Evaluation of Drug-Disease Interactions and Their Association with Unplanned Hospital Readmission Utilizing STOPP Version 2 Criteria

Are Lists of Potentially Inappropriate Medications Associated with Hospital Readmissions? A Systematic Review

BACKGROUND

Suboptimal prescribing, including the prescription of potentially inappropriate medications (PIM), is frequent in patients aged 65 years and older. PIMs are associated with adverse drug events, which may lead to hospital admissions and readmissions for the most serious cases. Several tools, known as lists of PIMs, can detect suboptimal prescription.

OBJECTIVE

This systematic review aimed to identify which lists of PIMs are associated with hospital readmission of older patients.

PATIENTS AND METHODS

MEDLINE, the Cochrane Library, EMBASE, and clinicaltrials.gov were searched for the period from 1 January 1991 up to 12 May 2022 to identify original studies assessing the association between PIMs and hospital readmissions or emergency department (ED) revisits within 30 days of discharge in older patients. This study is reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Checklist, and the risk of bias was assessed with the Newcastle-Ottawa Quality Assessment Scale for Cohort Studies (NOS) and the revised Cochrane risk-of-bias tool for randomized trials (RoB 2).

RESULTS

A total of six studies presenting four different lists of PIMs were included. Readmission rates varied from 4.3 to 25.5% and the odds ratio (OR) between PIMs and hospital readmission varied from 0.92 [95% confidence interval (CI) 0.59; 1.42] to 6.48 [95% CI 3.00; 14.00]. Only two studies found a statistically significant association between a list of PIMs and hospital readmission. These two studies used different tools: the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert Doctors to Right Treatment (START) and a combination of Beers Criteria® and STOPP and START.

CONCLUSION

This systematic review shows that the association between list of PIMs and 30-day unplanned readmissions remains unclear and seems dependent on the PIM detection tool. Further studies are needed to clarify this association. PROSPERO registration number CRD42021252107.

Risk factors for medication-related short-term readmissions in adults - a scoping review

BACKGROUND

Hospital readmissions due to medication-related problems occur frequently, burdening patients and caregivers emotionally and straining health care systems economically. In times of limited health care resources, interventions to mitigate the risk of medication-related readmissions should be prioritized to patients most likely to benefit. Focusing on general internal medicine patients, this scoping review aims to identify risk factors associated with drug-related 30-day hospital readmissions.

METHODS

We began by searching the Medline, Embase, and CINAHL databases from their inception dates to May 17, 2022 for studies reporting risk factors for 30-day drug-related readmissions. We included all peer-reviewed studies, while excluding literature reviews, conference abstracts, proceeding papers, editorials, and expert opinions. We also conducted backward citation searches of the included articles. Within the final sample, we analyzed the types and frequencies of risk factors mentioned.

RESULTS

After deduplication of the initial search results, 1159 titles and abstracts were screened for full-text adjudication. We read 101 full articles, of which we included 37. Thirteen more were collected via backward citation searches, resulting in a final sample of 50 articles. We identified five risk factor categories: (1) patient characteristics, (2) medication groups, (3) medication therapy problems, (4) adverse drug reactions, and (5) readmission diagnoses. The most commonly mentioned risk factors were polypharmacy, prescribing problems-especially underprescribing and suboptimal drug selection-and adherence issues. Medication groups associated with the highest risk of 30-day readmissions (mostly following adverse drug reactions) were antithrombotic agents, insulin, opioid analgesics, and diuretics. Preventable medication-related readmissions most often reflected prescribing problems and/or adherence issues.

CONCLUSIONS

This study's findings will help care teams prioritize patients for interventions to reduce medication-related hospital readmissions, which should increase patient safety. Further research is needed to analyze surrogate social parameters for the most common drug-related factors and their predictive value regarding medication-related readmissions.

Associations between hyper-polypharmacy and potentially inappropriate prescribing with clinical and functional outcomes in older adults

BACKGROUND

: Hyper-polypharmacy and potentially inappropriate prescribing (PIP) are common among older inpatients. This study investigated associations between hyper-polypharmacy and PIP with clinical and functional outcomes in older adults at 3-months after hospital discharge.

RESEARCH DESIGN AND METHOD

: At discharge, prescribed medications were collected and PIPs, comprising potentially inappropriate medications (PIM) and potential prescribing omissions (PPO), were retrospectively identified using STOPP/START version 2. Clinical and functional outcomes were collected prospectively via telephone follow-up and audit.

RESULTS

: Data for 232 patients (mean age 80 years, 51.7 % female) were analysed. PIP prevalence at discharge was 73.7% (PIMs 62.5%, PPOs 36.6%). Exposure to at least 1 PIM was associated with an increased occurrence of unplanned hospital readmission (adjusted odds ratio (AOR) 5.09; 95% CI 2.38─10.85), emergency department presentation (AOR 4.69; 95% CI 1.55─14.21) and the composite outcome (AOR 6.83; 95% CI 3.20─14.57). The number rather than presence of PIMs was significantly associated with increased dependency in at least 1 activity of daily living (ADL) (AOR 2.31; 95% CI 1.08─4.20). Increased PIP use was associated with mortality (AOR 1.45; 95% CI 1.05─1.99).

CONCLUSION

: PIPs overall, and PIMs specifically, were frequent in older adults at hospital discharge, and were associated with increased re-hospitalizations and dependence in ADLs at 3-months post-discharge.

The Impact of Drug Interactions in Patients with Community-Acquired Pneumonia on Hospital Length of Stay

(1) Background: An aging society is frequently affected by multimorbidity and polypharmacy, which, in turn, leads to an increased risk for drug interaction. The aim of this study was to evaluate the influence of drug interactions on the length of stay (LOS) in hospitals. (2) Methods: This retrospective, single-centre study is based on patients treated for community-acquired pneumonia in the hospital. Negative binomial regression was used to analyse the association between drug interactions and the LOS in the hospital. (3) Results: The total cohort contained 503 patients, yet 46 inpatients (9%) that died were not included in the analyses. The mean age was 74 (±15.3) years, 35% of patients older than 65 years were found to have more than two drug interactions, and 55% had a moderate, severe, or contraindicated adverse drug reaction. The regression model revealed a significant association between the number of drug interactions (rate ratio (RR) 1.02; 95%-CI 1.01–1.04) and the severity of drug interactions (RR 1.22; 95%-CI 1.09–1.37) on the LOS for the overall cohort as well as for the subgroup of patients aged 80 years and older. (4) Conclusion: Drug interactions are an independent risk factor for prolonged hospitalisation. Standardised assessment tools to avoid drug interactions should be implemented in clinical routines.

Potentially inappropriate prescribing and its associations with health-related and system-related outcomes in hospitalised older adults: A systematic review and meta-analysis

AIMS

To synthesise associations of potentially inappropriate prescribing (PIP) with health-related and system-related outcomes in inpatient hospital settings.

METHODS

Six electronic databases were searched: Medline Complete, EMBASE, CINAHL, PyscInfo, IPA and Cochrane library. Studies published between 1 January 1991 and 31 January 2021 investigating associations between PIP and health-related and system-related outcomes of older adults in hospital settings, were included. A random effects model was employed using the generic inverse variance method to pool risk estimates.

RESULTS

Overall, 63 studies were included. Pooled risk estimates did not show a significant association with all-cause mortality (adjusted odds ratio [AOR] 1.10, 95% confidence interval [CI] 0.90-1.36; adjusted hazard ratio 1.02, 83% CI 0.90-1.16), and hospital readmission (AOR 1.11, 95% CI 0.76-1.63; adjusted hazard ratio 1.02, 95% CI 0.89-1.18). PIP was associated with 91%, 60% and 26% increased odds of adverse drug event-related hospital admissions (AOR 1.91, 95% CI 1.21-3.01), functional decline (AOR 1.60, 95% CI 1.28-2.01), and adverse drug reactions and adverse drug events (AOR 1.26, 95% CI 1.11-1.43), respectively. PIP was associated with falls (2/2 studies). The impact of PIP on emergency department visits, length of stay, and health-related quality of life was inconclusive. Economic cost of PIP reported in 3 studies, comprised various cost estimation methods.

CONCLUSIONS

PIP was significantly associated with a range of health-related and system-related outcomes. It is important to optimise older adults' prescriptions to facilitate improved outcomes of care.

Adverse drug event of hypokalaemia-induced cardiotoxicity secondary to the use of laxatives: A systematic review of case reports

WHAT IS KNOWN AND OBJECTIVE

The imbalance in serum potassium caused by laxatives can negatively affect the cardiovascular system, leading to life-threatening consequences. Our objective was to evaluate the reported evidence of adverse events related to the cardiac system due to laxative-induced hypokalaemia from case reports.

METHODS

A systematic electronic literature search of PubMed, Embase, the Cochrane Library and Science Direct was conducted for the period 1995-2019. In these databases, search terms describing hypokalaemia and cardiotoxicity were combined with the term laxative use.

RESULTS AND DISCUSSION

Over the 23 years, 27 incidents were identified in 12 countries. There were 19 female and eight male patients, with ages ranging from 1 month to 93 years. The frequency of reported cases according to severity was the following: severe hypokalaemia 48%, moderate hypokalaemia 44.4% and mild hypokalaemia 7.4%. In 70% of patients, the effect of laxative on the heart was typical hypokalaemic electrographic changes, 7.4% showed abnormal changes in cardiac rhythm, whereas in 18.5%, the cardiotoxicity observed was a very serious kind. Two patients died due to severe cardiac effects.

WHAT IS NEW AND CONCLUSION

The laxatives-along with the involvement of some other contributing factors-caused mild-to-severe hypokalaemic cardiotoxicity. These factors were non-adherence of the patient to the recommended dosage, laxative abuse, drug-drug and drug-disease interactions, non-potassium electrolyte imbalances and the use of herbal laxatives. We recommend that laxatives and aggravating factors should be taken into account in the assessment of patients with suspected hypokalaemic cardiotoxicity.

Drug-disease interactions in Swedish senior primary care patients were dominated by non-steroid anti-inflammatory drugs and hypertension - a population-based registry study

OBJECTIVE

Drug-disease interactions (DDSIs) are present when a drug prescribed for one disease worsens a concomitant disease. The prevalence of DDSIs in older patients in primary care is largely unknown, as well as to what extent physicians individualize drug prescribing in relation to concomitant diseases. We therefore analysed the prevalence of DDSIs in older patients in primary care and explored to what extent physicians take possible DDSIs into account when prescribing. Design and Setting: Cross-sectional population-based register study in primary care in Region Stockholm, Sweden. Thirty-one DDSIs derived from Irish STOPP-START-Criteria were assessed. We derived data from a regional administrative healthcare database including information on all healthcare consultations and dispensed prescription drugs in the region. Data on demography, diagnoses, drug dispensations and healthcare consumption were extracted. Drugs were assessed during 2016.

SUBJECTS

A total of 336,295 patients aged ≥65 registered with one of the 206 primary care practices in Region Stockholm.

MAIN OUTCOME MEASURES

Prevalence and prevalence differences for DDSIs.

RESULTS

In 10.8% of older patients, at least one DDSI was observed. Non-steroidal anti-inflammatory drugs (NSAIDs) were implicated in more than 75% of cases. The most common DDSI was NSAID/hypertension (8.1%), followed by NSAID/cardiovascular disease and loop diuretics/urinary incontinence (both 0.7%). The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

CONCLUSION

DDSIs were present in every tenth older patient in primary care. Patients with cardiovascular disease receive NSAIDs to a lower extent, possibly indicating physician awareness of DDSI. Key points Evidence on the prevalence of drug-disease interactions in older patients in primary care is sparse despite their potential to cause harm. In this study, we found that every 10th older patient attending primary care had at least one drug-disease interaction. Interactions with NSAIDs were far more common than interactions with other drugs. The use of NSAIDs among patients with heart failure or impaired renal function was 15% lower than among patients without these diseases.

Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study

OBJECTIVE

To determine whether hospital admission is associated with potentially inappropriate prescribing among older primary care patients (aged ≥65 years) and whether such prescribing was more likely after hospital admission than before.

DESIGN

Longitudinal study of retrospectively extracted data from general practice records.

SETTING

44 general practices in Ireland in 2012-15.

PARTICIPANTS

Adults aged 65 years or over attending participating practices.

EXPOSURE

Admission to hospital (any hospital admission versus none, and post-admission versus pre-admission).

MAIN OUTCOME MEASURES

Prevalence of potentially inappropriate prescribing assessed using 45 criteria from the Screening Tool for Older Persons' Prescription (STOPP) version 2, analysed both as rate of distinct potentially inappropriate prescribing criteria met (stratified Cox regression) and binary presence of potentially inappropriate prescribing (logistic regression) and adjusted for patients' characteristics. A sensitivity analysis used matching with propensity scores based on patients' characteristics and diagnoses.

RESULTS

Overall 38 229 patients were included, and during 2012 the mean age was 76.8 (SD 8.2) years and 43% (13 212) were male. Each year, 10.4-15.0% (3015/29 077 in 2015 to 4537/30 231 in 2014) of patients had at least one hospital admission. The overall prevalence of potentially inappropriate prescribing ranged from 45.3% (13 940/30 789) of patients in 2012 to 51.0% (14 823/29 077) in 2015. Independently of age, sex, number of prescription items, comorbidity, and health cover, hospital admission was associated with a higher rate of distinct potentially inappropriate prescribing criteria met; the adjusted hazard ratio for hospital admission was 1.24 (95% confidence interval 1.20 to 1.28). Among participants who were admitted to hospital, the likelihood of potentially inappropriate prescribing after admission was higher than before admission, independent of patients' characteristics; the adjusted odds ratio for after hospital admission was 1.72 (1.63 to 1.84). Analysis of propensity score matched pairs showed a slight reduction in the hazard ratio for hospital admission to 1.22 (1.18 to 1.25).

CONCLUSION

Hospital admission was independently associated with potentially inappropriate prescribing. It is important to determine how hospital admission may affect appropriateness of prescribing for older people and how potential adverse consequences of admission can be minimised.

Drug-physiology interaction and its influence on the QT prolongation-mechanistic modeling study

The current study is an example of drug-disease interaction modeling where a drug induces a condition which can affect the pharmacodynamics of other concomitantly taken drugs. The electrophysiological effects of hypokaliemia and heart rate changes induced by the antiasthmatic drugs were simulated with the use of the cardiac safety simulator. Biophysically detailed model of the human cardiac physiology-ten Tusscher ventricular cardiomyocyte cell model-was employed to generate pseudo-ECG signals and QTc intervals for 44 patients from four clinical studies. Simulated and observed mean QTc values with standard deviation (SD) for each reported study point were compared and differences were analyzed with Student's t test (α = 0.05). The simulated results reflected the QTc interval changes measured in patients, as well as their clinically observed interindividual variability. The QTc interval changes were highly correlated with the change in plasma potassium both in clinical studies and in the simulations (Pearson's correlation coefficient > 0.55). The results suggest that the modeling and simulation approach could provide valuable quantitative insight into the cardiological effect of the potassium and heart rate changes caused by electrophysiologically inactive, non-cardiological drugs. This allows to simulate and predict the joint effect of several risk factors for QT prolongation, e.g., drug-dependent QT prolongation due to the ion channels inhibition and the current patient physiological conditions.