Okay, we admit it. We may have been backing a loser! For years we have been advocates of use of Beers’ List of potentially inappropriate medications in the elderly (see our What’s New in the Patient Safety World column for September 2010 “Beers List and CPOE”). But at least we have always mentioned that the Beers List concept is not truly “evidence-based”. The list was originally conceived by an expert consensus panel and there are no randomized controlled trials regarding the safety in the elderly for each of the drugs on the list or predictive utility of the list as a whole. But because there is ample evidence in the literature that each of those drugs may be associated with untoward effects in the elderly, we remained strong advocates of using clinical decision support tools to alert healthcare providers of such potentially inappropriate drugs in the elderly.
In reality, the literature has been mixed on the ability of Beers’ List to predict adverse drug events (ADE’s). But now Irish researchers (Hamilton 2011) have developed a new list and compared its usefulness to Beers’ List. First they developed and validated the STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions) tool (Gallagher 2008). Then they looked at 600 consecutive adults age 65 and older who were admitted to a university medical center. They found 329 ADE’s in these 600 patients, two-thirds of which were considered causal or contributory to admission to the hospital. And of those ADE’s, 69% were considered to be avoidable or potentially avoidable. There was a significant association between these ADE’s and prescription of potentially avoidable medications on the STOPP list but no significant association with medications from Beers’ List.
Take-home points from the study are that the STOPP criteria identified potentially avoidable ADE’s impacting on hospitalization over twice as often as did Beers’ criteria and that such ADE’s are extremely common. Future studies are needed to determine whether use of the STOPP criteria (and its related tool, the START criteria) may prove useful in actually reducing ADE’s in the elderly and potentially lead to reductions in medication costs and healthcare utilization costs. But this is a great start!
The editorial accompanying the Hamilton paper (Schnipper 2011) talks about using tools like STOPP to improve design and implementation of clinical decision support tools to minimize “alert fatigue” that we see so commonly with CPOE systems. In our What’s New in the Patient Safety World column for September 2010 “Beers List and CPOE” we noted a study (Mattison 2010) in which researchers carefully chose a subset of potentially inappropriate drug (PIM’s) from Beers’ list drugs to which to attach computerized warnings. They were able to demostrate approximately a 20% reduction in prescribing of flagged drugs. That decrease was noted immediately after implementation and was sustained over time. As a “control” they noted no reduction in those other Beers list drugs that were not flagged. The study is important in that it confirms that alerts during CPOE can reduce prescription of potentially inappropriate drugs in the elderly. But it also contains other very useful lessons:
There is considerable overlap of drugs on Beers’ List and the STOPP tool. A nice PowerPoint presentation on the STOPP and START tools is available at this site: O’Mahony 2010. The STOPP tool tends to focus more on the common avoidable instances of inappropriate prescribing. It puts more emphasis on drug-drug interactions and duplicate drug class prescribing. It adds some drugs not included on Beers’ List and omits other drugs that are included on Beers’ List.
The above, of course, does not mean that Beers’ List is useless. We owe a great deal to the clinicians who developed and revised Beers’ List over the years because it has raised awareness of inappropriate prescribing in the elderly. What the study done by Hamilton et al. does is demonstrate that what sound like good ideas really do need to be validated in more scientifically rigorous fashions for whatever intent they are designed for. We really look at their work as a refinement of the Beers’ List concept.
A second study in that same issue of the Archives of Internal Medicine looked at inappropriate medications in elderly ICU survivors (Morandi). That study did use Beers’ criteria for potentially avoidable medications (PIM’s) and actually inappropriate medications (AIM’s) and looked prospectively at 600 patients aged 60 and older who were discharged from the hospital after a stay in an ICU for either respiratory failure or shock. Though a significant number of patients were already on a PIM or AIM prior to admission, the numbers in both categories increased at the time of discharge. And of the 103 patients on at least one PIM at discharge, 59% also had at least one AIM and 59% of the AIM’s at discharge had been started while the patient was in the ICU. This study really highlights the importance of medication reconciliation not only at admission and discharge but also at all transitions of care, particularly transfers to and from ICU’s. Many medications may be temporarily needed in critically-ill patients in an ICU but are no longer indicated after transfer out of the ICU. We actually previously discussed the work of this group and others in our March 2011 What’s New in the Patient Safety World column “Inappropriate Medications Often Start in the ICU”.
Lastly, the STOPP tool and Beers’ list are not the only things to keep in mind in managing your older patients. There are many valuable lessons and recommendations in a recent article “Principles of Conservative Prescribing” (Schiff 2011) that we can all apply to all our patients.
Some of our past columns on Beers’ List and Inappropriate Prescribing in the Elderly:
Patient Safety Tips of the Week:
· January 15, 2008 “
· October 19, 2010 “ ”
· September 22, 2009 “Psychotropic Drugs and Falls in the SNF”
What’s New in the Patient Safety World columns:
· September 2010 “Beers List and CPOE”.
Hamilton H, Gallagher P, Ryan C, et al. Potentially Inappropriate Medications Defined by STOPP Criteria and the Risk of Adverse Drug Events in Older Hospitalized Patients. Arch Intern Med 2011; 171(11): 1013-1019
Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther 2008; 46(2): 72-83
Schnipper JL. Medication Safety: Are We There Yet?: Comment
on "Potentially Inappropriate Medications...
Arch Intern Med 2011; 171(11): 1019-1020
Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Preventing Potentially Inappropriate Medication Use in Hospitalized Older Patients With a Computerized Provider Order Entry Warning System. Arch Intern Med. 2010; 170(15): 1331-1336
O’Mahony D. Inappropriate Prescribing in Older People (Powerpoint presentation). BGS Autumn 2010
Morandi A, Vasilevskis EE, Pandharipande PP, et al. Inappropriate Medications in Elderly ICU Survivors: Where to Intervene? Arch Intern Med 2011; 171: 1032-1034
Schiff GD, Galanter WL, Duhig J, et al. Principles of Conservative Prescribing. Arch Intern Med. Published online June 13, 2011