An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People.

Objectives We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years. Design A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided. Setting and Participants Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries. Measures For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round. Results Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs. Conclusion and Implications We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies.pre-print896 K

Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial.

BACKGROUND A patient-centred approach to medicines optimisation is considered essential. The OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial evaluated the effectiveness of medication review with shared decision-making (SDM) in older people with multimorbidity. Beyond evaluating the clinical effectiveness, exploring the patient experience facilitates a better understanding of contextual factors and mechanisms affecting medication review effectiveness. OBJECTIVE To explore experiences of hospital-initiated medication changes in older people with multimorbidity. METHODS We conducted a multicentre mixed-methods study, embedded in the OPERAM trial, combining semi-structured interviews and the Beliefs about Medicines Questionnaire (BMQ) with a purposive sample of 48 patients (70-94 years) from four European countries. Interviews were analysed using the Framework approach. Trial implementation data on SDM were collected and the 9-item SDM questionnaire was conducted with 17 clinicians. RESULTS Patients generally displayed positive attitudes towards medication review, yet emphasised the importance of long-term, trusting relationships such as with their general practitioners for medication review. Many patients reported a lack of information and communication about medication changes and predominantly experienced paternalistic decision-making. Patients' beliefs that 'doctors know best', 'blind trust', having limited opportunities for questions, use of jargon terms by clinicians, 'feeling too ill', dismissive clinicians, etc highlight the powerlessness some patients felt during hospitalisation, all representing barriers to SDM. Conversely, involvement of companions, health literacy, empathetic and trusting patient-doctor relationships, facilitated SDM. Paradoxical to patients' experiential accounts, clinicians reported high levels of SDM. The BMQ showed that most patients had high necessity and low concern beliefs about medicines. Beliefs about medicines, experiencing benefits or harms from medication changes, illness perception, trust and balancing advice between different healthcare professionals all affected acceptance of medication changes. CONCLUSION To meet patients' needs, future medicines optimisation interventions should enhance information exchange, better prepare patients and clinicians for partnership in care and foster collaborative medication reviews across care settings

Development of a standardized chart review method to identify drug-related hospital admissions in older people

Aim: We aimed to develop a standardized chart review method to identify drug-related hospital admissions (DRA) in older people caused by non-preventable adverse drug reactions and preventable medication errors including overuse, underuse and misuse of medications: the DRA adjudication guide. Methods: The DRA adjudication guide was developed based on design and test iterations with international and multidisciplinary input in 4 subsequent steps: literature review, evaluation of content validity using a Delphi consensus technique, a pilot test and a reliability study. Results: The DRA adjudication guide provides definitions, examples and step-by-step instructions to measure DRA. A 3-step standardized chart review method was elaborated including 1) data abstraction, 2) explicit screening with a newly developed trigger tool for DRA in older people and 3) consensus adjudication for causality by a pharmacist and a physician using the World Health Organization-Uppsala Monitoring Centre and Hallas criteria. A 15-member international Delphi panel reached consensus agreement on 26 triggers for DRA in older people. The DRA adjudication guide showed good feasibility of use and achieved moderate inter-rater reliability for the evaluation of 16 cases by 4 European adjudication pairs (71% agreement, kappa = 0.41). Disagreements arose mainly for cases with potential underuse. Conclusions: The DRA adjudication guide is the first standardized chart review method to identify DRA in older persons. Content validity, feasibility of use and inter-rater reliability were found to be satisfactory. The method can be used as an outcome measure for interventions targeted at improving quality and safety of medication use in older people

Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial.

OBJECTIVE To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. DESIGN Cluster randomised controlled trial. SETTING 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. PARTICIPANTS 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). INTERVENTION Clinical 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 MEASURE Primary outcome was first drug related hospital admission within 12 months. RESULTS 2008 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 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). CONCLUSIONS Inappropriate 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. TRIAL REGISTRATION ClinicalTrials.gov NCT02986425

Medication review to prevent avoidable hospital admissions in older with multi-morbidity : measuring outcomes that matter to patients

Inappropriate polypharmacy and related adverse health outcomes represent significant challenges in the ageing multi-morbid population. Medication reviews are recommended to reduce inappropriate polypharmacy and a patient-centred approach to medication review is considered essential. In this context, the European OPERAM trial was undertaken to evaluate the impact of medication review on drug-related readmissions in 2009 multi-morbid older patients. This thesis aimed to inform medication review in older people with multi-morbidity and polypharmacy by measuring outcomes that matter to patients. We developed the first standardised method to identify drug-related admissions (DRAs) in older people, a growing patient safety threat and an outcome of medication review that is considered highly important to older people. We highlighted the challenges associated with achieving good inter-rater reliability in DRA adjudication. In a cross-sectional study, we demonstrated that DRAs resulting from inappropriate prescribing detected by the STOPP/START.v2 criteria accounted for 40% of admissions in older patients. In a multi-centre mixed methods study embedded in OPERAM, we evaluated the patient experience. We showed that patients’ attitudes towards hospital-initiated medication changes and medication review were generally positive, but an interplay of factors related to inadequate information and communication, paternalism, patients’ beliefs, clinicians’ attitudes and doctor-patient relationships may affect effectiveness of medication reviews. Finally, a scoping review will help to increase understanding of medication-related preferences of multi-morbid older people, in order to inform medication review. Our findings pave the way for a better measurement and understanding of DRAs and for medication review services to become more tailored to the needs and preferences of older people with multi-morbidity and polypharmacy.(BIFA - Sciences biomédicales et pharmaceutiques) -- UCL, 202

Medication-Related Preferences of Older People with Multi-Morbidity: Protocol for a Scoping Review

Protocol for a scoping review on medication-related preferences of older people with multi-morbidit

Development of a standardized chart review method to identify drug-related hospital admissions in older people

AIMS: We aimed to develop a standardized chart review method to identify drug-related hospital admissions (DRA) in older people caused by non-preventable adverse drug reactions and preventable medication errors including overuse, underuse and misuse of medications: the DRA adjudication guide. METHODS: The DRA adjudication guide was developed based on design and test iterations with international and multidisciplinary input in four subsequent steps: literature review; evaluation of content validity using a Delphi consensus technique; a pilot test; and a reliability study. RESULTS: The DRA adjudication guide provides definitions, examples and step-by-step instructions to measure DRA. A three-step standardized chart review method was elaborated including: (i) data abstraction; (ii) explicit screening with a newly developed trigger tool for DRA in older people; and (iii) consensus adjudication for causality by a pharmacist and a physician using the World Health Organization-Uppsala Monitoring Centre and Hallas criteria. A 15-member international Delphi panel reached consensus agreement on 26 triggers for DRA in older people. The DRA adjudication guide showed good feasibility of use and achieved moderate inter-rater reliability for the evaluation of 16 cases by four European adjudication pairs (71% agreement, κ = 0.41). Disagreements arose mainly for cases with potential underuse. CONCLUSIONS: The DRA adjudication guide is the first standardized chart review method to identify DRA in older persons. Content validity, feasibility of use and inter-rater reliability were found to be satisfactory. The method can be used as an outcome measure for interventions targeted at improving quality and safety of medication use in older people

Medication review and reconciliation in older adults

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient’s preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people

Potentially Inappropriate Prescribing and Related Hospital Admissions in Geriatric Patients: A Comparative Analysis between the STOPP and START Criteria Versions 1 and 2

BACKGROUND: Older persons are at significant risk of drug-related admissions (DRAs). We previously demonstrated that 27% of hospitalizations in geriatric patients were associated with potentially inappropriate medicines (PIMs) and/or potential prescribing omissions (PPOs) identified by the Screening Tool of Older People's Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) criteria version 1 (v1). The updated STOPP/START criteria version 2 (v2) comprised a 31% increase in prescribing criteria. OBJECTIVE: As a secondary analysis of our study conducted in 2008, we aimed to compare the prevalence and types of DRAs identified by STOPP/START.v1 and STOPP/START.v2. METHODS: We applied the STOPP/START.v2 criteria to a subset of 100 consecutively admitted geriatric patients selected from our original cross-sectional study of 302 patients. A geriatrician and a pharmacist adjudicated whether the identified PIMs and PPOs were related to acute hospitalization. Admissions were defined as DRAs if the identified PIM(s) and/or PPO(s) were related to the main cause of admission or played a significant contributory role in the admission. RESULTS: The median patient age was 83 years and the median number of medications at home was 8. Compared with STOPP/START.v1, STOPP/START.v2 not only yielded more instances of inappropriate prescribing but also targeted significantly more PIMs and PPOs associated with preventable DRAs (23% vs. 40% of all admissions, p < 0.001). PIMs of fall-risk-increasing drugs, and PPOs of musculoskeletal and cardiovascular system drugs, were most frequently associated with DRAs. CONCLUSION: The latter instances of inappropriate prescribing with major clinical relevance warrant particular attention during medication review in older persons