Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: A multicentre, prospective study.

Melissa T Baysari,Noorizan Abd Aziz,Mohd Taufiq Azmy,Yahaya Hassan,Ezlina Usir,Mathumalar Loganathan Fahrni

doi:10.1371/journal.pone.0219898

Melissa T Baysari, Noorizan Abd Aziz + Show 4 more

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https://doi.org/10.1371/journal.pone.0219898

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Abstract

ObjectivesTo provide baseline information on inappropriate prescribing (IP), and to evaluate whether potentially inappropriate medications (PIMs), as defined by STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) criteria, were associated with preventable adverse drug events (ADEs) and/or hospitalization.MethodsWe prospectively studied older patients (n = 301) admitted to three urban, public-funded hospitals. We scrutinized their medical records and used STOPP-START (Screening Tool to Alert Prescribers to Right Treatment) criteria to determine PIM and potential prescribing omissions (PPO) respectively- together these constitute IP. Prescriptions with PIM(s) were subjected to a pharmacist medication review, aimed at detecting cases of ADE(s). The vetted cases were further assessed by an expert consensus panel to ascertain: i) causality between the ADE and hospitalization, using, the World Health Organization Uppsala Monitoring Centre criteria, and, ii) whether the ADEs were avoidable (using Hallas criteria). Finally, percentages of PIM-associated ADEs that were both preventable and linked to hospitalization were calculated.ResultsIP prevalence was 58.5% (n = 176). A majority (49.5%, n = 150) had moderate to severe degree of comorbidities (Charlson Comorbidity Index score ≥ 3). Median age was 72 years. Median number of medications was 6 and 30.9% (n = 93) had ≥8 medications. PIM prevalence was 34.9% (117 PIMs, n = 105) and PPO 37.9% (191 PPOs, n = 114). Most PIMs and PPOs involved overuse of aspirin and underuse of both antiplatelets and statins respectively. With every increase in the number of medications prescribed, the likelihood of PIM occurrence increased by 20%, i.e.1.2 fold (OR 1.20, 95% CI: 1.1–1.3). Among the 105 patients with PIMs, 33 ADEs (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively. The most common ADEs were masked hypoglycemia and gastrointestinal bleed. With every additional PIM prescribed, the odds for ADE occurrence increased by 12 folds (OR 11.8, 95% CI 5.20–25.3).ConclusionThe majority of the older patients who were admitted to secondary care for acute illnesses were potentially exposed to IP. Approximately a quarter of the patients were prescribed with PIMs, which were plausibly linked with preventable ADEs that directly caused or contributed to hospitalization.

Highlights

Prescribing for older people is a complex process
With every increase in the number of medications prescribed, the likelihood of potentially inappropriate medications (PIMs) occurrence increased by 20%, i.e.1.2 fold
Among the 105 patients with PIMs, 33 adverse drug events (ADEs) (n = 33); 31 ADEs (n = 31) considered “causal” or “contributory” to hospitalization; 27 ADEs (n = 27) deemed “avoidable” or “potentially avoidable”; and 25 PIM-associated ADEs, preventable, and that induced hospitalization (n = 25), were identified: these equated to prevalence of 31.4%, 29.5%, 25.7%, and 23.8% respectively

Summary

Introduction

Prescribing for older people is a complex process. Older patients are often excluded from premarketing drug trials because of ethical considerations or age-related physiological changes that affect pharmacokinetics and pharmacodynamics of drugs,. Recommended doses for older patients are habitually drawn from extrapolated data of a young, healthy population, which may be inappropriate. Polypharmacy has been viewed negatively due to its association with drugdrug and drug-disease interactions. IP occurs in any of the following circumstances: prescribing of medications that pose more harm than benefit, when safer alternatives exist; prescribing of inappropriate dose or duration of drugs; presence of clinically significant drug-drug and drug-disease interactions; under-prescribing of potentially beneficial medications, and duplication of agents. Pharmacovigilance is crucial for detecting uncommon yet potentially hazardous adverse drug events (ADEs). [10] One inherent challenge in pharmacovigilance is that many case reports concern suspected ADE (adverse drug reactions), and these reactions are rarely An ADE is defined as any untoward medical occurrence that may present during treatment with medication but does not necessarily have a causal relationship with the treatment. [10] One inherent challenge in pharmacovigilance is that many case reports concern suspected ADE (adverse drug reactions), and these reactions are rarely

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