Optimizing therapy to prevent avoidable hospital admissions in multimorbid older adults (OPERAM): cluster randomised controlled trial

OBJECTIVETo examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.DESIGNCluster randomised controlled trial.SETTING110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.PARTICIPANTS2008 older adults (>= 70 years) with multimorbidity (>= 3chronic conditions) and polypharmacy (>= 5 drugs used long term).INTERVENTIONClinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person's prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.MAIN OUTCOME MEASUREPrimary outcome was first drug related hospital admission within 12 months.RESULTS2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had >= 1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).CONCLUSIONSInappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.Algorithms and the Foundations of Software technolog

Influence of weather conditions on fly abundance and its implications for transmission of Rabbit Haemorrhagic Disease Virus in the North Island of New Zealand

Blowflies (Diptera: Calliphoridae) and flesh flies (Diptera: Sarcophagidae) are potential vectors of rabbit haemorrhagic disease virus (RHDV) in New Zealand. The associations between habitat and weather factors on the abundance of these flies were investigated. Between October 1999 and June 2001, flies were trapped on open pasture and in dense vegetation patches on farmland in the Himatangi area of the North Island. Five calliphorid species were trapped commonly at scrub edges and the most abundant sarcophagid, Oxysarcodexia varia Walker, was trapped mainly on open pasture. An abundance peak of O. varia was probably associated with the occurrence of a rabbit haemorrhagic disease (RHD) outbreak in the study area. Overall abundance of flies varied according to habitat and species, and species numbers differed between seasons and years. The all-day minimum temperature 3 weeks before trapping was a significant variable in all models of fly abundance, whereas average rainfall did not affect fly abundance. The all-day temperature range was significant only for O. varia. The influence of other climatic factors varied between fly species. Climate dependent variations in fly abundance may contribute to the risk of transmission of RHD, which occurred intermittently on the site during the study period