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

1. 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

2. 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

3. 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

4. Introduction • STOPP&START • European • Consensus 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

5. START List : examples

6. START List • Currently • Limited data on prevalence of underprescribing according to START • No data on the link with adverse clinical outcomes

7. 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.

8. 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

9. 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

10. 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

11. 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

12. Results 2: drugs before admission Drugs: 2.028 drugs (6±3) > 5 drugs/day : 64 %

13. 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 %)

14. 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%).

15. 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.

16. 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

17. 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)

18. Results 3 : hospital admissions and PO events

19. 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

20. Conclusions • Screening for cardiovascular diseases and fall history = essential • Pharmacological prevention • 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 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.

21. Results 3 : hospital admissions (n=302) • The most frequent main reasons for acute hospital admission were • Cardio-respiratory symptoms : 115 • Falls : 103 • Abdominal reason : 38 • Infection : 31 • Other : 15