Dataset Information

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals.

ABSTRACT:

Background

Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm.

Objective

To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy.

Design

Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up.

Participants

Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs.

Interventions

Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines.

Main measures

Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients' quality of life.

Key results

At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75-1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3-10.1%] vs. 7.0% [3.6-10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge.

Conclusions

The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions.

Study registration

ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377.

SUBMITTER: Grischott T

PROVIDER: S-EPMC9432794 | biostudies-literature | 2022 Aug

REPOSITORIES: biostudies-literature

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Publications

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals.

Grischott Thomas T Rachamin Yael Y Senn Oliver O Hug Petra P Rosemann Thomas T Neuner-Jehle Stefan S

Journal of general internal medicine 20220831 3

<h4>Background</h4>Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm.<h4>Objective</h4>To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact he ...[more]

PMID: 36045192

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Project description:BackgroundInappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients.MethodsThe study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods.DiscussionSo far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period.Trial registrationISRCTN, ISRCTN18427377 . Registered 11 January 2018.

Project description:BackgroundOlder adults often face several chronic illnesses that require them to take multiple medications. The increased number of prescribed medications has led to more complex medication regimens, putting older adults at a higher risk of potential drug-drug interactions, inappropriate medication prescribing, and adverse events. This study aimed to assess inappropriate prescribing practices, polypharmacy, medication regimen complexity, and their determinants in older adults.MethodsA cross-sectional study was conducted among older adults (aged 65 years and above) who visited three referral hospitals in Asmara, Eritrea, between June and August, 2023. A stratified random sampling technique was used, and data were collected from patient prescriptions, medical cards, and through interviews with a questionnaire. Inappropriate medication prescribing was evaluated using STOPP (Screening Tool of Older Person's Prescriptions)/ START (Screening Tool to Alert to Right Treatment) criteria version 3. Potential drug-drug interactions (pDDIs) and medication regimen complexity (MRC) were assessed using Lexi-comp drug interaction checker and MRC index, respectively. Descriptive statistics, logistic regression, Pearson's correlation coefficient, independent samples t-test, one-way Analysis of Variance, and paired t-test were employed using IBM SPSS (version-26.0).ResultsA total of 430 respondents, with a similar male to female ratio, were included. The prevalence of polypharmacy was 5.3% (95%CI: 3.2, 7.5). Moreover, the prevalence of clinically significant pDDI was 51% (95%CI: 46, 56). The most common medicines involved in clinically significant pDDIs were enalapril (n = 179) and acetylsalicylic acid (n = 124). The presence of chronic illness (AOR = 7.58, 95%CI: 3.73, 15.39) and the number of drugs prescribed (AOR = 2.80, 95%CI: 1.91, 4.10) were predictors of clinically significant pDDIs. The prevalence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) were 27.4% (95% CI: 23.4, 31.8) and 13.3% (95% CI: 10.3, 16.7), respectively. The most common PIMs were long-acting sulfonylureas (n = 63) and aldosterone antagonists (n = 19). Besides, proton pump inhibitors (PPIs) (n = 41) and cardio-selective beta-blockers (n = 14) were the most common PPOs identified. Age (AOR: 0.95, 95% CI: 0.92, 0.98), presence of chronic illness (AOR: 1.51, 95% CI: 0.81, 2.80), and number of drugs prescribed (AOR: 2.01, 95% CI: 1.51, 2.69) were significant factors associated with PIM. MRCI score was a significant determinant of PPO (AOR: 1.25, 95% CI: 1.14, 1.38). The mean (SD) of the overall MRCI score was 9.1 (3.7), with dose frequency being the major contributor. The number of drugs prescribed was a determinant of MRCI score (r = 0.625, p < 0.001).ConclusionInappropriate medication prescribing and clinically significant drug-drug interactions were common among older adults, highlighting the need for immediate attention from policymakers, program managers, and healthcare professionals.

Project description:BackgroundEvidence regarding clinically relevant effects of interventions aiming at reducing polypharmacy is weak, especially for the primary care setting. This study was initiated with the objective to achieve clinical benefits for older patients (aged 75+) by means of evidence-based reduction of polypharmacy (defined as ≥8 prescribed drugs) and inappropriate prescribing in general practice.MethodsThe cluster-randomised controlled trial involved general practitioners and patients in a northern-Italian region. The intervention consisted of a review of patient's medication regimens by three experts who gave specific recommendations for drug discontinuation. Main outcome measures were non-elective hospital admissions or death within 24 months (composite primary endpoint). Secondary outcomes were drug numbers, hospital admissions, mortality, falls, fractures, quality of life, affective status, cognitive function.ResultsTwenty-two GPs/307 patients participated in the intervention group, 21 GPs/272 patients in the control group. One hundred twenty-five patients (40.7%) experienced the primary outcome in the intervention group, 87 patients (32.0%) in the control group. The adjusted rates of occurrence of the primary outcome did not differ significantly between the study groups (intention-to-treat analysis: adjusted odds ratio 1.46, 95%CI 0.99-2.18, p = 0.06; per-protocol analysis: adjusted OR 1.33, 95%CI 0.87-2.04, p = 0.2). Hospitalisations as single endpoint occurred more frequently in the intervention group according to the unadjusted analysis (OR 1.61, 95%CI 1.03-2.51, p = 0.04) but not in the adjusted analysis (OR 1.39, 95%CI 0.95-2.03, p = 0.09). Falls occurred less frequently in the intervention group (adjusted OR 0.55, 95%CI 0.31-0.98; p = 0.04). No significant differences were found regarding the other outcomes. Definitive discontinuation was obtained for 67 (16.0%) of 419 drugs rated as inappropriate. About 6% of the prescribed drugs were PIMs.ConclusionsNo conclusive effects were found regarding mortality and non-elective hospitalisations as composite respectively single endpoints. Falls were significantly reduced in the intervention group, although definitive discontinuation was achieved for only one out of six inappropriate drugs. These results indicate that (1) even a modest reduction of inappropriate medications may entail positive clinical effects, and that (2) focusing on evidence-based new drug prescriptions and prevention of polypharmacy may be more effective than deprescribing.Trial registrationCurrent Controlled Trials (ID ISRCTN: 38449870), date: 11/09/2013.

Project description:BackgroundStatin therapy in multimorbid older individuals with polypharmacy is controversial, particularly in primary prevention of cardiovascular disease. Thereby, physicians must weigh potential benefits against potential side effects, drug-drug interactions, and limited life expectancy.AimTo assess the prevalence and determinants of potentially inappropriate statin therapy in multimorbid older patients.MethodsWe conducted a cross-sectional analysis of patients aged ≥70 years with multimorbidity and polypharmacy in the Swiss study center of OPERAM, a cluster-randomized trial on pharmacotherapy optimization to reduce drug-related hospital admissions. We assessed potential underuse (no statin but formal indication) and potential overuse (statin but no formal indication, including predicted >60% one-year mortality based on the Walter Score) based on current guidelines for patients in secondary and primary cardiovascular prevention. We assessed the association of potential statin overuse and underuse with six patient characteristics (age, gender, number of diagnoses, number of medications, mental impairment, being housebound) in LASSO-selection analyses.ResultsOf 715 multimorbid older adults (79.7 ± 6.5 years, 39.9% women), 337 (47%) were on statin. Statin therapy was appropriate in 474 (66.3%), underused in 130 (18.2%), and overused in 111 (15.5%) patients. In participants in secondary cardiovascular prevention (n = 437), being female (odds ratio [OR] 2.65, 95% confidence interval [CI] 1.67-4.22) was significantly associated with potential underuse while being housebound (OR 3.53, 95%CI 1.32-9.46) and taking ≥10 medications (OR 1.95,95%CI 1.05-3.67) were associated with potential overuse. In participants in primary cardiovascular prevention (n = 278), 28.1% were potentially under- (9%) or overusing (19%) a statin, with no identified risk factor.ConclusionA third of hospitalized multimorbid older patients with polypharmacy potentially (either) overused or underused statin therapy. Among patients in secondary cardiovascular prevention, women were at risk for potential statin underuse. Housebound patients and those taking ≥10 medications were at risk for potential overuse of a statin. Physicians should carefully evaluate the indication for statin prescription in multimorbid older patients with polypharmacy.

Dataset Information

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals.

Background

Objective

Design

Participants

Interventions

Main measures

Key results

Conclusions

Study registration

Publications

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals.

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