[Potentially inappropriate prescriptions in elderly outpatiens. Results of implicit criteria applied by clinical pharmacists.] / Prescrizioni potenzialmente inappropriate in pazienti anziani non ospedalizzati. Risultati dell'applicazione di criteri impliciti da parte di farmacisti clinici.

BACKGROUND: Management of therapy in elderly patients is a critical issue in primary care. The physiopathological status is usually complex, and the prescription of multiple drugs is typically required, with a consequent higher risk of adverse effects. Many tools have been developed to cope with this problem, and identify drugs that are inappropriate in the elderly. The objective of the study was to evaluate the appropriateness of therapies in the elderly according to implicit criteria. METHOD: A prospective study of outpatients aged ≥65 years who visited our outpatient clinic on even calendar dates of the week, from Monday to Friday, from September 1, 2013 to March 31, 2014 was performed. Appropriateness of therapy was evaluated by applying three sets of implicit tools: Lipton Criteria, MAI and POM. A questionnaire was used assess information given to patients by physicians, and adherence to therapy. Information about clinical history and therapy was obtained from electronic medical records. Patient diagnosis and allergies, drugs, dosages, pharmacological indications, and questionnaire results, were entered into a database. The results were expressed in percentage. RESULTS: A total of 265 patients aged ≥65 years were included. Of these, 83% (220/265) had 2 to 6 comorbidities. According to the Lipton, MAI and POM criteria, the prescriptions were appropriate for 97% (1289/1327), 96% (1274/1327), and 94% (1251/1327) respectively. Only 33% (87/265) of the patients reported being thoroughly informed about the prescribed therapy and main side effects, and 67% (178/265) reported full compliance with the dosing schedule. DISCUSSION AND CONCLUSIONS: The overall assessment of the elderly patient, with particular reference to comorbidity, is essential in choosing the best tailored-therapy. For this reason, the support of tools that can make safer therapeutic choices is important. The implicit indicators used allow for a reduction of number of the medications, and inappropriate prescriptions, avoiding drugs with greater potential for interactions, and promoting adherence by patients.

Potentially inappropriate drug prescribing in elderly hospitalized patients: an analysis and comparison of explicit criteria.

BACKGROUND: The management of therapy in elderly is a critical aspect of primary care. The physio-pathological complexity of the elderly involves the prescription of multiple drugs, exposing them to a higher risk of adverse reactions. OBJECTIVE: Aim of this study was to assess the medication use and (potential) inappropriate medications and prescribing omissions in the elderly before and during hospitalization, according to the main tools in literature described, and their relation to the number of comorbidities. SETTING: The study was carried out by the Clinical Pharmacists at ISMETT, an Italian Research Institute. METHODS: The prescriptions of elderly, admitted in ISMETT between January and December 2012, were analyzed. The information about clinical profile of elderly and prescriptions was obtained from the electronic medical records. 2012 Beers criteria, Screening Tool of Older Person's Prescriptions/Screening Tool to Alert doctors to Right Treatment criteria, and Improving Prescribing in the Elderly criteria were used to evaluate the appropriateness of prescriptions. The correlation between the number of comorbidities and the different tools was analyzed with the Spearman correlation coefficient. The frequency analysis was done with the Pearson Chi square test. MAIN OUTCOME MEASURE: Percentage of potentially inappropriate medications and prescribing omissions before/during hospitalization in elderly. RESULTS: 1027 elderly were admitted between January and December 2012. At admission and during hospitalization, according to Beers criteria 24 and 49 % of elderly had at least one potentially inappropriate medication, respectively; according to the Screening Tool of Older Person's Prescriptions criteria 21 and 27 %, respectively; according to the Improving Prescribing in the Elderly criteria 28 and 25 %, respectively; and then, according to Screening Tool to Alert doctors to Right Treatment criteria 28 and 33 % had at least one potentially prescribing omission, respectively. A significant correlation between comorbidities number and potentially inappropriate medications was found. CONCLUSION: The number of potentially inappropriate medications globally increased during hospitalization. Statistical analysis showed that the comorbidity affects the level of inappropriate prescriptions. Specific tools can guide clinicians toward a more rational use of medicines and minimize probable complications related to multi-treatments.

Incidence of potential drug interactions in a transplant centre setting and relevance of electronic alerts for clinical practice support.

BACKGROUND: Adverse drug events may occur as a result of drug-drug interactions (DDIs). Information technology (IT) systems can be an important decision-making tool for healthcare workers to identify DDIs. OBJECTIVE: The aim of the study is to analyse drug prescriptions in our main hospital units, in order to measure the incidence and severity of potential DDIs. The utility of clinical decision-support systems (CDSSs) and computerised physician order entry (CPOE) in term of alerts adherence was also assessed. DDIs were assessed using a Micromedex® healthcare series database. METHODS: The system, adopted by the hospital, generates alerts for prescriptions with negative interactions and thanks to an 'acknowledgement function' it is possible to verify physician adherence to alerts. This function, although used previously, became mandatory from September 2010. Physician adherence to alerts and mean monthly incidence of potential DDIs in analysed units, before and after the mandatory 'acknowledgement function', were calculated. RESULTS: The intensive care unit (ICU) registered the greatest incidence of potential DDIs (49.0%), followed by the abdominal surgery unit and dialysis (43.4 and 42.0%, respectively). The cardiothoracic surgery unit (41.6%), step-down unit (38.3%) and post-anaesthesia care unit (30.0%) were comparable. The operating theatre and endoscopy registered the fewest potential DDIs (28.2 and 22.7%, respectively). Adherence to alerts after the 'acknowledgement function' increased by 25.0% in the ICU, 54.0% in the cardiothoracic surgery unit, 52.5% in the abdominal surgery unit, 58.0% in the stepdown unit, 67.0% in dialysis, 51.0% in endoscopy and 48.0% in the post-anaesthesia care unit. In the operating theatre, adherence to alerts decreased from 34.0 to 30.0%. The incidence of potential DDIs after mandatory use of the 'acknowledgement function' decreased slightly in endoscopy (-2.9%), the abdominal surgery unit (-2.7%), dialysis (-1.9%) and the step-down unit (-1.4%). CONCLUSIONS: Improving DDI alerts will improved patient safety by more appropriately alerting clinicians.