Frank Moriarty

Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study.

Objectives To examine: (1) changes in polypharmacy in 1997, 2002, 2007 and 2012 and; (2) changes in potentially inappropriate prescribing (PIP) prevalence and the relationship between PIP and polypharmacy in individuals aged ≥65 years over this period in Ireland. Methods This repeated cross-sectional study using pharmacy claims data included all individuals eligible for the General Medical Services scheme in the former Eastern Health Board region of Ireland in 1997, 2002, 2007 and 2012 (range 338 025–539 752 individuals). Outcomes evaluated were prevalence of polypharmacy (being prescribed ≥5 regular medicines) and excessive polypharmacy (≥10 regular medicines) in all individuals and PIP prevalence in those aged ≥65 years determined by 30 criteria from the Screening Tool for Older Persons’ Prescriptions. Results The prevalence of polypharmacy increased from 1997 to 2012, particularly among older individuals (from 17.8% to 60.4% in those aged ≥65 years). The adjusted incident rate ratio for polypharmacy in 2012 compared to 1997 was 4.16 (95% CI 3.23 to 5.36), and for excessive polypharmacy it was 10.53 (8.58 to 12.91). Prevalence of PIP rose from 32.6% in 1997 to 37.3% in 2012. High-dose aspirin and digoxin prescribing decreased over time, but long-term proton pump inhibitors at maximal dose increased substantially (from 0.8% to 23.8%). The odds of having any PIP in 2012 were lower compared to 1997 after controlling for gender and level of polypharmacy, OR 0.39 (95% CI 0.39 to 0.4). Conclusions Accounting for the marked increase in polypharmacy, prescribing quality appears to have improved with a reduction in the odds of having PIP from 1997 to 2012. With growing numbers of people taking multiple regular medicines, strategies to address the related challenges of polypharmacy and PIP are needed.

Potentially Inappropriate Prescribing and Vulnerability and Hospitalization in Older Community-Dwelling Patients

Background: The predictive validity of existing explicit process measures of potentially inappropriate prescribing (PIP) is not established. Objective: To determine the association between PIP, and vulnerability and hospital visits in older community-dwelling patients. Methods: This was a retrospective cohort study of 931 community-dwelling patients aged ≥70 years in 15 general practices in Ireland in 2010. PIP was defined by the Beers 2012 criteria and the Screening Tool of Older Person’s Potentially Inappropriate Prescriptions (STOPP). Vulnerability was measured by the Vulnerable Elders Survey (score ≥3). The number of hospital visits was measured using patients’ medical records and self-report for the previous 6 months. Multilevel logistic and Poisson regression was used to examine the association between PIP, and vulnerability and hospital visits after adjusting for patient and practice level covariates, socioeconomic status, comorbidity, number of drug classes, social support, and adherence. Results: The prevalence of PIP determined by the Beers 2012 and STOPP criteria was 28% (n = 246) and 42% (n = 377), respectively. Patients with ≥2 PIP indicators were almost twice as likely to be classified as vulnerable (Beers adjusted odds ratio [OR] = 1.80; 95% CI = 1.08, 3.01; P < 0.05; STOPP adjusted OR = 1.86; 95% CI = 1.13, 3.04; P < 0.05). Patients with ≥2 STOPP indicators had an increased risk in the expected rate of hospital visits (adjusted incidence rate ratio = 1.32; 95% CI = 1.14, 1.54; P < 0.01). The Beers 2012 criteria were not associated with increased hospital visits. Conclusion: STOPP is a more sensitive measure of PIP than the Beers 2012 criteria and of clinical benefit in primary care settings.

Characterizing Potentially Inappropriate Prescribing of Proton Pump Inhibitors in Older People in Primary Care in Ireland from 1997 to 2012

To characterize prescribing of proton pump inhibitors (PPIs) and medicines that increase gastrointestinal bleeding risk (ulcerogenic) in older people from 1997 to 2012 and assess factors associated with maximal‐dose prescribing in long‐term PPI users.

A narrative review of the safety concerns of deprescribing in older adults and strategies to mitigate potential harms

ABSTRACT Introduction: As with prescribing or continuing medications, deprescribing brings with it the potential for harm as well as benefit. Uncertainty and avoidance of harm has been reported as a barrier to deprescribing in practice and may contribute to continuation of inappropriate medications. Areas covered: This narrative review covers four main safety concerns/potential harms of deprescribing in older adults: adverse drug withdrawal events, return of medical condition(s), reversal of drug-drug interactions and damage to the doctor-patient relationship. These are discussed in relation to medications in general, with some examples of medication classes used to illustrate the potential safety concerns. The majority of these harms can be minimized or even prevented by using a patient-centered, structured deprescribing process with planning, tapering and close monitoring during, and after medication withdrawal. Expert opinion: More research is needed into the safety concerns of deprescribing, however, avenues exist during drug development and post-marketing surveillance to gain knowledge on this topic. Questions remain about when it is suitable to discontinue certain medications/medication classes and there is uncertainty about the harms and benefits of both medication continuation and discontinuation in complex older adults.

PIPc study: development of indicators of potentially inappropriate prescribing in children (PIPc) in primary care using a modified Delphi technique

Objective There is limited evidence regarding the quality of prescribing for children in primary care. Several prescribing criteria (indicators) have been developed to assess the appropriateness of prescribing in older and middle-aged adults but few are relevant to children. The objective of this study was to develop a set of prescribing indicators that can be applied to prescribing or dispensing data sets to determine the prevalence of potentially inappropriate prescribing in children (PIPc) in primary care settings. Design Two-round modified Delphi consensus method. Setting Irish and UK general practice. Participants A project steering group consisting of academic and clinical general practitioners (GPs) and pharmacists was formed to develop a list of indicators from literature review and clinical expertise. 15 experts consisting of GPs, pharmacists and paediatricians from the Republic of Ireland and the UK formed the Delphi panel. Results 47 indicators were reviewed by the project steering group and 16 were presented to the Delphi panel. In the first round of this exercise, consensus was achieved on nine of these indicators. Of the remaining seven indicators, two were removed following review of expert panel comments and discussion of the project steering group. The second round of the Delphi process focused on the remaining five indicators, which were amended based on first round feedback. Three indicators were accepted following the second round of the Delphi process and the remaining two indicators were removed. The final list consisted of 12 indicators categorised by respiratory system (n=6), gastrointestinal system (n=2), neurological system (n=2) and dermatological system (n=2). Conclusions The PIPc indicators are a set of prescribing criteria developed for use in children in primary care in the absence of clinical information. The utility of these criteria will be tested in further studies using prescribing databases.

Fixed-dose combination antihypertensives and risk of medication errors

Objective While fixed-dose combinations (FDC) can improve adherence, they may add complexity to the prescribing/dispensing process, potentially increasing risk of medication errors. This study aimed to determine if prescriptions for antihypertensive FDCs increase the risk of therapeutic duplication and drug–drug interactions (DDI). Methods This retrospective observational study used administrative pharmacy claims data from the Irish Primary Care Reimbursement Service. Prescriptions dispensed to adults in 2015 were included if they contained an antihypertensive FDC, or the same drugs prescribed separately. The outcomes were therapeutic duplication and potentially serious DDI involving FDC drugs. Relative risk (RR) of these outcomes, adjusted for prescription and patient factors, was determined using generalised linear models with Poisson distributions and propensity score matching. Results This study included 307 833 FDC prescriptions (67.0%) and 151 632 separate component prescriptions. Half of patients prescribed FDCs were female with a mean age of 67.1 (SD 12.5) years and, compared with separate component prescriptions, FDCs were less often coprescribed with other cardiovascular medications. Therapeutic duplication occurred in 0.8% of prescriptions, most often involving calcium channel blockers, and 10.6% contained a DDI (most often amlodipine and simvastatin). The RR of therapeutic duplication on FDC prescriptions compared with separate component prescriptions was 1.46 (95% CI 1.17 to 1.83) and the adjusted RR was 2.06 (95% CI 1.64 to 2.60). For DDIs, there was no significant difference between FDC and separate component prescriptions after confounder adjustment. Conclusions This study found FDCs were associated with increased risk of duplication. When considering prescribing FDCs, this safety consideration should be weighed against potential benefits.

Potentially inappropriate prescribing and its association with health outcomes in middle-aged people: a prospective cohort study in Ireland

Objectives To determine the prevalence of potentially inappropriate prescribing (PIP) in a cohort of community-dwelling middle-aged people and assess the relationship between PIP and emergency department (ED) visits, general practitioner (GP) visits and quality of life (QoL). Design Prospective cohort study. Setting The Irish Longitudinal Study on Ageing (TILDA), a nationally representative cohort study of ageing. Participants Individuals aged 45–64 years recruited to TILDA who were eligible for the means-tested General Medical Services scheme and followed up after 2 years. Exposure PIP was determined in the 12 months preceding baseline and follow-up TILDA data collection by applying the PRescribing Optimally in Middle-aged People’s Treatments (PROMPT) criteria to participants’ medication dispensing data. Outcome measures At follow-up, the reported rates of ED and GP visits over 12 months (primary outcome) and the CASP-R12 (Control Autonomy Self-realisation Pleasure) measure of QoL (secondary outcome). Analysis Multivariate negative binomial (rates) and linear regression (CASP-R12) models controlling for potential confounders. Results At 2-year follow-up (n=808), PIP was detected in 42.9% by the PROMPT criteria. An ED visit was reported by 18.7% and 94.4% visited a GP (median 4 visits, IQR 2–6). Exposure to ≥2 PROMPT criteria was associated with higher rates of healthcare utilisation and lower QoL in unadjusted regression. However, in multivariate analysis, the associations between PIP and rates of ED visits (adjusted incidence rate ratio (IRR) 0.92, 95% CI 0.53 to 1.58), and GP visits (IRR 1.06, 95% CI 0.87 to 1.28), and CASP-R12 score (adjusted β coefficient 0.35, 95% CI −0.93 to 1.64) were not statistically significant. Numbers of medicines and comorbidities were associated with higher healthcare utilisation. Conclusions Although PIP was prevalent in this study population, there was no evidence of a relationship with ED and GP visits and QoL. Further research should evaluate whether the PROMPT criteria are related to these and other adverse outcomes in the general middle-aged population.

Deprescribing recommendations: An essential consideration for clinical guideline developers

One area of focus of the Bruyère Evidence-Based Deprescribing Guidelines Symposium held in March 2018 was encouraging the routine inclusion of deprescribing recommendations in clinical guidelines. Clinical guidelines often do not accommodate frailty or patients with multiple comorbid conditions. This can give rise to complex medication regimens and risk of medication harm. Despite monitoring and stopping treatment being a key part of rational prescribing, deprescribing is often overlooked in general and in the context of guidelines. There are several challenges to increasing deprescribing recommendations in clinical guidelines. These include limited evidence on the effects of deprescribing, lack of awareness among guideline developers, potential conflicts of interest, and lack of incentives for deprescribing research. To date, medicines regulators, payers, governments, and journals have not encouraged the inclusion of deprescribing recommendations in guidelines. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system could address some of these challenges through its focus on values and preferences, distinct rating of quality of evidence and strength of recommendations, downgrading quality due to indirect evidence, and an explicit approach to conflicts of interest. Further work to adapt GRADE methods to deprescribing could be of benefit. Establishing deprescribing recommendations as a routine part of clinical guidelines is an important opportunity to improve evidence-based clinical practice, and ultimately, patient care.

Deprescribing guidelines: An international symposium on development, implementation, research and health professional education

Deprescribing is a clinically important and feasible innovation that ensures medication efficacy, reduces harms, and mitigates polypharmacy. It involves reducing doses or stopping medications that are not useful, no longer needed, or which may be causing harm. It may also involve changing to a safer agent or using non-pharmacological approaches for care instead. Clinical guidelines combined with behaviour changes (of health care providers (HCPs), the public, and health care decision-makers) are needed to integrate deprescribing into routine practice. Using rigorous international standards, the Bruyère Research Institute Deprescribing Guidelines research team validated a ground-breaking deprescribing guideline methodology and developed or co-developed 5 evidence-based deprescribing guidelines. In March 2018, the team hosted an international symposium convening HCPs, researchers, public agencies, policymakers, and patient advocates in Ottawa, Ontario, Canada. This 3-day symposium aimed to facilitate knowledge exchange amongst guideline developers, users, and the public; initiate partnerships and collaborations for new deprescribing guideline recommendations and effectiveness research; and to continue work on HCP deprescribing education activities. An interprofessional planning committee developed an overall agenda, and small groups worked on session objectives and formats for different components: methods for rigorous deprescribing guideline development, implementation experiences, research/evaluation experiences and educational needs. Through a series of keynote speakers, panel discussions, and small working groups, the symposium provided a forum for participants to meet one another, learn about their different experiences with deprescribing guidelines, and develop collaborations for future initiatives. One hundred thirty participants, from 10 countries and representing over 100 institutions and organizations took part. Symposium proceedings are presented in this issue of RSAP for sharing with the wider community engaged in the care of patients with problematic polypharmacy.

Deprescribing: Future directions for research

A World Café workshop was held at the Bruyère Evidence-Based Deprescribing Guidelines Symposium in March 2018 with 30 participants (researchers, clinicians, policy makers, stakeholders). This workshop explored priorities for future work in the field of deprescribing and deprescribing guidelines through group discussion. The discussions were guided by the following questions: (1) What are deprescribing research priorities (to inform guideline development), (2) What outcome measures are important for developing deprescribing guidelines, and (3) How do we evaluate the implementation and effectiveness of deprescribing guidelines? Discussion from all 3 questions identified 6 main priority areas: (1) conducting high-quality and long-term clinical trials that measure patient-important outcomes, (2) focusing on patient involvement and perspectives, (3) investigating the pharmacoeconomics of deprescribing interventions, (4) understanding deprescribing interventions in different populations, (5) generating evidence on clinical management during deprescribing (e.g. managing adverse drug withdrawal effects, subsequent re-prescribing), and (6) implementing interventions in clinical practice. These topics represent what a group of experienced researchers, clinicians, and stakeholders in the field collectively felt was important to consider for design and implementation of future deprescribing studies. The aim is for these findings to stimulate future discussions and be considered by granting agencies, policy makers, deprescribing research networks, and individual researchers planning future deprescribing studies.