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Background: Inappropriate prescribing (IP) is a common problem in the older population. Despite numerous attempts to tackle this issue, it remains a public health concern. In most European countries, general practitioners (GPs) are responsible for global primary care and are thus gatekeepers for the adequacy of medicines, specifically for older people. An in-depth analysis of the situation is necessary to understand why this phenomenon is still prevalent and to identify solutions that could help avoid IP in primary practice. Method: A qualitative study based on five focus groups (FG) comprising nine to thirteen general practitioners was conducted in the French-speaking part of Belgium. Participants were recruited among the Local Medical Evaluation Groups (LMEG) and selected to guarantee heterogeneity in working organisations, years of professional experience, gender and age. All interviews were recorded with prior agreement and transcribed in verbatims. The transcripts were coded and analysed to highlight the primary themes, considering dominant and marginal discourses. Results: Fifty four GPs participated in the study, with an average experience of 30 years. IPs are perceived as a significant problem in the older population, leading to dangerous health situations. The issue is associated with polypharmacy and multimorbidity, and GPs stated to manage IP using their clinical experience. Most of the study participants faced difficulties managing IP, mostly due to the specificity and complexity of elderly care. Indeed, managing an older patient is challenging due to medical complexity, poor adherence to drug regimes, or low medical literacy. In addition, the medical environment of general practice is challenging, with multiple providers, lack of time, prescribing routine and the absence of effective communication with specialists or other care providers. Additionally, the tools and support available to help medication management in primary care are inadequate. Enhancing collaboration with pharmacists is perceived as a strong potential facilitator. Conclusion: This article addresses the complex management of IP in the old age, from the point of view of GPs. Interesting clues were highlighted, like the need to clarify roles of healthcare providers, the better fit of tools to facilitate medication's review with particularities of GPs needs and the empowerment of pharmacist collaboration. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease (CKD) stages 3-4 present a significant clinical challenge due to the absence of a systematic approach to managing associated medication-related problems (MRPs). This lack of a structured framework hinders the timely identification and effective intervention for these complications, potentially compromising patient safety and prognosis. Objective: This study aims to leverage the Delphi method to establish an evaluation index for a rational drug use evaluation system dedicated to CKD patients in stages 3-4. This system will function as a platform for the continuous identification and management of MRPs, ultimately contributing to improved medication safety and patient outcomes. Methods: This research uses the modified Delphi technique to develop an evaluation system for rational drug use in patients with chronic kidney disease. The initial questionnaire was developed by literature review for patients with chronic kidney disease. Twenty-six senior experts formed a panel in order to evaluate items across two Delphi rounds. Consensus was defined as at least 95% agreement (first round) and 85% agreement (second round), agreeing with an average score of at least 4.5 (first round) and 4.0 (second round). Items that fulfill the stipulated criteria are eligible for inclusion in the consensus list. Results: All experts participated in both rounds (100% response rate). Consensus was achieved on three patient-related items in the first round of 34 items. Based on expert feedback, 18 revised items were included in the second round after refining, restructuring, and removing some elements. Following two rounds of consultation, 20 items achieved consensus, encompassing aspects such as drug selection, dosage assessment, treatment duration, prescription and dispensing practices, patient-related factors, and other relevant considerations. Conclusion: This study has successfully identified 20 key evaluation indicators for a rational drug use evaluation system specifically designed for CKD patients in stages 3 and 4. This system will serve as a tool for continuous MRP identification and timely intervention, ultimately enhancing medication safety and patient prognosis. [ABSTRACT FROM AUTHOR]

Introduction: The prevalent overprescribing of proton pump inhibitors (PPIs) poses health risks from prolonged use. GPs play a key role in initiating deprescribing PPIs, so understanding their decision-making factors and strategies to improve feasibility is crucial. This study aimed to investigate the perspectives of GPs on deprescribing PPIs with a focus on identifying facilitators, barriers, and strategies to enhance feasibility in clinical settings. Methods: A qualitative study involving semi-structured interviews was conducted with nine GPs or trainees. The thematic analysis of the interviews was conducted using NVivo R1 (2020). Results: Four main categories were identified: 1) Inappropriate prescribing of PPIs, 2) Facilitators for deprescribing PPIs, 3) Barriers to deprescribing PPIs, 4) Feasibility of deprescribing PPIs. GPs acknowledged excessive and often inappropriate PPI prescribing, with a lack of deprescribing efforts mainly due to time constraints. Other key barriers included patient reluctance, fear of symptom recurrence, and unawareness of long-term risks. Patient-initiated request is key facilitator for deprescribing PPIs. GPs emphasized the need for collaboration with healthcare professionals, clear guidelines, improved digital support, increased physician availability, and raising awareness among providers and patients to enhance deprescribing feasibility. Discussion: GPs are calling for a multifaceted approach to improve the feasibility of deprescribing PPIs, involving patient-centered approaches, systemic optimizations, support from other healthcare professionals, and providercentered strategies to emphasize the importance of deprescribing PPIs. [ABSTRACT FROM AUTHOR]

Background/Objectives: Numerous European countries, including Romania, are facing the concern of rapid ageing of their populations. Moreover, Romania's life expectancy ranks among the lowest in the European Union. In light of this, it is imperative that the assessment of medication-related harm be given national priority in order to secure and enhance pharmacotherapy and the medical act. In this study, we sought to describe and evaluate the under-prescribing practices among the Romanian elderly population. Methods: We conducted a cross-sectional study in urban areas of two counties in Western Romania (Timis and Arad) from November 2017 to February 2019. We collected chronic electronic prescriptions issued for elderly patients (>65 years old) with chronic conditions. The medication was prescribed by generalist or specialist physicians for periods ranging between 30 and 90 days. To assess inappropriate prescribing behaviours, a multidisciplinary team of specialists applied the Screening Tool of Older Persons' Prescriptions/Screening Tool to Alert to Right Treatment (STOPP/START) v.2 criteria to the collected prescriptions. Results: Within the 1498 prescriptions included in the study, 57% were issued to females, the mean age was 74.1 ± 6.95, and the average number of medicines per prescription was 4.7 ± 1.51. The STOPP criteria most commonly identified were the (1) long treatment duration (23.6%) and (2) prescription of neuroleptics (14.6%) or zopiclone (14.0%) as medications that increase the risk of falls. According to START criteria, the following medicines were under-prescribed: (1) statins (47.4%), (2) beta-blockers (24.5%), (3) antiresorptive therapy (10.0%), and (4) β2-agonists and muscarinic antagonists for chronic obstructive pulmonary disease (COPD) (4.5%). Within our study group, the prevalence of potentially inappropriate medications was 18.58%, whereas the prevalence of potential prescribing omissions was 49.2%. Conclusions: To decrease medication-related harm and morbid-mortality, and to increase the quality of life for elderly people in Romania, immediate actions are needed from national authorities. These actions include reinforcing primary care services, providing periodic training for physicians, implementing medication review services by pharmacists, and utilising electronic health records at their full capacity. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy is associated with the prescription of inappropriate medications and avoidable medication-related harm. A novel pharmacist-led intervention aims to identify and resolve inappropriate medication prescriptions in older adults with polypharmacy. Aim: To conduct a preliminary feasibility assessment of the intervention in primary care, testing whether specific components of the intervention procedures and processes can be executed as intended. Method: The mixed-methods study was approved by the New Zealand Health and Disability Ethics Committees and public health agency. Patients from a New Zealand general practice clinic were recruited over 4 weeks to receive the intervention. The preliminary feasibility assessment included measures of intervention delivery, patient-reported outcome measures, and perspectives from ten patients and six clinicians. Data were analysed quantitatively and qualitatively to determine if a full-scale intervention trial is warranted. The study's progression criteria were based on established research and guided the decision-making process. Results: The intervention met the study's progression criteria, including patient recruitment, retention, and adherence to the intervention procedures. However, several modifications were identified, including: (1) enhancing patient recruitment, (2) conducting a preliminary meeting between the patient and pharmacist, (3) supporting pharmacists in maintaining a patient-centred approach, (4) reviewing the choice of patient-reported outcome measure, (5) extending the 8-week follow-up period, (6) allocating more time for pharmacists to conduct the intervention. Conclusion: The study found the intervention feasible; however, additional development is required before progressing to a full-scale trial. This intervention has the potential to effectively reduce medication-related harm and improve outcomes for older adults with polypharmacy. Trial registration number: ACTRN12621000268842 Date registered: 11/03/2021 [ABSTRACT FROM AUTHOR]

Introduction: Current research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults. Methods: Swedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (=65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls. Results: PIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88-2.07]) and overall mortality (HR = 2.09 [2.03-2.16]), CV (HR = 1.34 [1.30-1.37]) and overall hospitalisation (HR = 1.48 [1.46-1.51]), stroke (HR = 1.93 [1.78-2.10]), bleeding (HR = 1.10 [1.01-1.21]), and falls (HR = 1.63 [1.56-1.71]). Conclusion: The present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population. [ABSTRACT FROM AUTHOR]

Purpose: To analyse the reliability and validity of the Swedish indicator 'Drugs that should be avoided in older people'. Methods: From a previous study that included consecutive primary care patients ≥ 65 years of age, all patients ≥ 75 years of age were analysed. Two physicians independently screened their medication lists and medical records, applying the Swedish indicator which includes potentially inappropriate medications (PIMs): long-acting benzodiazepines, drugs with anticholinergic action, tramadol, propiomazine, codeine, and glibenclamide. The clinical relevance of identified PIMs was independently assessed. Thereafter, the physicians determined in consensus whether some medical action related to the drug treatment was medically justified and prioritised before the next regular visit. If so, the drug treatment was considered inadequate, and if not, adequate. Results: A total of 1,146 drugs were assessed in 149 patients (75‒99 years, 62% female, 0‒20 drugs per patient). In 29 (19%) patients, at least one physician identified ≥ 1 PIM according to the indicator at issue; 24 (16%) patients were concordantly identified with ≥ 1 such PIM (kappa: 0.89). Of 26 PIMs concordantly identified, the physicians concordantly assessed four as clinically relevant and 12 as not clinically relevant (kappa: 0.17). After the consensus discussion, six (4%) patients had ≥ 1 PIM according to the studied indicator that merited action. Using the area under the receiver operating characteristic (ROC) curve, the indicator did not outperform chance in identifying inadequate drug treatment: 0.56 (95% confidence interval: 0.46 to 0.66). Conclusion: The Swedish indicator has strong reliability regarding PIM detection but does not validly reflect the adequacy of drug treatment. [ABSTRACT FROM AUTHOR]

Objectives: Among residents who had a residential medication management review (RMMR), there is a lack of studies assessing exposure to polypharmacy and potentially inappropriate medications (PIMs) in people with dementia. This study compared the exposure to polypharmacy and PIMs in residents with dementia and without dementia receiving RMMR. Methods: A retrospective analysis was performed using data of 16,261 residents living in 343 Australian residential aged care facilities who had an RMMR in 2019. Medication use was assessed as polypharmacy (defined as ≥9 medications) and use of ≥1 PIMs using the 2019 updated Beers criteria. Dementia diagnosis was determined with ICD‐10 coding from medical records. Descriptive analyses reported resident demographics and patterns of medication use. Pearson's χ2 tests and logistic regression analysis were conducted to compare medication exposure between residents with and without dementia. Results: Among 16,261 residents, 6781 (42%) had dementia. Residents with dementia were significantly more likely to be exposed to polypharmacy and PIMs, compared to those without dementia (74% vs. 70% and 83% vs. 73%, p <.001 respectively). Residents with dementia had 1.31 times the odds of exposure to polypharmacy (adjusted OR: 1.31, 95% CI: 1.22–1.41, p <.001) and 1.88 times the odds of being prescribed ≥1 PIMs than people without dementia (adjusted OR: 1.88, 95% CI: 1.73–2.04, p <.001). Conclusions: In a study of residents receiving RMMR, polypharmacy and PIMs were highly common, and those with dementia were more likely to be exposed to inappropriate polypharmacy. There is a need for targeted deprescribing strategies to immediately address inappropriate prescribing in residents, particularly those living with dementia. [ABSTRACT FROM AUTHOR]

Background: Inappropriate prescribing (IP) is common in hospitalised older adults with frailty. However, it is not known whether the presence of frailty confers an increased risk of mortality and readmissions from IP nor whether rectifying IP reduces this risk. This review was conducted to determine whether IP increases the risk of adverse outcomes in hospitalised middle-aged and older adults with frailty. Methods: A systematic review was conducted on IP in hospitalised middle-aged (45–64 years) and older adults (≥ 65 years) with frailty. This review considered multiple types of IP including potentially inappropriate medicines, prescribing omissions and drug interactions. Both observational and interventional studies were included. The outcomes were mortality and hospital readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, World of Science, SCOPUS and the Cochrane Library. The search was updated to 12 July 2024. Meta-analysis was performed to pool risk estimates using the random effects model. Results: A total of 569 studies were identified and seven met the inclusion criteria, all focused on the older population. One of the five observational studies found an association between IP and emergency department visits and readmissions at specific time points. Three of the observational studies were amenable to meta-analysis which showed no significant association between IP and hospital readmissions (OR 1.08, 95% CI 0.90–1.31). Meta-analysis of the subgroup assessing Beers criteria medicines demonstrated that there was a 27% increase in the risk of hospital readmissions (OR 1.27, 95% CI 1.03–1.57) with this type of IP. In meta-analysis of the two interventional studies, there was a 37% reduced risk of mortality (OR 0.63, 95% CI 0.40-1.00) with interventions that reduced IP compared to usual care but no difference in hospital readmissions (OR 0.83, 95% CI 0.19–3.67). Conclusions: Interventions to reduce IP were associated with reduced risk of mortality, but not readmissions, compared to usual care in older adults with frailty. The use of Beers criteria medicines was associated with hospital readmissions in this group. However, there was limited evidence of an association between IP more broadly and mortality or hospital readmissions. Further high-quality studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Despite reliable evidence of adverse drug effects, the substantially increased prescription rates of proton pump inhibitors (PPIs) remain at a high level. This study analyzed the appropriateness of PPI prescriptions among residents of nursing homes in three regions of Germany. Baseline data of a cluster-randomized controlled trial were used to determine the prevalence of PPI prescriptions, the validity of indications, and the adequacy of the prescribed dosages according to 1. their drug approvals and 2. valid recommendation guidelines. Regression analyses were conducted to assess associated factors. A total of 437 residents in 37 nursing homes were included (mean age 83 ± 9.2 years, 72% women). The PPI prescription prevalence was 44% (n = 193). In 52/193 (27%) there was no adequate indication, and in 54 (39%) of 138 indicated PPI prescriptions it was overdosed. Yet, in only less than one-third (28%) of "adequate" prescriptions, the indication was according to the PPI approvals, whereas the majority (72%) were off-label indications in line with valid guideline recommendations. Non-indicated PPI prescription was associated with the total number of prescribed drugs (OR 1.32; 95% CI 1.18–1.62; p = 0.013). There were no associations with age, level of care dependency, cognitive impairment, prescription of psychotropic drugs, number of chronic diseases, number of physicians' consultations, or study region. To conclude, in 55%, the high prescription prevalence among residents was either not indicated or overdosed. In total, only 20% (39/193) of cases of PPI use complied with the approved indications. There is a need for quality control of 1. PPI administration in German nursing homes, and 2. of guideline recommendations expanding the off-label PPI use by 72% within the indication scale, predominantly from wide prescription for low-dose ASA. [ABSTRACT FROM AUTHOR]

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Abstract Background Inappropriate prescribing (IP) is a common problem in the older population. Despite numerous attempts to tackle this issue, it remains a public health concern. In most European countries, general practitioners (GPs) are responsible for global primary care and are thus gatekeepers for the adequacy of medicines, specifically for older people. An in-depth analysis of the situation is necessary to understand why this phenomenon is still prevalent and to identify solutions that could help avoid IP in primary practice. Method A qualitative study based on five focus groups (FG) comprising nine to thirteen general practitioners was conducted in the French-speaking part of Belgium. Participants were recruited among the Local Medical Evaluation Groups (LMEG) and selected to guarantee heterogeneity in working organisations, years of professional experience, gender and age. All interviews were recorded with prior agreement and transcribed in verbatims. The transcripts were coded and analysed to highlight the primary themes, considering dominant and marginal discourses. Results Fifty four GPs participated in the study, with an average experience of 30 years. IPs are perceived as a significant problem in the older population, leading to dangerous health situations. The issue is associated with polypharmacy and multimorbidity, and GPs stated to manage IP using their clinical experience. Most of the study participants faced difficulties managing IP, mostly due to the specificity and complexity of elderly care. Indeed, managing an older patient is challenging due to medical complexity, poor adherence to drug regimes, or low medical literacy. In addition, the medical environment of general practice is challenging, with multiple providers, lack of time, prescribing routine and the absence of effective communication with specialists or other care providers. Additionally, the tools and support available to help medication management in primary care are inadequate. Enhancing collaboration with pharmacists is perceived as a strong potential facilitator. Conclusion This article addresses the complex management of IP in the old age, from the point of view of GPs. Interesting clues were highlighted, like the need to clarify roles of healthcare providers, the better fit of tools to facilitate medication’s review with particularities of GPs needs and the empowerment of pharmacist collaboration.

Abstract Purpose In recent years, the need for a more appropriate prescription of medications in the older population has emerged as a significant public health concern. In this study, we aimed to evaluate the prevalence of potentially inappropriate medications (PIM) in hospitalized adults aged ≥ 75. Patients and methods This was a retrospective descriptive observational study of patients at 16 hospitals in Spain. The study population included inpatients aged ≥ 75 admitted during a 7-day period (May 10 to 16, 2021). Data were obtained from the pharmacy databases of the participating hospitals. The list of PIMs was based on the Beers, STOPP-START, EU-PIM and PRISCUS criteria. Results A total of 4,183 patients were included. PIMs were detected in 23.5% (N = 1,126) of the cohort. The prevalence rates at the participating hospitals ranged from 10% to 42.5%. The PIM/patient ratio was 1.2. The most common PIMs were midazolam, dexketoprofen, diazepam, and doxazosin, all of which (except for doxazosin) were more common in women. Benzodiazepines accounted for 70% of all PIMs. In 35% of cases, the PIMs were initiated before hospital admission. Of the 818 PIMs initiated during hospitalization, the two most common were benzodiazepines (49%) and anti-inflammatory drugs (25%). At discharge, only 4.9% of the PIMs initiated during the hospital stay were still prescribed. Conclusion In this population of older hospitalized patients, the overall prevalence of PIMs was moderate. However, the prevalence rate at the participating hospitals was highly variable. In most cases, PIMs prescribed prior to hospitalization for chronic conditions were not withdrawn during the hospital stay. No significant increase in PIMs was observed from pre-admission to post-discharge. These findings underscore the need for multidisciplinary interventions to optimize the pharmaceutical treatment in older adults in the hospital setting to reduce the consequences of PIMs in patients.

Abstract Background Inappropriate prescribing (IP) is common in hospitalised older adults with frailty. However, it is not known whether the presence of frailty confers an increased risk of mortality and readmissions from IP nor whether rectifying IP reduces this risk. This review was conducted to determine whether IP increases the risk of adverse outcomes in hospitalised middle-aged and older adults with frailty. Methods A systematic review was conducted on IP in hospitalised middle-aged (45–64 years) and older adults (≥ 65 years) with frailty. This review considered multiple types of IP including potentially inappropriate medicines, prescribing omissions and drug interactions. Both observational and interventional studies were included. The outcomes were mortality and hospital readmissions. The databases searched included MEDLINE, CINAHL, EMBASE, World of Science, SCOPUS and the Cochrane Library. The search was updated to 12 July 2024. Meta-analysis was performed to pool risk estimates using the random effects model. Results A total of 569 studies were identified and seven met the inclusion criteria, all focused on the older population. One of the five observational studies found an association between IP and emergency department visits and readmissions at specific time points. Three of the observational studies were amenable to meta-analysis which showed no significant association between IP and hospital readmissions (OR 1.08, 95% CI 0.90–1.31). Meta-analysis of the subgroup assessing Beers criteria medicines demonstrated that there was a 27% increase in the risk of hospital readmissions (OR 1.27, 95% CI 1.03–1.57) with this type of IP. In meta-analysis of the two interventional studies, there was a 37% reduced risk of mortality (OR 0.63, 95% CI 0.40-1.00) with interventions that reduced IP compared to usual care but no difference in hospital readmissions (OR 0.83, 95% CI 0.19–3.67). Conclusions Interventions to reduce IP were associated with reduced risk of mortality, but not readmissions, compared to usual care in older adults with frailty. The use of Beers criteria medicines was associated with hospital readmissions in this group. However, there was limited evidence of an association between IP more broadly and mortality or hospital readmissions. Further high-quality studies are needed to confirm these findings.

Abstract Background More than 263,000 individuals died due to prescription opioid misuse between 1999 and 2020. Between 2013 and 2015 alone, pharmaceutical companies spent over $39 million to market opioids to over 67,000 prescribers. However, there is still limited information about differences in provider responses to promotions for medications. In this study we investigated and evaluated strategies used by opioid manufacturers to encourage overprescribing, specifically focusing on oncology. Methods We conducted a retrospective review of opioid industry documents released in litigation between 1999 and 2021. We began with a preliminary search for business plans in a subset of collections that identified key terms and phrases. These search terms were then used to narrow the investigation, which ultimately focused on Insys Therapeutics, and how they targeted oncology providers as well as patients with cancer pain. Results We found that, overall, Insys sought to market to institutions with fewer resources, to less experienced and high-volume providers, and directly to cancer patients, with the goal of encouraging increased opioid prescribing and use. Conclusions Our research revealed gaps in provider training that may make some providers more susceptible to pharmaceutical marketing. Developing and promoting continuing education courses for providers that are free from conflicts of interest, particularly at smaller institutions, may be one step towards reducing opioid overprescribing and its associated harms.

Abstract Background An increasing number of people are using multiple medications each day, named polypharmacy. This is driven by an ageing population, increasing multimorbidity, and single disease-focussed guidelines. Medications carry obvious benefits, yet polypharmacy is also linked to adverse consequences including adverse drug events, drug-drug and drug-disease interactions, poor patient experience and wasted resources. Problematic polypharmacy is ‘the prescribing of multiple medicines inappropriately, or where the intended benefits are not realised’. Identifying people with problematic polypharmacy is complex, as multiple medicines can be suitable for people with several chronic conditions requiring more treatment. Hence, polypharmacy is often potentially problematic, rather than always inappropriate, dependent on clinical context and individual benefit vs risk. There is a need to improve how we identify and evaluate these patients by extending beyond simple counts of medicines to include individual factors and long-term conditions. Aim To produce a Polypharmacy Assessment Score to identify a population with unusual levels of prescribing who may be at risk of potentially problematic polypharmacy. Methods Analyses will be performed in three parts: 1. A prediction model will be constructed using observed medications count as the dependent variable, with age, gender and long-term conditions as independent variables. A ‘Polypharmacy Assessment Score’ will then be constructed through calculating the differences between the observed and expected count of prescribed medications, thereby highlighting people that have unexpected levels of prescribing. Parts 2 and 3 will examine different aspects of validity of the Polypharmacy Assessment Score: 2. To assess ‘construct validity’, cross-sectional analyses will evaluate high-risk prescribing within populations defined by a range of Polypharmacy Assessment Scores, using both explicit (STOPP/START criteria) and implicit (Medication Appropriateness Index) measures of inappropriate prescribing. 3. To assess ‘predictive validity’, a retrospective cohort study will explore differences in clinical outcomes (adverse drug reactions, unplanned hospitalisation and all-cause mortality) between differing scores. Discussion Developing a cross-cutting measure of polypharmacy may allow healthcare professionals to prioritise and risk stratify patients with polypharmacy using unusual levels of prescribing. This would be an improvement from current approaches of either using simple cutoffs or narrow prescribing criteria.

Abstract Background The management of inappropriate medication use in older patients suffering from multimorbidity and polymedication is a major healthcare challenge. In a primary care setting, a medication review is an effective tool through which a pharmacist can collaborate with a practitioner to detect inappropriate drug use. Aim This project described the implementation of a systematic process for the management of potentially inappropriate medication use among Lebanese older adults. Its aim was to involve pharmacists in geriatric care and to suggest treatment optimization through the analysis of prescriptions using explicit and implicit criteria. Method This study evaluated the medications of patients over 65 years taking a minimum of five chronic medications a day in different regions of Lebanon. Descriptive statistics for all the included variables using mean and standard deviation (Mean (SD)) for continuous variables and frequency and percentage (n, (%)) for multinomial variables were then performed. Results A total of 850 patients (50.7% women, 28.6% frail, 75.7 (8.01) mean age (SD)) were included in this study. The mean number of drugs per prescription was 7.10 (2.45). Roughly 88% of patients (n = 748) had at least one potentially inappropriate drug prescription: 66.4% and 64.4% of the patients had at least 1 drug with an unfavorable benefit-to-risk ratio according to Beers and EU(7)-PIM respectively. Nearly 50.4% of patients took at least one medication with no indication. The pharmacists recommended discontinuing medication for 76.5% of the cases of drug related problems. 26.6% of the overall proposed interventions were implemented. Discussion The rate of potentially inappropriate drug prescribing (PIDP) (88%) was higher than the rates previously reported in Europe, US, and Canada. It was also higher than studies conducted in Lebanon where it varied from 22.4 to 80% depending on the explicit criteria used, the settings, and the medical conditions of the patients. We used both implicit and explicit criteria with five different lists to improve the detection of all types of inappropriate medication use since Lebanon obtains drugs from many different sources. Another potential source for variation is the lack of a standardized process for the assessment of outpatient medication use in the elderly. Conclusion The prevalence PIDP detected in the sample was higher than the percentages reported in previous literature. Systematic review of prescriptions has the capacity to identify and resolve pharmaceutical care issues thus improving geriatric care.

Abstract Background Healthcare regulators in many countries undertake inspections of healthcare providers and publish inspection outcomes with the intention of improving quality of care. Comprehensive inspections of general practices in England by the Care Quality Commission began for the first time in 2014. It is assumed that inspection and rating will raise standards and improve care, but the presence and extent of any improvements is unknown. We aim to determine if practice inspection ratings are associated with past performance on prescribing indicators and if prescribing behaviour changes following inspection. Methods Longitudinal study using a dataset of 6771 general practices in England. Practice inspection date and score was linked with monthly practice-level data on prescribing indicators relating to antibiotics, hypnotics and non-steroidal anti-inflammatory drugs. The sample covers practices receiving their first inspection between September 2014 and December 2018. Regression analysis and the differential timing of inspections is used to identify the impact on prescribing. Results Better-rated practices had better prescribing in the period before inspections began. In the six months following inspections, no overall change in prescribing was observed. However, the differences between the best and worse rated practices were reduced but not fully. The same is also true when taking a longer-term view. There is little evidence that practices responded in anticipation of inspection or reacted differently once the ratings were made public. Conclusion While some of the observed historic variation in prescribing behaviour has been lessened by the process of inspection and ratings, we find this change is small and appears to come from both improvements among lower-rated practices and deteriorations among higher-rated practices. While inspection and rating no doubt had other impacts, these prescribing indicators were largely unchanged.

Background: Overprescribing of potentially harmful medication in UK general practice has a complex association with socioeconomic deprivation. Aim: To assess trends in general practice prescribing of five high-risk medications and their relationship with deprivation. Design & setting: An observational study was conducted using general practice data from three English regions with varied sociodemographic factors: West Yorkshire and Harrogate (WY), Black Country and West Birmingham (BC), and Surrey and East Sussex (SE). Method: Practice-level prescribing data were obtained from 2016–2021 for five drug classes: opioids, hypnotics, gabapentinoids, non-steroidal anti-inflammatory drugs (NSAIDs), and antibacterials. Prescribing trends were demonstrated using a linear model. Results: Reduction in NSAID, opioid, hypnotic and antibacterial prescriptions, and the increase in gabapentinoid prescriptions, were significant at each financial year time period. Index of Multiple Deprivation (IMD) was positively associated with all drug classes except antibacterials, which showed a positive association when incorporating the interaction term between IMD and age. When adjusting for IMD and population, region was independently associated with prescribing rate. Compared with WY, IMD had a smaller association with prescribing in BC for NSAIDs (coefficient = −0.01578, P = 0.004) and antibacterials (coefficient = −0.02769, P = 0.007), whereas IMD had a greater association with prescribing in SE for NSAIDs (coefficient = 0.02443, P<0.001), opioids (coefficient = 0.08919, P<0.001), hypnotics (coefficient = 0.09038, P<0.001), gabapentinoids (coefficient = 0.1095, P<0.001), and antibacterials (coefficient = 0.01601, P = 0.19). Conclusion: The association of socioeconomic deprivation with overprescribing of high-risk medication in general practice varies by region and drug type. Geographical location is associated with overprescribing, independent of socioeconomic status. [ABSTRACT FROM AUTHOR]

Background: The management of inappropriate medication use in older patients suffering from multimorbidity and polymedication is a major healthcare challenge. In a primary care setting, a medication review is an effective tool through which a pharmacist can collaborate with a practitioner to detect inappropriate drug use. Aim: This project described the implementation of a systematic process for the management of potentially inappropriate medication use among Lebanese older adults. Its aim was to involve pharmacists in geriatric care and to suggest treatment optimization through the analysis of prescriptions using explicit and implicit criteria. Method: This study evaluated the medications of patients over 65 years taking a minimum of five chronic medications a day in different regions of Lebanon. Descriptive statistics for all the included variables using mean and standard deviation (Mean (SD)) for continuous variables and frequency and percentage (n, (%)) for multinomial variables were then performed. Results: A total of 850 patients (50.7% women, 28.6% frail, 75.7 (8.01) mean age (SD)) were included in this study. The mean number of drugs per prescription was 7.10 (2.45). Roughly 88% of patients (n = 748) had at least one potentially inappropriate drug prescription: 66.4% and 64.4% of the patients had at least 1 drug with an unfavorable benefit-to-risk ratio according to Beers and EU(7)-PIM respectively. Nearly 50.4% of patients took at least one medication with no indication. The pharmacists recommended discontinuing medication for 76.5% of the cases of drug related problems. 26.6% of the overall proposed interventions were implemented. Discussion: The rate of potentially inappropriate drug prescribing (PIDP) (88%) was higher than the rates previously reported in Europe, US, and Canada. It was also higher than studies conducted in Lebanon where it varied from 22.4 to 80% depending on the explicit criteria used, the settings, and the medical conditions of the patients. We used both implicit and explicit criteria with five different lists to improve the detection of all types of inappropriate medication use since Lebanon obtains drugs from many different sources. Another potential source for variation is the lack of a standardized process for the assessment of outpatient medication use in the elderly. Conclusion: The prevalence PIDP detected in the sample was higher than the percentages reported in previous literature. Systematic review of prescriptions has the capacity to identify and resolve pharmaceutical care issues thus improving geriatric care. [ABSTRACT FROM AUTHOR]

Aims: The aim of this study was to estimate the prevalence of potentially inappropriate prescriptions (PIPs) in patients starting their first noninsulin antidiabetic treatment (NIAD) using two explicit process measures of the appropriateness of prescribing in UK primary care, stratified by age and polypharmacy status. Methods: A descriptive cohort study between 2016 and 2019 was conducted to assess PIPs in patients aged ≥45 years at the start of their first NIAD, stratified by age and polypharmacy status. The American Geriatrics Society Beers criteria 2015 was used for older (≥65 years) patients and the Prescribing Optimally in Middle‐age People's Treatments criteria was used for middle‐aged (45‐64 years) patients. Prevalence of overall PIPs and individual PIPs criteria was reported using the IQVIA Medical Research Data incorporating THIN, a Cegedim Database of anonymized electronic health records in the UK. Results: Among 28 604 patients initiating NIADs, 18 494 (64.7%) received polypharmacy. In older and middle‐aged patients with polypharmacy, 39.6% and 22.7%, respectively, received ≥1 PIP. At the individual PIP level, long‐term proton pump inhibitors (PPI) use was the most frequent PIP among older adults, and strong opioid without laxatives was the most frequent PIP in middle‐aged patients with polypharmacy (11.1% and 4.1%, respectively). Conclusions: This study revealed that patients starting NIAD treatment receiving polypharmacy have the potential for pharmacotherapy optimization. [ABSTRACT FROM AUTHOR]

Background: Older people are at high risk of medicines‐related harms. otentially inappropriate medicines (PIMs) list has been developed to assist clinicians and researchers to identify medicines with risks that may potentially outweigh their benefits in order to improve medication management and safety. Aim: To develop a list of PIMs for older people specific to Australia. Methods: The study obtained expert consensus through the utilisation of the Delphi technique in Australia. A total of 33 experts partook in the initial round, while 32 experts engaged in the subsequent round. The primary outcomes encompass medicines assessed as potentially inappropriate, the specific contexts in which their inappropriateness arises and potentially safer alternatives. Results: A total of 16 medicines or medicine classes had one or more medicines deemed as potentially inappropriate in older people. Up to 19 medicines or medicine classes had specific conditions that make them more potentially inappropriate, while alternatives were suggested for 16 medicines or classes. Conclusion: An explicit PIMs list for older people living in Australia has been developed containing 19 drugs/drug classes. The PIMs list is intended to be used as a guide for clinicians when assessing medication appropriateness in older people in Australian clinical settings and does not substitute individualised treatment advice from clinicians. [ABSTRACT FROM AUTHOR]

Background Antibiotics provide minimal benefit for sore throat, otitis media, and sinusitis. Antibiotic stewardship, with reduced prescribing, is required to address antibiotic resistance. As most antibiotic prescribing occurs in general practice and prescribing habits develop early, general practitioner (GP) trainees (registrars) are important for effective antibiotic stewardship. Objectives To establish temporal trends in Australian registrars' antibiotic prescribing for acute sore throat, acute otitis media, and acute sinusitis. Design A longitudinal analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study from 2010 to 2019. Participants ReCEnT is an ongoing cohort study of registrars' in-consultation experiences and clinical behaviours. Pre-2016, 5 of 17 Australian training regions participated. From 2016, 3 of 9 regions (42% of Australian registrars) participate. Main measures The outcome was prescription of an antibiotic for a new acute problem/diagnosis of sore throat, otitis media, or sinusitis. The study factor was year (2010–2019). Key results Antibiotics were prescribed in 66% of sore throat diagnoses, 81% of otitis media, and in 72% of sinusitis. Prescribing frequencies decreased between 2010 and 2019 by 16% for sore throat (from 76% to 60%) by 11% for otitis media (from 88% to 77%) and by 18% for sinusitis (from 84% to 66%). In multivariable analyses, "Year" was associated with reduced prescribing for sore throat (OR 0.89; 95%CI 0.86–0.92; p < 0.001), otitis media (OR 0.90; 95%CI 0.86–0.94; p < 0.001), and sinusitis (OR 0.90; 95%CI 0.86, 0.94; p < 0.001). Conclusions Registrars' prescribing rates for sore throat, otitis media, and sinusitis significantly decreased during the period 2010–2019. However, educational (and other) interventions to further reduce prescribing are warranted. [ABSTRACT FROM AUTHOR]

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Purpose 'Low-value' clinical care and medical services are 'questionable' activities, being more likely to cause harm than good or with disproportionately low benefit relative to cost. This study examined the predictive ability of the QUestionable In Training Clinical Activities Index (QUIT-CAI) for general practice (GP) registrars' (trainees') performance in Australian GP Fellowship examinations (licensure/certification examinations for independent GP). Methods The study was nested in ReCEnT, an ongoing cohort study in which Australian GP registrars document their in-consultation clinical practice. Outcome factors in analyses were individual registrars' scores on the three Fellowship examinations ('AKT', 'KFP', and 'OSCE' examinations) and pass/fail rates during 2012–21. Analyses used univariable and multivariable regression (linear or logistic, as appropriate). The study factor in each analysis was 'QUIT-CAI score percentage'—the percentage of times a registrar performed a QUIT-CAI clinical activity when 'at risk' (i.e. when managing a problem where performing a QUIT-CAI activity was a plausible option). Results A total of 1265, 1145, and 553 registrars sat Applied Knowledge Test, Key Features Problem, and Objective Structured Clinical Exam examinations, respectively. On multivariable analysis, higher QUIT-CAI score percentages (more questionable activities) were significantly associated with poorer Applied Knowledge Test scores (P  = .001), poorer Key Features Problem scores (P  = .003), and poorer Objective Structured Clinical Exam scores (P  = .005). QUIT-CAI score percentages predicted Royal Australian College of General Practitioner exam failure [odds ratio 1.06 (95% CI 1.00, 1.12) per 1% increase in QUIT-CAI, P  = .043]. Conclusion Performing questionable clinical activities predicted poorer performance in the summative Fellowship examinations, thereby validating these examinations as measures of actual clinical performance (by our measure of clinical performance, which is relevant for a licensure/certification examination). Key message What is already known on this topic—   Frequent performance of 'Questionable' clinical activities—activities more likely to cause harm than good or whose benefit is disproportionately low compared with its cost—can be seen a marker of the quality of health care delivery and clinical competence. Summative medical licensure/certification examination performance should reflect clinically important attributes of the candidate and provide confidence of future patient safety. What this study adds—   This study demonstrates that the Royal Australian College of General Practitioners' (RACGPs') summative examination performance reflects clinical performance as assessed by a measure of 'questionable' actions in clinical practice. Performance on all three individual examination components—Applied Knowledge Test (a multiple-choice examination), Key Features Problem (a short answer plus multiple responses selection examination), and Objective Structured Clinical Exam (a clinical skills station examination), plus pass/fail status—was predicted by 'questionable' clinical practice. How this study might affect research, practice or policy—   The findings provide evidence for the validity of the RACGP Fellowship examination and similar licensure/certification examinations. [ABSTRACT FROM AUTHOR]

Background: Healthcare regulators in many countries undertake inspections of healthcare providers and publish inspection outcomes with the intention of improving quality of care. Comprehensive inspections of general practices in England by the Care Quality Commission began for the first time in 2014. It is assumed that inspection and rating will raise standards and improve care, but the presence and extent of any improvements is unknown. We aim to determine if practice inspection ratings are associated with past performance on prescribing indicators and if prescribing behaviour changes following inspection. Methods: Longitudinal study using a dataset of 6771 general practices in England. Practice inspection date and score was linked with monthly practice-level data on prescribing indicators relating to antibiotics, hypnotics and non-steroidal anti-inflammatory drugs. The sample covers practices receiving their first inspection between September 2014 and December 2018. Regression analysis and the differential timing of inspections is used to identify the impact on prescribing. Results: Better-rated practices had better prescribing in the period before inspections began. In the six months following inspections, no overall change in prescribing was observed. However, the differences between the best and worse rated practices were reduced but not fully. The same is also true when taking a longer-term view. There is little evidence that practices responded in anticipation of inspection or reacted differently once the ratings were made public. Conclusion: While some of the observed historic variation in prescribing behaviour has been lessened by the process of inspection and ratings, we find this change is small and appears to come from both improvements among lower-rated practices and deteriorations among higher-rated practices. While inspection and rating no doubt had other impacts, these prescribing indicators were largely unchanged. [ABSTRACT FROM AUTHOR]

Background Aims Methods Results Conclusion Unconfirmed beta‐lactam allergy in pregnant people has been associated with higher morbidity, unnecessary exposure to broad‐spectrum antibiotics and prolonged hospitalisation. There are no published data on beta‐lactam allergies in pregnant people in Australia.The aim was to describe patient‐reported beta‐lactam allergies and appropriateness for antibiotic allergy de‐labelling in a maternity cohort in Australia.Maternity patients aged ≥18 years admitted to our institution between March 2021 and June 2021 with a beta‐lactam allergy documented in their electronic medical record were interviewed for details of their allergy. The documented allergies were compared to the allergy history obtained from the interview. Severity of the allergy was rated, and appropriateness for allergy de‐labelling was assessed using the Victorian Therapeutics Advisory Group beta‐lactam antibiotic allergy assessment tool.One hundred and fifty‐three beta‐lactam allergies (182 reactions) were reported by 145 patients. Penicillin class antibiotics were the most frequently implicated, including unspecified penicillins (95/153, 62%), amoxicillin (19/153, 13%) and amoxicillin‐clavulanate (8/153, 5%). Allergy documentation required amending in 52 of 145 patients (36%); 85 of 153 (56%) of the beta‐lactam allergies were considered low risk and potentially appropriate for direct oral re‐challenge.Beta‐lactam allergies were inaccurately documented in more than one third of the maternity patients included in our study. As such, education of maternity care providers about the importance of accurate allergy history taking remains an urgent unmet need. Furthermore, allergy assessment and de‐labelling during pregnancy should be considered in maternity patients to optimise antibiotic prescribing and to improve maternal and neonatal health outcomes. [ABSTRACT FROM AUTHOR]

Improving the quality of medication use and medication safety are important priorities for healthcare providers who care for older adults. The objective of this article was to identify four exemplary articles with this focus in 2022. We selected high‐quality studies from an OVID search and hand searching of major high impact journals that advanced the field of research forward. The chosen articles cover domains related to deprescribing, medication safety, and optimizing medication use. The MedSafer Study, a cluster randomized clinical trial in Canada, evaluated whether patient specific deprescribing reports generated by electronic decision support software resulted in reduced adverse drug events in the 30 days post hospital discharge in older adults (domain: deprescribing). The second study, a retrospective cohort study using data from Premier Healthcare Database, examined in‐hospital adverse clinical events associated with perioperative gabapentin use among older adults undergoing major surgery (domain: medication safety). The third study used an open‐label parallel controlled trial in 39 Australian aged‐care facilities to examine the effectiveness of a pharmacist‐led intervention to reduce medication‐induced deterioration and adverse reactions (domain: optimizing medication use). Lastly, the fourth study engaged experts in a Delphi method process to develop a consensus list of clinically important prescribing cascades that adversely affect older persons' health to aid clinicians to identify, prevent, and manage prescribing cascades (domain: optimizing medication use). Collectively, this review succinctly highlights pertinent topics related to promoting safe use of medications and promotes awareness of optimizing older adults' medication regimens. [ABSTRACT FROM AUTHOR]

Objectives: Variations in management of sinusitis in primary care settings can be associated with inappropriate antibiotic prescriptions and delays in treatment. The objective of this study was to identify patient and provider characteristics associated with possible inaccurate diagnosis and management of sinusitis. Methods: We performed a cross-sectional retrospective analysis using an established regional healthcare database of patients who received a diagnosis of sinusitis between 2011 and 2022 from a non-otolaryngologist provider. Patient's comorbidities, insurance status, chronicity of sinusitis, and prescriptions were included. We noted if patients were referred to an otolaryngology practice and if they received a diagnosis of sinusitis from an otolaryngologist. Results: We analyzed 99 581 unique patients and 168 137 unique encounters. The mean age was 41.5 (±20.4 years) and 35.7% were male. Most patients had private insurance (88.5%), acute sinusitis (81.2%), and were seen at a primary care office (97.8%). Approximately 30% of patients were referred to an otolaryngology practice for sinusitis. Of referred patients, 50.6% did not receive a diagnosis of sinusitis from an otolaryngology practice. Patients without a sinusitis diagnosis by an otolaryngology practice received significantly more mean courses of antibiotics (5.04 vs 2.39, P <.0001) and oral steroids (3.53 vs 2.08, P <.0001). Conclusions: Over half of the patients referred to an otolaryngology practice from primary care for sinusitis did not receive a diagnosis of sinusitis from an otolaryngology practice. Further research should investigate implications for increased healthcare costs and inappropriate prescription trends associated with the management of sinusitis. [ABSTRACT FROM AUTHOR]

Objectives: This study aimed to determine the prevalence of potentially inappropriate prescriptions (PIPs) and potential prescription omissions (PPOs) in a Spanish cohort of people living with HIV (PLWH) aged ≥65 years and to identify risk factors for the presence of PIPs and PPOs. Methods: This retrospective cross‐sectional study was conducted across 10 public hospitals in the Autonomous Community of Madrid, Spain. Clinical and demographic data were cross‐checked against hospital and community pharmacy dispensation registries. PIPs and PPOs were assessed using the American Geriatrics Society (AGS)/Beers and Screening Tool of Older Persons' Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. Risk factors for PIPs and PPOs and agreement between AGS/Beers and STOPP/START criteria were statistically analysed. Results: This study included 313 PLWH (median age 72 years), of whom 80.5% were men. PIP prevalence rates were 29.4% and 44.4% based on the AGS/Beers and STOPP criteria, respectively. The concordance between AGS/Beers and STOPP criteria was moderate. Benzodiazepines and proton pump inhibitors were the chronic comedications most commonly involved in PIPs. PPOs were observed in 61.4% of the patients. The leading omissions were insufficient influenza and pneumococcal vaccine coverage and inadequate bone health‐related treatments. The number of chronic comedications, female sex, neuropsychiatric disorders, and cancer diagnosis were risk factors for PIPs, whereas osteopenia and osteoporosis were risk factors for PPOs. Conclusions: A high prevalence of PIPs and PPOs was observed in our cohort of older PLWH. These findings emphasize the importance of comprehensive medication reviews in this population to reduce inappropriate medication use and address their specific and underserved therapeutic needs. [ABSTRACT FROM AUTHOR]

IntroductionPotentially inappropriate medications (PIMs) cause adverse events and death. We evaluate the Care Ecosystem (CE) collaborative dementia care program on medication use among community-dwelling persons living with dementia (PLWD).MethodsSecondary analysis of a randomized clinical trial (RCT) comparing CE to usual care (UC) on changes in PIMs, over 12 months between March 2015 and May 2020. Secondary outcomes included change in number of medications, clinically relevant PIMs, and anti-dementia medications.ResultsOf 804 PLWD, N = 490 had complete medication data. The CE resulted in significantly fewer PIMs compared to UC (-0.35; 95% CI, -0.49 to -0.20; P

IntroductionThe prevalent overprescribing of proton pump inhibitors (PPIs) poses health risks from prolonged use. GPs play a key role in initiating deprescribing PPIs, so understanding their decision-making factors and strategies to improve feasibility is crucial. This study aimed to investigate the perspectives of GPs on deprescribing PPIs with a focus on identifying facilitators, barriers, and strategies to enhance feasibility in clinical settings.MethodsA qualitative study involving semi-structured interviews was conducted with nine GPs or trainees. The thematic analysis of the interviews was conducted using NVivo R1 (2020).ResultsFour main categories were identified: 1) Inappropriate prescribing of PPIs, 2) Facilitators for deprescribing PPIs, 3) Barriers to deprescribing PPIs, 4) Feasibility of deprescribing PPIs. GPs acknowledged excessive and often inappropriate PPI prescribing, with a lack of deprescribing efforts mainly due to time constraints. Other key barriers included patient reluctance, fear of symptom recurrence, and unawareness of long-term risks. Patient-initiated request is key facilitator for deprescribing PPIs. GPs emphasized the need for collaboration with healthcare professionals, clear guidelines, improved digital support, increased physician availability, and raising awareness among providers and patients to enhance deprescribing feasibility.DiscussionGPs are calling for a multifaceted approach to improve the feasibility of deprescribing PPIs, involving patient-centered approaches, systemic optimizations, support from other healthcare professionals, and provider-centered strategies to emphasize the importance of deprescribing PPIs.

IntroductionCurrent research on potentially inappropriate prescribing (PIP) in polymedicated older adults with atrial fibrillation (AF) and multimorbidity is predominantly focused on PIP of oral anticoagulants (OAC). Our study aimed to assess (i) the overall prevalence of PIP in older multimorbid adults with AF, (ii) potential associated factors of PIP, and (iii) the association of PIP with adverse health outcomes in a nationwide sample of Swedish older adults.MethodsSwedish national registries were linked to establish a cohort with a 2-year follow-up of older adults (≥65y) who, on 1 January 2017, had a diagnosis of AF and had at least one comorbidity (n = 203,042). PIP was assessed using the reduced STOPP/START version 2 screening tool. The STOPP criteria identify potentially inappropriate prescribed medications (PIM), while the START criteria identify potential prescribing omissions (PPO). PIP is identified as having at least one PIM and/or PPO. Cox regression analyses were conducted to examine the association between PIP and adverse health outcomes: mortality, hospitalisation, stroke, bleeding, and falls.ResultsPIP was highly prevalent in older adults with AF, with both polypharmacy (69.6%) and excessive polypharmacy (85.9%). In the study population, benzodiazepines (22.9%), hypnotic Z-medications (17.8%) and analgesics (8.7%) were the most frequent PIM. Anticoagulants (34.3%), statins (11.1%), vitamin D and calcium (13.4%) were the most frequent PPO. Demographic factors and polypharmacy were associated with different PIM and PPO categories, with the nature of these associations differing based on the specific type of PIM and PPO. The co-occurrence of PIM and PPO, compared to appropriate prescribing, was associated with an increased risk of adverse health outcomes compared to all appropriately prescribed medications: cardiovascular (CV) (Hazard ratio (HR) [95% confidence interval] = 1.97 [1.88–2.07]) and overall mortality (HR = 2.09 [2.03–2.16]), CV (HR = 1.34 [1.30–1.37]) and overall hospitalisation (HR = 1.48 [1.46–1.51]), stroke (HR = 1.93 [1.78–2.10]), bleeding (HR = 1.10 [1.01–1.21]), and falls (HR = 1.63 [1.56–1.71]).ConclusionThe present study reports a high prevalence of PIP in multimorbid polymedicated older adults with AF. Additionally, a nuanced relationship between prescribing patterns, patient characteristics, and adverse health outcomes was observed. These findings emphasise the importance of implementing tailored interventions to optimise medication management in this patient population.

Abstract Background Studies have shown that potentially inappropriate prescribing (PIP) is highly prevalent among people with dementia (PwD) and linked to negative outcomes, such as hospitalisation and mortality. However, there are limited data on prescribing appropriateness for PwD in Saudi Arabia. Therefore, we aimed to estimate the prevalence of PIP and investigate associations between PIP and other patient characteristics among PwD in an ambulatory care setting. Methods A cross-sectional, retrospective analysis was conducted at a tertiary hospital in Saudi Arabia. Patients who were ≥ 65 years old, had dementia, and visited ambulatory care clinics between 01/01/2019 and 31/12/2021 were included. Prescribing appropriateness was evaluated by applying the Screening Tool of Older Persons Potentially Inappropriate Prescriptions (STOPP) criteria. Descriptive analyses were used to describe the study population. Prevalence of PIP and the prevalence per each STOPP criterion were calculated as a percentage of all eligible patients. Logistic regression analysis was used to investigate associations between PIP, polypharmacy, age and sex; odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Analyses were conducted using SPSS v27. Results A total of 287 PwD were identified; 56.0% (n = 161) were female. The mean number of medications prescribed was 9.0 [standard deviation (SD) ± 4.2]. The prevalence of PIP was 61.0% (n = 175). Common instances of PIP were drugs prescribed beyond the recommended duration (n = 90, 31.4%), drugs prescribed without an evidence-based clinical indication (n = 78, 27.2%), proton pump inhibitors (PPIs) for > 8 weeks (n = 75, 26.0%), and acetylcholinesterase inhibitors with concurrent drugs that reduce heart rate (n = 60, 21.0%). Polypharmacy was observed in 82.6% (n = 237) of patients and was strongly associated with PIP (adjusted OR 24.1, 95% CI 9.0–64.5). Conclusions Findings have revealed a high prevalence of PIP among PwD in Saudi Arabia that is strongly associated with polypharmacy. Future research should aim to explore key stakeholders’ experiences and perspectives of medicines management to optimise medication use for this vulnerable patient population.

Clostridium butyricum, a probiotic commonly prescribed in Asia, most notably as MIYA-BM (Miyarisan Pharmaceutical Co., Ltd.; https://www.miyarisan.com), occasionally leads to bacteremia. The prevalence and characteristics of C. butyricum bacteremia and its bacteriologic and genetic underpinnings remain unknown. We retrospectively investigated patients admitted to Osaka University Hospital during September 2011–February 2023. Whole-genome sequencing revealed 5 (0.08%) cases of C. butyricum bacteremia among 6,576 case-patients who had blood cultures positive for any bacteria. Four patients consumed MIYA-BM, and 1 patient consumed a different C. butyricum-containing probiotic. Most patients had compromised immune systems, and common symptoms included fever and abdominal distress. One patient died of nonocclusive mesenteric ischemia. Sequencing results confirmed that all identified C. butyricum bacteremia strains were probiotic derivatives. Our findings underscore the risk for bacteremia resulting from probiotic use, especially in hospitalized patients, necessitating judicious prescription practices.

Purpose: Inappropriate prescribing (IP) is common among the elderly and is associated with adverse health outcomes. The role of different patterns of IP in clinical practice remains unclear. The aim of this study is to analyse the characteristics of different patterns of IP in hospitalized older adults. Methods: This is a prospective observational study conducted in the acute care of elderly (ACE) unit of an acute hospital in Barcelona between June and August 2021. Epidemiological and demographic data were collected, and a comprehensive geriatric assessment (CGA) was performed on admitted patients. Four patterns of inappropriate prescribing were identified: extreme polypharmacy (10 or more drugs), potentially inappropriate medications (PIMs), potential prescribing omissions (PPOs) and anticholinergic burden. Results: Among 93 admitted patients (51.6% male, mean age of 82.83), the main diagnosis was heart failure (36.6%). Overprescribing patterns (extreme polypharmacy, PIMs, PPOs and anticholinergic burden) were associated with higher comorbidity, increased dependence on instrumental activities of daily living (IADL) and greater prevalence of dementia. Underprescribing (omissions) was associated with important comorbidity, residence in nursing homes, an increased risk of malnutrition, higher social risk and greater frailty. Comparing different patterns of IP, patients with high anticholinergic burden exhibited more extreme polypharmacy and PIMs. In the case of omissions, no association was identified with other IP patterns. Conclusions: We found statistically significant association between patterns of inappropriate prescribing and clinical and CGA variables such as comorbidity, dependency, dementia or frailty. There is a statistically significant association between patterns of overprescribing among patients admitted to the ACE unit. [ABSTRACT FROM AUTHOR]

Background: Inappropriate polypharmacy in older adults is a major health problem associated with poor clinical and health service outcomes. Aim: We aimed to evaluate the effectiveness of a geriatric pharmacist service in the emergency department (ED) identifying potentially inappropriate prescribing (PIP). Method: Between 1 June 2018–31 May 2019, adults ≥70 years of age presenting to ED were reviewed by the Geriatric Emergency Department Intervention (GEDI) pharmacist. The intervention consisted of pharmacist-led medication review using Screening Tool of Older Person’s Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria, patient education on recommendations, an updated medication list, and a letter sent to their general practitioner (GP) electronically. For eligible consenting older adults, telephone calls were made at least 28 days post-discharge to assess the effectiveness of the intervention. A survey with GPs after 6 months determined how recommendations were perceived. Ethics approval was granted by the Metro North Health B Human Research Ethics Committee (reference no: HREC/18QCH/69–1245) and research governance approval was granted by the study site (Cairns Hinterland Hospital and Health Service, reference no: SSA/Q12345/40673). Informed consent was obtained from all participants via a project information sheet and either the completion of a written consent form (patient participants), verbal consent before interview (GP participants), or implied consent via email responses (GP participants). Routinely collected health data obtained for this study were de-identified and data included in the follow-up study was de-identified. Results: The GEDI pharmacist reviewed 1214 older adults with an average age of 81 years. The median number of prescribed medications was 10 and 36.8% of older adults had STOPP recommendations. When contacted (n = 35), of those enrolled in the follow-up study, 71% had stated their medications changed, 40% reported all STOPP medications had ceased, and 69% had START medications commenced, suggesting the recommendations provided were clinically appropriate and readily accepted by their GPs. Conclusion: Integration of a geriatric pharmacist demonstrated ample opportunities to address PIP in targeted older adults presenting to ED. This study shows that the pharmacist was able to promote appropriate prescribing through patient education and recommendations communicated to the GP on discharge. [ABSTRACT FROM AUTHOR]

Background: The prevalence of patients with chronic kidney disease (CKD) and polypharmacy is increasing and has amplified the importance of examining inappropriate prescribing (IP) in CKD. This review focuses on the latest research regarding the prevalence of IP in CKD and the related adverse clinical effects and explores new interventions against IP. Method: A literature search was performed using PubMed, EMBASE and the Cochrane Library searching articles published between June 2016 and March 2022. Results: Twenty‐seven studies were included. An IP prevalence of 12.6% to 96% and 0.3% to 66% was reported in hospital and outpatient settings, respectively. In nonhospital settings, the prevalence of IP varied between 3.9% and 60%. IP was associated with higher risk of hospitalisation (HR 1.46, 95% CI 1.17–1.81), higher bleeding rate (HR 2.34, 95% CI 1.32 to 3.37) and higher risk of all‐cause mortality (OR 1.07, 95% CI 1.02 to 1.13). Three studies reported the impact of interventions on IP. Conclusion: This review highlights widespread IP in CKD patients across healthcare settings, with varying prevalence rates. IP is substantially linked to adverse outcomes in patients. While limited interventions show promise, urgent research is needed to develop effective strategies addressing IP and improving CKD patient care. [ABSTRACT FROM AUTHOR]

Few theoretically-based, qualitative studies have explored determinants of antimicrobial prescribing behaviour in hospitals. Understanding these can promote successful development and implementation of behaviour change interventions (BCIs). (s): To use the Theoretical Domains Framework (TDF) to explore determinants of clinicians' antimicrobial prescribing behaviour, identifying barriers (i.e., impediments) and facilitators to appropriate antimicrobial practice. Semi-structured interviews with purposively-sampled doctors and pharmacists with a wide range of specialties and expertise in Hamad Medical Corporation hospitals in Qatar. Interviews based on previous quantitative research and the TDF were audio-recorded, transcribed and independently analysed by two researchers using the TDF as an initial coding framework. Data saturation was achieved after interviewing eight doctors and eight pharmacists. Inter-related determinants of antimicrobial prescribing behaviour linked to ten TDF domains were identified as barriers and facilitators that may contribute to inappropriate or appropriate antimicrobial prescribing. The main barriers identified were around hospital guidelines and electronic system deficiencies (environmental context and resources); knowledge gaps relating to guidelines and appropriate prescribing (knowledge); restricted roles/responsibilities of microbiologists and pharmacists (professional role and identity); challenging antimicrobial prescribing decisions (memory, attention and decision processes); and professional hierarchies and poor multidisciplinary teamworking (social influences). Key facilitators included guidelines compliance (goals and intentions), and participants' beliefs about the consequences of appropriate or inappropriate prescribing. Further education and training, and some changes to guidelines including their accessibility were also considered essential. Antimicrobial prescribing behaviour in hospitals is a complex process influenced by a broad range of determinants including specific barriers and facilitators. The in-depth understanding of this complexity provided by this work may support the development of an effective BCI to promote appropriate antimicrobial stewardship. • Determinants of hospital clinicians' antimicrobial prescribing behaviour. • Barriers and facilitators to appropriate antimicrobial practice identified. • In-depth understanding useful in designing behaviour change interventions. [ABSTRACT FROM AUTHOR]

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Background: Pharmacists involvement in residential aged care facilities has traditionally been limited to that of an external contractor providing medication reviews, or medication supply. Aim: To explore Australian pharmacists' interest and perceived preparedness to work as on-site pharmacists in residential aged care. Method: National cross-sectional anonymous online survey open for two weeks (September 17th to October 1st 2022) consisting of Likert-type, multiple choice and multiple selection questions. Australian pharmacists were recruited using a broad advertising strategy which included social and traditional media platforms, and snowball sampling. Data were collected on pharmacist self-reported interest and perceived preparedness to work as on-site aged care pharmacists in residential aged care. Data were analysed using descriptive statistics. Results: Responses were received from 720 participants, 643 were eligible. Most participants were female (n = 466, 73%) and mean (SD) age was 43.5 (SD 12.5) years. Over half the participants were interested or extremely interested in working as an on-site aged care pharmacist (56%, n = 360), and agreed or strongly agreed (n = 475, 76%) that they felt prepared to work as an on-site aged care pharmacist. Most pharmacists felt prepared to engage in a variety of roles within the facilities (> 73% for each role), including resident and system level roles, and the majority agreed they felt prepared to engage with stakeholders, including general practitioners (93%) and medical specialists (86%). Conclusion: Pharmacists reported they are interested and feel prepared to work as on-site aged care pharmacists. These findings will inform the roll-out of this new model of care to enhance multidisciplinary collaboration in residential aged care. [ABSTRACT FROM AUTHOR]

Introduction: Clinical practice guidelines recommend against the routine use of psychotropic medications in residential aged care facilities (RACFs). Knowledge brokers are individuals or groups who facilitate the transfer of knowledge into practice. The objective of this trial is to evaluate the effectiveness and cost-effectiveness of using knowledge brokers to translate Australia's new Clinical Practice Guidelines for the Appropriate Use of Psychotropic Medications in People Living with Dementia and in Residential Aged Care. Methods and analysis: The Evidence-based Medication knowledge Brokers in Residential Aged CarE (EMBRACE) trial is a helix-counterbalanced randomised controlled trial. The 12-month trial will be conducted in up to 19 RACFs operated by four Australian aged care provider organisations in Victoria, New South Wales, Western Australia and Queensland. RACFs will be randomised to receive three levels of implementation strategies (knowledge broker service, pharmacist-led quality use of medications education activities and distribution of the Guidelines and supporting materials) across three medication contexts (antipsychotics, benzodiazepines and antidepressants). Implementation strategies will be delivered by an embedded on-site aged care pharmacist working at a system level across each participating RACF. All RACFs will receive all implementation strategies simultaneously but for different medication contexts. The primary outcome will be a composite dichotomous measure of 6-month RACF-level concordance with Guideline recommendations and good practice statements among people using antipsychotics, benzodiazepines and antidepressants for changed behaviours. Secondary outcomes will include proportion of residents with Guideline concordant use of antipsychotics, benzodiazepines and antidepressants measured at the RACF-level and proportion of residents with psychotropic medication use, hospitalisation, falls, falls with injury, polypharmacy, quality of life, activities of daily living, medication incidents and behavioural incidents measured at the RACF-level. Discussion: The EMBRACE trial investigates a novel guideline implementation strategy to improve the safe and effective use of psychotropic medications in RACFs. We anticipate that the findings will provide new information on the potential role of knowledge brokers for successful and cost-effective guideline implementation. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12623001141639. Registered 6 November 2023 — retrospectively registered, https://www.anzctr.org.au/TrialSearch.aspx. [ABSTRACT FROM AUTHOR]

Copyright of Gaceta Médica de México is the property of Publicidad Permanyer SLU and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: The use of proton pump inhibitors (PPIs) has increased over the past decades. One potential gateway into new PPI use is following a hospital admission. The study aimed to examine the incidence of new PPI usage following admission to internal medicine services and the ratio of new persistent users. Methods: A retrospective descriptive study was conducted among all adults who had been admitted to internal medicine wards at the National University Hospital of Iceland from 2010–2020. Data was obtained from the Icelandic Internal Medicine Database. The proportion of patients who started treatment with PPI within 3 months of discharge (new users) and the proportion of patients who continued to use it after 3 months (persistent users) were examined. Results: Among 85.942 admissions during the study period, 7238 (15.6%) became new users, and of those 4942 (68%) were new persistent users. The incidence of new PPI use was highest for patients discharged from gastroenterology (32.2%), hematology (31.8%), and oncology (29.2%). Patients with new PPI use more commonly had a history of malignancy (19.5%) and liver disease (22.7%) and more commonly were admitted to the ICU during their hospitalization. The highest ratio of persistent usage was among patients discharged from geriatric medicine (84%). Conclusion: One in every six patients admitted to internal medicine wards filled out a prescription for PPI within 3 months from discharge, and a large proportion of them became persistent users. The high rate of new PPI users from oncology and hematology is noteworthy and requires further research. [ABSTRACT FROM AUTHOR]

Background: Overprescribing of potentially harmful medication in UK general practice has a complex association with socioeconomic deprivation. Aim: To assess trends in general practice prescribing of five high-risk medications and their relationship with deprivation. Design & setting: An observational study was conducted using general practice data from three English regions with varied sociodemographic factors: West Yorkshire and Harrogate (WY), Black Country and West Birmingham (BC), and Surrey and East Sussex (SE). Method: Practice-level prescribing data were obtained from 2016–2021 for five drug classes: opioids, hypnotics, gabapentinoids, non-steroidal anti-inflammatory drugs (NSAIDs), and antibacterials. Prescribing trends were demonstrated using a linear model. Results: Reduction in NSAID, opioid, hypnotic and antibacterial prescriptions, and the increase in gabapentinoid prescriptions, were significant at each financial year time period. Index of Multiple Deprivation (IMD) was positively associated with all drug classes except antibacterials, which showed a positive association when incorporating the interaction term between IMD and age. When adjusting for IMD and population, region was independently associated with prescribing rate. Compared with WY, IMD had a smaller association with prescribing in BC for NSAIDs (coefficient = −0.01578, P = 0.004) and antibacterials (coefficient = −0.02769, P = 0.007), whereas IMD had a greater association with prescribing in SE for NSAIDs (coefficient = 0.02443, P

This study presents the perspective of an international group of experts, providing an overview of existing models and policies and guidance to facilitate a proper and sustainable implementation of C-reactive protein point-of-care testing (CRP POCT) to support antibiotic prescribing decisions for respiratory tract infections (RTIs) with the aim to tackle antimicrobial resistance (AMR). AMR threatens to render life-saving antibiotics ineffective and is already costing millions of lives and billions of Euros worldwide. AMR is strongly correlated with the volume of antibiotics used. Most antibiotics are prescribed in primary care, mostly for RTIs, and are often unnecessary. CRP POCT is an available tool and has been proven to safely and cost-effectively reduce antibiotic prescribing for RTIs in primary care. Though established in a few European countries during several years, it has still not been implemented in many European countries. Due to the complexity of inappropriate antibiotic prescribing behavior, a multifaceted approach is necessary to enable sustainable change. The effect is maximized with clear guidance, advanced communication training for primary care physicians, and delayed antibiotic prescribing strategies. CRP POCT should be included in professional guidelines and implemented together with complementary strategies. Adequate reimbursement needs to be provided, and high-quality, and primary care-friendly POCT organization and performance must be enabled. Data gathering, sharing, and discussion as incentivization for proper behaviors should be enabled. Public awareness should be increased, and healthcare professionals’ awareness and understanding should be ensured. Impactful use is achieved when all stakeholders join forces to facilitate proper implementation.

The article views the inappropriate prescribing in older people as a patient safety issue and an avoidable source of environmental harm. It points out the rise in consumption of pharmaceuticals due to ageing populations and technological innovations in the treatment of chronic and ageing-related diseases. It considers the National Health Service's share of medicines in carbon emissions in the United Kingdom (UK) and urges for the need to tackle inappropriate polypharmacy in older people.

Background: During the Covid-19 pandemic, there has been a notable increase in self-medication with antibiotics or other medications due to impaired access to healthcare services. This kind of self-treatment, without comprehending the condition and its related risks, can result in misdiagnosis, overdosing and delaying in acquiring professional medical attention, or may even cause antimicrobial resistance. Additionally, reports have suggested that medical practitioners have prescribed medications inappropriately to patients with Covid-19. To investigate this further, this study compared the medications used by patients with Covid-19 prior to hospitalization with or without a medical recommendation. Methods: Data was extracted a mass survey of patients with of Covid-19 in Mashhad, and the patients were divided into two main groups: those who received medication with guidance from a medical professional (treatment group) and those who self-administered medications without professional oversight (self-treatment group). Statistical analysis was then conducted using SPSS version 26, the Chi-square, and multiple logistic regression test. Results: This study examined 3266 patients, with 1466 included in the analysis. Results showed that men (9.5 %), those living in rural areas (21 %), and those with no academic degree (37.5%) had a higher likelihood to self-medicating. Antibiotics were the most frequently used medications prior to hospitalization (9.5%). Comparing the two groups revealed that three drug categories- antibiotics, antivirals and other medications (medicines that are not in the other 4 main categories)- were utilized more often in the treatment group than in the self-treatment group, with a p-value of