Evaluation of potentially inappropriate prescribing among hospitalised geriatric patients: prevalence, predictors, association with quality of life and impact of a multifaceted intervention on healthcare providers` knowledge and practice in selected Pahang hospitals

Abstract

Background: Potentially inappropriate prescribing (PIP) is a global phenomenon among geriatric patients. The term PIP refers to either potentially inappropriate medication (PIM) or potentially prescribing omission (PPO). PIP is an underestimated problem in Malaysia with a paucity of published data in regards to this issue. Methods: This is a pre-test versus post-test interventional study. The pre-intervention phase was a cross-sectional study that evaluated the prevalence of PIP among hospitalised geriatric patients upon admission and its association with the patients’ health-related quality of life (HRQOL). The impact of hospitalisation on PIP was also assessed by comparing the prevalence of PIP before and after the hospitalisation. A multifaceted intervention consisted of academic detailing and a smartphone app. (Plus65 Med©) was delivered to hospital healthcare providers (HCPs), namely physicians and clinical pharmacist. The impact of this intervention on HCPs’ knowledge and practice regarding PIP was then assessed. Results: The study found that 58.5% of the involved patients had at least one PIP on admission as identified by the STOPP/START criteria version 2. The most common PIMs were medications that increase risk of falls, and those used in patients with persistent postural hypotension; the use of full dosage of proton pump inhibitors for more than 8 weeks in patients with uncomplicated peptic ulcer and the use of metformin in patients with creatinine clearance < 30 mL/min. The most common PPOs were; the omission of vitamin D supplements in patients with a history of falls, angiotensin-converting enzyme (ACE) inhibitors in patients with documented coronary artery diseases (CAD), heart failure or in diabetic patients with renal failure. No association was found between the presence of PIM (or PPO) with any aspects of the patients’ HRQOL. Hospitalisation significantly reduced the prevalence of PIMs from 33.3% at admission to 27% at discharge (p = 0.004) but it did not affect the PPOs. No significant changes found in the overall prevalence of PIPs and pattern of PIM or PPO, where hospitalisation did not significantly reduce the prevalence rates of any of individual STOPP or START criteria. Majority of hospital HCPs (67.1%) had inadequate knowledge coupled with low confidence regarding prescribing in geriatric patients, and participants who rated themselves as more confident in prescribing for geriatric patients had significantly higher knowledge scores than those with less confidence (p = 0.02). It was found that 60% of the respondents had never heard of geriatric-specific prescribing criteria and only 7.3% of them had ever used such criteria. Lack of formal education on prescribing for the elderly was cited by 78% of the participants as real barrier to appropriate prescribing in geriatric patients. The multifaceted intervention was effective in increasing the overall HCPs’ knowledge score (p = 0.007) and the number of HCPs who scored above the median point (p = 0.001). Moreover, the intervention significantly reduced the prevalence of PPOs among discharged patients (p = 0.015) and the two most common PPOs that were seen before intervention (i.e., omission of vitamin D and ACE inhibitors) were significantly lower in the intervention group (p1 = 0.001 and p2 = 0.03). However, the intervention did not significantly affect the prevalence or pattern of PIMs. Conclusion: The study showed that the applied intervention reduced the inappropriately omission of beneficial medications which might have a significant clinical impact on the patients by reducing the incidence of new fractures and by preventing the recurrence of CAD events.