Screening tools for elderly patients in primary care

1
Screening tools for elderly patients in primary
care

• Cristín Ryan1
• Prof. Julia Kennedy1
• Dr. Denis O Mahony2
• Dr. Stephen Byrne1
• Co-Investigator Dr. Paul Gallagher2
• 1Pharmaceutical Care Research Group, School of
  Pharmacy, University College Cork, Ireland.
• 2Department of Geriatrics, Cork University
  Hospital, Ireland.

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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

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Potential Inappropriate Prescribing

• Risk of an Adverse Drug Reaction (ADR) gt 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

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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)

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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  superseded with newer evidence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

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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 Persons
  potentially inappropriate Prescriptions/Screening
  Tool to Alert doctors to the Right i.e.
  appropriate, indicated Treatment)

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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

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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

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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 1,0788,937 (CSO 2002)
• Rate 10Range2, Confidence 95.
• Target 500 patients

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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

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• 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 2003.
• The frequency of potential inappropriate
  medicines (PIMs) prescribed , the number of
  patients affected and the NIC was evaluated for
  each tool

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Results (n500)

• Male211 (42.2)
• Female289 (57.8)
• Average age74.7 6.2 (range 65-94)
• Total number of medicines prescribed 2,257(mean
  4.5 2.6 SD Range 1-17).

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The medicines prescribed per BNF category (n2257)
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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 381.28 pm
• 6 PIMs for ß-blocker CCF

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Beers Criteria

• 69 PIMs for 13 of patients
• 61 (11.6 patients) ID
• 758.71 pm
• 8 (1.4 patients) CD)
• 66.17 pm

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PIMs Identified by STOPP per physiological system
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PIMs identified by the STOPP tool for the CVS
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PIMs identified by the STOPP tool for the CNS
GIS
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PIMs identified by the STOPP tool for the MS ES
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A comparison of the PIMs detected by each tool
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Statistical comparison of tools
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The medicines recommended for initiation by the
START tool
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The potential acts of prescribing omission as
identified by START tool.
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Summary of Cost Implications

• Cost Savings
• IPET 381.28
• Beers 824.88
• STOPP 2371.54
• Combined STOPP and START
• STOPP 2371.54
• START - 1912.68
• Total Savings 458.86

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Limitations of STOPP START

• Lack of documentation in patient notes
• Biochemical data was not available for every
  patient
• Unused criteria

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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