Multimorbidity is common among older adults. Now that people are living longer, they are also living with multiple conditions. The conditions may require a range of services and treatments, and often a case manager to discuss complex needs following an assessment, with the wider multidisciplinary team. A commonly found contributing factor to patients' deteriorating level of function on assessment may be inappropriately prescribed medication, mismanagement of medications and sometimes issues associated with polypharmacy.
Multimorbidity is defined as two or more chronic medical conditions. These increase with age and are seen at an estimated prevalence of 70% or greater across older populations aged 65 years and over. This accompanies increases in mortality, use of healthcare services, hospital admissions, and prescription rates of long-term medications, which often results in polypharmacy. While multiple medications may be indicated for some, this situation may present high risk in others.
The risks that inappropriate prescribing bring can commonly include overuse of drugs (prescription of medication without an evidence base for this), underuse of drugs (omission of prescription of medication despite evidence indicating its need), and drug misuse, whereby inappropriate combinations of medications may be prescribed, that result in drug interactions and inappropriate dosing (Daleur et al, 2015). Inappropriate prescribing has been found to be highly prevalent among older people and may lead to adverse outcomes, whereby drug-related hospital admissions, falls, mortality, and decreased quality of life have arisen from inappropriate prescribing in the context of polypharmacy (Chan et al, 2001). It is estimated that as many as 30% of hospital admissions in older people are linked to drugs, half of which are potentially preventable (Leendertse et al, 2008). Various interventions have therefore been designed to optimise pharmacotherapy in people with polypharmacy, with the aim of improving drug appropriateness and lowering the risk of adverse drug reactions.
This article discusses recent research examining the effect of the impact that such a team could have on drug-related hospital admissions, through optimising drug treatment. The research looks specifically at older adults admitted to hospital with multiple conditions and polypharmacy.
A recent trial
Recently published in the British Medical Journal, Blum et al's (2021) cluster randomised controlled trial looked at 110 clusters of inpatient wards within university-based hospitals across four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland), with the attending hospital doctor defining the problem and providing the details of the study, with consent. There were 2008 older adults (aged ≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term) analysed in total.
Clinical staff clusters were randomised to either their usual care methods or a structured pharmacotherapy optimisation intervention, performed jointly by a doctor and a pharmacist at the individual level, alongside the assistance of a clinical decision software system, which deployed the screening tool of older person's prescriptions and a screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.
The primary outcome was defined as first drug-related hospital admission within 12 months. Of the 2008 older adults, who on average had a polypharmacy prescription of nine drugs, the participants were randomised and enrolled to 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care.
The researchers found that for the intervention arm, 86.1% of participants (789) had inappropriate prescribing, with an average of 2.75 Screening Tool of Older Person's Prescriptions and Screening Tool to Alert to the Right Treatment (STOPP/START) recommendations for each participant. A total of 62.2% (491) of participants had ≥1 recommendation successfully implemented by 3 months, predominantly this action being the discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug-related hospital admission compared with 234 (22.4%) in the control group.
The team found that altogether, inappropriate prescribing was common among the older adults, and a significant number of older adults with multimorbidity and polypharmacy were admitted to hospital. The team concluded that this was reduced through an intervention to optimise pharmacotherapy, but that was without effect on drug-related hospital admissions. The team emphasised that additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes (Blum et al, 2021).
Software to optimise pharmacotherapy
Multifaceted approaches are often delivered by pharmacists, but software systems have also been created in recent years to support pharmacotherapy optimisation. Most computerised decision support systems focus on a single aspect, for example, the detection of drug-drug or drug-disease interactions, or potentially inappropriate drugs. However, the systematic tool to reduce inappropriate prescribing (STRIP) facilitated by the web-based STRIP assistant (STRIPA) can perform multiple tasks that are intrinsic to pharmacotherapy optimisation simultaneously. STRIP enables the combination of the STOPP/START criteria, which has a more global summarisation of drug appropriateness and shared decision-making with the patient (O'Mahoney et al, 2015). More research is required to know whether such computerised tools can make a difference to clinical outcomes such as hospitalisation or death.
Using the STOPP/START tool, a reduction of potentially inappropriate prescribing was found to lead to no detriment to patient outcomes, but drug-related hospital admissions were not significantly reduced throughout the 12-month follow-up period, when compared with usual care, despite providing evidence-based recommendations to hospital doctors, patients, and their GPs (Blum et al, 2021). Therefore, it remains questionable that the tool may be of some use but more actions from a wider would provide further clarity with regards to preventing a hospital admission, with polypharmacy being one facet of many complications caused by multimorbidity.
Limitations
The researchers also stated the limitations of their work. Although complete blinding was not possible, they sought to maximise blinding and lower the risk of related bias, in contrast with previous trials, by recruiting staff and adjudicators or outcome assessors who were fully blinded. Patients were partially blinded and received a sham intervention in the control group. In addition, the risk of death from cancer was included as a negative control outcome and did not point to strong selection bias (Blum et al, 2021). However, cluster randomisation was at the doctor and not hospital level; therefore, there was the potential for contamination in control clusters. STRIP was not applied in the control group and whether drug changes in the control group met STOPP/START criteria was not assessed, which therefore meant that the team could not disregard the possibility that some drug changes in the control group could have been made that were similar to the intervention recommendations, which may have been something that led to results between groups having little difference in some outcomes.
Conclusion
The Blum et al (2021) provided some interesting insight into the potential optimisation of medications in older people and, overall, the STOPP/START computerised tool is an interesting advance in technology, which was found to be of no detriment to patients. More research addressing the limitations of Blum et al's (2021) with a wider sample could examine the effectiveness of this tool, as it may prove to be useful for multidisciplinary teams when assessing patients and improving outcomes.