Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4524 (Published 14 November 2018) Cite this as: BMJ 2018;363:k4524Linked Editorial
Tackling potentially inappropriate prescribing
All rapid responses
Perez et al's interesting article used primary care electronic health records to investigate whether a hospital admission increased the rates of potentially inappropriate prescribing (PIP) within the same calendar year. The implications are that PIP is common in hospital and continues after discharge when patients are managed in primary care. However, the data used was from primary care prescribing records, and not actual discharge prescriptions, and will only reflect the hospital recommendations practitioners chose to prescribe. In addition, the use of a calendar year measure of PIP fails to address the temporality of when the medicine was prescribed, in relation to the hospital admission.
From the analysis presented, it is not clear whether the PIP in primary care occurred the week following admission or three months later. In an older, sicker population, where medications are frequently altered, can a hospital admission truly be expected to impact on whether a drug is prescribed several months later? By generalising, the paper fails to answer whether PIP changes as a consequence of a hospital admission, or whether PIP is just more frequent in patients who are sicker, require more medication, and thus at greater risk of being admitted to hospital. More evidence is needed to inform medication optimisation at the primary-secondary care interface in this vulnerable population.
Competing interests: No competing interests
We read with interest the article by Perez on the prevalence of potentially inappropriate medication (PIM) prescribing in older patients. It is of concern but perhaps not surprising that PIM prescribing actually increases rather than decreases post-hospitalization. With new investigations and diagnoses, treatments are often effected within the brief hospital stays for acute illnesses and of great concern is the increasing prevalence of PIMs, particularly in elderly living in residential care (1). Unfortunately, all too frequently, there is neither scrutiny of the admission medications nor in many cases timely and detailed communication back to the primary care provider on the need to rationalise drugs. In some of the work we have conducted on de-prescribing in acute internal medicine, about 30% of patients who are admitted to hospital take ten or more regular medications, often referred to as hyperpolypharmacy.
Patients’ stay in hospital is at times fragmented by changes in medical teams that care for them, limiting opportunities to address deprescribing of inappropriate medications. Other important considerations that lessen the likelihood of appropriate deprescribing include medical staff workload, competing priorities, delayed medication reconciliation by pharmacists and an overall unease and reluctance to stop medications started in primary care. This then potentially leads to patients being discharged on more medications than they were admitted with. All these factors can contribute to the reasons why doctors are not always able to use the hospital admission to review and reduce medications. This has particular significance in relation to high-risk drugs including the opioids, statins, psychotropics, proton pump inhibitors and anti-hypertensives, so patients remain vulnerable to adverse effects including falls, drug interactions and the risks for re-admission (2).
We agree that the inpatient hospitalisation should be considered as a valuable opportunity during which to reconcile medications, interrogate reasons for and duration of intended treatments and find potential opportunities to de-prescribe. There are however, many impediments to this, not the least of which are resources. Integrated care provides additional opportunities to pick up inappropriate prescribing at the time patients are discharged from hospital and to work in collaboration with primary care to continually verify and validate the need for patients’ medications and ensure they remain only on those considered essential.
References:
1. Morin, L, Laroche, ML, Texier, G, Johnell, K, Prevalence of Potentially Inappropriate Medication Use in Older Adults Living in Nursing Homes: A Systematic Review, Journal of the American Medical Directors Association 2016. ,17(9): 862.e1e862.e9
2. Al Odhayani A, Tourkmani A, Alshehri M, Alqahtani H, Mishriky A. Potentially inappropriate medications prescribed for elderly patients through family physicians. Saudi J Biol Sci. 2016;24(1):200-207.
Competing interests: No competing interests
When my father was 88, he was hospitalized for dizziness, which occurred after his medication was increased. In the hospital, he was given more medication which made him confused, frightened, and incoherent. Then the doctors transferred him to a nursing home, where he was dirty, crying, begging people to hold his hand, and listed as DNR (Do Not Resuscitate). I convinced the nursing home staff to take him off all medication and put him on my LOVE Diet, an organic lacto-ovo vegetarian diet that excludes toxins and addictions. In three days, my father made such a miraculous recovery, that the nurses on the ward didn't recognize him. When I called to speak to my father, he told me that he was bored and looking for a card game.
Competing interests: No competing interests
HANDFUL, MOUTHFUL and BELLYFUL !!
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The comprehensive note by Perez et al (BMJ 2018;363:k4524) focuses on the important aspect of prescribing pharmacological agents to the elderly. Not only is it illuminating but it also indirectly calls for remedial action.
The present process is unpardonable.
In second childhood, just as it is in the first one, any expressed response is brushed off: "Just swallow these pills."
The time has arrived for the providing person - especially the prescribing physician - to be acutely sensitive and watchful for every aspect of prescribing to the geriatric population while being mindful of the fact that old age awaits us all!
Competing interests: No competing interests
Re: Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study
We thank Denholm and Payne for their response to this article. As they rightly point out, the analysis only included primary care prescribing and the only hospital-initiated medications that are captured will be those continued by general practitioners (GPs) following discharge. We would ideally have liked to analyse any hospital discharge prescriptions to provide stronger evidence of a causal relationship. Although a prescription of a medication at discharge that is potentially inappropriate is one way by which hospitalisation may lead to increased potentially inappropriate prescribing (PIP) in primary care, there are a number of other mechanisms which may not be immediately reflected in GP record data. Increased investigations during hospitalisation could lead to a new diagnosis for a patient, which may render a medication that they are prescribed regularly or intermittently in primary care inappropriate. Prescriptions initiated in hospital may only become inappropriate after being continued for a certain amount of time following discharge, as is the case with the indicator for a non-steroidal anti-inflammatory drug prescribed for greater than 3 months. Lastly some patients may not return to their GP for several months after their hospitalisation, such as those 30% of our sample who do not have access to free medicines in the Irish healthcare system, so proximity to discharge may be less indicative of whether a prescribed medicine was due to a hospitalisation.
To take account of the increased likelihood of hospital admission among those with a higher burden of illness and/or medications, we used several statistical approaches. As well as standard multivariable adjustment for demographics, number of prescription items and co-morbidity, hazard ratios (rather than rate ratios) were estimated to allow the hazard of a new PIP to vary over time (for example allowing it to be higher after discharge). We also included hospitalisation as a time-dependent variable when estimating hazard ratios to capture the impact of change in patients’ status from no hospitalisation to hospitalisation. A propensity score matched approach was also undertaken, as well as a pre-post analysis in those who were hospitalised which accounts for measured and unmeasured time-stable factors within individual patients. Although this study cannot be certain that PIP was a direct effect of hospital admission, the robustness of the findings to this array of different statistical approaches does provide evidence of a relationship between hospitalisation and appropriateness of prescribing among older patients.
Competing interests: No competing interests