Original ArticleInappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing
Introduction
Inappropriate prescribing (IP) to older people can be defined as a situation in which pharmacotherapy is not within accepted medical standards. This can include overprescribing, misprescribing, and underprescribing [1], [2], [3], [4], [5].
Different criteria have been developed to identify the appropriate use of medicines in people ≥ 65 years old. Some are based on clinical judgements (implicit criteria) and others, the most widespread, on predetermined standards (explicit criteria). The explicit criteria include Potentially Inappropriate Medicines (PIMs) that should be avoided in any circumstances and drugs that should be avoided in patients with specific disorders [1], [6], [7], [8]. The most widely disseminated are the Beers [9], [10] and the STOPP (screening tool of older person's prescriptions) criteria [11]. The prevalence of PIMs described in the studies range from 25% to 75% of patients and polypharmacy is the main factor associated with PIMs[12], [13], [14].
The criteria for IP of medicines in older people focusing on the detection of underprescribing or potentially prescribing omissions (PPOs) are more recent. The START (screening tool to alert doctors to right treatment) criteria are a new tool in screening for PPOs in the elderly population, and the published results indicate a very high prevalence, between 51 and 72% of patients [13], [15].
Also for the most vulnerable older people, some health care quality indicators (assessing care of vulnerable elders — ACOVE) have been identified in recent years. The ACOVE project approach is more comprehensive as it includes pharmacologic care indicators [16], [17]. Studies in the United States, focusing on the ACOVE pharmacologic care indicators, show that underprescribing indicators get the worst results, affecting 50% of patients [18].
The objectives of the study were to analyze medicine consumption and inappropriate use of medications the month prior to hospital admission in medical units in older patients; to compare different tools of inappropriate prescribing focusing on PIMs (STOPP and Beers criteria) and PPOs (START criteria and ACOVE underprescribing indicators), and to explore factors associated with inappropriate use of medicines.
Section snippets
Methods
An observational, prospective, multicentric study of a cohort of patients hospitalized in the Internal Medicine Services of seven Spanish hospitals was carried out for a year (from April 2011 to March 2012).
Patients, 75 years or older, admitted with an acute illness or an exacerbation of a chronic condition who signed the informed consent, were included. Hospital admission was through either the emergency department or directly from primary care. Patients with a scheduled or a short-duration
Results
A total of six hundred and seventy-two patients were included in the study, with a median (Q1–Q3) age of 82 (79–86) years, and 55.9% were female. Table 1 shows the main baseline characteristics of the study population. The most frequent chronic conditions were arterial hypertension (78.3% of patients), heart failure (42.8%), chronic obstructive pulmonary disease (31%), diabetes mellitus (30.9%), cerebrovascular disease (27.2%) and dementia (18.4%). Sixty percent of patients were independent or
Discussion
This study focused on a comprehensive assessment of IP in older patients using different tools of PIMs as well as PPOs. In our study the prevalence of polypharmacy and the prevalence of PIMs and PPOs were high and a large proportion of patients had PIMs and PPOs concurrently according to the used instruments. In addition, a higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria and a higher prevalence of PPOs using the ACOVE-3 criteria than using the
Conclusions or key points
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More than half of our study population had simultaneous potentially inappropriate medicines and potentially prescribing omissions.
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A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria was observed.The risk factors associated to potentially inappropriate medicines differed fromthose associated with potentially prescribing omissions.
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Pharmacologic care indicators
Learning points
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Polypharmacy among older people is prevalent and it is associated with a high prevalence of potentially inappropriate medicines.
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More studies are needed to better know the factors associated with potentially prescribing omissions.
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A high proportion of older people may simultaneously have potentially inappropriate medicines and potentially prescribing omissions.
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Prescribing indicated medications of the ACOVE 3 can be considered a useful tool in detecting underprescribing in the elderly.
PIPOPS investigators
Coordinator group: Antonio San-José (main investigator), Antònia Agustí, Xavier Vidal, Cristina Aguilera, Elena Ballarín, Eulàlia Pérez, and Xavier Barroso.
Hospital Universitari Vall D'Hebron (Barcelona): José Barbé, Carmen Pérez Bocanegra, Ainhoa Toscano, Carme Pal, and Teresa Teixidor.
Hospital San Juan de Dios de Aljarafe (Sevilla): Antonio Fernández-Moyano, Mercedes Gómez Hernández, Rafael de la Rosa Morales, and María Nicolás Benticuaga Martínez.
Hospital Clínic (Barcelona): Alfonso
Author contributions
San-Jose A., and Agustí A., as directors and project leaders, had devised and wrote the proposal for obtaining the grant, wrote the manuscript and had final responsibility for the decision to submit the manuscript for publication. San-Jose A., Agustí A., Vidal X., Formiga F., López-Soto A., Fernández-Moyano A., García J., Ramírez-Duque N., Torres O.H., and Barbé J. contributed to the study design, coordinated data collection in each hospital, interpreted the data, reviewed the manuscript,
Conflict of interests
The authors declare that they have no conflicts of interest.
Acknowledgments
The project was financed by Grant No. EC10-211 obtained in a request for aid for the promotion of independent clinical research (SAS/2370/2010 Order of 27 September from the Spanish Ministry of Health, Social Affairs and Equality).
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