Table 3.
Summary of Key Findings and GRADE Assessment
| GRADE Assessment
|
|||||||
|---|---|---|---|---|---|---|---|
| Outcomes | Large Effectf/Dose Responseg | Pooled Effect Size(95% CI) | Certainty of Evidence GRADE | Risk of Biasa | Inconsistencyb | Imprecisionc/Publication Biasd/Indirectnesse | Large Effectf/Dose Responseg |
| PIP based on the Beers Criteria | |||||||
| Functional decline | 4,165 | RR 1.38 (1.06-1.80) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 29.5%, P= .234) |
No downgrade | No upgrade |
| Hospitalizations | 5,069 | RR 1.14 (1.01-1.29) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 37.0%,P = .204) |
No downgrade | No upgrade |
| Mortality | 73,533 | RR 0.98 (0.93-1.05) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 0.0%, P = .689) |
No downgrade | No upgrade |
| PIP based on the STOPP criteria | |||||||
| A&E visits | 3,588 | RR 1.63 (1.32-2.00) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 0.0%, P = .452) |
No downgrade | No upgrade |
| ADEs | 1,835 | RR 1.34 (1.09-1.66) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 41.3%, P = .192) |
No downgrade | No upgrade |
| Functional decline | 2,684 | RR 1.53 (1.08-2.18) |
●●○○○ Low |
No downgrade (NOS = 9) |
No downgrade (I2 = 17.6%, P= .271) |
No downgrade | No upgrade |
| HRQoL | 3,588 | SMD -0.26 (−0.36 to −0.16) |
●○○○○ Very low |
No downgrade (NOS = 9) |
Downgrade (I2 = 82.3%, P = .003) |
No downgrade | No upgrade |
| Hospitalizations | 2,338 | RR 1.25 (1.09-1.44) |
●●○○○ Low |
No downgrade (NOS = 8) |
No downgrade (I2 = 53.6%, P =.116) |
No downgrade | No upgrade |
A&E = accident and emergency department; ADE = adverse drug event; GRADE = Grading of Recommendations, Assessment, Development and Evaluations; HRQoL = health-related quality of life; NOS = Newcastle-Ottawa Scale; PIP = potentially inappropriate prescribing; RR = relative risk; SMD = standardized mean difference; STOPP = Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions.
We downgraded the GRADE assessment if the risk of bias assessment based on the NOS is <8 in at least one of the studies, suggesting the presence of risk of bias.
We downgraded the GRADE assessment if the Q test P < 0.10 or the I2 > 75%, indicating significantly high levels of heterogeneity in the results.
For RR, we considered a clinically meaningful threshold to be 0.90 or 1.10 and downgraded the GRADE assessment if the RR point estimate is ≥1 and the lower limit of its CI is <0.90, or if the RR point estimate is <1 and the upper limit of its CI is >1.10. For SMD, we considered a clinically meaningful threshold to be ±0.20 and downgraded the GRADE assessment if the point estimate is ≥0 and the lower limit of its CI is <–0.20, or if the point estimate is <0 and the upper limit of its CI is >0.20.
We could not assess for publication bias because there were <10 studies for each of the outcomes. Therefore, we did not downgrade any of the GRADE assessments due to publication bias.
We downgraded the GRADE assessment if the recruited participants were not representative of older persons in the primary care settings.
We upgraded the GRADE assessment if the RR is >2 or <0.5.
We upgraded the GRADE assessment in the presence of dose-response gradient, which provides stronger evidence of the cause-effect relationship.