小柯机器人

瑞士伯尔尼大学医院Nicolas Rodondi团队研究了优化治疗对防止多病老年人可避免的住院的影响。相关论文于2021年7月13日发表在《英国医学杂志》上。

为了探讨优化药物治疗对住院的多病且多药治疗的老年患者药物相关住院的影响，研究组在四个欧洲国家（瑞士、荷兰、比利时和爱尔兰共和国）大学医院的110组住院病房中进行了一项整群随机对照试验。共招募了2008位老年人（≥70岁），均有多发病（≥3种慢性病），且服用多种药物（≥5种药物长期使用）。

将这些老年人随机分配，分别接受常规护理或由医生和药剂师在个体水平上联合进行的结构化药物治疗优化干预，在临床决策软件系统的支持下，部署老年人处方筛选工具，以提醒正确的治疗（停止/开始）标准，并确定潜在的不适当处方。主要观察指标为12个月内首次药物相关入院率。

2008名老年人（平均使用9种药物）被随机分为54个干预组（963名参与者）和56个接受常规护理的对照组（1045名参与者）。干预组中86.1%的参与者（789例）有不适当的处方，平均每个参与者的停止/开始建议为2.75条。62.2%的参与者（491例）至少有1条建议在两个月内成功实施，主要是停止使用可能不合适的药物。

干预组有211名参与者（21.9%）经历了首次与药物相关的住院治疗，而对照组有234名（22.4%）。在以死亡作为竞争事件进行审查的意向治疗分析中（375例，18.7%），首次药物相关住院的危险比为0.95。在按方案分析中，药物相关住院的危险比为0.91。首次跌倒的危险比为0.96，死亡危险比为0.90。

研究结果表明，不恰当处方在住院的多病和多药治疗的老年人中很常见，通过干预以优化药物治疗而有所减少，但对药物相关的住院没有影响。

附：英文原文

Title: Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial

Author: Manuel R Blum, Bastiaan T G M Sallevelt, Anne Spinewine, Denis O’Mahony, Elisavet Moutzouri, Martin Feller, Christine Baumgartner, Marie Roumet, Katharina Tabea Jungo, Nathalie Schwab, Lisa Bretagne, Shanthi Beglinger, Carole E Aubert, Ingeborg Wilting, Stefanie Thevelin, Kevin Murphy, Corlina J A Huibers, A Clara Drenth-van Maanen, Benoit Boland, Erin Crowley, Anne Eichenberger, Michiel Meulendijk, Emma Jennings, Luise Adam, Marvin J Roos, Laura Gleeson, Zhengru Shen, Sophie Marien, Arend-Jan Meinders, Oliver Baretella, Seraina Netzer, Maria de Montmollin, Anne Fournier, Ariane Mouzon, Cian O’Mahony, Drahomir Aujesky, Dimitris Mavridis, Stephen Byrne, Paul A F Jansen, Matthias Schwenkglenks, Marco Spruit, Olivia Dalleur, Wilma Knol, Sven Trelle, Nicolas Rodondi

Issue&Volume: 2021/07/13

Abstract:

Objective To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital.

Design Cluster randomised controlled trial.

Setting 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors.

Participants 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term).

Intervention Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person’s prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing.

Main outcome measure Primary outcome was first drug related hospital admission within 12 months.

Results 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths).

Conclusions Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes.

DOI: 10.1136/bmj.n1585

Source: https://www.bmj.com/content/374/bmj.n1585

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