Hospital readmissions, mortality and potentially inappropriate prescribing: a retrospective study of older adults discharged from hospital

Counter, David; Millar, James W. T.; McLay, James S.

doi:10.1111/bcp.13607

Cited by 83 publications

(90 citation statements)

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“…At odds with some previous studies 25,34 , PIMs and PPOs were not significantly associated with all-cause mortality in both discharge settings. However, the study of Wauters et al included community-dwelling subjects with better health and functional status compared with the patients in our study 34 , whereas Counter et al retrospectively evaluated 259 hospital-discharged patients with scant clinical data and no CGA 25 . In a population of older hospital-discharged patients with high short-term mortality, it is very likely that the burden of comorbidities and poor health status may reduce the impact of inappropriate prescribing on hard outcomes such as mortality and unplanned readmissions.…”

Section: Discussioncontrasting

confidence: 99%

“…The main findings of this study were: 1) PIMs, PPOs and number of drugs at discharge were not significantly associated with all-cause mortality in the overall study sample and in each discharge setting; 2) a higher number of PIMs was significantly associated with unplanned hospital readmission in the overall study sample (OR 1. 23 25 . In a prospective study on 1,753 community-dwellers, the prevalence of PIMs and PPOs were 57% and 41.8%, respectively, and higher rates of emergency department visits were observed in those with at least one PIM, or with two or more PPOs 21 .…”

Section: Discussionmentioning

confidence: 99%

“…However, evidence on the impact of IP on hospitalization and mortality is scant and highly heterogeneous. PIMs identified according to STOPP criteria have been associated with higher morbidity, reduced quality of life and increased emergency department visits and hospital admissions [20][21][22][23][24][25] . The impact of PPOs has been far less studied; single studies have reported an association with emergency department visits 21 and 4-year mortality 25 .…”

Section: Introductionmentioning

confidence: 99%

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Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study

Brunetti

Aurucci

Boietti

et al. 2019

Journal of the American Medical Directors Association

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Objectives: To evaluate whether STOPP/START v2 potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are associated with 6-month mortality and unplanned hospitalization in hospital-discharged older patients. Design: Multicenter prospective cohort observational study Setting and participants: patients aged ≥65 years consecutively discharged from acute geriatric and internal medicine wards of two university hospitals in Northwestern Italy Methods: At discharge, a comprehensive geriatric assessment was performed in each patient, prescribed medications were recorded, and PIMs and PPOs were determined according to STOPP/START v2. Death and unplanned readmissions at 6 months were investigated through telephone interviews; variables associated with outcomes were identified in the overall sample and according to discharge setting (i.e. home vs medium/long-term care facility, MLTCF) through a multivariate logistic regression model. Results: Among 611 patients (mean age 81.6 years, 48.4% females, 34.2% MLTCFdischarged, mean number of drugs 7.7±3.2), with an inappropriate prescription (IP) prevalence at discharge of 71.7% (PIMs 54.8%, PPOs 47.3%), mortality and unplanned readmission rate were 25.0% and 30.9%. Neither PIMs nor PPOs were associated with overall mortality. A higher number of PIMs was significantly associated with unplanned readmission in the overall sample (OR 1.23, 95%CI 1.03-1.46), and in home-discharged patients (OR 1.38, 95%CI 1.13-1.68). The number of drugs at discharge was associated with readmissions in the overall sample (OR 1.11, 95%CI 1.05-1.18) and in MLTCF-discharged patients (OR 1.27, 95%CI 1.13-1.42). PPOs were not significantly associated with clinical outcomes. Conclusions and implications: In hospital-discharged polymorbid older patients, 6-month unplanned readmissions were associated with number of PIMs in home-discharged patients Commento [EB1]: Forse sia per questione di spazio che di rilevanza, mettere l'associazione dicotomica dei PPO all'univariata, come richiesto dal reviewer 1 sarebbe inappropriato? Commento [MB2]: Non ho trovato questa richiesta da parte di R1 4 and with number of drugs in MLTCF-discharged patients. This reaffirms the importance of performing a systematic and careful review of medication appropriateness in hospitaldischarged older patients.

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Section: Discussioncontrasting

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study

Brunetti

Aurucci

Boietti

et al. 2019

Journal of the American Medical Directors Association

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“…5,15,20,22 Our study found much higher rates of deprescribing than those quoted in the literature. 5,15,20,22 Our study found much higher rates of deprescribing than those quoted in the literature.…”

Section: Discussioncontrasting

confidence: 51%

“…Rates of in-hospital deprescribing vary widely and range from a complete lack of deprescribing to 1 in 5 patients having a PIM stopped or tapered at discharge. 5,15,20,22 Our study found much higher rates of deprescribing than those quoted in the literature. All sites had a strong baseline culture of deprescribing and were highly sensitized to the issues of polypharmacy and ADEs.…”

Section: Discussioncontrasting

confidence: 51%

The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care

McDonald

Rashidi

et al. 2019

J American Geriatrics Society

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OBJECTIVES Polypharmacy is common, costly, and harmful for hospitalized older adults. Scalable strategies to reduce the burden of potentially inappropriate medications (PIMs) are needed. We sought to leverage medication reconciliation in hospitalized older adults by pairing with MedSafer, an electronic decision support tool for deprescribing. DESIGN This was a nonrandomized controlled before‐and‐after study. SETTING The study took place on four internal medicine clinical teaching units. PARTICIPANTS Subjects were aged 65 years and older, had an expected prognosis of 3 or more months, and were taking five or more usual home medications. INTERVENTION In the baseline phase, patients received usual care that was medication reconciliation. Patients in the intervention arm also had a “deprescribing opportunity report” generated by MedSafer and provided to their in‐hospital treating team. MEASUREMENTS The primary outcome was ascertained at the time of hospital discharge and was the proportion of patients who had one or more PIMs deprescribed. RESULTS A total of 1066 patients were enrolled, and deprescribing opportunities were present for 873 (82%; 418 during the control and 455 during the intervention phases, respectively). The proportion of patients with one or more PIMs deprescribed at discharge increased from 46.9% in the control period to 54.7% in the intervention period with an adjusted absolute risk difference of 8.3% (2.9%‐13.9%). Not all classes of drugs in the intervention arm were associated with an increase in deprescribing, and new PIM starts were equally common in both arms of the study. CONCLUSION Using an electronic decision support tool for deprescribing, we increased the proportion of patients with one or more PIMs deprescribed at hospital discharge as compared with usual care. Although this type of intervention may help address medication overload in hospitalized patients, it also underscores the importance of powering future trials for a reduction in adverse drug events. Trial registration: NCT02918058. J Am Geriatr Soc 67:1843–1850, 2019

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Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

et al. 2022

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ImportancePotentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) are used in research to reflect the quality of drug treatment in older people and have been suggested for inclusion in core outcome sets for evaluation of interventions for improved prescribing. Their validation so far, however, is primarily restricted to expert opinion–based processes.ObjectiveTo evaluate the performance of 3 explicit PIM/PPO criteria sets as diagnostic tools to identify inadequate drug treatment in older patients.Design, Setting, and ParticipantsThis diagnostic study analyzed patients aged 65 years or older consecutively included from 2 primary health care centers from October to November 2017. Data were analyzed from February to August 2022.ExposuresThe PIMs/PPOs were concordantly identified by 2 specialist physicians (2018-2019) retrospectively after a planned physician visit, using 3 European PIM/PPO criteria sets and without knowledge of this diagnostic study.Main Outcomes and MeasuresArea under the receiver operating characteristic (ROC) curve, reflecting the ability of PIM/PPO criteria sets to identify the reference standard of inadequate drug treatment, determined by 2 specialist physicians in consensus. Inadequate drug treatment implied that additional action related to the medication could be medically justified before the next regular visit.ResultsA total of 302 patients were analyzed (median age, 74 [IQR, 69-81] years; 178 women [59%]; median number of drugs in the medication list, 6 [IQR, 3-9]); 98 patients (32%) had inadequate drug treatment. A total of 0 to 8 PIMs/PPOs per patient were identified using the Screening Tool of Older Persons’ Prescriptions (STOPP)/Screening Tool to Alert to Right Treatment (START) criteria, 0 to 6 with the European EU(7)-PIM list, and 0 to 12 with the Swedish set of indicators of prescribing quality. The areas under the ROC curve for the 3 sets to identify the reference standard for inadequate drug treatment were 0.60 (95% CI, 0.53-0.66) for the STOPP/START criteria, 0.69 (95% CI, 0.63-0.75) for the EU(7)-PIM list, and 0.73 (95% CI, 0.67-0.80) for the Swedish set. For comparison, the area under the ROC curve was 0.71 (95% CI, 0.65-0.78) using the number of drugs in the medication list.Conclusions and RelevanceIn this diagnostic study, the evaluated PIM/PPO sets had poor to fair performance as diagnostic tools to identify inadequate drug treatment, comparable with a simple count of the number of drugs in the medication list. These findings suggest that use of PIMs/PPOs as indicators of drug treatment quality in core outcome sets for the evaluation of interventions for improved prescribing may need reconsideration.

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Hospital readmissions, mortality and potentially inappropriate prescribing: a retrospective study of older adults discharged from hospital

Abstract: Using version 2 of the STOPP/START criteria, the presence of PIMs and/or PPOs in older adults discharged from hospital is significantly associated with repeated hospital admissions and mortality respectively.

Cited by 83 publications

References 50 publications

Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study

Clinical Implications of Potentially Inappropriate Prescribing According to STOPP/START Version 2 Criteria in Older Polymorbid Patients Discharged From Geriatric and Internal Medicine Wards: A Prospective Observational Multicenter Study

The MedSafer Study: A Controlled Trial of an Electronic Decision Support Tool for Deprescribing in Acute Care

Performance of 3 Sets of Criteria for Potentially Inappropriate Prescribing in Older People to Identify Inadequate Drug Treatment

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