Potential Prescribing Omissions Research Articles

Implementation of a pharmacovigilance system to detect adverse events and improve medication appropriateness in a hospital in Indonesia

Background: The growing elderly population has led to an increased occurrence of adverse drug reactions (ADRs) due to the various drugs they are prescribed, posing the problem of potential drug interactions. The application of causality instruments combined with trigger tools and the competency of healthcare professionals has yielded better results in detecting ADRs. Objective: To evaluate the implementation of a pharmacovigilance system to detect ADRs, potentially inappropriate medications, and potential prescription omissions. Methods: An observational, descriptive, prospective study was conducted over six weeks at one of the largest hospitals in Indonesia. The pharmacist and the physicians collaborated in reviewing patient medication records using the pharmacovigilance system. Results: The study enrolled 144 patients. The 163 positive triggers identified helped detect 28 Adverse Drug Events (ADEs) caused by at least one high-alert medication. These ADEs occurred in 25 patients. Additionally, 62 potentially inappropriate medications and 41 potential prescription omissions were detected. Conclusion: The pharmacovigilance system could reduce the frequency of ADEs caused by medications used in elderly patients.

Potentially inappropriate prescriptions and potential prescription omissions in older people living with HIV.

This study aimed to determine the prevalence of potentially inappropriate prescriptions (PIPs) and potential prescription omissions (PPOs) in a Spanish cohort of people living with HIV (PLWH) aged ≥65 years and to identify risk factors for the presence of PIPs and PPOs. This retrospective cross-sectional study was conducted across 10 public hospitals in the Autonomous Community of Madrid, Spain. Clinical and demographic data were cross-checked against hospital and community pharmacy dispensation registries. PIPs and PPOs were assessed using the American Geriatrics Society (AGS)/Beers and Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. Risk factors for PIPs and PPOs and agreement between AGS/Beers and STOPP/START criteria were statistically analysed. This study included 313 PLWH (median age 72 years), of whom 80.5% were men. PIP prevalence rates were 29.4% and 44.4% based on the AGS/Beers and STOPP criteria, respectively. The concordance between AGS/Beers and STOPP criteria was moderate. Benzodiazepines and proton pump inhibitors were the chronic comedications most commonly involved in PIPs. PPOs were observed in 61.4% of the patients. The leading omissions were insufficient influenza and pneumococcal vaccine coverage and inadequate bone health-related treatments. The number of chronic comedications, female sex, neuropsychiatric disorders, and cancer diagnosis were risk factors for PIPs, whereas osteopenia and osteoporosis were risk factors for PPOs. A high prevalence of PIPs and PPOs was observed in our cohort of older PLWH. These findings emphasize the importance of comprehensive medication reviews in this population to reduce inappropriate medication use and address their specific and underserved therapeutic needs.

Potentially Inappropriate Prescribing and Potential Prescribing Omissions and Their Association with Adverse Drug Reaction-Related Hospital Admissions.

This study aimed to determine the prevalence of potentially inappropriate prescribing (PIP) and potential prescribing omissions (PPOs) and their association with ADR-related hospital admissions in patients aged ≥ 65 years admitted acutely to the hospital. Information on medications and morbidities was extracted from the Adverse Drug Reactions in an Ageing Population (ADAPT) cohort (N = 798: N = 361 ADR-related admissions; 437 non-ADR-related admissions). PIP and PPOs were assessed using Beers Criteria 2019 and STOPP/START version 2. Multivariable logistic regression (adjusted odds ratios (aOR), 95%CI) was used to examine the association between PIP, PPOs and ADR-related admissions, adjusting for covariates (age, gender, comorbidity, polypharmacy). In total, 715 (90%; 95% CI 87-92%) patients had ≥1 Beers Criteria, 555 (70%; 95% CI 66-73%) had ≥ 1 STOPP criteria and 666 patients (83%; 95% CI 81-86%) had ≥ 1 START criteria. Being prescribed at least one Beers (aOR = 1.66, 95% CI = 1.00-2.77), or meeting STOPP (aOR = 1.07, 95% CI = 0.79-1.45) or START (aOR = 0.72; 95%CI = 0.50-1.06) criteria or the number of PIP/PPO criteria met was not significantly associated with ADR-related admissions. Patients prescribed certain drug classes (e.g., antiplatelet agents, diuretics) per individual PIP criteria were more likely to have an ADR-related admission. There was a high prevalence of PIP and PPOs in this cohort but no association with ADR-related admissions.

Time-dependent association between STOPP and START criteria and gastrointestinal bleeding in older patients using routinely collected primary care data

Purpose Only few studies have assessed the preventive effect of the STOPP/START criteria on adverse events. We aim to quantify 1) the association between nonadherence to STOPP/START criteria and gastrointestinal bleedings, and 2) the association between exposure to the potentially harmful START-medications and gastrointestinal bleedings. Design A retrospective cohort study using routinely collected data of patients aged ≥ 65 years from the electronic health records (EHR) of 49 general practitioners (GPs) in 6 GP practices, from 2007 to 2014. The database is maintained in the academic research network database (AHA) of Amsterdam UMC, the Netherlands. Methods Gastrointestinal bleedings were identified using ICPC codes and free text inspections. Three STOPP and six START criteria pertaining to gastrointestinal bleedings were selected. Cox proportional hazards regression with time-dependent covariate analysis was performed to assess the independent association between nonadherence to the STOPP/START criteria and gastrointestinal bleedings. The analysis was performed with all criteria as a composite outcome, as well as separately for the individual criteria. Results Out of 26,576 participants, we identified 19,070 Potential Inappropriate Medications (PIM)/Potential Prescribing Omission (PPO) instances for 3,193 participants and 146 gastrointestinal bleedings in 143 participants. The hazard ratio for gastrointestinal bleedings of STOPP/STARTs, taken as composite outcome, was 5.45 (95% CI 3.62–8.21). When analysed separately, two out of nine STOPP/STARTs showed significant associations. Conclusion This study demonstrates a significant positive association between nonadherence to the STOPP/START criteria and gastrointestinal bleeding. We emphasize the importance of adherence to the relevant criteria for gastrointestinal bleeding, which may be endorsed by decision support systems.

The Prevalence of Potential Prescribing Omissions for Antiplatelets and Statins in Older Adults With Atherosclerotic Cardiovascular Disease.

Background The Screening Tool to Alert to Right Treatment (START) criteria for older adults was developed to recognize potential prescribing omissions (PPOs) of clinically indicated medications. According to these criteria, statins and antiplatelets should be prescribed for older adults with a documented history of coronary artery, cerebral, or peripheral vascular disease unless contraindicated. Aim This study aimed to investigate physicians' adherence to START criteria and identify the prevalence of PPO, considering the prescription of statins and antiplatelets in older patients with a history of coronary artery, cerebral, or peripheral vascular disease. Methods In this single-center, cohort, retrospective study, patients aged >65 years with a history of coronary artery, cerebral, or peripheral vascular disease were included. The prevalence of PPO for statins and antiplatelet therapy was identified. This study was guided by the screening Tool of Older Persons'Prescriptions (STOPP)/START criteria published in 2016. Results A total of 244 patients with a history of coronary, cerebral, or peripheral vascular disease were included in this study. Statin use was appropriately observed in 131/220 (59.5%)while antiplatelets were appropriately observed in 219/237 (92.4%). Therefore, the PPO for statins and antiplatelets was 40.5% and 7.6%, respectively. Conclusion The results of this study identified that the prevalence of PPO for statins and antiplatelets for older adults was high. We encourage prescribers to utilize tools such as Beer's criteria or STOPP/START, which may assist their decision in addition to their clinical judgment in weighing the benefit to the risk of starting or stopping antiplatelets or statins in older adult patients.

Development of a Malaysian potentially inappropriate prescribing screening tool in older adults (MALPIP): a Delphi study

IntroductionPolypharmacy and potentially inappropriate medications (PIM) are common among older adults. To guide appropriate prescribing, healthcare professionals often rely on explicit criteria to identify and deprescribe inappropriate medications, or to start medications due to prescribing omission. However, most explicit PIM criteria were developed with inadequate guidance from quality metrics or integrating real-world data, which are rich and valuable data source.AimTo develop a list of medications to facilitate appropriate prescribing among older adults.MethodsA preliminary list of PIM and potential prescribing omission (PPO) were generated from systematic review, supplemented with local pharmacovigilance data of adverse reaction incidents among older people. Twenty-one experts from nine specialties participated in two Delphi to determine the list of PIM and PPO in February and March 2023. Items that did not reach consensus after the second Delphi round were adjudicated by six geriatricians.ResultsThe preliminary list included 406 potential candidates, categorised into three sections: PIM independent of diseases, disease dependent PIM and omitted drugs that could be restarted. At the end of Delphi, 92 items were decided as PIM, including medication classes, such as antacids, laxatives, antithrombotics, antihypertensives, hormones, analgesics, antipsychotics, antidepressants, and antihistamines. Forty-two disease-specific PIM criteria were included, covering circulatory system, nervous system, gastrointestinal system, genitourinary system, and respiratory system. Consensus to start potentially omitted treatment was achieved in 35 statements across nine domains.ConclusionsThe newly developed PIM criteria can serve as a useful tool to guide clinicians and pharmacists in identifying PIMs and PPOs during medication review and facilitating informed decision-making for appropriate prescribing.

Prevalence of potentially inappropriate medications among elderly patients with diabetes – study based on STOPP/START criteria

Objective: The prevalence of drug-related problems in elderly patients is a concerning issue that can lead to elevated morbidity, mortality, and health care resource utilisation. This study focuses on the significance of addressing diabetes in the context of an ageing population, where elderly individuals face higher risks of comorbidities and mortality. The main objective of this study was to assess potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among patients with diabetes in Bulgaria, using the explicit STOPP/START criteria, version 2. By evaluating the appropriateness of drug prescriptions in this specific patient population, this study aims to shed light on areas that require optimisation to enhance patient safety and treatment outcomes. Materials and methods: A national prospective questionnaire study was conducted in Bulgaria among patients aged over 65 years. The research was conducted in 25 randomly selected pharmacies. The study supports the use of the STOPP/START criteria based on the clinical information provided. A total of 133 patients with T1DM or T2DM participated in the study. The evaluation of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) was performed in 131 patients. sStatistical differences in demographics and medication numbers between patients with and without PIMs or PPOs were assessed using a Chi-square test, with a p-value of ≤ 0.05 considered statistically significant. Results: The pharmacotherapy of 131 patients with diabetes was assessed, and it was found that 57% of them had polypharmacy. Among the study population, 90 PIMs were identified, indicating that 66% of the patients had inappropriate prescribing. Notably, inappropriate prescribing concerning diabetes was associated with the use of long-acting sulfonylureas (n=10) and beta-blockers (n=13). Applying the START criteria revealed 67 PPOs among 67 patients, representing a prevalence of 50% in the study population. However, no PPOs were detected in the context of diabetes pharmacotherapy. Furthermore, a significant relationship was observed between the number of medications and PIMs, as evidenced by the chi-square test result with a p-value close to zero, indicating statistical significance. Conclusion: The study revealed a high prevalence of PIMs in elderly patients with diabetes in Bulgaria. Endocrine disorders contribute to 26% of PIMs. As Bulgaria’s ageing population faces increasing diabetes challenges, effective management strategies are crucial. These findings underscore the significance of addressing prescribing practises to enhance disease control and prevent complications.

Associations between potentially inappropriate prescribing and increased number of medications with postdischarge health outcomes among geriatric rehabilitation inpatients: RESORT study.

Older adults are vulnerable to medication-related harm mainly due to high use of medications and inappropriate prescribing. This study aimed to investigate the associations between inappropriate prescribing and number of medications identified at discharge from geriatric rehabilitation with subsequent postdischarge health outcomes. RESORT (REStORing health of acutely unwell adulTs) is an observational, longitudinal cohort study of geriatric rehabilitation inpatients. Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were measured at acute admission, and at admission and discharge from geriatric rehabilitation, using Version 2 of the STOPP/START criteria. In total, 1890 (mean age 82.6 ±8.1years, 56.3% female) were included. The use of at least 1 PIM or PPO at geriatric rehabilitation discharge was not associated with 30-day and 90-day readmission and 3-month and 12-month mortality. Central nervous system/psychotropics and fall risk PIMs were significantly associated with 30-day hospital readmission (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.09-2.15), and cardiovascular PPOs with 12-month mortality (AOR 1.34; 95% CI 1.00-1.78). Increased number of discharge medications was significantly associated with 30-day (AOR 1.03; 95% CI 1.00-1.07) and 90-day (AOR 1.06; 95% CI 1.03-1.09) hospital readmissions. The use and number of PPOs (including vaccine omissions) were associated with reduced independence in instrumental activities of daily living scores at 90-days after geriatric rehabilitation discharge. The number of discharge medications, central nervous system/psychotropics and fall risk PIMs were significantly associated with readmission, and cardiovascular PPOs with mortality. Interventions are needed to improve appropriate prescribing in geriatric rehabilitation patients to prevent hospital readmission and mortality.

Inappropriate prescribing in geriatric rural primary care: impact on adverse outcomes and relevant risk factors in a prospective observational cohort study

BackgroundSeveral tools have revealed an association between potentially inappropriate medications (PIM) and adverse outcomes, but the one most fitted for the rural population has not been determined.AimsWe investigated the performance of the Screening Tool of Older Persons' Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START) in identifying inappropriate prescribing and its association with adverse outcomes among older rural primary health care users.MethodsA cohort of consenting outpatients aged ≥ 65 years in a rural Greek primary care center was assessed for PIM and potential prescribing omissions (PPO) using the START/STOPP version 2 criteria. Medications, comorbidities, functional status, and laboratory data were recorded along with 6-month incidence of emergency department visits, hospitalization, and death prospectively.ResultsAmong 104 participants (median age 78 years, 49.1% women, receiving a median of 6 drugs), PPO was found in 78% and PIMs in 61%. PIM was multivariately correlated with multimorbidity (p = 0.029) and polypharmacy (p < 0,001), while drug-PPO was only associated with multimorbidity (p = 0.039). The number of PIM predicted emergency department visits and hospitalizations at 6-month follow-up (p value 0.011), independent of age, sex, frailty, comorbidities, and total medication number.DiscussionThe START/STOPP tool is useful in identifying inappropriate prescribing patterns leading to increased utilization of acute care services in older adults followed at a rural primary care setting.ConclusionInappropriate prescribing as identified by the START/STOPP criteria is prevalent among older adults with multimorbidity in rural primary care, and independently associated with future acute care visits.

Personal Continuity and Appropriate Prescribing in Primary Care.

Personal continuity between patient and physician is a core value of primary care. Although previous studies suggest that personal continuity is associated with fewer potentially inappropriate prescriptions, evidence on continuity and prescribing in primary care is scarce. We aimed to determine the association between personal continuity and potentially inappropriate prescriptions, which encompasses potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs), by family physicians among older patients. We conducted an observational cohort study using routine care data from patients enlisted in 48 Dutch family practices from 2013 to 2018. All 25,854 patients aged 65 years and older having at least 5 contacts with their practice in 6 years were included. We calculated personal continuity using 3 established measures: the usual provider of care measure, the Bice-Boxerman Index, and the Herfindahl Index. We used the Screening Tool of Older Person's Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) specific to the Netherlands version 2 criteria to calculate the prevalence of potentially inappropriate prescriptions. To assess associations, we conducted multilevel negative binomial regression analyses, with and without adjustment for number of chronic conditions, age, and sex. The patients' mean (SD) values for the usual provider of care measure, the Bice-Boxerman Continuity of Care Index, and the Herfindahl Index were 0.70 (0.19), 0.55 (0.24), and 0.59 (0.22), respectively. In our population, 72.2% and 74.3% of patients had at least 1 PIM and PPO, respectively; 30.9% and 34.2% had at least 3 PIMs and PPOs, respectively. All 3 measures of personal continuity were positively and significantly associated with fewer potentially inappropriate prescriptions. A higher level of personal continuity is associated with more appropriate prescribing. Increasing personal continuity may improve the quality of prescriptions and reduce harmful consequences.

Potentially inappropriate medications and potential prescribing omissions in hospitalised older adults in New Zealand: A retrospective study.

Medication errors can have detrimental effects on patient outcomes, yet there are limited data on the prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) among older adult inpatients in New Zealand (NZ). This study investigated exposure to PIMs and PPOs in older adults in a New Zealand hospital. Electronic medical records of 846 older adults (≥ 65 years) discharged from the Auckland District Health Board between June 2020 and May 2021 were retrospectively reviewed to extract data on sociodemographic, medication and diagnostic information. STOPP/START version 2 was used to evaluate PIMs and PPOs on admission and discharge. The mean age was 77.47 ± 8.12 years, and 51% were female. On admission, 48% had ≥1 PIMs and 40% had ≥1 PPOs. On discharge, 45% had ≥1 PIMs and 40% had ≥1 PPOs. Increasing age (adjusted odds ratio [AOR] = 1.02, 95% CI [confidence interval] 1.01, 1.04), number of medicines (AOR = 1.23, CI 1.17, 1.29) and 28-day admission history (AOR = 1.58, CI 1.15, 2.18) were associated with higher odds of PIMs use on admission. At discharge, the number of medicines (AOR = 1.19, CI 1.13, 1.25) and history of readmission (AOR = 1.47, CI 1.08, 2.02) were associated with higher odds of PIMs. Female patients had higher odds of PPOs both on admission (AOR = 1.35, CI 1.02, 1.78) and discharge (AOR = 1.34, CI 1.01, 1.78). Māori, Asian and Pacific patients were more likely to have prescribing omissions compared to NZ Europeans. Prescribing omissions and inappropriate medications were common in older inpatients. There were differences observed between different ethnic groups, with NZ Europeans having fewer omissions than other ethnic groups. These findings highlight key opportunities for health-care providers to improve medication use in older adults in NZ.

Implementation and evaluation of STOPP/START criteria to address polypharmacy in older adults in an inpatient psychiatric setting

BackgroundThere is a scarcity of research in applying the Screening Tool of Older Person's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria to older adults admitted to a psychiatric hospital. ObjectivesThe primary aim of this study was to determine the extent of polypharmacy in older adults admitted to a psychiatric hospital and to assess the number of STOPP/START triggers detected and recommended by pharmacists. Secondary objectives include evaluating if the STOPP/START criteria is a useful tool to improve prescribing in this setting by assessing the implementation rates of STOPP/START triggers. MethodsThis was a prospective, longitudinal study in a psychiatry inpatient setting. Data were collected over a 7-week period. Explicit informed consent was obtained from participants. Medication reconciliation was completed and participants' medications were reviewed using STOPP/START criteria. The number of STOPP/START triggers detected, recommended and implemented was recorded. ResultsSixty-two patients were included in the study. Ninety-four percent were prescribed ≥5 medications and 55% were prescribed ≥10 medications on admission. The mean number of medications prescribed per patient increased from 10 on admission to 12 at follow-up. Of 174 Potential Inappropriate Medications (PIMs) detected, 41% were recommended for review and, of these only 31% were implemented. 27% of the 77 Potential Prescribing Omissions (PPOs) detected were recommended for review and only 23% of those were implemented. ConclusionSTOPP/START did not reduce the prevalence of polypharmacy in this setting. The implementation rates observed in this study were much lower than those observed in non-psychiatric settings.

Detecting Medication Risks among People in Need of Care: Performance of Six Instruments.

Numerous tools exist to detect potentially inappropriate medication (PIM) and potential prescribing omissions (PPO) in older people, but it remains unclear which tools may be most relevant in which setting. This cross sectional study compares six validated tools in terms of PIM and PPO detection. We examined the PIM/PPO prevalence for all tools combined and the sensitivity of each tool. The pairwise agreement between tools was determined using Cohen's Kappa. We included 226 patients in need of care (median (IQR age 84 (80-89)). The overall PIM prevalence was 91.6 (95% CI, 87.2-94.9)% and the overall PPO prevalence was 63.7 (57.1-69.9%)%. The detected PIM prevalence ranged from 76.5%, for FORTA-C/D, to 6.6% for anticholinergic drugs (German-ACB). The PPO prevalences for START (63.7%) and FORTA-A (62.8%) were similar. The pairwise agreement between tools was poor to moderate. The sensitivity of PIM detection was highest for FORTA-C/D (55.1%), and increased to 79.2% when distinct items from STOPP were added. Using a single screening tool may not have sufficient sensitivity to detect PIMs and PPOs. Further research is required to optimize the composition of PIM and PPO tools in different settings.

Evaluating Potentially Inappropriate Medications in the Elderly with Seven Different Screening Tools

Introduction: We aimed to determine the rates of potentially inappropriate medications using various screening tools and also the affecting factors in elderly patients. Materials and Method: In this prospective cross-sectional study, we recorded in detail the concomitant chronic diseases, geriatric syndromes, and drugs used in elderly patients admitted to a university hospital and then assessed potentially inappropriate medications using seven different screening tools. Results: The study included 315 patients (190 female; 125 male). We evaluated potentially inappropriate medication use with the PRISCUS, EU(7), Beers 2019, STOPP v2, and TIME-to-STOP criteria and evaluated potential prescription omissions with the START v2 and TIME-to-START criteria; the resulting identified rates of PIMs were 15.9%, 45.1%, 48.9%, 44.8%, 48.3%, 73.9%, and 97.5%, respectively. The lowest value was found with PRISCUS, as it uses fewer criteria than the others. The EU(7), Beers 2019, STOPP v2, and TIME-to-STOP results were similar to one another. START v2 and TIME-to-START yielded higher outcomes than the others due to the omission of vaccines in patients. The highest outcome was found with TIME-to-START due to the omission of the herpes zoster vaccine (97.5%), which appears only in that screening tool. Potentially inappropriate medication rates increased with the number of drugs used and with the number of concomitant chronic diseases. Conclusion: This study detected potentially inappropriate medication use in approximately half of the patients with the EU(7), Beers 2019, STOPP v2, and TIME-to-STOP screening tools. There was a positive correlation between potentially inappropriate medications and polypharmacy and increased disease burden. Keywords: Potentially Inappropriate Medication List; Polypharmacy; Aged.

Prescribing Practices in Geriatric Patients with Cardiovascular Diseases.

Inappropriate prescribing (IP) increases the risk of adverse medication reactions and hospitalizations in elderly patients. Therefore, it is crucial to evaluate prescribing patterns among this population. This study was designed to assess the prevalence of potentially inappropriate medication (PIMs) use and potential prescribing omissions (PPOs) among geriatrics with cardiovascular diseases (CVDs). In addition, it determined the predictors for IP in this population. A multi-center study was performed retrospectively on 605 patients' medical records collected randomly from seven governmental hospitals in Kuwait. Three of these hospitals have specialized cardiac centers (tertiary care). Inclusion criteria were age ≥ 65 years, diagnosed with at least one CVD, and attended the outpatient clinic during the last 6 months before data collection. A total of 383 patients (63.3%; 95% CI: 59.3-67.1%) were found using at least one PIM or having PPO or both, based on STOPP/START criteria. Three hundred and ninety-one patients (64.6%; 95% CI: 60.7-68.4%) were prescribed PIMs categorized as C and/or D medicines according to the Euro-FORTA list. Over one-quarter (28.8%; 95% CI: 25.2-32.6%) of the patients had drug-drug interactions class D that require therapy modification and/or X that should be avoided. Patients taking ≥ five medications had significantly higher PIMs based on STOPP and FORTA criteria, drug-drug interactions (p &lt; 0.001), and significantly higher PPOs based on START criteria (p = 0.041). Patients with three or more chronic diseases had significantly higher PIMs based on STOPP and FORTA criteria and PPOs based on START criteria (p-values: 0.028, 0.035, and 0.005, respectively). Significantly higher PIMs based on STOPP criteria and PPOs based on START criteria were found in general hospitals compared to specialized cardiac centers (p= 0.002, p= 0.01, respectively). These findings highlight the need to develop and implement multifaceted interventions to prevent or minimize inappropriate prescribing among the geriatric population with CVDs in Kuwait.

Evaluation of potentially inappropriate medication in older patients with cardiovascular diseases-STOPP/START-based study.

This study aims to evaluate the use of STOPP/START criteria in the identification of Potentially inappropriate medication and potential prescribing omissions in older patients with cardiovascular diseases in Bulgaria. Excessive morbidity and mortality has been linked to drug-related problems and increased use of healthcare services and is an understudied problem for Bulgaria. A prospective, questionnaire-based study was conducted among 543 older patients across 25 pharmacies in Bulgaria. Socio-demographic characteristic, disease profile, symptoms, and medication data were collected. The questionnaire was developed for the purposes of the EUROAGEISM project. Out of all 543 patients, only those with documented cardio-vascular diseases were extracted and the medication profile per patient was evaluated for Potentially inappropriate medication (PIMs) and potentially prescribing omissions (PPOs) using STOPP/START criteria version 2. In addition, several risks for potentially inappropriate prescribing (PIPs), PPOs and PIMs were calculated with the focus being on the Odds and Risks to develop a PIP. Four hundred and twenty eight from 531 patients with known therapy for cardiovascular diseases (CVDs) were included in the analysis of PIP (40.52% aged 65-69 years, 61.88% female, 64% had up to 6 comorbidities, and 21.72% presenting with polypharmacy). A total of 71 PIMs in 64 patients with polypharmacy were identified during applying STOPP criteria. 56% of patients taking above five medicines daily had PIMs. The majority of PIMs (31%) were related to CVDs treatment, followed by PIMs in the treatment of endocrine diseases (22.54%), duplication of medicines (8.46%) and prolonged treatment with benzodiazepines (8.46%). Forty four PPOs were identified with START criteria. 22.72% were related to lack of proton pump inhibitors (PPI) in the presence of gastroesophageal disorders, and the same percentage was for lack of Calcium-vitamin D supplementation in osteoporosis. Applying the methodology of risks calculation the sample risk for PPO was 2.1% and for PIM 3.4%. At sample level the relative risk for PPO was 62% out of the risk for PIM and at population level varied between 42.8 and 89.8% and it is statistically significant. The number needed to treat for the event to happen is 77.5, meaning that at every 78 prescriptions there is a chance to appear PIP. Application of methodologies for detection of potentially inappropriate prescribing is not part of routine clinical practice in Bulgaria. Our study demonstrates a high percentage of potentially inappropriate medication among older patients with polypharmacy. Along with the aging population in Bulgaria, economic burden of polypharmacy and the prevalence of cardiovascular diseases, it is especially important to address potentially inappropriate medication use in cardiovascular patients. There is a considerable necessity for implementation of measures for early detection of potentially inappropriate medication and potentially prescribing omission as a part of de-prescribing strategies in older patients.

284 DO MEDICATIONS GET OPTIMISED DURING AN ACUTE ADMISSION TO HOSPITAL?

Abstract Background Potentially Inappropriate Prescriptions (PIPs) and Potential Prescribing Omissions (PPOs) are common in hospitalised older adults and associated with poor outcomes. The aim of this study was to assess whether PIPs and PPOs are reduced during an acute hospital admission. Methods All inpatients on 5 gerontological wards (1 acute, 1 subacute, 2 rehabilitation, 1 long-stay) on October 31st 2021 were eligible for inclusion. Medical records were retrospectively reviewed. Medication appropriateness was assessed by two assessors at admission and discharge using STOPP/START version 2. Records were consecutively reviewed according to discharge date. Ethical approval was received from the local research and innovation office (ref6275) Results Of 144 eligible patients, 41 were included; mean age 82.1 (SD6.8) years; 48.8% female, 95.1% under the care of geriatricians. The median length of stay was 24 (IQR10-67.5) days. Mean number of conditions was 5.6 (SD2.9) with dementia present in 22.5%. The mean number of medications increased during admission from 7.2 (SD3.2) to 9 (SD3.1); p=0.006 The number of patients prescribed at least 1 STOPP-PIP reduced by 20.6%; 82.9% (admission) vs 65.9% (discharge), p&amp;lt;0.001. The most common PIPs at were (i) drugs without a clear indication, 34.1% (admission) vs 14.6% (discharge), (ii) high dose proton pump inhibitors, 34.1% (admission) vs 34.1% (discharge) and (iii) Z-drugs in fallers; 17.1% (admission) vs 12.2% (discharge). Of 41 patients, 35 could have START criteria applied. START PPOs were reduced by 53%; 47.2% (admission) vs 22.2% (discharge), p=0.001. The largest improvement was seen in bone absorptive therapy (11.4% (admission) vs 2.9% (discharge) and vitamin d in those experiencing falls/osteopenia; 5.57% (admission) vs 2.9% (discharge). Of the 134 STOPP/START criteria listed, 36 (19.4%) were identified in this cohort. Conclusion Although the average number of medications increased, PIPs reduced significantly. Only 19.4% of STOPP/START criteria were identified, suggesting that focusing on a number of key PIPs going forward could improve prescribing practices.

237 POTENTIALLY INAPPROPRIATE PRESCRIBING IN HOSPITALISED FRAIL OLDER ADULTS: DEVELOPMENT OF THE OPTI-3S PRELIMINARY STATEMENTS

Abstract Background Few assessment criteria exist for Potentially Inappropriate Medications (PIMs) in the hospital setting. This study aims to develop the preliminary statements of OPTI-3S, criteria for optimising medicines by stopping, stepping down or switching to safer alternatives. These are designed to be of value to clinical practitioners in the routine care of hospitalised, frail older adults. Methods A systematic literature review was conducted in the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, CINAHL, EMBASE and Scopus (2010-2021). Search terms included the concepts of inappropriate prescribing, deprescribing and the target population (e.g. older, frail, hospitalized). This was supplemented with a PubMed focused search (2010-2021) using key words pertaining to the index diseases/conditions or inappropriate medications. The structured reviews included clinical based guidelines, PIMs lists, systematic/non-systematic reviews, or clinical/observational trials that assessed safe and/or effective use of medications in older adults. The preliminary statements were then drafted based on the available relevant evidence. Results Searches yielded ~1500 articles. These were included in structured reviews, yielding a total of 109 initial statements across seven physiological systems, and one patient-centred point of care (perioperative care). In addition to detailed PIMs statements (n=98), 11 statements address clinically important Potential Prescribing Omissions (PPOs) (e.g. anticoagulant underdosing) and altered blood pressure and glycaemic targets. Uniquely for criteria of this kind, 23 statements suggest PIMs be considered based on the different frailty levels, according to the Clinical Frailty Scale. 11/98 PIMs statements concern prescribing cascades and suggest tapering regimens for six inappropriate medication classes (e.g. antipsychotics, benzodiazepines). Several statements address medication appropriateness in other frailty related circumstances (e.g. non-compliance, overlapping co-morbidities, feeding tube incompatibility, pill burden/ polypharmacy). Conclusion Literature provides a large body of evidence to support prescribing optimization. This has been distilled into consensus-based statements, which should guide hospital-based health care professionals caring for frail older adults.

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

Potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion-based processes. To evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients. This diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022. The PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study. Area under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit. A total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list. In this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

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

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. 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. 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. When the STOPP/START criteria are applied in PIM/PPO research, reliability seems to be an issue not encountered in previous reliability studies.