Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

BMJ, vol. 374, pp. n1585

Abstract

Abstract Objective To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. Design Cluster randomised controlled trial. Setting 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. Participants 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). Intervention Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person’s prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. Main outcome measure Primary outcome was first drug related hospital admission within 12 months. Results 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly 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. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). Conclusions Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. Trial registration ClinicalTrials.gov NCT02986425 .

Authors 45

1. Manuel R. Blum

   University of Bern · University Hospital of Bern

   Affiliation as printed

   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

   Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

2. Bastiaan Theodoor Gerard Marie Sallevelt

   Utrecht University · University Medical Center Utrecht

   Affiliation as printed

   Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

3. Anne Spinewine

   CHU Dinant Godinne UCL Namur · UCLouvain

   Affiliation as printed

   Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Belgium

   Department of Pharmacy, CHU UCL Namur, Yvoir, Belgium

4. Denis O’Mahony

   University College Cork

   Affiliation as printed

   School of Medicine, University College Cork, Cork, Republic of Ireland

5. Elisavet Moutzouri

   University of Bern · University Hospital of Bern

   Affiliation as printed

   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

   Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

6. Martin Feller

   University of Bern · University Hospital of Bern

   Affiliation as printed

   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

   Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

7. Christine Baumgartner

   University of Bern · University Hospital of Bern

   Affiliation as printed

   Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

8. Marie Roumet

   University of Bern

   Affiliation as printed

   CTU Bern, University of Bern, Bern, Switzerland

9. Katharina Tabea Jungo

   University of Bern

   Affiliation as printed

   Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

10. Nathalie Schwab

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

11. Lisa Bretagne

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

12. Shanthi Beglinger

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

13. Carole Elodie Aubert

    University of Bern · University of Michigan · University Hospital of Bern · VA Ann Arbor Healthcare System · VA Center for Clinical Management Research

    Affiliation as printed

    Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

14. Ingeborg Wilting

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

15. Stefanie Thevelin

    UCLouvain

    Affiliation as printed

    Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Belgium

16. Kevin Daniel Murphy

    University College Cork

    Affiliation as printed

    Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland

17. Corlina Johanna Alida Huibers

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

18. A. Clara Drenth‐van Maanen

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

19. Benoit B. Boland

    Cliniques Universitaires Saint-Luc · UCLouvain

    Affiliation as printed

    Geriatric Medicine Division, Cliniques Universitaires Saint-Luc, Brussels, Belgium

    Institute of Health and Society, Université Catholique de Louvain, Belgium

20. Erin K. Crowley

    University College Cork

    Affiliation as printed

    Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland

21. Anne Eichenberger

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Institute of Hospital Pharmacy, Bern University Hospital, University of Bern, Bern, Switzerland

22. Michiel C. Meulendijk

    Utrecht University

    Affiliation as printed

    Department of Information and Computing Sciences, Utrecht University, Utrecht, Netherlands

23. Emma L. M. Jennings

    University College Cork

    Affiliation as printed

    School of Medicine, University College Cork, Cork, Republic of Ireland

24. Luise Adam

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Division of Angiology, Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

25. Marvin J. Roos

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

26. Laura L. Gleeson

    University College Cork

    Affiliation as printed

    Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland

27. Zhengru Shen

    Utrecht University

    Affiliation as printed

    Department of Information and Computing Sciences, Utrecht University, Utrecht, Netherlands

28. Sophie Marien

    Cliniques Universitaires Saint-Luc · UCLouvain

    Affiliation as printed

    Geriatric Medicine Division, Cliniques Universitaires Saint-Luc, Brussels, Belgium

    Institute of Health and Society, Université Catholique de Louvain, Belgium

29. Arend‐Jan Meinders

    St. Antonius Ziekenhuis

    Affiliation as printed

    Department of Internal Medicine and Intensive Care Unit, St Antonius Hospital, Nieuwegein and Utrecht, Netherlands

30. Oliver Baretella

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

31. Seraina Netzer

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

32. Maria de Montmollin

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

33. Anne Fournier

    UCLouvain

    Affiliation as printed

    Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Belgium

34. Ariane Mouzon

    CHU Dinant Godinne UCL Namur

    Affiliation as printed

    Department of Pharmacy, CHU UCL Namur, Yvoir, Belgium

35. Cian O’Mahony

    University College Cork

    Affiliation as printed

    Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland

36. Drahomir Aujesky

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

37. Dimitris Mavridis

    University of Ioannina

    Affiliation as printed

    Department of Primary School Education, University of Ioannina, Greece

38. Stephen Byrne

    University College Cork

    Affiliation as printed

    Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Republic of Ireland

39. Paul A. F. Jansen

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

40. Matthias M. Schwenkglenks

    University of Basel

    Affiliation as printed

    Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland

41. Marco René Spruit Aachen Public Health and Primary Care

    Utrecht University · Leiden University Medical Center

    Affiliation as printed

    Department of Information and Computing Sciences, Utrecht University, Utrecht, Netherlands

    Public Health and Primary Care, Leiden University Medical Center, Leiden, Netherlands

42. Olivia Dalleur

    Cliniques Universitaires Saint-Luc · UCLouvain

    Affiliation as printed

    Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain, Belgium

    Pharmacy, Cliniques Universitaires Saint-Luc, Brussels, Belgium

43. Wilma Knol

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Department of Geriatric Medicine and Expertise Centre Pharmacotherapy in Old Persons, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands

44. Sven Trelle

    University of Bern

    Affiliation as printed

    CTU Bern, University of Bern, Bern, Switzerland

45. Nicolas Rodondi corresponding

    University of Bern · University Hospital of Bern

    Affiliation as printed

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland nicolas.rodondi@insel.ch

    Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland

    Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland