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Prescribing Omissions according to START and related hospital admission in geriatric patients

O. Dalleur1, A. Spinewine2, S. Henrard3, C. Losseau4, N. Speybroeck3, B. Boland3,4

1 Pharmacy and 4 Geriatric Medicine departments , St-Luc Hospital, 2 Louvain Drug Research Institute and CHU Mont-Godinne

3 Institute of Health and Society,

4ème Symposium du CRIV à Bruxelles 29 septembre 2011

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Introduction Use of medicine in elderly patients is complex:

PK/PD changes Increased sensitivity to adverse drug events

Hospitalization risk Many co-morbidities Polymedication Compliance issue

Inappropriate prescribing : Overuse Misuse UNDERUSE

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Introduction

Explicit tools to detect inappropriate prescription in elderly : Beers, Laroche, STOPP-START …

Under-prescription : ACOVE criteria START = Screening Tool to Alert doctors to Right

Treatment

STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation International Journal of Clinical Pharmacology and Therapeutics, Vol. 46 – No. 2/2008 (72-83) Screening Tool of Older Persons' Potentially inappropriate Prescriptions Age and Ageing 2008; 37: 673–9

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Introduction

STOPP&STARTEuropeanConsensus opinion of a panel of experts in

geriatric medicine, clinical pharmacology, psychiatry of old age, pharmacy and general practice.

>65y

START : 22 situations/comorbidities « at risk » linked with 17 drugs

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START List : examples

Situation Drugs to “start”

Chronic atrial fibrillation Warfarin

or Aspirin where warfarin is contraindicated

Chronic heart failure Angiotensin converting enzyme

Patients taking maintenance corticosteroid therapy

Bisphosphonates

Diabetes mellitus with coexisting major cardiovascular risk factors (hypertension, hypercholesterolemia, smoking history)

Antiplatelet therapy

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START List

CurrentlyLimited data on prevalence of

underprescribing according to START

No data on the link with adverse clinical outcomes

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Purpose

To study the performance of START (Screening Tool to Alert doctors to Right Treatment)

in detecting prescribing omissions (PO) at home

and related acute hospital admissions in frail older people.

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Methods Study: transversal retrospective study

Eligibility: acute hospital admission (not in a geriatric unit) in 2008 in St

Luc age ≥ 75 years frailty score ISAR ≥ 2/6 CGA by the geriatric liaison team

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Methods

Data collection geriatric : social situation, functional/mental status,

nutrition medical :

detailed medical history/comorbidities (including GFR) drug list at home (prescription + OTC) Main reason for admission

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Methods

Outcome measures Prevalence of PO events at home

PO = prescribing omission = the patient does not receive a drug he/she should receive according to START criteria

Events identified by screening of drug list according to START criteria by a clinical pharmacist and a geriatrician

Multivariate analysis to identify risk factors

Link between PO and hospitalizations By a clinical pharmacist and a geriatrician Based on clinical judgement Multivariate analysis to identify risk factors

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Results 1 : population characteristics

Geriatric Syndromes falls (58 %), malnutrition (30 %), cognitive decline (25 %), depression (25 %)

Co-morbidities hypertension (55 %), ischemic CV diseases (40 %), osteoporosis (26 %), atrial fibrillation (25 %), diabetes (23 %), COPD (15 %)

302 frail older people Age 84 years ± 5; ♀ 61 %Home 83 % (alone 43 %) vs. nursing home 17 %ISAR score : 2 - 6 / 6 ; average 3,5 ± 1

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Results 2: drugs before admission

Drugs: 2.028 drugs (6±3)> 5 drugs/day : 64 %

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Results 2: PO prevalence

Detection of 362 PO events

Prevalence 63 % (189/302) (>1 patient/ 2)

Distribution : 0 (37 %), 1 (29 %), 2 (19 %), ≥ 3 (15 %)

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Results 2 : PO according to STARTdrug classes Three medical conditions (ischemic disease, diabetes,

osteoporotic fracture) accounted for 52 % of all PO events.

The drugs which were the most frequently omitted were: aspirin (prevalence = 21%), statins (19%), calcium and vitamin D (17%), vitamin K antagonists (11%) biphosphonates (10%).

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Results 2: drugs before admission

Multivariate analysis PO significantly associated with :

diabetes [OR=13.1; 95% CI: 5-34] atrial fibrillation [OR 7.9; 3.5-17.9]

osteoporotic fracture [OR 4.3; 2.0-9.2] COPD [OR 3.8; 1.3-10.6]

ischemic disease [OR 2.3; 1.5-3.5] No significant association was observed with any

geriatric syndrome.

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Results 3 : hospital admissions and PO events

Hospital admission was related to PO

in 38 patients (13%) 38/189 having POs =1 patient/5

19 falls with fracture while not receiving fracture prevention

calcium, vitamin D, biphosphonate

16 cardiovascular problems aspirin, statins, ACEI

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Results 3 : hospital admissions and PO events

Multivariate analyses : predictors of PO-related admission

previous osteoporotic fracture (p<0.001) atrial fibrillation (p=0.004)

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Results 3 : hospital admissions and PO events

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Conclusions PO at home is too frequent in frail older

persons… 1 patient/2

Most frequent ones : aspirin statins calcium and vitamin D

PO may have contributed to one in eight acute hospital admissions

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Conclusions

Screening for cardiovascular diseases and fall history = essential

Pharmacological prevention

Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria.Gallagher PF, O'Connor MN, O'Mahony D.Clin Pharmacol Ther. 2011 Jun;89(6):845-54.

How to do better?Gallagher : STOPP/START → prescribing appropriateness improvement in older patients?

•Number needed to screen of 4.7 to yield improvement in AOU. •Recommendation to apply STOPP/START screening to elderly patients’ prescription every 6 months. •Helping comprehensive data on the patients’ treatment and co-morbidities, the application of the criteria to the patient’s treatments takes only a few minutes

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Results 3 : hospital admissions (n=302)

The most frequent main reasons for acute hospital admission were Cardio-respiratory symptoms : 115 Falls : 103Abdominal reason : 38 Infection : 31Other : 15