OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly

The objective of this RCT is to evaluate whether the Systematic Tool to Reduce Inappropriate Prescribing (STRIP) including STRIP assistant (STRIPA) implemented by an appropriately qualified team will lead to an improvement in clinical and economic outcomes among patients aged 70 years and more with multimorbidity and polypharmacy.

The primary objective is to assess the effect of pharmacotherapy optimisation on drug-related hospitalisations caused by non-preventable adverse drug reactions of preventable medication error related to over-, miss-, and underuse or over-, miss-, and underprescribing of prescription and non-prescription medications.
Secondary objectives will be to assess the impact of pharmacotherapy optimisation by STRIP on economic parameters, health care utilisation, falls, mortality, quality of life, polypharmacy, medication changes, activities of daily living, and patient understanding of their medication and to assess the patient’s perspective on the STRIP.

Reducing avoidable hospital admissions in multimorbid elderly by optimising pharmacotherapy using the STRIP method including a webbased decision support software tool with integrated STOPP/START criteria, carried out by a physician and a pharmacist.

Inclusion will take place during the index hospitalisation

SHiM within 72 hours after admission
Follow-up telephone calls at 2 (±14 days), 6 (±28 days), and 12 (±28 days) months

STRIP is a structured method to perform pharmacotherapy optimisation. This STRIP-intervention consists of 9 steps:

1. structured history taking of medication (SHIM)

2. recording medication and diagnoses in STRIPA

3. structured drug review based on the STRIPA with the integrated STOPP/START criteria

4. communication and discussion of the structured drug review with prescribing physician with possible adaptation of the recommendation

5. shared decision-making with the patient with possible adaptation of the recommendation

6. optional revision based on new accumulating data during hospitalisation (e.g. new diagnoses, adverse drug reactions)

7. generation of GP report

8. delivery of the report to the patient and to the GP (optional additional direct communication)

9. follow-up

A structured questionnaire is used for taking the medication history: Structured History taking of Medication use (SHIM) questionnaire. SHIM will be administered on the bases of the medication which was taken at home and will not consider drugs being administered or stopped during the hospitalization.

The STRIPA is a Dutch software-based tool for the support of the pharmaceutical analysis (step 2 of STRIP) by 1) taking into account the predictable adverse medication effects, 2) advising safe and appropriate therapy using established STOPP/START criteria, 3) interaction monitoring and 4) appropriate dosing in accordance with renal function. It represents a highly efficient and user-friendly software engine capable of individually screening the clinical status and pharmacological therapy of older patients with multimorbidity to define optimal drug therapy and highlight ADR risk.

The STRIPA supported advice provides clinicians with the necessary information for optimising the individual patient’s drug therapy based on a list of clinical data inputs: gender, current medical problems and diagnoses, all medicines that are actually used by the patient according to the SHIM (ATC codes) and dosage, clinical measurements such as heart rate and rhythm, blood pressure, estimated GFR (CKD-epi formula) and other relevant laboratory data. These measurements take about 10 minutes34, and SHIM takes also about 10 minutes28. The STRIPA generates 5 output datasets:

1. potential prescribing omissions of beneficial drugs

2. instances of potentially inappropriate medication

3. presence of ADRs (with use of MedDRA terminology)

4. potential adverse drug interactions

5. dosing advice