Reduction of Potentially Inappropriate Medications Using the STOPP Criteria in Frail Older Inpatients: A Randomised Controlled Study
Hospital admissions may provide an opportunity to discontinue potentially inappropriate medications (PIMs) in older patients. Little is known about the effect of using the Screening Tool of Older People’s potentially inappropriate Prescriptions (STOPP) in this context. This study aimed to test the hypothesis that specific STOPP recommendations from an inpatient geriatric consultation team (IGCT) to the hospital physician leads to reductions in PIMs for patients at discharge.
This was a randomised controlled study in 146 frail inpatients (in 2011). The intervention consisted of STOPP recommendations made by the IGCT to ward physicians to discontinue PIMs, in addition to the standard geriatric advice.
Intervention (n = 74) and control (n = 72) groups were similar in terms of patient characteristics (median age 85 years; median number of daily drugs, seven) and PIM distribution (68 and 57 PIMs in 53 and 51 % of patients, respectively). At discharge, the reduction in PIMs was twice as high for the intervention group as for the control group (39.7 and 19.3 %, respectively; p = 0.013). The proportion of patients who still had one or more PIM at discharge did not differ between groups. In the 50 patients followed-up a year later, the majority of PIMs that had been stopped during hospitalisation had not been restarted after discharge (17/28; 61 %). The clinical relevance of PIMs identified at baseline in those patients was considered major (29 %), moderate (37 %), minor (5 %), deleterious (8 %), or not assessed (11 %). Discontinuation rate was not associated with clinical importance.
Specific STOPP recommendations provided to hospital physicians doubled the reduction of PIMs at discharge in frail older inpatients. To further improve the appropriateness of prescribing in older patients, clinicians should focus on the STOPP criteria that are of major clinical importance, and general practitioners should be actively involved.
KeywordsAdverse Drug Event Medication Review Clinical Pharmacist Comprehensive Geriatric Assessment Inappropriate Medication
O. Dalleur was funded by the Federal Public Service Health of the Belgian government as part of a national project on the implementation of clinical pharmacy in hospitals. O. Dalleur, B. Boland, C. Losseau, S. Henrard, D. Wouters, N. Speybroeck, J.M. Degryse and A. Spinewine have no conflicts of interest that are directly relevant to the content of this article. The researchers would like to thank the internal geriatric consultation team at the Cliniques universitaires Saint-Luc for their valuable contribution to data collection, and Ana Bastos, Barbara Sneyers and Rebecca Jones for their advice.
- 4.Hanlon JT, Schmader KE, Ruby CM, et al. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49(2):200–9.Google Scholar
- 7.Page RL 2nd, Linnebur SA, Bryant LL, et al. Inappropriate prescribing in the hospitalized elderly patient: defining the problem, evaluation tools, and possible solutions. Clin Interv Aging. 2010;5:75–87.Google Scholar
- 8.Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165(16):1842–7.Google Scholar
- 10.Deschodt M, Flamaing J, Rock G, et al. Implementation of inpatient geriatric consultation teams and geriatric resource nurses in acute hospitals: a national survey study. Int J Nurs Stud. 2012;49(7):842–9.Google Scholar
- 11.Rubenstein LZ, Stuck AE, Siu AL, et al. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. J Am Geriatr Soc. 1991;39(9 Pt 2):8–16S (discussion 7–8S).Google Scholar
- 13.Deschodt M, Flamaing J, Haentjens P, et al. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis. BMC Med. 2013;11:48.Google Scholar
- 14.Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.Google Scholar
- 15.Gallagher P, Baeyens JP, Topinkova E, et al. Inter-rater reliability of STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment) criteria amongst physicians in six European countries. Age Ageing. 2009;38(5):603–6.PubMedCrossRefGoogle Scholar
- 16.Hill-Taylor B, Sketris I, Hayden J, et al. 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(5):360–72.Google Scholar
- 17.Hamilton H, Gallagher P, Ryan C, et al. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013–9.Google Scholar
- 18.Dalleur O, Spinewine A, Henrard S, et al. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging. 2012;29(10):829–37.Google Scholar
- 22.McCusker J, Bellavance F, Cardin S, et al. Detection of older people at increased risk of adverse health outcomes after an emergency visit: the ISAR screening tool. J Am Geriatr Soc. 1999;47(10):1229–37.Google Scholar
- 24.Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–9.Google Scholar
- 26.Nakash RA, Hutton JL, Jorstad-Stein EC, et al. Maximising response to postal questionnaires: a systematic review of randomised trials in health research. BMC Med Res Methodol. 2006;6:5.Google Scholar
- 27.Spinewine A, Dhillon S, Mallet L, et al. Implementation of ward-based clinical pharmacy services in Belgium: description of the impact on a geriatric unit. Ann Pharmacother. 2006;40(4):720–8.Google Scholar
- 28.Hogan DB, Fox RA, Badley BW, et al. Effect of a geriatric consultation service on management of patients in an acute care hospital. CMAJ. 1987;136(7):713–7.Google Scholar
- 29.McVey LJ, Becker PM, Saltz CC, et al. Effect of a geriatric consultation team on functional status of elderly hospitalized patients: a randomized, controlled clinical trial. Ann Intern Med. 1989;110(1):79–84.Google Scholar
- 34.Gillespie U, Alassaad A, Hammarlund-Udenaes M, et al. Effects of pharmacists’ interventions on appropriateness of prescribing and evaluation of the instruments’ (MAI, STOPP and STARTs’) ability to predict hospitalization: analyses from a randomized controlled trial. PLoS ONE. 2013;8(5):e62401.PubMedCentralPubMedCrossRefGoogle Scholar
- 35.Barry PJ, Gallagher P, Ryan C, et al. START (screening tool to alert doctors to the right treatment): an evidence-based screening tool to detect prescribing omissions in elderly patients. Age Ageing. 2007;36(6):632–8.Google Scholar