Development of prescribing indicators for elderly medical inpatients

Oborne, C. Alice; Batty, Gwenno M.; Maskrey, Vivienne; Swift, CG; Jackson, S. H. D.

doi:10.1111/j.1365-2125.1997.tb00143.x

Cited by 54 publications

(33 citation statements)

References 13 publications

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“…In contrast, there are very few published data on screening tools that measure multiple acts of prescribing omission i.e. the failure on the part of doctors to prescribe drugs that are clearly indicated and likely to benefit the patient [10][11][12]. This may, in part, result from the lack of suitable screening tools designed to alert the clinician to consider indicated drugs when identified in individual patients.…”

Section: Introductionmentioning

confidence: 73%

START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients

et al. 2007

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Background inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people. Methods a screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidencebased prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission. Results using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%). Conclusion failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.

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Section: Introductionmentioning

confidence: 73%

START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients

et al. 2007

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“…Additional instructions were developed on the contraindications (available upon request). These were based on previous publications [30][31][32] and on minor adaptations related to local considerations. An inappropriate rating was given if the patient had the condition of interest and no contraindication to receiving the medication, but did not receive it, or the patient had the condition and received the medication but had a contraindication to receiving the drug.…”

Section: Primary Outcome Measurementioning

confidence: 99%

Effect of a Collaborative Approach on the Quality of Prescribing for Geriatric Inpatients: A Randomized, Controlled Trial

Spinewine

Swine

Dhillon

et al. 2007

J American Geriatrics Society

268

260

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OBJECTIVES: To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing. DESIGN: Randomized, controlled trial, with the patient as unit of randomization. SETTING: Acute GEM unit. PARTICIPANTS: Two hundred three patients aged 70 and older. INTERVENTION: Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients. MEASUREMENTS: Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge. RESULTS: Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR)=9.1, 95% confidence interval (CI)=4.2–21.6 and OR=6.1, 95% CI=2.2–17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria. CONCLUSION: Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes.

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“…38 Changes in pharmacodynamics and pharmacokinetics mean that these patients often need lower doses, and the presence of multiple medical problems Box 2 Types of prescribing quality indicators 35 Quantitative indicators Such as the mean number of drugs prescribed or the number classified in the British National Formulary as "black triangle" or "less suitable for prescribing." 11 These indicators are best used in conjunction with others…”

Section: Discussionmentioning

confidence: 99%

“…Furthermore, amalgamated data distance the prescriber from specific errors and make it harder to see obvious ways to improve. Audit does not necessarily change behaviour, 34 but prescribing indicators have been developed for older patients, [35][36][37] which could provide immediate feedback when integrated into electronic prescribing systems. Box 2 shows the types of indicators used to assess prescribing quality.…”

Section: Electronic Prescribingmentioning

confidence: 99%

Prescribing in older people

Gosney¹,

Harper²,

Conroy³

2012

ODR Geriatric Medicine

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About a fifth of the population in the United Kingdom is 60 years or older, 1 yet people in this age group receive 59% of dispensed prescriptions and account for more than half of NHS drug costs.2 Older people often have several coexisting medical problems and take multiple drugs. Increasing age is associated with changes in pharmacokinetics and pharmacodynamics, so prescribing in this age group can be problematic. 3Many randomised controlled trials involving older patients focus on managing a single disease state, such as hypertension or osteoporosis, but people in this age group often have many interacting conditions and are taking many drugs, so guidance on their treatment often has to be based on consensus and involves extrapolating data derived from healthier patients. This review highlights some of the difficulties in prescribing in older patients and offers guidance for appropriate prescribing. Sources and selection criteriaWe searched the National Library for Health, PubMed, and Embase databases using the keywords "elderly" and "prescribing", including synonyms by the MeSH or major descriptor headings. Our search was limited to studies undertaken in humans that were published in English during the past five years. We displayed abstracts of interest using Abstract Plus before obtaining the full text of articles of interest. In addition, we searched the Cochrane Library and our own personal archives of references What physiological changes occur with ageing? Pharmacokinetic and pharmacodynamic changes With age the body undergoes several changes that can affect the distribution, metabolism, and excretion of drugs. These changes included a reduction in renal clearance, liver size, and lean body mass. 4 Hepatic enzyme activity and serum albumin may also be reduced in the presence of chronic disease. The most clinically important of these changes is the reduction in renal clearance, which results in reduced excretion of water soluble drugs. This is especially important for drugs with a narrow therapeutic window (ratio of desired effect to toxic effect), such as digoxin, lithium, and gentamicin.As well as changes in pharmacokinetics, older people are also more sensitive to the effects of some drugs, especially those that act on the central nervous system, such as benzodiazepines, which are associated with an increase in postural sway and risk of falls. Multiple pathology and polypharmacyPolypharmacy is common in older people-around 20% of people over 70 take five or more drugs. 5 In the past decade, the average number of items prescribed to people aged 60 and over has almost doubled from 21.2 to 40.8 items for each person each year. 6 Previously, polypharmacy implied inappropriate prescribing, but this is not necessarily true, because all of the prescribed drugs may have an appropriate indication.

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Development of prescribing indicators for elderly medical inpatients

Abstract: To identify and improve suboptimal prescribing for elderly patients we have developed a number of prescribing indicators which focus on areas of concern and allow evaluation of the benefit of interventions. We report here on fourteen indicators

Cited by 54 publications

References 13 publications

START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients

START (screening tool to alert doctors to the right treatment) an evidence-based screening tool to detect prescribing omissions in elderly patients

Effect of a Collaborative Approach on the Quality of Prescribing for Geriatric Inpatients: A Randomized, Controlled Trial

Prescribing in older people

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