Inappropriate, Omitted Rx Common at Discharge for Older Adults

Troy Brown, RN

May 17, 2018

Potentially unsafe prescriptions are common at the time of discharge for older patients, according to a new study, with 83.8% of patients receiving at least one potentially inappropriate medication (PIM) or having a potential prescribing omission (PPO).

Patients with at least one PIM were significantly more likely to experience three or more readmissions, and those with at least one PPO were significantly more likely to die during the study follow-up.

"The study provides good evidence that older patients are often prescribed potentially harmful medications, and there are missed opportunities for prescribing medications that would be beneficial," said Andrew Dunn, MD, MPH, FACP, SFHM, who was not involved in the study. Dunn is chair of the American College of Physicians Board of Regents and professor of medicine, chief, Division of Hospital Medicine, Department of Medicine, Mount Sinai Health System, New York City.

David Counter, MBChB, from the NHS Grampian Aberdeen Royal Infirmary in, Aberdeen, United Kingdom, and colleagues report their findings online May 10 in the British Journal of Clinical Pharmacology.

The Screening Tool of Older Person's Prescriptions/Screening Tool to Alert Doctors to the Right Treatment (STOPP/START) criteria were published in 2008 and are widely used in Europe. They were updated in 2014 to include 80 STOPP criteria and 34 START criteria. Additions to the STOPP criteria cover antiplatelet/anticoagulant medications, medications that affect or are affected by renal function, and medications that raise anticholinergic burden. Added START categories include urogenital system medications, analgesic drugs, and vaccines.

"PIMs and PPOs identified using this tool have been associated with increased frequency of adverse drug reactions, increased morbidity and mortality and reduced quality of life," Counter and colleagues explain. "Interventional studies applying these criteria to reduce PIMs and PPOs have reported reduced incidence of [adverse drug events], falls, and delirium with reduced duration of hospitalisation and healthcare costs."

To determine the association between PIMs and PPOs and hospital readmission and mortality rates among older adults, the researchers conducted a retrospective study using the updated criteria. They examined data on consecutive emergency admissions of 259 patients (mean age, 77 years; range, 65 - 97 years; 51% women) to a hospital medical ward during an 8-month period, with a mean follow-up duration of 41.5 months (standard deviation [SD], 2.0; range, 38 - 46 months).

At discharge, patients had a mean of 5.4 comorbidities (SD, 2.1; range, 0 - 14 comorbidities). Patients were prescribed a mean of 9.3 distinct medications at discharge (SD, 4.0; range, 1 - 31 medications), with 88.8% (n = 230) receiving five or more distinct medications and 44% (n = 114) receiving 10 or more distinct medications.

Patients had a median number of two readmissions (interquartile range, 1 - 4), and just more than half (50.2%; n = 130) died during follow-up.

After adjusting for demographic and outcome variables, patients who had more than five medications prescribed were more than twice as likely to have PIMs (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.34 - 5.62), and more than threefold as likely to have PPOs (OR, 3.20; 95% CI, 1.57 - 6.54), compared with patients who had fewer than five medications.

PIMs and PPOs were tied to worse patient outcomes. Specifically, those who had a PIM were twice as likely to have three or more hospital readmissions (OR, 2.43; 95% CI, 1.19 - 4.98; P < .05), and those with PPOs were also significantly more likely to die (OR, 1.88; 95% CI, 1.09 - 3.27; P < .05) overall.

After adjustment, patients who received prescriptions for more than five medications at discharge were five times more likely to experience at least one potentially inappropriate prescription (PIP; OR, 5.86; 95% CI, 2.56 - 13.39; P < .001). Those who had one or more PIP were also significantly more likely to die during the follow-up period (OR, 2.51; 1.20 - 5.28; P = .015).

The reasons for the increased mortality are unclear. "[H]owever it is possible that the failure to commence evidence based therapies may result in increased morbidity and mortality or that in a population with high inherent mortality and poor prognosis prescribers are less willing to add to their medication burden," the researchers explain.

"[S]ometimes it is hard to disentangle if it's medications that are causing the problem, the kind of access to higher-quality primary care that's the problem, or the underlying issues around psychiatric illness or pain which cause these problems. [T]hose are all very tightly interrelated and hard to disentangle in the observational study," Andrew Auerbach, MD, MPH, editor-in-chief, Journal of Hospital Medicine, and professor of medicine, University of California, San Francisco, School of Medicine, told Medscape Medical News.

Clinical Judgement Critical, Experts Say

Most physicians use their clinical judgment, rather than strict criteria alone. "The Beers criteria are helpful and can be used for older adults; however, they may not apply well to all patients. For example, an older adult with no comorbidities and excellent functional status may tolerate a medication on the list better than a patient with multiple severe comorbidities," Dunn explained.

"Many clinicians pay close attention to the medications they prescribe to older adults, but there is a lack of a standardized process to reduce the risks of overprescribing and underprescribing," he added.

Auerbach concurred. It is true that there is no standard algorithm, "because there's probably multiple algorithms based on whether it's a patient with chronic pain or patients with difficult-to-control thought disorders or refractory depression. A lot the medications that you use for all those are on the list of potentially inappropriate medications from Beers and STOPP/START. That's where you have to start using clinical judgment," he said.

Auerbach said in some cases, a patient's primary physician may have put them on a "third- or fourth-line medication" after trying others that were ineffective or had intolerable adverse effects, and the patient may have taken that medication for a long time with good results.

That said, the authors emphasize that their findings are clinically important. "Applying version 2 of the STOPP/START criteria to a population of older adults before discharge from hospital identifies those at high risk of readmission and death who may benefit from interventions to reduce PIMs and PPOs," the researchers conclude.

"We now need studies that rigorously assess whether applying these criteria prior to discharge can help physicians provide better care and improve patient outcomes," Dunn said.

The authors have disclosed no relevant financial relationships. Dunn and Auerbach have disclosed no relevant financial relationships.

Br J Clin Pharmacol. Published online May 10, 2018. Abstract

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