SciELO - Scientific Electronic Library Online

 
vol.27 issue2Secular Trends in the Mortality by Cerebrovascular Diseases in Portugal: 1902-2012Are Outcomes of Non-Invasive Ventilation in Acute Respiratory Failure Similar in Very Old Adults? author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Journal

Article

Indicators

Related links

  • Have no similar articlesSimilars in SciELO

Share


Medicina Interna

Print version ISSN 0872-671X

Medicina Interna vol.27 no.2 Lisboa Apr. 2020

https://doi.org/10.24950/O/290/19/2/2020 

ARTIGOS ORIGINAIS / ORIGINAL ARTICLES

 

Improving Elderly Patients’ Medication Appropriateness in an Internal Medicine Ward: Application of the STOPP/START Criteria

Simplificação Terapêutica em Idosos Internados numa Enfermaria de Medicina Interna: Aplicação dos Critérios STOPP/START

 

Miguel Oliva Teles1
https://orcid.org/0000-0002-0862-6345

Margarida R. Fonseca1
https://orcid.org/0000-0001-9066-2830

Ana Gomes Parola2
https://orcid.org/0000-0002-8588-820X

1Serviço de Medicina I, Centro Hospitalar de Lisboa Ocidental, Hospital Egas Moniz, Lisboa, Portugal

2Serviços Farmacêuticos, Centro Hospitalar de Lisboa Ocidental, Hospital Egas Moniz, Lisboa, Portugal

 

Abstract:

Introduction: In elderly people, polypharmacy and inappropriate prescribing are prevalent and associated with adverse events. STOPP/START criteria are a tool aiming to improve elderly medication appropriateness that has shown good validity, inter-rater reliability and applicability.

Our aim was to evaluate the impact of the application of STOPP/START criteria version 2 to the prescription of hospitalized elderly patients.

Methods: A prospective, single-centre study carried out in a tertiary internal medicine ward. Patients admitted with 65 years or more and with 5 or more medications were randomized to receive either usual physician and pharmacist care (control) or providing the patient´s attending medical team, within the first 72 hours, a pop-up recommendation indicating potentially inappropriate medications (PIM) and potentially prescribing omissions (PPO) as a result of the application of the STOPP/START version 2 criteria (intervention). Statistical analysis done with SPSS version 23 considered a p < 0.05.

Results: 156 patients were included and randomized, and 64 on the intervention group and 62 on the control group were analysed. The team observed an average PIM and PPO reduction of 49% and 31% in the intervention group versus 13% and 0% in the control group (p = 0.01). There was an average acceptance of 63% for STOPP and 40% for START criteria recommendations. In the overall population the team found a prevalence of polypharmacy of 21% and of inappropriate prescription (at least one PIM) of 75.4% and identified a total of 230 PIM and 153 PPO.

Conclusion: The team reports a high prevalence of polypharmacy and inappropriate prescription among Portuguese elderly patients admitted to an internal medicineward. The latter was significantly reduced using pop-up recommendations reporting the application of STOPP/START version 2 criteria within 72 hours of admission.

Keywords: Aged; Drug-Related Side Effects and Adverse; Reactions; Hospitalization; Inappropriate Prescribing; Polypharmacy.

 

Resumo:

Introdução: A polifarmácia e a medicação inadequada são prevalentes e contribuem para eventos adversos na população idosa. Os critérios STOPP/START são uma ferramenta que tem como objetivo contribuir para a maior adequação medicamentosa neste grupo da população.

O objetivo foi avaliar o impacto da aplicação dos critérios STOPP/START versão 2 à medicação de uma população idosa hospitalizada.

Métodos: Estudo prospetivo realizado numa enfermaria de medicina interna de um hospital terciário. Doentes internados com mais de 65 anos e medicados habitualmente com  5  ou  mais  medicamentos  foram  aleatorizados  para receber cuidados médicos e farmacêuticos habituais (controlo) ou para o envio de uma recomendação à sua equipa clínica assistente, nas primeiras 72 horas de internamento, indicando medicações potencialmente inapropriadas (MPI) e medicações potencialmente omissas (MPO), como resultado da aplicação dos critérios STOPP/START versão 2 (intervenção). Análise estatística realizada com o SPSS versão 23, considerando um p < 0,05.

Resultados: Incluídos 156 pacientes e analisados 64 na intervenção e 62 no controlo. Redução média de MPI e MPO de 49% e 31% no braço da intervenção versus 13% e 0% no controlo (p = 0,01). Aceitação média de 63% das recomendações pelos critérios STOPP e de 40% pelos START. Prevalência de polifarmácia na população total de 21% e de prescrição inadequada (pelomenos umMPI)de 75%. Identificados, no total, 230MPI e 152MPO.

Conclusão: Reportada uma alta prevalência de polifarmácia e prescrição inadequada numa população idosa internada num serviço de medicina interna, tendo esta última sido significativamente diminuída pela aplicação dos critérios STOPP/START versão 2durante as primeiras 72 horas de admissão.

Palavras-chave: Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos; Idoso; Hospitalização; Polifarmácia; Prescrição Inadequada.

 

Introduction

In elderly people, polypharmacy and potentially inadequate  prescriptions  are  prevalent and associated with a higher risk of falls, adverse reactions, hospital admissions and death.1,2 With this considered, minimizing these risks becomes an urgent imperative when caring for these patients.3 Appropriate prescribing might be considered the use of drugs with strong evidence of benefit together with the avoidance of medications with questionable or no evidence of efficacy, unfavourable risk-benefit ratio or usage, despite the patient’s life expectancy, level of functioning, goals, and personal values or preferences.3,4  Many strategies and tools have been developed to assess this appropriateness1 and, despite being limited, the scientific evidence available so far suggests them to be safe and to produce more benefits than harms.1,5-7 STOPP/START criteria version 2 is one of these tools aiming to improve elderly medication appropriateness. It combines a deprescribing method, by identifying potential inappropriate medications (PIM), with the identification of potential prescribing omissions (PPO). It consists of 80 STOPP and 34 START criteria, grouped according to physiological systems (e.g. cardiovascular, musculoskeletal, respiratory, etc.) to allow for easy and rapid medication reviews. STOPP consists of 80 indicatorsfor potentially inappropriate medications, meaning medications commonly causing drug-drug and drug-disease interactions, unnecessary therapeutic duplication, and increased risks of cognitive decline and falls in older people. START is comprised of 34 criteria identifying under-prescribed medications that should be considered. The tool has been validated and demonstrated good inter-rater-reliability and applicability in the United Kingdom and Europe.8

Aim of the Study: This study’s aim was to evaluate the impact of the application of STOPP/START version 2 criteria to the prescription of elderly patients admitted to a Tertiary Hospital’s Internal Medicine Ward.

 

Methods

Study design and population: The study was a prospective, single-centre study conducted in an internal medicine ward of Hospital Egas Moniz (Centro Hospitalar Lisboa Ocidental), a state-funded, tertiary hospital in Lisbon, Portugal. During an 8-month period, all patients aged 65 or older and with 5 or more prescribed medications were included. The following drop-out criteria were admitted: admissions shorter than 72 hours and death during admission. The study’s protocol was approved by the local Ethics Committee and was conducted in accordance with the Declaration of Helsinki.

Baseline data collection: All included patient’s information was obtained from the hospital’s and primary care electronic medical records and from interviews with the patient and/or relatives. On admission, baseline data regarding demographic details, functional status (Katz Index of Independence in Activities of Daily Living) and previous medications (number of drugs, dose, frequency and duration) were collected.

Randomization: All included patients were randomly assigned at a 1:1 ratio to the intervention and control group through simple randomization.

Intervention: Within the first 72 houres of admission the team of investigators (5 physicians and 1 hospital pharmacist) applied the STOPP/START version 2 criteria to the baseline data of patients in the intervention group, identifying poten- tially inappropriate medications (PIM) and potential prescribing omissions (PPO). Interventional recommendations were sent within the same day of theapplication of the criteria to the patient’s attending team through a pop-up message on the in-hospital prescription software and consisted of simple statements informing the team about the patient’s specific PIM and PPO. The attending team judged these and decided whether to or not to follow and implement the recommended changes.

Participants in the control group received usual hospital physician and pharmacist care.

Outcome measures: The primary outcomes were the rate of difference in the number of PIM and PPO between admission and discharge and the rate of recommendations acceptance (calculated as the ratio between the number of changed PIM and PPO according to the recommendations and the total identified at admission).

Collection of outcome data: At discharge, the research team collected data on all patient’s medication and applied the STOPP/START version 2 criteria to both group’s discharge medication list.

Data analysis: All statistical analysis was performed using the SPSS Statistics version 23. Patient characteristics were described as number, percentage and mean, as appropriate. Independent t-test was used to examine the continuous variables while contingency tables and chi-square tests were used to evaluate the categorical variables (assumptions of their applicability were tested and confirmed). Analyses were two-sided and the statistical significance level was set at á 0.05 with a 95% confidence interval; a p-value of 0.05 was considered as statistically significant.

 

Results

Baseline characteristics: The research team randomized 156 eligible patients and thirty patients were lost to follow-up due to death during admission, resulting in 126 included in the final statistical analysis (Fig. 1). The baseline characteristics (Table 1) did not differ between the control and intervention groups nor between the analysed patients and those who died (p > 0.05).

Primary Outcomes: At the time of discharge, comparing the differences from admission to discharge between the intervention and control groups, the team observed an average PIM reduction of 49% [0.30, 0.69] on the intervention group and 13% [0.03, 0.24] on the control group (p < 0.01). Regarding PPO they observed a 31% [0.16, 0.46] reduction in the intervention group, whereas in the control group there was no reduction (p = 0.01). The frequency of PIM and PPO on each group at times of admission and discharge is represented in Fig. 2.

Individually, the team saw an average reduction of 1 PIM [0.45, 1.14] per patient on the intervention group, which was not observed in the control group (p = 0.06). The average reduction of PPO was lower than 1 in both groups.

There was an average STOPP criteria acceptance of 63% [0.50, 0.75] (meaning that among the total of PIM criteria identified 63% were changed according to the recommendations) and an average START criteria acceptance of 40% [0.27, 0.59]. As depicted in Fig. 3 the most accepted STOPP criteria groups were those from the renal system (E), musculoskeletal system (H), and cardiovascular system (B). Among the renal system criteria, the drugs withdrawn were drugs not recommended in the presence of a lower glomerular filtration rate, as was the case of digoxin, metformin or nonsteroidal anti-inflammatory drugs (NSAIDs). Regarding the musculoskeletal system criteria, it corresponded to the withdrawing of NSAIDs in the presence of arterial hypertension. Within the cardiovascular system criteria, the drugs discontinued were related either to the absence of evidence-based recommendation (as the use of digoxin in heart failure with preserved left ventricular function, amiodarone as first-line anti-arrhythmic for supraventricular arrhythmia and loop diuretics for ankle oedema without heart failure) or to the risk of adverse effects (as the concomitant use of beta-blockers and verapamil or diltiazem, aldosterone and other potassium-conserving drugs without proper monitoring and the use of thiazides with known risk of hydroelectrolytic disturbances).

Regarding the START criteria, as represented in Fig. 4, the most accepted groups were the analgesics (H), respiratory system (C) and urogenital system (G). Among the first group it concerned the initiation of opioids for moderate-to-severe pain as well as the initiation of laxatives for those already using them; among the respiratory system criteria the initiation of home continuous oxygen and regular bronchodilator for mild to moderate asthma or COPD were the recommendations accepted and applied; and regarding the urogenital system it was concerned with the initiation of 5-alpha reductase inhibitor for prostatism.

Secondary Outcomes: The prevalence of polypharmacy on our total population was 21% (out of 760 patients over 65 years old, 156 had 5 or more medications).

The prevalence of inappropriate prescription (the presence of at least one PIM) at the time of admission was 75.4% in the overall population, 38.1% in the intervention group and 37.3% in the control group. At the time of discharge, in the intervention group there was a reduction of this prevalence in 13.5%(from), compared with 2% in the control group (p < 0.01).

There was no reduction of the number of medications (and subsequently no changes in the prevalence of polypharmacy) between admission and discharge on neither of the study groups.

The research team identified 230 potentially inappropriate medications (PIM) and 153 potential prescribing omissions (PPO) after applying the STOPP/START version 2 criteria to the time of admission’s medication list from both study groups (Table 2). Each patient had on average two PIM and two PPO. More than half of the patients (53%) had two or more PIM and 36% of them had 2 or more PPO. The minimum was no PIM or PPO found and the maximum was 6 PIM or PPO per patient. Less than10% of the population (10 patients) hadboth no STOPP nor START criteria identified.

The most common PIM criteria groups identified were “any drug prescribed without an evidence-based clinical indication” (30%), “central nervous system and psychotropic drugs” (20%) and “drugs that predictably increase the risk of falls in older people” (20%). The most common PPO criteria groups were “vaccines” (41%), “endocrine system” (24%) and “cardiovascular system” (21%).

Discussion: We found a high prevalence of polypharmacy in our randomized sample (21%), which is consistent with the international data concerning the problem of polypharmacy among elderly patients. Despite differences in the methodology and distinct definitions of polypharmacy and old age, this is reported as a global issue - 16.3% in a Scottish study, 11% in a Swedish primary care population, 15% in a nation-wide USA database, 6% in a rural Chinese population, 33% in elderly Brazilians and 86.4% of Korean elders.9-14 As noted by a recent report from SYMPATHY - an EU-funded consortium dedicated to innovating the management of polypharmacy among European elders - studies in the Portuguese population are scarce and limited to a few hospital services and nursing homes.15 Considering the direct association between polypharmacy and medication appropriateness, in ours and others’ opinion, the best way to tackle the problem of overmedication in the elderly is to unite simplification or deprescribing methods with ones that aim to improve medication appropriateness.16-18

Hence, the aim of this study was to evaluate the results of applying the STOPP/START version 2 criteria in a systematic way to patients admitted to an internal medicine ward. As with polypharmacy, we also report a high prevalence of potentially inappropriate medication (75.4%), which has been defined by the existence of at least one PIM and is in accordance to those reported by recent systematic reviews.6,7,19 We also observed that the use of pop-up recommendations reporting the application of these criteria within 72 houres of admission resulted in a significant reduction of the prevalence of potentially inappropriate medications and potential prescribing omissions, when compared with usual physician and pharmacist care. Despite the need for more robust studies, the systematic reviews mentioned previously suggest that these interventions might result in an improvement of medication appropriateness and clinical outcomes, such as the use of primary care services and the rate of hospital admissions, medication-related outcomes and quality of life.6,7

Regarding the acceptance rates of the recommendations for prescription changes they were lower than previously reported ones.20 This could be interpreted as a result of potential methodological limitations – associated learning curve to the application of the criteria and understanding of the recommendations7, ineffective communication interface and/or inherent inertia from the home teams. On the other hand, we could also hypothesize that the reported results could be amplified after the improvement of these weaknesses and the criteria’s application to a bigger sample.

The team did not observe a reduction in the number of medications or pills in neither of the groups. This could be a reflection of the complexity of polypharmacy, particularly the difficulty between achieving a balance between its harms and the increasing need of medications recommended by a growing body of guidelines, in an effort to better manage the multiple comorbidities prevalent among the elderly.2

The pharmacotherapeutic group most implicated in PIM was the class of benzodiazepines (both D5, G5 and K1, Table 2). Benzodiazepines have been broadly reported as an important public health issue in elderly care, due to its association with serious adverse drug events as impaired cognitive function, delirium, respiratory insufficiency, falls and fall-related injuries, such as hip fractures.1 The presence of these PIM were reduced more in the intervention group than in the control, which seems to us to reinforce the need of a cared and systematized medication review, such as that aimed by the use of the STOPP/START version 2 criteria or other similar tools. Following benzodiazepines, the most frequent PIM was A1, regarding drugs prescribed without evidence-based indication, hence comprising a varied list of drugs that were either used with- out an objective presence of its proper indication (as happened mainly with anti-platelet therapy like aspirin or clopidogrel, antidementia agents, bronchodilators, betahistine, pentoxyfilline, benzodiazepines and anti-psychotics) or other drugs without supporting evidence as trimetazidine dihydrochloride, citicoline, and multiple vitamin supplements. Despite not having the highest acceptation rate this was the recommendation that result in the higher absolute number of drug discontinuation.

The most common PPO found were vaccines (influenza and pneumococcal) and vitamin D supplementation, for both of which we found no considerable difference in both groups between admission and discharge. While the former is probably explained by the fact that vaccination is usually a measure concerning primary care, the latter is based on the differences between the criteria and the national recommendations regarding the use of vitamin D supplements in the elderly.21

As mains limitations the team would point the small population, probably underpowering its results, and the methodological weaknesses already discussed above.

 

Conclusion

Polypharmacy is an important issue regarding the healthcare of the elderly, and efforts to tackle this problem are becoming part of national and international recommendations and task forces. This was the first study evaluating the application of a deprescribing process in a Portuguese internal medicine ward. It found a high prevalence of polypharmacy and inappropriate prescription among Portuguese elderly patients admitted to an internal medicine ward that was significantly reduced by the use of pop-up recommendations reporting the application of STOPP/START version 2 criteria within 72 houres of admission, when compared with usual physician and pharmacist care. Considering its limitations and the need for more research, it will contribute to raise awareness for the problem of polypharmacy and be a starting point for further studies or clinical experiences on systematic deprescribing programs for the multi-faceted care of our elderly population.

 

REFERENCES

1.      Motter FR, Fritzen JS, Hilmer SN, Paniz ÉV, Maria V, Paniz V. Potentially inappropriate medication in the elderly: a systematic review of validated explicit criteria.  Eur J Clin Pharmacol. 2018;74:679-700. doi: 10.1007/s00228-018-2446-0.         [ Links ]

2.      Payne RA. The epidemiology of polypharmacy. Clin Med. 2016;16:465-9. doi: 10.7861/clinmedicine.16-5-465.         [ Links ]

3.      Scott I a, Gray LC, Martin JH, Pillans PI, Mitchell C. Deciding when to stop: towards evidence-based deprescribing of drugs in older populations. Evid Based Med. 2013;18:121–4.         [ Links ]

4.      Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy. JAMA Intern Med. 2015;175:82734. doi: 10.1001/jamainternmed.2015.0324.         [ Links ]

5.      Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. The benefits and harms of deprescribing. Med J Aust. 2014;201:386–9.         [ Links ]

6.      Rankin A, Ca C, Sm P, Kerse N, Cr C, Mc B, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev. 2018;9: CD008165.  doi: 10.1002/14651858.CD008165.pub4.         [ Links ]

7.      Hill-Taylor B, Sketris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: A systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38:360–72.

8.      O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2014;44:1–6.

9.      Guthrie B, Makubate B, Hernandez-santiago V, Dreischulte T. The rising tide of polypharmacy and drug-drug interactions : population database analysis 1995 – 2010. BMC Med. 2015;1–10.         [ Links ]

10.     Kantor ED, Rehm CD, Haas JS, Chan AT, Giovannucci EL, Sloan M, et al. Trends in Prescription Drug Use among Adults in the United States from 1999-2012. JAMA. 2016 ;314:1818-31. doi: 10.1001/jama.2015.13766.         [ Links ]

11.      Kim H, Shin J, Kim M, Park B. Prevalence and Predictors of Polypharmacy among Korean Elderly. PLoS One. 2014;9:e98043. doi: 10.1371/journal.pone.0098043.         [ Links ]

12.      Dong L, Yan H, Wang D. Polypharmacy and its correlates in village health clinics across 10 provinces of Western China. J Epidemiol Community Health. 2010;549–53.         [ Links ]

13.      Passos LC. Factors associated with potentially inappropriate medication use by the elderly in the Brazilian primary care setting. Int J Clin Pharm. 2012;626–32.         [ Links ]

14.      Hovstadius  B, Hovstadius K, Åstrand B, Petersson G. Increasing polypharmacy - an individual-based study of the Swedish population 2005-2008. BMC Clin Pharmacol. 2010; 10:16.  doi: 10.1186/1472-6904-10-16.         [ Links ]

15.      Malva J, Llimos-Fernandez F. Case Study Summary Portugal. SIMPATHY 2019 [accessed Dec 2019]. Disponível em http://www.simpathy.eu/re-sources/case-studies/case-study-portugal        [ Links ]

16.      Stewart D, Mair A, Wilson M, Kardas P, Alonso A, Mcintosh J, et al. Guidance to manage  inappropriate polypharmacy in older  people: systematic review and future developments. Expert Opin Drug Saf. 2017;16:203-13. doi: 10.1080/14740338.2017.1265503.         [ Links ]

17.      Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175:827-34. doi: 10.1001/jamainternmed.2015.0324.         [ Links ]

18.      Wilson M, Mair A, Dreischulte T, Witham M. Prescribing to fit the needs of older people - the NHS Scotland Polypharmacy Guidance, 2nd edition. J R Coll Physicians Edinb. 2015;108–13.         [ Links ]

19.      Thomas RE, Thomas BC. A Systematic Review of Studies of the STOPP / START 2015 and American Geriatric Society Beers 2015 Criteria in Patients ≥ 65 Years. Curr Aging Sci. 2019;12:121-54. doi: 10.2174/1874609812666190516093742.         [ Links ]

20.      Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89:845–54. doi: 10.1038/clpt.2011.44.

21.      Direção-Geral da Saúde. Norma de Orientação Clínica No 004/2019. Prevenção e Tratamento da Deficiênciade Vitamina D. Lisboa:DGS; 2019.

 

Responsabilidades Éticas

Conflitos de Interesse: Os autores declaram a inexistência de conflitos de interesse na realização do presente trabalho.

Fontes de Financiamento: Não existiram fontes externas de financiamento para a realização deste artigo.

Confidencialidade dos Dados: Os autores declaram ter seguido os protocolos da sua instituição acerca da publicação dos dados de doentes.

Proteção de Pessoas e Animais: Os autores declaram que os procedimentos seguidos estavam de acordo com os regulamentos estabelecidos pelos responsáveis da Comissão de Investigação Clínica e Ética e de acordo com a Declaração de Helsínquia da Associação Médica Mundial.

Proveniência e Revisão por Pares: Não comissionado; revisão externa por pares.

 

Ethical Disclosures

Conflicts of interest: The authors have no conflicts of interest to declare.

Financing Support: This work has not received any contribution, grant or scholarship

Confidentiality of Data: The authors declare that they have followed the protocols of their work center on the publication of data from patients.

Protection of Human and Animal Subjects: The authors declare that the procedures followed were in accordance with the regulations of the relevant clinical research ethics committee and with those of the Code of Ethics of the World Medical Association (Declaration of Helsinki).

Provenance and Peer Review: Not commissioned; externally peer reviewed.

 

© Autor (es) (ou seu (s) empregador (es)) 2019. Reutilização permitida de acordo com CC BY-NC. Nenhuma reutilização comercial.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use.

 

Correspondence / Correspondência:

Miguel Oliva Teles – migueloteles@gmail.com

Serviço de Medicina I, Centro Hospitalar de Lisboa Ocidental, Hospital Egas Moniz, Lisboa, Portugal

Rua da Junqueira, 126, 1349-019 Lisboa

 

Received / Recebido: 15/01/2020

Accepted / Aceite: 28/02/2020

 

Publicado / Published: 27 de Junho de 2020

 

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License