Revisiting the inter-rater reliability of drug treatment assessments according to the STOPP/START criteria.

AIMS: The aim of this study is to revisit the inter-rater reliability of drug treatment assessments according to the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria. METHODS: Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were independently identified by two physicians in two cohorts of older people (I: 200 hip fracture patients, median age 85 years, STOPP/START version 1; II: 302 primary care patients, median age 74 years, STOPP/START version 2). Kappa statistics were used to evaluate inter-rater agreement. RESULTS: In cohort I, a total of 782 PIMs/PPOs, related to 68 (78%) out of 87 criteria, were identified by at least one assessor, 500 (64%) of which were discordantly identified by the assessors, that is, by one assessor but not the other. For four STOPP criteria, all PIMs (n = 9) were concordantly identified. In cohort II, 955 PIMs/PPOs, related to 80 (70%) out of 114 criteria, were identified, 614 (64%) of which were discordantly identified. For three STOPP criteria, all PIMs (n = 3) were concordantly identified. For no START criterion, with ≥1 PPO identified, were all assessments concordant. The kappa value for PIM/PPO identification was 0.52 in both cohorts. In cohort II, the kappa was 0.37 when criteria regarding influenza and pneumococcal vaccines were excluded. Further analysis of discordantly identified PIMs/PPOs revealed methodological aspects of importance, including the data source used and criteria wording. CONCLUSIONS: When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.

[Many patients with suboptimal drug treatment are missed. Sensitivity, specificity and prediction value of drug-specific quality indicators for the elderly]. / Många patienter med suboptimal läkemedelsbehandling missas - Sensitivitet, specificitet och prediktionsvärde hos läkemedelsspecifika kvalitetsindikatorer för äldre.

This study aimed to evaluate the concurrent validity of drug-specific indicators of prescribing quality developed by the National Board of Health and Welfare. In 200 hip fracture patients, quality of drug treatment was assessed according to a gold standard as well as to Swedish drug-specific indicators. As gold standard, two specialist physicians independently assessed and then agreed on the quality of treatment, after initial systematic assessments with explicit screening tools. According to the indicators and the gold standard, 82 (41%) 141 (71%) patients had inappropriate drug treatment. The sensitivity for individual indicators ranged from 0.02 to 0.32, and the specificity from 0.90 to 1.00.

Number of drugs in the medication list as an indicator of prescribing quality: a validation study of polypharmacy indicators in older hip fracture patients.

PURPOSE: Indicators based on the number of drugs in the medication list are sometimes used to reflect quality of drug treatment. This study aimed to evaluate the concurrent validity of such polypharmacy indicators, i.e., their ability to differentiate between appropriate and suboptimal drug treatment. METHODS: In 200 hip fracture patients (≥65 years of age), consecutively recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was assessed according to a gold standard as well as to indicators based on the number of drugs in the medication list. As gold standard, two specialist physicians independently assessed and then agreed on the quality for each patient, after initial screening with Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START). Suboptimal drug treatment was defined as ≥1 STOPP/START outcomes assessed as clinically relevant at the individual level. RESULTS: A total of 141 (71 %) patients had suboptimal drug treatment according to the gold standard. The corresponding figures according to the indicators ≥5 and ≥10 drugs were 149 (75) and 49 (25 %), respectively. The sensitivity for the indicators ≥5 and ≥10 drugs to detect suboptimal drug treatment was 0.86 (95 % confidence interval: 0.80; 0.92) and 0.32 (0.25; 0.40), respectively. The specificity was 0.53 (0.41; 0.65) and 0.93 (0.82; 0.97). CONCLUSIONS: The findings suggest that no polypharmacy indicator could serve as a general indicator of prescribing quality; cut-offs for such indicators need to be chosen according to purpose.

Prevalence of suboptimal drug treatment in patients with and without multidose drug dispensing--a cross-sectional study.

PURPOSE: The aim of this study was to compare the prevalence of suboptimal drug treatment in older patients with and without multidose drug dispensing (MDD). METHODS: In 200 hip fracture patients (≥65 years of age), originally recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was compared between patients with and without MDD. Two specialist physicians independently assessed and then agreed on the quality of the drug treatment of each patient. Suboptimal drug treatment was defined as ≥1 STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) or ≥1 START (Screening Tool to Alert to Right Treatment) outcome assessed as clinically relevant after individual considerations had been made, i.e. over- or undertreatment (≥1 inappropriate and ≥1 missing drug, respectively). RESULTS: Patients with MDD (n=100) differed from patients without MDD (n=100) in several ways, for example by being older (87.6 vs. 81.5 years) and using more drugs (8.4 vs. 5.9 drugs). The total number (±standard deviation) of inappropriate and/or missing drugs per person was greater in MDD patients compared with patients without MDD (1.92±1.52 vs. 1.06±1.29, P<0.0001); MDD patients had an additional 0.77 inappropriate drugs and an additional 0.09 missing drugs per person. The prevalence of suboptimal drug treatment was greater in patients with MDD than in those without MDD (86 vs. 55%, P<0.0001). Logistic regression revealed that suboptimal drug treatment was 8.0 times as common in MDD patients, after adjustments for age, sex, number of drugs, cognition, and residence (95% confidence interval 2.4; 26.9). Corresponding figures for over- and undertreatment were 2.9 (1.1; 7.4) and 1.8 (0.8; 4.3), respectively. CONCLUSIONS: Suboptimal drug treatment, including over- and undertreatment, is more common in MDD patients than in patients who receive their drugs via ordinary prescriptions. The findings confirm safety concerns regarding quality of drug treatment in MDD patients.