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Under‐prescription of medications in older adults according to START criteria: A cross‐sectional study in Lebanon

Abstract Background and Aims Under‐prescription is defined as the exclusion of medications indicated for the treatment of certain conditions without any rationale for not prescribing them. The under‐prescription of medications is highly prevalent among older adults (≥65 years) receiving polypharmacy. This study aimed to assess the prevalence of the under‐prescription of medications using the Screening Tool to Alert to Right Treatment (START) criteria version 2 and to identify the predictors of having potential prescribing omissions (PPOs). Methods This cross‐sectional, face‐to‐face interview study was carried out between September 2021 and February 2022. The study comprised community‐dwelling older adults taking at least one medication on a regular basis. The study questionnaire included the patients' demographics, clinical data, and comorbidities. PPOs were identified using the START criteria. The χ 2 test was used to assess the association between under‐prescription of medication and the demographic/clinical variables. Multivariable logistic regression was performed to explore factors associated with under‐prescription of medications as the dependent variable and taking all variables that showed a p < 0.05 in the bivariate analysis as independent. Results A total of 444 older adults agreed to participate in this study. The mean age of participants was 71 ± 8.6; the majority of them, 305 (68.7%), were men. Polypharmacy was present in 261 patients (58.8%) and underprescribing of medications in 260 patients (58.6%). The highest percentage of under‐prescribing of medications was reported with statins in 115 patients (44.2%) followed by aspirin in 93 (35.7%), and angiotensin‐converting enzyme inhibitors in 61 (23.4%). The results of the multivariable analysis showed that patients with underprescribed medications had higher odds of polypharmacy (odds ratio [OR]: 2.015, confidence interval [CI] 95% 1.362–2.980, p < 0.001) and higher Charlson Comorbidity Index (OR 2.807, CI 95% 1.463–5.85, p = 0.02). Conclusion The present findings highlight that PPOs are highly prevalent among community‐dwelling older adults in Lebanon. Multimorbidity and polypharmacy were the identified predictors for under‐prescription of medications in this population.


| INTRODUCTION
While an average of one in every 11 persons worldwide is currently 65 years or older, this proportion is expected to rise to one in six persons by 2050, thus creating a major shift in the global demography. 1 Lebanon is reported to have the most number of older adults in the Middle East, where 10% of its total population will be aged over 65 years by 2050. 1 This necessitates further emphasis on this age group as they greatly contribute to the increased healthcare needs and the country's financial burden. 2 Several different factors are accountable for this demographic shift, most pivotal of which is the major improvement in medical care delivery.
Despite this improvement, major public health concerns are emerging among the older population including complications associated with polypharmacy, morbidity, and mortality due to adverse drug outcomes, potentially inappropriate medications (PIMs), and potential prescribing omissions (PPOs). 3,4 The World Health Organization defines patients as older adults if they are 65 years or older. 5 In this population, polypharmacy is frequently observed due to physicians' reliance on separate treatment guidelines for multiple morbidities, lower treatment threshold for chronic disease, the ongoing use of preventative medications, and the normal aging process. 6 Polypharmacy is defined as consuming five or more regular medications, which may be clinically indicated and beneficial in specific conditions (e.g., hypertension, diabetes mellitus) and patient populations (e.g., patients with multimorbidity). 6,7 However, polypharmacy may oftentimes comprise the use of medications in the absence of strong indications and result in decreased patient compliance, increased risk of drug-drug interactions (DDI), and increased risk for complications in patients with multiple conditions. 7,8 PIM is another healthcare problem that is frequently seen among older adults. These are considered medications that should be avoided in older individuals due to a high risk of adverse effects among this population and/or a lack of proof of their advantages when safer and equally or more effective therapeutic options are available. 9 It is worth mentioning that exposure to the latter phenomenon is very common. According to the literature, it is reported that around 20%-65% of older adults are currently exposed to at least one PIM; meanwhile, about one in every five medications prescribed to older adults was found inappropriate by a study. [10][11][12] This is alarming as such malpractice may result in negative consequences; including adverse drug reactions (ADRs), unnecessary hospitalization and healthcare utilization, and increased financial burden. 13 Despite the high prevalence of polypharmacy among older adults, many of them are still deprived of some essential medications for their treatment plan. [14][15][16] Under-prescription of medications is defined as the exclusion of medications that are indicated or needed for the treatment of a certain condition without any rationale for not prescribing them. 14 This prescription pattern is surprisingly prevalent among older adults receiving polypharmacy (22%-77%) based on data from previously published studies. [14][15][16] Under-prescription of medications is associated with ADRs (such as a greater risk of cardiovascular events, disability, and mortality). 16,17 It is worth mentioning that under-prescription of medications does not take into account that some patients may truly have a good reason not to initiate the treatment, which limits the reliability of its definition.
Previously, under-prescribing of medications focused on the treatment of specific diseases (e.g., heart failure, diabetes, dementia, depression, and osteoporosis) or symptoms (e.g., pain). In this regard, several criteria have been designed in an attempt to identify PIMs and PPOs, such as the STOPP (Screening Tool of Older People's Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria. 18 The STOPP criterion was developed to identify PIMs and the START criterion was designed to identify PPOs. The interventional utilization of these tools significantly improves medication appropriateness and reduces the incidence of ADRs in older adults. 18 These tools were originally developed in Ireland and published for the first time in 2008, where a panel of only Irish and UK experts were involved in the primary version's validation. 19 The criteria were classified according to the major physiological systems affected by specific medications or medication classes. 19 Recently, these criteria were revised by 19 experts from 13 European countries with the aim of a wider input from different experts. Such review supported the tools' reflection of Europe-wide prescribing practices in the general population of older adults and enhanced the application of the STOPP/START version 2. 18 Appropriate polypharmacy is defined as an optimized medication regimen based on clinical practice guidelines to improve the patient's clinical outcomes. 6 Thus, it is necessary to consider whether each medication has been prescribed appropriately or inappropriately, in an effort to achieve an "appropriate polypharmacy" in older adults. 6 Under-prescription of medications in older adults has not been addressed in Lebanon yet. We, therefore, aimed in this study to assess the prevalence of under-prescribing of medications using the START criteria version 2 and to identify the predictors of having PPOs.

| Study design and population
This cross-sectional face-to-face interview study was carried out between September 2021 and February 2022 after receiving ethical approval from Lebanese International University 2021RC-037-LIUSOP. All participants provided verbal consent before completing the questionnaire. The study comprised older adults taking at least one chronic medication and presenting to one of 30 community pharmacies located across Lebanon to fill their own prescription.

| Data collection
A sample of 30 community pharmacies was randomly selected from list provided by the order of Lebanese pharmacists' using the Statistical Package for the Social Sciences (SPSS) version 25, and the pharmacist in charge was briefed about the study's objectives and granted his or her permission to perform the study on their premises.
Three researchers each attended 10 pharmacies for 2 days at first to determine the average number of older adults served per day.
A minimum of 1 week was then assigned for each researcher to visit these pharmacies and interview potential older adults. The three researchers were extensively trained in conducting interviews with older adults before data collection following the National Institute on Aging recommendations for obtaining an older patient's medical history. 20 A random group of five older adults was then interviewed in an attempt to evaluate the researchers' interview skills.
A face-to-face interview was undertaken with older adult outpatients, who agreed to participate, in the pharmacy consulting area. The patients were assessed initially through simple questions before the study to confirm their orientation and concentration using the Short-Orientation-Memory-Concentration (SOMC) such as asking them about the current date, time, and location, where a score more than or equal to 20/28 was considered normal. 21 The study questionnaire included patients' demographics (i.e., age, weight, height, level of education, marital status) and clinical data (i.e., past medical history, current medical problems, number of medications taken daily including the name/dosage/and frequency of each medication, in addition to over-the-counter medications and multivitamins) to evaluate the applied therapy. Comorbidities of the patients were also self-reported and the Charlson Comorbidity Index (CCI) was used to quantify the presence of co-existing diseases using an online calculator. 22 All the reported comorbidities were based on a previous diagnosis by a physician and only patients with established diagnosis were included. Patients were interviewed in Arabic.
PPOs were identified by comparing patients' profiles to the START criteria. The evaluation of medication under-prescribing of medications was performed by one of the study researchers to minimize variability and reduce any possible bias. The list of medications for each patient was reviewed, when a medication was not prescribed but is clinically indicated in concordance with one of the START criteria, it was recorded as under-prescribed.

| STATISTICAL ANALYSES
The SPSS version 25 was utilized for data analysis. For the patient characteristics and under-prescribing of medications analysis, descriptive statistics were used. Mean and standard deviation were

| DISCUSSION
Our study reported a high prevalence of PPOs s and found that  16 While optimizing polypharmacy should be of a major concern among healthcare personnel, avoiding under-prescribing of medications in the process should not be of less importance.
According to the START criteria, and similar to other studies, at least one PPO was detected among more than half of the participants. This is in line with data from Gallagher  access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ACKNOWLEDGMENT
There was no relevant financial support related to this research.

CONFLICT OF INTEREST
The author declares no conflict of interest.

TRANSPARENCY STATEMENT
The lead author Bahia Chahine affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The datasets used and analyzed during the current study are available on reasonable request.