Screening Tool To Alert Doctors To The Right Treatment Research Articles

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.

Potential prescribing omissions of medications in older adults based on START version 2 criteria in a tertiary Jordanian teaching hospital

Potential prescribing omission (PPO) represents a failure in prescribing drugs when indicated due to lack of the evidence base. Published data are scarce on the prevalence of prescribing omissions in Jordan. This study aimed to assess the prevalence of prescribing omissions in elderly patients in a Jordanian teaching hospital. Screening Tool to Alert doctors to the Right Treatment (START) version 2 was used to identify the prescribing omissions in older adults admitted to a tertiary hospital in Jordan for 18 months. During the study period, data relating to the patients’ medical problems and prescribed medicines were collected by two clinical pharmacists via reviewing the clinical and prescription records of the included patients. Data were collected using a predefined data collection form and statistical analysis was conducted using Statistical Package of Social Sciences (SPPSS). One or more prescribing omissions were found in 40.5%, 41.0%, and 39.5% of the patients upon admission, during hospitalization, and on discharge, respectively. The most common prescribing omission was about START criterion I1 which was “seasonal trivalent influenza vaccine annually” in 54.8% upon admission, 51.5% during hospitalization, and 51.9% on discharge. Logistic regression found that the higher number of medical conditions was associated with an increased risk of PPO occurrence upon admission, during hospitalization, and on discharge (p value < 0.05). Acts of omission of appropriate medications were highly prevalent among older patients in our hospital setting. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice. Application of validated START criteria can help detect and prevent PPO occurrence among older patients

Prevalence and follow-up of potentially inappropriate medication and potentially omitted medication in older patients with cancer – The PIM POM study

ObjectivesTo determine the prevalence of Potentially Inappropriate Medication (PIMs) and Potentially Omitted Medication (POMs) in older patients with cancer. Materials and MethodsIn this prospective observational study (hospital) pharmacists conducted comprehensive medication reviews in older patients with cancer (aged ≥65 years) receiving parenteral chemotherapy and/or immunotherapy at the Deventer Hospital. PIMs and POMs were identified using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP), the Screening Tool to Alert doctors to the Right Treatment (START), and pharmacists' expert opinion. Recommendations regarding PIMs and POMs were communicated to the patient's oncologist/haematologist and follow-up was measured. Associations between covariates and the prevalence of PIMs and POMs were statistically analysed. ResultsFor the 150 patients included, 180 PIMs and 86 POMs were identified with a prevalence of 78%. Using pharmacists' expert opinion in addition to only STOPP/START criteria contributed to 49% of the PIMs and 23% of the POMs. A follow-up action was required in 73% of the 266 PIMs and POMs. Number of medicines and Charlson Comorbidity Index score were both associated with having at least one PIM and/or POM (p = .031 and p = .016, respectively). ConclusionThe prevalence of PIMs and POMs and subsequent follow-up in older patients with cancer is high. A pharmacist-led comprehensive medication review is a good instrument to identify these PIMs and POMs and to optimize patients' treatment. A complete approach, including pharmacists' expert opinion, is recommended to identify all PIMs and POMs in clinical practice.

1825P - Prevalence and management of potentially inappropriate medication use and potential omissions in medication in older cancer patients: The PIM POM study

BackgroundOlder cancer patients are a vulnerable group of medication users. Pharmacist-led medication reviews may optimize treatment and thereby reduce the risk of harmful effects from medication use. This study aims to determine the prevalence and management of Potentially Inappropriate Medication use (PIM’s) and Potential Omissions in Medication (POM’s) in older cancer patients. MethodsIn this prospective observational study (hospital) pharmacists conducted medication reviews with older cancer patients (aged ≥65 years) treated with parenteral chemo and/or immunotherapy to determine the prevalence of PIM’s and POM’s. PIM’s and POM’s were identified using the Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP), the screening Tool to Alert doctors to the Right Treatment (START) and pharmacists’ expert opinion. Recommendations regarding PIM’s and POM’s were made to the patient’s oncologist/haematologist and follow-up was measured. Associations between covariates and the prevalence of PIM’s and POM’s were statistically analysed. Results117 (78%) of the 150 patients included (median age 72 years, 59% male, 68% solid tumours, mean number of medicines 11) had at least one PIM and/or PIM. In total 266 PIM’s and POM’s were identified, and these led to 195 (73%) follow-up actions (table). The number of medicines and Charlson Comorbidity Index score (as a measure of vulnerability) were both independently associated with having at least one PIM and/or POM (p = .031 and p = .002 respectively).Table1825P Identification and follow-up of PIM’s and POM’sTablePIM’s and POM’sn (%)PIM’s, total Using STOPP180 89 (49)Using expert opinion85 (47)Using both6 (3)POM’s, total Using START86 66 (77)Using expert opinion20 (23)Follow-up actions By oncologist/haematologist266 77 (29)By general practitioner118 (44)No follow-up action71 (27) ConclusionsPIM’s and POM’s are highly prevalent among older cancer patients. A pharmacist-led medication review using STOPP/START criteria and pharmacists’ expert opinion is an excellent way to identify these PIM’s and POM’s and to optimize patients’ medication use. The majority of recommendations made regarding PIM’s and POM’s leads to a follow-up action. Legal entity responsible for the studyDeventer Teaching Hospital. FundingHas not received any funding. DisclosureF.G.A. Jansman: Advisory / Consultancy, 2016: Amgen; Advisory / Consultancy, 2016: Servier. All other authors have declared no conflicts of interest.

Effectiveness of using STOPP/START criteria to identify potentially inappropriate medication in people aged ≥ 65years with chronic kidney disease: a randomized clinical trial.

Polypharmacy and inappropriate prescribing are common in elderly with chronic kidney disease (CKD). This study identified potentially inappropriate prescriptions (PIPs) and potential prescribing omissions (PPOs) using the Screening Tool of Older Persons' Prescriptions (STOPP) and the Screening Tool to Alert doctors to the Right Treatment (START) criteria in elderly with advanced CKD and determined the effect of a medication review on medication adherence and health-related quality of life (HRQoL). The intervention consisted of a medication review using STOPP/START criteria with a recommendation to a nephrologist or similar review without a recommendation. End points were prevalence of PIP and PPO, medication adherence, and HRQoL. Group differences in outcomes were assessed using a generalized linear mixed model. The trial was registered under www.clinicaltrial.gov (ID: NCT02424786). We randomized 180 patients with advanced CKD (mean age 77years, 23% female). The prevalence of PIPs and PPOs in the intervention group was 54% and 50%, respectively. The odds of PPOs were lower in the intervention than the control group (OR 0.42, 95% CI 0.19-0.92, p = 0.032), while there was no intergroup difference in the number of PIPs (OR 0.57, CI 0.27-1.20, p = 0.14). There was no difference in changes in medication adherence or HRQoL from baseline to 6months between the groups. The intervention with the STOPP/START criteria identified a high prevalence of inappropriate medicationsin the elderly with advanced CKD and reduced the number of PPOs. However, there was no detectable impact of the intervention on medication adherence or HRQoL.

Inappropriate medication use in hospitalised oldest old patients across transitions of care.

Oldest old patients aged 85years and over are at risk of experiencing potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) across transitions of care. Geriatricians also face enormous challenges in prescribing medications for these patients. A mixed-methods, sequential explanatory design was undertaken of electronic medical records and semi-structured interviews with geriatricians at a public teaching hospital. Data were collected at four time points using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START). Of 249 patients, the prevalence of at least 1 PIM varied between 36.9 and 51.0%, while the prevalence of at least 1 PPO varied between 36.9 and 44.6%. The most common PIM was use of proton pump inhibitors while the most common PPO was omission of vitamin D supplements in housebound patients or patients experiencing falls. Poisson regression analysis showed that PIMs were significantly associated with use of mobility aids, 1.430 (95% CI 1.109-1.843, p = 0.006), and number of medications prescribed at admission, 1.083 (95% CI 1.058-1.108, p < 0.001). PPOs were significantly associated with comorbidities, 1.172 (95% CI 1.073-1.280, p < 0.001), medications prescribed at admission, 0.989 (95% CI 0.978-0.999, p = 0.035), and length of stay, 1.004 (95% CI 1.002-1.006, p < 0.001). Geriatrician interviews (N = 9) revealed medication-related, health professional-related and patient-related challenges with managing medications. Inappropriate prescribing is common in oldest old patients. Greater attention is needed on actively de-prescribing medications that are not beneficial and commencing medications that would be advantageous. Tailored strategies for improving prescribing practices are needed.

Assessing the overall medication use by elderly people in a Brazilian hospital using the start/stopp criteria version 2

To estimate the frequency of the use of medicines listed in the Screening Tool to Alert Doctors to the Right Treatment (START) and Screening Tool of Older Person’s Prescriptions (STOPP) criteria version 2 among the elderly. A cross-sectional study was conducted on elderly who were attended in medical clinic and cardiology sectors in a hospital in southern Brazil attended at a hospital from February through September 2016. A data-collection tool was used to obtain information on variables, such as demographic and clinical data, and medications used before and during the hospitalization period. The adequacy of the medicines taken was examined with regard to omission (START) or inappropriate use (STOPP). This study was approved by the Research Ethics Committee of the University of Southern Santa Catarina. A total of 307 subjects were included in the final sample. The mean age was 75.2 years (SD = 8; range 65-102). Of the total, 93.5% had had at least one potential prescribing omission (PPO) listed in the START criteria, whereas 95.4% used at least one medicine of the STOPP criteria. PPO was significantly associated with lower mean age (74.9 years, SD = 7.9 versus 79.0 years, SD = 8.8) among the elderly who did not have PPOs detected by the START criteria (p-value=0.03). Furthermore, PPO was associated with longer hospital stay (18 versus 9 days; p-value=0.03). This study revealed inadequate prescription affecting 99.3% of the participating patients. To the best of our knowledge, this was the first to use the START and STOPP criteria, version 2, in Brazil.

Potentially Inappropriate Antihypertensive Prescriptions to Elderly Patients: Results of a Prospective, Observational Study.

Previous studies of antihypertensive treatment of older patients have focused on blood pressure control, cardiovascular risk or adherence, whereas data on inappropriate antihypertensive prescriptions to older patients are scarce. The aim of the study was to assess inappropriate antihypertensive prescriptions to older patients. An observational, prospective multicentric study was conducted to assess potentially inappropriate prescription of antihypertensive drugs, in patients aged 75years and older with arterial hypertension (HTN), in the month prior to hospital admission, using four instruments: Beers, Screening Tool of Older Person's Prescriptions (STOPP), Screening Tool to Alert Doctors to the Right Treatment (START) and Assessing Care of Vulnerable Elders 3 (ACOVE-3). Primary care and hospital electronic records were reviewed for HTN diagnoses, antihypertensive treatment and blood pressure readings. Of 672 patients, 532 (median age 85years, 56% female) had HTN. 21.6% received antihypertensive monotherapy, 4.7% received no hypertensive treatment, and the remainder received a combination of antihypertensive therapies. The most frequently prescribed antihypertensive drugs were diuretics (53.5%), angiotensin-converting enzyme inhibitors (ACEIs) (41%), calcium antagonists (32.2%), angiotensin receptor blockers (29.7%) and beta-blockers (29.7%). Potentially inappropriate prescription was observed in 51.3% of patients (27.8% overprescription and 35% underprescription). The most frequent inappropriately prescribed drugs were calcium antagonists (overprescribed), ACEIs and beta-blockers (underprescribed). ACEI and beta-blocker underprescriptions were independently associated with heart failure admissions [beta-blockers odds ratio (OR) 0.53, 95% confidence interval (CI) 0.39-0.71, p<0.001; ACEIs OR 0.50, 95% CI 0.36-0.70, p<0.001]. Potentially inappropriate prescription was detected in more than half of patients receiving antihypertensive treatment. Underprescription was more frequent than overprescription. ACEIs and beta-blockers were frequently underprescribed and were associated with heart failure admissions.

Impact of hospitalization in an acute geriatric unit on polypharmacy and potentially inappropriate prescriptions: A retrospective study.

Polypharmacy is a highly prevalent geriatric syndrome, and hospitalizations can worsen it. The aim of the present study was to analyze the influence of hospitalization on polypharmacy and indicators of quality of prescribing, and their possible association with health outcomes. A retrospective study of 200 patients discharged from an acute geriatric unit was carried out. Indicators of quality of prescription were registered at admission and discharge: polypharmacy defined as ≥5 medications, hyperpolypharmacy (≥10), potentially inappropriate prescribing by Beers and Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, potentially prescribing omissions by Screening Tool to Alert doctors to the Right Treatment (START) criteria, drug interactions and anticholinergic burden measured with the Anticholinergic Risk Scale. Mortality, emergency room visits and hospital admissions occurring during 6months after discharge were also registered. The total number of drugs increased at discharge (9.1 vs 10.1, P<0.001), without increasing chronic medications (8.5 vs 8.3, P=0.699). No significant variations were observed in the prevalence of polypharmacy (86.5% vs 82.2%), potentially inappropriate prescribing (68.5% vs 71.5%), potential prescribing omissions (58% vs 58%) or drug interactions (82.5% vs 83.5%). Patients with anticholinergic drugs tended to increase, not reaching statistical significance (39.5% vs 44.5%; P=0.064). Polypharmacy was associated with emergency room visits (OR 2.62, 95% CI 1.07-6.40; P=0.034), and hyperpolypharmacy with hospitalizations (OR 2.49, 95% CI 1.25-4.93; P=0.009). After hospitalization in an acute geriatric unit, the prevalence of polypharmacy, potentially inappropriate prescribing, potential prescribing omissions, interactions or anticholinergic drugs is still very high. Polypharmacy is a risk factor for hospitalization and emergency room visits. Measuring indicators of quality of prescription might be useful to design interventions to optimize pharmacotherapy and improve health outcomes in elderly acute patients. Geriatr Gerontol Int 2017; 17: 2354-2361.

Cross-cultural adaptation and content validation of START.

Non-treatment of diseases or clinical conditions has been considered to constitute omission of care in several countries. The aim of the present study was to develop a transcultural adaptation of the Screening Tool to Alert Doctors to the Right Treatment (START) to Brazilian Portuguese and to validate the tool's content. Cultural adaptation and validation of the START criteria using the Delphi consensus technique. START was translated from its original language into Brazilian Portuguese, followed by back-translation and validation by means of the modified Delphi technique. For this, an electronic form was developed and sent to 20 experts, who were asked to use a Likert scale to assess the statements included in START, in relation to their pertinence to Brazilian realities. All of the statements that exhibited mean scores greater than 4.0 were considered to have attained consensus. The experts' identities were kept confidential throughout the validation process. In the first phase of the validation process, 63.6% (14/22) of the statements in START attained consensus. The remaining statements were returned to the experts so that they could have the opportunity to review their comments and statements and to assess them again, based on the Likert scale used earlier. In this phase, 100% of the START instrument attained consensus. The content of START was entirely validated for Brazil, with all of the original criteria maintained.

Risk factors for potentially inappropriate prescribing to older patients in primary care

The aim of this study is to determine modifiable risk factors contributing to potentially inappropriate prescribing in older primary care outpatients (≥65years). Two separate, age- and sex-matched case-control studies were carried out simultaneously at the Primary Health Care Center Kragujevac, Serbia, during the period September 2013-September 2014. The cases were defined as patients with at least one prescription for potentially inappropriate medication (PIM) according to Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) criteria (n = 122), and patients who had at least one potential prescribing omission (PPO) listed in Screening Tool to Alert doctors to the Right Treatment (START) criteria (n = 108), while the control groups consisted of patients without such outcomes (n = 244 and n = 216, respectively). A total of 138 PIM and 161 PPO events were identified using 26 (41.3%) of STOPP criteria and 17 (77.3%) of START indicators, respectively. The unhealthy behaviors including at least two of the following: sedentary lifestyle, improper nutrition, active smoking or heavy alcohol consumption (adjusted OR 2.57, 95% CI 1.28-5.20), use of multiple drugs (five to eight drugs, adjusted OR 3.05, 95% CI 1.59-5.85; ≥9 of drugs adjusted OR 7.17, 95% CI 3.07-16.74) and frequent contacts between patients chosen general practitioners (GPs) and pharmaceutical sales representatives (adjusted OR 2.28, 95% CI 1.10-4.75), were identified as major risk factors for PIM use. Patients who were handled by GPs from smaller practices (adjusted OR 0.51, 95% CI 0.29-0.93), those with more organ systems affected by the extremely severe disorders and those who often visited the outpatient specialist services (adjusted OR 0.88, 95% CI 0.81-0.95), had a significantly reduced risk of PPO. This study suggests that avoidance of major polypharmacy, use of nonpharmacological measures to improve lifestyle habits and decreasing the exposure of physicians to drug promotional material may reduce the risk of PIM use in older primary care outpatients. The only modifiable protective factors for PPOs were working environment of the patients chosen GPs and more frequent ambulatory visits to specialists.

Survey of Potentially Inappropriate Prescription Using STOPP/START Criteria in Inha University Hospital

BackgroundPrescribing potentially harmful drugs and omitting essential drugs to older patients is a common problem because they take so many medications. In this study, our goal was to identify potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) using Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START) criteria to improve proper prescription and reduce improper prescription.MethodsEnrolled in this study were 117 patients older than 65 years old who were hospitalized at Inha University Hospital in Incheon due to pneumonia from January 2012 to March 2012. Patient data, including medical histories, current diagnoses, current medications, and biochemical data were recorded from electronic records. STOPP and START were applied to their clinical datasheets.ResultsSTOPP criteria identified 24 patients who had 29 PIMs. Most potential inappropriate prescribing was of cardiovascular medications, followed by drugs whose primary effect is on the urogenital system and gastrointestinal system. START criteria identified 31 patients who had 46 PPOs. The cardiovascular system drugs comprised most of the PPOs. No PPOs were identified under the central nervous system criteria.ConclusionGiven the current Korean medical system conditions and considering the many clinically important situations when prescribing drugs, STOPP/START criteria are not absolute criteria to prevent improper prescription, but sagacious usage of these standards can help physicians to prescribe properly in clinical practice.

Tools in polypharmacy

Increasing evidence in managing polypharmacy in the growing elderly population with a higher prevalence of multiple chronic disease is the basis for this paper. Poor adherence, drug-drug interactions, drug-disease interactions, and inappropriate medication challenge the prescriptions of health care providers in this group of patients. Risk factors, the prevalence of polypharmacy, and the impact on health issues will be shown by analyzing the recent literature. Based on intervention trials, several tools in polypharmacy have emerged as practical guides for clinical practice or for the geriatric ward to solve this problem. The Medication Appropriateness Index (MAI) and national lists of potentially inappropriate medication used in clinical practice are presented, including Screening Tool to Alert Doctors to the Right Treatment (START), Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP), and Assess, Comprehensive Geriatric Assessment, Adherence, Development, Emergence, Minimization, Interdisciplinarity, Alertness (ACADEMIA).

Prescribing omissions in elderly patients admitted to a stroke unit: descriptive study using START criteria

Underuse of medication considered beneficial is particularly common in elderly patients. A new Screening Tool to Alert Doctors to the Right Treatment (START) has been published to identify potential prescribing omissions. To quantify and characterize potential prescribing omissions of cardiovascular risk management therapy using START criteria. This study was conducted in the Stroke Unit of the university teaching hospital of Cova da Beira Hospital Centre, Covilhã, located in the Eastern Central Region of Portugal. During 6 months, the medical files of all elderly patients (age ≥ 65 years) admitted with acute cardiovascular disease were reviewed and the START criteria applied to the information of medication, at admission and at the time of discharge from the hospital Stroke Unit. Potential prescribing omissions of cardiovascular and endocrine pharmacological therapy were identified and the difference in the potential prescribing omissions between admission and discharge from hospital Stroke Unit was also evaluated. At the time of admission to the Stroke Unit, 101 potential prescribing omissions were found in 68.1 % (n = 91) of elderly (average 1.11 omissions per patient), of which 84.2 % (n = 85) were corrected at the time of discharge. In 14 patients, 16 omissions found at admission were not corrected during hospitalization, and in 5 patients 5 new omissions were detected. Prescribing omissions of beneficial drugs are highly prevalent in acutely ill admitted to a Stroke Unit. START criteria represent a simple, evidence-based and easy-to-use tool to screen underuse of cardiovascular risk management therapy in elderly patients.

SP2-7 Prescribing omissions of cardiovascular risk management therapy in elderly patients admitted to a stroke unity

IntroductionDrug-related problems (DRPs) are common in elderly patients, the majority being preventable. Several criteria have been published to help clinicians identify DRPs due to inappropriate prescribing. However, few studies provide...

START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients

Inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people. A screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidence-based prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission. Using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%). Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.