Skip to main content
SpringerLink
Log in

Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial

  • Clinical Trial
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Purpose

The use of potentially inappropriate medications (PIMs) in hospitalized older adults is a complex problem, but the use of computerized alert systems (CAS) has shown some potential. The study’s objective is to assess the change in PIM use with a CAS-based pharmacist-physician intervention model compared to usual clinical care.

Methods

Pragmatic single-site randomized controlled trial was conducted at a university teaching hospital. Hospitalizations identified with selected Beers or STOPP criteria were randomized to usual clinical care or to the CAS-based pharmacist-physician intervention. The primary outcome was PIM drug cessation or dosage decrease. Clinical relevance of the CAS alerts was assessed.

Results

Analyses included 231 patients who had 128 and 126 hospitalizations in the control and intervention groups, respectively. Patients had a mean age of 81, and 60% were female. In the intervention compared to the control group, drug cessation or dosage decrease were more frequent at 48 h post-alert (45.8 vs 15.9%; absolute difference 30.0%; 95%CI 13.8 to 46.1%) and at discharge from the hospital (48.1 vs 27.3%; absolute difference 20.8%; 95%CI 4.6 to 37.0%). In a post hoc analysis of all alerts, regardless of their clinical relevance, the absolute difference in drug cessation or dosage decrease between the intervention and control groups was 16.2% (95%CI 2.9 to 29.6%) at 48 h and 8.0% (95%CI −4.0 to 20.0%) at discharge from the hospital.

Conclusions

In hospitalized older adults, a CAS-based pharmacist-physician intervention, compared to usual clinical care, resulted in significant higher number of drug cessation and dosage reductions for targeted PIMs.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Lehnert T, Heider D, Leicht H, Heinrich S, Corrieri S, Luppa M, Riedel-Heller S, Konig HH (2011) Review: health care utilization and costs of elderly persons with multiple chronic conditions. Med Care Res Rev 68(4):387–420

    Article  PubMed  Google Scholar 

  2. Beijer HJ, de Blaey CJ (2002) Hospitalisations caused by adverse drug reactions (ADR): a meta-analysis of observational studies. Pharm World Sci 24(2):46–54

    Article  CAS  PubMed  Google Scholar 

  3. Bressler R, Bahl JJ (2003) Principles of drug therapy for the elderly patient. Mayo Clin Proc 78(12):1564–1577

    Article  CAS  PubMed  Google Scholar 

  4. Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M (2009) Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes. PLoS One 4(2):e4439

    Article  PubMed  PubMed Central  Google Scholar 

  5. Merle L, Laroche ML, Dantoine T, Charmes JP (2005) Predicting and preventing adverse drug reactions in the very old. Drugs Aging 22(5):375–392

    Article  PubMed  Google Scholar 

  6. Alhawassi TM, Krass I, Bajorek BV, Pont LG (2014) A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging 9:2079–2086

    PubMed  PubMed Central  Google Scholar 

  7. O'Sullivan D, O'Mahony D, O'Connor MN, Gallagher P, Gallagher J, Cullinan S, O'Sullivan R, Eustace J, Byrne S (2016) Prevention of adverse Drug reactions in hospitalised older patients using a software-supported structured pharmacist intervention: a cluster randomised controlled trial. Drugs Aging 33(1):63–73

    Article  PubMed  Google Scholar 

  8. Klopotowska JE, Wierenga PC, Stuijt CC, Arisz L, Dijkgraaf MG, Kuks PF, Asscheman H, de Rooij SE, Lie AHL, Smorenburg SM (2013) Adverse drug events in older hospitalized patients: results and reliability of a comprehensive and structured identification strategy. PLoS One 8(8):e71045

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Tangiisuran B, Davies JG, Wright JE, Rajkumar C (2012) Adverse drug reactions in a population of hospitalized very elderly patients. Drugs Aging 29(8):669–679

    PubMed  Google Scholar 

  10. Jano E, Aparasu RR (2007) Healthcare outcomes associated with Beers’ criteria: a systematic review. Ann Pharmacother 41(3):438–447

    Article  PubMed  Google Scholar 

  11. Page RL 2nd, Linnebur SA, Bryant LL, Ruscin JM (2010) Inappropriate prescribing in the hospitalized elderly patient: defining the problem, evaluation tools, and possible solutions. Clin Interv Aging 5:75–87

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370(9582):173–184

    Article  PubMed  Google Scholar 

  13. Hill-Taylor B, Sketris I, Hayden J, Byrne S, O'Sullivan D, Christie R (2013) 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 38(5):360–372

    Article  CAS  PubMed  Google Scholar 

  14. Tosato M, Landi F, Martone AM, Cherubini A, Corsonello A, Volpato S, Bernabei R, Onder G (2014) Potentially inappropriate drug use among hospitalised older adults: results from the CRIME study. Age Ageing 43(6):767–773

    Article  PubMed  Google Scholar 

  15. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015;63(11):2227–46.

  16. O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P (2015) STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing 44(2):213–218

    Article  PubMed  Google Scholar 

  17. Duran CE, Azermai M, Vander Stichele RH (2013) Systematic review of anticholinergic risk scales in older adults. Eur J Clin Pharmacol 69(7):1485–1496

    Article  CAS  PubMed  Google Scholar 

  18. Hilmer SN, Mager DE, Simonsick EM, Cao Y, Ling SM, Windham BG, Harris TB, Hanlon JT, Rubin SM, Shorr RI, Bauer DC, Abernethy DR (2007) A drug burden index to define the functional burden of medications in older people. Arch Intern Med 167(8):781–787

    Article  PubMed  Google Scholar 

  19. Page RL 2nd, Ruscin JM (2006) The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use. Am J Geriatr Pharmacother 4(4):297–305

    Article  PubMed  Google Scholar 

  20. Onder G, Landi F, Cesari M, Gambassi G, Carbonin P, Bernabei R (2003) Inappropriate medication use among hospitalized older adults in Italy: results from the Italian Group of Pharmacoepidemiology in the Elderly. Eur J Clin Pharmacol 59(2):157–162

    Article  PubMed  Google Scholar 

  21. Laroche ML, Charmes JP, Nouaille Y, Fourrier A, Merle L (2006) Impact of hospitalisation in an acute medical geriatric unit on potentially inappropriate medication use. Drugs Aging 23(1):49–59

    Article  PubMed  Google Scholar 

  22. Liu CL, Peng LN, Chen YT, Lin MH, Liu LK, Chen LK (2012) Potentially inappropriate prescribing (IP) for elderly medical inpatients in Taiwan: a hospital-based study. Arch Gerontol Geriatr 55(1):148–151

    Article  PubMed  Google Scholar 

  23. Wahab MS, Nyfort-Hansen K, Kowalski SR (2012) Inappropriate prescribing in hospitalised Australian elderly as determined by the STOPP criteria. Int J Clin Pharm 34(6):855–862

    Article  PubMed  Google Scholar 

  24. Cossette B, Bergeron J, Ricard G, Ethier JF, Joly-Mischlich T, Levine M, Sene M, Mallet L, Lanthier L, Payette H, Rodrigue MC, Brazeau S (2016) Knowledge Translation Strategy to Reduce the Use of Potentially Inappropriate Medications in Hospitalized Elderly Adults. J Am Geriatr Soc.

  25. Approche adaptée à la personne âgée, cadre de référence. MSSS. 2011. http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2010/10-830-03.pdf. Accessed November 7, 2016.

  26. Arvisais K, Bergeron-Wolff S, Bouffard C, Michaud AS, Bergeron J, Mallet L, Brazeau S, Joly-Mischlich T, Bernier-Filion N, Lanthier L, Ricard G, Rodrigue MC, Cossette B (2015) A pharmacist-physician intervention model using a computerized alert system to reduce high-risk medication use in elderly inpatients. Drugs Aging 32(8):663–670

    Article  PubMed  Google Scholar 

  27. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.

  28. Ghibelli S, Marengoni A, Djade CD, Nobili A, Tettamanti M, Franchi C, Caccia S, Giovarruscio F, Remuzzi A, Pasina L (2013) Prevention of inappropriate prescribing in hospitalized older patients using a computerized prescription support system (INTERcheckR). Drugs Aging 30(10):821–828

    Article  PubMed  Google Scholar 

  29. Peterson JF, Kripalani S, Danciu I, Harrell D, Marvanova M, Mixon AS, Rodriguez C, Powers JS (2014) Electronic surveillance and pharmacist intervention for vulnerable older inpatients on high-risk medication regimens. J Am Geriatr Soc 62(11):2148–2152

    Article  PubMed  PubMed Central  Google Scholar 

  30. O'Sullivan D, O'Mahony D, O'Connor MN, Gallagher P, Cullinan S, O'Sullivan R, Gallagher J, Eustace J, Byrne S (2014) The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients. Drugs Aging 31(6):471–481

    Article  PubMed  Google Scholar 

  31. Grion AM, Gallo U, Tinjala DD, Daragjati J, Loreggian M, Cardaci G, Mangoni A, Pilotto A (2016) A new computer-based tool to reduce potentially inappropriate prescriptions in hospitalized geriatric patients. Drugs Aging 33(4):267–275

    Article  PubMed  Google Scholar 

  32. Cockcroft DW, Gault MH (1976) Prediction of creatinine clearance from serum creatinine. Nephron 16(1):31–41

    Article  CAS  PubMed  Google Scholar 

  33. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V (2011) Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol 173(6):676–682

    Article  PubMed  Google Scholar 

  34. Canadian Institute for Health Informartion. Hospital Standardized Mortality Ratio (HSMR). www.cihi.ca/CIHI-ext-portal/pdf/internet/HSMR_TECH_NOTES_EN. Accessed November 7, 2016.

Download references

Acknowledgments

The authors are grateful to Guillaume Joly for his help in developing and structuring the CAS, and to Jean-Michel Gagnon, Philippe Nault, and Philip-André Fillion for their informatics support. The interventions were conducted by four pharmacists: Sabrina Bergeron-Wolff, Nora Bernier-Fillion, Martine Grondin, and Claudia Pelletier-Mayette.

Author information

Authors and Affiliations

  1. Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada

    Benoit Cossette, Jean-François Éthier, Thomas Joly-Mischlich, Geneviève Ricard & Hélène Payette

  2. Research Centre on Aging, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada

    Benoit Cossette & Hélène Payette

  3. Department of Pharmacy, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada

    Benoit Cossette, Thomas Joly-Mischlich & Josée Bergeron

  4. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

    Benoit Cossette & Mitchell Levine

  5. Department of Medicine, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada

    Jean-François Éthier, Geneviève Ricard & Serge Brazeau

  6. Research Center of the Centre hospitalier universitaire de Sherbrooke, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada

    Jean-François Éthier

  7. Department of Information Technology, Centre Intégré Universitaire de Santé et de Services Sociaux de l’Estrie – Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada

    Mathieu Caron

  8. Department of Mathematics, Université de Sherbrooke, Sherbrooke, QC, Canada

    Olivier Germain

  9. Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada

    Janusz Kaczorowski

  10. Research Center of the Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada

    Janusz Kaczorowski

  11. Programs for Assessment of Technology in Health (PATH), Research Institute of St. Joseph’s Hamilton, Hamilton, ON, Canada

    Mitchell Levine

Authors
  1. Benoit Cossette
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jean-François Éthier
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas Joly-Mischlich
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Josée Bergeron
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Geneviève Ricard
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Serge Brazeau
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Mathieu Caron
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Olivier Germain
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hélène Payette
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Janusz Kaczorowski
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Mitchell Levine
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Benoit Cossette, Jean-François Éthier, Thomas Joly-Mischlich, Josée Bergeron, Geneviève Ricard, Serge Brazeau, Janusz Kaczorowski, and Mitchell Levine designed the study; Benoit Cossette, Jean-François Éthier, Thomas Joly-Mischlich, Mathieu Caron, and Olivier Germain acquired and analyzed the data; Benoit Cossette, Jean-François Éthier, Thomas Joly-Mischlich, Josée Bergeron, Geneviève Ricard, Serge Brazeau, Mathieu Caron, Hélène Payette, Janusz Kaczorowski, and Mitchell Levine interpreted the data; Benoit Cossette drafted the manuscript; Jean-François Éthier, Thomas Joly-Mischlich, Josée Bergeron, Geneviève Ricard, Serge Brazeau, Mathieu Caron, Olivier Germain, Hélène Payette, Janusz Kaczorowski, and Mitchell Levine critically revised the manuscript.

Corresponding author

Correspondence to Benoit Cossette.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

This study was approved by the CHUS ethics committee. The committee did not request patient consent before randomization but required that each patient be contacted after the hospitalization to determine if their relevant hospitalization information could be included in the analysis.

Funding

This study was funded through a grant received from the Merck funds of the Faculty of Medicine and Health Sciences of the University of Sherbrooke. The funding source had no involvement in the study design, data collection, analysis, or interpretation, the writing of the report, or the decision to submit the report for publication.

Additional information

ClinicalTrials.gov Identifier: NCT02570945

Electronic supplementary material

ESM 1

(PDF 181 kb)

ESM 2

(PDF 144 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Cossette, B., Éthier, JF., Joly-Mischlich, T. et al. Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial. Eur J Clin Pharmacol 73, 1237–1245 (2017). https://doi.org/10.1007/s00228-017-2293-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00228-017-2293-4

Keywords

Search

Navigation