Intervention to Improve Prescribing in Elderly Patients

Study Overview
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Brief Summary
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This study tested the efficacy of an easy-to-use checklist aimed at supporting the therapeutic reasoning of physicians in order to reduce inappropriate prescribing and polypharmacy in elderly adults admitted to an internal medicine unit.

Detailed Description
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Background: Polypharmacy and inappropriate medication prescriptions are associated with increased morbidity and mortality. Most interventions proposed to improve appropriate prescribing are time and resource intensive and therefore hardly applicable in daily clinical practice. Objective: To test the efficacy of an easy-to-use checklist aimed at supporting the therapeutic reasoning of physicians in order to reduce inappropriate prescribing and polypharmacy. Design: single-center, interventional, quasi-experimental before-after study. Patients: Consecutive patients aged ≥65 years, hospitalized in the division of internal medicine of a Swiss secondary-level hospital from September to November 2012 (control group, N=450) and from September to November 2013 (intervention group, N=450). Intervention: Introduction of a 5-point checklist to be used by all physicians on the internal medicine wards. Main Measures: The proportion of patients with prescription of potentially inappropriate medications (PIMs) at discharge, according to Screening tool of older people's prescriptions (STOPP) criteria, and the number of prescribed medications at discharge, before and after the introduction of the checklist. Secondary outcomes were the prevalence of polypharmacy (≥ 5 drugs) and hyperpolypharmacy (≥ 10 drugs), and the prevalence of potentially inappropriate prescribing omissions (PPOs) according to START criteria.

Official Title
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Intervention to Improve Appropriate Prescribing and Reduce Polypharmacy in Elderly Patients Admitted to an Internal Medicine Unit

Conditions
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Elderly Internal Medicine Patients

Intervention / Treatment
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* Other: Checklist


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Consecutive patients aged ≥65 years, patients hospitalized in the division of internal medicine of a Swiss secondary-level hospital from September to November 2012 (control group, N=450) and from September to November 2013 (intervention group, N=450). Exclusion Criteria: none

Ages Eligible for Study
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Minimum Age: 65 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: After introduction of the checklist<br>Review of medications of all consecutive admitted patients during the study period using a checklist | Other: Checklist<br>* Introduction of a 5-point checklist to be used by all physicians on the internal medicine wards to review and adapt the medications of the patient.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in the proportion of patients prescribed potentially inappropriate medications (PIM) at discharge | The proportion of patients prescribed PIMs at discharge, according to STOPP (Screening Tool of Older Person's potentially inappropriate Prescriptions) criteria, before and after the introduction of the checklist. | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Change in the number of prescribed medications at discharge | Number of prescribed medications at discharge, before and after the introduction of the checklist. | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of prescribed drugs at admission and discharge |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Prevalence of polypharmacy at admission and discharge | concomitant use of more than 5 drugs | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Prevalence of hyperpolypharmacy at admission and discharge | concomitant use of more than 10 drugs | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Prevalence of potentially inappropriate prescribing omissions (PPO) at admission and discharge | according to START (Screening Tool of Alert doctors to the Right Treatment) criteria | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Number of patients prescribed NSAID at admission and discharge | Non-steroidal anti-inflammatory drugs (NSAID) | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Rate (%) of inappropriate prescriptions of NSAID at admission and discharge | Non-steroidal anti-inflammatory drugs (NSAID) | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Number of patients prescribed proton pump inhibitors at admission and discharge | proton pump inhibitor (PPI) | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Rate (%) of inappropriate prescriptions of proton pump inhibitors at admission and discharge | proton pump inhibitor (PPI) | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Number of patients prescribed systemic corticosteroids at admission and discharge |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Rate (%) of inappropriate prescriptions of systemic corticosteroids at admission and discharge |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Number of patients prescribed metamizole at admission and discharge |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| Rate (%) of inappropriate prescriptions of metamizole at admission and discharge |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| In-Hospital mortality rate |  | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 
| All-cause re-hospitalization rate | re-hospitalization rate 30 days after discharge | In the 3 months after introduction of the checklist (Sept.-Nov. 2013, intervention group) and in 3 months (Sept.-Nov. 2012) one year before the introduction of the checklist (control group) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Polypharmacy, Clinical decision-making