Consensus validation of the FORTA (Fit fOR The Aged) List: a clinical tool for increasing the appropriateness of pharmacotherapy in the elderly

Alexandra M Kuhn-Thiel, Christel Weiß, Martin Wehling, FORTA authors/expert panel members, Martin Wehling, Heinrich Burkhardt, Lutz Frölich, Stefan Schwarz, Ulrich Wedding, Jürgen Bauer, Heiner K Berthold, Peter Dovjak, Helmut Frohnhofen, Thomas Frühwald, Christoph Gisinger, Manfred Gogol, Markus Gosch, Hans Gutzmann, Isabella Heuser, Werner Hofmann, Michael Hüll, Bernhard Iglseder, Anja Kwetkat, Michael Meisel, Wolfgang Mühlberg, Wolfgang von Renteln-Kruse, Regina Roller, Ralf-Joachim Schulz, Ulrike Sommeregger, Alexandra M Kuhn-Thiel, Christel Weiß, Martin Wehling, FORTA authors/expert panel members, Martin Wehling, Heinrich Burkhardt, Lutz Frölich, Stefan Schwarz, Ulrich Wedding, Jürgen Bauer, Heiner K Berthold, Peter Dovjak, Helmut Frohnhofen, Thomas Frühwald, Christoph Gisinger, Manfred Gogol, Markus Gosch, Hans Gutzmann, Isabella Heuser, Werner Hofmann, Michael Hüll, Bernhard Iglseder, Anja Kwetkat, Michael Meisel, Wolfgang Mühlberg, Wolfgang von Renteln-Kruse, Regina Roller, Ralf-Joachim Schulz, Ulrike Sommeregger

Abstract

Background: Multimorbidity and polypharmacy represent a major problem for elderly patients; improvement of medication schemes is important and listing approaches (e.g. Beers list) are considered to be potentially useful.

Objectives: The aim of this study was to perform expert consensus validation of the FORTA (Fit fOR The Aged) List, a drug classification combining positive and negative labelling of drugs chronically prescribed to elderly patients.

Methods: A two-round Delphi procedure was conducted involving 20 experts, 17 geriatric internists and 3 geriatric psychiatrists from Germany and Austria, evaluating the labels assigned to 190 substances or substance groups. These labels ranged from A (indispensable), B (beneficial), C (questionable) to D (avoid), depending on the state of evidence for safety, efficacy and overall age-appropriateness. The experts were also requested to suggest additional substances and indication areas for assessment and possible inclusion in the FORTA List. A weighted (corrected) consensus coefficient was generated for each substance to reflect (1) agreement with the original label, and (2) distribution among raters' labels.

Results: The overall consensus for all items and raters was 92% (corrected). For 54/190 items (28.4%), a unanimous response was achieved as to the original author-based FORTA label choice. Twenty-four substances (12.6%) fell short of the consensus cutoff and were re-evaluated in a second round. This yielded confirmation of 171/190, or 90%, of the original author-based FORTA labels. A total of 35 new substances were also accepted for the FORTA List. Drugs used for dementia and dementia syndromes provoked particular response heterogeneity.

Conclusion: The FORTA List now reflects a wider consensus among experts, increasing its validity for clinical use. It represents a tool to improve the quality of drug prescription in older patients by identifying both inappropriate and omitted drugs, and thus overtreatment and undertreatment. The validation of FORTA's impact on clinical endpoints has yielded promising preliminary results, to be corroborated in ongoing larger trials.

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