Potentially inappropriate prescribing among people with Type 2 Diabetes Mellitus – tool development and validation

Abstract

<p><b>Background:</b> People with type 2 diabetes mellitus (T2DM) are at an increased risk of inappropriate prescribing due to the presence of multiple co-morbidities and poly-pharmacy. Despite the availability of a number of PIP identification tools targeting the older population, there was no explicit tool specifically designed to detect PIP among people with T2DM. This project was aimed to explore and map the studies investigating PIP among people with diabetes" and to develop and validate an explicit tool that could be used to identify PIP for people with T2DM.</p> <p><b>Methods:</b> The scoping review was conducted following the Joanna Briggs Institute (JBI) guidelines for scoping reviews and the published protocol. Studies for this review were identified from a systematic search of eight databases for published studies and three grey literature sources. Potential items for the new tool, IMPACT2DM (Inappropriate Medication Prescribing Assessment Criteria for Type 2 Diabetes Mellitus), were generated from selected diabetes guidelines and drug information sources. The content of the tool was validated using 2 rounds of Delphi survey involving physicians and clinical pharmacists experienced in diabetes care and authors of selected diabetes guidelines. Clinical applicability of the tool was tested through a retrospective review of medical records of people with T2DM at a general hospital in Ethiopia. As a result, major and minor modifications were applied to the items to improve the face and clinical validity of the tool. Logistic regression was used to identify factors associated with PIP and determine the predictive ability of the tool for hospital admission.</p> <p><b>Results and Discussion:</b>PIP was less studied in low- and middle-income countries, nursing homes and community dwelling settings. Of the 190 studies included in the scoping review none has used an explicit tool specifically designed to identify potentially inappropriate prescribing among people with diabetes. A new tool, IMPACT2DM, has been developed from current quality evidence and undergone review in a Delphi study to validate its content by a panel of 12 experts (first round) and 7 experts (second round) consisting of physicians and pharmacists. IMPACT2DM identified PIPs from a large proportion (>90%) of people with T2DM. Adults with prescribing omissions were more likely to be ≥40 years old or to be prescribed with <5 medications. Adults with dosing problems were more likely ≥50 years old, or have had a fasting blood sugar (FBS) level out of the target range (80-130 mg/dL). The number of PIPs identified using IMPACT2DM predicts the risk of hospitalization. For every additional PIP identified from people with T2DM the risk of hospitalization was increased by 30%. The final version of IMPACT2DM contains 69 items grouped by the type of PIP.</p> <p><b>Conclusion:</b>This research project has explored and mapped studies conducted on PIP among adults living with diabetes and produced a new explicit tool for use to identify PIP for people with T2DM. IMPACT2DM was validated, in the Ethiopian context, for its content, clinical applicability and predictive ability for hospital admission due to PIP. Health professionals should be alert to check for potential prescribing omissions for adults ≥40 years old and dosing problems for adults with an FBS level out of the target range or >50 years old.</p>