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

Abstract

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.

Medication appropriateness tool for co‐morbid health conditions in dementia: consensus recommendations from a multidisciplinary expert panel

“…General prescribing criteria for older adults do not specifically consider the particularities of a progressive, life‐limiting nature of dementia 45, 46, 47, 48, 49. We anticipated that this project would generate a list of appropriate and inappropriate medications for managing co‐morbidities in dementia, similar to other existing explicit prescribing criteria in older people such as the Beers and STOPP/START criteria 60, 61.…”

“…Medication management decisions for people with dementia are often based on data collected in younger adults or peers, which may not be generalisable or relevant to this population. The existing explicit prescribing criteria developed for older people do not account for the additional complexities of dementia or its life‐limiting nature 45, 46, 47, 48, 49. Consensus‐based guidance specifically for people with dementia would assist clinicians with decision‐making in this population 50, 51.…”

Potentially inappropriate prescribing in an Irish elderly population in primary care

“…A follow-up study using the STOPP criteria found at least one PIM among the regular prescriptions of 35% of acutely hospitalized elderly patients [21]. A PPO rate of 57.9% was identified using the START criteria in a similar hospitalized elderly population [22]. Elderly patients admitted to hospital are generally sicker and frailer than elderly patients reviewed in primary care, and the prevalence rates for IP and PPOs among elderly patients obtained in these Irish hospital studies do not reflect the Irish population as a whole.…”

Inappropriate prescribing to older patients admitted to hospital: A comparison of different tools of misprescribing and underprescribing

“…The START (Screening Tool to Alert doctors to Right Treatment) criteria are a new tool in screening for PPOs in the elderly population, and the published results indicate a very high prevalence, between 51 and 72% of patients [13,15].…”