriate drug prescribing is an avoidable cause of adverse drug events, sources of an increase in morbimortality, excess spending and a decrease in quality of life. Many actions exist to improve prescribing quality and to secure the medication circuit in nursing homes. As part of the deployment of telemedicine, the benefit of a medico-pharmaceutical tele-expertise system for medication is evident.

[Assessment of medication prescribing in a geriatric follow-up care and rehabilitation]

The aim of the study was to analyse the prescriptions and identify the factors associated with inappropriate prescribing (IP) and polypharmacy. Polypharmacy and IP concerned 80% of the 54 patients included in the study upon admission, and 78% upon discharge without a statistically significant reduction. A critical analysis of prescriptions would help to reduce inappropriate prescribing and polypharmacy in elderly patients.

Prescribing issues in elderly individuals living with HIV

Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.

Using a structured reconciliation medication form improves medication transition from hospital to community care and primary care physicians' adherence with medication adaptations and recommendations

BACKGROUND

Hospital admission and discharge are weakness points in the transition of care.

OBJECTIVE

To lower the risk of errors and improve medication information transfer to primary care physician (PCP), we conducted an experimental study using a structured medication reconciliation form (SMRF) in an Acute Care for Elders unit.

RESULTS

1242 drugs of 173 patients were reconciliated at admission, optimized during the stay, and transmitted via the SMRF to the 143 corresponding PCPs. While the optimization led to 779 adaptations from admission to discharge, of which 39.0% were omissions, exposure to polypharmacy was reduced from 83.2 to 74.6% (P < 0.05). One-month post-discharge, with an answer rate of 62.2% among PCPs, the adherence to recommendations was high (85.0%) and the exposure to polypharmacy was further decreased (67.7%; P < 0.05).

CONCLUSION

These results provide elements to consider SMRF as an example of good practice for which the impact should be analyzed at larger scale.

A comparison of two tools to screen potentially inappropriate medication in internal medicine patients

WHAT IS KNOWN

Potentially inappropriate medication (PIM) is an important issue for inpatient management; it has been associated with safety problems, such as increases in adverse drugs events, and with longer hospital stays and higher healthcare costs.

OBJECTIVE

To compare two PIM-screening tools-STOPP/START and PIM-Check-applied to internal medicine patients. A second objective was to compare the use of PIMs in readmitted and non-readmitted patients.

METHOD

A retrospective observational study, in the general internal medicine ward of a Swiss non-university hospital. We analysed a random sample of 50 patients, hospitalized in 2013, whose readmission within 30 days of discharge had been potentially preventable, and compared them to a sample of 50 sex- and age-matched patients who were not readmitted. PIMs were screened using the STOPP/START tool, developed for geriatric patients, and the PIM-Check tool, developed for internal medicine patients. The time needed to perform each patient's analysis was measured. A clinical pharmacist counted and evaluated each PIM detected, based on its clinical relevance to the individual patient's case. The rates of screened and validated PIMs involving readmitted and non-readmitted patients were compared.

RESULTS

Across the whole population, PIM-Check and STOPP/START detected 1348 and 537 PIMs, respectively, representing 13.5 and 5.4 PIMs/patient. Screening time was substantially shorter with PIM-Check than with STOPP/START (4 vs 10 minutes, respectively). The clinical pharmacist judged that 45% and 42% of the PIMs detected using PIM-Check and STOPP/START, respectively, were clinically relevant to individual patients' cases. No significant differences in the rates of detected and clinically relevant PIM were found between readmitted and non-readmitted patients.

WHAT IS NEW AND CONCLUSION

Internal medicine patients are frequently prescribed PIMs. PIM-Check's PIM detection rate was three times higher than STOPP/START's, and its screening time was shorter thanks to its electronic interface. Nearly half of the PIMs detected were judged to be non-clinically relevant, however, potentially overalerting the prescriber. These tools can, nevertheless, be considered useful in daily practice. Furthermore, the relevance of any PIM detected by these tools should always be carefully evaluated within the clinical context surrounding the individual patient.

PIM-Check: development of an international prescription-screening checklist designed by a Delphi method for internal medicine patients

OBJECTIVES

Potentially inappropriate medication (PIM) occurs frequently and is a well-known risk factor for adverse drug events, but its incidence is underestimated in internal medicine. The objective of this study was to develop an electronic prescription-screening checklist to assist residents and young healthcare professionals in PIM detection.

DESIGN

Five-step study involving selection of medical domains, literature review and 17 semistructured interviews, a two-round Delphi survey, a forward/back-translation process and an electronic tool development.

SETTING

22 University and general hospitals from Canada, Belgium, France and Switzerland.

PARTICIPANTS

40 physicians and 25 clinical pharmacists were involved in the study.Agreement with the checklist statements and their usefulness for healthcare professional training were evaluated using two 6-point Likert scales (ranging from 0 to 5).

PRIMARY AND SECONDARY OUTCOME MEASURES

Agreement and usefulness ratings were defined as: >65% of the experts giving the statement a rating of 4 or 5, during the first Delphi-round and >75% during the second.

RESULTS

166 statements were generated during the first two steps. Mean agreement and usefulness ratings were 4.32/5 (95% CI 4.28 to 4.36) and 4.11/5 (4.07 to 4.15), respectively, during the first Delphi-round and 4.53/5 (4.51 to 4.56) and 4.36/5 (4.33 to 4.39) during the second (p<0.001). The final checklist includes 160 statements in 17 medical domains and 56 pathologies. An algorithm of approximately 31 000 lines was developed including comorbidities and medications variables to create the electronic tool.

CONCLUSION

PIM-Check is the first electronic prescription-screening checklist designed to detect PIM in internal medicine. It is intended to help young healthcare professionals in their clinical practice to detect PIM, to reduce medication errors and to improve patient safety.