Hospital pharmacists' opinions on a risk prediction tool for medication-related harm in older people.

AIM: Older adults are particularly affected by medication-related harm (MRH) during transitions of care. There are no clinical tools predicting those at highest risk of MRH post hospital discharge. The PRIME study (prospective study to develop a model to stratify the risk of MRH in hospitalized patients) developed and internally validated a risk-prediction tool (RPT) that provides a percentage score of MRH in adults over 65 in the 8 weeks following hospital discharge. This qualitative study aimed to explore the views of hospital pharmacists around enablers and barriers to clinical implementation of the PRIME-RPT. METHODS: Ten hospital pharmacists: (band 6, n = 3; band 7, n = 2; band 8, n = 5) participated in semistructured interviews at the Royal Sussex County Hospital (Brighton, UK). The pharmacists were presented with five case-vignettes each with a calculated PRIME-RPT score to help guide discussion. Case-vignettes were designed to be representative of common clinical encounters. Data were thematically analysed using a "framework" approach. RESULTS: Seven themes emerged in relation to the PRIME-RPT: (1) providing a medicine-prioritisation aide; (2) acting as a deprescribing alert; (3) facilitating a holistic review of patient medication management; (4) simplifying communication of MRH to patients and the multidisciplinary team; (5) streamlining community follow-up and integration of risk discussion into clinical practice; (6) identifying barriers for the RPTs integration in clinical practice; and (7) acknowledging its limitations. CONCLUSION: Hospital pharmacists found the PRIME-RPT beneficial in identifying older patients at high risk of MRH following hospital discharge, facilitating prioritising interventions to those at highest risk while still acknowledging its limitations.

Characterising older adults' risk of harm from blood-pressure lowering medications: a sub-analysis from the PRIME study.

AIM: Cardiovascular disease (CVD) is common amongst frail older people. The evidence base for CVD commonly excludes older adults with multimorbidity or chronic conditions. Most cardiovascular drugs have the potential to lower blood pressure (BP) and therefore cause medication-related harm (MRH). We aimed to identify key clinical and sociodemographic characteristics associated with MRH in older people taking BP-lowering drugs for whatever indication they were prescribed. METHODS: The PRIME (prospective study to develop a model to stratify the risk of MRH in hospitalised elderly patients in the UK) study investigating the incidence and cost of MRH in older people across Southern England. Adults ≥65 years were recruited from five teaching hospitals at hospital discharge and followed up for 8 weeks. Telephone interviews with study participants, review of primary care records and hospital readmissions were undertaken to identify MRH. PRIME study participants taking BP-lowering drugs (as defined by National Institute for Health and Care Excellence hypertension guidelines) were included in this analysis. RESULTS: One hundred and four (12%) study patients experienced a total of 153 MRH events associated with BP-lowering drugs. Patients on four BP-lowering drugs were five times more likely to experience MRH compared to those taking one medication (OR 4.96; 95%CI 1.63-15.13; P = 0.01). Most MRH events were classified 'serious' (80%, n = 123), requiring dose change or treatment cessation. Almost half of MRH were potentially preventable (49%, n = 75). CONCLUSION: Polypharmacy from BP-lowering drugs in older people is associated with preventable harm. Decisions around cardiovascular risk reduction should be carefully considered in view of MRH arising from BP-lowering drugs.

A multi-centre cohort study on healthcare use due to medication-related harm: the role of frailty and polypharmacy.

OBJECTIVES: To determine the association between frailty and medication-related harm requiring healthcare utilisation. DESIGN: Prospective observational cohort study. SETTING: Six primary and five secondary care sites across South East England, September 2013-November 2015. PARTICIPANTS: One thousand and two hundred and eighty participants, ≥65 years old, who were due for discharge from general medicine and older persons' wards following an acute episode of care. Exclusion criteria were limited life expectancy, transfer to another hospital and consent not gained. MAIN OUTCOME MEASURES: Medication-related harm requiring healthcare utilisation (including primary, secondary or tertiary care consultations related to MRH), including adverse drug reactions, non-adherence and medication error determined via the review of data from three sources: patient/carer reports gathered through a structured telephone interview; primary care medical record review; and prospective consultant-led review of readmission to recruiting hospital. Frailty was measured using a Frailty Index, developed using a standardised approach. Marginal estimates were obtained from logistic regression models to examine how probabilities of healthcare service use due to medication-related harm were associated with increasing number of medicines and frailty. RESULTS: Healthcare utilisation due to medication-related harm was significantly associated with frailty (OR = 10.06, 95% CI 2.06-49.26, P = 0.004), independent of age, gender, and number of medicines. With increasing frailty, the need for healthcare use as a result of MRH increases from a probability of around 0.2-0.4. This is also the case for the number of medicines. CONCLUSIONS: Frailty is associated with MRH, independent of polypharmacy. Reducing the burden of frailty through an integrated health and social care approach, alongside strategies to reduce inappropriate polypharmacy, may reduce MRH related healthcare utilisation.

Implementation of a medicine management plan (MMP) to reduce medication-related harm (MRH) in older people post-hospital discharge: a randomised controlled trial.

BACKGROUND: Medication-related harm (MRH) is an escalating global challenge especially among older adults. The period following hospital discharge carries high-risk for MRH due to medication discrepancies, limited patient/carer education and support, and poor communication between hospital and community professionals. Discharge Medical Service (DMS), a newly introduced NHS scheme, aims to reduce post-discharge MRH through an electronic communication between hospital and community pharmacists. Our study team has previously developed a risk-prediction tool (RPT) for MRH in the 8-weeks period post discharge from a UK hospital cohort of 1280 patients. In this study, we aim to find out if a Medicines Management Plan (MMP) linked to the DMS is more effective than the DMS alone in reducing rates of MRH. METHOD: Using a randomized control trial design, 682 older adults ≥ 65 years due to be discharged from hospital will be recruited from 4 sites. Participants will be randomized to an intervention arm (individualised medicine management plan (MMP) plus DMS) or a control arm (DMS only) using a 1:1 ratio stratification. Baseline data will include patients' clinical and social demographics, and admission and discharge medications. At 8-weeks post-discharge, a telephone interview and review of GP records by the study pharmacist will verify MRH in both arms. An economic and process evaluation will assess the cost and acceptability of the study methods. DATA ANALYSIS: Univariate analysis will be done for baseline variables comparing the intervention and control arms. A multivariate logistic regression will be done incorporating these variables. Economic evaluation will compare the cost-of-service use among the study arms and modelled to provide national estimates. Qualitative data from focus-group interviews will explore practitioners' understanding, and acceptance of the MMP, DMS and the RPT. CONCLUSION: This study will inform the use of an objective, validated RPT for MRH among older adults after hospital discharge, and provide a clinical, economic, and service evaluation of a specific medicines management plan alongside the DMS in the National Health Service (UK).

Do the 2015 Beers Criteria predict medication-related harm in older adults? Analysis from a multicentre prospective study in the United Kingdom.

PURPOSE: To investigate whether inappropriate prescribing, defined by the Beers Criteria, is associated with medication-related harm (MRH), hospital admission, and mortality in older adults in England. METHODS: A multicentre, prospective cohort study recruited 1280 patients (median age 82 years) at hospital discharge. Patients were followed-up in the community by pharmacists for 8 weeks to identify MRH (harm from adverse drug reactions, non-adherence, and medication errors) and hospital admissions. One-year mortality was determined using hospital records. Potentially inappropriate medications (PIMs) were determined using the 2015 version of the Beers criteria. Logistic regression was used to investigate the relationship between patients prescribed PIMs and adverse outcomes. RESULTS: Two hundred and seventy-six patients (22%) were prescribed one or more PIMs at hospital discharge. The main PIM classes prescribed at hospital discharge were benzodiazepines and related drugs (30%) and antidepressants (27%). 1116 out of 1280 patients completed follow-up and 413 (37%) experienced MRH. In 51 cases (12%), MRH was attributable to a PIM. There was no significant relationship between patients prescribed PIMs and overall MRH, hospital readmission or all-cause one-year mortality. Multiple PIMs at discharge was independently associated with an increased risk of ADR (OR 2.32, 95% CI 1.03-5.23). CONCLUSION: The prescribing of PIMs is common at hospital discharge of older adults in England. The 2015 Beers criteria have a limited clinical value to predict adverse outcomes following hospital discharge in this setting.

'They must help if the doctor gives them to you': a qualitative study of the older person's lived experience of medication-related problems.

Objective: medication-related problems (MRP) are common for older adults and can lead to harm. The older person's perspective on MRP has been seldom reported in published literature. This study explored the lived experience of MRP in older adults with varying functional levels, focussing on the hospital discharge period. Design, setting, participants: this qualitative study was conducted in Brighton and Hove, UK. A purposive sample of 20 older people with experience of MRP, involving carers, took part in focus groups and semi-structured interviews. Data were thematically analysed using a 'framework' approach. Results: four major themes associated with MRP were identified; (1) experience of the healthcare system, (2) practicalities of using medicines, (3) management of medication problems and (4) participant beliefs. Participants encountered problems in communication with healthcare professionals such as passive listening and paternalistic consultations. A conflict was acknowledged between participants' implicit trust in the healthcare system and their negative experience of MRP. Participants felt vulnerable around hospital discharge, describing reduced capacity to comprehend information, pressured discharge circumstances and lack of integrated care in the community. Drug formulations, packaging and information leaflets were felt to be poorly tailored to the needs of older people. Conclusions: the lived experience of older people with MRP in this study was multifaceted and complex. Participants felt communication was poor around hospital discharge, and insufficient support with medicines was offered in the community when problems arose. Harm due to MRP might be reduced if the contributory factors described by patients inform clinical and policy-level intervention.

Can doctors identify older patients at risk of medication harm following hospital discharge? A multicentre prospective study in the UK.

AIMS: Medication-related harm (MRH) is common in older adults following hospital discharge. In resource-limited health systems, interventions to reduce this risk can be targeted at high-risk patients. This study aims to determine whether (1) doctors can predict which older patients will experience MRH requiring healthcare following hospital discharge, (2) clinical experience and confidence in prediction influence the accuracy of the prediction. METHODS: This was a multicentre observational prospective study involving five teaching hospitals in England between September 2013 and November 2015. Doctors discharging patients (aged ≥65 years) from medical wards predicted the likelihood of their patient experiencing MRH requiring healthcare (hospital readmission or community healthcare) in the initial 8-week period post-discharge. Patients were followed up by senior pharmacists to determine MRH occurrence. RESULTS: Data of 1066 patients (83%) with completed predictions and follow-up, out of 1280 recruited patients, were analysed. Patients had a median age of 82 years (65-103 years), and 58% were female. Most predictions (85%) were made by junior doctors with less than 5 years' clinical experience. There was no relationship between doctors' predictions and patient MRH (OR 1.10, 95% CI 0.82-1.46, P = 0.53), irrespective of years of clinical experience. Doctors' predictions were more likely to be accurate when they reported higher confidence in their prediction, especially in predicting MRH-associated hospital readmissions (OR 1.58, 95% CI 1.42-1.76, P < 0.001). CONCLUSIONS: Clinical judgement of doctors is not a reliable tool to predict MRH in older adults post-discharge.

Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK.

AIMS: Polypharmacy is increasingly common in older adults, placing them at risk of medication-related harm (MRH). Patients are particularly vulnerable to problems with their medications in the period following hospital discharge due to medication changes and poor information transfer between hospital and primary care. The aim of the present study was to investigate the incidence, severity, preventability and cost of MRH in older adults in England postdischarge. METHODS: An observational, multicentre, prospective cohort study recruited 1280 older adults (median age 82 years) from five teaching hospitals in Southern England, UK. Participants were followed up for 8 weeks by senior pharmacists, using three data sources (hospital readmission review, participant telephone interview and primary care records), to identify MRH and associated health service utilization. RESULTS: Overall, 413 participants (37%) experienced MRH (556 MRH events per 1000 discharges), of which 336 (81%) cases were serious and 214 (52%) potentially preventable. Four participants experienced fatal MRH. The most common MRH events were gastrointestinal (n = 158, 25%) or neurological (n = 111, 18%). The medicine classes associated with the highest risk of MRH were opiates, antibiotics and benzodiazepines. A total of 328 (79%) participants with MRH sought healthcare over the 8-week follow-up. The incidence of MRH-associated hospital readmission was 78 per 1000 discharges. Postdischarge MRH in older adults is estimated to cost the National Health Service £396 million annually, of which £243 million is potentially preventable. CONCLUSIONS: MRH is common in older adults following hospital discharge, and results in substantial use of healthcare resources.

Protocol for a Prospective (P) study to develop a model to stratify the risk (RI) of medication (M) related harm in hospitalized elderly (E) patients in the UK (The PRIME study).

BACKGROUND: Medication related harm (MRH) is a common cause of morbidity and hospital admission in the elderly, and has significant cost implications for both primary and secondary healthcare resources. The development of risk prediction models has become an increasingly common phenomenon in medicine and can be useful to guide objective clinical decision making, resource allocation and intervention. There are no risk prediction models that are widely used in clinical practice to identify elderly patients at high risk of MRH following hospital discharge. The aim of this study is to develop a risk prediction model (RPM) to identify elderly patients at high risk of MRH upon discharge from hospital, and to compare this with routine clinical judgment. METHODS/DESIGN: This is a multi-centre, prospective observational study following a cohort of patients for 8 weeks after hospital discharge. Data collection including patient characteristics, medication use, social factors and frailty will take place prior to patient discharge and then the patient will be followed up in the community over the next 8 weeks to determine if they have experienced MRH. Research pharmacists will determine whether patients have experienced MRH by prospectively reviewing records for unplanned emergency department attendance, hospital readmission and GP consultation related to MRH. Research pharmacists will also telephone patients directly to determine self-reported MRH, which patients may not have sought further medical attention for. The data collected will inform the development of a RPM which will be externally validated in a follow-up study. DISCUSSION: There are no RPMs that are used in clinical practice to help stratify elderly patients at high risk of MRH in the community following hospital discharge, despite this being a significant public health problem. This study plans to develop a clinically useful RPM that is better than routine clinical judgment. As this is a multi-centre study involving clinical settings that serve elderly people of heterogeneous sociodemographic background, it is anticipated that this RPM will be generalizable.

Concussion in youth rugby union and rugby league: a systematic review.

BACKGROUND: Children and adolescents who play rugby are at increased risk of concussion and its effects. Competitive rugby union and rugby league feature as major sports in the school sport curriculum in the UK. There is a need for a thorough understanding of the epidemiology of concussion in youth rugby, the mechanisms involved in injuries and predisposing risk factors. DATA SOURCES: The publication databases Pubmed, Embase and SportDISCUS were searched in April 2014 for primary research studies of child and adolescent rugby union and rugby league (under 20 years) in English language with data on concussion injuries. The review was conducted within a larger all injury systematic review on rugby union and rugby league where key words used in the search included rugby, injury and concussion with child, adolescent, paediatric and youth. RESULTS: There were 25 studies retrieved with data on child or adolescent rugby and concussion, 20 were on rugby union, three on rugby league and in two the code of rugby was unspecified. There was significant heterogeneity in the definitions of injuries and of concussion. The incidence of child and adolescent match concussion ranged from 0.2 to 6.9 concussions per 1000 player-hours for rugby union and was 4.6 and 14.7 concussions per 1000 player-hours for rugby league, equivalent to a probability of between 0.3% and 11.4% for rugby union and of 7.7% and 22.7% for rugby league. CONCLUSIONS: There is a significant risk of concussion in children and adolescents playing rugby union and rugby league evident from the studies included in this systematic review. There is a need for reliable data through routine monitoring and reporting in schools and clubs and in hospital emergency departments in order to inform prevention. Concussion protocols should be implemented and tested.

Ethnic inequities in 6-8 week baby check coverage in England 2006-2021: a cohort study using the Clinical Practice Research Datalink.

BACKGROUND: Inequities in the coverage of 6-8 week maternal checks, health visitor reviews and infant vaccinations have been reported in England. Ethnic inequities in 6-8 week baby checks have not been studied nationally. AIM: To examine the effect of maternal ethnicity on 6-8 week baby check coverage in England 2006-2021. DESIGN AND SETTING: Cohort study using electronic health records. METHODS: We calculated baby check coverage in 16 ethnic groups, by year and region, and risk ratios using modified Poisson regression. We calculated coverage and timing of baby checks in relation to maternal checks and infant vaccinations by ethnic group. RESULTS: Ethnic inequities in 6-8 week baby check coverage in England varied by year and region. Coverage increased 2006-07 to 2015-16, then stabilised to 80-90% for most groups. Coverage was lowest for Bangladeshi and Pakistani groups 2006-07 to 2011-12. In the West Midlands, coverage was lowest at 59% for four groups: Bangladeshi, Caribbean, African, and Any other Black, African or Caribbean background. In the North West, coverage was lowest for Bangladeshi (65%) and Pakistani (69%) groups. These patterns remained after adjusting for other factors, and persisted over time. Coverage was highest in those whose mothers received a maternal check and those who received at least one dose of 8 week infant vaccinations. CONCLUSIONS: Coordinated action at the level of integrated commissioning boards, primary care networks and GP practices is required to better understand the reasons behind these inequities and redress the persistent disparities in 6-8 week baby check coverage.

Communicating the risk of injury in schoolboy rugby: using Poisson probability as an alternative presentation of the epidemiology.

BACKGROUND: The communication of injury risk in rugby and other sports is underdeveloped and parents, children and coaches need to be better informed about risk. METHOD: A Poisson distribution was used to transform population based incidence of injury into average probabilities of injury to individual players. RESULTS: The incidence of injury in schoolboy rugby matches range from 7 to 129.8 injuries per 1000 player-hours; these rates translate to average probabilities of injury to a player of between 12% and 90% over a season. CONCLUSION: Incidence of injury and average probabilities of injury over a season should be published together in all future epidemiological studies on school rugby and other sports. More research is required on informing and communicating injury risks to parents, staff and children and how it affects monitoring, decision making and prevention strategies.

Rugby union injuries in Scottish schools.

BACKGROUND: Rugby union is the most popular worldwide collision sport, yet concerns have been raised regarding the safety of the sport due to the physical, high impact nature and an increasing number of injuries. METHODS: A prospective, cohort study of the incidence, pattern and severity of injuries in rugby players in six Scottish schools during the second half of the 2008-09 season. Definition of injury and severity of injury were taken from International Rugby Board (IRB) consensus guidelines. Injury report forms and exposure data for match play were completed by a nominated staff member. RESULTS: Four hundred and seventy consent forms with survey information were returned. Of 37 rugby injuries in the study, 11 occurred during training. Head and face were the most injured body part and sprain/ligament injury the most common injury. Twenty injuries required attendance at Accident & Emergency with one admission. The tackle was the commonest phase of play causing injury. In the 193 matches played, the injury incidence during the match play was 10.8 injuries per 1000 player hours. CONCLUSIONS: This study confirms the feasibility of collecting relevant injury data in schools rugby in Scotland. The findings are consistent with other studies with respect to incidence and profile of injuries sustained.

Health inequalities of the Roma in Europe: a literature review.

The Roma are the most populous marginalised community in Europe and have some of the greatest health needs. There is a higher prevalence of communicable and non-communicable diseases within the community and significantly shorter life expectancies than national averages. Efforts by governments across Europe to address these health inequalities have been relatively weak and the Roma suffer poorer access to health care, education and employment in every country that they inhabit in comparison to the majority population. As the socioeconomic determinants of health become better understood over the past decade, it is becoming clear that societies with greater inequalities are less healthy overall. It is important for public health across Central and Eastern Europe that the health needs of the Roma are prioritised by governments concerned. We provide a review of the literature on the health inequalities of the Roma community in Europe.

Wegener's granulomatosis complicated by pulmonary embolism: a case report and review of the literature.

We describe the case of a 79-year-old lady who developed pulmonary emboli on a background of active Wegener's granulomatosis (WG). The literature reports an increased association of venous thromboembolic disease and the small vessel vasculitides, including WG. This case report explores the issues surrounding systemic anticoagulation in the context of a systemic vasculitis that predisposes to severe bleeding, in particular from the respiratory tract.

Aortic stiffness and central systolic pressure are associated with ambulatory orthostatic BP fall in chronic kidney disease.

OBJECTIVE: Orthostatic hypotension (OH) has a significant association with cardiovascular disease. OH becomes more common in older age, as does arterial stiffness, shown to be independently associated with impaired baroreflex sensitivity and OH. Measurement of arterial compliance and central blood pressures are increasingly important, with evidence that central BP more closely correlates to end-organ damage and mortality than peripheral measurements. Patients with chronic kidney disease (CKD) are high risk for cardiovascular events, which can be predicted through measures of arterial compliance. We hypothesised that OH is associated with arterial stiffness and central blood pressure in CKD patients. DESIGN/SETTING: We tested this hypothesis within the arterial compliance and oxidant stress as predictors of loss of renal function, morbidity and mortality in chronic kidney disease (ACADEMIC) study, a single-centre prospective observational study of the progression of arterial stiffness and renal function. PARTICIPANTS: One hundred and forty-six patients with CKD 3 or 4. MEASUREMENTS: Twenty-four-hour ambulatory BP monitoring with postural sensing (DIASYS Integra 2, Novacor France); central systolic and diastolic BP (cSBP and cDBP) and aortic Augmentation Index using Sphygmocor® (Atcor, Australia); Carotid-femoral pulse wave velocity (cfPWV) using Complior® (ALAM Medical, France). RESULTS: Twenty-three patients had a postural SBP fall (prevalence 15.8%), with mean drop 7 mmHg. Patients with OH had higher cfPWV (15.2 m/s vs 12.7 m/s in patients without OH, p < 0.001) and central SBP (147.5 vs 135.7, p = 0.012). Regression analysis gave an odds ratio (OR) of orthostatic SBP fall for cfPWV of 1.46 (95% CI 1.16-1.84, p = 0.001) and 1.03 for cSBP (95% CI 1.004-1.06, p = 0.024) after adjustment for cardiovascular risk factors. CONCLUSION: Aortic stiffness and central SBP are independently associated with orthostatic SBP fall in CKD patients. This suggests that enhanced arterial stiffness may be an underlying mechanism in baroreflex dysfunction, and may partly explain the vascular risk in CKD patients.

The Association of a Single-Nucleotide Polymorphism in the Nuclear Factor (Erythroid-Derived 2)-Like 2 Gene With Adverse Drug Reactions, Multimorbidity, and Frailty in Older People.

Susceptibility to adverse drug reactions (ADRs), multimorbidity, and frailty are associated with human aging, yet there is wide variation in the severity and age at which individuals are afflicted. Identifying genetic markers of increased risk of this phenotype would help stratify individuals to specialist interventions. Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) regulates a cell's response to stressors, including the expression of enzymes involved in drug metabolism. Its expression has been shown to decline in animal aging models. In this study, we tested the hypothesis that Nrf2 gene (NFE2L2) transcription/translation decline in human aging and that single-nucleotide polymorphisms (SNPs) in the NFE2L2 gene are associated with increased ADR risk, multimorbidity, and frailty in older people. Gene expression and protein levels were measured in peripheral blood mononuclear cells donated from healthy patients aged 18-80 years old. NFE2L2 genotypes were determined at three loci in a subpopulation of patients recruited to the PRIME study (a multicenter prospective cohort study that followed older adults for 8 weeks post-discharge to determine ADR). Both NFE2L2 gene and Nrf2 protein expression declined significantly with age in human peripheral blood mononuclear cells. In the PRIME substudy population, the rs35652124 NFE2L2 SNP was associated with increased ADR risk and decreased frailty and multimorbidity scores.

Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool.

OBJECTIVES: To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge. DESIGN, SETTING, PARTICIPANTS: Multicentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015. PRIMARY OUTCOME MEASURE: Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information: hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated. RESULTS: 1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases ('possible' and 'probable') were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced 'definite' MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge: age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool's discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches. CONCLUSIONS: The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool's evaluation in other settings.

Incidence of Medication-Related Harm in Older Adults After Hospital Discharge: A Systematic Review.

OBJECTIVES: To determine the incidence, severity, and preventability of and risk factors for medication-related harm (MRH) in community-dwelling older adults after hospital discharge. DESIGN: Systematic review. SETTING: A search of Medline, EMBASE, CINAHL, and the Cochrane Library was undertaken without time restrictions. PARTICIPANTS: Older adults (average age ≥65) participating in observational studies investigating postdischarge adverse drug reactions (ADRs) or adverse drug events (ADEs) within a defined follow-up period. MEASUREMENTS: One author screened abstracts of all articles to exclude obviously irrelevant articles. Two authors independently screened the remaining articles for inclusion. Two authors independently extracted data, including study characteristics, MRH incidence, and risk factors; a third reviewer critically appraised and verified the data. Disagreements were resolved through discussion. RESULTS: From 584 potentially relevant articles, 8 studies met our inclusion criteria: 5 North American and 3 European. Most of the included studies were of moderate quality. There was a wide range in MRH incidence, from 0.4% to 51.2% of participants, and 35% to 59% of MRH was preventable. MRH incidence within 30 days after discharge ranged from 167 to 500 events per 1,000 individuals discharged (17-51% of individuals). There is substantial methodological heterogeneity across multiple domains of the studies, including ADR and ADE definitions, characteristics of recruited populations, follow-up duration after discharge, and data collection. CONCLUSION: MRH is common after hospital discharge in older adults, but methodological inconsistencies between studies and a paucity of data on risk factors limits clear understanding of the epidemiology. There is a need for international consensus on conducting and reporting MRH studies. Data from large, multicenter studies examining a range of biopsychosocial risk factors could provide insight into this important area of safety.