Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial
Authors: Blum Manuel R , Sallevelt Bastiaan T G M , Spinewine Anne , O’Mahony Denis , Moutzouri Elisavet , Feller Martin , Baumgartner Christine , Roumet Marie , Jungo Katharina Tabea , Schwab Nathalie , Bretagne Lisa , Beglinger Shanthi , Aubert Carole E , Wilting Ingeborg , Thevelin Stefanie , Murphy Kevin , Huibers Corlina J A , Drenth-van Maanen A Clara , Boland Benoit , Crowley Erin , Eichenberger Anne , Meulendijk Michiel , Jennings Emma , Adam Luise , Roos Marvin J , Gleeson Laura , Shen Zhengru , Marien Sophie , Meinders Arend-Jan , Baretella Oliver , Netzer Seraina , de Montmollin Maria , Fournier Anne , Mouzon Ariane , O’Mahony Cian , Aujesky Drahomir , Mavridis Dimitris , Byrne Stephen , Jansen Paul A F , Schwenkglenks Matthias , Spruit Marco , Dalleur Olivia , Knol Wilma , Trelle Sven , Rodondi Nicolas 
Published: July 2021

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
.