In addition to Beers List, we have described the START and STOPP tools for avoiding prescribing potentially inappropriate medications. Now we also have STRIP (Systematic Tool to Reduce Inappropriate Prescribing).
The STRIP combines both implicit and explicit prescribing tools (Drenth-van Maanen 2018). Explicit prescribing tools are usually developed on the basis of literature reviews, expert opinion, and consensus. These often include lists of drugs or drug classes to be avoided in older people because these drugs have an increased risk of negative outcomes or potential adverse consequences in this population. Beers criteria and the START and STOPP tools are examples of explicit criteria.
On the other hand, implicit criteria use the knowledge or expertise a clinician or pharmacist can apply to any prescription. For example, they may take into account such patient-related factors like comorbidities, patient preferences, or previously unsuccessful treatment approaches.
STRIP has actually been around for some time now and has been shown to effective in helping final‐year medical students improve their prescribing skills (Keijsers 2014). Another showed that physicians were able to significantly improve medication optimization for polypharmacy patients with the online STRIP Assistant tool (Meulendijk 2015). Appropriate decisions increased from 58% without the STRIP Assistant to 76% with it, and inappropriate decisions decreased from 42% without the STRIP Assistant to 24% with it. However, that came at a time expense. More time was spent optimizing medication with the STRIP Assistant (24 min.) than without it (13 min.), perhaps accounting for a marginal user satisfaction rating.
The STRIP consists of 5 steps:
1. medication assessment
2. pharmacotherapy review
3. pharmaceutical care plan
4. shared decision‐making
5. follow‐up and monitoring
The second step is the pharmacotherapy review. Here the patient's current morbidities and symptoms should be matched with the medications used by the patient. Additional information, such as blood pressure, weight, estimated glomerular filtration rate, and HbA1c are taken into consideration. Once therapeutic aims have been formulated, the medication list is checked for underprescribing, ineffective prescribing, overprescribing, side effects, contraindications, and drug‐drug and drug‐disease interactions, incorrect dosages/dosing frequencies, and practical intake issues. This is also where the START and STOPP criteria are implemented.
The third step is the pharmaceutical care plan, which sets:
The fourth step, shared decision-making, takes into account patient preferences and addresses other problems that might interfere with the patients ability to comply with the treatment plan.
The fifth step, followup and monitoring, is very important and one that often gets neglected. Note that you specified in Step 3 how, when, and by whom the interventions will be evaluated.
And note that we did not call the fifth step the last step. Thats because the whole process is a cycle and one moves from Step 5 back to Step 1 and we start all over again.
The ongoing OPERAM study in Europe is investigating the effect of STRIP use on clinical and economic outcomes. A video demonstration of the online STRIP Assistant tool is available online (make sure you click the full screen icon so you can see details).
Another recently published study did not use the STRIP tool but did use two explicit criteria, the START and STOPP tools, to study the impact of prescribing at hospital discharge (Counter 2018). Counter and colleagues showed that the presence of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs) in older adults discharged from hospital is significantly associated with repeated hospital admissions and mortality, respectively. Prescription of more than five medications was significantly associated with PIMs and PPOs. Presence of a PIM was associated with three or more readmissions (odds ratio 2.43) and PPOs were associated with mortality (OR 1.88). This, of course, was a retrospective study. It would be interesting to see how something, like the STRIP tool, applied proactively would impact readmissions and mortality.
Inappropriate prescribing, particularly in the elderly, remains a significant patient safety issue. Add the STRIP tool to our armamentarium to combat such inappropriate prescribing.
Of course, the other very important part of medication management in all patients, not just the elderly, is medication reconciliation performed at all transitions of care. Regarding medication reconciliation, there is some recent disappointing news. Five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators (Schnipper 2018). Each study site used a pharmacist and a hospitalist to implement the toolkit with 11 intervention components. Unfortunately, though there was a reduction in total medication discrepancies, overall potentially harmful discrepancies did not decrease over time beyond baseline temporal trends. But there were significant differences between the study sites. Sites that successfully implemented the recommended interventions were more likely to achieve reductions in harmful medication discrepancies. Interestingly, sites that had installed new EHRs did not fare as well. Another study (Horsky 2018) compared 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) and found the manner of presentation may have an important influence. Significantly fewer errors were made with the EHR that presented lists in a side-by-side view, automatically grouped medications by therapeutic class and more effectively identified duplicates. Participants favored that design and indicated that they routinely used several workarounds in the other EHR. Yet another study last year (Stockton 2017) found medication errors were common after the implementation of electronically prepopulated medication reconciliation forms. The authors recommended that prospective research examine the impact of prepopulated medication reconciliation forms and ensure they do not facilitate errors of commission. We actually highlighted problems with prepopulated medication lists a decade ago (see our December 30, 2008 Patient Safety Tip of the Week Unintended Consequences: Is Medication Reconciliation Next?). Bottom line: we still have a long way to go for optimal medication reconciliation.
Some of our past columns on Beers List and Inappropriate Prescribing in the Elderly:
Some of our past columns on deprescribing:
Drenth-van Maanen AC, Leendertse AJ, Jansen PA, et al. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): Combining implicit and explicit prescribing tools to improve appropriate prescribing. Journal of Evaluation in Clinical Practice 2018; 24(2): 317-322 First published: 04 August 2017
Keijsers CJPW, van Doorn ABD, van Kalles A, et al. Structured Pharmaceutical Analysis of the Systematic Tool to Reduce Inappropriate Prescribing Is an Effective Method for Final‐Year Medical Students to Improve Polypharmacy Skills: A Randomized Controlled Trial. J Amer Geriatr Soc 2014; 62(7): 1353-1359
Meulendijk MC1, Spruit MR, Drenth-van Maanen AC, et al. Computerized Decision Support Improves Medication Review Effectiveness: An Experiment Evaluating the STRIP Assistant's Usability. Drugs Aging 2015; 32(6): 495-503
STRIP Assistant (STRIPA) for OPERAM. Video demonstration.
Counter D, Millar JWT, McLay JS. Hospital readmissions, mortality and potentially inappropriate prescribing: a retrospective study of older adults discharged from hospital. British Journal of Clinical Pharmacology 2018; 84(8): 1757-1763
Schnipper JL, Mixon A, Stein J, et al. Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study. BMJ Qual Saf 2018; Published Online First: 20 August 2018
Horsky J, Drucker EA, Ramelson HZ. Higher accuracy of complex medication reconciliation through improved design of electronic tools . Journal of the American Medical Informatics Association 2018; 25(5): 465-475
Stockton KR, Wickham ME, Lai S, et al. Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review. CMAJ Open 2017; 5: E345-E353