MEDICATION ASSESSMENT

AND QUALITY PARAMETERS

Ika Norcahyanti
Bagian Farmasi Klinik dan Komunitas
Fakultas Farmasi UNEJ
 Introduction
• Medications can be used
To treat and cure
disease
To treat symptoms of
chronic disease
To treat or manage
complications of chronic
disease
• Older people are prescribed multiple medications and also frequently
take over-the-counter and dietary supplements
• Medications are frequently beneficial for the management of chronic
diseases
 Introduction
• Drug-related problems occur frequently in older people
• May be related to changes in pharmacokinetics and or pharmacodynamics
• Sub-optimal medication use
• Too much
• Too little
• Wrong medication
• Adverse drug events
• Undesirable health outcomes associated with drug therapy
• “Inappropriate” medication use
 Inappropriate Medications
• In 1991, Mark Beers MD developed a set of criteria designating certain
medications as potentially “inappropriate” using consensus criteria

• Since that time, the “Beers” list of potentially inappropriate medications

have been updated 3 times
 A Brief History
• 1991 – medications to avoid in frail long-term care residents
• 2003 – added medication classes to be avoided for efficacy reasons and
certain medications to be avoided in elders with certain medical conditions
• 2012 – evidence based
• 2015 – evidence based, added new sections on
renal elimination, drug-drug interactions and
oral anticoagulants (JAGS 2015;63:2227-46)
 Inappropriate Medications
• It’s important to always emphasize that these medications are potentially
inappropriate

• Use of the Beer’s potentially inappropriate medications as a drug screen, or as a

measure of quality, is common because it’s easy to identify the presence or absence
of these medications in various computerized pharmacy data bases, particularly
claims data bases
• This is controversial because it’s difficult to assess patient-specific information that may
warrant the use of a potentially inappropriate medication

• Best approached as a starting point for improving patient safety

 Conclusions about the Beer’s Criteria
• In general, we should avoid using Beer’s medications in frail older patients
• However, data that evaluates the medication related causes that lead
hospitalization show that other, more commonly prescribed medications, are
linked to hospitalizations.
• Study conducted over two years using a national drug surveillance system
• Identified over 5,000 cases representing 100,000 hospital admissions
• 2/3rd were unintended over-dosages
• Nearly half occurred in patients over 80 years of age
 STOPP/START
STOPP: Screening Tool of Older Persons’ Prescriptions
START: Screening Tool to Alert to Right Treatment
STOPP/START Criteria – version 1 (2008)

• Created by European panel of experts to address

limitations of 2003 Beers Criteria

• Highlights Potentially Inappropriate Medications

(PIMs) that should be stopped

• Prevents Potential Prescribing Omissions (PPOs) by

including medications that may need to be started
 Version 1
(continued)
• Screening tool shown to significantly improve
appropriateness of inpatient medications
• Reduces adverse drug events (ARR 9.3%) when used
within 72 hours of admission
• Reduces average length of stay by three days for older
adults hospitalized for acute illness

• High inter-rater reliability between physicians and

between pharmacists
 STOPP/START Criteria – version 2
(2014)
• Panel reviewed 2008 version to add new evidence-based information and
remove recommendations that are no longer relevant
• Version 2 has total of 80 STOPP criteria and 34 START criteria (31% increase)
• Current STOPP includes antiplatelet/anticoagulants, medications affected
by renal impairment, medications that increase anticholinergic burden
• Current START includes urogenital medications, analgesics, immunizations
 Summary
• STOPP/START Criteria can be used to identify potential inappropriate
medications that should be stopped and medications that may be missing
for older adults.
• Use of the criteria may result in a reduction in medication-related adverse
events and length of inpatient stay.
• The criteria may change over time due to availability of new medications
and discovery of increased adverse events in older adults associated with
currently approved medications.
 Medication Appropriateness Index
• A methodical evaluation of each drug • Practical directions (2)
in a patient’s medication list • Duplication of therapy (1)
• Indication (3) • Duration of therapy (1)
• Effectiveness (3) • Cost (1)
• Dosage (2)
• Directions (2)
• Drug - drug
interactions (2)
• Drug - disease
interactions (1)
 Advantages/Disadvantages
• Beer’s – yes no scoring ability; used by government agencies as quality
indicator; doesn’t really ‘assess’ a patient’s complete medication list
• STOPP/START – similar to Beer’s with suggestions to use medications for
common diagnoses that are current practice; still doesn’t really assess a
patient’s complete medication list
• MAI – more complete, time consuming, requires a fair amount
of knowledge about drugs, includes cost, helps ‘train’ your mind
to systematically evaluate an entire regimen; drug focused
 Conclusions
• There are 3 recognized methods of medication assessment
• Each have their distinct advantages and disadvantages
• Always be mindful that, even if there are no Beer’s drugs in a patient’s
medication regimen,
• Mistakes and errors can still happen
• Adverse drug events can still happen
• Must always continue to carefully monitor every patient