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

INTRODUCTION: Multimorbidity and polypharmacy are risk factors for drug-related hospital admissions (DRAs) in the ageing population. DRAs caused by medication errors (MEs) are considered potentially preventable. The STOPP/START criteria were developed to detect potential MEs in older people. OBJECTIVE: The aim of this study was to assess the detectability of MEs with a STOPP/START-based in-hospital medication review in older people with polypharmacy and multimorbidity prior to a potentially preventable DRA. METHODS: Hospitalised older patients (n = 963) with polypharmacy and multimorbidity from the intervention arm of the OPERAM trial received a STOPP/START-based in-hospital medication review by a pharmacotherapy team. Readmissions within 1 year after the in-hospital medication review were adjudicated for drug-relatedness. A retrospective assessment was performed to determine whether MEs identified at the first DRA were detectable during the in-hospital medication review. RESULTS: In total, 84 of 963 OPERAM intervention patients (8.7%) were readmitted with a potentially preventable DRA, of which 72 patients (n = 77 MEs) were eligible for analysis. About half (48%, n = 37/77) of the MEs were not present during the in-hospital medication review and therefore were not detectable at that time. The pharmacotherapy team recommended a change in medication regimen in 50% (n = 20/40) of present MEs, which corresponds to 26% (n = 20/77) of the total identified MEs at readmission. However, these recommendations were not implemented. CONCLUSION: MEs identified at readmission were not addressed by a prior single in-hospital medication review because either these MEs occurred after the medication review (~50%), or no recommendation was given during the medication review (~25%), or the recommendation was not implemented (~25%). Future research should focus on optimisation of the timing and frequency of medication review and the implementation of proposed medication recommendations. REGISTRATION: ClinicalTrials.gov identifier: NCT02986425. December 8, 2016. FUNDING: European Union HORIZON 2020, Swiss State Secretariat for Education, Research and Innovation (SERI), Swiss National Science Foundation (SNSF).

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.

Prescribing medicines to older people-How to consider the impact of ageing on human organ and body functions.

Ageing is associated with several changes in human organs, which result in altered medication pharmacokinetics and pharmacodynamics. Ageing is also associated with changes in human body functions, such as impaired vision, hearing, swallowing, motor and cognitive functions, which can affect the adequate intake and administration of drugs. As a consequence, older people, and especially patients older than 75 years, are the main users of many drugs and they frequently use 5 drugs or more long-term (i.e. polypharmacy). All this increases the complexity of adequate drug intake, administration and adherence. However, there is a lack of evidence on the considerations that should be taken into account to ensure appropriate drug prescribing to older people. This review article summarizes the most clinically relevant changes in human organ and body functions and the consequential changes in pharmacokinetics and pharmacodynamics in older people, along with possible dosing consequences or alternatives for drugs frequently prescribed to this patient population. Recommendations are given on how ageing could be considered in clinical drug development, drug authorization and appropriate prescribing.

The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing.

Inappropriate prescribing is a major health care issue, especially regarding older patients on polypharmacy. Multiple implicit and explicit prescribing tools have been developed to improve prescribing, but these have hardly ever been used in combination. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) combines implicit prescribing tools with the explicit Screening Tool to Alert physicians to the Right Treatment and Screening Tool of Older People's potentially inappropriate Prescriptions criteria and has shared decision-making with the patient as a critical step. This article describes the STRIP and its ability to identify potentially inappropriate prescribing. The STRIP improved general practitioners' and final-year medical students' medication review skills. The Web-application STRIP Assistant was developed to enable health care providers to use the STRIP in daily practice and will be incorporated in clinical decision support systems. It is currently being used in the European Optimizing thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly (OPERAM) project, a multicentre randomized controlled trial involving patients aged 75 years and older using multiple medications for multiple medical conditions. In conclusion, the STRIP helps health care providers to systematically identify potentially inappropriate prescriptions and medication-related problems and to change the patient's medication regimen in accordance with the patient's needs and wishes. This article describes the STRIP and the available evidence so far. The OPERAM study is investigating the effect of STRIP use on clinical and economic outcomes.

Adherence with Dosing Guideline in Patients with Impaired Renal Function at Hospital Discharge.

OBJECTIVES: To determine the prevalence, determinants, and potential clinical relevance of adherence with the Dutch dosing guideline in patients with impaired renal function at hospital discharge. DESIGN: Retrospective cohort study between January 2007 and July 2011. SETTING: Academic teaching hospital in the Netherlands. SUBJECTS: Patients with an estimated glomerular filtration rate (eGFR) between 10-50 ml/min/1.73 m(2) at discharge and prescribed one or more medicines of which the dose is renal function dependent. MAIN OUTCOME MEASURES: The prevalence of adherence with the Dutch renal dosing guideline was investigated, and the influence of possible determinants, such as reporting the eGFR and severity of renal impairment (severe: eGFR<30 and moderate: eGFR 30-50 ml/min/1.73 m(2)). Furthermore, the potential clinical relevance of non-adherence was assessed. RESULTS: 1327 patients were included, mean age 67 years, mean eGFR 38 ml/min/1.73 m(2). Adherence with the guideline was present in 53.9% (n=715) of patients. Reporting the eGFR, which was incorporated since April 2009, resulted in more adherence with the guideline: 50.7% vs. 57.0%, RR 1.12 (95% CI 1.02-1.25). Adherence was less in patients with severe renal impairment (46.0%), compared to patients with moderate renal impairment (58.1%, RR 0.79; 95% CI 0.70-0.89). 71.4% of the cases of non-adherence had the potential to cause moderate to severe harm. CONCLUSION: Required dosage adjustments in case of impaired renal function are often not performed at hospital discharge, which may cause harm to the majority of patients. Reporting the eGFR can be a small and simple first step to improve adherence with dosing guidelines.

Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant's Usability.

BACKGROUND: Polypharmacy poses threats to patients' health. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP) is a drug optimization process for conducting medication reviews in primary care. To effectively and efficiently incorporate this method into daily practice, the STRIP Assistant--a decision support system that aims to assist physicians with the pharmacotherapeutic analysis of patients' medical records--has been developed. It generates context-specific advice based on clinical guidelines. OBJECTIVE: The aim of this study was to validate the STRIP Assistant's usability as a tool for physicians to optimize medical records for polypharmacy patients. METHODS: In an online experiment, 42 physicians were asked to optimize medical records for two comparable polypharmacy patients, one in their usual manner and one using the STRIP Assistant. Changes in effectiveness were measured by comparing respondents' optimized medicine prescriptions with medication prepared by an expert panel of two geriatrician-pharmacologists. Efficiency was operationalized by recording the time the respondents took to optimize the two cases. User satisfaction was measured with the System Usability Scale (SUS). Independent and paired t tests were used for analysis. RESULTS: Medication optimization significantly improved with the STRIP Assistant. Appropriate decisions increased from 58% without the STRIP Assistant to 76% with it (p < 0.0001). Inappropriate decisions decreased from 42% without the STRIP Assistant to 24% with it (p < 0.0001). Participants spent significantly more time optimizing medication with the STRIP Assistant (24 min) than without it (13 min; p < 0.0001). They assigned it a below-average SUS score of 63.25. CONCLUSION: The STRIP Assistant improves the effectiveness of medication reviews for polypharmacy patients.

Use of a structured medication history to establish medication use at admission to an old age psychiatric clinic: a prospective observational study.

OBJECTIVE: Medication reconciliation results in fewer adverse drug events. The first step in medication reconciliation is to carry out a structured interview about medication use. It is not known whether such an interview is useful in inpatient old age psychiatry. The object of this study was to determine at admission the number of discrepancies in medication use, comparing the structured history of medication use (SHIM) procedure with the usual procedure for taking the medication history. METHODS: A prospective observational study was conducted. All consecutive patients aged 55 years and older admitted from January until April 2011 to the inpatient old age psychiatric clinic of a large psychiatric teaching hospital in The Hague, the Netherlands, were eligible for inclusion; 50 patients were included. In every patient, the usual procedure (medication history-taking at admission by the treating physician) was compared with the SHIM procedure administered by the researcher. The SHIM procedure consists of a structured interview with the patient about the actual use of medication, incorporating the information from the community pharmacy and the patient's medications brought to the interview. The main outcome was the number of discrepancies in recorded medication use between the SHIM and the usual procedure. RESULTS: In total, 100 discrepancies (median 2 per patient, range 0-8) in medication use were identified; 78 % (n = 39) of the patients had at least one discrepancy. Of the discrepancies, 69 % were drug omissions, and 31 % were drug additions or discrepancies in the frequency or dosage of medications. Eighty-two percent of all discrepancies were potentially clinically relevant. In 24 % of the patients, the discrepancies had clinical consequences. CONCLUSION: The number of discrepancies that were found suggests that the usual procedure for taking the medication history can be improved. The SHIM procedure enables a comprehensive and accurate overview of the medication used by older patients admitted to a psychiatric hospital, and contributes to the prevention of clinically relevant adverse drug events.

Renal function assessment in older adults.

AIMS: The Cockcroft-Gault (CG), the Modification of Diet in Renal Disease (MDRD) and the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) formulae are often used to estimate glomerular filtration rate (GFR). The objective was to determine the best method for estimating GFR in older adults. METHODS: A cross-sectional study was conducted at the geriatric wards of two hospitals in The Netherlands. Patients aged 70 years or above with an estimated (e)GFR below 60 ml min⁻¹ 1.73 m⁻² were included. The CG, CG calculated with ideal bodyweight (IBW), MDRD and CKD-EPI formulae were compared with a criterion standard, sinistrin clearance. Renal function was classified into five stages according to the National Kidney Foundation Disease Outcomes Quality Initiative chronic kidney disease classification, as follows (in ml min⁻¹ 1.73 m)⁻²: stage 1, eGFR ≥ 90; stage 2, eGFR of 60-89; stage 3, eGFR of 30-59; stage 4, eGFR of 15-29; and stage 5, eGFR < 15. RESULTS: Sixteen patients, 50% male, with a mean age of 82 years (range 71-87 years) and mean body mass index 26 kg m⁻² (range 18-36 kg m⁻²), were included. On average, all formulae slightly overestimated GFR, as follows (in ml min⁻¹ 1.73 m⁻²: CG +0.05 [95% confidence interval (CI) -28 to +28]; CG with IBW +0.03 (95% CI -20 to +20); MDRD +9 (95% CI -16 to +34); and CKD-EPI +5 (95% CI -20 to +29). They classified kidney disease correctly in 68.8% (CG), 75% (CG with IBW), 43.8% (MDRD) and 68.8% (CKD-EPI) of the participants, respectively. CONCLUSIONS: The CG, CG with IBW, MDRD and CKD-EPI formulae estimate the mean GFR of a population rather well. In individual cases, all formulae may misclassify kidney disease by one stage.

[The process of bringing medication in line: the additional benefits of a Structured Medication History]. / Gestructureerde medicatieanamnese bij opname: helpt een juist overzicht van de thuismedicatie te verkrijgen.

OBJECTIVE: To determine the additional benefits of a structured history-taking of medication use (SHIM) from patients admitted to a geriatric ward for obtaining a complete and accurate list of medication used at home, in comparison to an unstructured medication history-taking by the resident physician. DESIGN: Prospective, observational. METHOD: The SHIM, a standardized questionnaire, was used for history-taking from patients admitted to the geriatric ward, and often from their caregivers, too. The number and type of discrepancies were noted between this medication history and the medication history obtained by the resident physician at admission as noted on the medical chart. Discrepancies were assessed for clinical relevance. RESULTS: The SHIM was used for 47 patients with a mean age of 84.4 years. At least one discrepancy was found in all patients. Comparison of the SHIM to the medication history obtained by the resident physician revealed 4.2 discrepancies per patient on average. Omission of medication in the history taken by the resident was the most common discrepancy. 66% of all discrepancies were considered as potentially clinically relevant; in 19% of the patients this actually resulted in a moderate degree of discomfort or clinical deterioration. The number of discrepancies was statistically significantly associated with the use of a higher number of medications and with the use of 'over the counter' (OTC) medications. CONCLUSION: The SHIM provides a better insight into the actual use of medication by the patient than history taking of medication use by the resident at admission.

Prescribing optimization method for improving prescribing in elderly patients receiving polypharmacy: results of application to case histories by general practitioners.

BACKGROUND: Optimizing polypharmacy is often difficult, and critical appraisal of medication use often leads to one or more changes. We developed the Prescribing Optimization Method (POM) to assist physicians, especially general practitioners (GPs), in their attempts to optimize polypharmacy in elderly patients. The POM is based on six questions: (i) is undertreatment present and addition of medication indicated; (ii) does the patient adhere to his/her medication schedule; (iii) which drug(s) can be withdrawn or which drugs(s) is/are inappropriate for the patient; (iv) which adverse effects are present; (v) which clinically relevant interactions are to be expected; and (vi) should the dose, dose frequency and/or form of the drug be adjusted? OBJECTIVE: The aim of this study was to evaluate the usefulness of the POM as a tool for improving appropriate prescribing of complex polypharmacy in the elderly. METHODS: Forty-five GPs were asked to optimize the medication of two case histories, randomly chosen from ten histories of geriatric patients admitted to a hospital geriatric outpatient clinic with a mean +/- SD of 7.9 +/- 1.2 problems treated with 8.7 +/- 3.1 drugs. The first case was optimized without knowledge of the POM. After a 2-hour lecture on the POM, the GPs used the POM to optimize the medication of the second case history. The GPs were allowed 20 minutes for case optimization. Medication recommendations were compared with those made by an expert panel of four geriatricians specialized in clinical pharmacology. Data were analysed using a linear mixed effects model. RESULTS: Optimization was significantly better when GPs used the POM. The proportion of correct decisions increased from 34.7% without the POM to 48.1% with the POM (p = 0.0037), and the number of potentially harmful decisions decreased from a mean +/- SD of 3.3 +/- 1.8 without the POM to 2.4 +/- 1.4 with the POM (p = 0.0046). CONCLUSION: The POM improves appropriate prescribing of complex polypharmacy in case histories.