Paul Gallagher

The Impact of a Structured Pharmacist Intervention on the Appropriateness of Prescribing in Older Hospitalized Patients

BackgroundThroughout the literature, drug-related problems (DRPs), such as medication reconciliation issues and potentially inappropriate prescribing, have been reported to be associated with adverse outcomes in older individuals. Both structured pharmacist review of medication (SPRM) interventions and computerized decision support systems (CDSSs) have been shown to reduce DRPs.ObjectiveThe objectives of this study were to (i) evaluate the impact of a specially developed SPRM/CDSS intervention on the appropriateness of prescribing in older Irish hospital inpatients, and (ii) examine the acceptance rates of these recommendations.MethodsWe prospectively reviewed 361 patients, aged ≥65xa0years who were admitted to an Irish university teaching hospital over a 12-month period. At the point of admission, the patients received a SPRM/CDSS intervention, which screened for DRPs. Any DRPs that were identified were then communicated in writing to the attending medical team. The patient’s medical records were reviewed again at 7–10xa0days, or at the point of discharge (whichever came first).ResultsOf the 361 patients reviewed, 181 (50.1xa0%) were female; the median age was 77 years [interquartile range (IQR) 71–83xa0years). A total of 3,163 (median 9, IQR 6–12) and 4,192 (median 12, IQR 8–15) medications were prescribed at admission and discharge, respectively. The SPRM generated 1,000 recommendations in 296 patients. Of the 1,000 recommendations, 548 (54.8xa0%) were implemented by the medical teams accordingly. The SPRM/CDSS intervention resulted in an improvement in the appropriateness of prescribing as defined by the medication appropriateness index (MAI), with a statistically significant difference in the median summated MAI at admission (15, IQR: 7–21) and follow-up (12, IQR: 6–18); pxa0<xa00.001. However, the SPRM did not result in an improvement in appropriateness of underprescribing as defined by a modified set assessment of care of vulnerable elders (ACOVE) criteria.ConclusionThis study indicated that DRPs are prevalent in older Irish hospitalized inpatients and that a specially developed SPRM intervention supported by a CDSS can improve both the appropriateness and accuracy of medication regimens of older hospitalized inpatients.

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

BACKGROUNDnadverse 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.nnnMETHODSnwe 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.nnnRESULTSnin-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).nnnCONCLUSIONnthe GerontoNet ADR risk score incorrectly classified 38% of patients as low risk. Inappropriate medications and increasing age also contribute to ADR risk.

Prevention of Hospital-Acquired Adverse Drug Reactions in Older People Using Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment Criteria: A Cluster Randomized Controlled Trial.

To determine whether use of the Screening Tool of Older Persons Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria reduces incident hospital‐acquired adverse drug reactions (ADRs), 28‐day medication costs, and median length of hospital stay in older adults admitted with acute illness.

Doctors' perspectives on the barriers to appropriate prescribing in older hospitalized patients: a qualitative study.

AIMSnOlder patients commonly suffer from multimorbidites and take multiple medications. As a result, these patients are more vulnerable to potentially inappropriate prescribing (PIP). PIP in older patients may result in adverse drug events (ADEs) and hospitalizations. However, little has been done to identify why PIP occurs. The objectives of this study were (i) to identify hospital doctors perceptions as to why PIP occurs, (ii) to identify the barriers to addressing the issues identified and (iii) to determine which intervention types would be best suited to improving prescribing.nnnMETHODSnSemi-structured interviews based on the Theoretical Domains Framework (TDF), a tool used to apply behaviour change theories, were conducted with 22 hospital doctors. Content analysis was conducted to identify domains of the TDF that could be targeted to improve prescribing for older people. These domains were then mapped to the behaviour change wheel to identify possible intervention types.nnnRESULTSnContent analysis identified five of the 12 domains in the TDF as relevant: (i) environmental context and resources, (ii) knowledge, (iii) skills, (iv) social influences and (v) memory/attention and decision processes. Using the behaviour change wheel, the types of interventions deemed suitable were those based on training and environmental restructuring.nnnCONCLUSIONnThis study shows that doctors feel there is insufficient emphasis on geriatric pharmacotherapy in their undergraduate/postgraduate training. An intervention providing supplementary training, with particular emphasis on decision processes and dealing with social influences would be justified. This study has, however, uncovered many areas for potential intervention in the future.

Prevention of Adverse Drug Reactions in Hospitalised Older Patients Using a Software-Supported Structured Pharmacist Intervention: A Cluster Randomised Controlled Trial

BackgroundProven interventions to reduce adverse drug reactions (ADRs) in older hospitalised patients are lacking. Previous randomised controlled trial (RCT) data indicate that a structured pharmacist review of medication (SPRM) can reduce inappropriate prescribing in older hospitalised patients. However, no RCT data show that an SPRM reduces ADRs in this population.MethodsWe performed a cluster RCT comparing a clinical decision support software (CDSS)-supported SPRM intervention with standard pharmaceutical care in older patients hospitalised with an acute unselected illness. Over 13xa0months, we screened 1833 patients aged ≥65xa0years admitted to specialist services other than geriatric medicine for study inclusion. We randomised 361 patients to the trial intervention arm and 376 patients to the control arm, applying the intervention at a single timepoint within 48xa0h of admission. The primary endpoint (ADR incidence) was assessed at 7–10xa0days post-admission or at discharge (whichever came first). The secondary endpoints were the median hospital length of stay (LOS) and hospital mortality rate.ResultsAttending clinicians in the intervention group implemented 54.8xa0% of SPRM/CDSS prescribing recommendations. Ninety-one ADRs occurred in 78 control patients (20.7xa0%) compared with 61 ADRs in 50 intervention patients (13.9xa0%), i.e., an absolute risk reduction of 6.8xa0%. The number needed to treat (NNT) to prevent one patient having one ADR was 15; the total NNT to prevent one ADR was 14. The median LOS and hospital mortality were not significantly different.ConclusionAn SPRM delivered on a CDSS platform significantly reduces ADR incidence in acutely hospitalised older people.

Acute hospital dementia care: results from a national audit

BackgroundAdmission to an acute hospital can be distressing and disorientating for a person with dementia, and is associated with decline in cognitive and functional ability. The objective of this audit was to assess the quality of dementia care in acute hospitals in the Republic of Ireland.MethodsAcross all 35 acute public hospitals, data was collected on care from admission through discharge using a retrospective chart review (nu2009=u2009660), hospital organisation interview with senior management (nu2009=u200935), and ward level organisation interview with ward managers (nu2009=u200976). Inclusion criteria included a diagnosis of dementia, and a length of stay greater than 5xa0days.ResultsMost patients received physical assessments, including mobility (89xa0%), continence (84xa0%) and pressure sore risk (87xa0%); however assessment of pain (75xa0%), and particularly functioning (36xa0%) was poor. Assessment for cognition (43xa0%) and delirium (30xa0%) was inadequate. Most wards have access at least 5xa0days per week to Liaison Psychiatry (93xa0%), Geriatric Medicine (84xa0%), Occupational Therapy (79xa0%), Speech & Language (81xa0%), Physiotherapy (99xa0%), and Palliative Care (89xa0%) Access to Psychology (9xa0%), Social Work (53xa0%), and Continence services (34xa0%) is limited. Dementia awareness training is provided on induction in only 2 hospitals, and almost half of hospitals did not offer dementia training to doctors (45xa0%) or nurses (48xa0%) in the previous 12xa0months. Staff cover could not be provided on 62xa0% of wards for attending dementia training. Most wards (84xa0%) had no dementia champion to guide best practice in care. Discharge planning was not initiated within 24xa0h of admission in 72xa0% of cases, less than 40xa0% had a single plan for discharge recorded, and 33xa0% of carers received no needs assessment prior to discharge. Length of stay was significantly greater for new discharges to residential care (pu2009<u2009.001).ConclusionDementia care relating to assessment, access to certain specialist services, staffing levels, training and support, and discharge planning is sub-optimal, which may increase the risk of adverse patient outcomes and the cost of acute care. Areas of good practice are also highlighted.

Does admission to a specialist geriatric medicine ward lead to improvements in aspects of acute medical care for older patients with dementia

The objective of this study is to clarify if admission to a specialist geriatric medicine ward leads to improvements in aspects of acute medical care for patients with dementia.

Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians

PurposeSTOPPFrail is an explicit tool, developed by Delphi consensus, to assist physicians with deprescribing medications in frail older adults with poor survival prognosis. This study aimed to determine the inter-rater reliability (IRR), amongst physicians, of STOPPFrail application.MethodsTwenty clinical cases were collated to represent frail older patients. Eighteen cases met STOPPFrail inclusion criteria. They had a mean age of 79.5 (SD6) years and a median of 7 (IQR6–8.25) comorbidities and were prescribed a median of 9 (IQR7.75–11.25) medications. Two of the STOPPFrail originators reached complete agreement (gold standard) in determining 91 of 165 medications (55.2%) as inappropriate. Twelve physicians (6 geriatricians, 3 general practitioners and 3 palliative care physicians) independently applied STOPPFrail criteria. IRR between physicians and gold standard (GS) assessment was determined using Cohen’s kappa statistic.ResultsEighteen of the 20 cases that met STOPPFrail inclusion criteria were correctly identified by 9 of 12 physicians (75%). The average time taken per clinical case was 2.7 (SD0.94) minutes. The kappa co-efficient between physicians and GS assessment ranged from 0.71 (substantial) to 0.86 (good), with a mean kappa value of 0.758 (SD0.059). The Fleiss kappa coefficients between GS assessment and geriatricians, GPs and palliative care physicians were 0.80 (SD0.6), 0.77 (SD0.9) and 0.75 (SD0.1), respectively. No significant difference was noted, between groups or between participants within groups, as determined by one-way ANOVA, (df (2, 9)u2009=u20090.712, pu2009=u20090.516).ConclusionsIRR of STOPPFrail criteria between physicians, practising in different specialties, is substantial, despite no prior knowledge of the criteria.

Symptom Assessment for a Palliative Care Approach in People With Dementia Admitted to Acute Hospitals: Results From a National Audit.

Context: As the prevalence of dementia increases, more people will need dementia palliative and end-of-life (EOL) care in acute hospitals. Published literature suggests that good quality care is not always provided. Objective: To evaluate the prescription of antipsychotics and performance of multidisciplinary assessments relevant to palliative care for people with dementia, including those at EOL, during hospital admission. Method: As part of a national audit of dementia care, 660 case notes were reviewed across 35 acute hospitals. Results: In the entire cohort, many assessments essential to dementia palliative care were not performed. Of the total sample, 76 patients died, were documented to be receiving EOL care, and/or were referred for specialist palliative care. In this cohort, even less symptom assessment was performed (eg, no pain assessment in 27%, no delirium screening in 68%, and no mood or behavioral and psychological symptoms of dementia in 93%). In all, 37% had antipsychotic drugs during their admission and 71% of these received a new prescription in hospital, most commonly for “agitation.” Conclusion: This study suggests a picture of poor symptom assessment and possible inappropriate prescription of antipsychotic medication, including at EOL, hindering the planning and delivery of effective dementia palliative care in acute hospitals.

Comments on “Intervention with the Screening Tool of Older Persons Potentially Inappropriate Prescriptions/Screening Tool to Alert Doctors to Right Treatment Criteria in Elderly Residents of a Chronic Geriatric Facility: A Randomized Clinical Trial”

eral population of nursing home residents by collecting data on all residents who had died during a 2-month period. A comparison of our results with data from that study revealed no significant differences regarding sex. Regarding the combination of CSD and withholding artificial nutrition and hydration, we would like to stress that most individuals in our study no longer had sufficient oral intake of food and fluids before the administration of CSD. Hence, we do not believe that the lives of all sedated individuals were ended through the withholding of artificial nutrition. Nevertheless, we share Dr. Finucane’s concerns on the use of CSD to end an individual’s life. We conducted a similar survey among the coordinating and advisory physicians of all nursing homes in Flanders in which we collected data on the physician’s intention when administering CSD. In 62.2% of the studied cases, the attending physician reported that CSD was not used to hasten death. In the remaining cases, the physician reported a partial (32.7%) or explicit (5.1%) intention to hasten death. Moreover, our findings strongly suggest that CSD is sometimes being used as a substitute for euthanasia, which is a legally accepted practice in Belgium (provided that all the formal requirements are fulfilled). In approximately one-fifth of the cases in which CSD was used to hasten death, the individual requested euthanasia, although this request was frequently declined to avoid the legal euthanasia procedure or to comply with local nursing home policy. In conclusion, we think that the distinction between CSD and physician-assisted death (euthanasia) is often blurred in clinical practice.