Medication-related harm in older adults following hospital discharge: development and validation of a prediction tool

Abstract

Objectives: To develop and validate a tool to predict the risk of an older adult experiencing medication-related harm (MRH) requiring healthcare use following hospital discharge.

Design, setting, participants: Multicentre, prospective cohort study recruiting older adults (≥65 years) discharged from five UK teaching hospitals between 2013 and 2015.

Primary outcome measure: Participants were followed up for 8 weeks in the community by senior pharmacists to identify MRH (adverse drug reactions, harm from non-adherence, harm from medication error). Three data sources provided MRH and healthcare use information: hospital readmissions, primary care use, participant telephone interview. Candidate variables for prognostic modelling were selected using two systematic reviews, the views of patients with MRH and an expert panel of clinicians. Multivariable logistic regression with backward elimination, based on the Akaike Information Criterion, was used to develop the PRIME tool. The tool was internally validated.

Results: 1116 out of 1280 recruited participants completed follow-up (87%). Uncertain MRH cases ('possible' and 'probable') were excluded, leaving a tool derivation cohort of 818. 119 (15%) participants experienced 'definite' MRH requiring healthcare use and 699 participants did not. Modelling resulted in a prediction tool with eight variables measured at hospital discharge: age, gender, antiplatelet drug, sodium level, antidiabetic drug, past adverse drug reaction, number of medicines, living alone. The tool's discrimination C-statistic was 0.69 (0.66 after validation) and showed good calibration. Decision curve analysis demonstrated the potential value of the tool to guide clinical decision making compared with alternative approaches.

Conclusions: The PRIME tool could be used to identify older patients at high risk of MRH requiring healthcare use following hospital discharge. Prior to clinical use we recommend the tool's evaluation in other settings.

Keywords: Medication harm; healthcare use; hospital discharge; older adults; risk prediction.

Figure 1

Prime tool to calculate patient risk of experiencing MRH requiring healthcare use within 8 weeks following hospital discharge. ADR, adverse drug reaction; GP, general practitioner; MRH, medication-related harm.

Figure 2

Prime prediction tool compared with number of medicines alone to discriminate patient risk of medication harm. ROC, receiver operating characteristic.

Figure 3

Decision curve comparing the net benefit of alternative models for clinical decision making.