Screening tools for elderly patients in primary care

Transcription

1 Screening tools for elderly patients in primary care Cristín Ryan 1 Prof. Julia Kennedy 1 Dr. Denis O Mahony 2 Dr. Stephen Byrne 1 Co-Investigator: Dr. Paul Gallagher 2 1 Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Ireland. 2 Department of Geriatrics, Cork University Hospital, Ireland.

2 Introduction Elderly constitute 11% of Irish population Greatest consumers of pharmacotherapy globally Physiological changes occur with age Altered pharmacokinetics Altered pharmacodynamics Multiple co-morbidities Polypharmacy Side effects, drug interactions, adverse drug reactions

3 Potential Inappropriate Prescribing Risk of an Adverse Drug Reaction (ADR) > Clinical Benefit Irrational choice of medicines Higher frequency Longer periods than clinically indicated Overuse of medicines Not indicated Under use of medicines Failure to prescribe potentially beneficial, clinically indicated medicines

4 Screening Tools Beers Criteria (US 2003): Considering Diagnoses (CD) and Independent of Diagnoses (ID) International Primary Care Data: Turkey (9.8%), Ay et al (2005) Finland (12.5%), Pitkala et al (2002) Poland (almost 30%), Rajska-Neumann et al (2007) United States (21.3%), Zhan et al (2001) Improving Prescribing in the Elderly Tool (IPET) (Canadian 1997)

5 Limitations Omit several important and common inappropriate prescribing instances Contain criteria that would not identify any medicines as inappropriate Some evidence used in these tools has been superseded with newer evidence Do not address the issues of under use of medicines Beers Criteria are quite cumbersome-lack organisation

6 Formulation of a new tool Comprehensive & up to date Current clinical evidence Consensus opinion of a panel of experts Include commonly encountered errors Easy to use, time efficient STOPP/START (Screening Tool of Older Person s potentially inappropriate Prescriptions/Screening Tool to Alert doctors to the Right i.e. appropriate, indicated Treatment)

7 STOPP/START List of well-established instances of potentially inappropriate prescribing Compiled according to the main physiological systems affected Draft criteria were agreed on a consensus basis within our own research group Subsequently distributed to a panel of 18 experts in geriatric pharmacotherapy for validation One postal round for START 22 criteria Two postal rounds for STOPP 65/68 criteria

8 Aims and Objectives Determine and compare the rates of potentially inappropriate prescribing using Beers Criteria, IPET and STOPP in an Irish elderly primary care population Determine the patients affected by acts of prescribing ommission Determine the applicability and usability of STOPP/START in primary care Determine the Net Ingredient Cost (NIC) of the potentially inappropriately prescribed medicines and the medicines that would be recommended by START

9 Method Ethics approval waiver of consent Permission obtained for use of notes by General Practitioners (GPs) in a single surgery Power calculation for population size: 480 Elderly: Total 1,078:8,937 (CSO 2002) Rate: 10%;Range:2%, Confidence: 95%. Target 500 patients

10 Method Data collection form was peer reviewed, piloted & modified accordingly to improve usability Patients were prospectively & consecutively recruited from an alphabetical list Inclusion Criteria Over 65 years of age Taking at least one regular medicine. Excluded If nursing home residents or terminally ill

11 Medical histories, current diagnosis, current medications and biochemical data and basic demographics were recorded Each patient was given a unique number All patients had the screening tools applied to their profiles. Data was collated using Microsoft Excel The frequency of potential inappropriate medicines (PIMs) prescribed, the number of patients affected and the NIC was evaluated for each tool

12 Results (n=500) Male:211 (42.2%) Female:289 (57.8%) Average age:74.7 ± 6.2 (range 65-94) Total number of medicines prescribed: 2,257;(mean 4.5 ± 2.6 SD; Range 1-17).

13 The medicines prescribed per BNF category (n=2257) SKIN EAR & NOSE EYE MUSCLOSKELETAL SYSTEM BNF Catogery NUTRITION MALIGANAT OBSTETRICS & GYNAE ENDOCRINE SYSTEM INFECTION CNS RESPIRATORY CVS GIS Number of Medicines

14 Potential Inappropriate Medicines (PIMs) as Identified by the IPET 52 (10.4%) patients received a total of 63 PIMs 7 of the 14 criteria (50%) were used The NIC of these PIMs was pm 6 PIMs for β-blocker & CCF

15 Beers Criteria 69 PIMs for 13% of patients 61 (11.6% patients) ID; pm 8 (1.4% patients) CD) pm

16 PIMs Identified by STOPP per physiological system Number of Potentially Inappropriate Prescriptions CVS 36 CNS 19 GIS 38 MS ES DUPLICATE CLASS 5

17 PIMs identified by the STOPP tool for the CVS Criteria Number of PIMs Digoxin >125mcg & Renal Imp. 5 β-blocker + COPD 17 Ca 2+ blockers + constipation 3 Thiazide + gout 1 Aspirin + warfarin without histamine H 2 antagonist or PPI Aspirin + hx of PUD without histamine H 2 antagonist or PPI Aspirin 150mg day 2 Aspirin with no hx of coronary, cerebral or peripheral vascular symptoms or occlusive event 2 4 2

18 PIMs identified by the STOPP tool for the CNS & GIS Criteria CNS PIMs TCA's + constipation 2 TCA s +opiate/ca 2+ blocker 1 Benzodiazepines 15 Prolonged use of 1 st generation antihistamines 1 GIS PPIs for PUD >8 weeks 38

19 PIMs identified by the STOPP tool for the MS & ES Criteria MS PIMs NSAID & HTN 22 NSAID & CCF 1 Aspirin & warfarin & NSAID 1 L/term steroid as monotherapy for RA or OA ES Glibenclamide 3 DM & ß-Blocker 14 Duplicate Class 5 1 Total STOPP 140

20 A comparison of the PIMs detected by each tool Tool Beers CD Beers ID No. of PIMs % Patients 1 PIM 2 PIMs 4 PIMs NIC ( ) IPET STOPP

21 Statistical comparison of tools Tools Odds Ratio CI 95% STOPP Vs Beers CD STOPP Vs Beers ID STOPP Vs IPET

22 The medicines recommended for initiation by the START tool Number of Patients Aspirin & HX of CVD 13 Antihypertensive BP >160 1 Statin hx of CVD 35 B2 agoinst & COPD Ca & Vit D & osteoporosis Bisphosphonates & gluc Metformin & type Ace I & proteinuria Aspirin & DM 7 Statin & DM 10

23 The potential acts of prescribing omission as identified by START tool. Criteria Number Cost ( ) CVD and Aspirin Antihypertensives CVD & Statins COPD & B 2 agonist Bisphosphonate OP & Ca 2+ Vit D NIDDM & Metformin NIDDM & Ace I NIDDM & Aspirin NIDDM & Statin TOTAL

24 Summary of Cost Implications Cost Savings IPET Beers STOPP Combined STOPP and START STOPP START Total Savings

25 Limitations of STOPP & START Lack of documentation in patient notes Biochemical data was not available for every patient Unused criteria

26 Conclusion It is hoped that GPs as a whole will embrace this tool Limitations such as lack of biochemical data will be overcome Tool will prompt clinicians to examine their prescribing more closely Would be very useful in a primary care setting Usefulness and usability to be further evaluated in different GP surgeries