The impact of frailty on initiation, continuation and discontinuation of secondary prevention medications following myocardial infarction.

AIM: To evaluate the association between frailty and initiating, continuing, or discontinuing secondary prevention medications following myocardial infarction (MI). METHODS: We conducted a cohort study using linked health data, including all adults aged ≥65 years who discharged from hospital following MI from January 2013 to April 2018 in Victoria, Australia (N = 29,771). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. Logistic regression was used to investigate associations of frailty with initiation, continuation, and discontinuation of secondary prevention medications (P2Y12 inhibitor antiplatelets, beta-blockers, renin-angiotensin-aldosterone system (RAAS) inhibitors, and lipid-lowering therapies) in the 90 days from discharge post-MI, by HFRS, adjusted for age, sex, and Charlson Comorbidity Index. RESULTS: Increasing frailty was associated with lower probability of initiating and continuing P2Y12 inhibitors, RAAS inhibitors, and lipid-lowering therapies, but not beta-blockers. At at an HFRS of 0, the predicted probabiliy of having all four medications initiated or continued was 0.59 (95 %CI 0.57-0.62) for STEMI and 0.35 (0.34-0.36) for non-STEMI, compared to 0.38 (0.33-0.42) and 0.16 (0.14-0.18) at an HFRS of 15. Increasing frailty was associated with higher probability of discontinuing these medications post-MI. The predicted probability of discontinuing at least one secondary prevention medication post-MI at an HFRS of 0 was 0.10 (0.08-0.11) for STEMI and 0.14 (0.13-0.15) for non-STEMI, compared to 0.27 (0.22-0.32) and 0.34 (0.32-0.36) at an HFRS of 15. CONCLUSION: People with higher levels of frailty were managed more conservatively following MI than people with lower levels of frailty. Whether this conservative treatment is justified warrants further study.

Guideline concordant prescribing following myocardial infarction in people who are frail: A systematic review.

AIMS: The risk-to-benefit ratio of cardioprotective medications in frail older adults is uncertain. The objective was to systematically review prescribing of guideline-recommended cardioprotective medications following myocardial infarction (MI) in people who are frail. DATA SOURCES: Ovid Medline, PubMed and Cochrane were searched from inception to October 2022 for studies that reported prescribing of one or more cardioprotective medication classes post-MI or acute coronary syndromes in people with frailty. STUDY SELECTION: We included observational studies that reported prescribing of cardioprotective medications post-MI stratified by frailty status. RESULTS: Overall, 16 cohort studies published from 2013 to 2022 that used seven different frailty scales were included. Prescribing of all cardioprotective medication classes following MI was lower in frail compared to non-frail people, with absolute rates of prescribing varying substantially across studies. Median prescribing in frail and non-frail people, respectively, was 88.9% (IQR 81.5-96.2) and 93.1% (IQR 92.0-98.9) for aspirin; 68.1% (IQR 61.9-91.2) and 86.7% (IQR 79.5-92.8) for P2Y12-inhibitors; 83.1% (IQR 76.9-91.3) and 94.0% (IQR 87.1-95.9) for lipid-lowering therapy; 67.9% (IQR 60.6-74.0) and 74.7% (IQR 71.3-84.5) for angiotensin-converting enzyme inhibitor/angiotensin II receptor blockers; and 74.1% (IQR 69.2-79) and 77.6% (IQR 71.8-85.9) for beta-blockers. CONCLUSION: People who were frail were less likely to be prescribed guideline recommended medication classes post-MI than those who were non-frail. Further research is needed into treatment benefits and risks in frail people to avoid unnecessarily withholding treatment in this high-risk population, while also minimising potential for medication related harm.

The effect of Computerised Physician Order Entry on prescribing errors: An interrupted time-series study at a secondary referral hospital in Australia.

BACKGROUND: Computerised Physician Order Entry (CPOE) software is increasingly used across the world to improve medication safety. However, few high-quality studies have reviewed the impact of CPOE on prescribing errors and patient harm. OBJECTIVE: To investigate the effect of a hybrid CPOE-paper prescribing system on prescribing errors at a secondary hospital site. DESIGN: An interrupted time-series study was conducted by identifying prescribing errors via prospective medical chart review before and after the implementation of CPOE across three medical wards. PARTICIPANTS: The medication orders of all patients admitted to the medical wards during the study period were reviewed. INTERVENTION: Implementation of a CPOE across three medical wards. MEASURES: A blinded expert panel risk stratified the errors according to level of severity, preventability and potential for harm. Pearson's chi square and segmented regressions were used to determine if there were differences in prescribing errors pre- and post-CPOE implementation. KEY RESULTS: A total of 10,535 medication orders were reviewed pre-CPOE and 13,841 medication orders reviewed post-CPOE. Analysis demonstrated that after implementation of CPOE there were reductions in the proportion of orders with one or more of any error (-30.1%, 95 %CI: -36.5%, -23.7%, p < 0.001). Reductions in the proportion of orders with one or more errors were seen across the error categories of dosing errors (-20.1%, 95 %CI: -25.1%, -15%, p < 0.001), procedural/administrative errors (-18.9%, 95 %CI: -22.8%, -15%, p < 0.001), and therapeutic errors (-2.6%, 95 %CI: -4.1%, -1%, p = 0.002). Post-CPOE there were reductions in the proportion of orders with at least one non-intercepted serious error (-12.6%, 95 %CI: -16.4%, -8.8%, p < 0.001). CONCLUSION: The introduction of CPOE was associated with reductions in prescribing errors. There is also evidence that this translated into a reduced risk of harm to patients post-CPOE implementation through the reduction in actual adverse drug events.