Abstract
Purpose
Older people with advanced frailty are among the highest consumers of medications. When life expectancy is limited, some of these medications are likely to be inappropriate. The aim of this study was to compare STOPPFrail, a concise, easy-to-use, deprescribing tool based on explicit criteria, with gold standard, systematic geriatrician-led deprescribing.
Methods
One hundred standardized clinical cases involving 1024 medications were prepared. Clinical cases were based on anonymized hospitalized patients aged ≥ 65 years, with advanced frailty (Clinical Frailty Scale ≥ 6), receiving ≥ 5 regular medications, who were selected from a recent observational study. Level of agreement between deprescribing methods was measured by Cohen’s kappa coefficient. Sensitivity and positive predictive value of STOPPFrail-guided deprescribing relative to gold standard deprescribing was also measured.
Results
Overall, 524 medications (51.2%) of medications prescribed to this frail, elderly cohort were potentially inappropriate by gold standard criteria. STOPPFrail-guided deprescribing led to the identification of 70.2% of the potentially inappropriate medications. Cohen’s kappa was 0.60 (95% confidence interval 0.55–0.65; p < 0.001) indicating moderate agreement between STOPPFrail-guided and gold standard deprescribing. The positive predictive value of STOPPFrail was 89.3% indicating that the great majority of deprescribing decisions aligned with gold standard care.
Conclusions
STOPPFrail removes an important barrier to deprescribing by explicitly highlighting circumstances where commonly used medications can be safely deprescribed in older people with advanced frailty. Our results suggest that in multi-morbid older patients with advanced frailty, the use of STOPPFrail criteria to address inappropriate polypharmacy may be reasonable alternative to specialist medication review.
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References
Steinman MA, Hanlon JT (2010) Managing medications in clinically complex elders: “There’s got to be a happy medium”. JAMA 304:1592–1601
Curtin D, O’Mahony D, Gallagher P (2018) Drug consumption and futile medication prescribing in the last year of life: an observational study. Age Ageing 47:749–753
Jansen J, Naganathan V, Carter SM, et al (2016) Too much medicine in older people? Deprescribing through shared decision making. BMJ;353:I2893
Anderson K, Freeman C, Stowasser D, Scott I (2014) Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open;4:e006544
Wouters H, Scheper J, Koning H, Brouwer C, Twisk JW, van der Meer H, Boersma F, Zuidema SU, Taxis K (2017) Discontinuing inappropriate medication use in nursing home residents: a cluster randomized controlled trial. Ann Intern Med 167(9):609–617
Potter K, Flicker L, Page A, Etherton-Beer C (2016) Deprescribing in frail older people: a randomised controlled trial. PLoS One 11(3):e0149984
Garfinkel D (2018) Poly-de-prescribing to treat polypharmacy: efficacy and safety. Ther Adv Drug Saf 9(1):25–43
Scott IA, Hilmer SN, Reeve E, Potter K, le Couteur D, Rigby D, Gnjidic D, del Mar CB, Roughead EE, Page A, Jansen J, Martin JH (2015) Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med 175(5):827–834
Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT (2007) Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet 370(9582):173–184
Scott I, Anderson K, Freeman C (2017) Review of structured guides for deprescribing. Eur J Hosp Pharm 24:51–57
Lavan AH, Gallagher P, Parsons C, O’Mahony D (2017) STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing 0:1–8
Lavan AH, Gallagher P, O’Mahony D (2017) Inter-rater reliability of STOPPFrail [Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy] criteria amongst 12 physicians. Eur J Clin Pharmacol 74:331–338. https://doi.org/10.1007/s00228-017-2376-2. [Epub ahead of print]
Watson PF, Petrie A (2010) Method agreement analysis: a review of correct methodology. Theriogenology 73(9):1167–1179
Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, Mitnitski A (2005) A global clinical measure of fitness and frailty in elderly people. CMAJ 173:489–495
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174
Leventhal H (1965) Effects of fear and specificity of recommendation upon attitudes and behavior. J Pers Soc Psychol 2(1):20–29
Bucher T, Collins C, Rollo ME, McCaffrey TA, de Vlieger N, van der Bend D, Truby H, Perez-Cueto FJA (2016) Nudging consumers towards healthier choices: a systematic review of positional influences on food choice. Br J Nutr 115(12):2252–2263
Bednall TC, Bove LL (2011) Donating blood: a meta-analytic review of self-reported motivators and deterrents. Transfus Med Rev 25(4):317–334
Benetos A, Rossignol P, Cherubini A, et al (2015). Polypharmacy in the aging patient: management of hypertension in octogenarians. JAMA.;14;314(2):170–80
Autier P, Mullie P, Macacu A, Dragomir M, Boniol M, Coppens K, Pizot C, Boniol M (2017) Effect of vitamin D supplementation on non-skeletal disorders: a systematic review of meta-analyses and randomised trials. Lancet Diabetes Endocrinol 5(12):986–1004
Zheng Y, Zhu J, Zhou M, Cui L, Yao W, Liu Y, Bencharit S (2013) Meta-analysis of Long-term vitamin D supplementation on overall mortality. PLoS ONE 8(12):e82109
Hill TR, Aspray TJ (2017) The role of vitamin D in maintaining bone health in older people. Ther Adv Musculoskelet Dis 9(4):89–95
Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK (2012) Prognostic indices for older adults. JAMA 307(2):182
Versi E (1992) “Gold standard” is an appropriate term. BMJ 305(6846):187–187
Funding
Curtin and O’Mahony are supported by the European Union’s Horizon 2020 research and innovation programme (grant number 634238).
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Curtin, O’Mahony, Gallagher: study concept and design. Curtin, Dukelow, James, O’Donnell: application of deprescribing methods. Curtin, O’Mahony, Gallagher: preparation of manuscript. All authors: critical revision and final approval of manuscript.
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Conflict of interest
O’Mahony and Gallagher were involved in the development of the STOPPFrail criteria.
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The European Union’s Horizon 2020 research and innovation programme had no role in the design, conduct, or reporting of this study.
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Curtin, D., Dukelow, T., James, K. et al. Deprescribing in multi-morbid older people with polypharmacy: agreement between STOPPFrail explicit criteria and gold standard deprescribing using 100 standardized clinical cases. Eur J Clin Pharmacol 75, 427–432 (2019). https://doi.org/10.1007/s00228-018-2598-y
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DOI: https://doi.org/10.1007/s00228-018-2598-y