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.
↵a 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.
↵b 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.
↵c 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.
↵d 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.
↵e We downgraded the GRADE assessment if the recruited participants were not representative of older persons in the primary care settings.
↵f We upgraded the GRADE assessment if the RR is >2 or <0.5.
↵g We upgraded the GRADE assessment in the presence of dose-response gradient, which provides stronger evidence of the cause-effect relationship.