Marie O'Connor

STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

Abstract Purpose: screening tool of older peoples prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.

Prevention of Potentially Inappropriate Prescribing for Elderly Patients: A Randomized Controlled Trial Using STOPP/START Criteria

Inappropriate prescribing is particularly common in older patients and is associated with adverse drug events (ADEs), hospitalization, and wasteful utilization of resources. We randomized 400 hospitalized patients aged ≥65 years to receive either the usual pharmaceutical care (control) or screening with STOPP/START criteria followed up with recommendations to their attending physicians (intervention). The Medication Appropriateness Index (MAI) and Assessment of Underutilization (AOU) index were used to assess prescribing appropriateness, both at the time of discharge and for 6 months after discharge. Unnecessary polypharmacy, the use of drugs at incorrect doses, and potential drug–drug and drug–disease interactions were significantly lower in the intervention group at discharge (absolute risk reduction 35.7%, number needed to screen to yield improvement in MAI = 2.8 (95% confidence interval 2.2–3.8)). Underutilization of clinically indicated medications was also reduced (absolute risk reduction 21.2%, number needed to screen to yield reduction in AOU = 4.7 (95% confidence interval 3.4–7.5)). Significant improvements in prescribing appropriateness were sustained for 6 months after discharge.

Delirium in an adult acute hospital population: predictors, prevalence and detection

Background To date, delirium prevalence and incidence in acute hospitals has been estimated from pooled findings of studies performed in distinct patient populations. Objective To determine delirium prevalence across an acute care facility. Design A point prevalence study. Setting A large tertiary care, teaching hospital. Patients 311 general hospital adult inpatients were assessed over a single day. Of those, 280 had full data collected within the studys time frame (90%). Measurements Initial screening for inattention was performed using the spatial span forwards and months backwards tests by junior medical staff, followed by two independent formal delirium assessments: first the Confusion Assessment Method (CAM) by trained geriatric medicine consultants and registrars, and, subsequently, the Delirium Rating Scale-Revised-98 (DRS-R98) by experienced psychiatrists. The diagnosis of delirium was ultimately made using DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria. Results Using DSM-IV criteria, 55 of 280 patients (19.6%) had delirium versus 17.6% using the CAM. Using the DRS-R98 total score for independent diagnosis, 20.7% had full delirium, and 8.6% had subsyndromal delirium. Prevalence was higher in older patients (4.7% if <50 years and 34.8% if >80 years) and particularly in those with prior dementia (OR=15.33, p<0.001), even when adjusted for potential confounders. Although 50.9% of delirious patients had pre-existing dementia, it was poorly documented in the medical notes. Delirium symptoms detected by medical notes, nurse interview and patient reports did not overlap much, with inattention noted by professional staff, and acute change and sleep-wake disturbance noted by patients. Conclusions Our point prevalence study confirms that delirium occurs in about 1/5 of general hospital inpatients and particularly in those with prior cognitive impairment. Recognition strategies may need to be tailored to the symptoms most noticed by the detector (patient, nurse or primary physician) if formal assessments are not available.

Inappropriate prescribing: criteria, detection and prevention.

Inappropriate prescribing is highly prevalent in older people and is a major healthcare concern because of its association with negative healthcare outcomes including adverse drug events, related morbidity and hospitalization. With changing population demographics resulting in increasing proportions of older people worldwide, improving the quality and safety of prescribing in older people poses a global challenge.To date a number of different strategies have been used to identify potentially inappropriate prescribing in older people. Over the last two decades, a number of criteria have been published to assist prescribers in detecting inappropriate prescribing, the majority of which have been explicit sets of criteria, though some are implicit. The majority of these prescribing indicators pertain to overprescribing and misprescribing, with only a minority focussing on the underprescribing of indicated medicines. Additional interventions to optimize prescribing in older people include comprehensive geriatric assessment, clinical pharmacist review, and education of prescribers as well as computerized prescribing with clinical decision support systems.In this review, we describe the inappropriate prescribing detection tools or criteria most frequently cited in the literature and examine their role in preventing inappropriate prescribing and other related healthcare outcomes. We also discuss other measures commonly used in the detection and prevention of inappropriate prescribing in older people and the evidence supporting their use and their application in everyday clinical practice.

Adverse drug reactions in older patients during hospitalisation: are they predictable?

BACKGROUND adverse drug reactions (ADRs) are a major cause of morbidity and healthcare utilisation in older people. The GerontoNet ADR risk score aims to identify older people at risk of ADRs during hospitalisation. We aimed to assess the clinical applicability of this score and identify other variables that predict ADRs in hospitalised older people. METHODS we prospectively studied 513 acutely ill patients aged ≥65 years. The GerontoNet ADR risk score was calculated for all patients. ADRs were identified through patient and physician consultation together with analysis of case notes. Receiver operator characteristic (ROC) curves were constructed to test the ability of the GerontoNet risk score to predict ADRs. Multivariate logistic regression examined the influence of individual variables on the presence of ADRs. RESULTS in-hospital ADRs were identified in 135 patients (26%). The area under the ROC curve was 0.62 (95% CI: 0.57-0.68). Variables which increased ADR risk include (i) renal failure (OR: 1.81, 95% CI: 1.12-2.92), (ii) increasing number of medications (OR: 1.09, 95% CI: 1.02-1.17) (iii) inappropriate medications (OR: 2.40, 95% CI: 1.26-4.50) and (iv) age ≥75 years (OR: 2.12, 95% CI: 1.23-3.70). CONCLUSION the GerontoNet ADR risk score incorrectly classified 38% of patients as low risk. Inappropriate medications and increasing age also contribute to ADR risk.

The financial implications of falls in older people for an acute hospital

BackgroundFalls are a common occurrence in older people and frequently lead to hospital admission. There is a current lack of cohesive fall prevention strategies in the Republic of Ireland.AimTo demonstrate the cost of fall-related admissions to an acute hospital.MethodsA review of Hospital Inpatient Enquiry (HIPE) data and medical case notes was performed for all fall-related admissions over a one-year period. The cost of fall-related admissions was calculated. In addition a detailed cost analysis was performed to determine the true cost of a hip fracture admission.ResultsThere were 810 fall-related admissions, resulting in 8,300 acute bed days, and 6,220 rehabilitation bed days, costing €10.3 million. Fall-related readmissions resulted in 650 bed-days, bringing the total cost to €10.8 million. A typical hip fracture incident admission episode costs €14,300.ConclusionsFall-related admissions of older people are a significant financial burden to the health service.

Irish National Lottery Sports Capital Grant Allocations, 1999-2007: Natural Experiments on Political Influence

Irish National Lottery Sports Capital Grant Allocations show a clear bias towards the geographical areas represented by the Minister for Arts, Sports and Tourism and the Minister for Finance. This bias is the result of the procedures by which the funds are allocated.

Audit-guided action can improve the compliance with thromboembolic prophylaxis prescribing to hospitalized, acutely ill older adults

We read with interest the articles by Minno and Tufano (2004) and Zakai et al. (2004), which serve to highlight the need for prevention of venous thromboembolism (VTE) in at-risk patients. We recently audited our use of prophylactic low molecular weight heparin (LMWH) in hospitalized older adults (65 years or older) over a 6-week period. Patients were included if they had an indication for thromboembolic prophylaxis as defined by our departmental guidelines (severe heart failure; acute myocardial infarction; respiratory failure; past history of thromboembolic disease; hypercoagulable state; nephrotic syndrome; acute illness with dehydration). Patients were excluded if they received therapeutic LMWH for suspected myocardial infarction or VTE, were already receiving longterm warfarin therapy, or died or were discharged within 48 h of admission. To comply with departmental guidelines, a patient had to be prescribed subcutaneous tinzaparin, 3500 units once a day, within 2 days of admission. There were three predetermined exceptions to this standard: (a) a documented contraindication to LMWH; (b) the patient had suffered a stroke, in which case they had to be either prescribed compression stockings or have a documented contraindication to these; and (c) inappropriateness of thromboembolic prophylaxis due to the patient’s overall condition (i.e. patient was moribund or terminally ill). There were 120 acute admissions to the ward during the audit period, with 16 of these cases excluded (six received therapeutic LMWH, five were taking warfarin and five died or were discharged within 48 h). Of the remaining 104 patients, 27 (26%) had an indication for thromboembolic prophylaxis. Of these, six cases (22%) met the prescribing standard, four cases were inappropriate for prophylaxis and three cases had a contraindication to LMWH. Thus, in total, only 48% of those eligible for thromboembolic prophylaxis met the prescribing standard or an exception. (No case failed because of a missing drug prescription sheet, suboptimal dose of tinzaparin or the prescription of an alternative LMWH). Following discussion of the baseline audit results, a program of medical staff education on the content of the departmental guidelines, including those for VTE prevention, was initiated. In addition, a specific prompt for thromboembolic prophylaxis was inserted into the ward admission form. Data collection was subsequently repeated. On this occasion, 20 patients had an indication for thromboembolic prophylaxis. Of these, 17 received prophylaxis (85%), and one patient met a prescribing exception (receiving palliative care). Thus, there was a 90% compliance with, or exception to, the prescribing standard on this occasion, in comparison with 48% on the first occasion, a significant improvement (P < 0.02, Fisher’s exact test). It has been previously reported that hospitalized patients at risk of VTE are underprescribed thromboembolic prophylaxis [3–5]. A study of medical patients at Kings hospital, London, found that only 23% of those at high risk, and none of those at moderate risk of VTE, received prophylaxis [6]. In Italy, only 46% of patients who met the American College of Chest Physicians consensus statement criteria received thromboembolic prophylaxis [7]. It is known that education can increase prophylaxis prescribing – Anderson described an increase from 29% to 52% [8]. Our audit cycle clearly demonstrates that thromboembolic prophylaxis prescribing can be significantly improved, at least in the short term, by a combination of education and written prompting.