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      Potentially inappropriate prescribing in Ethiopian geriatric patients hospitalized with cardiovascular disorders using START/STOPP criteria

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          Abstract

          Background

          There was a paucity of data on the magnitude of potentially inappropriate prescriptions (PIPs) among Ethiopian elderly cardiovascular patients.

          Objective

          The aim of this study was to assess PIPs and associated factors in the elderly population with cardiovascular disorders using the START/STOPP screening criteria.

          Methods

          A hospital-based cross-sectional study was conducted at medical wards of a teaching hospital in Ethiopia from 1 December 2016–30 May 2017. Included patients were hospitalized elderly patients aged 65 years or older with cardiovascular disorders; their medications were evaluated using the START/STOPP screening criteria from admission to discharge. Multivariable logistic regression was applied to identify factors associated with inappropriate medications. One Way Analysis Of Variance (ANOVA) was carried out to test significant differences on the number of PIPs per individual diagnosis.

          Results

          Two hundred thirty-nine patients were included in the analysis. More-than a third of the patients were diagnosed with heart failure, 88 (36.82%). A total of 221 PIPs were identified in 147 patients, resulting in PIP prevalence of 61.5% in the elderly population. Of the total number of PIPs, occurrence of one, two and three PIPs accounted for 83 (56.4%), 52(35.4%), and 12(8.2%) respectively. One way ANOVA test showed significant differences on the mean number of PIPs per individual diagnosis (f = 5.718, p<0.001). Angiotensin Converting Enzyme Inhibitors (ACEIs) were the most common inappropriately prescribed medications, 32(14.5%). Hospital stay, AOR: 1.086 (1.016–1.160), number of medications at discharge, AOR: 1.924 (1.217–3.041) and the presence of co-morbidities, AOR: 3.127 (1.706–5.733) increased the likelihood of PIP.

          Conclusion

          Approximately, two-thirds of elderly cardiovascular patients encountered potentially inappropriate prescriptions. ACEIs were the most commonly mis-prescribed medications. Longer hospital stay, presence of comorbidities and prescription of large number of medications at discharge have been correlated with the occurrence of inappropriate medication. It is essential to evaluate patients’ medications during hospital stay using the STOPP and START tool to reduce PIPs.

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          Most cited references55

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          STOPP/START criteria for potentially inappropriate prescribing in older people: version 2

          Denis O’Mahony, David O'Sullivan, Stephen Byrne … (2014)
          Purpose: screening tool of older people's prescriptions (STOPP) and screening tool to alert to right treatment (START) criteria were first published in 2008. Due to an expanding therapeutics evidence base, updating of the criteria was required. Methods: we reviewed the 2008 STOPP/START criteria to add new evidence-based criteria and remove any obsolete criteria. A thorough literature review was performed to reassess the evidence base of the 2008 criteria and the proposed new criteria. Nineteen experts from 13 European countries reviewed a new draft of STOPP & START criteria including proposed new criteria. These experts were also asked to propose additional criteria they considered important to include in the revised STOPP & START criteria and to highlight any criteria from the 2008 list they considered less important or lacking an evidence base. The revised list of criteria was then validated using the Delphi consensus methodology. Results: the expert panel agreed a final list of 114 criteria after two Delphi validation rounds, i.e. 80 STOPP criteria and 34 START criteria. This represents an overall 31% increase in STOPP/START criteria compared with version 1. Several new STOPP categories were created in version 2, namely antiplatelet/anticoagulant drugs, drugs affecting, or affected by, renal function and drugs that increase anticholinergic burden; new START categories include urogenital system drugs, analgesics and vaccines. Conclusion: STOPP/START version 2 criteria have been expanded and updated for the purpose of minimizing inappropriate prescribing in older people. These criteria are based on an up-to-date literature review and consensus validation among a European panel of experts.
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            Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction.

            Jeppe Rasmussen, Alice Chong, David Alter (2007)
            The extent to which drug adherence may affect survival remains unclear, in part because mortality differences may be attributable to "healthy adherer" behavioral attributes more so than to pharmacological benefits. To explore the relationship between drug adherence and mortality in survivors of acute myocardial infarction (AMI). Population-based, observational, longitudinal study of 31 455 elderly AMI survivors between 1999 and 2003 in Ontario. All patients filled a prescription for statins, beta-blockers, or calcium channel blockers, with the latter drug considered a control given the absence of clinical trial-proven survival benefits. Patient adherence was subdivided a priori into 3 categories--high (proportion of days covered, > or =80%), intermediate (proportion of days covered, 40%-79%), and low (proportion of days covered, <40%)--and compared with long-term mortality (median of 2.4 years of follow-up) using multivariable survival models (and propensity analyses) adjusted for sociodemographic factors, illness severity, comorbidities, and concomitant use of evidence-based therapies. Among statin users, compared with their high-adherence counterparts, the risk of mortality was greatest for low adherers (deaths in 261/1071 (24%) vs 2310/14,345 (16%); adjusted hazard ratio, 1.25; 95% confidence interval, 1.09-1.42; P = .001) and was intermediary for intermediate adherers (deaths in 472/2407 (20%); adjusted hazard ratio, 1.12; 95% confidence interval, 1.01-1.25; P = .03). A similar but less pronounced dose-response-type adherence-mortality association was observed for beta-blockers. Mortality was not associated with adherence to calcium channel blockers. Moreover, sensitivity analyses demonstrated no relationships between drug adherence and cancer-related admissions, outcomes for which biological plausibility do not exist. The long-term survival advantages associated with improved drug adherence after AMI appear to be class-specific, suggesting that adherence outcome benefits are mediated by drug effects and do not merely reflect an epiphenomenon of "healthy adherer" behavioral attributes.
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              STOPP (Screening Tool of Older Person's Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation.

              P. Gallagher, C. Ryan, S Byrne … (2008)
              Older people experience more concurrent illnesses, are prescribed more medications and suffer more adverse drug events than younger people. Many drugs predispose older people to adverse events such as falls and cognitive impairment, thus increasing morbidity and health resource utilization. At the same time, older people are often denied potentially beneficial, clinically indicated medications without a valid reason. We aimed to validate a new screening tool of older persons' prescriptions incorporating criteria for potentially inappropriate drugs called STOPP (Screening Tool of Older Persons' Prescriptions) and criteria for potentially appropriate, indicated drugs called START (Screening Tool to Alert doctors to Right, i.e. appropriate, indicated Treatment). A Delphi consensus technique was used to establish the content validity of STOPP/START. An 18-member expert panel from academic centers in Ireland and the United Kingdom completed two rounds of the Delphi process by mail survey. Inter-rater reliability was assessed by determining the kappa-statistic for measure of agreement on 100 data-sets. STOPP is comprised of 65 clinically significant criteria for potentially inappropriate prescribing in older people. Each criterion is accompanied by a concise explanation as to why the prescribing practice is potentially inappropriate. START consists of 22 evidence-based prescribing indicators for commonly encountered diseases in older people. Inter-rater reliability is favorable with a kappa-coefficient of 0.75 for STOPP and 0.68 for START. STOPP/START is a valid, reliable and comprehensive screening tool that enables the prescribing physician to appraise an older patient's prescription drugs in the context of his/her concurrent diagnoses.
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                Author and article information

                Contributors
                Tadesse Melaku Abegaz:
                ORCID: http://orcid.org/0000-0002-7813-3407
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: Writing – original draft
                Eshetie Melese Birru: Role: Formal analysisRole: ValidationRole: Writing – review & editing
                Gashaw Binega Mekonnen: Role: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Alessandra Marengoni: Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, CA USA )
                ISSN (Electronic): 1932-6203
                Publication date (Electronic): 3 May 2018
                Publication date Collection: 2018
                Volume: 13
                Issue: 5
                Electronic Location Identifier: e0195949
                Affiliations
                [1 ] Department of clinical pharmacy, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
                [2 ] Department of pharmacology, school of pharmacy, college of medicine and health sciences, university of Gondar, Gondar, Ethiopia
                University of Brescia, ITALY
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0002-7813-3407
                Article
                Publisher ID: PONE-D-17-41600
                DOI: 10.1371/journal.pone.0195949
                PMC ID: 5933717
                PubMed ID: 29723249
                SO-VID: 3d6151d4-ae9b-4d22-b25b-a1b2ddb4fb24
                Copyright © © 2018 Abegaz et al
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 23 December 2017
                Date accepted : 3 April 2018
                Page count
                Figures: 1, Tables: 4, Pages: 14
                Funding
                The authors received no specific funding for this work.
                Categories
                Subject: Research Article
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Medicine and Health Sciences
                Subject: Geriatrics
                Subject: People and Places
                Subject: Population Groupings
                Subject: Age Groups
                Subject: Elderly
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Heart Failure
                Subject: Medicine and Health Sciences
                Subject: Health Care
                Subject: Health Care Facilities
                Subject: Hospitals
                Subject: Medicine and Health Sciences
                Subject: Cardiovascular Medicine
                Subject: Cardiovascular Diseases
                Subject: Medicine and Health Sciences
                Subject: Cardiology
                Subject: Arrhythmia
                Subject: Atrial Fibrillation
                Subject: Medicine and Health Sciences
                Subject: Pharmaceutics
                Subject: Drug Therapy
                Subject: Receptor Antagonist Therapy
                Subject: Beta-Adrenergic Antagonist Therapy
                Custom metadata
                Data Availability All relevant data are within the paper.

                ScienceOpen disciplines: Uncategorized
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