Multidisciplinary medication review during older patient hospitalization according to STOPP/START criteria reduces potentially inappropriate prescriptions: MoPIM cohort study.

PURPOSE: Multimorbidity and polypharmacy in older adults converts the detection and adequacy of potentially inappropriate drug prescriptions (PIDP) in a healthcare priority. The objectives of this study are to describe the clinical decisions taken after the identification of PIDP by clinical pharmacists, using STOPP/START criteria, and to evaluate the degree of accomplishment of these decisions. METHODS: Multicenter, prospective, non-comparative cohort study in patients aged 65 and older, hospitalized because of an exacerbation of their chronic conditions. Each possible PIDP was manually identified by the clinical pharmacist at admission and an initial decision was taken by a multidisciplinary clinical committee. At discharge, criteria were re-applied and final decisions recorded. RESULTS: From all patients (n = 674), 493 (73.1%) presented at least one STOPP criteria at admission, significantly reduced up to 258 (38.3%) at discharge. A similar trend was observed for START criteria (36.7% vs. 15.7%). Regarding the top 10 most prevalent STOPP criteria, the clinical committee initially agreed to withdraw 257 (34.2%) prescriptions and to modify 93 (12.4%) prescriptions. However, the evaluation of final clinical decisions revealed that 503 (67.0%) of those STOPP criteria were ultimately amended. For the top 10 START criteria associated PIDP, the committee decided to initiate 149 (51.7%) prescriptions, while a total of 198 (68.8%) were finally introduced at discharge. CONCLUSIONS: The clinical committee, through a pharmacotherapy review, succeeded in identifying and reducing the degree of prescription inadequacy, for both STOPP and START criteria, in older patients with high degree of multimorbidity and polypharmacy. TRIAL REGISTRATION: NCT02830425.

Variability in the prevalence of inappropriate medication use among older adults: A review highlighting the importance of screening methods and database types.

AIMS: The global older population is growing rapidly, and the rise in polypharmacy has increased potentially inappropriate medication (PIM) encounters. PIMs pose health risks, but detecting them automatically in large medical databases is complex. This review aimed to uncover PIM prevalence in individuals aged 65 years or older using health databases and emphasized the risk of underestimating PIM prevalence due to underutilization of detection tools. METHODS: This study conducted a broad search on the Medline database to identify articles about the prevalence of PIMs in older adults using various databases. Articles published between January 2010 and June 2023 were included, and specific criteria were applied for study selection. Two literature reviews conducted before our study period were integrated to obtain a perspective from the 1990s to the present day. The selected papers were analysed for variables including database type, screening method, adaptations and PIM prevalence. The study categorized databases and original screening tools for clarity, examined adaptations and assessed concordance among different screening methods. RESULTS: This study encompassed 48 manuscripts, covering 58 sample evaluations. The mean prevalence of PIMs within the general population aged over 65 years was 27.8%. Relevant heterogeneity emerged in both the utilized databases and the detection methods. Adaptation of original screening tools was observed in 86.2% (50/58) of cases. Half of the original screening tools used for assessing PIMs belonged to the simple category. About a third of the studies employed less than half of the original criteria after adaptation. Only three studies used over 75% of the original criteria and more than 50 criteria. CONCLUSIONS: This extensive review highlights PIM prevalence among the older adults, emphasizing method intricacies and the potential for underestimation due to data limitations and algorithm adjustments. The findings call for enhanced methodologies, transparent algorithms and a deeper understanding of intricate rules' impact on public health implications.

One Hundred Explicit Definitions of Potentially Inappropriate Prescriptions of Antibiotics in Hospitalized Older Patients: The Results of an Expert Consensus Study.

BACKGROUND: In geriatrics, explicit criteria for potentially inappropriate prescriptions (PIPs) are useful for optimizing drug use. OBJECTIVE: To produce an expert consensus on explicit definitions of antibiotic-PIPs for hospitalized older patients. METHODS: We conducted a Delphi survey involving French experts on antibiotic stewardship in hospital settings. During the survey's rounds, the experts gave their opinion on each explicit definition, and could suggest new definitions. Definitions with a 1-to-9 Likert score of between 7 and 9 from at least 75% of the participants were adopted. The results were discussed during consensus meetings after each round. RESULTS: Of the 155 invited experts, 128 (82.6%) participated in the whole survey: 59 (46%) infectious diseases specialists, 45 (35%) geriatricians, and 24 (19%) other specialists. In Round 1, 65 explicit definitions were adopted and 21 new definitions were suggested. In Round 2, 35 other explicit definitions were adopted. The results were validated during consensus meetings (with 44 participants after Round 1, and 54 after Round 2). CONCLUSIONS: The present study is the first to have provided a list of explicit definitions of potentially inappropriate antibiotic prescriptions for hospitalized older patients. It might help to disseminate key messages to prescribers and reduce inappropriate prescriptions of antibiotics.

[Evaluation of Pharmacists' Active Intervention to Reduce Potentially Inappropriate Medications in Special Older Adult Nursing Home].

Currently, elderly care facilities that do not offer long-term care are not required to employ pharmacists, and duties such as the dispensing and distribution of medicines are entrusted to external pharmacies. Pharmacists seldom spend sufficient time at the facilities for elderly people requiring special care. Thus, in many cases, the pharmacists have insufficient knowledge of the residents' medication status, leading to their inability in determining whether the residents are receiving a suitable drug therapy. We previously documented various problems in the practices adopted by nursing staff (with negligible intervention by pharmacists) for assisting residents in taking their medications. In the present pilot study, we attempted to eliminate the use of potentially inappropriate medications by stationing a pharmacist at a nursing home for 24 h every week (3 d/week). We proactively collected information from nurses and other nursing staff and observed the residents' actual living conditions and medication use. As a result of this intervention, 56 prescriptions were changed. However, only two of these were changed exclusively based on the prescription information. Most prescriptions were able to change based on the information obtained by the pharmacist present at the facility. Therefore, pharmacists' presence at the facility (at least for a few hours) is necessary, as they can actively intervene and collaborate with other staff to prevent the use of potentially inappropriate medications.

Clinical characteristics and use of antibiotics in a group of patients with snake bites in Colombia.

Introduction: Millions of snake bites occur worldwide each year. Clinical practice guidelines generally do not recommend the use of prophylactic antibiotics. Objective: To determine the sociodemographic, clinical, and pharmacological variables and the use of antibiotics in a group of patients with snake bites in Colombia. Methods: A retrospective cross-sectional study was carried out. Patients affiliated with a Colombian health insurer who presented with snake bites between 2015 and 2022 were included. The cases were identified from the National Public Health Surveillance System. Sociodemographic, clinical and pharmacological variables were identified. Descriptive and bivariate analyses were performed. Results: A total of 643 patients were analyzed, with a median age of 30.8 years, and 74.7% were men. The most frequently identified genus of snake was Bothrops (88.8%), and most incidents were classified as mild ophidian accidents (61.6%). A total of 59.7% of patients received snake antivenom. A total of 13.8% and 2.2% of the patients had cellulitis or abscesses, respectively. A total of 63.5% received antibiotics (50.6% for prophylaxis and 12.9% for treatment), especially cephalexin (25.9%), and most of the antibiotic management was considered inappropriate (91.7%). Conclusion: Most patients with snake bites received antibiotics, especially for prophylactic purposes, a clinical behavior that goes against current evidence. The use of antibiotics with an unsuitable spectrum for the microorganisms that are usually found in the wounds of these patients is frequent. The development of local clinical practice guidelines is required to help reduce the overprescription of antibiotics, as the excessive use of antimicrobials is the main determinant of antimicrobial resistance.

The Burden of Inappropriate Prescriptions and Predictors for Hospitalized Patients with Liver Cirrhosis in Ethiopia.

Background: Pathophysiological alterations in liver cirrhosis affect how medications are metabolized and eliminated. Therefore, when prescribing medicines for patients with cirrhosis, appropriate prescription of medication is an accepted standard of practice. Since patients with cirrhosis require a complex therapy plan, it necessitates regular reviews of medication utilization. However, no research was conducted in Ethiopia. The aim of this study was to figure out the predictors of inappropriate prescriptions and the pattern of prescription in patients with cirrhosis. Patients and methods: A cross-sectional study design was carried out at Felege-Hiwot, a specialized and comprehensive referral hospital, from June 30, 2022, to November 30, 2022, in 123 hospitalized patients with cirrhosis. Patients were recruited using a simple random sampling procedure, and data were collected using an interviewer-administered questionnaire. For the purpose of identifying determinants of inappropriate prescription, logistic regression analyses have been carried out and statistical significance was defined by a p-value of less than 0.05 and a 95% confidence range. Results: The burden of inappropriate prescriptions among patients with cirrhosis was 35.8%. An increased number of medications prescribed (AOR = 4.88 (1.05-22.68)), prescription by a general practitioner (AOR = 3.57 (95% CI 1.07-11.44)), increased level of bilirubin (AOR = 3.54 (95% CI 1.95-6.45)), and decreased level of albumin (AOR = 0.18 (95% CI 0.04-0.72)) were predictors for an inappropriate prescription. Conclusion: It has been found that there were inappropriate prescriptions among patients with liver cirrhosis. Prescribers should pay close attention to patients who have prescribed with higher number of medications, increased level of bilirubin and decreased level of albumin. Moreover, educational level of prescribers needs to be upgraded in order to adopt evidence-based medication prescriptions and adhere to recommended practices.

Clinical Pharmacist Intervention Reduces Potentially Inappropriate Prescriptions in a Geriatric Perioperative Care Unit Dedicated to Hip Fracture.

INTRODUCTION: Clinical pharmacist (CP) intervention improves drug prescription by identifying potentially inappropriate prescriptions (PIPs). Geriatric perioperative care units (UPOGs) provide enhanced care for patients with hip fracture, including drug prescription. However, it is not known whether adding a CP intervention in a UPOG decreases the number of PIPs. This study aimed to evaluate the effect of a CP intervention, combining an implicit and an explicit method, on the number of PIPs in a UPOG. METHODS: This single centre before-after-control-impact study recruited patients aged over 75 years admitted to a UPOG for a hip fracture. The "control group" ("before period") received usual care including two medication reconciliations, one at admission and one at discharge. The "intervention group" ("after period") received usual care and a CP intervention including two medication reconciliations, a medication review with two tools, STOPP/START and Medication Appropriateness Index, and a meeting between a CP and geriatricians. PIPs were assessed in both groups by STOPP/START and Medication Appropriateness Index and compared from hospital admission to discharge. RESULTS: A total of 209 patients were included, 150 in the control group and 59 in the intervention group (mean age: 87.2 ± 5.9 years). The number of PIPs decreased in both groups from hospital admission to discharge (p < 0.001). The number of PIPs, potentially inappropriate medications, and potential prescribing omissions decreased more in the intervention group than in the control group (adjusted intervention effect: -2.46 (95% CI: -2.63; -2.24); -1.13 (95% CI: -1.27; -0.98); and -1.35 (95% CI: -1.52; -1.18), respectively, p < 0.001 for all). DISCUSSION/CONCLUSION: A CP intervention with an explicit and implicit method improved prescriptions in a UPOG. Further randomized studies are necessary to evaluate the effect of a CP intervention on adverse drug events, health costs, and mortality.

A tool for screening potentially inappropriate prescribing in Chinese children.

Background: More than half of adverse drug events in pediatric patients are avoidable and blocking medication errors at the prescribing stage might be one of the most effective preventive measures. Objective : To form a tool (a series of criteria) for detecting potentially inappropriate prescriptions in children, promote clinical rational drug use and reduce risks of medication in children. Methods: Potentially inappropriate prescription propositions for children were collected through a systematic review. Then, the Delphi technique was adopted to form the final criteria. Panelists were asked to use a 5-point Likert scale to rate their agreement with each potentially inappropriate prescription proposition and were encouraged to add new propositions based on their clinical experience and knowledge. After 2 rounds of Delphi survey and propositions were fully revised and improved, the final criteria for identifying potentially inappropriate prescriptions in children were formed. Results: The final criteria for identifying potential inappropriate prescriptions in children has 136 propositions, which were divided into "criteria for children with non-specific diseases/conditions" (71 propositions: 68 for potentially inappropriate medication, 3 for potential prescribing omission) and "criteria for children with specific diseases/conditions" (65 propositions: 55 for potentially inappropriate medication, 10 for potential prescribing omission), according to whether the proposition was about identifying specific risks associated with one drug in children with a specific other diseases/conditions that do not exist in children with other diseases/conditions. Conclusion: A tool for screening potentially inappropriate prescriptions in children is formed to detect potentially inappropriate medication and prescribing omission in pediatrics and is available to all medical professionals liable to prescribe or dispense medicines to children.

Detección de la prescripción inadecuada en personas mayores. Papel de la enfermera / Detection of inappropriate prescription in elderly patients. Role of the nurse

En las últimas décadas se han producido una serie de cambios a nivel sanitario y farmacológico que han aumentado la esperanza de vida de la sociedad, dando lugar a un notable incremento de personas mayores.El envejecimiento progresivo junto con las comorbilidades asociadas, se traduce en un perfil de paciente susceptible de sufrir polimedicación y, por consiguiente, fenómenos tales como prescripción inadecuada, reacciones adversas a medicamentos o interacciones farmacológicas. Esta situación genera la mayor parte de las admisiones hospitalarias en personas de más de 65 años, lo que conlleva un aumento del empleo de los recursos sanitarios y un incremento del gasto farmacéutico.Para poder optimizar las prescripciones en los pacientes mayores pluripatológicos, reduciendo la prescripción potencialmente inadecuada y las reacciones adversas a medicamentos, existen diversas herramientas a nivel mundial. Estas las podemos englobar en dos grandes grupos, por una parte, los métodos implícitos que se basan en juicios críticos y, por otro lado, los métodos explícitos en los cuales se emplean criterios definidos basados en datos científicos y creados por grupos de expertos a través de métodos de generación de consenso, generalmente método Delphi. Los criterios STOPP/START representan el método explícito más adecuado para la detección de prescripción potencialmente inadecuada en comparación con el resto de herramientas disponibles, aunque continúan las investigaciones con el objetivo de optimizarse. (AU)

In the last decades there have been a series of changes at the health and pharmacological level that have increased the life expectancy of society, leading to a notable increase in the number of seniors.Progressive aging with associated comorbidities, translates into a patient profile susceptible to polymedication and therefore, phenomena such as inappropriate prescription, adverse drug reactions or drug interactions. This situation generates the majority of hospital admissions in people over 65 years, which leads to an increase in the use of healthcare resources and an increase in pharmaceutical spending.In order to optimize prescriptions in multipathological senior patients, reducing potentially inappropriate prescription and adverse drug reactions, there are various tools worldwide. These can be grouped into two large groups, on the one hand, the implicit methods that are based on critical judgments, and on the other hand, the explicit methods in which defined criteria based on scientific data and created by groups of experts through consensus-building methods, usually the Delphi. The STOPP / START criteria represent the most appropriate explicit method for the detection of potentially inappropriate prescription compared to the rest of the available tools, although research continues with the aim of optimization. (AU)

Eventos adversos a insulina en ancianos de UCI y prescripción inapropiada de medicamentos / Adverse insulin events in elderly ICU patients and inappropriate medication prescription

El tratamiento de la diabetes tipo 2 en el anciano representa un importante reto tanto desde el punto de vista clínico como del de la salud pública.La prescripción inapropiada es aquella donde los medicamentos prescriptos no manifiestan claros beneficios frente a los riesgos habiendo alternativas más seguras y disponibles.Objetivo: Este estudio se propone como objetivo medir la tasa de eventos adversos a insulina en ancianos diabéticos tipo II hospitalizados en una unidad de cuidados intensivos y analizar la prescripción inapropiada de medicamentos con los criterios de Beers 2015.Materiales y métodos: Estudio observacional prospectivo.Resultados: Se estudiaron 308 pacientes. El número de eventos de hipo e hiperglucemias asociadas a insulina fue de 36 (11,7%), de los cuales: 20 fueron hiperglucemias y 16 fueron hipoglucemias. Los pacientes con estos eventos han sido 30 (9,7%), de los cuales 18 han presentado criterios Beers positivos (60%). En el total de la población, 21 pacientes, es decir el 6,8% presentó criterios Beers.Conclusiones: La proporción de pacientes ancianos con eventos adversos a insulina en esta muestra de pacientes ha sido del orden del 9,7% y en un 60% han presentado criterios Beers positivos de prescripción inapropiada. (AU)

The treatment of type 2 diabetes in the elderly represents a major challenge from both a clinical and public health point of view.Inappropriate prescription is one where the prescribed drugs do not show clear benefits versus risks, with safer and more available alternatives.Objective: The objective of this study is to measure the rate of adverse events to insulin in type II diabetic elderly hospitalized in an intensive care unit and to analyze inappropriate prescription of drugs with the Beers 2015 criteria.Materials and methods: Prospective observational study.Results: 308 patients were studied. The number of events of hypo and hyperglycemia associated with insulin was 36 (11.7%), of which: 20 were hyperglycemic and 16 were hypoglycemic. There were 30 patients with these events (9.7%), of which 18 had positive Beers criteria (60%). In the total population, 21 patients, that is, 6.8% presented Beers criteria.Conclusions: The proportion of elderly patients with adverse events to insulin in this sample of patients has been of the order of 9.7% and 60% have presented positive Beers criteria of inappropriate prescription. (AU)

Improving individualized prescription in patients with multimorbidity through medication review.

BACKGROUND: Older patients tend to have multimorbidity, represented by multiple chronic diseases or geriatric conditions, which leads to a growing number of prescribed medications. As a result, pharmacological prescription has become a major concern because of the increased difficulties to ensure appropriate prescription in older adults. The study's main objectives were to characterize a cohort of older adults with multimorbidity, carry out a medication review and compare the pharmacological data before and after the medication review globally and according to the frailty index. METHODS: This was a quasi-experimental (uncontrolled pre-post) study with a cohort of patients ≥ 65 years old with multimorbidity. Data were collected from June 2019 to October 2020. Variables assessed included demographic, clinical, and pharmacological data, degree of frailty (Frail-VIG index), medication regimen complexity index, anticholinergic and or sedative burden index, and monthly drug expenditure. Finally, a medication review was carried out by an interdisciplinary team (primary care team and a consultant team with a geriatrician and a clinical pharmacist) by applying the Patient-Centered Prescription model to align the treatment with care goals. RESULTS: Four hundred twenty-eight patients were recruited [66.6% women; mean age 85.5 (SD 7.67)]. The mean frail index was 0.39 (SD 0.13), corresponding with moderate frailty. Up to 90% of patients presented at least one inappropriate prescription, and the mean of inappropriate prescriptions per patient was 3.14 (SD 2.27). At the three-month follow-up [mortality of 17.7% (n = 76)], the mean chronic medications per patient decreased by 17.96%, varying from 8.13 (SD 3.87) to 6.67 (SD 3.72) (p < 0.001). The medication regimen complexity index decreased by 19.03%, from 31.0 (SD 16.2) to 25.1 (SD 15.1), and the drug burden index mean decreased by 8.40%, from 1.19 (SD 0.82) to 1.09 (SD 0.82) (p < 0.001). A decrease in polypharmacy, medication regimen complexity index, and drug burden index was more frequent among frail patients, especially those with severe frailty (p < 0.001). CONCLUSIONS: An individualized medication review in frail older patients, applying the Patient-Centered Prescription model, decreases pharmacological parameters related to adverse drug effects, such as polypharmacy, therapeutical complexity, and anticholinergic and, or sedative burden. The benefits are for patients with frailty.

Individualized Medication Review in Older People with Multimorbidity: A Comparative Analysis between Patients Living at Home and in a Nursing Home.

(1) Background: aging is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. A periodic medication review (MR) in frail older people leads to optimizing medication use. The aims of the study were to perform a comparative analysis of the impact of place of residence (own home versus nursing home) in a cohort of older patients on the characteristics of the baseline therapeutic plan and characteristics of the therapeutic plan after an MR; (2) Methods: Study with paired pre- and post-MR data based on person-centred prescription, with a follow-up assessment at three months. Patients who lived either in their own home or in a nursing home were recruited. We selected patients of 65 years or more with multimorbidity whose General Practitioner identified difficulties with the prescription management and the need for an MR. Each patient's treatment was analysed by applying the Patient-Centred Prescription (PCP) model; (3) Results: 428 patients. 90% presented at least one inappropriate prescription (IP) in both settings. In nursing homes, a higher number of implemented optimization proposals was detected (81.6% versus 65.7% (p < 0.001)). After the MR, nursing-home patients had a greater decrease in their mean number of medications, polypharmacy prevalence, therapeutic complexity, and monthly drug expenditure (p < 0.001); (4) Conclusions: PCP model detected a high number of IP in both settings. However, after an individualized MR, nursing-home patients presented a greater decrease in some pharmacological parameters related to adverse events, such as polypharmacy and therapeutic complexity, compared to those living at home. Nursing homes may be regarded as a highly suitable scenario to carry out a periodic MR, due to its high prevalence of frail people and its feasibility to apply the recommendations of an MR. Prospective studies with a robust design should be performed to demonstrate this quasi-experimental study along with a longitudinal follow-up on clinical outcomes.

Potentially inappropriate medication use and the hospitalization rate among Thai elderly patients: a retrospective cohort study.

PURPOSE: To examine the association between potentially inappropriate medications (PIMs) use and the hospitalization rate in elderly Thai patients. METHODS: In this retrospective cohort study, we collected the electronic medical data of elderly patients aged 60 years and older who visited the outpatient department (OPD) at Thammasat University Hospital in Thailand in 2015. The patients were categorized into PIM and non-PIM users according to the Beers 2019 criteria. We calculated descriptive statistics for demographic variables. We also examined the association between PIM use and various different factors with hospitalization rate during follow-up using log-binomial regression. We calculated the relative risk for association between PIM use and other factors with the hospitalization rate. RESULTS: We collected data for a total of 32,261 patients. The majority of participants were female (59.65%) and had a mean age of 70.21 years (SD = 7.88). Overall, 63.98% of the patients (n = 20,641) were PIM users and 49.45% (n = 15,952) received polypharmacy (≥ 5 medications). The most common PIM prescription was proton-pump inhibitors, which were 27.51% of all medications prescribed. We found that PIM use increased the risk of hospitalization by 1.31 times (adjusted RR = 1.31, 95% CI: 1.21-1.41, p-value < 0.001). Other factors associated with a higher rate of hospitalizations included older age, male gender, polypharmacy, and a higher number of OPD visits. CONCLUSION: PIMs were commonly prescribed to the elderly in the OPD, and were significantly associated with subsequent hospitalization. The provision of an alternative drug list can help physicians avoid prescribing PIMs to the elderly. If PIMs prescription is unavoidable, physicians should closely monitor patients for drug-related problems and deprescribe PIMs when they are no longer indicated.

The integration of physicians in nursing homes has a positive impact on the perceived quality of care / L'intégration de médecins prescripteurs en Ehpad : une amélioration de la qualité des soins perçue

INTRODUCTION: Since 2017, the Regional Health Agency of 'Île-de-France' has implemented an experiment to subsidize the recruitment of part-time doctors in nursing homes, so that residents without a primary care physician can benefit from regular medical follow-up. PURPOSE OF RESEARCH: The purpose of the study is to estimate the effects of this experiment: how is it implemented? What are its effects on the perceived quality of care? METHOD: The method used was based on a qualitative survey involving semi-structured individual or group interviews. On the whole, 20 professionals, one resident, and two daughters of residents were interviewed in four different nursing homes. RESULTS: The investigation shows that this experiment addresses an unmet medical need. However, the recruiting of doctors appears to be difficult and significant delays have been noted. The experimentation is considered to be beneficial by professionals and recipients: It provides an opportunity to re-evaluate prescriptions in time, to prevent the deterioration of the residents' health and to reduce the need for emergency services. These physicians are involved in the care for cognitive disorders and play an important role in the support of the end-of-life. CONCLUSIONS: The experimentation has a positive effect on the perceived quality of care, according to professionals as well as residents or their relatives, which could provide a rationale for its sustainability or even its extension.

Introduction: L'agence régionale de santé d'Île-de-France a mis en place, depuis 2017, une expérimentation consistant à subventionner le recrutement de médecins à temps partiel dans les établissements d'hébergement pour personnes dépendantes (Ehpad) afin que les résidents sans médecin traitant bénéficient d'un suivi médical régulier. But de l'étude: L'objectif de cette étude est d'estimer les effets du dispositif en tentant de répondre à ces deux questions : comment se passe l'intégration du médecin dans l'Ehpad ? Quels sont les effets du dispositif sur la qualité des soins perçue ? Méthode: La méthode employée est une enquête qualitative par entretiens semi-directifs individuels ou collectifs. Au total, 20 professionnels, une résidente et deux filles de résidentes ont été interrogés, dans quatre établissements différents. Résultats: L'enquête montre que ce dispositif répond à un besoin médical insatisfait. Le recrutement de médecins apparaît toutefois difficile et des délais importants ont été relevés dans l'étude. L'expérimentation est jugée bénéfique par les personnes interrogées : elle permettrait une réévaluation des prescriptions en temps voulu, éviterait des dégradations de l'état de santé des résidents et limiterait le recours aux urgences. Les médecins interviennent dans la prise en soins des troubles cognitifs et jouent un rôle important dans l'accompagnement des fins de vie. Conclusions: L'expérimentation a un effet positif sur la qualité des soins perçue, aussi bien d'après les professionnels que les résidents ou leurs proches, ce qui pourrait justifier sa pérennisation voire son extension.

Potential inappropriate use of strong opioid analgesics in cancer outpatients during the last year of life in France and associated factors.

AIMS: A better knowledge of opioid prescribing patterns would help to identify areas of potential improvement in cancer pain management. This study aimed to identify potential inappropriate use (PIU) of strong opioid analgesics in cancer outpatients in their last year of life. METHODS: A retrospective cohort of cancer patients who died between 2011 and 2014 and were exposed as outpatient to a strong opioid analgesic in the last year of life was identified in the Echantillon Généraliste de Bénéficiaires (a 1/97th random sample of the French general population). Prescribing patterns of strong opioids were analysed and PIU was defined by at least 1 of these criteria: overlapping prescriptions; contraindicated prescriptions; lack of laxatives; potential drug interactions; prescription in patients hospitalized for opioid-related disorders. Factors associated with PIU were investigated through a multiple logistic regression model. RESULTS: One third of the 2236 patients (median age 72 years [interquartile range: 61-82], 44.1% women) presented a PIU (insufficient laxative prescription [19.6% of patients], insufficient background treatment with transmucosal fentanyl [14.8%], overlapping prescriptions [2.6%]). The rate of PIU significantly decreased from 37.6% (2011) to 29.8% (2014). For patients with a duration of opioid use ≥3 months, factors associated with PIU were fentanyl prescription (adjusted odds ratio = 2.36; 95% confidence interval [1.86-3.00]) and previous use of strong opioid (adjusted odds ratio = 1.88; [1.50-2.36]). CONCLUSION: In France, 1/3 of cancer patients exposed to strong opioids experienced PIU and this proportion tended to decrease over time. There is still room for progress in cancer pain management at the end of life.

Antibiotic Use and Misuse in Dentistry in India-A Systematic Review.

Background: Infections caused by antibiotic resistance pose a serious global health threat, undermining our ability to treat common infections and deliver complex medical procedures. Antibiotic misuse, particularly in low--middle-income countries, is accelerating this problem. Aim: The aim of this systematic review was to investigate the use and misuse of antibiotics in dentistry in India. Method: We included studies carried out on Indian populations evaluating the prescription of prophylactic or therapeutic antibiotics by dental practitioners or other healthcare providers, along with antibiotic self-medication by the general population. The primary outcome measure was prescription rate/use of antibiotics for dental/oral problems. The secondary outcome measures included indications for antibiotic use in dentistry, their types and regimens, factors influencing practitioners' prescription patterns and any differences based on prescriber and patient characteristics. Multiple databases were searched with no restrictions on language or publication date. The quality assessment of all included studies was carried out using the AXIS tool for cross-sectional studies and the Joanna Briggs Institute checklist for qualitative studies. Results: Of the 1377 studies identified, 50 were eligible for review, comprising 35 questionnaire surveys, 14 prescription audits and one qualitative study (semi-structured interviews). The overall quality of the included studies was found to be low to moderate. The proportion of antibiotic prescriptions amongst all prescriptions made was found to range from 27% to 88%, with most studies reporting antibiotics in over half of all prescriptions; studies also reported a high proportion of prescriptions with a fixed dose drug combination. Worryingly, combination doses not recommended by the WHO AWaRe classification were being used. The rate of antibiotic self-medication reported for dental problems varied from 5% to 35%. Conclusions: Our review identified the significant misuse of antibiotics for dental diseases, with inappropriate use therapeutically and prophylactically, the use of broad spectrum and combination antibiotics not recommended by WHO, and self-medication by the general population. There is an urgent need for targeted stewardship programmes in this arena.

Factors Associated with the Detection of Inappropriate Prescriptions in Older People: A Prospective Cohort.

(1) Background: Ageing is associated with complex and dynamic changes leading to multimorbidity and, therefore, polypharmacy. The main objectives were to study an older community-dwelling cohort, to detect inappropriate prescriptions (IP) applying the Patient-Centred Prescription model, and to evaluate the most associated factors. (2) Methods: This was a prospective, descriptive, and observational study conducted from June 2019 to October 2020 on patients ≥ 65 years with multimorbidity who lived in the community. Demographic, clinical and pharmacological data were assessed. Variables assessed were: degree of frailty, using the Frail-VIG index; therapeutical complexity and anticholinergic and sedative burden; and the number of chronic drugs to determine polypharmacy or excessive polypharmacy. Finally, a medication review was carried out through the application of the Patient-Centred Prescription model. We used univariate and multivariate regression to identify the factors associated with IP. (3) Results: We recruited 428 patients (66.6% women; mean age 85.5, SD 7.67). A total of 50.9% of them lived in a nursing home; the mean Barthel Index was 49.93 (SD 32.14), and 73.8% of patients suffered some degree of cognitive impairment. The prevalence of frailty was 92.5%. Up to 90% of patients had at least one IP. An increase in IP prevalence was detected when the Frail-VIG index increased (p < 0.05). With the multivariate model, the relationship of polypharmacy with IP detection stands out above all. (4) Conclusions: 90% of patients presented one IP or more, and this situation can be detected through the PCP model. Factors with higher association with IP were frailty and polypharmacy.

Assessment of Prescriptions in Elderly Patients Hospitalized in Medicine Departments.

Drug-related iatrogenesis is an important issue in the elderly population, and preventing iatrogenic accidents helps to reduce hospitalizations. Our study's objective was to evaluate prescriptions in the geriatric population of our establishment. The study conducted is a targeted clinical audit. Ten criteria were tested on the hospital prescriptions of people over 75 years old in 11 medical departments, before and after improvement actions. The non-compliance threshold was set at 10% of prescriptions for each criterion. In each phase, 165 patients were included. Four criteria were non-compliant (NC) in the first phase: the presence of Potentially Inappropriate Medications for the Elderly (PIMs) (NC = 57.6%), the adaptation of the medication to renal clearance (NC = 24.9%), the presence of illogical combination (NC = 9.7%), and the total anti-cholinergic score of the prescription (NC = 12.1%). After the implementation of improvement actions, the number of non-compliant criteria decreased between the two phases, from four to two. We obtained a significant improvement for three of the four criteria found to be non-compliant in the first phase. The criterion adaptation to renal function is close to compliance (NC = 10.1%) and the PIMs criterion remained non-compliant after reassessment (NC = 32.1%). Vigilance must be ongoing in order to limit drug iatrogeny, particularly in frail elderly patients.

Antibiotic use and associated factors in adult outpatients from 2000 to 2019.

The aims of the study were to assess the changes in 19-years use of antibiotics (overall, by age, sex and geographical area) and of those classes deemed to be quality indicators for their consumption and to evaluate factors associated to antibiotic use. We analyzed drug prescription data collected in the administrative database of the Lombardy Region (Northern Italy) for outpatients aged 40+ years from 2000 to 2019. Logistic regression analyses were performed to evaluate the association between receiving at least one antibiotic prescription and year of observation, gender, age groups, area of residence, polypharmacy and hospitalizations in the index year. The prevalence of patients prescribed with antibiotics remained high from 2000 (33.8%) to 2019 (32.6%). Prevalence of use of second-line choice antibiotics (penicillin combinations with beta-lactamase inhibitors, third and fourth generation cephalosporins, macrolides) continued to increase, only fluoroquinolones decreased in 2019 (19%) comparing to 2018 (26%), at the time when the Italian Medicines Agency promulgated safety warnings. Females (OR 1.28, 95%CI 1.27-1.28), people living in Brescia (OR 1.24, 95%CI 1.24-1.25), those exposed to polypharmacy (OR 2.57, 95%CI 2.56-2.57) and those hospitalized 1 to 3 (OR 1.86, 95%CI 1.85-1.86) or more than 3 (OR 2.02, 95%CI 2.01-2.03) times a year had a statistically significant higher risk of receiving antibiotics. The high use of antibiotics over the study period further reinforces the need of impactful interventions, in order to improve the rational use of antibiotics and to reduce the risks of antimicrobial resistance. The differences outlined should be considered when monitoring and planning these interventions.

Guideline for the evaluation of prescription appropriateness.

Evaluation of prescriptions is a necessary process of evaluating the appropriateness of clinical drug usage, discovering existing problems, and formulating solutions. There are challenges for professionals within hospital medical departments and for clinicians and pharmacists who have clinical questions relating to inappropriate or abnormal prescriptions as identified by the electronic evaluation system of prescription. Medications are usually used correctly according to the drug instructions or guidelines. At present, there are no relevant domestic or international guidelines, or principles or standards for identifying inappropriate or abnormal prescriptions. To develop the guideline for evaluation of prescriptions appropriateness in clinical practice, the Pharmaceutical Affairs Commission of the Chinese Hospital Association formed the guideline working group consisting of multidisciplinary experts. The guideline working group summarized clinical questions in the evaluation of prescriptions, searched for supporting evidence, and reached a consensus for recommendations. The guideline contains 6 recommendations for evaluating prescription appropriateness, and the general principle of these recommendations is that clinicians should provide drug instructions, guidelines, or moderate evidence supporting the prescription, and the evaluators will then judge the prescription to be either appropriate or irrational. The recommendations resolve common clinical questions, using supporting examples, explanations and a flow chart. The evaluation of prescription appropriateness could be made more systematic and transparent based on this guideline's conclusions.