Original Article
Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

https://doi.org/10.1016/j.ejim.2014.07.011Get rights and content

Highlights

  • A high prevalence of polypharmacy and of PIMs and PPOs were reported in the study.

  • More than half of our study population had simultaneous PIMs and PPOs.

  • The risk factors associated to PIMs differed from those associated with PPOs.

  • The STOPP criteria detect a higher prevalence rate of PIMs than the Beers criteria.

  • The ACOVE-3 criteria detect a higher prevalence of PPOs than the START criteria.

Abstract

Purpose

This study aims to assess inappropriate prescribing (IP) to elderly patients during the month prior to hospitalization and to compare different IP criteria.

Methods

An observational, prospective and multicentric study was carried out in the internal medicine services of seven Spanish hospitals. Patients aged 75 years and older were randomly selected after hospital admission for a year. To assess potentially inappropriate medicines (PIMs), the Beers and STOPP criteria were used and to assess potentially prescribing omissions (PPOs), the START criteria and ACOVE-3 medicine quality indicators were used. An analysis to assess factors associated with IP was performed.

Results

672 patients [median age (Q1–Q3) 82 (79–86) years, 55.9% female] were included. Median prescribed medicines in the month prior to hospitalization were 10(Q1–Q3 7–13). The prevalence of IP was 87.6%, and 54.3% of patients had PIMs and PPOs concurrently. A higher prevalence rate of PIMs was predicted using the STOPP criteria than with the Beers criteria (p < 0.001) and a higher prevalence of PPOs using the ACOVE-3 criteria than using the START criteria (p < 0.001) was observed. Polypharmacy (≥ 10 medicines) was the strongest predictor of IP [OR = 11.34 95% confidence interval (CI) 4.96–25.94], PIMs [OR = 14.16, 95% CI 6.44–31.12], Beers-listed PIMs [OR = 8.19, 95% CI 3.01–22.28] and STOPP-listed PIMs [OR = 8.21, 95% CI 3.47–19.44]. PIMs was the strongest predictor of PPOs [OR = 2.79, 95% CI 1.81–4.28].

Conclusions

A high prevalence of polypharmacy and PIMs and PPOs were reported. More than half the patients had simultaneous PIMs and PPOs. The related factors to PIMs and PPOs were different.

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

  • More than half of our study population had simultaneous potentially inappropriate medicines and potentially prescribing omissions.

  • 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.

  • Pharmacologic care indicators

Learning points

  • Polypharmacy among older people is prevalent and it is associated with a high prevalence of potentially inappropriate medicines.

  • More studies are needed to better know the factors associated with potentially prescribing omissions.

  • A high proportion of older people may simultaneously have potentially inappropriate medicines and potentially prescribing omissions.

  • 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).

References (32)

  • C.B. Chang et al.

    Potentially inappropriate medications in geriatric outpatients with polypharmacy: application of six sets of published explicit criteria

    Br J Clin Pharmacol

    (2011)
  • M.S. Dimitrow et al.

    Comparison of prescribing criteria to evaluate the appropriateness of drug treatment in individuals aged 65 and older: a systematic review

    J Am Geriatr Soc

    (2011)
  • D.M. Fick et al.

    Updating the Beers Criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts

    Arch Intern Med

    (2003)
  • American Geriatrics Society

    Beers Criteria update expert panel. American Geriatics Society updated Beers Criteria for potentially inappropriate medication use in older adults

    J Am Geriatr Soc

    (2012)
  • P.F. Gallagher et al.

    STOPP (screening tool of older persons' potentially inappropriate prescriptions): application to acutely ill elderly patients and comparison with Beers Criteria

    Age Ageing

    (2008)
  • D. Fialová et al.

    Potentially inappropriate medication use among elderly home care patients in Europe

    JAMA

    (2005)
  • Cited by (50)

    • Proactive inter-disciplinary CME to improve medication management in the elderly population

      2021, Research in Social and Administrative Pharmacy
      Citation Excerpt :

      A univariate logistic regression analysis was carried out to identify variables that were dependently associated with PIPs. It was found that older age, number of daily drugs taken and DDIs were positively associated with PIPs (p-values respectively: 0.047, <0.001, <0.001), confirming the close association between a higher number of drugs and inappropriate prescriptions, which has been extensively reported in the literature.33–35 GPs were asked to evaluate their level of satisfaction of attending the CME, focusing on: selection method used, inter-disciplinary approach, use of the Infologic CDSS and patient response to the proposed program.

    • Integrated health intervention on polypharmacy and inappropriate prescribing in elderly people with multimorbidity: Results at the end of the intervention and at 6 months after the intervention

      2021, Medicina Clinica
      Citation Excerpt :

      The appropriate use of medicines in the elderly, especially in those with high multimorbidity and polypharmacy, is complex.6 Recent studies in our area have shown a high prevalence of inappropriate prescribing (IP) in elderly people,7,8 and more than half of them had simultaneously problems of both over and under prescribing.7 There is also evidence that in these people, IP is associated with poorer health outcomes, adverse events and more visits to the emergency room and unplanned hospital admissions.9,10

    View all citing articles on Scopus
    View full text