Multimorbidity is common among older adults. Now that people are living longer, many are also living with multiple conditions. The conditions may require a range of services and treatments and, often, the patient will require a case manager to discuss their needs following an assessment, with the wider multidisciplinary team.
On assessment, a commonly found contributing factor to the patient's deteriorating level of function may be inappropriately prescribed medication or mismanagement of medications. Polypharmacy can also sometimes pose an issue. This article touches on some recent research examining the effect of the impact that a multidisciplinary team could have on drug-related hospital admissions by optimising drug treatment. The research looks specifically at older adults with multiple conditions and polypharmacy who have been admitted to hospital (Blum et al, 2021).
In a cluster randomised controlled trial, Blum et al (2021) looked at 110 clusters of inpatient wards within university-based hospitals across four European countries (Switzerland, Netherlands, Belgium and Republic of Ireland), with the attending hospital doctor defining the problem and providing the details for the study, with consent. In total, 2008 older adults (≥70 years) with multimorbidity (≥three chronic conditions) and polypharmacy (≥five drugs used long term) were analysed.
Clinical staff clusters were randomised to either their usual care methods or a structured pharmacotherapy optimisation intervention, performed at the individual level jointly by a doctor and a pharmacist, alongside the assistance of a clinical decision-making software system, which deployed the screening tool of an older person's prescriptions and a screening tool to alert to the right treatment (STOPP/START) criteria (O'Mahony et al, 2015), in order to identify potentially inappropriate prescribing.
The primary outcome was defined as first drug-related hospital admission within 12 months. Of the 2008 older adults, who on average had a polypharmacy prescription of nine drugs, the participants were randomised and enrolled to 54 intervention clusters (963 participants), with 56 control clusters (1045 participants) receiving usual care.
The researchers found that, for the intervention arm, 86.1% of participants (789) had inappropriate prescribing, with an average of 2.75 STOPP/START recommendations for each participant; 62.2% (491) of participants had ≥1 recommendation successfully implemented by 2 months (predominantly the discontinuation of potentially inappropriate drugs). In the intervention group, 211 participants (21.9%) experienced a first drug-related hospital admission compared with 234 (22.4%) in the control group.
Overall, there was a common level of inappropriate prescribing among the older adults, and a significant number of older adults with multimorbidity and polypharmacy were admitted to hospital. The team concluded that this was reduced through an intervention to optimise pharmacotherapy, but this was without effect on drug-related hospital admissions. The team noted that additional efforts are required to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes (Blum et al, 2021).
Polypharmacy is often the result of multimorbidity, which is associated with higher mortality, use of healthcare services, hospital admissions and prescription rates of long-term medications. Although multiple medications are indicated for some, they may present a high risk in others.
Potential risks of inappropriate prescribing may include the overuse of drugs (prescription of medication without an evidence base), underuse of drugs (omission of prescription of medication despite evidence indicating its need) and drug misuse, whereby inappropriate combinations of medications may be prescribed that result in drug interactions and inappropriate dosing (Dalleur et al, 2015). Inappropriate prescribing has been found to be highly prevalent among older people and may lead to adverse outcomes, whereby drug-related hospital admissions, falls, mortality and decreased quality of life have arisen from inappropriate prescribing in the context of polypharmacy (Chan et al, 2001). It is estimated that as many as 30% of hospital admissions in older people are linked to drugs, half of which are potentially preventable (Leendertse et al, 2008).
As a result, various interventions have been designed to optimise pharmacotherapy in people with polypharmacy, with the aim of improving drug appropriateness and lowering the risk of adverse drug reactions. Multifaceted approaches are often delivered by pharmacists, but software systems have also been created in recent years to support pharmacotherapy optimisation. Most computerised decision-support systems focus on a single aspect; for example, the detection of drug-drug or drug-disease interactions, or potentially inappropriate drugs.
In using the STOPP/START tool, a reduction in potentially inappropriate prescribing was found to lead to no detriment to patient outcomes, but drug-related hospital admissions were not significantly reduced throughout the 12-month follow-up period, when compared with usual care, despite providing evidence-based recommendations to hospital doctors, patients and their GPs (Blum et al, 2021). More research is required to know whether such computerised tools can make a difference to clinical outcomes, such as hospitalisation or death.
The STOPP/START computerised tool is an interesting advance in technology and was of no detriment to patients in Blum et al's (2021) study. More research could address any limitations and widen the sample to examine the effectiveness of this tool, as it may prove useful for multidisciplinary teams during patient assessment and potentially improve outcomes.