Edward Kalendaryev

OBJECTIVES: To assess the effect of a Screening Tool of Older Persons potentially inappropriate Prescriptions/Screening Tool to Alert doctors to Right Treatment (STOPP/START) medication intervention on clinical and economic outcomes. DESIGN: Parallel-group randomized trial. SETTING: Chronic care geriatric facility. PARTICIPANTS: Residents aged 65 and older prescribed with at least one medication (N = 359) were randomized to receive usual pharmaceutical care or undergo medication intervention. INTERVENTION: Screening medications with STOPP/START criteria followed up with recommendations to the chief physician. MEASUREMENTS: The outcome measures assessed at the initiation of the intervention and 1 year later were number of hospitalizations and falls, Functional Independence Measure (FIM), quality of life (measured using the Medical Outcomes Study 12-item Short-Form Health Survey), and costs of medications. RESULTS: The average number of drugs prescribed was significantly lower in the intervention than in the control group after 1 year (P < .001). The average drug costs in the intervention group decreased by 103 shekels (US$29) per participant per month (P < .001). The average number of falls in the intervention group dropped significantly (P = .006). Rates of hospitalization, FIM scores, and quality of life measurements were similar for both groups. CONCLUSION: Implementation of STOPP/START criteria reduced the number of medications, falls, and costs in a geriatric facility. Their incorporation in those and similar settings is recommended.

OBJECTIVES: To compare 24-month outcomes of participants of a prospective randomized controlled trial (RCT) assigned to undergo a medication intervention of orally communicated recommendations based on Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP) and Screening Tool to Alert Doctors to Right Treatment (START) (intervention group) with outcomes of those assigned to undergo written medication review (control group). DESIGN: Retrospective cohort study. SETTING: Chronic care geriatric facility. PARTICIPANTS: Of 359 participants from a prospective RCT conducted between April 2012 and September 2013, 306 were evaluable for another 12-month follow-up. MEASUREMENTS: Outcomes at 24-month follow-up included quality of prescribing (assessed according to STOPP/START), hospitalizations, falls, costs of medications, and all-cause mortality. Outcomes were compared with those reported at the beginning (baseline) and end (12-month follow-up) of the RCT. RESULTS: There was a significant rise in potentially inappropriate prescriptions (PIPs) (P = .01) and potentially prescriptions omissions (PPOs) (P < .001) in the intervention group between 12 and 24 months, although the prevalence of PIPs was significantly lower in the intervention group (33.3%) than the control group (48.4%) at 24-month follow-up (P = .02). Costs of medications were significantly lower in the intervention group than the control group (P < .001) at 24-month follow-up. The average number of falls in both groups dropped significantly between baseline and study closure (P = .04 and P = .008, respectively). There was no significant difference in hospitalizations and mortality between the two groups at 24-month follow-up. CONCLUSION: The effect of an orally communicated medication intervention with the STOPP/START criteria on falls was maintained over time. Direct communication between pharmacists and prescribing physicians is more efficient than written medication review and is recommended every 6 months in geriatric facilities.

To the Editor: We thank Lavan and colleagues for their interest in our article,1 and we are pleased to respond to the issues that were raised in their letter.2 Because the outcome variable “number of falls” was not normally distributed, we used the appropriate Mann–Whitney and Wilcoxon nonparametric tests to compare between and within groups.3 Comprehensive discussion of the differences in the primary outcome between control and intervention groups was too lengthy to be included in the abstract. Those findings are provided in the Results section of the text: “The average number of falls in the intervention group dropped significantly during the follow-up period (P = .006), whereas that of the control group did not (P = .66), although there was no similar group difference in the average number of falls (P = .28) or the prevalence of falls (P = .60).” The suggested additional statistical analysis will be performed in future publications. The training that started at the time of study onset refers to the use of the Functional Independence Measure and Medical Outcomes Study 12-item Short-Form Survey questionnaire and not to the manner in which falls are defined and recorded. Head nurses in geriatric facilities in Israel routinely reported falls in the patient files. The same criteria were used before and during the study. We found that the application of Screening Tool of Older People's potentially inappropriate Prescriptions/Screening Tool to Alert Doctors to Right Treatment (STOPP/START) criteria reduced recurrent falls in the intervention group. The chief physician accepted all the recommendations on first-generation antihistamines, benzodiazepines, long-term opiates, and vasodilators with persistent postural hypotension included in the list of “drugs that adversely affect fallers.” In addition, 12 of 13 recommendations to stop long-term neuroleptics as long-term hypnotics were accepted, as were most of the recommendations to stop long-acting benzodiazepines and alpha-blockers in men. There is little argument that falls are among the major causes of morbidity in older adults;4 as many as half of nursing home residents fall each year, and 10% to 25% of those events cause serious injuries.5 The results of our study demonstrated that the STOPP/START criteria may serve as a supplementary tool in the risk assessment of falls in people with recurrent falls. Conflict of Interest: The authors report no conflicts of interest related to the letter. There was no funding source to this paper. Author Contributions: Preparation of the letter: DF, YL, EK, YL. All authors contributed to this paper. Sponsor's Role: No role.