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Prescribing Omissions according to START and
related hospital admission in geriatric patients
O. Dalleur1, A. Spinewine2, S. Henrard3, C. Losseau4,
N. Speybroeck3, B. Boland3,4
1 Pharmacy and 4 Geriatric Medicine departments , St-Luc Hospital,
2 Louvain Drug Research Institute and CHU Mont-Godinne
3 Institute of Health and Society,
4ème Symposium du CRIV à Bruxelles
29 septembre 2011
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Introduction

Use of medicine in elderly patients is complex:
 PK/PD
changes
 Increased sensitivity to adverse drug events
 Hospitalization risk
 Many co-morbidities
 Polymedication
 Compliance issue

Inappropriate prescribing :
 Overuse
 Misuse
 UNDERUSE
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Introduction

Explicit tools to detect inappropriate prescription
in elderly : Beers, Laroche, STOPP-START …

Under-prescription :
 ACOVE
criteria
 START = Screening Tool to Alert doctors to Right
Treatment
STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right
Treatment). Consensus validation International Journal of Clinical Pharmacology and Therapeutics, Vol. 46 –
No. 2/2008 (72-83)
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Screening Tool of Older Persons' Potentially inappropriate Prescriptions Age and Ageing 2008; 37: 673–9
Introduction

STOPP&START
 European
 Consensus opinion of a panel of experts in
geriatric medicine, clinical pharmacology,
psychiatry of old age, pharmacy and general
practice.
 >65y

START : 22 situations/comorbidities « at risk »
linked with 17 drugs
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START List : examples
Situation
Drugs to “start”
Chronic atrial fibrillation
Warfarin
or Aspirin where
warfarin is
contraindicated
Chronic heart failure
Angiotensin converting
enzyme
Patients taking maintenance corticosteroid Bisphosphonates
therapy
Diabetes mellitus with coexisting major
cardiovascular risk factors (hypertension,
hypercholesterolemia, smoking history)
Antiplatelet therapy
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START List

Currently
 Limited data on prevalence of
underprescribing according to START
 No
data on the link with adverse clinical
outcomes
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Purpose
To study the performance of START
(Screening Tool to Alert doctors to Right
Treatment)
in detecting prescribing omissions (PO) at
home
and related acute hospital admissions in frail
older people.
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Methods

Study: transversal retrospective study

Eligibility:

acute hospital admission (not in a geriatric unit) in 2008 in St
Luc

age ≥ 75 years

frailty score ISAR ≥ 2/6
CGA by the geriatric liaison team

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Methods

Data collection
 geriatric
: social situation, functional/mental status,
nutrition
 medical :



detailed medical history/comorbidities (including GFR)
drug list at home (prescription + OTC)
Main reason for admission
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Methods

Outcome measures

Prevalence of PO events at home

PO = prescribing omission = the patient does not receive a drug he/she
should receive according to START criteria

Events identified by screening of drug list according to
START criteria by a clinical pharmacist and a geriatrician
Multivariate analysis to identify risk factors


Link between PO and hospitalizations



By a clinical pharmacist and a geriatrician
Based on clinical judgement
Multivariate analysis to identify risk factors
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Results 1 : population characteristics
302 frail older people
Age 84 years ± 5; ♀ 61 %
Home 83 % (alone 43 %) vs. nursing home 17 %
ISAR score : 2 - 6 / 6 ; average 3,5 ± 1

Geriatric Syndromes
 falls (58 %),
 malnutrition (30 %),
 cognitive decline (25 %),
 depression (25 %)

Co-morbidities
 hypertension (55 %),
 ischemic CV diseases (40 %),
 osteoporosis (26 %),
 atrial fibrillation (25 %),
 diabetes (23 %),
 COPD (15 %)
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Results 2: drugs before admission
Drugs:
2.028 drugs (6±3)
> 5 drugs/day : 64 %
# drugs
60
# patients
50
40
30
20
10
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
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Results 2: PO prevalence
Detection of 362 PO events
Prevalence 63 % (189/302) (>1 patient/ 2)
Distribution : 0 (37 %), 1 (29 %), 2 (19 %), ≥ 3 (15 %)
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Results 2 : PO according
to START
drug classes

Three medical conditions (ischemic disease,
diabetes, osteoporotic fracture) accounted for 52
% of all PO events.

The drugs which were the most frequently
omitted were:
 aspirin
(prevalence = 21%),
 statins (19%),
 calcium and vitamin D (17%),
 vitamin K antagonists (11%)
 biphosphonates (10%).
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Results 2: drugs before admission
Multivariate analysis

PO significantly associated with :
 diabetes [OR=13.1; 95% CI: 5-34]
 atrial fibrillation [OR 7.9; 3.5-17.9]
 osteoporotic fracture [OR 4.3; 2.0-9.2]
 COPD [OR 3.8; 1.3-10.6]
 ischemic disease [OR 2.3; 1.5-3.5]
 No significant association was observed with any
geriatric syndrome.
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Results 3 : hospital admissions and
PO events


Hospital admission was related to PO
in 38 patients (13%)
38/189 having POs =1 patient/5
 19 falls with fracture while not receiving
fracture prevention

 16

calcium, vitamin D, biphosphonate
cardiovascular problems
aspirin, statins, ACEI
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Results 3 : hospital admissions and
PO events

Multivariate analyses :
 predictors of PO-related admission
 previous osteoporotic fracture (p<0.001)
 atrial fibrillation (p=0.004)
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Results 3 : hospital admissions and
PO events
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Conclusions

PO at home is too frequent in frail older
persons…
 1 patient/2

Most frequent ones :
 aspirin
 statins
 calcium and vitamin D

PO may have contributed to one in eight
acute hospital admissions
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Conclusions
 Screening
for cardiovascular diseases
and fall history = essential
 Pharmacological prevention
How to do better?
Gallagher : STOPP/START → prescribing appropriateness improvement in
older patients?
•Number needed to screen of 4.7 to yield improvement in AOU.
•Recommendation to apply STOPP/START screening to elderly patients’ prescription
every 6 months.
•Helping comprehensive data on the patients’ treatment and co-morbidities, the
application of the criteria to the patient’s treatments takes only a few minutes
Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria.
Gallagher PF, O'Connor MN, O'Mahony D.
Clin Pharmacol Ther. 2011 Jun;89(6):845-54.
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Results 3 : hospital admissions (n=302)

The most frequent main reasons for acute
hospital admission were

Cardio-respiratory symptoms : 115
 Falls : 103
 Abdominal reason : 38
 Infection : 31
 Other : 15
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