Development of a standardized chart review method to identify drug-related hospital admissions in older people

Drug-related emergency department visits: external validation of an assessment tool in a general emergency department population

BACKGROUND

The process of identifying drug-related hospitalisations is subjective and time-consuming. Assessment tool for identifying hospital admissions related to medications (AT-HARM10) was developed to simplify and objectify this process. AT-HARM10 has not previously been externally validated, thus the predictive precision of the tool is uncertain.

AIM

To externally validate AT-HARM10 in adult patients admitted to the emergency department (ED).

METHOD

This retrospective cross-sectional study investigated 402 patients admitted to the ED, Diakonhjemmet Hospital, Oslo, Norway. A trained 5th-year pharmacy student used AT-HARM10 to assess all patients and to classify their ED visits as possibly or unlikely drug-related. Assessment of the same patients by an interdisciplinary expert panel acted as the gold standard. The external validation was conducted by comparing AT-HARM10 classifications with the gold standard.

RESULTS

According to AT-HARM10 assessments, 169 (42%) patients had a possible drug-related ED visit. Calculated sensitivity and specificity values were 95% and 71%, respectively. Further, positive and negative predictive values were 46% and 98%, respectively. Adverse effects/over-treatment and suboptimal treatment were the issues most frequently overestimated by AT-HARM10 compared with the gold standard.

CONCLUSION

AT-HARM10 identifies drug-related ED visits with high sensitivity. However, the low positive predictive value indicates that further review of ED visits classified as possible drug-related by AT-HARM10 is necessary. AT-HARM10 can serve as a useful first-step screening that efficiently identifies unlikely drug-related ED visits, thus only a smaller proportion of the patients need to be reviewed by an interdisciplinary expert panel.

Adverse Drug Event-Related Hospital Admissions among Australian Aged Care Residents: A Cross-Sectional Study

OBJECTIVES

To investigate the proportion, characteristics, causality, severity, preventability, and independently associated factors for adverse drug event (ADE)-related admissions in aged care residents admitted to the major public hospitals in Tasmania, Australia.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

Residential aged care facility (RACF) patients aged ≥65 years who had an unplanned admission to one of the 4 Tasmanian public hospitals between July 1, 2018, and June 30, 2021.

METHODS

We accessed the medical records of RACF patients. The ADEs were initially identified via chart review and a trigger tool. Hospitalizations attributable to ADEs were then determined by expert consensus. The causality, preventability, and severity of each ADE admission were assessed using standard criteria.

RESULTS

Ninety-one residents (18.2%) of 500 randomly selected experienced potential ADE-related hospitalizations. ADEs were considered possible (n = 58, 64%) or definite/probable (n = 33, 36%). The most common ADEs were falls (n = 19, 21%), hypotension (n = 16, 18%), and confusion or delirium (n = 10, 11%). ADEs were frequently associated with renin-angiotensin system inhibitors (n = 43, 47.3%), opioids (n = 43, 47.3%), and diuretics (n = 40, 44%). Most ADEs were of moderate severity (n = 90, 99%) and considered not preventable (n = 60, 66%). Rheumatologic disease [odds ratio (OR) 1.89, 95% CI 1.09-3.30; P = .024] and previous adverse drug reaction (ADR) (OR 12.91, 95% CI 6.84-24.37; P < .001) were associated with ADE hospitalizations.

CONCLUSIONS AND IMPLICATIONS

This study highlights that hospitalization for moderately severe ADEs is common among RACF residents. Opioids and antihypertensives were the common drug classes associated with harm. Rheumatologic disease (due to opioids) and previous ADR were identified as independently associated factors, which may warrant tailored interventions.

Application of trigger tools for detecting adverse drug events in older people: A systematic review and meta-analysis

OBJECTIVE

To identify trigger tools applied to detect adverse drug events (ADEs) in older people and describe their utility and performance.

METHODS

A systematic review was conducted in the PubMed, Lilacs, and Scopus databases (January 2024). Studies that developed, applied, or validated trigger tools and evaluated their utility and/or performance for detecting ADEs in older people were considered. Direct proportion meta-analyses using the inverse-variance method were performed for prevalence of ADEs and positive predictive value (PPV).

RESULTS

Twenty-four studies (25 publications) were included. Twelve trigger tools were identified, of which six were developed for detecting ADEs in older population, four developed for general population and modified for older people, and two developed for general population. No tools for detecting ADEs in older people receiving palliative care or hospitalized in intensive or surgical care units were found. The performance of triggers was presented through PPV (11.5-71%), negative predictive values (83.3%), and sensitivity (30-94.8%). The overall PPV was 33.3% (95%CI: 32.5-34.2%). Triggers with good performance were changes in plasma levels of digoxin, glucose, and potassium; changes in international normalized ratio; abrupt medication stop; hypotension; and constipation. The prevalence of ADEs ranged from 2.8 to 66%, with overall prevalence of ADEs of 20% (95%CI: 19.3-20.8%). Preventability ranged from 8.4 to 94.4%. Metabolic or electrolyte disturbances induced by diuretics, constipation induced by opioids, and falls and delirium induced by benzodiazepines were the most prevalent ADEs.

CONCLUSION

The trigger tools are flexible and easy to apply, and they can contribute to the detection of ADEs, their associated risk factors, the level of harm, and preventability in different health settings. However, there is no consensus on good or poor values of PPV, which indicate the performance of triggers. Furthermore, there is limited evidence regarding the evaluation of performance through negative predictive value, sensitivity, and specificity.

PROSPERO

CRD42022379893.

Antipsychotic prescribing and drug-related readmissions in multimorbid older inpatients: a post-hoc analysis of the OPERAM population

BACKGROUND

Limited data are available on characteristics associated with antipsychotic use in multimorbid older adults.

AIM

Primary: to identify patient characteristics associated with antipsychotic prescribing in a multimorbid population of older inpatients with polypharmacy. Secondary: (1) to observe if antipsychotics use during an index hospitalisation was associated with a drug related admission (DRA) within one year, and (2) to describe these cases of antipsychotic-related readmissions.

METHOD

This was a secondary analysis of the OPERAM randomized controlled trial. Multivariate analysis assessed the association between characteristics and comorbidities with antipsychotic use. An expert team assessed DRA occurring during the one-year follow-up.

RESULTS

Antipsychotics were prescribed to 5.5% (n = 110) patients upon admission while 7.7% (n = 154) inpatients received antipsychotics at any time (i.e. upon admission, during hospitalisation, and/or at discharge). The most frequently prescribed antipsychotics were quetiapine (n = 152), haloperidol (n = 48) and risperidone (n = 22). Antipsychotic prescribing was associated with dementia (OR = 3.7 95%CI[2.2;6.2]), psychosis (OR = 26.2 [7.4;92.8]), delirium (OR = 6.4 [3.8;10.8]), mood disorders (OR = 2.6 [1.6;4.1]),  ≥ 15 drugs a day (OR = 1.7 [1.1;2.6]), functional dependency (Activities of Daily Living score < 50/100) (OR = 3.9 [2.5;6.1]) and < 2 units of alcohol per week (OR = 2.2 [1.4;3.6]). DRA occurred in 458 patients (22.8%) within one year. Antipsychotic prescribing at any time was not associated with DRA (OR = 1.0 [0.3;3.9]) however contributed to 8 DRAs, including 3 falls.

CONCLUSION

In this European multimorbid polymedicated older inpatients, antipsychotics were infrequently prescribed, most often at low dosage. Besides neuro-psychiatric symptoms, risk factors for inhospital antipsychotic prescribing were lower functional status and polymedication.

Renal drug dosage adjustments and adverse drug events in patients with chronic kidney disease admitted to the hospital: a cross-sectional study

BACKGROUND

The study aimed to evaluate the agreement of prescribed drug dosages with renal dosing recommendations and describe adverse drug events (ADEs) contributing to hospital admissions of patients with chronic kidney disease (CKD).

METHODS

This cross-sectional study focused on CKD patients admitted to University Hospital Hradec Králové, with an estimated glomerular filtration rate below 60 ml/min. The necessity for renal dosage adjustments was determined using the Summary of Product Characteristics (SmPC). For medications requiring renal dosage adjustment according to SmPC, agreement between the prescribed and recommended renal dosage was assessed. ADEs were adjudicated using the OPERAM drug-related hospital admissions adjudication guide.

RESULTS

Of 375 CKD patients, 112 (30%, 95% CI 25-34) were prescribed drug dosages in disagreement with SmPC renal dosage recommendations. Perindopril, metformin, and ramipril were most frequently dosed in disagreement with SmPC. ADE-related hospital admissions occurred in 20% (95% CI 16-24) of CKD patients.

CONCLUSION

CKD patients are often prescribed medication dosages in disagreement with SmPC renal dosing recommendations. Besides explicit factors, treatment goals, feasibility of monitoring and alternative treatment must be weighed when assessing drug and dosage appropriateness. Gastrointestinal bleeding was the most frequent ADE that contributed to hospital admissions of CKD patients.

Potentially clinically significant drug-drug interactions in older patients admitted to the hospital: A cross-sectional study

Background: An international consensus list of potentially clinically significant drug-drug interactions (DDIs) in older people has been recently validated. Our objective was to describe the prevalence and characteristics of drug combinations potentially causing clinically significant DDIs identified in the medication history of older patients admitted to the hospital and the prevalence and characteristics of manifest DDIs-DDIs involved in adverse drug events present at hospital admission, DDIs that contributed to ADE-related hospital admissions, and DDIs involved in drug-related laboratory deviations. Methods: The data were obtained from our previous study that examined the drug-relatedness of hospital admissions to University Hospital Hradec Králové via the department of emergency medicine in the Czech Republic. Patients ≥ 65 years old were included. Drug combinations potentially causing clinically significant DDIs were identified using the international consensus list of potentially clinically significant DDIs in older people. Results: Of the 812 older patients admitted to the hospital, 46% were exposed to drug combinations potentially causing clinically significant DDIs. A combination of medications that affect potassium concentrations accounted for 47% of all drug combinations potentially causing clinically significant DDIs. In 27 cases, potentially clinically significant DDIs were associated with drug-related hospital admissions. In 4 cases, potentially clinically significant DDIs were associated with ADEs that were present at admissions. In 4 cases, the potentially clinically significant DDIs were associated with laboratory deviations. Manifest DDIs that contributed to drug-related hospital admissions most frequently involved antithrombotic agents and central nervous system depressants. Conclusion: The results confirm the findings from the European OPERAM trial, which found that drug combinations potentially causing clinically significant DDIs are very common in older patients. Manifest DDIs were present in 4.3% of older patients admitted to the hospital. In 3.3%, manifest DDIs contributed to drug-related hospital admissions. The difference in the rates of potential and manifest DDIs suggests that if a computerized decision support system is used for alerting potentially clinically significant DDIs in older patients, it needs to be contextualized (e.g., take concomitant medications, doses of medications, laboratory values, and patients' comorbidities into account).

Medication-Related Acute Care Admission and Inappropriate Polypharmacy of Nursing Home Residents

OBJECTIVES

To evaluate the prevalence of medication-related admissions (MRAs) and their association with potentially inappropriate medications (PIMs) used by nursing home residents admitted to the geriatric center of a tertiary hospital.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Older patients admitted from nursing homes to the geriatric center of the Seoul National University Bundang Hospital who had undergone comprehensive geriatric assessment from January 1, 2016, to December 31, 2020.

METHODS

MRAs were determined and verified using a previously described MRA adjudication guide. The PIMs in the preadmission medication lists were identified according to each of the following criteria (as well as the combined criteria), the Beers, NORGEP-NH, STOPP/START-NH, and STOPPFrail criteria. Medication use factors associated with MRAs were analyzed using multivariate logistic regression.

RESULTS

Among the 304 acute care admissions, 32.2% were MRAs. The main cause of MRAs was acute kidney injury related with use of renin-angiotensin system inhibitors. Approximately 81% of the patients used at least 1 PIM according to the combined criteria. The use of 1 or more PIMs, renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, and benzodiazepines was significantly associated with MRAs. The combined criteria were able to predict MRAs better than the individual criteria.

CONCLUSIONS AND IMPLICATIONS

Approximately one-third of acute admissions of nursing home residents may be MRAs. Interventions for the optimal use of medication among nursing home residents are needed.

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

BACKGROUND

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Detectability of Medication Errors With a STOPP/START-Based Medication Review in Older People Prior to a Potentially Preventable Drug-Related Hospital Admission

INTRODUCTION

Multimorbidity and polypharmacy are risk factors for drug-related hospital admissions (DRAs) in the ageing population. DRAs caused by medication errors (MEs) are considered potentially preventable. The STOPP/START criteria were developed to detect potential MEs in older people.

OBJECTIVE

The aim of this study was to assess the detectability of MEs with a STOPP/START-based in-hospital medication review in older people with polypharmacy and multimorbidity prior to a potentially preventable DRA.

METHODS

Hospitalised older patients (n = 963) with polypharmacy and multimorbidity from the intervention arm of the OPERAM trial received a STOPP/START-based in-hospital medication review by a pharmacotherapy team. Readmissions within 1 year after the in-hospital medication review were adjudicated for drug-relatedness. A retrospective assessment was performed to determine whether MEs identified at the first DRA were detectable during the in-hospital medication review.

RESULTS

In total, 84 of 963 OPERAM intervention patients (8.7%) were readmitted with a potentially preventable DRA, of which 72 patients (n = 77 MEs) were eligible for analysis. About half (48%, n = 37/77) of the MEs were not present during the in-hospital medication review and therefore were not detectable at that time. The pharmacotherapy team recommended a change in medication regimen in 50% (n = 20/40) of present MEs, which corresponds to 26% (n = 20/77) of the total identified MEs at readmission. However, these recommendations were not implemented.

CONCLUSION

MEs identified at readmission were not addressed by a prior single in-hospital medication review because either these MEs occurred after the medication review (~50%), or no recommendation was given during the medication review (~25%), or the recommendation was not implemented (~25%). Future research should focus on optimisation of the timing and frequency of medication review and the implementation of proposed medication recommendations.

REGISTRATION

ClinicalTrials.gov identifier: NCT02986425. December 8, 2016.

FUNDING

European Union HORIZON 2020, Swiss State Secretariat for Education, Research and Innovation (SERI), Swiss National Science Foundation (SNSF).

Prevalence and predictors of medication-related emergency department visit in older adults: A multicenter study linking national claim database and hospital medical records

Objectives: Older adults are more likely to experience drug-related problems (DRP), which could lead to medication-related emergency department visits (MRED). To properly evaluate MRED, the entire history of drug use should be evaluated in a structured manner. However, limited studies have identified MRED with complete prescription records. We aimed to evaluate the prevalence and risk factors of MRED among community-dwelling older patients by linking national claims data and electronic medical records using a standardized medication related admission identification method. Methods: We included older patients who visited the emergency departments of four participating hospitals in 2019. Among the 54,034 emergency department (ED) visitors, we randomly selected 6,000 patients and structurally reviewed their medical records using a standardized MRED identification method after linking national claims data and electronic medical records. We defined and categorized MRED as ED visits associated with adverse drug events and those caused by the underuse of medication, including treatment omission and noncompliance and assessed as having probable or higher causality. We assessed preventability using Schumock and Thornton criteria. Results: MRED was observed in 14.3% of ED visits, of which 76% were preventable. In addition, 32.5% of MRED cases were related to underuse or noncompliance, and the rest were related to adverse drug events. Use of antipsychotics, benzodiazepines, anticoagulants, traditional nonsteroidal anti-inflammatory drugs without the use of proton pump inhibitors, P2Y12 inhibitors, insulin, diuretics, and multiple strong anticholinergic drugs were identified as predictors of MRED. Conclusion: One in seven cases of ED visits by older adults were medication related and over three-quarters of them were preventable. These findings suggest that DRPs need to be systemically screened and intervened in older adults who visit ED.

Defining explicit definitions of potentially inappropriate prescriptions for antidiabetic drugs in patients with type 2 diabetes: A systematic review

Introduction

Potentially inappropriate prescriptions (PIPs) of antidiabetic drugs (ADs) (PIPADs) to patients with type 2 diabetes mellitus (T2DM) have been reported in some studies. The detection of PIPs in electronic databases requires the development of explicit definitions. This approach is widely used in geriatrics but has not been extended to PIPADs in diabetes mellitus. The objective of the present literature review was to identify all explicit definitions of PIPADs in patients with T2DM.

Materials and methods

We performed a systematic review of the literature listed on Medline (via PubMed), Scopus, Web of Science, and, Embase between 2010 and 2021. The query included a combination of three concepts ("T2DM" AND "PIPs" AND "ADs") and featured a total of 86 keywords. Two independent reviewers selected publications, extracted explicit definitions of PIPADs, and then classified the definitions by therapeutic class and organ class.

Results

Of the 4,093 screened publications, 39 were included. In all, 171 mentions of PIPADs (corresponding to 56 unique explicit definitions) were identified. More than 50% of the definitions were related to either metformin (34%) or sulfonylureas (29%). More than 75% of the definitions were related to either abnormal renal function (56%) or age (22%). In addition, 20% (n = 35) mentions stated that biguanides were inappropriate in patients with renal dysfunction and 17.5% (n = 30) stated that sulfonylureas were inappropriate above a certain age. The definitions of PIPADs were heterogeneous and had various degrees of precision.

Conclusion

Our results showed that researchers focused primarily on the at-risk situations related to biguanide prescriptions in patients with renal dysfunction and the prescription of sulfonylureas to older people. Our systematic review of the literature revealed a lack of consensus on explicit definitions of PIPADs, which were heterogeneous and limited (in most cases) to a small number of drugs and clinical situations.

The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study

Background

The effectiveness of interventions to improve medication safety in older inpatients is unclear, given a paucity of properly designed intervention studies applying clinically relevant endpoints such as hospital-acquired preventable Adverse Drug Events (pADEs) and unrecognized Adverse Drug Events (uADEs). Therefore, we conducted a quality improvement study and used hospital-acquired pADEs and uADEs as main outcomes to assess the effect of an intervention aimed to improve medication safety in older inpatients.

Method

The study followed an interrupted time series design and consisted of three equally spaced sampling points during baseline and during intervention measurements. Each sampling point included between 80 to 90 patients. A total of 500 inpatients ≥65 years and admitted to internal medicine wards of three Dutch hospitals were included. An expert team retrospectively identified and assessed ADEs via a structured patient chart review. The findings from baseline measurement and meetings with the internal medicine and hospital pharmacy staff were used to design the intervention. The intervention consisted of a structured medication review by hospital pharmacists, followed by face-to-face feedback to prescribers, on average 3 days per week.

Results

The rate of hospital-acquired pADEs per 100 hospitalizations was reduced by 50.6% (difference 16.8, 95% confidence interval (CI): 9.0 to 24.6, P <  0.001), serious hospital-acquired pADEs by 62.7% (difference 12.8, 95% CI: 6.4 to 19.2, P <  0.001), and uADEs by 51.8% (difference 11.2, 95% CI: 4.4 to 18.0, P <  0.001). Additional analyses confirmed the robustness of the intervention effect, but residual bias cannot be excluded.

Conclusions

The intervention significantly decreased the overall and serious hospital-acquired pADE occurrence in older inpatients, and significantly improved overall ADE recognition by prescribers.

Trial registration

International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN64974377, registration date (date assigned): 07/02/2011.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03118-z.

Drug-Related Hospital Admissions via the Department of Emergency Medicine: A Cross-Sectional Study From the Czech Republic

Background: Drug-related hospital admissions (DRAs) represent a significant problem affecting all countries worldwide. This study aimed to determine the prevalence and preventability of DRAs, identify the most common medications involved in DRAs, the most common clinical manifestations of DRAs and describe the preventability aspects of DRAs.

Methods: This cross-sectional study examined unplanned hospital admissions to the University Hospital Hradec Králové via the department of emergency medicine in August–November 2018. Data were obtained from electronic medical records. The methodology of DRA identification was adapted from the OPERAM DRA adjudication guide.

Results: Out of 1252 hospital admissions, 195 DRAs have been identified (145 related to treatment safety, 50 related to treatment effectiveness). The prevalence of DRAs was 15.6% (95% CI 13.6–17.6). The most common medication classes involved in DRAs related to treatment safety were Antithrombotic agents, Antineoplastic agents, Diuretics, Corticosteroids for systemic use, and Beta blocking agents. The most common medication classes involved in DRAs related to treatment effectiveness included Diuretics, Antithrombotic agents, Drugs used in diabetes, Agents acting on the renin-angiotensin system, and Lipid modifying agents. Gastrointestinal disorders were the leading causes of DRAs related to treatment safety, while Cardiac disorders were the leading causes of DRAs related to treatment effectiveness. The potential preventability of DRAs was 51%. The highest share of potential preventability in medication classes repeatedly involved in DRAs related to treatment safety was observed for Anti-inflammatory and antirheumatic products, Psycholeptics, and Drugs used in diabetes. Potentially preventable DRAs related to treatment safety were most commonly associated with inappropriate drug selection, inappropriate monitoring, inappropriate dose selection, and inappropriate lifestyle measures. On the contrary, DRAs related to treatment effectiveness were more commonly associated with medication nonadherence.

Conclusion: It should be emphasized that in most DRAs, medications were only a contributory reason of hospital admissions and that benefits and risks have to be carefully balanced. It is highlighted by the finding that the same medication classes (Antithrombotic agents and Diuretics) were among the most common medication classes involved in DRAs related to treatment safety and simultaneously in DRAs related to treatment effectiveness. The study highlighted that apart from problems related to prescribing, problems related to monitoring and patient-related problems represent significant preventability aspects.

Performance of a trigger tool for detecting adverse drug reactions in patients with polypharmacy acutely admitted to the geriatric ward

Aim

To investigate the performance of an adverse drug reaction (ADR) trigger tool in patients with polypharmacy acutely admitted to our geriatric ward.

Findings

The ADR trigger tool had a positive predictive value (PPV) of 41.8%. Usual care recognised 83.5% of ADRs considered as possible, probable or certain, increasing to 97.1% when restricted to probable and certain ADRs.

Message

It is unlikely that implementation of the ADR trigger tool will improve detection of unrecognised ADRs in older patients acutely admitted to our geriatric ward.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00649-x.

Purpose

Adverse drug reactions (ADRs) account for 10% of acute hospital admissions in older people, often under-recognised by physicians. The Dutch geriatric guideline recommends screening all acutely admitted older patients with polypharmacy with an ADR trigger tool comprising ten triggers and associated drugs frequently causing ADRs. This study investigated the performance of this tool and the recognition by usual care of ADRs detected with the tool.

Methods

A cross-sectional study was performed in patients ≥ 70 years with polypharmacy acutely admitted to the geriatric ward of the University Medical Centre Utrecht. Electronic health records (EHRs) were screened for trigger–drug combinations listed in the ADR trigger tool. Two independent appraisers assessed causal probability with the WHO-UMC algorithm and screened EHRs for recognition of ADRs by attending physicians. Performance of the tool was defined as the positive predictive value (PPV) for ADRs with a possible, probable or certain causal relation.

Results

In total, 941 trigger–drug combinations were present in 73% (n = 253/345) of the patients. The triggers fall, delirium, renal insufficiency and hyponatraemia covered 86% (n = 810/941) of all trigger–drug combinations. The overall PPV was 41.8% (n = 393/941), but the PPV for individual triggers was highly variable ranging from 0 to 100%. Usual care recognised the majority of ADRs (83.5%), increasing to 97.1% when restricted to possible and certain ADRs.

Conclusion

The ADR trigger tool has predictive value; however, its implementation is unlikely to improve the detection of unrecognised ADRs in older patients acutely admitted to our geriatric ward. Future research is needed to investigate the tool’s clinical value when applied to older patients acutely admitted to non-geriatric wards.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00649-x.

Drug-related hospital admissions in older adults: comparison of the Naranjo algorithm and an adjusted version of the Kramer algorithm

PURPOSE

Drug-related admissions (DRAs) are an important cause of preventable harm in older adults. Multiple algorithms exist to assess causality of adverse drug reactions, including the Naranjo algorithm and an adjusted version of the Kramer algorithm. The performance of these tools in assessing DRA causality has not been robustly shown. This study aimed to evaluate the ability of the adjusted Kramer algorithm to adjudicate DRA causality in geriatric inpatients.

METHODS

DRAs were assessed in a convenience sample of patients admitted to the acute geriatric wards of an academic hospital. DRAs were identified by expert consensus and causality was evaluated using the Naranjo and the adjusted Kramer algorithms. Positive agreement with expert consensus was calculated for both algorithms. A multivariable logistic regression analysis was performed to explore determinants for a DRA.

RESULTS

A total of 218 geriatric inpatients was included of whom 65 (29.8%) experienced a DRA. Positive agreement was 72.3% (95% confidence interval (CI), 59.6-82.3%) and 100% (95% CI, 93.0-100%) for the Naranjo and the adjusted Kramer algorithm, respectively. Diuretics were the main culprits and most DRAs were attributed to a fall (n = 18; 27.7%). A fall-related principal diagnosis was independently associated with a DRA (odds ratio 20.11; 95% CI, 5.60-72.24).

CONCLUSION

The adjusted Kramer algorithm demonstrated a higher positive agreement with expert consensus in assessing DRA causality in geriatric inpatients compared to the Naranjo algorithm. Our results further support implementation of the adjusted Kramer algorithm as part of a standardized DRA assessment in older adults.

Predictors of 1‐year drug‐related admissions in older multimorbid hospitalized adults

Background

Methods

Results

Conclusion

Performance of a trigger tool for detecting drug-related hospital admissions in older people: analysis from the OPERAM trial

BACKGROUND

identifying drug-related hospital admissions (DRAs) in older people is difficult. A standardised chart review procedure has recently been developed. It includes an adjudication team (physician and pharmacist) screening using 26 triggers and then performing causality assessment to determine whether an adverse drug event (ADE) occurred (secondary to an adverse drug reaction, overuse, misuse or underuse) and whether the ADE contributed to hospital admission (DRA).

OBJECTIVE

to assess the performance of those triggers in detecting DRA.

DESIGN

retrospective study using data from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people) trial.

SETTINGS

four European medical centres.

SUBJECTS

multimorbid (≥ 3 chronic medical conditions) older (≥ 70 years) inpatients with polypharmacy (≥ 5 chronic medications) were enrolled in the OPERAM trial (N = 2,008) and followed for 12 months. We included patients with ≥1 adjudicated hospitalisation during the follow-up.

METHODS

the positive predictive value (PPV; number of DRAs identified by trigger/number of triggers) was calculated for each trigger and for the tool as a whole.

RESULTS

of 1,235 hospitalisations adjudicated for 832 patients, 716 (58%) had at least one trigger; an ADE was identified in 673 (54%) and 518 (42%) were adjudicated as DRAs. The overall PPV of the trigger tool for detecting DRAs was 0.66 [0.62-0.69].

CONCLUSIONS

this tool performs well for identifying DRAs in older people. Based on our results, a revised version of the tool was proposed but will require external validation before it can be incorporated into research and clinical practice.

Drug-related emergency department visits in older patients: an applicability and reliability study of an existing assessment tool

BACKGROUND

AT-HARM10 is a research tool to identify possible drug-related hospital admissions. It is unclear whether the tool can be applied to emergency department visits as well.

AIM

The aim of this study was to investigate the applicability and reliability to identify drug-related emergency department visits in older patients with AT-HARM10.

METHOD

A random sample of 400 patients aged 65 years or older from a clinical trial in four Swedish hospitals was selected. All patients' emergency department visits within 12 months after discharge were assessed with AT-HARM10. The main outcome measures were the percentage of successfully assessed visits for applicability and the interrater reliability (Cohen's kappa).

RESULTS

Of the initial sample (n = 400), 113 patients [median age (interquartile range): 81 (76-88) years] had at least one emergency department visit within 12 months. The patients had in total 184 visits, of which 179 (97%) were successfully assessed. Fifty-three visits (29%) were possibly drug-related. The Cohen's kappa value was 0.70 (substantial).

CONCLUSION

It seems applicable and reliable to identify possible drug-related emergency department visits in addition to hospital admissions in older patients with AT-HARM10. As a consequence, the tool has been updated to support its novel use in clinical research.

Defining Potentially Inappropriate Prescriptions for Hypoglycaemic Agents to Improve Computerised Decision Support: A Study Protocol

In France, around 5% of the general population are taking drug treatments for diabetes mellitus (mainly type 2 diabetes mellitus, T2DM). Although the management of T2DM has become more complex, most of these patients are managed by their general practitioner and not a diabetologist for their antidiabetics treatments; this increases the risk of potentially inappropriate prescriptions (PIPs) of hypoglycaemic agents (HAs). Inappropriate prescribing can be assessed by approaches that are implicit (expert judgement based) or explicit (criterion based). In a mixed, multistep process, we first systematically reviewed the published definitions of PIPs for HAs in patients with T2DM. The results will be used to create the first list of explicit definitions. Next, we will complete the definitions identified in the systematic review by conducting a qualitative study with two focus groups of experts in the prescription of HAs. Lastly, a Delphi survey will then be used to build consensus among participants; the results will be validated in consensus meetings. We developed a method for determining explicit definitions of PIPs for HAs in patients with T2DM. The resulting explicit definitions could be easily integrated into computerised decision support tools for the automated detection of PIPs.

Identifying medication-related readmissions: Two students using tools vs a multidisciplinary panel

BACKGROUND

Polypharmacy may result in medication-related readmissions (MRRs). Identifying MRRs is time consuming. Screening of readmissions by students could increase efficiency for healthcare professionals. Recently, two screening tools have been published: the Assessment Tool for identifying Hospital Admissions Related to Medications (AT-HARM10) tool and the Drug-Related Admission (DRA) adjudication guide. It is unknown whether pharmacy students could identify MRRs with these tools.

OBJECTIVE

To compare the agreement between two pharmacy students applying the AT-HARM10 tool and DRA adjudication guide in identifying MRRs vs a multidisciplinary panel.

METHODS

A retrospective study was conducted from February to July 2020 at OLVG hospital. Readmissions within 30 days after discharge from seven departments were reviewed by a multidisciplinary panel (pharmacists and physicians). MRRs were defined as readmission where medication was the main cause or medication significantly contributed to the readmission. Two 5th year pharmacy-students volunteered to blindly apply both tools individually on all MRRs and a random sample of non-MRRs. The consensus results of the students and the multidisciplinary panel were compared and displayed as a percentage and Cohen's kappa (κ).

RESULTS

Three hundred sixty-six readmission cases were selected in total, consisting of 181 MRRs and 185 non-MRRs. The agreement between the students using the AT-HARM10 tool vs the multidisciplinary panel was moderate (80%, κ = 0.60 (95% confidence interval (CI): 0.52-0.68)). The DRA adjudication guide had a moderate agreement (81%, κ = 0.62 (CI: 0.54-0.70)). Students misclassified MRRs mainly because the multidisciplinary panel found disease progression more profound than a contribution of medication.

CONCLUSIONS

Two students have an overall agreement of 80% in comparison with the multidisciplinary panel with a moderate Cohen's kappa. Students are more often overestimated, but they may be a good option to preselect potential MRRs to save time for healthcare professionals. However, some MRRs will be missed.

Prevalence of drug-drug interactions in older people before and after hospital admission: analysis from the OPERAM trial

Background

Drug-drug interactions (DDIs) are highly prevalent in older patients but little is known about prevalence of DDIs over time. Our main objective was to assess changes in the prevalence and characteristics of drug-drug interactions (DDIs) during a one-year period after hospital admission in older people, and associated risk factors.

Methods

We conducted a sub-study of the European OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people), which assessed the effects of a structured medication review (experimental arm) compared to usual care (control arm) on reducing drug-related hospital readmissions. All OPERAM patients (≥70 years, with multimorbidity and polypharmacy, hospitalized in four centers in Bern, Brussels, Cork and Utrecht between December 2016 and October 2018, followed over 1 year) who were alive at hospital discharge and had full medication data during the index hospitalization (at baseline i.e., enrolment at admission, and at discharge) were included. DDIs were assessed using an international consensus list of potentially clinically significant DDIs in older people. The point-prevalence of DDIs was evaluated at baseline, discharge, and at 2, 6 and 12 months after hospitalization. Logistic regression models were performed to assess independent variables associated with changes in DDIs 2 months after baseline.

Results

Of the 1950 patients (median age 79 years) included, 1045 (54%) had at least one potentially clinically significant DDI at baseline; point-prevalence rates were 58, 57, 56 and 57% at discharge, and 2, 6 and 12 months, respectively. The prevalence increased significantly from baseline to discharge (P < .001 [significant only in the control group]), then remained stable over time (P for trend .31). The five most common DDIs –all pharmacodynamic in nature– accounted for 80% of all DDIs and involved drugs that affect potassium concentrations, centrally-acting drugs and antithrombotics. At 2 months, DDIs had increased in 459 (27%) patients and decreased in 331 (19%). The main factor predictive of a change in the prevalence of DDIs was hyperpolypharmacy (≥10 medications).

Conclusions

DDIs were very common; their prevalence increased during hospitalization and tended to remain stable thereafter. Medication review may help control this increase and minimize the risk of adverse drug events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02532-z.

Use of the Delphi technique in pharmacy practice research

Consensus research methods are used in health services research to generate evidence through systematic means of measuring collective agreement and developing consensus from experts of a subject matter. Delphi technique is the most commonly reported consensus research method and is a structured, multistage interaction method to determine consensus using repetitive administration of anonymous questionnaires across two or three rounds. The Delphi technique is increasingly being used in pharmacy practice research. Despite its wide use in the development of statements of policies, guidelines, and performance indicators, there is lack of standardized guidelines and criteria to support the Delphi technique study design, conduct, and reporting, leading to inconsistent approaches and methodological difficulties among researchers. In this themed article, we provide the reader with a collation of best practices and highlight key methodological issues and areas of uncertainty of the Delphi method, especially as it pertains to pharmacy practice research.

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

OBJECTIVE

To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.

DESIGN

Cluster randomised controlled trial.

SETTING

110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.

PARTICIPANTS

2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term).

INTERVENTION

Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.

MAIN OUTCOME MEASURE

Primary outcome was first drug related hospital admission within 12 months.

RESULTS

2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).

CONCLUSIONS

Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02986425.

Hospital admissions to geriatric ward related to adverse drug events: a cross-sectional study from the Czech Republic

Background Geriatric patients represent a vulnerable population in terms of adverse drug events (ADEs). Objective The aims of this study were to determine the prevalence and preventability of hospital admissions to a geriatric ward related to ADEs, to identify medications involved in these ADEs and to describe potential preventability aspects of ADE-related admissions. Setting University Hospital Hradec Králové, Czech Republic. Methods This cross-sectional study evaluated acute hospital admissions to the geriatric ward of University Hospital Hradec Králové over a period of nine months (April-December 2017). Medication reviews were performed in order to identify ADE-related hospital admissions. Causality was assessed using the World Health Organization-Uppsala Monitoring Centre criteria. Modified Schumock-Thornton algorithm was used to assess the preventability of ADEs. Main outcome measure 9-month-prevalence of ADE-related hospital admissions. Results A total of 366 hospital admissions were included. The 9-month-prevalence of ADE-related hospital admissions was 11.75% [95% confidence interval 8.45-15.05]. Antithrombotic agents and diuretics represented the most common medication classes associated with ADEs (30.2% each). Electrolyte disturbances and gastrointestinal haemorrhages and ulcerations were the most frequently observed ADEs associated with hospital admission. Out of 43 ADE-related hospitalisations, 23 (53.5%) were considered potentially preventable. Conclusion The contribution of ADEs to hospital admission to the geriatric ward was not negligible. Our results also suggest that 53.5% of identified ADE-related admissions could be potentially prevented. This finding demonstrates just how important the research on the preventability of medication-related hospitalisations is. Further studies and implementations are still needed aiming to minimize the risk of medication-related harm.

Inter-rater reliability of assessments regarding the quality of drug treatment, and drug-related hospital admissions

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.

Adverse drug event presentation and tracking (ADEPT): semiautomated, high throughput pharmacovigilance using real-world data

Objective

To advance use of real-world data (RWD) for pharmacovigilance, we sought to integrate a high-sensitivity natural language processing (NLP) pipeline for detecting potential adverse drug events (ADEs) with easily interpretable output for high-efficiency human review and adjudication of true ADEs.

Materials and methods

The adverse drug event presentation and tracking (ADEPT) system employs an open source NLP pipeline to identify in clinical notes mentions of medications and signs and symptoms potentially indicative of ADEs. ADEPT presents the output to human reviewers by highlighting these drug-event pairs within the context of the clinical note. To measure incidence of seizures associated with sildenafil, we applied ADEPT to 149 029 notes for 982 patients with pediatric pulmonary hypertension.

Results

Of 416 patients identified as taking sildenafil, NLP found 72 [17%, 95% confidence interval (CI) 14–21] with seizures as a potential ADE. Upon human review and adjudication, only 4 (0.96%, 95% CI 0.37–2.4) patients with seizures were determined to have true ADEs. Reviewers using ADEPT required a median of 89 s (interquartile range 57–142 s) per patient to review potential ADEs.

Discussion

ADEPT combines high throughput NLP to increase sensitivity of ADE detection and human review, to increase specificity by differentiating true ADEs from signs and symptoms related to comorbidities, effects of other medications, or other confounders.

Conclusion

ADEPT is a promising tool for creating gold standard, patient-level labels for advancing NLP-based pharmacovigilance. ADEPT is a potentially time savings platform for computer-assisted pharmacovigilance based on RWD.

Knowledge on and use of the FORTA ("Fit fOR The Aged")-list and the FORTA App by general practitioners in Baden-Württemberg, Germany

Aim

To identify the knowledge on and use of the FORTA (“Fit fOR The Aged”)-list and FORTA App in Baden-Württemberg, Germany.

Findings

48% of responding GP claim to know the FORTA list, 54.5% of them the FORTA App. 32.5% use at least one of them regularly, 27% at least once a week.

Message

The results may indicate that the medication tools the FORTA list, and the FORTA App has been successfully disseminated underlining their utility, implementability and teachability though the response rate was low (9.4%).

Purpose

Drug treatment of older people is complicated as multimorbidity and polypharmacy are highly prevalent. To increase the drug appropriateness in older people, the FORTA (“Fit fOR The Aged”)-list was developed. A survey was designed to describe knowledge and use of the FORTA list and the related FORTA App in a German state.

Methods

Survey conducted among 872 general practitioners (GP) from districts (n = 694; 79.6%) or from district-free cities (n = 178; 20.4%) in Baden-Württemberg, Germany who were contacted by e-mail and/or phone.

Results

The response rate was 9.4%. 48% of GP claim to know the FORTA list, 54.5% the FORTA App. 32.5% use one of them regularly, 27% at least once a week.

Conclusions

Responding GP expose knowledge and use of the FORTA list and/or the App exceeding expectations given the limited time since the wider appearance of either tool. These results, though limited by a low response rate, tentatively indicate their successful dissemination underlining utility, implementability and teachability.

Potentially Inappropriate Prescribing and Related Hospital Admissions in Geriatric Patients: A Comparative Analysis between the STOPP and START Criteria Versions 1 and 2

BACKGROUND

Older persons are at significant risk of drug-related admissions (DRAs). We previously demonstrated that 27% of hospitalizations in geriatric patients were associated with potentially inappropriate medicines (PIMs) and/or potential prescribing omissions (PPOs) identified by the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 1 (v₁). The updated STOPP/START criteria version 2 (v₂) comprised a 31% increase in prescribing criteria.

OBJECTIVE

As a secondary analysis of our study conducted in 2008, we aimed to compare the prevalence and types of DRAs identified by STOPP/START.v₁ and STOPP/START.v₂.

METHODS

We applied the STOPP/START.v₂ criteria to a subset of 100 consecutively admitted geriatric patients selected from our original cross-sectional study of 302 patients. A geriatrician and a pharmacist adjudicated whether the identified PIMs and PPOs were related to acute hospitalization. Admissions were defined as DRAs if the identified PIM(s) and/or PPO(s) were related to the main cause of admission or played a significant contributory role in the admission.

RESULTS

The median patient age was 83 years and the median number of medications at home was 8. Compared with STOPP/START.v₁, STOPP/START.v₂ not only yielded more instances of inappropriate prescribing but also targeted significantly more PIMs and PPOs associated with preventable DRAs (23% vs. 40% of all admissions, p < 0.001). PIMs of fall-risk-increasing drugs, and PPOs of musculoskeletal and cardiovascular system drugs, were most frequently associated with DRAs.

CONCLUSION

The latter instances of inappropriate prescribing with major clinical relevance warrant particular attention during medication review in older persons.

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study

Objectives

To provide baseline information on inappropriate prescribing (IP), and to evaluate whether potentially inappropriate medications (PIMs), as defined by STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, were associated with preventable adverse drug events (ADEs) and/or hospitalization.

Methods

We prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.

Results

IP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1–1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20–25.3).

Conclusion

The majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.

Rationale and design of OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM): a cluster randomised controlled trial

INTRODUCTION

Multimorbidity and polypharmacy are important risk factors for drug-related hospital admissions (DRAs). DRAs are often linked to prescribing problems (overprescribing and underprescribing), as well as non-adherence with drug regimens for different reasons. In this trial, we aim to assess whether a structured medication review compared with standard care can reduce DRAs in multimorbid older patients with polypharmacy.

METHODS AND ANALYSIS

OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people is a European multicentre, cluster randomised, controlled trial. Hospitalised patients ≥70 years with ≥3 chronic medical conditions and concurrent use of ≥5 chronic medications are included in the four participating study centres of Bern (Switzerland), Utrecht (The Netherlands), Brussels (Belgium) and Cork (Ireland). Patients treated by the same prescribing physician constitute a cluster, and clusters are randomised 1:1 to either standard care or Systematic Tool to Reduce Inappropriate Prescribing (STRIP) intervention with the help of a clinical decision support system, the STRIP Assistant. STRIP is a structured method performing customised medication reviews, based on Screening Tool of Older People's Prescriptions/Screening  Tool to Alert to Right Treatment criteria to detect potentially inappropriate prescribing. The primary endpoint is any DRA where the main reason or a contributory reason for the patient's admission is caused by overtreatment or undertreatment, and/or inappropriate treatment. Secondary endpoints include number of any hospitalisations, all-cause mortality, number of falls, quality of life, degree of polypharmacy, activities of daily living, patient's drug compliance, the number of significant drug-drug interactions, drug overuse and underuse and potentially inappropriate medication.

ETHICS AND DISSEMINATION

The local Ethics Committees in Switzerland, Ireland, The Netherlands and Belgium approved this trial protocol. We will publish the results of this trial in a peer-reviewed journal.

MAIN FUNDING

European Union's Horizon 2020 programme.

TRIAL REGISTRATION NUMBER

NCT02986425 , SNCTP000002183 , NTR6012, U1111-1181-9400.

Assessment tool for hospital admissions related to medications: development and validation in older patients

Background Medication-related hospital admissions (MRAs) are frequently used to measure outcomes in studies involving medication reviews. The process of identifying MRAs is subjective and time-consuming, and practical, validated alternatives are required. Objective The aim of this study was to develop and validate a practical tool to identify MRAs. Setting Uppsala University Hospital, Sweden. Method We reviewed existing literature on methods to identify MRAs. The tool AT-HARM10 was developed using an iterative process including content validity and feasibility testing. The tool’s inter-rater reliability (IRR) and criterion-related validity (CRV) were assessed: four pairs of either final-year undergraduate or postgraduate pharmacy students applied the tool to one of two batches of 50 older patients’ hospital admissions. Assessment of the same 100 admissions by two experienced clinicians acted as gold standard. Main outcome measure Cohen’s and Fleiss’ kappa for IRR, and sensitivity, specificity, and positive and negative predictive value for CRV. Results AT-HARM10 consists of ten closed questions to distinguish between admissions that are unlikely to be and those that are possibly medication-related. The IRR was moderate to substantial (Cohen’s kappa values were 0.45–0.75 and Fleiss’ kappa values were 0.46 and 0.58). The sensitivity and specificity values were 70/86% and 74/70%, positive and negative predictive values were 73/74% and 71/83% respectively. Both AT-HARM10 and the gold standard identified approximately 50% of the admissions as MRAs. Conclusion AT-HARM10 has been developed as a practical tool to identify MRAs and the tool is valid for use in older patients by final-year undergraduate and postgraduate pharmacy students.

Development of a standardized chart review method to identify drug-related hospital admissions in older people

AIMS

We aimed to develop a standardized chart review method to identify drug-related hospital admissions (DRA) in older people caused by non-preventable adverse drug reactions and preventable medication errors including overuse, underuse and misuse of medications: the DRA adjudication guide.

METHODS

The DRA adjudication guide was developed based on design and test iterations with international and multidisciplinary input in four subsequent steps: literature review; evaluation of content validity using a Delphi consensus technique; a pilot test; and a reliability study.

RESULTS

The DRA adjudication guide provides definitions, examples and step-by-step instructions to measure DRA. A three-step standardized chart review method was elaborated including: (i) data abstraction; (ii) explicit screening with a newly developed trigger tool for DRA in older people; and (iii) consensus adjudication for causality by a pharmacist and a physician using the World Health Organization-Uppsala Monitoring Centre and Hallas criteria. A 15-member international Delphi panel reached consensus agreement on 26 triggers for DRA in older people. The DRA adjudication guide showed good feasibility of use and achieved moderate inter-rater reliability for the evaluation of 16 cases by four European adjudication pairs (71% agreement, κ = 0.41). Disagreements arose mainly for cases with potential underuse.

CONCLUSIONS

The DRA adjudication guide is the first standardized chart review method to identify DRA in older persons. Content validity, feasibility of use and inter-rater reliability were found to be satisfactory. The method can be used as an outcome measure for interventions targeted at improving quality and safety of medication use in older people.