Potentially inappropriate prescriptions according to explicit and implicit criteria in patients with multimorbidity and polypharmacy. MULTIPAP : a cross-sectional study

Background Multimorbidity is a global health challenge that is associated with polypharmacy, increasing the risk of potentially inappropriate prescribing (PIP). There are tools to improve prescription, such as implicit and explicit criteria. Objective To estimate the prevalence of PIP in a population aged 65 to 74 years with multimorbidity and polypharmacy, according to American Geriatrics Society Beers Criteria® (2015, 2019), the Screening Tool of Older Person’s Prescription -STOPP- criteria (2008, 2014), and the Medication Appropriateness Index -MAI- criteria in primary care. Methods This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling elderly aged 65 to 74 years, with multimorbidity and polypharmacy, who participated in the MULTIPAP trial. Socio-demographic, clinical, professional, and pharmacological-treatment variables were recorded. Potentially inappropriate prescribing was detected by computerized prescription assistance system, and family doctors evaluated the MAI. The MAI-associated factors were analysed using a logistic regression model. Results A total of 4,386 prescriptions were evaluated. The mean number of drugs was 7.4 (2.4 SD). A total of 94.1% of the patients in the study had at least one criterion for drug inappropriateness according to the MAI. Potentially inappropriate prescribing was detected in 57.7%, 43.6%, 68.8% and 71% of 50 patients according to the explicit criteria STOPP 2014, STOPP 2008, Beers 2019 and Beers 2015 respectively. For every new drug taken by a patient, the MAI score increased by 2.41 (95% CI 1.46; 3.35) points. Diabetes, ischaemic heart disease and asthma were independently associated with lower summated MAI scores.   Conclusions The prevalence of potentially inappropriate prescribing detected in the sample was high and in agreement with previous literature for populations with multimorbidity and polypharmacy. The MAI criteria detected greater inappropriateness than did the explicit criteria, but their application was more complex and difficult to automate.Publisher PDFPeer reviewe

Use of an electronic clinical decision support system in primary care to assess inappropriate polypharmacy in young seniors with multimorbidity : Observational, descriptive, cross-sectional study

This study was funded by National Institute for Health Research ISCIII (Grant numbers PI15/00276 (APT), PI15/00572 (ICG), PI15/00996 (JDPT), RD16/0001/0004 (ICG), RD16/0001/0005 (APT), RD16/0001/0006 (JDPT)) Co-funded by European Regional Development Fund, (ERDF) “A way of shaping Europe”. National Plan I+D+I 2013-2016.Background: Multimorbidity is a global health problem that is usually associated with polypharmacy, which increases the risk of potentially inappropriate prescribing (PIP). PIP entails higher hospitalization rates and mortality and increased usage of services provided by the health system. Tools exist to improve prescription practices and decrease PIP, including screening tools and explicit criteria that can be applied in an automated manner. Objective: This study aimed to describe the prevalence of PIP in primary care consultations among patients aged 65-75 years with multimorbidity and polypharmacy, detected by an electronic clinical decision support system (ECDSS) following the 2015 American Geriatrics Society Beers Criteria, the European Screening Tool of Older Person’s Prescription (STOPP), and the Screening Tool to Alert doctors to Right Treatment (START). Methods: This was an observational, descriptive, cross-sectional study. The sample included 593 community-dwelling adults aged 65-75 years (henceforth called young seniors), with multimorbidity (3 diseases) and polypharmacy (5 medications), who had visited their primary care doctor at least once over the last year at 1 of the 38 health care centers participating in the Multimorbidity and Polypharmacy in Primary Care (Multi-PAP) trial. Sociodemographic data, clinical and pharmacological treatment variables, and PIP, as detected by 1 ECDSS, were recorded. A multivariate logistic regression model with robust estimators was built to assess the factors affecting PIP according to the STOPP criteria.  Results: PIP was detected in 57.0% (338/593; 95% CI 53-61) and 72.8% (432/593; 95% CI 69.3-76.4) of the patients according to the STOPP criteria and the Beers Criteria, respectively, whereas 42.8% (254/593; 95% CI 38.9-46.8) of the patients partially met the START criteria. The most frequently detected PIPs were benzodiazepines (BZD) intake for more than 4 weeks (217/593, 36.6%) using the STOPP version 2 and the prolonged use of proton pump inhibitors (269/593, 45.4%) using the 2015 Beers Criteria. Being a woman (odds ratio [OR] 1.43, 95% CI 1.01-2.01; P.04), taking a greater number of medicines (OR 1.25, 95%CI 1.14-1.37; P.04), working in the primary sector (OR 1.91, 95% CI 1.25-2.93; P.003), and being prescribed drugs for the central nervous system (OR 3.75, 95% CI 2.45-5.76; P<.001) were related to a higher frequency of PIP. Conclusions: There is a high prevalence of PIP in primary care as detected by an ECDSS in community-dwelling young seniors with comorbidity and polypharmacy. The specific PIP criteria defined by this study are consistent with the current literature. This ECDSS can be useful for supervising prescriptions in primary health care consultations.Publisher PDFPeer reviewe

Sex differences in social support perceived by polymedicated older adults with multimorbidity. MULTIPAP study.

The beneficial effects of social support on morbidity, mortality, and quality of life are well known. Using the baseline data of the MULTIPAP study (n = 593), an observational, descriptive, cross-sectional study was carried out that analyzed the sex differences in the social support perceived by polymedicated adults aged 65 to 74 years with multimorbidity. The main outcome variable was social support measured through the Duke-UNC-11 Functional Social Support (DUFSS) questionnaire in its two dimensions (confident support and affective support). For both sexes, the perception of functional social support was correlated with being married or partnered and having a higher health-related quality of life utility index. In women, it was correlated with a higher level of education, living alone, and treatment adherence, and in men with higher monthly income, prescribed drugs and fewer diagnosed diseases

Social support, social context and nonadherence to treatment in young senior patients with multimorbidity and polypharmacy followed-up in primary care. MULTIPAP Study.

ObjectiveTo estimate the prevalence of nonadherence to treatment and its relationship with social support and social context in patients with multimorbidity and polypharmacy followed-up in primary care.MethodsThis was an observational, descriptive, cross-sectional, multicenter study with an analytical approach. A total of 593 patients between 65-74 years of age with multimorbidity (≥3 diseases) and polypharmacy (≥5 drugs) during the last three months and agreed to participate in the MULTIPAP Study. The main variable was adherence (Morisky-Green). The predictors were social support (structural support and functional support (DUFSS)); sociodemographic variables; indicators of urban objective vulnerability; health-related quality of life (EQ-5D-5L-VAS & QALY); and clinical variables. Descriptive, bivariate and multivariate analyses with logistic regression models and robust estimators were performed.ResultsFour out of ten patients were nonadherent, 47% had not completed primary education, 28.7% had an income ≤1050 €/month, 35% reported four or more IUVs, and the average perceived health-related quality of life (HRQOL) EQ-5D-5L-VAS was 65.5. The items that measure functional support, with significantly different means between nonadherent and adherent patients were receiving love and affection (-0.23; 95%CI: -0.40;-0.06), help when ill (-0.25; 95%CI: -0.42;-0.08), useful advice (-0.20; 95%CI: -0.37;-0.02), social invitations (-0.22; 95%CI:-0.44;-0.01), and recognition (-0.29; 95%CI:-0.50;-0.08). Factors associated with nonadherence were belonging to the medium vs. low tertile of functional support (0.62; 95%CI: 0.42;0.94), reporting less than four IUVs (0.69; 95%CI: 0.46;1.02) and higher HRQOL perception (0.98; 95%CI: 0.98;0.99).ConclusionsAmong patients 65-74 years of age with multimorbidity and polypharmacy, lower functional support was related to nonadherence to treatment. The nonadherence decreased in those patients with higher functional support, lower urban vulnerability and higher perceived health status according to the visual analog scale of health-related quality of life

Drug interactions detected by a computer-assisted prescription system in primary care patients in Spain: MULTIPAP study.

Drug interactions increase the risk of treatment failure, intoxication, hospital admissions, consultations and mortality. Computer-assisted prescription systems can help to detect interactions. To describe the drug-drug interaction (DDI) and drug-disease interaction (DdI) prevalence identified by a computer-assisted prescription system in patients with multimorbidity and polypharmacy. Factors associated with clinically relevant interactions were analysed. Observational, descriptive, cross-sectional study in primary health care centres was undertaken in Spain. The sample included 593 patients aged 65-74 years with multimorbidity and polypharmacy participating in the MULTIPAP Study, recruited from November 2016 to January 2017. Drug interactions were identified by a computer-assisted prescription system. Descriptive, bivariate, and multivariate analyses with logistic regression models and robust estimators were performed. Half (50.1% (95% CI 46.1-54.1)) of the patients had at least one relevant DDI and 23.9% (95% CI 18.9-25.6) presented with a DdI. Non-opioid-central nervous system depressant drug combinations and benzodiazepine-opioid drug combinations were the two most common clinically relevant interactions (10.8% and 5.9%, respectively). Factors associated with DDI were the use of more than 10 drugs (OR 11.86; 95% CI 6.92-20.33) and having anxiety/depressive disorder (OR 1.98; 95% CI 1.31-2.98). Protective factors against DDI were hypertension (OR 0.62; 95% CI 0.41-0.94), diabetes (OR 0.57; 95% CI 0.40-0.82), and ischaemic heart disease (OR 0.43; 95% CI 0.25-0.74). Drug interactions are prevalent in patients aged 65-74 years with multimorbidity and polypharmacy. The clinically relevant DDI frequency is low. The number of prescriptions taken is the most relevant factor associated with presenting a clinically relevant DDI

Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial

del Cura-Gonzalez I, Lopez-Rodriguez JA, Leiva-Fernandez F, et al. Effectiveness of the MULTIPAP Plus intervention in youngest-old patients with multimorbidity and polypharmacy aimed at improving prescribing practices in primary care: study protocol of a cluster randomized trial. Trials. 2022;23(1): 479.Background: The progressive ageing of the population is leading to an increase in multimorbidity and polypharmacy, which in turn may increase the risk of hospitalization and mortality. The enhancement of care with information and communications technology (ICT) can facilitate the use of prescription evaluation tools and support system for decision-making (DSS) with the potential of optimizing the healthcare delivery process. Objective: To assess the effectiveness and cost-effectiveness of the complex intervention MULTIPAP Plus, compared to usual care, in improving prescriptions for young-old patients (65-74 years old) with multimorbidity and polypharmacy in primary care. Methods/design: This is a pragmatic cluster-randomized clinical trial with a follow-up of 18 months in health centres of the Spanish National Health System. Unit of randomization: family physician. Unit of analysis: patient. Population: Patients aged 65-74 years with multimorbidity (>= 3 chronic diseases) and polypharmacy (>= 5 drugs) during the previous 3 months were included. Sample size: n = 1148 patients (574 per study arm). Intervention: Complex intervention based on the ARIADNE principles with three components: (1) family physician (FP) training, (2) FP-patient interview, and (3) decision-making support system. Outcomes: The primary outcome is a composite endpoint of hospital admission or death during the observation period measured as a binary outcome, and the secondary outcomes are number of hospital admission, all-cause mortality, use of health services, quality of life (EQ-5D-5L), functionality (WHODAS), falls, hip fractures, prescriptions and adherence to treatment. Clinical and sociodemographic factors will be explanatory variables. Statistical analysis: The main result is the difference in percentages in the final composite endpoint variable at 18 months, with its corresponding 95% CI. Adjustments by the main confounding and prognostic factors will be performed through a multilevel analysis. All analyses will be carried out in accordance to the intention-to-treat principle. Discussion: It is important to prevent the cascade of negative health and health care impacts attributable to the multimorbidity-polypharmacy binomial. ICT-enhanced routine clinical practice could improve the prescription process in patient care