Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

Abstract

Objective To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. Design Cluster randomised controlled trial. Setting 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. Participants 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). Intervention Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person’s prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. Main outcome measure Primary outcome was first drug related hospital admission within 12 months. Results 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). Conclusions Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. Trial registration ClinicalTrials.gov NCT02986425 .

Frequency and Acceptance of Clinical Decision Support System-Generated STOPP/START Signals for Hospitalised Older Patients with Polypharmacy and Multimorbidity

“…In addition, our geriatric population was relatively functionally independent, with only 8.4% of participants living in nursing homes. Results from a study investigating the impact of STOPP/START criteria (v1) in frail geriatric chronic care residents found that 82.4% of STOPP and 92.6% of START recommendations made by a research pharmacist were implemented by the attending physician [ 28 , 29 ], whereas only 62.2% of all OPERAM patients had one or more STOPP/START recommendations implemented at 2-month follow-up [ 30 ]. Interestingly, implementation of recommendations to discontinue benzodiazepines was lower in the geriatric chronic care setting (23%; n = 3/13) than in the OPERAM trial at 2-month follow-up (39.1%; n = 45/115) [ 28 , 30 ].…”

“…Results from a study investigating the impact of STOPP/START criteria (v1) in frail geriatric chronic care residents found that 82.4% of STOPP and 92.6% of START recommendations made by a research pharmacist were implemented by the attending physician [ 28 , 29 ], whereas only 62.2% of all OPERAM patients had one or more STOPP/START recommendations implemented at 2-month follow-up [ 30 ]. Interestingly, implementation of recommendations to discontinue benzodiazepines was lower in the geriatric chronic care setting (23%; n = 3/13) than in the OPERAM trial at 2-month follow-up (39.1%; n = 45/115) [ 28 , 30 ]. These differences may illustrate that decisions to optimise pharmacotherapy in a hospitalised population are likely to differ from decisions made for long-term care facility residents or in primary care.…”

“…Implementation of the proposed recommendations after discussion with both the attending hospital physician and the patient, and the persistence after discharge, were not included in the design of this study. In the main OPERAM trial results, data on implementation of recommendations at 2 months after index hospitalisation were provided [ 30 ]. However, in this substudy, the study population and the term ‘recommendations’ were defined differently than in the OPERAM main trial (see ESM 3).…”

Development and validation of a life expectancy estimator for multimorbid older adults: a cohort study protocol

“…A major strength of this study is its high feasibility due to the follow-up of 822 already included multimorbid participants with strong strategies of containment of loss to follow-up. 22 Notably, individuals with cognitive impairment were included, who are commonly excluded from studies. In addition to the development and internal validation of the LE estimator, we also assess its implementation and clinical usability.…”

Social Pharmacology as an Underappreciated Field in Medical Education: A Single Medical School’s Experience

“…Therefore, the lack of knowledge and skills in ELSI may, in turn, lead to suboptimal medical practice towards vulnerable groups. In fact, contemporary data on drug misuse ( Culberson and Ziska, 2008 ), polypharmacy linked to multimorbidity ( Blum et al, 2021 ), inappropriate and/or non-evidence-based self-medication ( Yousef et al, 2008 ; Rather et al, 2017 ), misdosing ( Nemati et al, 2016 ), inappropriate prescription trends ( Hovstadius et al, 2014 ; Moriarty et al, 2015 ) (both hold true especially in the elderly), and mortality and morbidity outcomes in relation to drug overuse such as for opioids ( Cheatle, 2015 ), alongside suboptimal medical practice ( Ma et al, 2005 ; Massey et al, 2009 ), reinforce more than ever the call-to-action for developing Social Pharmacology courses to address these alarming issues.…”