Potentially Inappropriate Prescribing Research Articles

De-imFAR phase II project: a study protocol for a cluster randomised implementation trial to evaluate the effectiveness of de-implementation strategies to reduce low-value statin prescribing in the primary prevention of cardiovascular disease

IntroductionThis study aims to reduce potentially inappropriate prescribing (PIP) of statins and foster healthy lifestyle promotion in cardiovascular disease (CVD) primary prevention in low-risk patients. To this end, we will...

Potentially inappropriate prescribing for people with dementia in ambulatory care: a cross-sectional observational study

BackgroundStudies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting.MethodsA cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27.ResultsA total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0–64.5).ConclusionsFindings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders’ experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.

One Hundred Explicit Definitions of Potentially Inappropriate Prescriptions of Antibiotics in Hospitalized Older Patients: The Results of an Expert Consensus Study.

In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use. To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients. We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round. Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2). The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.

Clinical decision support system supported interventions in hospitalized older patients: a matter of natural course and adequate timing

BackgroundDrug-related problems (DRPs) and potentially inappropriate prescribing (PIP) are associated with adverse patient and health care outcomes. In the setting of hospitalized older patients, Clinical Decision Support Systems (CDSSs) could reduce PIP and therefore improve clinical outcomes. However, prior research showed a low proportion of adherence to CDSS recommendations by clinicians with possible explanatory factors such as little clinical relevance and alert fatigue.ObjectiveTo investigate the use of a CDSS in a real-life setting of hospitalized older patients. We aim to (I) report the natural course and interventions based on the top 20 rule alerts (the 20 most frequently generated alerts per clinical rule) of generated red CDSS alerts (those requiring action) over time from day 1 to 7 of hospitalization; and (II) to explore whether an optimal timing can be defined (in terms of day per rule).MethodsAll hospitalized patients aged ≥ 60 years, admitted to Zuyderland Medical Centre (the Netherlands) were included. The evaluation of the CDSS was investigated using a database used for standard care. Our CDSS was run daily and was evaluated on day 1 to 7 of hospitalization. We collected demographic and clinical data, and moreover the total number of CDSS alerts; the total number of top 20 rule alerts; those that resulted in an action by the pharmacist and the course of outcome of the alerts on days 1 to 7 of hospitalization.ResultsIn total 3574 unique hospitalized patients, mean age 76.7 (SD 8.3) years and 53% female, were included. From these patients, in total 8073 alerts were generated; with the top 20 of rule alerts we covered roughly 90% of the total. For most rules in the top 20 the highest percentage of resolved alerts lies somewhere between day 4 and 5 of hospitalization, after which there is equalization or a decrease. Although for some rules, there is a gradual increase in resolved alerts until day 7. The level of resolved rule alerts varied between the different clinical rules; varying from > 50–70% (potassium levels, anticoagulation, renal function) to less than 25%.ConclusionThis study reports the course of the 20 most frequently generated alerts of a CDSS in a setting of hospitalized older patients. We have shown that for most rules, irrespective of an intervention by the pharmacist, the highest percentage of resolved rules is between day 4 and 5 of hospitalization. The difference in level of resolved alerts between the different rules, could point to more or less clinical relevance and advocates further research to explore ways of optimizing CDSSs by adjustment in timing and number of alerts to prevent alert fatigue.

Prevalence of potentially inappropriate medications among newly treated patients with type 2 diabetes in UK primary care.

The aim of this study was to estimate the prevalence of potentially inappropriate prescriptions (PIPs) in patients starting their first noninsulin antidiabetic treatment (NIAD) using two explicit process measures of the appropriateness of prescribing in UK primary care, stratified by age and polypharmacy status. A descriptive cohort study between 2016 and 2019 was conducted to assess PIPs in patients aged ≥45 years at the start of their first NIAD, stratified by age and polypharmacy status. The American Geriatrics Society Beers criteria 2015 was used for older (≥65 years) patients and the Prescribing Optimally in Middle-age People's Treatments criteria was used for middle-aged (45-64 years) patients. Prevalence of overall PIPs and individual PIPs criteria was reported using the IQVIA Medical Research Data incorporating THIN, a Cegedim Database of anonymized electronic health records in the UK. Among 28 604 patients initiating NIADs, 18 494 (64.7%) received polypharmacy. In older and middle-aged patients with polypharmacy, 39.6% and 22.7%, respectively, received ≥1 PIP. At the individual PIP level, long-term proton pump inhibitors (PPI) use was the most frequent PIP among older adults, and strong opioid without laxatives was the most frequent PIP in middle-aged patients with polypharmacy (11.1% and 4.1%, respectively). This study revealed that patients starting NIAD treatment receiving polypharmacy have the potential for pharmacotherapy optimization.

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.

Identification of Barriers for Active Disease Management and of Medication-Related Problems through Therapeutic Patient Education in Older Home-Care Patients.

Combining therapeutic patient education (TPE) with a medication review service could foster the adoption of appropriate lifestyles by patients and support care-providers in identifying strategies to improve the quality of prescribed care. This study aimed to identify barriers experienced by patients in managing their diseases and medication-related problems. This was a monocentric, case series, observational study involving home-care patients from the Local Health Authority ASL TO4. Patients were enrolled for a TPE intervention where drug therapies and patient habits were collected through narrative interviews. Medication review was performed to identify potentially inappropriate prescriptions (PIPs). Twenty patients (13 females) with a mean age of 74.7 years were enrolled. Patients had an average of 4.3 diseases and 80.0% of them were treated with ≥5 daily medications. The main PIPs involved ibuprofen, furosemide and pantoprazole. The qualitative analysis of the interviews identified seven macro-themes relating to different aspects of medication management: therapy; diseases; patient; patient journey; professionals; family and caregivers; drug information. The results of this study revealed some critical aspects related to the treatment path and healthcare professionals. These results will be used to plan educational interventions for polypharmacy patients to improve medication adherence and the understanding and management of diseases.

Potentially inappropriate prescriptions of antibiotics in geriatric psychiatry-a retrospective cohort study.

Older patients are frequently affected by infectious diseases and adverse drug reactions (ADRs) of consecutively prescribed antibiotics. Particularly within geriatric psychiatry, high rates of potentially inappropriate prescriptions (PIPs) have been described, significantly complicating pharmacological treatment. Therefore, this study aimed to investigate the frequency and characteristics of antibiotic PIPs in geriatric psychiatry. Medication charts of 139 patient cases (mean age 78.8 years; 69.8% female) receiving antibiotic treatment on a geriatric psychiatric ward were analyzed. Utilizing previously published definitions of antibiotic PIPs, adequacy of the antibiotic prescriptions was subsequently assessed. 16.3% of all screened patient cases (139/851) received an antibiotic treatment during their inpatient stay. 59.5% of antibiotic prescriptions were due to urinary tract infections, followed by pulmonary (13.3%) and skin and soft tissue infections (11.3%). 46.7% of all antibiotic prescriptions fulfilled at least one PIP criterium, with the prescription of an antibiotic course for more than seven days as the most common PIP (15.3%). Antibiotic PIPs can be considered as a frequent phenomenon in geriatric psychiatry. Especially the use of fluoroquinolones and cephalosporins should be discussed critically due to their extensive side effect profiles. Due to the special characteristics of geriatric psychiatric patients, international guidelines on the use of antibiotics should consider frailty and psychotropic polypharmacy of this patient population more closely.

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.

Analysis of Potentially Inappropriate Prescriptions (PIP) Based on STOPP/START Criteria in Geriatric Patients with Cardiovascular Disorders at Hasan Sadikin Hospital, Bandung, West Java, Indonesia

The geriatric population in Indonesia is increasing rapidly every year. The large number of drugs consumed by geriatric patients results in potentially inappropriate prescriptions (PIP) in the form of mis-prescribing drugs (potentially inappropriate medicines or PIM) and under-prescribing drugs (potentially prescription omission or PPO). In Indonesia, especially in Bandung, there is limited research on PIP in geriatric patients with cardiovascular disorders (CVDs). This study aims to identify PIP and factors that influence PIM and PPO based on STOPP/START criteria and the relationship between the incidence of PIM and kidney function in geriatric inpatients with CVDs at Hasan Sadikin Hospital, Bandung, West Java, Indonesia. The present retrospective study was cross-sectionally conducted from January to December 2022. The Chi-square tests were carried out to determine factors that were significantly related to PIM and PPO. Of the 192 patients, 33.4% patients experienced PIM with the most being NSAIDs with eGFR <30 mL/min/1.73 m2 (36%). As many as 35% of patients experienced PPO with the most frequent PPO not being given angiotensin-converting enzyme inhibitor (ACEi) in patients with systolic heart failure (41.8%). Factors that were significantly associated with PIM were comorbid kidney dysfunctions (OR 5; 95% CI: 2.367-10.342), and no factors were found that were significantly associated with PPO. Taking everything into consideration, it was found that PIM and PPO were common in hospitalized geriatric patients with CVDs. Kidney dysfunctions are a risk factor for PIM. These findings suggest that it is important to evaluate prescribing for geriatric patients during hospitalization using STOPP/START criteria to reduce the prevalence of PIP

Multidisciplinary care of older adults in the emergency department to influence deprescribing in older adults: a cohort study

AbstractBackgroundInappropriate polypharmacy in older adults is a major health problem associated with poor clinical and health service outcomes.AimWe aimed to evaluate the effectiveness of a geriatric pharmacist service in the emergency department (ED) identifying potentially inappropriate prescribing (PIP).MethodBetween 1 June 2018–31 May 2019, adults ≥70 years of age presenting to ED were reviewed by the Geriatric Emergency Department Intervention (GEDI) pharmacist. The intervention consisted of pharmacist‐led medication review using Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, patient education on recommendations, an updated medication list, and a letter sent to their general practitioner (GP) electronically. For eligible consenting older adults, telephone calls were made at least 28 days post‐discharge to assess the effectiveness of the intervention. A survey with GPs after 6 months determined how recommendations were perceived. Ethics approval was granted by the Metro North Health B Human Research Ethics Committee (reference no: HREC/18QCH/69–1245) and research governance approval was granted by the study site (Cairns Hinterland Hospital and Health Service, reference no: SSA/Q12345/40673). Informed consent was obtained from all participants via a project information sheet and either the completion of a written consent form (patient participants), verbal consent before interview (GP participants), or implied consent via email responses (GP participants). Routinely collected health data obtained for this study were de‐identified and data included in the follow‐up study was de‐identified.ResultsThe GEDI pharmacist reviewed 1214 older adults with an average age of 81 years. The median number of prescribed medications was 10 and 36.8% of older adults had STOPP recommendations. When contacted (n = 35), of those enrolled in the follow‐up study, 71% had stated their medications changed, 40% reported all STOPP medications had ceased, and 69% had START medications commenced, suggesting the recommendations provided were clinically appropriate and readily accepted by their GPs.ConclusionIntegration of a geriatric pharmacist demonstrated ample opportunities to address PIP in targeted older adults presenting to ED. This study shows that the pharmacist was able to promote appropriate prescribing through patient education and recommendations communicated to the GP on discharge.

Primary care pharmacist-led medication review in older adult patients in coordination with general practitioners: an observational retrospective cohorts study

BackgroundPolypharmacy and risk of potentially inappropriate prescribing (PIP) in older adult are being continuously increased. Including a primary care pharmacist (PCP) in the healthcare team is associated with lower rates of medication-related problems (MRPs). ObjectivesTo determine the impact (in terms of variation of PIP, MRPs and polymedication) of treatment reviews (TR) carried out by the PCP by comparing two cohorts: standard TR vs coordinated TR with prescribing General Practitioners (GP). To assess possible health outcomes in both groups 6 months post-TR. MethodsThis is an observational study of two retrospective cohorts (2018 to 2020). All patients who met the inclusion/exclusion criteria were analyzed. Patients ≥65 years, who underwent complete TR by the PCP were included. Patients in a situation of exitus at the time of TR and those who underwent a partial TR were excluded. Control group cohort consisted of patients who underwent standard TR, and intervention group cohort consisted of those who underwent TR coordinated with GP. Sociodemographic, clinical and pharmacological variables were analyzed. Results181 patients were enrolled. Mean age 84.4 ± 7.2 years, 78.5% women. Variables (GP-coordinated vs standard TRs) pre-post: decrease in drugs/patient 1.9 (95%CI: 1.4–2.4) vs 0.6 (95%CI: 0.2–1.3), p < 0.05; decrease in MRPs/patient 3.1 (95%CI: 2.8–3.4) vs 1.0 (95%CI: 0.6–1.4), p < 0.05; decrease in PIP/patient 2.0 (95% CI: 1.6–2.2) vs 0.6 (95% CI: 0.2–0.9), p < 0.05. Health outcomes: there was significant difference in average primary-care visits/patient 1.3 ± 0.5 vs 2.2 ± 1.8, p < 0.05. ConclusionsMultidisciplinary interventions between PCP and GP, together with a systematic approach to TR can improve the quality of pharmacotherapy in the elderly. Prospective large follow-up studies are needed to demonstrate a positive trend in health outcomes.

How potentially inapropriate are psychotropic drugs prescribing in acute psychiatric unit for the elderly? Results from a large multicentric audit in France

Adverse drug reactions (ADRs) are a major public health issue, especially when it comes to the elderly. Potentially inappropriate prescribing (PIP) are one of the causes of ADRs in older people. A PIP can be defined as a prescription for which the benefit/risk ratio is unfavourable compared to other therapeutic alternatives. Psychotropic drugs are the second highest risk class for ADRs in the elderly. In order to reduce the prevalence of PIP, prescription assistance tools have been created. An inventory of PIP of psychotropic drugs in older patients hospitalized in psychiatry units was carried out in a French regional setting in 2019. A criteria grid was established based on 2 tools: STOPP/START criteria and Laroche's list adapted to French practice. This grid targeted each class of psychotropic drugs, drugs with a high anticholinergic burden and non-recommended combinations of psychotropic drugs. Three hundred forty-seven patients were included. A high prevalence of PPI was found for each class of psychotropic drugs. The highest prevalence of PPI was found among benzodiazepines (90.3%): long-term prescription, long half-life drugs, respiratory insufficiency or cognitive impairment condition. 56.5% of the subjects had a not-recommended combination of psychotropic drugs (prescription of drugs of the same pharmacotherapeutic class), 26% had a PIP of antipsychotics: prescription for insomnia, use of phenothiazine, 11.8% of drugs with anticholinergic properties and 7.4% of antidepressants: especially prescription of tricyclic drugs. These results obtained on a large population underline the interest of considering the specificities of prescriptions in the elderly. It shows both the interest and the limits of the current criteria defining the PIP in the context of a hospitalization in psychiatry for an acute disorder in elderly subjects.

The Prevalence of Potentially Inappropriate Prescribing in Two Family Health Units in Portugal.

Polypharmacy and potentially inappropriate prescribing (PIP) are growing concerns in the ageing population. They carry the risk of increasing adverse effects, medical interactions, and difficulties managing the medication. Few studies in Portugal evaluate the prevalence of polypharmacy and PIP in primary care. No previous studies in the primary care setting in Portugal have been conducted using the European Union (EU)(7)-PIM (potentially inappropriate medication) list tool. In this study, we aimed to estimate the prevalence of polypharmacy and PIP in two family health units in Portugal. Methods: To answer this question, we enrolled a sample of 361 elderly patients from two family health units in a descriptive observational transversal study. We randomly selected patients, consulted their prescription records in the previous 12 months, and applied the EU(7)-PIM list tool, validated for the Portuguese population. The data was then analyzed using descriptive and inferential statistics and the StatisticalPackage for the Social Sciences (IBMSPSSStatisticsforWindows,IBMCorp., Version 24.0, Armonk,NY). Our results showed a prevalence of 79.8% of polypharmacy in the elderly population and 73.4% of PIP. These values are higher than predicted in the literature, but different screening tools have been used among papers. The mean number of prescribed drugs per patient was nine in one unit and seven in the other, and the mode was eleven per patient. The most identified PIP-associated drugs were proton pump inhibitors in 46.4% of the patients in one unit and 43.7% in the other. We also found a statistically significant higher prevalence of PIP and polypharmacy in females and patients over 75 years. From a prevalence perspective, we found higher-than-expected prevalences of PIP and polypharmacy in our population. Contributing factors might be a higher ageing index in the Portuguese population, modern practices using combination therapy, and the use of a screening tool that does not take into account the personal clinical history of patients. Further limitations involve only including patients with follow-up in the units studied. Even so, it suggests both PIP and polypharmacy asconcerns to address, and we will strive to educate both health teams on PIP, polypharmacy, and deprescribing. We also emphasize the need to widen the study to other family health units.

Potentially inappropriate prescribing in multimorbid and polymedicated older adults with AF: A Systematic Review and Meta-Analysis.

Polypharmacy in multimorbid older patients with atrial fibrillation (AF) is a risk factor for potentially inappropriate prescribing (PIP). We aimed to systematically assess the evidence on the prevalence of PIP and its impact on adverse health outcomes in this patient group. A systematic search of the published peer-reviewed literature describing the prevalence of PIP and/or its association with adverse health outcomes in multimorbid (AF plus one comorbidity) and polymedicated (≥ 2 drugs) adults ≥ 65 years was done up to March 2023. A meta-analysis of the prevalence of PIP of (direct) oral anticoagulants ((D)OACs) was conducted using a random-effects model. Leave-one-out analysis was performed with R (version 4.2.2) and RStudio (version 2022.12.0+353). Of the 12 studies included, only one reported on the prevalence of overall PIP (65%). The meta-analysis of 10 studies assessing PIP of (D)OACs produced a pooled prevalence [95% confidence interval (CI)] of 35% [30-40%], with significant heterogeneity between the included studies (I2 95%). No statistically significant association was reported in three studies between PIP of (D)OACs, cardiovascular (CV) and all-cause mortality, hospital readmission, CV hospitalisation and stroke. Reported associations between PIP and major bleeding differed, with one study demonstrating a significant association (odds ratio 2.17; 95% CI 1.14-4.12) and the other study not showing such association. This systematic review highlights the scarce evidence regarding the prevalence of PIP and its association with adverse health outcomes in multimorbid older adults with AF. Large, prospective and better-designed studies are needed.

Impacto de la Intervención Farmacéutica en el tratamiento del paciente mayor pluripatológico

Objectiveto analyze the impact of Pharmacy Intervention (PI), within the healthcare team who manages elderly multi-pathological patients, regarding the evolution of Drug Related Problems (DRPs) and Negative Outcomes Associated with Medication (NOMs). To estimate the prevalence of DRPs, NOMs, and Potentially Inappropriate Prescriptions (PIPs), and the drugs involved, considering the characteristics of their healthcare location. Methodmulticenter, prospective study, on > 65-year-old patients with multiple pathologies, either institutionalized or hospitalized. The Pharmacist reviewed the chronic medication of the patient in order to detect DRPs and NOMs, and issued recommendations to the physician responsible for the patient, and this intervention was subsequently evaluated. DRPs and NOMs were classified according to the Third Consensus of Granada. The STOPP/START Criteria were used for PIP detection. The primary variables were: number of PIs conducted and accepted by the physician. Outcomes338 patients were included, and 326 (96.4%) presented some DRP. 1089 DRPs were detected, with 983 PIs suggested for their solution, and 651 (69.9%) of these were accepted. PIs solved 58.9% of DRPs, and an association was found between PI and the solution for the DRP (p < 0.001). PIs were more accepted in institutionalized than in hospitalized patients (p = 0.002), by physicians with a higher specialization (p < 0.001) and when they involved quantitative safety NOMs (p = 0.042). The STOPP/START Criteria detected 65% of PIPs, and more PIPs not associated with these criteria were found in institutionalized than in hospitalized patients (p < 0.001). Conclusionspharmacy Intervention within the multidisciplinary team can solve in a significant way both DRPs and NOMs in elderly multi-pathological patients, and thus help to improve the quality of their pharmacological therapy. This is the first multicenter clinical trial with these characteristics that has been conducted in Spain.

The impact of team-based primary care on medication-related outcomes in older adults: A comparative analysis of two Canadian provinces

ObjectiveTo evaluate if access to team-based primary care is related to medication management outcomes for older adults. MethodsWe completed two retrospective cohort studies using administrative health data for older adults (66+) in Ontario (n = 428,852) and Québec (n = 310,198) who were rostered with a family physician (FP) between the 2001/02 and 2017/18 fiscal years. We generated matched comparison groups of older adults rostered to an FP practicing in a team-based model, and older adults rostered to an FP in a non-team model. We compared the following outcomes between these groups: any adverse drug reactions (ADRs), any potentially inappropriate prescription (PIP), and polypharmacy. Average treatment effects of access to team-based care were estimated using a difference-in-differences estimator. ResultsThe risk of an ADR was 22 % higher (RR = 1.22, 95 % CI = 1.18, 1.26) for older adults rostered to a team-based FP in Québec and 6 % lower (RR = 0.943, 95 % CI = 0.907, 0.978) in Ontario. However, absolute risk differences were less than 0.5 %. Differences in the risk of polypharmacy were small in Québec (RR = 1.005, 95 % CI = 1.001, 1.009) and Ontario (RR = 1.004, 95 % CI = 1.001, 1.007) and had absolute risk differences of less than 1 % in both provinces. Effects on PIP were not statistically or clinically significant in adjusted models. InterpretationWe did not find evidence that access to team-based primary care in Ontario or Québec meaningfully improved medication management outcomes for older adults.

Investigation Into Potentially Inappropriate Prescribing Patterns of Loop Diuretics in a Nationally Representative Outpatient Population.

Loop diuretic therapy effectively treats edema related to heart failure, chronic kidney disease, and liver impairment; however, evidence supporting other indications is lacking. For indications such as hypertension or dependent edema or treatment of adverse events associated with other medications, the benefits likely do not outweigh the risks, putting patients at an unacceptably high risk of poor outcomes. What is the proportion of loop diuretic prescribing that occurs in the absence of a diagnosis of heart failure, chronic kidney disease, liver impairment, or other evidence-based indications? This was a national, retrospective, cross-sectional investigation conducted using the National Ambulatory Care Survey from 2013 to 2016. Outpatient visits for patients aged 18 years or older prescribed with loop diuretics were included. The primary end point was the frequency of potentially inappropriate loop diuretic prescribing. The secondary end point was a multivariable regression model that identified predictors of potentially inappropriate loop diuretic utilization. This analysis identified 5261 outpatient visits conducted during the study period in which loop diuretics were prescribed. Of these, 3648 visits (65.8% of weighted visits) were of patients without a history of heart failure, chronic kidney disease, or liver impairment. Positive predictors included age older than 65 years (odds ratio [OR] 1.71; 95% confidence interval [CI] 1.38-2.13), concomitant calcium channel blocker (OR 1.42; 95% CI, 1.09-1.84), sodium-containing medication use (OR 2.78; 95% CI, 1.23-6.25), and office visit with a cardiology specialist (OR 2.84; 95% CI, 2.31-3.50). This analysis identified that loop diuretics are prescribed in the absence of evidence-based indications more frequently than they are prescribed for them. This prescribing pattern creates a unique opportunity for clinicians to optimize patient care. Further study of the outcomes associated with this prescribing pattern is warranted.

Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium

ObjectivesThis study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada. DesignPopulation-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument–Minimum Dataset version 2.0 (RAI-MDS 2.0). Setting and ParticipantsLTC residents in Ontario between January 1, 2016, and December 31, 2019. MethodsWe used residents’ first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. ResultsThe study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non–CNS-related PIP criteria. Conclusions and ImplicationsThis population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.

Global Mapping of Potentially Inappropriate Prescribing for Older Adults in Community Settings: An Umbrella Review.

Potentially inappropriate prescribing (PIP) is a major public health concern with several undesirable health consequences for older adults. In this overview, we aimed to map and gather information from existing literature to provide a better insight into the prevalence of PIP among community dwellers. Electronic databases were searched from their inception to April 2022. The quality of the included systematic reviews (SRs) was assessed using the assessment of multiple systematic reviews checklist. The degree of overlap within the SRs was also evaluated (2% overlap). All SRs on the prevalence of PIP in older individuals in community settings were included, and a narrative approach was used to synthesize data. Nineteen SRs comprising 548 primary studies met the inclusion criteria, and the average quality of the included SRs was moderate. More than half (50.5%) of the primary studies were conducted in Europe, followed by the United States (22.8%), and Asia (18.9%). Thirty different criteria were used in the primary studies to estimate the prevalence of PIP. The most widely used criteria were those presented in Beers (41.8%) and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) (21.8%) criteria. Benzodiazepines, nonsteroidal anti-inflammatory drugs, and antidepressants were the most frequently reported PIPs. A considerable variation in the prevalence of PIP ranging from 0% to 98% was reported by SRs. However, there is a high degree of uncertainty regarding the extent of PIP in community settings. To identify knowledge-to-action gaps, SR authors should consider the differences in prevalence of PIP according to settings, applied tools, data sources, geographical areas, and specific pathologies. There is also a need for primary and SR studies from low- and middle-income countries regarding the prevalence of PIP.