ORIGINALES

 

Agreement between the 2009 STOPP Criteria and the 2003 Beers Criteria at the time of hospital admission

Concordancia entre los criterios STOPP 2009 y los Beers 2003 en el momento del ingreso hospitalario

 

 

María Muñoz García¹, Eva Delgado Silveira¹, Sagrario Martín-Aragón Álvarez², Teresa Bermejo Vicedo¹ and Alfonso José Cruz-Jentoft³

¹ Pharmacy Department. Hospital Universitario Ramón y Cajal.
² Pharmacology Department. School of Pharmacy. Universidad Complutense de Madrid (UCM).
³ Geriatrics Department. Hospital Universitario Ramón y Cajal.

Correspondence

 

 

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ABSTRACT

Potentially inappropriate prescription in elderly patients can be evaluated by different methods. The STOPP Criteria and Beers Criteria stand out among the explicit criteria most widely used.
Objective: The main objective of this study is to identify the agreement in the detection of potentially inappropriate prescribing between the STOPP criteria and the Beers Criteria, in elderly patients assessed at the time of hospital admission.
Method: An observational retrospective study was designed in order to estimate the prevalence of potentially inappropriate prescription in the habitual treatment before admission, and to compare the agreement in detection capability between the 2003 Beers Criteria and the 2009 STOPP Criteria, in >70-year-old patients with an emergency hospital admission. There was also a specific analysis of the prescription of first-generation antihistamines, tricyclic antidepressants, benzodiazepines, and selective serotonin reuptake inhibitors, which are considered drugs with irregular management and potential toxicity.
Results: The total prevalence of patients with a potentially inappropriate prescription was 23.8% using the Beers Criteria and 33.3% using the STOPP Criteria. There was a low level of agreement between both questionnaires. First-generation antihistamines (Beers) and pharmacological duplication (STOPP J) were the criteria most frequently found. There were differences in the prevalence of potentially inappropriate prescription in the four pharmacological groups selected; and in all cases, detection by Beers Criteria was superior.
Conclusion: There is no agreement between the STOPP Criteria and the Beers Criteria regarding the detection of patients with potentially inappropriate prescribing at the time of hospital admission.

Key words: Potentially inappropriate prescribing, STOPP, Beers.

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RESUMEN

La prescripción potencialmente inapropiada en personas mayores puede evaluarse mediante diferentes métodos. Entre los criterios explícitos más usados en nuestro país destacan los criterios STOPP y los criterios de Beers.
Objetivo: El objetivo principal de este estudio es identificar la concordancia en la detección de prescripción potencialmente inapropiada entre los criterios STOPP y los criterios de Beers, en pacientes mayores valorados en el momento del ingreso hospitalario.
Método: Se diseñó un estudio observacional retrospectivo para estimar la prevalencia de prescripción potencialmente inapropiada en el tratamiento habitual previo al ingreso y comparar la concordancia en la capacidad de detección de los criterios Beers 2003 y STOPP 2009 en pacientes mayores de 70 años ingresados por un motivo urgente. Se analizó además de forma específica la prescripción de antihistamínicos de primera generación, antidepresivos tricíclicos, benzodiazepinas e inhibidores selectivos de la recaptación de serotonina como fármacos de manejo irregular y potencial toxicidad.
Resultados: La prevalencia total de pacientes con prescripción potencialmente inapropiada fue del 23,8% utilizando los criterios de Beers y del 33,3% con los STOPP. El grado de concordancia entre ambos cuestionarios fue bajo. Los antihistamínicos de primera generación (Beers) y la duplicidad farmacológica (STOPP J) fueron los criterios encontrados con más frecuencia. Se encontraron diferencias en la prevalencia de prescripción potencialmente inapropiada de los cuatro grupos farmacológicos seleccionados, siendo superior la detección en todos los casos por los criterios de Beers.
Conclusión: Los criterios STOPP y Beers no son concordantes en la detección de pacientes con prescripciones potencialmente inapropiadas en el momento del ingreso hospitalario.

Palabras clave: Prescripción potencialmente inapropiada; STOPP; Beers.

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Contribution to Scientific Literature

Potentially inappropriate prescription in elderly people can be assessed by different methods. The STOPP Criteria and Beers Criteria stand out among the explicit criteria most widely used in our country.

Though some international and national studies have been conducted in order to compare the STOPP Criteria and the Beers Criteria, so far there has been no analysis of the level of agreement with the Kappa Coefficient at hospital admission. Given the low agreement coefficient found (Kappa=0.325, p=0.000), this study has allowed us to reach the conclusion that, at the time of hospital admission, for different reasons, both criteria will identify potentially inappropriate prescriptions in different patients who are suitable for a reinforced pharmaceutical care in order to prevent potential problems associated with medication.

Moreover, we have analyzed specifically the prescription of four pharmacological groups of interest for elderly patients: first-generation antihistamines, tricyclic antidepressants, benzodiazepines, and selective serotonin reuptake inhibitors; these are drugs widely used in these patients, regardless of their irregular management and potential toxicity.

 

Introduction

The inappropriate prescription of medications is a problem particularly frequent in elderly persons and represents a major cause of morbimortality because it leads to an increase in adverse reactions to medications, a higher number of hospitalizations, presentations at the Emergency Department and, ultimately, an increase in the cost of healthcare resources¹.

A potentially inappropriate prescription (PIP) is defined as that prescription which: a) is used in conditions other than indicated; b) entails a high risk of interactions with other drugs and/or certain conditions; c) represents a duplication regarding other pharmacological groups; or d) is not cost-effective^2-4.

Appropriate prescription can be assessed both by explicit and implicit criteria. Due to their frequency of use in our setting, the Beers Criteria⁵ and the STOPP/START (Screening Tool of Older People's Prescriptions/ Screening Tool to Alert to Right Treatment)⁶ stand out among the explicit criteria.

Beers Criteria appeared in 1991 and were the first explicit criteria for PIP in elderly persons⁵. There were subsequent modifications in various occasions, and they have been recently taken over by the American Geriatrics Society, which has been responsible for its latest update⁸. In 2008, the European STOPP/START Criteria were developed⁶; these originated in Ireland, and their clinical development, through a board of experts, was taken over by the European Union Geriatric Medicine Society. These criteria are organized by physiological systems and can be implemented within a short time. Their evidence has been confirmed by the British National Formulary and has been supported by an extensive review of literature⁹. A second version has been recently published in English¹⁰ and in Spanish¹¹.

Different evaluation studies on the prevalence of patients with PIP in Europe and the United States have been conducted with the methods previously mentioned, obtaining values that range between 15 and 79%, depending on the type of population^11-14. In Spain, the prevalence data range between 25 and 58% of patients in Hospitals for Acute Cases¹¹.

The main objective of this study is to identify the agreement for PIP detection between the 2009 STOPP Criteria and the 2003 Beers Criteria, in elderly patients assessed at the time of their hospital admission. A secondary objective is to describe the prevalence of PIP in four pharmacological groups of interest for the treatment of the elderly: first-generation antihistamines, tricyclic antidepressants, benzodiazepines, and selective serotonin reuptake inhibitors.

 

Methods

An observational and retrospective study was conducted in patients hospitalized in a University Hospital with 1,070 beds. The study included patients since the date of approval of the study by the Clinical Research Ethics Committee of the hospital (March, 2009) until the estimated sample size of 424 patients was completed, during 4 months.

Those patients who met the inclusion criteria were selected: ≥ 70-year-old patients who had been admitted through the Emergency Department. Those patients who had been previously included in the study and were re-admitted during the recruitment period were excluded, as well as those with incomplete reports. A sample size of 424 was estimated for the study which would allow to obtain outcomes with a statistically significant level of α = 0.05 and 80% power; considering that the proportion of patients with PIP is 25% according to Beers Criteria and 35% according to STOPP/START Criteria, and considering potential losses of 10%¹⁵. After the calculation, the number required for the sample was of at least 374 patients. The creation of the Hospitalization Unit for Acute Geriatric Patients had been planned before this study was started. However, it was not implemented as an effective unit until March 2010. For this reason, in addition to the 374 patients from four hospitalization units in the medical area (Cardiology, Gastroenterology, Internal Medicine, and Pulmonology), 50 patients were included in the study following the previous methodology, all of them admitted to Geriatrics.

A daily list of admissions was obtained from the previous five hospitalization units, and patient selection was conducted consecutively according to their order of admission, until the sample size was completed. The study recruited patients who were admitted any day of the week including holidays. For each patient, there was a review of the Emergency report for the episode of the study, and a list of chronic medication was obtained, defined as the medication taken by the patient at home before there were any changes in treatment due to the disease causing the hospitalization. The presence of at least 1 PIP in patients (categorical variable) was established as a dependent variable; and the following were established as independent variables: age, gender, number of drugs, and Charlson Comorbidity Index. The latter one is an index predicting mortality at long term according to a score by different conditions with a value ranging between 0 and 37. The 2003 Beers Criteria⁷ and the 2009 STOPP Criteria³ were applied on the medication that the patient had been prescribed, as it appeared in the report by the Emergency Department.

Finally, there was an analysis of the differences found in the PIPs detected by Beers Criteria and STOPP Criteria which involved first-generation antihistamines, tricyclic antidepressants, benzodiazepines and selective serotonin reuptake inhibitors.

The significance level was determined as p<0.05. All contrasts were bilateral. The assessment of the agreement between the Beers and STOPP questionnaires was conducted by obtaining the Kappa statistic between two categories, with a 95% Confidence Interval.

 

Results

During the period of the study, 5,067 patients were admitted to hospital. From these, 424 patients were selected from the following Hospital Units: Cardiology, 93 (21.9%); Gastroenterology, 52 (12.3%); Geriatrics, 50 (11.8%); Internal Medicine, 165 (38.9%), and Pulmonology, 64 (15.1%).

The median age of the population was 82 (IQR 10.25) and the distribution by gender was homogeneous. The Charlson Index median was 2 (IQR 2) at the time of admission. The median number of drugs prescribed by patient and before admission was 7 (IQR 5.25).

From these 424 patients, 101 (23.8%) presented some PIP according to the Beers Criteria, and 141 (33.3%) according to the STOPP Criteria.

From the 3,060 prescriptions analyzed, 155 (5.1%) were considered potentially inappropriate with Beers Criteria, and 208 (6.8%) with the STOPP Criteria.

Seventeen (24.6%) of the 69 Beers Criteria were found in at least one patient. The most frequently detected criterion (in 6.1% of patients) was anticholinergic and antihistamine prescription, followed by amiodarone prescription, detected in 4.5% of patients.

Thirty-eight (58.4%) of the 65 STOPP Criteria were found in some patient. The majority of the PIPs detected by STOPP Criteria involved the cardiovascular system; however, the most frequently detected criterion was pharmacological duplication (STOPP J1) in 5.7% of patients, followed by the prescription of loop diuretics as first line monotherapy for hypertension (STOPP A3) in 4.5% of patients.

STOPP Criteria detected 1.7% PIPs of individual medications not identified in the Beers list; the main ones were the use of loop diuretics for isolated malleolar oedema, and of neuroleptics as hypnotic agents.

The kappa value obtained in order to measure the level of agreement between the Beers Criteria and the STOPP Criteria was 0.325, showing a low level of agreement between both questionnaires (p=0.000).

The PIPs associated with the prescription of the four groups of drugs mentioned, which were detected through Beers and STOPP Criteria, appear in Table 1.

 

Discussion

The total prevalence of patients with PIP in our study was of 23.8% using Beers Criteria and 33.3% with STOPP Criteria. These values are within the wide range of 15 to 79% described in literature^11-14. The variability in prevalence may be due to different factors, such as the criteria used, the study duration, characteristics of patients and their location.

Using the 2003 version of the Beers Criteria, the value of prevalence detected in hospitals has been found to be similar to the one described in literature, ranging between 14 and 44%^14-16. In other levels of chronic patient care, such as Primary Care, this value usually ranges between 18 and 42%^17-22.

The prevalence of patients with PIP detected by the STOPP Criteria lies within the range detected by other authors at hospital level, ranging between 25.4 and 51.3%^13,23-26. In Primary Care, there is no such disparity between the outcomes of different studies, and the prevalence of PIPs detected by STOPP Criteria usually ranges between 32 and 51.4%¹¹.

Though some studies have been conducted with the aim of comparing both the STOPP Criteria and the Beers Criteria, so far there has been no analysis of the level of agreement with the Kappa Coefficient. In our study, the low level agreement shown through this coefficient among patients with PIPs detected according to Beers Criteria and STOPP Criteria could be due to different reasons. First of all, the drugs considered in each set of criteria are different; STOPP Criteria take into account the relationship of drug-drug interaction or duplication, and contain 33 situations of PIP detection with clinical relevance, not found in the 2003 version of Beers Criteria. Even so, 1.7% of the PIPs detected that were identified by STOPP Criteria were not identified by Beers Criteria; the main ones are the use of loop diuretics for malleolar oedemas without heart failure (STOPP A2), and the use of neuroleptic drugs as hypnotic agents outside delirium or for patients with frequent falls (STOPP B8).

However, the greatest difference seems to lie in the availability of drugs in the formulary of each country. In our hospital, besides the 30 drugs included in the Beers Criteria which are not marketed in Spain, 31 drugs of those included in the Beers lists are not included in the Hospital Formulary, vs. one single drug in the STOPP Criteria which is not included (dipyridamole)^5-6. Finally, the Beers Criteria were developed for non-hospitalized patients, and therefore PIP detection could be less relevant in hospitalized patients^5-6.

Among all the prescriptions for individual medications that were analyzed, 5.1% were detected according to Beers Criteria and 6.8% according to STOPP Criteria, which means that the latter detect 33% more PIPs than the former.

Among older patients, psychotropics and antihistamines are two pharmacological groups with special relevance among older patients, since they are frequently prescribed inadequately and are associated with a high number of adverse reactions. It is worth pointing out that in our study, unlike the outcomes for overall drug, Beers Criteria showed a higher ability for detecting problems associated with psychotropics and antihistamines than STOPP Criteria did.

First-generation antihistamines are difficult to manage in elderly patients due to their undesirable anticholinergic effects and potential toxicity. Without including those PIPs detected in patients who had suffered from previous falls, these represented a 16.8% of PIP detection according to Beers Criteria vs. a 2.4% according to STOPP. The reason for this difference is that STOPP only classifies their prolonged term as a PIP, while the Beers Criteria will detect PIP regardless of the time of use. However, these outcomes were slightly superior to those found by other authors also at hospital level, with values ranging between 0.3 and 2.7% by applying the STOPP Criteria, and 1.8% according to Beers^12,16,21. The outcomes obtained could be explained by a high use of the antihistamine hydroxyzine as an antipruritic agent, with a deep sedative effect, which was positioned among the 10 drugs with the highest number of associated PIPs according to both types of criteria.

Tricyclic antidepressants are no longer first-line drugs for elderly people due to their high potential of causing adverse effects. However, these drugs are still frequently prescribed. In our study, these drugs represented 7.7 and 2.9% of PIPs detected by the Beers and STOPP Criteria, respectively, being quite similar to the results found by other authors whose PIPs for this group range between 7.1 and 7.7%, according to Beers Criteria, and between 1.5 and 4.1% according to STOPP^12,16,20. The reason for this difference in prevalence is that Beers Criteria contraindicate the use of tricyclic antidepressants per se (doxe-pin, amitriptyline and imipramine) regardless of diagnosis and clinical setting, whereas the STOPP Criteria only state certain scenarios in which these drugs should not be used (dementia, glaucoma, altered cardiac conduction and constipation), being therefore more flexible and allowing a higher selection in prescription⁵.

Regarding benzodiazepines, frequently included in the studies about PIP prevalence²⁷,detection rates were different between the Beers and the STOPP Criteria, of 11 and 5.3% respectively. In our study, the reason for this difference in the detection rates between both criteria is that STOPP only detected as inappropriate the prolonged use of long half-life benzodiazepines, unlike Beers Criteria, which also considered short-acting benzodiazepines. Values in other studies fall between 2.7 and 23.9% according to Beers Criteria, and between 5.1 and 20.4% when using the STOPP Criteria, in agreement with our outcomes^{12,14,16,25,28-30}.

Regarding selective serotonin reuptake inhibitors, it stands out that 10.3% of PIPs detected by Beers Criteria were due to their prescription in patients with a previous history of clinically significant hyponatraemia; these data doubles the 5-8% detected by the STOPP B12 Criteria, because in the latter, the prescription of fluoxetine per se is not considered a PIP, but only in patients with clinically significant hyponatraemia. Our group found this problem in 3.3% of cases using the STOPP Criteria; however, those patients were managed at the Geriatrics Unit in which pharmacy care is part of the multidisciplinary team²⁴.

The detection of certain criteria could be limited as a consequence of the study design. The list of medications in the report by the Emergency Department is not always accurate since it is often based on verbal information at the time of recording the medication. Besides, sometimes there is lack of knowledge about the previous situation, and the real situation of the patient in temporary circumstances is not always well captured in the clinical record, and this clinical information is important for assessing the associated conditions required by the STOPP Criteria, as well as the time of treatment initiation with the drugs, and the assessment of first line treatments.

Nonetheless, the present research has allowed us to conduct an exhaustive analysis of PIPs and their importance, because, on one hand, a great number of prescriptions were reviewed in detail; and on the other hand, patients were not subject to the influence of the investigator, which provides external validity to the outcomes obtained.

In terms of a practical application of this study, we can confirm what was previously published²⁵, that is to say, that the medication of patients admitted to the Hospital Acute Geriatric Unit is currently analyzed using PIP detection criteria, specifically the STOPP/START Criteria, for which prescription alerts have been included in the assisted electronic prescribing program, as well as the Beers Criteria. Due to the recent updates for the Beers Criteria in 2012⁸ and the STOPP/START in 2014^10-11, it would be interesting to conduct a new comparison between then, in order to detect whether the differences found in the present study are still the same or have varied.

As a conclusion drawn from the present study, we can state that there is a high prevalence of PIPs in elderly patients before hospital admission by applying two different explicit criteria. The STOPP Criteria presented a higher ability of quantitative PIP detection at hospital admission vs. Beers Criteria; however, the latter ones detected a higher percentage of PIPs associated with the use of psychotropics and antihistamines. A low level of agreement between both criteria was found.

 

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Correspondence:
Correo electrónico: maria.munoz.garcia@salud.madrid.org
(María M García).

Recibido el 15 de febrero de 2015;
aceptado el 26 de agosto de 2016.