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Parodi López N, Svensson SA, Lönnbro J, Hoffmann M, Wallerstedt SM. Reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'-an appraisal of a set of potentially inappropriate medications. Eur J Clin Pharmacol 2024; 80:1285-1293. [PMID: 38743072 PMCID: PMC11303435 DOI: 10.1007/s00228-024-03700-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/05/2024] [Indexed: 05/16/2024]
Abstract
PURPOSE To analyse the reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'. METHODS From a previous study that included consecutive primary care patients ≥ 65 years of age, all patients ≥ 75 years of age were analysed. Two physicians independently screened their medication lists and medical records, applying the Swedish indicator which includes potentially inappropriate medications (PIMs): long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. The clinical relevance of identified PIMs was independently assessed. Thereafter, the physicians determined in consensus whether some medical action related to the drug treatment was medically justified and prioritised before the next regular visit. If so, the drug treatment was considered inadequate, and if not, adequate. RESULTS A total of 1,146 drugs were assessed in 149 patients (75‒99 years, 62% female, 0‒20 drugs per patient). In 29 (19%) patients, at least one physician identified ≥ 1 PIM according to the indicator at issue; 24 (16%) patients were concordantly identified with ≥ 1 such PIM (kappa: 0.89). Of 26 PIMs concordantly identified, the physicians concordantly assessed four as clinically relevant and 12 as not clinically relevant (kappa: 0.17). After the consensus discussion, six (4%) patients had ≥ 1 PIM according to the studied indicator that merited action. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance in identifying inadequate drug treatment: 0.56 (95% confidence interval: 0.46 to 0.66). CONCLUSION The Swedish indicator has strong reliability regarding PIM detection but does not validly reflect the adequacy of drug treatment.
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Affiliation(s)
- Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Nötkärnan Bergsjön Health Centre, Gothenburg, Sweden
| | - Johan Lönnbro
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Hoffmann
- NEPI Foundation - Swedish Network for Pharmacoepidemiology, Linköping University, Linköping, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Kindstedt J, Andersson P, Westberg A, Glader EL, Lövheim H, Gustafsson M. Exploring medication-related hospital admissions and their association with cognitive impairment among acutely admitted older people. Res Social Adm Pharm 2023; 19:1048-1053. [PMID: 37105774 DOI: 10.1016/j.sapharm.2023.04.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/05/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Medication-related hospital admissions (MRAs) are common among older people. Persons with cognitive impairment are especially vulnerable to adverse drug effects. At the same time, increased home health care and social support could theoretically prevent medication-related problems. This study aims to estimate the proportion of MRAs and explore their relationship with cognitive impairment in a population of acutely admitted older people. METHODS This cross-sectional study comprised 300 individuals aged 75 years or older admitted to an acute medical ward. Two assessors identified possibly MRAs using the Assessment Tool for Hospital Admissions Related to Medications 10 (AT-HARM10). Screening for cognitive impairment was performed during ward stay using a 4-item test related to time orientation. Prevalence odds ratios between cognitive test scores and MRAs were analysed through logistic regression. RESULTS Using AT-HARM10, 108 out of 300 admissions (36%) were classified as possibly MRAs by both assessors. Moreover, MRAs were least common among patients with the lowest cognitive test scores. There was an association regarding MRAs when the lowest test score was treated as a cut-off and compared against a reference category comprising all other scores (OR, 0.31 [95% CI 0.10-0.93]; p = 0.037) in a logistic regression model adjusted for cohabitation and home health care. CONCLUSION Approximately one-third of the hospital admissions among acutely admitted older people were considered at least possibly medication-related. Hence, there is still a great need to manage medication-related problems and reduce MRAs in this vulnerable population. Using a 4-item instrument to screen for cognitive impairment, there was a negative association between MRA and lowest cognitive test score. Further exploration of the relationship between MRAs and cognitive impairment may indicate appropriate components and target populations for interventions that aims to reduce the risk of MRA.
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Affiliation(s)
- Jonas Kindstedt
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
| | - Pernilla Andersson
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
| | - Annica Westberg
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
| | - Eva-Lotta Glader
- Department of Public Health and Clinical Medicine, Umeå University, SE-901 87, Umeå, Sweden.
| | - Hugo Lövheim
- Department of Community Medicine and Rehabilitation, Umeå University, SE-901 87, Umeå, Sweden.
| | - Maria Gustafsson
- Department of Integrative Medical Biology, Umeå University, SE-901 87, Umeå, Sweden.
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Which Adverse Events and Which Drugs Are Implicated in Drug-Related Hospital Admissions? A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12041320. [PMID: 36835854 PMCID: PMC9963366 DOI: 10.3390/jcm12041320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Adverse drug events (ADEs) and adverse drug reactions (ADRs) are leading causes of iatrogenic injury, which can result in emergency department (ED) visits or admissions to inpatient wards. The aim of this systematic review and meta-analysis was to provide up-to-date estimates of the prevalence of (preventable) drug-related ED visits and hospital admissions, as well as the type and prevalence of implicated ADRs/ADEs and drugs. A literature search of studies published between January 2012 and December 2021 was performed in PubMed, Medline, EMBASE, Cochrane Library, and Web of Science. Retrospective and prospective observational studies investigating acute admissions to EDs or inpatient wards due to ADRs or ADEs in the general population were included. Meta-analyses of prevalence rates were conducted using generalized linear mixed models (GLMM) with the random-effect method. Seventeen studies reporting ADRs and/or ADEs were eligible for inclusion. The prevalence rates of ADR- and ADE-related admissions to EDs or inpatient wards were estimated at 8.3% ([95% CI, 6.4-10.7%]) and 13.9% ([95% CI, 8.1-22.8%]), respectively, of which almost half (ADRs: 44.7% [95% CI: 28.1; 62.4]) and more than two thirds (ADEs: 71.0% [95% CI, 65.9-75.6%]) had been classified as at least possibly preventable. The ADR categories most frequently implicated in ADR-related admissions were gastrointestinal disorders, electrolyte disturbances, bleeding events, and renal and urinary disorders. Nervous system drugs were found to be the most commonly implicated drug groups, followed by cardiovascular and antithrombotic agents. Our findings demonstrate that ADR-related admissions to EDs and inpatient wards still represent a major and often preventable health care problem. In comparison to previous systematic reviews, cardiovascular and antithrombotic drugs remain common causes of drug-related admissions, while nervous system drugs appear to have become more commonly implicated. These developments may be considered in future efforts to improve medication safety in primary care.
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Parodi López N, Svensson SA, Wallerstedt SM. Clinical relevance of potentially inappropriate medications and potential prescribing omissions according to explicit criteria-a validation study. Eur J Clin Pharmacol 2022; 78:1331-1339. [PMID: 35648150 PMCID: PMC9283130 DOI: 10.1007/s00228-022-03337-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/12/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the clinical relevance of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), and to evaluate the association between PIMs/PPOs and inadequate drug treatment. METHODS PIMs/PPOs, concordantly identified by two physicians applying the STOPP/START criteria, the EU(7)-PIM list, and a Swedish set in 302 consecutive older primary care patients, were assessed regarding clinical relevance for the specific patient. The physicians determined, in consensus, whether an action related to the medication was medically justified prior to the next regular consultation. If so, the drug treatment was categorised as inadequate, and if not, the treatment was considered adequate. RESULTS In all, 259 (86%) patients had 1010 PIMs/PPOs, 150 (15%) of which, in 81 (27%) patients, were assessed as clinically relevant (kappa: 0.26). A total of 75 (50%) clinically relevant PIMs and PPOs were prioritised for medical action before the next regular consultation. Action-requiring clinically relevant PIMs most often concerned acetylsalicylic acid (ASA) for primary prevention (four out of 68 patients on ASA). The corresponding PPOs concerned beta-blockers in ischaemic heart disease (four out of 61 patients with this condition). When an overall medical perspective was applied, 164 (63%) out of 259 patients with PIMs/PPOs were assessed as having adequate treatment. In adjusted logistic regression, number of PIMs and/or PPOs and number of drugs were associated with inadequate drug treatment. CONCLUSION One in seven PIMs/PPOs may be clinically relevant, half of these not of priority for medical action. Cautious interpretation is warranted when PIMs/PPOs are used as outcome measures.
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Affiliation(s)
- Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden. .,Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden.
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden.,Närhälsan Hjällbo Health Centre, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 431, 405 30, Gothenburg, Sweden.,HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden
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Tukukino C, Parodi López N, Svensson SA, Wallerstedt SM. Drug interaction alerts in older primary care patients, and related medically justified actions. Eur J Clin Pharmacol 2022; 78:1115-1126. [PMID: 35355082 PMCID: PMC9184366 DOI: 10.1007/s00228-022-03292-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 02/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To describe presented interaction alerts in older patients, and the extent to which these require further medical action for the specific patient or are already being addressed. METHODS Interaction alerts presented at a physician consultation, for 274 consecutive primary care patients treated with two or more drugs (median age: 75 years; 59% female), were extracted. These alerts are based on Janusmed, a decision support integrated in the medical records that provides recommendations for managing the interactions. One general practitioner (GP) and one GP/clinical pharmacologist determined in retrospect, first independently and then in consensus, whether the alerts justified further medical action, considering each patient's health condition. RESULTS In all, 405 drug interaction alerts in 151 (55%) patients were triggered. Medical action in response was deemed medically justified for 35 (9%) alerts in 26 (17%) patients. These actions most often involved a switch to a less interacting drug from the same drug class (n = 10), a separate intake (n = 9), or the ordering of a laboratory test (n = 8). Out of 531 actions suggested by the alert system, only 38 (7%) were applicable to the specific patient, as, for instance, laboratory parameters were already being satisfactorily monitored or a separate intake implemented. CONCLUSIONS More than every other older patient receives drug treatment that triggers drug interaction alerts. Nine in ten alerts were already being addressed or were not relevant in the clinical setting, whereas, for the remaining tenth, some medical action, that for unknown reasons had not been taken, was reasonable. These findings show that interaction alerts are questionable as indicators of problematic prescribing.
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Affiliation(s)
- Carina Tukukino
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Department of Clinical Pharmacology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Naldy Parodi López
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Närhälsan Kungshöjd Health Centre, Gothenburg, Sweden
| | - Staffan A Svensson
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden.,Närhälsan Hjällbo Health Centre, Gothenburg, Sweden
| | - Susanna M Wallerstedt
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Box 430, 405 30, Gothenburg, Sweden. .,HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Heck J, Krichevsky B, Stichtenoth DO, Zu Siederdissen CH, Krause O. Duplicate prescriptions-proposal of a clinically oriented categorisation. Eur J Clin Pharmacol 2021; 77:1589-1591. [PMID: 33893520 PMCID: PMC8440296 DOI: 10.1007/s00228-021-03143-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/11/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Johannes Heck
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany.
| | | | - Dirk O Stichtenoth
- Institute for Clinical Pharmacology, Hannover Medical School, Hannover, Germany.,Drug Commissioner of Hannover Medical School, Hannover, Germany
| | | | - Olaf Krause
- Institute for General Medicine, Hannover Medical School, Hannover, Germany
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