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

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.

A mixed methods analysis of the medication review intervention centered around the use of the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA) in Swiss primary care practices

BACKGROUND

Electronic clinical decision support systems (eCDSS), such as the 'Systematic Tool to Reduce Inappropriate Prescribing' Assistant (STRIPA), have become promising tools for assisting general practitioners (GPs) with conducting medication reviews in older adults. Little is known about how GPs perceive eCDSS-assisted recommendations for pharmacotherapy optimization. The aim of this study was to explore the implementation of a medication review intervention centered around STRIPA in the 'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) trial.

METHODS

We used an explanatory mixed methods design combining quantitative and qualitative data. First, quantitative data about the acceptance and implementation of eCDSS-generated recommendations from GPs (n = 21) and their patients (n = 160) in the OPTICA intervention group were collected. Then, semi-structured qualitative interviews were conducted with GPs from the OPTICA intervention group (n = 8), and interview data were analyzed through thematic analysis.

RESULTS

In quantitative findings, GPs reported averages of 13 min spent per patient preparing the eCDSS, 10 min performing medication reviews, and 5 min discussing prescribing recommendations with patients. On average, out of the mean generated 3.7 recommendations (SD=1.8). One recommendation to stop or start a medication was reported to be implemented per patient in the intervention group (SD=1.2). Overall, GPs found the STRIPA useful and acceptable. They particularly appreciated its ability to generate recommendations based on large amounts of patient information. During qualitative interviews, GPs reported the main reasons for limited implementation of STRIPA were related to problems with data sourcing (e.g., incomplete data imports), preparation of the eCDSS (e.g., time expenditure for updating and adapting information), its functionality (e.g., technical problems downloading PDF recommendation reports), and appropriateness of recommendations.

CONCLUSIONS

Qualitative findings help explain the relatively low implementation of recommendations demonstrated by quantitative findings, but also show GPs' overall acceptance of STRIPA. Our results provide crucial insights for adapting STRIPA to make it more suitable for regular use in future primary care settings (e.g., necessity to improve data imports).

TRIAL REGISTRATION

Clinicaltrials.gov NCT03724539, date of first registration: 29/10/2018.

Implementation of clinical medication review in a geriatric ward to reduce potentially inappropriate prescriptions among older adults

PURPOSE

The impact of several pharmaceutical interventions to reduce the use of potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) has been recently studied. We aimed to determine whether clinical medication review (CMR) (i.e. a systematic and patient-centred clinical assessment of all medicines currently taken by a patient) performed by a geriatrician and a pharmacist added to standard pharmaceutical care (SPC) (i.e. medication reconciliation and regular prescription review by the pharmacist) resulted in more appropriate prescribing compared to SPC among older inpatients.

METHODS

A retrospective observational single-centre study was conducted in a French geriatric ward. Six criteria for appropriate prescribing were chosen: the number of PIMs and POMs as defined by the STOPP/STARTv2 list, the total number of drugs prescribed, the number of administrations per day and the number of psychotropic and anticholinergic drugs. These criteria were compared between CMR and SPC group using linear and logistic regression models weighted on propensity scores.

RESULTS

There were 137 patients included, 66 in the CMR group and 71 in the SPC group. The mean age was 87 years, the sex ratio was 0.65, the mean number of drugs prescribed was 9, the mean MMSE was 21 and at admission 242 POMs, and 363 PIMs were prescribed. Clinical medication review did not reduce the number of PIMs at discharge compared to SPC (beta = - 0.13 [- 0.84; 0.57], p = 0.71) nor did it reduce the number of drugs prescribed (p = 0.10), the number of psychotropic drugs (p = 0.17) or the anticholinergic load (p = 0.87). Clinical medication review resulted in more POMs being prescribed than in standard pharmaceutical care (beta = - 0.39 [- 0.72; - 0.06], p = 0.02). Cardiology POMs were more implemented in the medication review group (p = 0.03).

CONCLUSION

Clinical medication review did not reduce the number of PIMs but helped clinicians introduce underused drugs, especially cardiovascular drugs, which are known to be associated with morbidity and mortality risk reduction.

Statin therapy in multimorbid older patients with polypharmacy- a cross-sectional analysis of the Swiss OPERAM trial population

Background

Statin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy.

Aim

To assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients.

Methods

We conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses.

Results

Of 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor.

Conclusion

A third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Clinical Decision Support Systems in Hospitalized Older Patients: An Exploratory Analysis in a Real-Life Clinical Setting

BACKGROUND

Inappropriate prescribing is associated with negative patient outcomes. In hospitalized patients, the use of Clinical Decision Support Systems (CDSSs) may reduce inappropriate prescribing and thereby improve patient-related outcomes. However, recently published large clinical trials (OPERAM and SENATOR) have shown negative results on the use of CDSSs and patient outcomes and strikingly low acceptance of recommendations.

OBJECTIVE

The purpose of the present study was to investigate the use of a CDSS in a real-life clinical setting of hospitalized older patients. As such, we report on the real-life pattern of this in-hospital implemented CDSS, including (i) whether generated alerts were resolved; (ii) whether a recorded action by the pharmacist led to an improved number of resolved alerts; and (iii) the natural course of generated alerts, in particular of those in the non-intervention group; as these data are largely lacking in current studies.

METHODS

Hospitalized patients, aged 60 years and older, admitted to Zuyderland Medical Centre, the Netherlands, in 2018 were included. The evaluation of the CDSS was investigated using a database used for standard care. Alongside demographic and clinical data, we also collected the total numbers of CDSS alerts, the number of alerts 'handled' by the pharmacist, those that resulted in an action by the pharmacist, and finally the outcome of the alerts at day 1 and day 3 after the alert was generated.

RESULTS

A total of 3574 unique hospitalized patients, mean age 76.7 (SD 8.3) years and 53% female, were included. From these patients, 8073 alerts were generated, of which 7907 (97.9% of total) were handled by the pharmacist (day 1). In 51.6% of the alerts handled by the pharmacist, an action was initiated, resulting in 36.1% of the alerts resolved after day 1, compared with 27.3% if the pharmacist did not perform an action (p < 0.001). On day 3, in 52.6% of the alerts an action by the pharmacist was initiated, resulting in 62.4% resolved alerts, compared with 48.0% when no action was performed (p < 0.001). In the category renal function, the percentages differed significantly between an action versus no action of the pharmacist at day 1 and at day 3 (16.6% vs 10.6%, p < 0.001 [day 1]; 29.8% vs 19.4%, p < 0.001 [day 3]).

CONCLUSION

This study demonstrates the pattern and natural course of clinical alerts of an in-hospital implemented CDSS in a real-life clinical setting of hospitalized older patients. Besides the already known beneficial effect of actions by pharmacists, we have also shown that many alerts become resolved without any specific intervention. As such, our study provides an important insight into the spontaneous course of resolved alerts, since these data are currently lacking in the literature.

A fuzzy based dietary clinical decision support system for patients with multiple chronic conditions (MCCs)

Due to the multifaceted nature of Multiple Chronic Conditions (MCCs), setting a diet for these patients is complicated and time-consuming. In this study, a clinical decision support system based on fuzzy logic was modeled and evaluated to aid dietitians in adjusting the diet for patients with MCCs. Mamdani fuzzy logic with 1144 rules was applied to design the model for MCCs patients over 18 years who suffer from one or more chronic diseases, including obesity, diabetes, hypertension, hyperlipidemia, and kidney disease. One hundred nutrition records from three nutrition clinics were employed to measure the system's performance. The findings showed that the diet set by nutritionists had no statistically significant difference from the diet recommended by the fuzzy model (p > 0.05), and there was a strong correlation close to one between them. In addition, the results indicated a suitable model performance with an accuracy of about 97%. This system could adjust the diet with high accuracy as well as humans. In addition, it could increase dietitians' confidence, precision, and speed in setting the diet for MCCs patients.

Benzodiazepine Receptor Agonists Use and Cessation Among Multimorbid Older Adults with Polypharmacy: Secondary Analysis from the OPERAM Trial

BACKGROUND

Benzodiazepine receptor agonists (BZRAs) are commonly prescribed in older adults despite an unfavorable risk-benefit ratio. Hospitalizations may provide a unique opportunity to initiate BZRA cessation, yet little is known about cessation during and after hospitalization. We aimed to measure the prevalence of BZRA use before hospitalization and the rate of cessation 6 months later, and to identify factors associated with these outcomes.

METHODS

We conducted a secondary analysis of a cluster randomized controlled trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly [OPERAM]), comparing usual care and in-hospital pharmacotherapy optimization in adults aged 70 years or over with multimorbidity and polypharmacy in four European countries. BZRA cessation was defined as taking one or more BZRA before hospitalization and not taking any BZRA at the 6-month follow-up. Multivariable logistic regression was performed to identify factors associated with BZRA use before hospitalization and with cessation at 6 months.

RESULTS

Among 1601 participants with complete 6-month follow-up data, 378 (23.6%) were BZRA users before hospitalization. Female sex (odds ratio [OR] 1.52 [95% confidence interval 1.18-1.96]), a higher reported level of depression/anxiety (OR up to 2.45 [1.54-3.89]), a higher number of daily drugs (OR 1.08 [1.05-1.12]), use of an antidepressant (OR 1.74 [1.31-2.31]) or an antiepileptic (OR 1.46 [1.02-2.07]), and trial site were associated with BZRA use. Diabetes mellitus (OR 0.60 [0.44-0.80]) was associated with a lower probability of BZRA use. BZRA cessation occurred in 86 BZRA users (22.8%). Antidepressant use (OR 1.74 [1.06-2.86]) and a history of falling in the previous 12 months (OR 1.75 [1.10-2.78]) were associated with higher BZRA cessation, and chronic obstructive pulmonary disease (COPD) (OR 0.45 [0.20-0.91]) with lower BZRA cessation.

CONCLUSION

BZRA prevalence was high among included multimorbid older adults, and BZRA cessation occurred in almost a quarter of them within 6 months after hospitalization. Targeted BZRA deprescribing programs could further enhance cessation. Specific attention is needed for females, central nervous system-acting co-medication, and COPD co-morbidity.

REGISTRATION

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

Cardiovascular disease and type 2 diabetes in older adults: a combined protocol for an individual participant data analysis for risk prediction and a network meta-analysis of novel anti-diabetic drugs

Introduction

Older and multimorbid adults with type 2 diabetes (T2D) are at high risk of cardiovascular disease (CVD) and chronic kidney disease (CKD). Estimating risk and preventing CVD is a challenge in this population notably because it is underrepresented in clinical trials. Our study aims to (1) assess if T2D and haemoglobin A1c (HbA1c) are associated with the risk of CVD events and mortality in older adults, (2) develop a risk score for CVD events and mortality for older adults with T2D, (3) evaluate the comparative efficacy and safety of novel antidiabetics.

Methods and analysis

For Aim 1, we will analyse individual participant data on individuals aged ≥65 years from five cohort studies: the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People study; the Cohorte Lausannoise study; the Health, Aging and Body Composition study; the Health and Retirement Study; and the Survey of Health, Ageing and Retirement in Europe. We will fit flexible parametric survival models (FPSM) to assess the association of T2D and HbA1c with CVD events and mortality. For Aim 2, we will use data on individuals aged ≥65 years with T2D from the same cohorts to develop risk prediction models for CVD events and mortality using FPSM. We will assess model performance, perform internal-external cross validation, and derive a point-based risk score. For Aim 3, we will systematically search randomized controlled trials of novel antidiabetics. Network meta-analysis will be used to determine comparative efficacy in terms of CVD, CKD, and retinopathy outcomes, and safety of these drugs. Confidence in results will be judged using the CINeMA tool.

Ethics and dissemination

Aims 1 and 2 were approved by the local ethics committee (Kantonale Ethikkommission Bern); no approval is required for Aim 3. Results will be published in peer-reviewed journals and presented in scientific conferences.

Prescribing, deprescribing and potential adverse effects of proton pump inhibitors in older patients with multimorbidity: an observational study

BACKGROUND

Proton pump inhibitors (PPIs) contribute to polypharmacy and are associated with adverse effects. As prospective data on longitudinal patterns of PPI prescribing in older patients with multimorbidity are lacking, we sought to assess patterns of PPI prescribing and deprescribing, as well as the association of PPI use with hospital admissions over 1 year in this population.

METHODS

We conducted a prospective, longitudinal cohort study using data from the Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM) trial, a randomized controlled trial testing an intervention to reduce inappropriate prescribing (2016-2018). This trial included adults aged 70 years and older with at least 3 chronic conditions and prescribed at least 5 chronic medications. We assessed prevalence of PPI use at time of hospital admission, and new prescriptions and deprescribing at discharge, and at 2 months and 1 year after discharge, by intervention group. We used a regression with competing risk for death to assess the association of PPI use with readmissions related to their potential adverse effects, and all-cause readmission.

RESULTS

Overall, 1080 (57.4%) of 1879 patients (mean age 79 yr) had PPI prescriptions at admission, including 496 (45.9%) patients with a potentially inappropriate indication. At discharge, 133 (24.9%) of 534 patients in the intervention group and 92 (16.8%) of 546 patients in the control group who were using PPIs at admission had deprescribing. Among 680 patients who were not using PPIs at discharge, 47 (14.6%) of 321 patients in the intervention group and 40 (11.1%) of 359 patients in the control group had a PPI started within 2 months. Use of PPIs was associated with all-cause readmission (n = 770, subdistribution hazard ratio 1.31, 95% confidence interval 1.12-1.53).

INTERPRETATION

Potentially inappropriate use of PPI, new PPI prescriptions and PPI deprescribing were frequent among older adults with multimorbidity and polypharmacy. These data suggest that persistent PPI use may be associated with clinically important adverse effects in this population.

Patterns of patients with polypharmacy in adult population from Korea

Polypharmacy and its rising global prevalence is a growing public health burden. Using a large representative nationwide Korean cohort (N = 761,145), we conducted a retrospective cross-sectional study aiming to identify subpopulations of patients with polypharmacy and characterize their unique patterns through cluster analysis. Patients aged ≥ 30 years who were prescribed at least one medication between 2014 and 2018 were included in our study. Six clusters were identified: cluster 1 mostly included patients who were hospitalized for a long time (4.3 ± 5.3 days); cluster 2 consisted of patients with disabilities (100.0%) and had the highest mean number of prescription drugs (7.7 ± 2.8 medications); cluster 3 was a group of low-income patients (99.9%); cluster 4 was a group of high-income patients (80.2%) who frequently (46.4 ± 25.9 days) visited hospitals/clinics (7.3 ± 2.7 places); cluster 5 was mostly elderly (74.9 ± 9.8 years) females (80.3%); and cluster 6 comprised mostly middle-aged (56.4 ± 1.5 years) males (88.6%) (all P < 0.001). Patients in clusters 1-5 had more prescribed medications and outpatient visit days than those in cluster 6 (all P < 0.001). Given limited health care resources, individuals with any of the identified phenotypes may be preferential candidates for participation in intervention programs for optimal medication use.

The development and validation of a medicines optimisation tool to protect the physical health of people with severe mental illness (OPTIMISE)

BACKGROUND

The life expectancy of people with severe mental illness (SMI) is shorter than those without SMI, with multimorbidity and poorer physical health contributing to health inequality. Screening tools could potentially assist the optimisation of medicines to protect the physical health of people with SMI. The aim of our research was to design and validate a medicines optimisation tool (OPTIMISE) to help clinicians to optimise physical health in people with SMI.

METHODS

A review of existing published guidelines, PubMed and Medline was carried out. Literature was examined for medicines optimisation recommendations and also for reference to the management of physical illness in people with mental illness. Potential indicators were grouped according to physiological system. A multidisciplinary team with expertise in mental health and the development of screening tools agreed that 83 indicators should be included in the first draft of OPTIMISE. The Delphi consensus technique was used to develop and validate the contents. A 17-member multidisciplinary panel of experts from the UK and Ireland completed 2 rounds of Delphi consensus, rating their level of agreement to 83 prescribing indicators using a 5-point Likert scale. Indicators were accepted for inclusion in the OPTIMISE tool after achieving a median score of 1 or 2, where 1 indicated strongly agree and 2 indicated agree, and 75^th centile value of ≤ 2. Interrater reliability was assessed among 4 clinicians across 20 datasets and the chance corrected level of agreement (kappa) was calculated. The kappa statistic was interpreted as poor if 0.2 or less, fair if 0.21-0.4, moderate if 0.41-0.6, substantial if 0.61-0.8, and good if 0.81-1.0.

RESULTS

Consensus was achieved after 2 rounds of Delphi for 62 prescribing indicators where 53 indicators were accepted after round 1 and a further 9 indicators were accepted after round 2. Interrater reliability of OPTIMISE between physicians and pharmacists indicated a substantial level of agreement with a kappa statistic of 0.75.

CONCLUSIONS

OPTIMISE is a 62 indicator medicines optimisation tool designed to assist decision making in those treating adults with SMI. It was developed using a Delphi consensus methodology and interrater reliability is substantial. OPTIMISE has the potential to improve medicines optimisation by ensuring preventative medicines are considered when clinically indicated. Further research involving the implementation of OPTIMISE is required to demonstrate its true benefit.

TRIAL REGISTRATION

This article does not report the results of a health care intervention on human participants.

Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial

BACKGROUND

A patient-centred approach to medicines optimisation is considered essential. The OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial evaluated the effectiveness of medication review with shared decision-making (SDM) in older people with multimorbidity. Beyond evaluating the clinical effectiveness, exploring the patient experience facilitates a better understanding of contextual factors and mechanisms affecting medication review effectiveness.

OBJECTIVE

To explore experiences of hospital-initiated medication changes in older people with multimorbidity.

METHODS

We conducted a multicentre mixed-methods study, embedded in the OPERAM trial, combining semi-structured interviews and the Beliefs about Medicines Questionnaire (BMQ) with a purposive sample of 48 patients (70-94 years) from four European countries. Interviews were analysed using the Framework approach. Trial implementation data on SDM were collected and the 9-item SDM questionnaire was conducted with 17 clinicians.

RESULTS

Patients generally displayed positive attitudes towards medication review, yet emphasised the importance of long-term, trusting relationships such as with their general practitioners for medication review. Many patients reported a lack of information and communication about medication changes and predominantly experienced paternalistic decision-making. Patients' beliefs that 'doctors know best', 'blind trust', having limited opportunities for questions, use of jargon terms by clinicians, 'feeling too ill', dismissive clinicians, etc highlight the powerlessness some patients felt during hospitalisation, all representing barriers to SDM. Conversely, involvement of companions, health literacy, empathetic and trusting patient-doctor relationships, facilitated SDM. Paradoxical to patients' experiential accounts, clinicians reported high levels of SDM. The BMQ showed that most patients had high necessity and low concern beliefs about medicines. Beliefs about medicines, experiencing benefits or harms from medication changes, illness perception, trust and balancing advice between different healthcare professionals all affected acceptance of medication changes.

CONCLUSION

To meet patients' needs, future medicines optimisation interventions should enhance information exchange, better prepare patients and clinicians for partnership in care and foster collaborative medication reviews across care settings.

Hospital physicians' and older patients' agreement with individualised STOPP/START-based medication optimisation recommendations in a clinical trial setting

Aim

To evaluate the agreement of hospital physicians and older patients with individualised STOPP/START based medication optimisation recommendations from a pharmacotherapy team.

Findings

In total, 371 recommendations were discussed with patients and physicians, overall agreement was 61.6% for STOPP and 60.7% for START recommendations. Highest agreement (74%) was found for initiation of osteoporosis agents and discontinuation of proton pump inhibitors.

Message

Better patient and physician education regarding the benefit/risk balance of pharmacotherapy, in addition to more precise and up-to-date medical records to avoid irrelevant recommendations, will likely result in higher adherence with future pharmacotherapy optimisation recommendations.

Objective

To evaluate the agreement of hospital physicians and older patients with individualised STOPP/START-based medication optimisation recommendations from a pharmacotherapy team.

Methods

This study was embedded within a large European, multicentre, cluster randomised controlled trial examining the effect of a structured medication review on drug-related hospital admissions in multimorbid (≥ 3 chronic conditions) older people (≥ 70 years) with polypharmacy (≥ 5 chronic medications), called OPERAM. Data from the Dutch intervention arm of this trial were used for this study. Medication review was performed jointly by a physician and pharmacist (i.e. pharmacotherapy team) supported by a Clinical Decision Support System with integrated STOPP/START criteria. Individualised STOPP/START-based medication optimisation recommendations were discussed with patients and attending hospital physicians.

Results

139 patients were included, mean (SD) age 78.3 (5.1) years, 47% male and median (IQR) number of medications at admission 11 (9–14). In total, 371 recommendations were discussed with patients and physicians, overall agreement was 61.6% for STOPP and 60.7% for START recommendations. Highest agreement was found for initiation of osteoporosis agents and discontinuation of proton pump inhibitors (both 74%). Factors associated with higher agreement in multivariate analysis were: female gender (+ 17.1% [3.7; 30.4]), ≥ 1 falls in the past year (+ 15.0% [1.5; 28.5]) and renal impairment i.e. eGFR 30–50 ml/min/1.73 m²; (+ 18.0% [2.0; 34.0]). The main reason for disagreement (40%) was patients’ reluctance to discontinue or initiate medication.

Conclusion

Better patient and physician education regarding the benefit/risk balance of pharmacotherapy, in addition to more precise and up-to-date medical records to avoid irrelevant recommendations, will likely result in higher adherence with future pharmacotherapy optimisation recommendations.

Clinical trial registration

Trial Registration Number NCT02986425.

Frequency and Acceptance of Clinical Decision Support System-Generated STOPP/START Signals for Hospitalised Older Patients with Polypharmacy and Multimorbidity

BACKGROUND

The Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) instrument is used to evaluate the appropriateness of medication in older people. STOPP/START criteria have been converted into software algorithms and implemented in a clinical decision support system (CDSS) to facilitate their use in clinical practice.

OBJECTIVE

Our objective was to determine the frequency of CDSS-generated STOPP/START signals and their subsequent acceptance by a pharmacotherapy team in a hospital setting.

DESIGN AND METHODS

Hospitalised older patients with polypharmacy and multimorbidity allocated to the intervention arm of the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly) trial underwent a CDSS-assisted structured medication review in four European hospitals. We evaluated the frequency of CDSS-generated STOPP/START signals and the subsequent acceptance of these signals by a trained pharmacotherapy team consisting of a physician and pharmacist after evaluation of clinical applicability to the individual patient, prior to discussing pharmacotherapy optimisation recommendations with the patient and attending physicians. Multivariate linear regression analysis was used to investigate potential patient-related (e.g. age, number of co-morbidities and medications) and setting-related (e.g. ward type, country of inclusion) determinants for acceptance of STOPP and START signals.

RESULTS

In 819/826 (99%) of the patients, at least one STOPP/START signal was generated using a set of 110 algorithms based on STOPP/START v2 criteria. Overall, 39% of the 5080 signals were accepted by the pharmacotherapy team. There was a high variability in the frequency and the subsequent acceptance of the individual STOPP/START criteria. The acceptance ranged from 2.5 to 75.8% for the top ten most frequently generated STOPP and START signals. The signal to stop a drug without a clinical indication was most frequently generated (28%), with more than half of the signals accepted (54%). No difference in mean acceptance of STOPP versus START signals was found. In multivariate analysis, most patient-related determinants did not predict acceptance, although the acceptance of START signals increased in patients with one or more hospital admissions (+ 7.9; 95% confidence interval [CI] 1.6-14.1) or one or more falls in the previous year (+ 7.1; 95% CI 0.7-13.4). A higher number of co-morbidities was associated with lower acceptance of STOPP (- 11.8%; 95% CI - 19.2 to - 4.5) and START (- 11.0%; 95% CI - 19.4 to - 2.6) signals for patients with more than nine and between seven and nine co-morbidities, respectively. For setting-related determinants, the acceptance differed significantly between the participating trial sites. Compared with Switzerland, the acceptance was higher in Ireland (STOPP: + 26.8%; 95% CI 16.8-36.7; START: + 31.1%; 95% CI 18.2-44.0) and in the Netherlands (STOPP: + 14.7%; 95% CI 7.8-21.7). Admission to a surgical ward was positively associated with acceptance of STOPP signals (+ 10.3%; 95% CI 3.8-16.8).

CONCLUSION

The involvement of an expert team in translating population-based CDSS signals to individual patients is essential, as more than half of the signals for potential overuse, underuse, and misuse were not deemed clinically appropriate in a hospital setting. Patient-related potential determinants were poor predictors of acceptance. Future research investigating factors that affect patients' and physicians' agreement with medication changes recommended by expert teams may provide further insight for implementation in clinical practice.

REGISTRATION

ClinicalTrials.gov Identifier: NCT02986425.

Effects of an interprofessional deprescribing intervention in Swiss nursing homes: the Individual Deprescribing Intervention (IDeI) randomised controlled trial

BACKGROUND

Deprescribing polypharmacy and potentially inappropriate medications (PIMs) has been shown to be beneficial to nursing home (NH) residents' health. Medication reviews are the most widely studied deprescribing intervention; in a previous trial, we showed that another intervention, a deprescribing-focused interprofessional quality circle, can reduce the use of inappropriate medications at the NH level. However, this intervention cannot account for the variety of the residents' clinical situations. Therefore, we trialled a subsequent intervention in NH that enacted the quality circle intervention in the previous year.

METHODS

In 7 NHs, the most heavily medicated residents were recruited and randomised to receive usual care or the intervention. The intervention was a pharmacist-led, deprescribing-focused medication review, followed by the creation of an individualised treatment modification plan in collaboration with nurses and physicians. Intervention's effects were assessed after four months on the number and dose of PIMs used, quality of life, and safety outcomes (mortality, hospitalisations, falls, and use of physical restraints). Data were analysed using Poisson multivariate regression models.

RESULTS

Sixty-two NH residents participated, falling short of the expected 100 participants; 4 died before initial data collection. Participants used a very high number of drugs (median 15, inter-quartile range [12-19]) and PIMs (median 5, IQR [3-7]) at baseline. The intervention did not reduce the number of PIMs prescribed to the participants; however, it significantly decreased their dose (incidence rate ratio 0.763, CI95 [0.594; 0.979]), in particular for chronic drugs (IRR 0.716, CI95 [0.546; 0.938]). No adverse effects were seen on mortality, hospitalisations, falls, and restraints use, but, in the intervention group, three participants experienced adverse events that required the reintroduction of withdrawn treatments, and a decrease in quality of life is possible.

CONCLUSIONS

As it did not reach its recruitment target, this trial should be seen as exploratory. Results indicate that, following a NH-level deprescribing intervention, a resident-level intervention can further reduce some aspects of PIMs use. Great attention must be paid to residents' well-being when further developing such deprescribing interventions, as a possible reduction in quality of life was found in the intervention group, and some participants suffered adverse events following deprescribing.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03688542, https://clinicaltrials.gov/ct2/show/NCT03688542 ), registered on 31.08.2018.

Cross-sectional study on the prevalence of influenza and pneumococcal vaccination and its association with health conditions and risk factors among hospitalized multimorbid older patients

BACKGROUND

Older adults with chronic conditions are at high risk of complications from influenza and pneumococcal infections. Evidence about factors associated with influenza and pneumococcal vaccination among older multimorbid persons in Europe is limited. The aim of this study was to investigate the prevalence and determinants of these vaccinations in this population.

METHODS

Multimorbid patients aged ≥70 years with polypharmacy were enrolled in 4 European centers in Switzerland, Belgium, the Netherlands, and Ireland. Data on vaccinations, demographics, health care contacts, and comorbidities were obtained from self-report, general practitioners and medical records. The association of comorbidities or medical contacts with vaccination status was assessed using multivariable adjusted log-binomial regression models.

RESULTS

Among 1956 participants with available influenza vaccination data (median age 79 years, 45% women), 1314 (67%) received an influenza vaccination within the last year. Of 1400 patients with available pneumococcal vaccination data (median age 79 years, 46% women), prevalence of pneumococcal vaccination was 21% (n = 291). The prevalence of vaccination remained low in high-risk populations with chronic respiratory disease (34%) or diabetes (24%), but increased with an increasing number of outpatient medical contacts. Chronic respiratory disease was independently associated with the receipt of both influenza and pneumococcal vaccinations (prevalence ratio [PR] 1.09, 95% confidence interval [CI] 1.03-1.16; and PR 2.03, 95%CI 1.22-3.40, respectively), as was diabetes (PR 1.06, 95%CI 1.03-1.08; PR 1.24, 95%CI 1.16-1.34, respectively). An independent association was found between number of general practitioner visits and higher prevalence of pneumococcal vaccination (p for linear trend <0.001).

CONCLUSION

Uptake of influenza and particularly of pneumococcal vaccination in this population of European multimorbid older inpatients remains insufficient and is determined by comorbidities and number and type of health care contacts, especially outpatient medical visits. Hospitalization may be an opportunity to promote vaccination, particularly targeting patients with few outpatient physician contacts.

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.

Development and validation of a life expectancy estimator for multimorbid older adults: a cohort study protocol

BACKGROUND

Older multimorbid adults have a high risk of mortality and a short life expectancy (LE). Providing high-value care and avoiding care overuse, including of preventive care, is a serious challenge among multimorbid patients. While guidelines recommend to tailor preventive care according to the estimated LE, there is no tool to estimate LE in this specific population. Our objective is therefore to develop an LE estimator for older multimorbid adults by transforming a mortality prognostic index, which will be developed and internally validated in a prospective cohort.

METHODS AND ANALYSIS

We will analyse data of the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People cohort study in Bern, Switzerland. 822 participants were included at hospitalisation with age of 70 years or older, multimorbidity (three or more chronic medical conditions) and polypharmacy (use of five drugs or more for >30 days). All-cause mortality will be assessed during 3 years of follow-up. We will apply a flexible parametric survival model with backward stepwise selection to identify the mortality risk predictors. The model will be internally validated using bootstrapping techniques. We will derive a point-based risk score from the regression coefficients. We will transform the 3-year mortality prognostic index into an LE estimator using the Gompertz survival function. We will perform a qualitative assessment of the clinical usability of the LE estimator and its application. We will conduct the development and validation of the mortality prognostic index following the Prognosis Research Strategy (PROGRESS) framework and report it following the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement.

ETHICS AND DISSEMINATION

Written informed consent by patients themselves or, in the case of cognitive impairment, by a legal representative, was required before enrolment. The local ethics committee (Kantonale Ethikkommission Bern) has approved the study. We plan to publish the results in peer-reviewed journals and present them at national and international conferences.

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.

Effects of Hospital-Based Comprehensive Medication Reviews Including Postdischarge Follow-up on Older Patients' Use of Health Care: A Cluster Randomized Clinical Trial

Importance

Suboptimal use of medications is a leading cause of health care-related harm. Medication reviews improve medication use, but evidence of the possible benefit of inpatient medication review for hard clinical outcomes after discharge is scarce.

Objective

To study the effects of hospital-based comprehensive medication reviews (CMRs), including postdischarge follow-up of older patients' use of health care resources, compared with only hospital-based reviews and usual care.

Design, Setting, and Participants

The Medication Reviews Bridging Healthcare trial is a cluster randomized crossover trial that was conducted in 8 wards with multiprofessional teams at 4 hospitals in Sweden from February 6, 2017, to October 19, 2018, with 12 months of follow-up completed December 6, 2019. The study was prespecified in the trial protocol. Outcome assessors were blinded to treatment allocation. In total, 2644 patients aged 65 years or older who had been admitted to 1 of the study wards for at least 1 day were included. Data from the modified intention-to-treat population were analyzed from December 10, 2019, to September 9, 2020.

Interventions

Each ward participated in the trial for 6 consecutive 8-week periods. The wards were randomized to provide 1 of 3 treatments during each period: CMR, CMR plus postdischarge follow-up, and usual care without a clinical pharmacist.

Main Outcomes and Measures

The primary outcome measure was the incidence of unplanned hospital visits (admissions plus emergency department visits) within 12 months. Secondary outcomes included medication-related admissions, visits with primary care clinicians, time to first unplanned hospital visit, mortality, and costs of hospital-based care.

Results

Of the 2644 participants, 7 withdrew after inclusion, leaving 2637 for analysis (1357 female [51.5%]; median age, 81 [interquartile range, 74-87] years; median number of medications, 9 [interquartile range, 5-13]). In the modified intention-to-treat analysis, 922 patients received CMR, 823 received CMR plus postdischarge follow-up, and 892 received usual care. The crude incidence rate of unplanned hospital visits was 1.77 per patient-year in the total study population. The primary outcome did not differ between the intervention groups and usual care (adjusted rate ratio, 1.04 [95% CI, 0.89-1.22] for CMR and 1.15 [95% CI, 0.98-1.34] for CMR plus postdischarge follow-up). However, CMR plus postdischarge follow-up was associated with an increased incidence of emergency department visits within 12 months (adjusted rate ratio, 1.29; 95% CI, 1.05-1.59) compared with usual care. There were no differences between treatment groups regarding other secondary outcomes.

Conclusions and Relevance

In this study of older hospitalized patients, CMR plus postdischarge follow-up did not decrease the incidence of unplanned hospital visits. The findings do not support the performance of hospital-based CMRs as conducted in this trial. Alternative forms of medication reviews that aim to improve older patients' health outcomes should be considered and subjected to randomized clinical trials.

Trial Registration

ClinicalTrials.gov Identifier: NCT02986425.

Measurement properties of EQ-5D-3L and EQ-5D-5L in recording self-reported health status in older patients with substantial multimorbidity and polypharmacy

BACKGROUND

The EQ-5D-3L and EQ-5D-5L are two generic health-related quality of life measures, which may be used in clinical and health economic research. They measure impairment in 5 aspects of health: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The aim of this study was to assess the performance of the EQ-5D-3L and EQ-5D-5L in measuring the self-reported health status of older patients with substantial multimorbidity and associated polypharmacy.

METHODS

Between 2017 and 2019, we administered EQ-5D-3L and EQ-5D-5L to a subset of patients participating in the OPERAM trial at 6 months and 12 months after enrolment. The OPERAM trial is a two-arm multinational cluster randomised controlled trial of structured medication review assisted by a software-based decision support system versus usual pharmaceutical care, for older people (aged ≥ 70 years) with multimorbidity and polypharmacy. In the psychometric analyses, we only included participants who completed the measures in full at 6 and 12 months. We assessed whether responses to the measures were consistent by assessing the proportion of EQ-5D-5L responses, which were 2 or more levels away from that person's EQ-5D-3L response. We also compared the measures in terms of informativity, and discriminant validity and responsiveness relative to the Barthel Index, which measures independence in activities of daily living.

RESULTS

224 patients (mean age of 77 years; 56% male) were included in the psychometric analyses. Ceiling effects reported with the EQ-5D-5L (22%) were lower than with the EQ-5D-3L (29%). For the mobility item, the EQ-5D-5L demonstrated better informativity (Shannon's evenness index score of 0.86) than the EQ-5D-3L (Shannon's evenness index score of 0.69). Both the 3L and 5L versions of EQ-5D demonstrated good performance in terms of discriminant validity, i.e. (out of all items of the EQ-5D-3L and EQ-5D-5L, the pain/discomfort and anxiety/depression items had the weakest correlation with the Barthel Index. Both the 3L and 5L versions of EQ-5D demonstrated good responsiveness to changes in the Barthel Index.

CONCLUSION

Both EQ-5D-3L and EQ-5D-5L demonstrated validity and responsiveness when administered to older adults with substantial multimorbidity and polypharmacy who were able to complete the measures.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Intervention protocol: OPtimising thERapy to prevent avoidable hospital Admission in the Multi-morbid elderly (OPERAM): a structured medication review with support of a computerised decision support system

BACKGROUND

Several approaches to medication optimisation by identifying drug-related problems in older people have been described. Although some interventions have shown reductions in drug-related problems (DRPs), evidence supporting the effectiveness of medication reviews on clinical and economic outcomes is lacking. Application of the STOPP/START (version 2) explicit screening tool for inappropriate prescribing has decreased inappropriate prescribing and significantly reduced adverse drug reactions (ADRs) and associated healthcare costs in older patients with multi-morbidity and polypharmacy. Therefore, application of STOPP/START criteria during a medication review is likely to be beneficial. Incorporation of explicit screening tools into clinical decision support systems (CDSS) has gained traction as a means to improve both quality and efficiency in the rather time-consuming medication review process. Although CDSS can generate more potential inappropriate medication recommendations, some of these have been shown to be less clinically relevant, resulting in alert fatigue. Moreover, explicit tools such as STOPP/START do not cover all relevant DRPs on an individual patient level. The OPERAM study aims to assess the impact of a structured drug review on the quality of pharmacotherapy in older people with multi-morbidity and polypharmacy. The aim of this paper is to describe the structured, multi-component intervention of the OPERAM trial and compare it with the approach in the comparator arm.

METHOD

This paper describes a multi-component intervention, integrating interventions that have demonstrated effectiveness in defining DRPs. The intervention involves a structured history-taking of medication (SHiM), a medication review according to the systemic tool to reduce inappropriate prescribing (STRIP) method, assisted by a clinical decision support system (STRIP Assistant, STRIPA) with integrated STOPP/START criteria (version 2), followed by shared decision-making with both patient and attending physician. The developed method integrates patient input, patient data, involvement from other healthcare professionals and CDSS-assistance into one structured intervention.

DISCUSSION

The clinical and economical effectiveness of this experimental intervention will be evaluated in a cohort of hospitalised, older patients with multi-morbidity and polypharmacy in the multicentre, randomized controlled OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in the Multi-morbid elderly), which will be completed in the last quarter of 2019.

TRIAL REGISTRATION

Universal Trial Number: U1111-1181-9400 Clinicaltrials.gov: NCT02986425, Registered 08 December 2016. FOPH (Swiss national portal): SNCTP000002183. Netherlands Trial Register: NTR6012 (07-10-2016).

A systems approach to identifying the challenges of implementing deprescribing in older adults across different health-care settings and countries: a narrative review

Introduction: There is increasing recognition of the need for deprescribing of inappropriate medications in older adults. However, efforts to encourage implementation of deprescribing in clinical practice have resulted in mixed results across settings and countries.Area covered: Searches were conducted in PubMed, Embase, and Google Scholar in June 2019. Reference lists, citation checking, and personal reference libraries were also utilized. Studies capturing the main challenges of, and opportunities for, implementing deprescribing into clinical practice across selected health-care settings internationally, and international deprescribing-orientated policies were included and summarized in this narrative review.Expert opinion: Deprescribing intervention studies are inherently heterogeneous because of the complexity of interventions employed and often do not reflect the real-world. Further research investigating enhanced implementation of deprescribing into clinical practice and across health-care settings is required. Process evaluations in deprescribing intervention studies are needed to determine the contextual factors that are important to the translation of the interventions in the real-world. Deprescribing interventions may need to be individually tailored to target the unique barriers and opportunities to deprescribing in different clinical settings. Introduction of national policies to encourage deprescribing may be beneficial, but need to be evaluated to determine if there are any unintended consequences.

Benefits, risks and impacts on quality of life of medications used in multimorbid older adults: a Delphi study

Background Multimorbidity and polypharmacy are common in older people. Despite the existence of quality criteria for medication use among this population, there is little guidance for managing the complex pharmacological arsenal in a multimorbidity context. Objective To establish consensus on benefits, risks and impacts on quality of life of medications used in an older adult with three chronic diseases that require complex pharmacotherapy. Setting International experts in pharmacology. Method A panel of experts responded to three rounds of a Delphi survey. They assessed the benefits, risks and positive impacts on quality of life of 50 different medications or medication classes that could be used by a hypothetical multimorbid older patient aged 65-75 years, with type 2 diabetes, heart failure and chronic obstructive pulmonary disease. Each aspect was evaluated on a 5-level Likert scale. Main outcome measure Percentage of agreement on each of the three aspects for all medication. Results Consensus was reached on 95% of items (166/174). Only two medication classes were associated with both the highest category of benefits and positive impacts on quality of life, and the lowest risk category: long-acting anticholinergics and long-acting beta-2-agonists. Nine other medications/classes of medications were categorized within the highest benefits level (metformin, DPP-4-inhibitors, short-acting beta-2-agonists, ACE inhibitors, beta-blockers, warfarin, non-vitamin K oral anticoagulants, nitrates and acetaminophen). Fifteen medications were included in the highest level of risks, among which warfarin and Non-vitamin K oral anticoagulants. Conclusions Medications recommended in clinical guidelines for individual diseases are generally considered positive for multimorbid older patients. Nevertheless, a non-negligible number of medications was deemed negative or very negative by our panelists. For multimorbid patients, individualizing treatment according to their preferences seems of utmost importance.

'Optimising PharmacoTherapy In the multimorbid elderly in primary CAre' (OPTICA) to improve medication appropriateness: study protocol of a cluster randomised controlled trial

INTRODUCTION

Multimorbidity and polypharmacy are major risk factors for potentially inappropriate prescribing (eg, overprescribing and underprescribing), and systematic medication reviews are complex and time consuming. In this trial, the investigators aim to determine if a systematic software-based medication review improves medication appropriateness more than standard care in older, multimorbid patients with polypharmacy.

METHODS AND ANALYSIS

Optimising PharmacoTherapy In the multimorbid elderly in primary CAre is a cluster randomised controlled trial that will include outpatients from the Swiss primary care setting, aged ≥65 years with ≥three chronic medical conditions and concurrent use of ≥five chronic medications. Patients treated by the same general practitioner (GP) constitute a cluster, and clusters are randomised 1:1 to either a standard care sham intervention, in which the GP discusses with the patient if the medication list is complete, or a systematic medication review intervention based on the use of the 'Systematic Tool to Reduce Inappropriate Prescribing'-Assistant (STRIPA). STRIPA is a web-based clinical decision support system that helps customise medication reviews. It is based on the validated 'Screening Tool of Older Person's Prescriptions' (STOPP) and 'Screening Tool to Alert doctors to Right Treatment' (START) criteria to detect potentially inappropriate prescribing. The trial's follow-up period is 12 months. Outcomes will be assessed at baseline, 6 and 12 months. The primary endpoint is medication appropriateness, as measured jointly by the change in the Medication Appropriateness Index (MAI) and Assessment of Underutilisation (AOU). Secondary endpoints include the degree of polypharmacy, overprescribing and underprescribing, the number of falls and fractures, quality of life, the amount of formal and informal care received by patients, survival, patients' quality adjusted life years, patients' medical costs, cost-effectiveness of the intervention, percentage of recommendations accepted by GPs, percentage of recommendation rejected by GPs and patients' willingness to have medications deprescribed.

ETHICS AND DISSEMINATION

The ethics committee of the canton of Bern in Switzerland approved the trial protocol. The results of this trial will be published in a peer-reviewed journal.

MAIN FUNDING

Swiss National Science Foundation, National Research Programme (NRP 74) 'Smarter Healthcare'.

TRIAL REGISTRATION NUMBERS

Clinicaltrials.gov (NCT03724539), KOFAM (Swiss national portal) (SNCTP000003060), Universal Trial Number (U1111-1226-8013).