Quality of prescribing predicts hospitalisation in octogenarians: life and living in advanced age: a cohort study in New Zealand (LiLACS NZ)

Validation of MyFORTA: An Automated Tool to Improve Medications in Older People Based on the FORTA List

BACKGROUND

Listing tools have been developed to improve medications in older patients, including the Fit fOR The Aged (FORTA) list, a clinically validated, positive-negative list of medication appropriateness. Here, we aim to validate MyFORTA, an automated tool for individualized application of the FORTA list.

METHODS

331 participants of a multi-center cohort study (AgeCoDe) for whom the FORTA score (sum of overtreatment and undertreatment errors) had been determined manually (gold standard [GS]) were reassessed using the automated MyFORTA (MF) tool. This tool determines the score from ATC and ICD codes combined with clinical parameters.

RESULTS

The FORTA scores were 9.01 ± 2.91 (mean ± SD, MF) versus 6.02 ± 2.52 (GS) (p < 0.00001). Removing undertreatment errors for calcium/vitamin D (controversial guidelines) and influenza/pneumococcal vaccinations (no robust information in the database), the difference decreased: 7.5 ± 2.7 (MF) versus 5.98 ± 2.55 (GS) (p < 0.00001). The remaining difference was driven by, for example, missing nitro spray in coronary heart disease/acute coronary syndrome as the related information was rarely found in the database, but notoriously detected by MF. Three hundred and forty errors from those 100 patients with the largest score deviation accounted for 68% of excess errors by MF.

CONCLUSION

MF was more sensitive to detect medication errors than GS, all frequent errors only detected by MF were plausible, and almost no adaptations of the MF algorithm seem indicated. This automated tool to check medication appropriateness according to the FORTA list is now validated and represents the first clinically directed algorithm in this context. It should ease the application of FORTA and help to implement the proven beneficial effects of FORTA on clinical endpoints.

[The FORTA (Fit fOR The Aged) List]

BACKGROUND

Multimorbidity and the resulting polypharmacy are widespread in the very old and the evidence on the efficacy and safety of drugs in older people is sparse. Driven by guidelines, this often leads to inappropriate prescribing and drug-related problems.

MATERIAL AND METHODS

To improve this, numerous listing approaches were developed as tools to optimize medication. These approaches can be divided into drug-oriented listing approaches (DOLA), such as the Beers Criteria®, a list of potentially inappropriate medications for older people or patient-in-focus listing approaches (PILA), such as the Fit fOR The Aged (FORTA) list.

RESULTS

The most recent version of the FORTA list was published in 2022 and contains 299 drugs or drug groups targeting 30 age-related indications. In addition, several country-specific or region-specific FORTA lists, such as the EURO-FORTA list have been developed. Very few randomized controlled trials have demonstrated the utility of existing listing approaches for improving clinical outcomes, such as adverse drug events, falls or hospitalizations. In the VALFORTA study, the use of FORTA led to a significant improvement in medication treatment. In addition, important clinical endpoints, such as the occurrence of adverse drug events (number needed to treat = 5), activities of daily living (ADL) and the incidence of falls were significantly improved by the FORTA intervention in a clinically relevant manner.

CONCLUSION

Based on these promising results, the use of the FORTA list for medication optimization in older patients is recommended; the prerequisite for application is the needs analysis for drugs according to diagnoses, severity, life expectancy, functional status, and patient wishes.

The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review

In the context of an ageing population, the burden of disease and medicine use is also expected to increase. As such, medicine safety and preventing avoidable medicine-related harm are major public health concerns, requiring further research. Potentially suboptimal medicine regimens is an umbrella term that captures a range of indicators that may increase the risk of medicine-related harm, including polypharmacy, underprescribing and high-risk prescribing, such as prescribing potentially inappropriate medicines. This narrative review aims to provide a background and broad overview of the patterns and implications of potentially suboptimal medicine regimens among older adults. Original research published between 1990 and 2021 was searched for in MEDLINE, using key search terms including polypharmacy, inappropriate prescribing, potentially inappropriate medication lists, medication errors, drug interactions and drug prescriptions, along with manual checking of reference lists. The review summarizes the prevalence, risk factors and clinical outcomes of polypharmacy, underprescribing and potentially inappropriate medicines. A synthesis of the evidence regarding the longitudinal patterns of polypharmacy is also provided. With an overview of the existing literature, we highlight a number of key gaps in the literature. Directions for future research may include a longitudinal investigation into the risk factors and outcomes of extended polypharmacy, research focusing on the patterns and implications of underprescribing and studies that evaluate the applicability of tools measuring potentially inappropriate medicines to study settings.

Ethnic Variations in the Quality Use of Medicines in Older Adults: Māori and Non-Māori in Aotearoa New Zealand

In Aotearoa New Zealand (NZ), ethnic inequities in health outcomes exist. Non-Māori experience better access to healthcare than Māori, including access to the quality use of medicines. Quality medicines use requires that medicines provide maximal therapeutic benefit with minimal harm. As older adults are more at risk of harm from medicines, and, because inequities are compounded with age, Māori older adults may be at more risk of medicines-related harm than younger and non-Māori populations. This narrative review examined ethnic variation in the quality use of medicines, including medicines utilisation and associated clinical outcomes, between Māori and non-Māori older adult populations in NZ. The review was structured around prevalence of medicine utilisation by medicine class and in particular disease states; high-risk medicines; polypharmacy; prevalence of potentially inappropriate prescribing (PIP); and association between PIP and clinical outcomes. 22 studies were included in the review. There is ethnic variation in the access to medicines in NZ, with Māori older adults often having reduced access to particular medicine types, or in particular disease states, compared with non-Māori older adults. Māori older adults are less likely than non-Māori to be prescribed medicines inappropriately, as defined by standardised tools; however, PIP is more strongly associated with adverse outcomes for Māori than non-Māori. This review identifies that inequities in quality medicines use exist and provides a starting point to develop pro-equity solutions. The aetiology of inequities in the quality use of medicines is multifactorial and our approaches to addressing the inequitable ethnic variation also need to be.

A pharmacist-led medicines review intervention in community-dwelling Māori older adults- a feasibility study protocol

BACKGROUND

Pharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults.

METHOD

This is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12619001070123.

Does potentially inappropriate prescribing predict an increased risk of admission to hospital and mortality? A longitudinal study of the 'oldest old'

Background

Potentially inappropriate prescribing (PIP) is associated with negative health outcomes, including hospitalisation and mortality. Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACS NZ) is a longitudinal study of Māori (the indigenous population of New Zealand) and non-Māori octogenarians. Health disparities between indigenous and non-indigenous populations are prevalent internationally and engagement of indigenous populations in health research is necessary to understand and address these disparities. Using LiLACS NZ data, this study reports the association of PIP with hospitalisations and mortality prospectively over 36-months follow-up.

Methods

PIP, from pharmacist applied criteria, was reported as potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs). The association between PIP and hospitalisations (all-cause, cardiovascular disease-specific and ambulatory-sensitive) and mortality was determined throughout a series of 12-month follow-ups using binary logistic (hospitalisations) and Cox (mortality) regression analysis, reported as odds ratios (ORs) and hazard ratios (HRs), respectively, and the corresponding confidence intervals (CIs).

Results

Full demographic data were obtained for 267 Māori and 404 non-Māori at baseline, 178 Māori and 332 non-Māori at 12-months, and 122 Māori and 281 non-Māori at 24-months. The prevalence of any PIP (i.e. ≥1 PIM and/or PPO) was 66, 75 and 72% for Māori at baseline, 12-months and 24-months, respectively. In non-Māori, the prevalence of any PIP was 62, 71 and 73% at baseline, 12-months and 24-months, respectively. At each time-point, there were more PPOs than PIMs; at baseline Māori were exposed to a significantly greater proportion of PPOs compared to non-Māori (p = 0.02). In Māori: PPOs were associated with a 1.5-fold increase in hospitalisations and mortality. In non-Māori, PIMs were associated with a double risk of mortality.

Conclusions

PIP was associated with an increased risk of hospitalisation and mortality in this cohort. Omissions appear more important for Māori in predicting hospitalisations, and PIMs were more important in non-Māori in predicting mortality. These results suggest understanding prescribing outcomes across and between population groups is needed and emphasises prescribing quality assessment is useful.

A systematic review of pharmacist-led medicines review services in New Zealand - is there equity for Māori older adults?

BACKGROUND

Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults.

OBJECTIVE

This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported.

RESULTS

The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori.

CONCLUSION

Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.