Ability to detect potentially inappropriate prescribing in older patients: comparative analysis between PIM-Check and STOPP/STARTv2.

Potentially inappropriate prescribing (PIP) is a source of preventable adverse drug events. The objective of this study was a comparative analysis (quantitative and qualitative) between two tools used to detect PIP, PIM-Check and STOPP/START. First, a qualitative analysis (QAC) was conducted to evaluate the concordance between the criteria, which constitute PIM-Check and the gold standard STOPP/START. Second, a retrospective comparative and observational study was performed on the list of treatment at the admission of 50 older patients hospitalized in an acute geriatric ward of a university hospital in Switzerland in 2016 using both tools. The QAC has shown that 50% (57 criteria) of STOPP/START criteria are fully or partially concordant with those of PIM-Check. The retrospective study was performed on 50 patients aged 87 years, suffering from 5 co-morbidities (min-max 1-11) and treated by of 8 drugs (min-max 2-16), as medians. The prevalence of the detected PIP was 80% by PIM-Check and 90% by STOPP/START. Medication review shows that 4.2 PIP per patient were detected by PIM-Check and 3.5 PIP by STOPP/START among which 1.9 PIP was commonly detected by both tools, as means. PIM-Check detected more PIP related to cardiology, angiology, nephrology, and endocrinology in older patients but missed the PIP related to geriatric syndromes (e.g., fall, dementia, Alzheimer) detected by STOPP/START. By using PIM-Check in geriatric settings, some PIP will not be detected. It is considered as a limitation for this tool in this frail population but brings a certain complementarity in other areas of therapy not covered by STOPP/START

An evaluation of polypharmacy medication reviews in GP practices

Polypharmacy, defined as the concurrent use of four or more medications by a single patient, is ever-increasing. It enhances the risk of adverse drug reactions (ADRs) and can represent a huge burden to patients. Medication reviews are the proposed panacea for reducing such problematic polypharmacy. These reviews conducted on patients aged 65 years or over can be aided by activation of the STOPP/START toolkit, an electronic tool that gives alerts, specific to a patient’s current medication regime, to recommend that GPs stop and/or start certain medications. Unique to this toolkit, the alerts are significantly associated with the Royal College of General Practitioners (RCGP) prescribing safety indicators – indicators designed to reduce ADRs – and, thus, the toolkit attempts to enhance patient safety. The aim of this study was to determine whether the STOPP/START toolkit improves medication reviews conducted on elderly polypharmacy patients. Forty patients aged 75 years or over, all of whom were registered with a North Kirklees commissioned GP practice, were currently prescribed ten or more medications, and had received a STOPP/START medication review, formed the study’s participant cohort. Recruited patients were asked a series of questions via a retrospective telephone interview to help determine the patient-perceived usefulness of, and satisfaction with, the medication review. Data regarding the number of alerts identical or similar to the RCGP prescribing safety indicators of defined ‘high’ (level 3) or ‘extreme’ (level 4) risk that were triggered and resolved during the North Kirklees commissioned STOPP/START medication reviews was also accessed and analysed. This helped to determine whether improved patient safety could be deemed an attribute of STOPP/START. It was found that 75% of patients believed their medication review was useful, regardless of whether any medications were stopped and/or started. If medications were stopped and/or started, patients felt greater involvement in and heightened satisfaction with the change(s) made if change(s) were based on STOPP/START recommendations (p<0.1). Furthermore, in North Kirklees, 388 STOPP/START alerts linked to level 3/4 RCGP indicators were resolved; these resolutions potentially prevented 78 hospital admissions. This study suggests that the stopping and/or starting of medications is not crucial in establishing overall patient satisfaction in medication reviews. Instead, it would seem that elderly patients merely desire the opportunity to discuss their medications with a healthcare professional. However, the STOPP/START toolkit can help to improve patient safety, and can better engage patients in decisions for medication change(s), heightening patient satisfaction with the change(s). This suggests that activation of the STOPP/START toolkit in polypharmacy medication reviews conducted on the elderly would be beneficial

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

Purpose: screening tool of older people’s 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

Revisión de medicación según criterios STOPP/START en pacientes mayores del servicio de sistema personalizado de dosificación de medicamentos de una farmacia comunitaria

Objetivos: Detectar de forma sistemática según los criterios STOPP-START la medicación inadecuada y los fármacos necesarios no prescritos en pacientes del servicio del sistema personalizado de administración de medicamentos (SPD) de una farmacia comunitaria.Métodos: Estudio cuasi experimental pre-post sin grupo control realizado en una farmacia comunitaria de Málaga durante 4 meses (noviembre 2013-febrero 2014). Los sujetos de estudio seleccionados son 84 pacientes mayores de 65 años inscritos en el servicio de SPD. Se registraron los siguientes datos: edad, sexo, medicamentos, criterios STOPP-START identificados. La identificación de los criterios se realizó con la herramienta informática CheckTheMeds®.Resultados: Se revisaron las historias farmacoterapéuticas de 84 pacientes. Un 54,8% de los pacientes presentaron como mínimo un criterio STOPP-START, con una media de 1,07 (DE=1,3) criterios por paciente. De estos pacientes, un 36,9% solo presentaban criterios STOPP, un 32,6% criterios START y un 30,5% criterios STOPP-START. En los criterios START la situación más prevalente corresponde al sistema endocrino (Antiagregantes plaquetarios en la diabetes mellitus si coexisten uno o más factores mayores de riesgo cardiovascular) con un 15,6%. Respecto a los criterios STOPP se ha detectado como la situación más frecuente el sistema nervioso central y psicofármacos con un 14,4% (Uso prolongado de benzodiacepinas de vida media larga o benzodiacepinas con metabolitos de larga acción).Conclusiones: La revisión sistemática de la medicación según criterios STOPP-START en pacientes del servicio de SPD mediante el programa informático CheckTheMeds® puede constituirse en una buena herramienta para mejorar el seguimiento de pacientes ancianos, polimedicados y/o con patologías crónicas. Es necesario mejorar las intervenciones farmacéuticas dirigidas a aumentar la calidad de la prescripción derivando al médico este tipo de situaciones

STOPP-START Medication Review: A Non-Randomized Trial in an Indonesian Tertiary Hospital to Improve Medication Appropriateness and to Reduce the Length of Stay of Older Adults

Background: Inappropriate prescribing may lead to medication errors among older adults. Pharmacists can curb the occurrences of these errors by conducting medication reviews. Screening Tool of Older Person’s Prescriptions (STOPP) or Screening Tool to Alert doctors to Right Treatments (START) may curb the incidence of adverse drug reactions and improve medication appropriateness by providing guides about when particular types of medications should be started or stopped. Objective: This study aimed to evaluate the use of STOPP/START to improve the Adapted Medication Appropriateness Index (MAI), to reduce the risk of ADRs (GerontoNet score), and length of stay (LOS). Setting: Geriatric Inpatient Ward, Sanglah General Hospital, Bali, Indonesia. Method: A non-randomized controlled trial was conducted in older adults (>60 years) who were selected consecutively from inpatient units in a tertiary hospital in Bali, Indonesia. The intervention group received medication reviews by pharmacists in collaboration with physicians to assess its appropriateness with STOPP/START criteria on admission and during their stay at the hospital. The control group obtained standard care. Main Outcome Measures: The outcomes were measured using the Adapted MAI, GerontoNet Score, and LOS. Results: Thirty patients in the intervention group and 33 patients in the control group were included in this study. The adapted MAI was 2.97 (2.25) and 9.94 (6.14) with P < .001. The GerontoNet score was 3.33 (2.28) and 5.18 (2.10) with P=.003, LOS was 7.63 (3.00) days and 14.18 (9.97) days with P=.011, respectively. Conclusion: The use of STOPP/START as a tool for medication review improved medication appropriateness and reduced ADR risk and LOS

Identification of Potentially Inappropriate Prescribing in Outpatient Geriatric using STOPP/START Criteria at X Hospital Jakarta

Chronic diseases and decreased physiological function in geriatric patients play a role in the increased Potentially Inappropriate Prescribing (PIP) and Adverse Drug Reactions (ADR). STOPP/START Criteria (Screening Tool of Older Person's Prescriptions/Screening Tool to Alert to Right Treatment) is one of the screening tools to identify Potentially Inappropriate Prescribing. The purpose of this study was to find out how much Potentially Inappropriate Medicines (PIM) potential and Potency Prescribing Omissions (PPO) at X hospital using STOPP START toolkit. This was a non-experimental descriptive study. Samples were collected retrospective in January-March 2017. STOPP/START criteria were used as a screening tool to identify Potentially Inappropriate Medication (PIM) and Potential Prescribing Omissions (PPO). In 91 samples of outpatient geriatric at X hospital, the potential for PIM according to the STOPP Criteria was 1.9% of a total of 560 drugs with criteria were for the administration of benzodiazepines in patients with a history of falls, anticholinergics and antipsychotics in dementia patients, glimepiride administration in geriatric patients with DM type 2. For the potential of negligence in drug administration according to the START Criteria, there was 3.8% with the most occurrence being the administration of acetylcholinesterase inhibitors in dementia patients. Of the 560 medications administered to outpatient geriatric patients, 1.9% were included in the STOPP criteria and 3.8% included in the START criteria

Educational Intervention for Healthcare Providers on Using the STOPP/START Tool to Manage Polypharmacy in Older Adults: A Quality Improvement Program

Polypharmacy is a significant healthcare issue among older adults in the United States. It is associated with an increased risk of medication errors, adverse drug interactions, adverse outcomes, and a high mortality rate. Application of polypharmacy management protocols such as the Screening Tool of Older Persons\u27 Prescriptions (STOPP) and Screening Tool to Alert to Right Treatment (START) criteria can result in a significant reduction in polypharmacy rates among older adults. However, healthcare providers often lack knowledge and awareness of such protocols and fail to use them to improve outcomes for older adults with or at risk of polypharmacy. This project aimed to implement an educational intervention for healthcare providers to improve their awareness and application of the STOPP/START tool in practice. A total of 25 healthcare providers were recruited into the project, completed a pre/post-intervention survey, and watched an educational video. Results showed that the intervention led to an improvement in knowledge of the STOPP/START tool from 30% to 100%. Regular application of the tool in practice improved from 12% to 85%. Perceptions, behaviors, and practices concerning the application of the tool also improved with all participants answering that screening for polypharmacy should be done always or sometimes, up from 80% pre-intervention. Post-intervention 96% of the participants reported always or sometimes screening for polypharmacy up from 60% pre-intervention. The findings show that an educational intervention for healthcare providers on the use of the STOPP/START tool can improve their awareness of the tool and its application in the screening and management of polypharmacy in older adults

The four or more medicines (FOMM) support service:results from an evaluation of a new community pharmacy service aimed at over-65s

Background: 57% of all prescriptions dispensed in the UK in 2003 were for people aged ≥60, where ≥20% of them were prescribed ≥ five medicines. Inappropriate prescribing and non-adherence have a significant impact on hospital admissions and patient quality of life. The English government has identified that community pharmacy could make a significant contribution to reducing non-adherence and improving the quality of prescribing, reducing both hospital admissions and medicines wastage. Objective: To evaluate a community pharmacy service aimed at patients over the age of 65 years prescribed four or more medicines. Method: Patients were invited to participate in the service by the community pharmacy team. The pharmacist held regular consultations with the patient and discussed risk of falls, pain management, adherence and general health. They also reviewed the patient’s medication using STOPP/START criteria. Data wereas analysed for the first six months of participation in the service. Key findings: 620 patients were recruited with 441 (71.1%) completing the six month study period. Pharmacists made 142 recommendations to prescribers in 110 patients largely centred on potentially inappropriate prescribing of NSAIDs, PPIs or duplication of therapy. At follow-up there was a significant decrease in the total number of falls (mean -0.116 (-0.217 - -0.014)) experienced and a significant increase in medicines adherence (mean difference in MMAS-8: 0.513 (0.337 – 0.689)) and quality of life. Cost per QALY estimates ranged from £11,885 to £32,466 depending on the assumptions made. Conclusion: By focussing on patients over the age of 65 years with four or more medicines, community pharmacists can improve medicines adherence and patient quality of life