Safer Prescribing and Care for the Elderly (SPACE): a pilot study in general practice

Katharine A Wallis; C Raina Elley; Simon Moyes; Ngaire Kerse

doi:10.3399/bjgpopen18X101594

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Figure 1. High-risk prescribing rates in study population (vulnerable at baseline) for each high-risk category and combined. BL = baseline.

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Type of adverse drug event	Vulnerable patients (at increased risk of ADE)	High-risk prescribing^a
Gastrointestinal bleed	Prior peptic ulcer ever	NSAID or aspirin without gastroprotection, in patient with prior peptic ulcer
	Aged ≥75 years	NSAID without gastroprotection, in patient ≥75 years
	Aged ≥65 years prescribed aspirin	NSAID without gastroprotection, in patient ≥65 years taking aspirin
	Aged ≥65 years prescribed aspirin	Clopidogrel without gastroprotection, in patient ≥65 years taking aspirin
	Prescribed oral anticoagulant	NSAID without gastroprotection, in patient taking an oral anticoagulant
	Prescribed oral anticoagulant	Aspirin or clopidogrel without gastroprotection, in patient taking an oral anticoagulant
Renal impairment	Prescribed both renin-angiotensin system blocker and diuretic	NSAID, in patient taking both renin-angiotensin system blocker and diuretic
Renal impairment	Chronic kidney disease (most recent eGFR <60)	NSAID, in patient with chronic kidney disease (eGFR <60)
Cardiac failure	Heart failure ever	NSAID, in patient with history of heart failure

^aMedicines prescribed within the previous 14 weeks. ADE = adverse drug event. eGFR = estimated glomerular filtration rate. NSAID = nonsteroidal anti-inflammatory drug.

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Table 1. Characteristics of study population (patients who were vulnerable at baseline, that is at increased risk of an adverse drug event with non-steroidal anti-inflammatory drugs and/or antiplatelet medicines^a) from the two participating general practices

	General practice A (registered patients: n = 7944)	General practice B (registered patients: n = 2500)	Total
Vulnerable patients^a, n (%)	668 (8.6)	202 (8.1)	870 (8.9)
Age, mean (SD)	74.9 (11.2)	73.2 (12.3)	74.5 (11.4)
Female, n (%)	392 (58.7)	96 (47.5)	488 (56.1)
Ethnicity, n (%):
New Zealand European	321 (48.1)	157 (77.7)	478 (54.9)
Other European	253 (37.9)	23 (11.4)	276 (31.7)
New Zealand Maori	7 (1.0)	4 (2.0)	11 (1.3)
Pasifika	5 (0.7)	1 (0.5)	6 (0.7)
East Asian	29 (4.3)	6 (3.0)	35 (4.0)
Indian	12 (1.8)	7 (3.5)	19 (2.2)
Other	41 (6.1)	4 (2.0)	45 (5.2)
Number of long-term medicines, mean (SD)	4.07 (1.86)	1.35 (0.56)	3.44 (2.01)

^aPatients with one or more risk factor for gastrointestinal, renal, or cardiac adverse effects when prescribed NSAID and/or antiplatelet medicines. SD = standard deviation.

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Table 2. Rates of high-risk prescribing at baseline, and 6 and 12 months post-intervention for study population and for practice population overall

		Study population^a				Practice population^b
Outcome measure	Baseline	6-month n/N (%)	P-value	12-month n/N (%)	P-value^c	6-month n/N (%)	12-month n/N (%)
Primary outcome: high-risk prescribing	70/870 (8.0)	47/807 (5.8); 52/870 (6.0) LVCF	0.030.04	62/757 (8.2); 74/870 (8.5) LVCF	0.90.7	71/890 (8.0)	101/1026 (9.8)
Secondary outcomes
High-risk prescribing among patients with any gastrointestinal risk factor	35/649 (5.4)	26/596 (4.4); 29/649 (4.5) LVCF	0.40.4	33/554 (6.0); 42/649 (6.5) LVCF	0.60.4	39/698 (5.6)	52/731 (7.1)
High-risk prescribing amongst patients with any renal risk factor	41/476^d (8.6)	22/444 (5.0); 25/476 (5.3) LVCF	0.0070.008	33/414 (8.0); 38/476 (8.0) LVCF	0.70.7	38/365 (10.4)	61/536 (11.4)
High-risk prescribing among patients with congestive heart failure	1/27 (3.7)	1/23 (4.4); 1/27 (3.7) LVCF	0.91.0	1/21 (4.8); 1/27 (3.7) LVCF	0.91.0	1/26 (3.9)	1/25 (4.0)

^aPatients vulnerable at baseline; that is at increased risk of adverse drug events (ADE) when prescribed NSAID and/or antiplatelet medicines (see Table 1). ^bAll practice vulnerable patients; that is includes patients who were not vulnerable at baseline but who have become so at 6 months and/or 12 months. ^cCompared with baseline.^d32/870 (3.7%) patients were included as at-risk of ADE due to a low eGFR, where it could not be confirmed that the latest eGFR was still <60. LVCF = last value carried forward, which assumes that those lost to follow-up (left the practice or died) had the same high-risk prescribing status as baseline.