A Collaborative Medication Review Including Deprescribing for Older Patients in an Emergency Department: A Longitudinal Feasibility Study

Morten Baltzer Houlind, Aino Leegaard Andersen, Charlotte Treldal, Lillian Mørch Jørgensen, Pia Nimann Kannegaard, Luana Sandoval Castillo, Line Due Christensen, Juliette Tavenier, Line Jee Hartmann Rasmussen, Mikkel Zöllner Ankarfeldt, Ove Andersen, Janne Petersen, Morten Baltzer Houlind, Aino Leegaard Andersen, Charlotte Treldal, Lillian Mørch Jørgensen, Pia Nimann Kannegaard, Luana Sandoval Castillo, Line Due Christensen, Juliette Tavenier, Line Jee Hartmann Rasmussen, Mikkel Zöllner Ankarfeldt, Ove Andersen, Janne Petersen

Abstract

Medication review for older patients with polypharmacy in the emergency department (ED) is crucial to prevent inappropriate prescribing. Our objective was to assess the feasibility of a collaborative medication review in older medical patients (≥65 years) using polypharmacy (≥5 long-term medications). A pharmacist performed the medication review using the tools: Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, a drug-drug interaction database (SFINX), and Renbase® (renal dosing database). A geriatrician received the medication review and decided which recommendations should be implemented. The outcomes were: differences in Medication Appropriateness Index (MAI) and Assessment of Underutilization Index (AOU) scores between admission and 30 days after discharge and the percentage of patients for which the intervention was completed before discharge. Sixty patients were included from the ED, the intervention was completed before discharge for 50 patients (83%), and 39 (61.5% male; median age 80 years) completed the follow-up 30 days after discharge. The median MAI score decreased from 14 (IQR 8-20) at admission to 8 (IQR 2-13) 30 days after discharge (p < 0.001). The number of patients with an AOU score ≥1 was reduced from 36% to 10% (p < 0.001). Thirty days after discharge, 83% of the changes were sustained and for 28 patients (72%), 1≥ medication had been deprescribed. In conclusion, a collaborative medication review and deprescribing intervention is feasible to perform in the ED.

Keywords: Medication Appropriateness Index; clinical pharmacy; deprescribing; emergency department; geriatric; medication review; polypharmacy; potentially inappropriate medication.

Conflict of interest statement

The authors declare no conflict of interest in relation to this study.

Figures

Figure 1
Figure 1
Flowchart of inclusion of patients in the study. In total, 39 patients completed the 30 days follow-up.
Figure 2
Figure 2
Summated Medication Appropriateness Index (MAI) scores at admission, after intervention, and at 30 days after discharge (n = 39). Light grey lines represent each patient, solid black line is the median.

References

    1. Spinewine A., Schmader K.E., Barber N., Hughes C., Lapane K.L., Swine C., Hanlon J.T. Appropriate prescribing in elderly people: How well can it be measured and optimised? Lancet. 2007;370:173–184. doi: 10.1016/S0140-6736(07)61091-5.
    1. Kongkaew C., Noyce P.R., Ashcroft D.M. Hospital admissions associated with adverse drug reactions: A systematic review of prospective observational studies. Ann. Pharmacother. 2008;42:1017–1025. doi: 10.1345/aph.1L037.
    1. Jensen L.D., Andersen O., Hallin M., Petersen J. Potentially inappropriate medication related to weakness in older acute medical patients. Int. J. Clin. Pharm. 2014;36:570–580. doi: 10.1007/s11096-014-9940-y.
    1. Mangoni A.A., Jackson S.H.D. Age-related changes in pharmacokinetics and pharmacodynamics: Basic principles and practical applications. Br. J. Clin. Pharmacol. 2004;57:6–14. doi: 10.1046/j.1365-2125.2003.02007.x.
    1. Hakkarainen K.M., Hedna K., Petzold M., Hägg S. Percentage of patients with preventable adverse drug reactions and preventability of adverse drug reactions--a meta-analysis. PLoS ONE. 2012;7:e33236. doi: 10.1371/journal.pone.0033236.
    1. Kalisch L.M., Caughey G.E., Barratt J.D., Ramsay E.N., Killer G., Gilbert A.L., Roughead E.E. Prevalence of preventable medication-related hospitalizations in Australia: An opportunity to reduce harm. Int. J. Qual. Health Care. 2012;24:239–249. doi: 10.1093/intqhc/mzs015.
    1. Jyrkkä J., Enlund H., Korhonen M.J., Sulkava R., Hartikainen S. Polypharmacy status as an indicator of mortality in an elderly population. Drugs. Aging. 2009;26:1039–1048. doi: 10.2165/11319530-000000000-00000.
    1. Budnitz D.S., Lovegrove M.C., Shehab N., Richards C.L. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N. Engl. J. Med. 2011;365:2002–2012. doi: 10.1056/NEJMsa1103053.
    1. Graabaek T., Kjeldsen L.J. Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: A systematic review. Basic. Clin. Pharmacol. Toxicol. 2013;112:359–373. doi: 10.1111/bcpt.12062.
    1. Hilmer S.N., McLachlan A.J., Couteur D.G.L. Clinical pharmacology in the geriatric patient. Fundam & Clin. Pharm. 2007;21:217–230.
    1. Thompson W., Lundby C., Graabaek T., Nielsen D.S., Ryg J., Søndergaard J., Pottegård A. Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review. J. Am. Geriatr. Soc. 2019;67:172–180. doi: 10.1111/jgs.15616.
    1. Frank C. Deprescribing: A new word to guide medication review. Can. Med. Assoc. J. 2014;186:407–408. doi: 10.1503/cmaj.131568.
    1. Scott I.A., Hilmer S.N., Reeve E., Potter K., Le Couteur D., Rigby D., Gnjidic D., Del Mar C.B., Roughead E.E., Page A., et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern. Med. 2015;175:827–834. doi: 10.1001/jamainternmed.2015.0324.
    1. Juul-Larsen H.G., Petersen J., Sivertsen D.M., Andersen O. Prevalence and overlap of Disease Management Program diseases in older hospitalized patients. Eur. J. Ageing. 2017;14:283–293. doi: 10.1007/s10433-017-0412-9.
    1. O’Mahony D., O’Sullivan D., Byrne S., O’Connor M.N., Ryan C., Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age. Ageing. 2015;44:213–218. doi: 10.1093/ageing/afu145.
    1. Graabaek T., Hedegaard U., Christensen M.B., Clemmensen M.H., Knudsen T., Aagaard L. Effect of a medicines management model on medication-related readmissions in older patients admitted to a medical acute admission unit-A randomized controlled trial. J. Eval. Clin. Pract. 2019;25:88–96. doi: 10.1111/jep.13013.
    1. Christensen M., Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst. Rev. 2016 doi: 10.1002/14651858.CD008986.pub3.
    1. Ravn-Nielsen L.V., Duckert M.-L., Lund M.L., Henriksen J.P., Nielsen M.L., Eriksen C.S., Buck T.C., Pottegård A., Hansen M.R., Hallas J. Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial. JAMA Intern. Med. 2018;178:375–382. doi: 10.1001/jamainternmed.2017.8274.
    1. Nielsen T.R.H., Honoré P.H., Rasmussen M., Andersen S.E. Clinical Effects of a Pharmacist Intervention in Acute Wards - A Randomized Controlled Trial. Basic. Clin. Pharmacol. Toxicol. 2017;121:325–333. doi: 10.1111/bcpt.12802.
    1. Skjøt-Arkil H., Lundby C., Kjeldsen L.J., Skovgårds D.M., Almarsdóttir A.B., Kjølhede T., Duedahl T.H., Pottegård A., Graabaek T. Multifaceted Pharmacist-led Interventions in the Hospital Setting: A Systematic Review. Basic. Clin. Pharmacol. Toxicol. 2018;123:363–379. doi: 10.1111/bcpt.13030.
    1. Bergkvist A., Midlöv P., Höglund P., Larsson L., Eriksson T. A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management. J. Eval. Clin.l Pract. 2009;15:660–667. doi: 10.1111/j.1365-2753.2008.01080.x.
    1. Spinewine A., Swine C., Dhillon S., Lambert P., Nachega J.B., Wilmotte L., Tulkens P.M. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: A randomized, controlled trial. J. Am. Geriatr. Soc. 2007;55:658–665. doi: 10.1111/j.1532-5415.2007.01132.x.
    1. Hellström L.M., Bondesson A., Höglund P., Midlöv P., Holmdahl L., Rickhag E., Eriksson T. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur. J. Clin. Pharm. 2011;67:741–752. doi: 10.1007/s00228-010-0982-3.
    1. Bodilsen A.C., Juul-Larsen H.G., Petersen J., Beyer N., Andersen O., Bandholm T. Feasibility and inter-rater reliability of physical performance measures in acutely admitted older medical patients. PLoS ONE. 2015;10:e0118248. doi: 10.1371/journal.pone.0118248.
    1. Herdman M., Gudex C., Lloyd A., Janssen M., Kind P., Parkin D., Bonsel G., Badia X. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L) Qual. Life. Res. 2011;20:1727–1736. doi: 10.1007/s11136-011-9903-x.
    1. Katzman R., Brown T., Fuld P., Peck A., Schechter R., Schimmel H. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am. J. Psychiatry. 1983;140:734–739.
    1. Kaiser M.J., Bauer J.M., Ramsch C., Uter W., Guigoz Y., Cederholm T., Thomas D.R., Anthony P., Charlton K.E., Maggio M., et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): A practical tool for identification of nutritional status. J. Nutr. Health. Aging. 2009;13:782–788. doi: 10.1007/s12603-009-0214-7.
    1. Klausen H.H., Petersen J., Bandholm T., Juul-Larsen H.G., Tavenier J., Eugen-Olsen J., Andersen O. Association between routine laboratory tests and long-term mortality among acutely admitted older medical patients: A cohort study. BMC Geriatr. 2017;17:62. doi: 10.1186/s12877-017-0434-3.
    1. Levey A.S., Stevens L.A., Schmid C.H., Zhang Y.L., Castro A.F., Feldman H.I., Kusek J.W., Eggers P., Van Lente F., Greene T., et al. A new equation to estimate glomerular filtration rate. Ann. Intern. Med. 2009;150:604–612. doi: 10.7326/0003-4819-150-9-200905050-00006.
    1. Shared Medicine Card. [(accessed on 19 November 2019)]; Available online: .
    1. Medbase, Ltd. Renbase—Drug Dosing in Renal Failure. Medbase, Ltd.; Turku, Finland: 2016.
    1. – information om medicin. [(accessed on 19 November 2019)]; Available online:
    1. Medbase, Ltd. SFINX Interaction Database. Medbase, Ltd.; Turku, Finland: 2016.
    1. . [(accessed on 19 November 2019)]; Available online:
    1. Hanlon J.T., Schmader K.E., Samsa G.P., Weinberger M., Uttech K.M., Lewis I.K., Cohen H.J., Feussner J.R. A method for assessing drug therapy appropriateness. J. Clin. Epidemiol. 1992;45:1045–1051. doi: 10.1016/0895-4356(92)90144-C.
    1. Gallagher P.F., O’Connor M.N., O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: A randomized controlled trial using STOPP/START criteria. Clin. Pharmacol. Ther. 2011;89:845–854. doi: 10.1038/clpt.2011.44.
    1. Samsa G.P., Hanlon J.T., Schmader K.E., Weinberger M., Clipp E.C., Uttech K.M., Lewis I.K., Landsman P.B., Cohen H.J. A summated score for the medication appropriateness index: Development and assessment of clinimetric properties including content validity. J. Clin. Epidemiol. 1994;47:891–896. doi: 10.1016/0895-4356(94)90192-9.
    1. Md K.S., Hanlon J.T., Weinberger M., Landsman P.B., Samsa G.P., Lewis I., Uttech K., Cohen H.J., Feussner J.R. Appropriateness of Medication Prescribing in Ambulatory Elderly Patients. J. Am. Geriatr. Soc. 1994;42:1241–1247. doi: 10.1111/j.1532-5415.1994.tb06504.x.
    1. Bregnhøj L., Thirstrup S., Kristensen M.B., Sonne J. Reliability of a modified medication appropriateness index in primary care. Eur. J. Clin. Pharmacol. 2005;61:769–773. doi: 10.1007/s00228-005-0963-0.
    1. Luo R., Scullin C., Mullan A.M.P., Scott M.G., McElnay J.C. Comparison of tools for the assessment of inappropriate prescribing in hospitalized older people. J. Eval. Clin. Pract. 2012;18:1196–1202. doi: 10.1111/j.1365-2753.2011.01758.x.
    1. Hanlon J.T., Schmader K.E. The Medication Appropriateness Index at 20: Where it Started, Where it has been and Where it May be Going. Drugs. Aging. 2013;30 doi: 10.1007/s40266-013-0118-4.
    1. Jeffrey S., Ruby C., Twersky J., Hanlon J. Effect of an interdisciplinary team on suboptimal prescribing in a long term care facility. Consult. Pharm. 1999;14:1391–1396.
    1. McHugh M.L. Interrater reliability: The kappa statistic. Biochem. Med. (Zagreb) 2012;22:276–282. doi: 10.11613/BM.2012.031.
    1. Scullin C., Hogg A., Luo R., Scott M.G., McElnay J.C. Integrated medicines management - can routine implementation improve quality? J. Eval. Clin. Pract. 2012;18:807–815. doi: 10.1111/j.1365-2753.2011.01682.x.
    1. Schmader K.E., Hanlon J.T., Pieper C.F., Sloane R., Ruby C.M., Twersky J., Francis S.D., Branch L.G., Lindblad C.I., Artz M., et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am. J. Med. 2004;116:394–401. doi: 10.1016/j.amjmed.2003.10.031.
    1. Cornish P.L., Knowles S.R., Marchesano R., Tam V., Shadowitz S., Juurlink D.N., Etchells E.E. Unintended medication discrepancies at the time of hospital admission. Arch. Intern. Med. 2005;165:424–429. doi: 10.1001/archinte.165.4.424.
    1. Bülow C., Flagstad Bech C., Ullitz Faerch K., Trærup Andersen J., Byg Armandi H., Treldal C. Discrepancies Between the Medication List in Electronic Prescribing Systems and Patients’ Actual Use of Medicines. Sr. Care. Pharm. 2019;34:317–324.
    1. Bülow C., Faerch K.U., Armandi H., Jensen B.N., Sonne J., Christensen H.R., Christensen M.B. Important Aspects of Pharmacist-led Medication Reviews in an Acute Medical Ward. Basic. Clin. Pharmacol. Toxicol. 2018;122:253–261. doi: 10.1111/bcpt.12901.
    1. Nielsen T.R.H., Andersen S.E., Rasmussen M., Honoré P.H. Clinical pharmacist service in the acute ward. Int J. Clin. Pharm. 2013;35:1137–1151. doi: 10.1007/s11096-013-9837-1.
    1. Bondesson A., Holmdahl L., Midlöv P., Höglund P., Andersson E., Eriksson T. Acceptance and importance of clinical pharmacists’ LIMM-based recommendations. Int. J. Clin. Pharm. 2012;34:272–276. doi: 10.1007/s11096-012-9609-3.
    1. Larsen M.D., Rosholm J.U., Hallas J. The influence of comprehensive geriatric assessment on drug therapy in elderly patients. Eur. J. Clin. Pharmacol. 2014;70:233–239. doi: 10.1007/s00228-013-1601-x.
    1. Strehlau A.G., Larsen M.D., Søndergaard J., Almarsdóttir A.B., Rosholm J.-U. General practitioners’ continuation and acceptance of medication changes at sectorial transitions of geriatric patients—A qualitative interview study. BMC Fam. Pract. 2018;19:168. doi: 10.1186/s12875-018-0855-x.
    1. Crotty M., Rowett D., Spurling L., Giles L.C., Phillips P.A. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am. J. Geriatr. Pharmacother. 2004;2:257–264. doi: 10.1016/j.amjopharm.2005.01.001.
    1. Iversen E., Bodilsen A.C., Klausen H.H., Treldal C., Andersen O., Houlind M.B., Petersen J. Kidney function estimates using cystatin C versus creatinine: Impact on medication prescribing in acutely hospitalized elderly patients. Basic. Clin. Pharmacol. Toxicol. 2019;124:466–478. doi: 10.1111/bcpt.13156.
    1. Nielsen A.L., Henriksen D.P., Marinakis C., Hellebek A., Birn H., Nybo M., Søndergaard J., Nymark A., Pedersen C. Drug dosing in patients with renal insufficiency in a hospital setting using electronic prescribing and automated reporting of estimated glomerular filtration rate. Basic. Clin. Pharmacol. Toxicol. 2014;114:407–413. doi: 10.1111/bcpt.12185.
    1. Helldén A., Bergman U., von Euler M., Hentschke M., Odar-Cederlöf I., Ohlén G. Adverse drug reactions and impaired renal function in elderly patients admitted to the emergency department: A retrospective study. Drugs. Aging. 2009;26:595–606. doi: 10.2165/11315790-000000000-00000.
    1. Baxmann A.C., Ahmed M.S., Marques N.C., Menon V.B., Pereira A.B., Kirsztajn G.M., Heilberg I.P. Influence of Muscle Mass and Physical Activity on Serum and Urinary Creatinine and Serum Cystatin C. Clin J. Am. Soc. Nephrol. 2008;3:348–354. doi: 10.2215/CJN.02870707.
    1. Segarra A., de la Torre J., Ramos N., Quiroz A., Garjau M., Torres I., Azancot M.A., López M., Sobrado A. Assessing Glomerular Filtration Rate in Hospitalized Patients: A Comparison Between CKD-EPI and Four Cystatin C-Based Equations. Clin. J. Am. Soc. Nephrol. 2011;6:2411–2420. doi: 10.2215/CJN.01150211.
    1. Fan L., Inker L.A., Rossert J., Froissart M., Rossing P., Mauer M., Levey A.S. Glomerular filtration rate estimation using cystatin C alone or combined with creatinine as a confirmatory test. Nephrol. Dial. Transplant. 2014;29:1195–1203. doi: 10.1093/ndt/gft509.
    1. Olsson I.N., Runnamo R., Engfeldt P. Medication quality and quality of life in the elderly, a cohort study. Health Qual. Life Outcomes. 2011;9:95. doi: 10.1186/1477-7525-9-95.
    1. Somers A., Mallet L., van der Cammen T., Robays H., Petrovic M. Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients. Am. J. Geriatr. Pharmacother. 2012;10:101–109. doi: 10.1016/j.amjopharm.2012.01.003.
    1. Gillespie U., Alassaad A., Hammarlund-Udenaes M., Mörlin C., Henrohn D., Bertilsson M., Melhus H. Effects of Pharmacists’ Interventions on Appropriateness of Prescribing and Evaluation of the Instruments’ (MAI, STOPP and STARTs’) Ability to Predict Hospitalization–Analyses from a Randomized Controlled Trial. PLoS ONE. 2013;8:e62401. doi: 10.1371/journal.pone.0062401.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir