Background
Methods
Study design, setting and participants
Data collection
Medical and background data
Drugs and inappropriate prescribing
Determinants of PIP
Clinical importance
Statistical analysis
Results
Characteristics of the patients
| ||
Age (years), median [Q25;Q75] | 84.0 [81.7;86.6] | |
Gender, women, n (%) | 356 (62.8) | |
Resident in a nursing home, n (%) | 57 (10.1) | |
Number of drugs/day, median [Q25;Q75] | 5 [4;7] | |
Geriatric features
| ||
Polypharmacy (≥ 5 drugs/day), n (%) | 337 (61) | |
ADL,a median [Q25;Q75] | 25 [21;27] | |
Living alone at home, n (%) | 212 (37.4) | |
Urinary incontinence, n (%) | 126 (22.2) | |
Cognitive impairement, n (%) | 89 (15.7) | |
BMI < 21 kg/m², n (%) | 49 (8.6) | |
MMSE,b median [Q25;Q75] | 28 [25;29] | |
Tinetti score,c median [Q25;Q75] | 27 [24;28] | |
GDS-15,d median [Q25;Q75] | 2 [1;4] | |
CIRS median [Q25;Q75] | 4 [3;5] | |
Most frequent comorbidities
| ||
Hypertension, n (%) | 396 (69.8) | |
Osteoarthritis, n (%) | 324 (57.1) | |
Ischemic disease, n (%) | 210 (37.0) | |
Chronic heart failure, n (%) | 166 (29.3) | |
Chronic renal disease (GFR < 50 ml/min), n (%) | 143 (25.2) | |
Osteoporosis, n (%) | 125 (22.0) | |
Diabetes, n (%) | 107 (18.9) | |
Depression, n (%) | 74 (13.1) | |
COPD, n (%) | 65 (11.5) | |
Atrial fibrillation, n (%) | 58 (10.2) | |
Most frequent drugs prescribed, n patients (%)
| ||
Antithrombotic agents (B01) | 312 (55.0) | |
Beta-blocking agents (C07) | 238 (42.0) | |
Agents acting on the renin-angiotensin system (C09) | 237 (41.8) | |
Psycholeptics (N05) | 220 (38.8) | |
Diuretics (C03) | 189 (33.3) | |
Lipid Modifying Agents (C10) | 180 (31.7) | |
Drugs for acid related disorders (A02) | 138 (24.3) | |
Calcium Channel Blockers (C08) | 135 (23.8) | |
Psychoanaleptics (N06) | 131 (23.1) | |
Cardiac Therapy (C01) | 115 (20.3) | |
Potentially inappropriate prescribing, n patients (%)
| ||
START-PIPs | 336 (59.3) | |
STOPP-PIPs | 232 (40.9) | |
Beers-PIPs | 180 (31.7) |
Inappropriate prescribing
Therapeutic class/medication ± disease | Prevalence % (n) | |
---|---|---|
Under prescribing according to START
| ||
Aspirin or clopidogrel with a documented history of atherosclerotic coronary, cerebral or peripheral vascular disease in patients with sinus rhythm | 15,0 (85) | |
Calcium and vitamin D supplement in patients in the presence of known osteoporosis | 13,9 (79) | |
ACE inhibitor in the presence of chronic heart failure | 12,7 (72) | |
Statin therapy with a documented history of coronary, cerebral or peripheral vascular disease, where the patient’s functional status remains independent for activities of daily living and life expectancy is greater than 5 years | 9,5 (54) | |
Antiplatelet therapy in diabetes mellitus with coexisting major cardiovascular risk factors (hypertension, hypercholesterolemia, smoking history) | 9,5 (54) | |
Over/misprescribing according to STOPP or/and Beers
| ||
STOPP and Beers | Aspirin for primary cardiovascular preventiona | 16,9 (96) |
Beers | Nonbenzodiazepine (“Z”) hypnotics (i.e., eszoplicone, zaleplon, zolpidem) | 6,2 (35) |
STOPP | Any duplicate drug class prescription | 6,2 (35) |
Beers | Benzodiazepines in the presence of dementia and cognitive impairment | 5,8 (33) |
STOPP and Beers | Long-acting benzodiazepines | 4,9 (28) |
STOPP | Aspirin at dose > 150 mg/day | 4,4 (25) |
STOPP | NSAIDs with moderate to severe hypertension | 3,7 (21) |
Beers | Tertiary TCAs, alone or in combination | 2,6 (15) |
Determinants of PIP
Covariates | OR [95 % CI] | p value | |
---|---|---|---|
START-PIP
| |||
ADL lowest quintilea | 0.8 [0.4–1.5] | 0,523 | |
Age, per year | 1.0 [0.9–1.1] | 0,227 | |
CIRS >4 | 1.0 | ||
CIRS <4 | 0.2 [0.1–0.3] | <0,001 | |
CIRS=4 | 0.6 [0.3–1.1] | 0,090 | |
GDS-15 >4b | 1.2 [0.7–2.0] | 0,442 | |
Gender, women | 0.9 [0.6–1.4] | 0,727 | |
Tinetti ≤ 18c | 1.0 | ||
Tinetti 25–28 | 0.5 [0.2–1.2] | 0,130 | |
Tinetti 19–24 | 0.9 [0.3–2.2] | 0,840 | |
STOPP-PIP
| |||
ADL lowest quintile | 1.5 [1.0–2.4] | 0.050 | |
Age, per year | 1.0 [0.9–1.0] | 0.957 | |
Gender, women | 1.2 [0.9–1.8] | 0.211 | |
Resident in a nursing home | 1.8 [0.9–3.2] | 0.056 | |
BEERS-PIP
| |||
ADL lowest quintile | 1.1 [0.7–1.9] | 0.558 | |
Age, per year | 0.9 [0.9–1.0] | 0.515 | |
CIRS >4 | 1.0 | ||
CIRS < 4 | 0.4 [0.3–0.7] | <0.001 | |
CIRS = 4 | 0.6 [0.4–0.9] | 0.041 | |
GDS-15 >4 | 1.5 [0.9–2.3] | 0.094 | |
Gender, women | 1.2 [0.8–1.8] | 0.364 | |
Resident in a nursing home | 1.8 [1.0–3.4] | 0.045 |
Clinical importance of the recommendations to modify the treatment in the presence of PIP
Examples | |||
---|---|---|---|
Major clinical importance (n = 43) |
Modification of the treatment according to this criteria may prevent serious morbidity, including readmission, serious organ dysfunction, serious adverse drug event
| ||
Criterion: START-PIP “Angiotensin converting enzyme (ACE) inhibitor with chronic heart failure”. | Context: The GP reports chronic heart failure, with marked limitation of physical activity and dyspnea, and a recent episode of congestive heart failure. | ||
Criterion: STOPP-PIP “Calcium channel blockers with NYHA class III or IV heart failure”/Beers- PIP “Diltiazem in heart failure”. | Context: The medical history and the clinical examination confirm that the patient has NYHA class III heart failure. | ||
Criterion: Beers- PIP “Anticholinergics in dementia and cognitive impairment”. | Context: The patient has cognitive impairment (MMSE = 22/30a) and takes several drugs with anticholinergic properties (amisulpride, trihexyfenidyl). | ||
Moderate clinical importance (n = 33) |
Modification of the treatment according to this criteria brings care to a more acceptable and appropriate level of practice or that may prevent an adverse drug event of moderate importance
| ||
Criterion: START-PIP “Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient is 87 years, and still has good cognitive and functional status. She has diabetes, hypertension and hypercholesterolemia. | ||
Criterion: STOPP-PIP “Long-term long-acting benzodiazepines”. | Context: The patient has been taking 8mg prazepam every day for more than a month. She has low fall risk (Tinetti score 26/28b) but she has cognitive impairment (MMSE=18/30). | ||
Criterion: STOPP-PIP/Beers-PIP “Aspirin in primary cardiovascular prevention”. | Context: The patient has no history of coronary, cerebral or peripheral vascular symptoms or occlusive event. | ||
Criterion: Beers- PIP “Tertiary tricyclic antidepressants”. | Context: The patient is on clomipramine for “depressive tendencies” according to the GP. The GDS-15 score is low (3/15c). Non pharmacologic or safer alternatives are available. | ||
Minor clinical importance (n = 2) |
Modification of the treatment according to these criteria brings no benefit or minor benefit, depending on professional interpretation
| ||
Criterion: Beers-PIP “Avoid antiarrhythmic drugs as first-line treatment of atrial fibrillation”. | Context: This patient receives amiodarone and does not suffer from any side effect of this drug. | ||
Criterion: Beers-PIP “Avoid long duration sulfonylurea”. | Context: The patient is on gliclazide extended release formula. He is intolerant to metformine. No hypoglycemia were reported. | ||
Deleterious clinical importance (n = 1) |
Modification of the treatment according to this may lead to adverse outcome.
| ||
Criterion: START-PIP “Statin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient has a documented allergy to statins. | ||
Non applicable (n = 40) |
The criterion is not applicable to the individual context of the patient.
| ||
Criterion: START-PIP “beta-blocker with chronic stable angina”. | Context: The patient had a single episode of suspected angina in the past, and he has asthma. | ||
Criterion: START-PIP “Aspirin therapy in diabetes mellitus if coexisting major cardiovascular risk factors present”. | Context: The patient is already on anti-vitamin K and he has no acute coronary disease. | ||
Criterion: STOPP-PIP “Any duplicate drug class prescription”. | Context: The prescription includes a patch of nitroglycerin and tablets of isosorbide dinitrate. However, in his notes, the GP specifies that the patient uses the tablets “as needed” only. | ||
Criterion: STOPP-PIP “Long-term use of NSAID for symptom relief of mild osteoarthritis”. | Context: The 83 year old patient has chronic knee pain despite the use of paracetamol. Unfortunately, his severe respiratory and cardiac status is a contra-indication to surgery and he is intolerant to alternatives to NSAID. He is on proton-pump inhibitor. | ||
Criterion: Beers-PIP “Avoid antipsychotics in dementia & cognitive impairment”. | Context: This patient has cognitive impairment but also a long story of psychiatric disorders. | ||
Criterion: Beers-PIP “Avoid benzodiazepines for the treatment of insomnia, agitation, or delirium”. | Context: This patient received alprazolam to improve her sleep in a context of severe chronic anxiety. |
Elements of the patient’s record that influence the applicability of the criteriaa |
• Level of severity of a disease • Certainty of the diagnoses • Timing of the medical history (recent event vs. long ago) • Actual intake of the drug that differs from the prescription • Patient’s preferences and objectives • Mental status of the patient and associated psychiatric conditions • Absence of alternative treatment • Patient’s pain status • Drug-drug interactions • Risk factors for bleeding or for stroke • Contra-indication • Allergies |
Situations that question the content validity of the criteria: |
• START-PIP in patients already treated by suitable alternative medications e.g., “Proton pump inhibitor with severe gastroesophageal acid reflux disease” in a patient already on histamine H2-receptor antagonist. • START-PIP “Warfarin in the presence of chronic atrial fibrillation” in patients with low stroke risk • START-PIP “Regular inhaled β2-agonist or anticholinergic agent for mild-to-moderate asthma or COPD” in a patient with asthma due to acid reflux • STOPP-PIP “Any duplicate drug class prescription” because insufficiently defined. • Beers-PIPs mentioning that a medication should be avoided as “first-line therapy” because such a feature is often difficult to detect • Beers-PIP “Avoid antidepressants in dementia & cognitive impairment” in a patient with severe depression |
Discussion
Summary
Comparison with existing literature
Strengths and limitations
Implications for research and/or practice
Recommendations to improve the validity of the criteria | Recommendations to improve the applicability of the criteria |
---|---|
• mention of contra-indications of the criteria • no contradictions between criteria • no overlap between criteria • precise range of application of the criteria (inclusion criteria) | • clear definitions (conditions, diseases, drug categories) • monitoring tips • suggestions of alternatives (pharmacological and non-pharmacological) • mention of adaptation to functional and cognitive status, life-expectancy, and multimorbidity. |