Categorization and association analysis of risk factors for adverse drug events

Risk Factors Associated With Drug-Related Side Effects in Children: A Scoping Review

Objective. Children's vulnerability to drug-related side effects has been highlighted in several studies. However, there is no consensus on the risk factors associated with these side effects. This study aimed to investigate risk factors associated with drug-related side effects in children. Methods. This scoping review was conducted across multiple databases. The search strategy was created with a focus on drug-related side effects, as they are more predictable based on the pre-determined risk factors. Data were collected, and reported narratively. Results. The demographic, health, hospital, and drug-related risk factors may cause drug-related side effects in children. Among them, low age, sex, polypharmacy, length of hospitalization, and medications used for comorbidities may increase the risk. Conclusion. While most of the risk factors might be similar in adults and children, their impact might be different in these 2 groups. Therefore, future studies should identify more details about the impact of the risk factors in children.

Application of trigger tools for detecting adverse drug events in older people: A systematic review and meta-analysis

OBJECTIVE

To identify trigger tools applied to detect adverse drug events (ADEs) in older people and describe their utility and performance.

METHODS

A systematic review was conducted in the PubMed, Lilacs, and Scopus databases (January 2024). Studies that developed, applied, or validated trigger tools and evaluated their utility and/or performance for detecting ADEs in older people were considered. Direct proportion meta-analyses using the inverse-variance method were performed for prevalence of ADEs and positive predictive value (PPV).

RESULTS

Twenty-four studies (25 publications) were included. Twelve trigger tools were identified, of which six were developed for detecting ADEs in older population, four developed for general population and modified for older people, and two developed for general population. No tools for detecting ADEs in older people receiving palliative care or hospitalized in intensive or surgical care units were found. The performance of triggers was presented through PPV (11.5-71%), negative predictive values (83.3%), and sensitivity (30-94.8%). The overall PPV was 33.3% (95%CI: 32.5-34.2%). Triggers with good performance were changes in plasma levels of digoxin, glucose, and potassium; changes in international normalized ratio; abrupt medication stop; hypotension; and constipation. The prevalence of ADEs ranged from 2.8 to 66%, with overall prevalence of ADEs of 20% (95%CI: 19.3-20.8%). Preventability ranged from 8.4 to 94.4%. Metabolic or electrolyte disturbances induced by diuretics, constipation induced by opioids, and falls and delirium induced by benzodiazepines were the most prevalent ADEs.

CONCLUSION

The trigger tools are flexible and easy to apply, and they can contribute to the detection of ADEs, their associated risk factors, the level of harm, and preventability in different health settings. However, there is no consensus on good or poor values of PPV, which indicate the performance of triggers. Furthermore, there is limited evidence regarding the evaluation of performance through negative predictive value, sensitivity, and specificity.

PROSPERO

CRD42022379893.

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

BACKGROUND

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

METHODS

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

CONCLUSIONS

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

Patient safety: adverse effects of Clozapine and their management at the Psychiatric Hospital Ghrasia in Yogyakarta, Indonesia

Clozapine is an atypical antipsychotic indicated for treating patients resistant to antipsychotic therapy when other medications in this class have no therapeutic effect. Clozapine has greater efficacy but more side effects than other atypical antipsychotics (e.g., agranulocytosis, seizures, sedation, and weight gain). Side effects can cause discomfort to patients and can affect patient compliance, interfering with therapeutical outcomes. This study aims to identify the side effects of clozapine use in patients at the Psychiatric Hospital Grhasia, in Yogyakarta, Indonesia. Using a cross-sectional design, this research provides a retrospective descriptive analysis using medical records of patients at the Psychiatric Hospital Ghrasia Yogyakarta. Inpatient and outpatient medical records of patients who had received a clozapine prescription from January to December 2019 were analyzed. In the 336 patients that met the inclusion criteria, the incidence of side effects from clozapine use was 16.07% (95%, CI:2.2-4.1), with the most frequent being dizziness, vomiting, diarrhea, and hypersalivation. There was no effect of age, gender, profession, or patient's disease on their incidence. The management of side effects is classified into three aspects: the drug is stopped, the patient is given additional therapy, and the patient is not given therapy. The results showed that the use of clozapine at the Psychiatric Hospital Ghrasia Yogyakarta was relatively safe. Identification of side effects is necessary to determine the follow-up treatment.

Intervention of pharmacist included in multidisciplinary team to reduce adverse drug event: a qualitative systematic review

BACKGROUND

Preventable harm in healthcare is a growing public health challenge. In addition to the economic costs of safety failures, adverse drug events (ADE) may lead to complication or even death. Multidisciplinary care team involving a pharmacist appears to be an adequate response to prevention of adverse drug event. This qualitative systematic review aims to identify and describe multidisciplinary planned team-based care involving at least one pharmacist to limit or prevent adverse drug events in the adult patients.

METHODS

To determine the type of interprofessional collaboration to prevent adverse drug event in which a pharmacist was involved, we conducted a qualitative systematic review of the literature of randomized controlled trials. Two independent reviewers screened trials in three databases: Medline, Web of Science, ScienceDirect. Prospective studies of at least three different health professionals' interventions, one of whom was a pharmacist in the last five years were included. Two reviewers performed data extraction and quality appraisal independently. We used TIDieR checklist to appraise articles quality.

RESULTS

In total 803 citations were retrieved, 34 were analysed and 16 full-text articles were reviewed. Only 3 studies published an implementation evaluation. More than half of the interventions (62%) targeted elderly patients including 6 whom lived in nursing homes. Studies outcomes were heterogeneous, and we did not perform a statistical analysis of the impact of these interventions. Most teams are composed of a physician/pharmacist/nurse trio (94%; 100%; 88%). Half of the teams were composed of the primary care physician. Other professionals were included such as physical therapists (25%), social worker (19%), occupational therapists (12%), and community health educator (6%). Multidisciplinary medication review was the most common intervention and was generally structured in four steps: data collection and baseline assessment, appraisal report by health professionals, a multidisciplinary medication review meeting and a patient follow-up.

CONCLUSIONS

The most common multidisciplinary intervention to prevent ADE in the adult population is the multidisciplinary drug review meeting at least the physician/pharmacist/nurse trio. Interventions target mostly elderly people in nursing homes, although complex chronic patients could benefit from this type of assessment.

TRIAL REGISTRATION

PROSPERO registration: CRD42022334685.

Evaluation of Factors Associated with Adverse Drug Events in South Korea Using a Population-Based Database

This retrospective study aims to investigate the factors associated with the occurrence of ADEs using nationally representative claims data. All patients with at least one claim with diagnosis codes denoting potential ADE between 1 July 2015 and 31 December 2015 were included. Potential ADE was defined as ADE identified in the claims data, because it was not verified. The index date was defined as the date of the first claim with potential ADEs. Demographic data were collected at the index date, while data on comorbidities and number of medications used were collected six months before the index date. Multivariate logistic regression was used to explore the association between potential ADEs and several factors, including sex, age group, insurance type, comorbidities, and number of prescribed medications. Patients with potential ADEs were older, had more chronic diseases, and used more medications than those without potential ADEs. In the multivariate analysis, occurrence of potential ADEs was associated with age (≥65 years, odds ratio [OR] 1.15, 95% confidence interval [CI] 1.08–1.21), Medical Aid program (OR 1.37, 95% CI 1.27–1.47), Charlson Comorbidity Index scores (≥5, OR 2.87, 95% CI 2.56–3.20), and use of six or more medications (6–10 medications, OR 1.89, 95% CI 1.79–1.99). Age, Medical Aid program, comorbidities, and number of medications were associated with occurrence of potential ADEs.

Sources of medication omissions among hospitalized older adults with polypharmacy

BACKGROUND

Hospitalized older adults have a high prevalence of polypharmacy and medication inaccuracies. Gathering the best possible medication history (BPMH) is necessary to accurately identify each medication for multimorbid older adults. The objective was to describe a multipronged approach to obtaining the BPMH for hospitalized older adults, quantify the medication discrepancies identified through these sources, and explore factors associated with these discrepancies.

METHODS

Cross-sectional analysis of 372 hospitalized older adults (age ≥ 50) transitioning to post-acute care as part of a randomized controlled trial to reduce medication burden. We used four information sources to yield a BPMH. Medication discrepancies at hospital admission were categorized as omissions, additions, and dose discrepancies after comparing alternate sources with the electronic medical record (EMR). Multivariate regression analysis, including patient factors (e.g., age, prehospital medication count, number of pharmacies), was performed to identify factors associated with the total count of medication discrepancies.

RESULTS

Ninety percent of participants had at least one medication discrepancy and 46% used more than one pharmacy. The majority of discrepancies were omissions. Among the entire cohort, there was a median of two omitted medications per patient across two alternate sources-pharmacy refill history and bedside interview. Lower age, greater total number of prehospital medications, and admission from assisted living or skilled nursing facility were significantly associated with greater medication discrepancies.

CONCLUSION

A multipronged and consistent approach to obtain a BPMH during hospitalization for multimorbid older adults revealed medication discrepancies that should be addressed prior to hospital discharge to support safe prescribing practices.

Frequency and Factors Associated With Adverse Events Among Multi-Drug Resistant Tuberculosis Patients in Pakistan: A Retrospective Study

Background

Treatment of multi-drug resistant tuberculosis (MDR-TB) for a prolonged period with comparatively less effective and more toxic second-line anti-TB drugs is associated with greater incidence of adverse events.

Study aim

This study aimed to evaluate the frequency and factors associated with occurrence of adverse events among patients with MDR-TB attending the Bahawal Victoria Hospital, Bahawalpur, Pakistan.

Study design

This retrospective study included all patients with MDR-TB who were registered and treated at the study site between June 2014 and December 2016 and had their treatment outcomes available at the time of data collection (i.e., November 2018).

Measures and outcomes

The Electronic Nominal Record System (ERNS) records, medical charts of patients, and laboratory reports were reviewed to obtain the data. Adverse events were reported as per the standard criteria recommended by the WHO. Multivariate binary logistic regression was used to find the independent factors associated with the occurrence of adverse events.

Results

A total of 179 patients with MDR-TB were included in the final analysis. Out of these, 114 (63.7%) patients experienced at least one adverse event during the course of their treatment. Depression was the most common adverse events (33%), followed by nausea and vomiting (27.4%) and arthralgia (27.4%). The factors associated with the occurrence of adverse events included presence of comorbidity (adjusted odds ratio [AOR] 2.951; 95% CI 1.423, 6.118) and being employed (AOR 3.445; 95% CI 1.188, 9.993).

Conclusion

Adverse events were prevalent in this cohort, however, resolved with the effective management approaches. Patients with identified factors for occurrence of adverse events need special attention and enhanced clinical management.

Comparison of the prevalence and nature of potentially inappropriate medication use in geriatric outpatients between tertiary and community healthcare settings: a multicenter cross-sectional study

Background Geriatric outpatients with polypharmacy have a high risk of potentially inappropriate medication (PIM) use. Aim To identify differences in both prevalence and patterns of PIMs and drug-related problems (DRPs) in older outpatients who visited the tertiary hospitals (THs) and community health centers (CHCs) and analyze associated factors. Method A prospective cross-sectional study was conducted in five THs and five CHCs from September 2018 to November 2019 in Beijing, China. Data were collected from outpatients aged ≥ 65 years with chronic diseases and polypharmacy. PIMs were evaluated using the 2015 and 2019 Beers Criteria and the Screening Tool of Older Persons' Prescriptions (STOPP) criteria. DRPs were classified using the Helper-Strand DRP Classification. The prevalence and types of PIMs and DRPs were compared, and relevant factors were analyzed. Results The prevalence of PIMs based on the 2015 Beers Criteria was higher in patients from the THs, while PIMs based on the 2019 Beers Criteria did not show a significant difference. PIM prevalence based on STOPP Criteria and DRPs was higher in patients from CHCs. Visiting CHCs was an independent factor of PIMs based on the 2015 Beers Criteria (OR 0.774, 95% CI 0.604-0.992) and the STOPP Criteria (OR 2.427, 95% CI 1.883-3.128), and DRPs (OR 3.612, 95% CI 2.682-4.865). Conclusion Differences in PIM and DRP might be due to the patients and settings. Specific measures to improve the appropriateness of medications in both settings should be used.

Access to Telepharmacy Services May Reduce Hospital Admissions in Outpatient Populations During the COVID-19 Pandemic

Introduction:

Avoidable hospital admissions put increased pressure on already strained health care resources, causing emotional and financial distress for patients and their families while taxing the health system. Pharmacist involvement in patient care has been shown to improve health care outcomes. Telepharmacy allows for personalized interaction and access to pharmacy services in a flexible format. The primary aim of this report is to explore the impact that access to a personalized telepharmacy service has on the hospital admission rate in an outpatient population before and during the COVID-19 pandemic.

Materials and Methods:

A retrospective, double-arm cohort study was performed. Hospital admission rates were analyzed in two similarly aged groups; one group (n = 2,242) had access to telepharmacy services through their primary care provider and another group did not (n = 1,540), from 2019 to 2020. Statistical analysis was performed to explore hospitalization rates in both groups.

Results:

An increase in hospitalization rates was observed in both groups of patients from 2019 to 2020. The patient group that had access to the telepharmacy service demonstrated a reduced rise in hospitalization rates versus the group without access to the telepharmacy service (access group +12.9% vs. nonaccess group +40.2%, p < 0.05, Student's t-test).

Discussion:

The patient group with access to telepharmacy services demonstrated a reduced increase in hospitalizations versus the group without access in 2020. While this represents a preliminary investigation into the potential impacts of telepharmacy on hospitalization rates, telepharmacy services may have a role in improving patient outcomes and cost savings.

Retrospective study of the prevalence and characteristics of adverse drug events in adults who present to an Australian emergency department

OBJECTIVE

To determine the burden, on the ED, of harm from unintentional adverse drug events (ADEs) in the community.

METHODS

A retrospective, observational study of 936 randomly selected presentations to a level 6 ED at a principal referral hospital in Brisbane, Australia, in November 2017. Clinical records were screened by a pharmacist, who identified suspected ADEs. All suspected ADEs and a random selection of presentations without ADEs were reviewed by an expert panel, which classified, by consensus: occurrence and type of ADE, contribution of ADE to presentation, severity of harm and preventability of presentation. Medication-related ED presentations (ADE-Ps) and potential ADEs were, respectively, defined as presentations directly attributable to an ADE, and medication events that occurred but did not cause the ED presentation. Descriptive data analysis was performed.

RESULTS

The median (interquartile range) age of patients was 40 (27-58) years, with 49.7% (95% confidence interval [CI] 46.5-52.9) being male. The prevalences of ADE-Ps and potential ADEs were 9.2% (95% CI 7.5-11.3) and 5.0% (95% CI 3.8-6.6), respectively. The severity of harm was classified as 'death or likely permanent harm' in 4.7% (95% CI 0.2-9.1) of ADE-Ps, 'temporary harm' (89.5%, 95% CI 83.1-96.0) and 'minimal or no harm' (5.8%, 95% CI 0.9-10.8). Most (79.1%, 95% CI 70.5-87.7) ADE-Ps were preventable.

CONCLUSIONS

There is a high burden on emergency care because of unintended medication harm in the community. Interventions to reduce such harm are likely to require a co-ordinated primary, acute and public healthcare response. The high proportion of presentations with potential ADEs indicates opportunity for harm mitigation in the ED.

Analysis of Influencing Factors of Acute Medication Poisoning in Adults in Emergency Department of Our Hospital from 2016 to 2019 and Observation of Curative Effect of Optimizing Emergency Procedures

Objective. This study analyzed the influencing factors of acute medication poisoning in adults in the emergency department of our hospital from January 2016 to December 2019 and observed the curative effect of optimizing emergency procedures on adult acute medication poisoning. Our results showed that, among all acute drug poisoning patients, the most common poisoning drug was sleeping pills (24.22%), followed by painkillers (20.31%) and antipsychotics (16.41%). Education level, drug category, drug source, drug dosage, unknown drug composition, and medication side effect were all influencing factors of acute drug poisoning. High school education level or below, self-purchasing medicine, medication overdose, unknown drug composition, and medication side effect were the risk factors of acute medication poisoning. In addition, after the nursing management of optimizing emergency procedures for this type of patients, the rescue time, observation time, and hospital stay of the patients had been shortened, the incidence of complications was low, the rescue success rate was high, and the clinical application effect was good.

Developing a framework regarding a complex risk based methodology in the evaluation of hazards associated with medicinal products sourced via the internet

Today, the increasing number of illicit internet pharmacies is a global phenomenon, however, the size of the online pharmaceutical market is still relatively unknown and the dubious quality of products is questionable and warrants investigation. Descriptive data from this black market channel are derived from studies analyzing the online availability of different medications procured over the internet and their methodology is quite heterogeneous. Our aim was to develop a comprehensive and specific risk assessment for selecting high patient safety risk medications from the online pharmaceutical market. A rapid tool was developed based upon the two quality and safety standard resolutions in pharmaceutical practice, published by the European Directorate for the Quality of Medicines, and was illustrated on eye drops. We developed five dimensions in support of the risk assessment including intrinsic, extrinsic and potential risks of counterfeiting. The five criteria were integrated in a comprehensively weighted risk-scoring format. The probability of procuring the product from the internet was also assessed based on the number of relevant links within the first twenty search engine results and the cost of the products. With the application of the tool a dorzolamide & timolol combination eye drop represented the highest overall patient safety risk score. In consideration of our literature review of the past 20 years, there is no current, standardized methodology to effectively identify pharmaceutical products associated with high patient safety risks. Notably, the fully comprehensive analysis of the internet pharmaceutical market and the test purchase of all online available medicines is unrealistic. Therefore, we developed a method to aid online surveillance researches and targeted international organizational led joint actions against the uncontrolled sale of falsified and substandard medications (e.g.: Operation Pangea).

Adverse Drug Events and Contributing Factors Among Hospitalized Adult Patients at Jimma Medical Center, Southwest Ethiopia: A Prospective Observational Study

Background

Adverse drug events (ADEs) are common complications of clinical care resulting in significant morbidity, mortality, and high clinical expenditure. Population-level estimates of inpatient ADEs are limited in Ethiopia.

Objective

This study aimed to assess the incidence, contributing factors, severity, and preventability of ADEs among hospitalized adult patients at Jimma Medical Center, Ethiopia.

Methods

A prospective observational study design was conducted among hospitalized adult patients at tertiary hospital in Ethiopia. A structured data collection tool was prepared from relevant literatures for data collection. Data were analyzed using statistical software. Logistic regression was performed to identify factors contributing to ADE occurrence. P values < 0.05 were considered statistically significant.

Results

A total of 319 patients were included with follow-up period of 5667 person-days. About 50.5% were women. The mean (SD) age of patients was 43 (17.6) years. One hundred sixteen ADEs were identified with the incidence of 36.4 (95% CI, 30.1-43.6) per 100 admissions and 20.5 (95% CI, 16.9-24.6) per 1000 person-days. Antituberculosis agents (adjusted odds ratio [aOR] = 2.52; 95% CI, 1.06-5.98; P = 0.036), disease of the circulatory system (aOR = 2.67; 95% CI, 1.46-4.89; P = 0.001), disease of the digestive system (aOR = 2.84; 95% CI, 1.45-5.57; P = 0.002), being on medication during admission (aOR = 3.09; 95% CI, 1.77-5.41; P < 0.001), and hospital stay more than 2 weeks (aOR = 3.93; 95% CI, 1.39-11.12; P = 0.010) were independent predictors of ADE occurrence.

Conclusions

One in every 4 patients admitted to the hospital experienced ADEs during their hospital stay. Most ADEs were moderate in severity. About two-thirds of the ADEs identified were deemed probably or definitely preventable. Therefore, it is high time to reinforce large-scale efforts to redesign safer, higher quality health care systems to adequately tackle the problem.

Using Machine Learning to Identify Adverse Drug Effects Posing Increased Risk to Women

Adverse drug reactions are the fourth leading cause of death in the US. Although women take longer to metabolize medications and experience twice the risk of developing adverse reactions compared with men, these sex differences are not comprehensively understood. Real-world clinical data provide an opportunity to estimate safety effects in otherwise understudied populations, i.e., women. These data, however, are subject to confounding biases and correlated covariates. We present AwareDX, a pharmacovigilance algorithm that leverages advances in machine learning to predict sex risks. Our algorithm mitigates these biases and quantifies the differential risk of a drug causing an adverse event in either men or women. AwareDX demonstrates high precision during validation against clinical literature and pharmacogenetic mechanisms. We present a resource of 20,817 adverse drug effects posing sex-specific risks. AwareDX, and this resource, present an opportunity to minimize adverse events by tailoring drug prescription and dosage to sex.

Challenges in pharmacotherapy for older adults: a framework for pharmacogenomics implementation

Older adults are at high risk for inappropriate prescribing, developing polypharmacy, adverse drug events and poor treatment outcomes due to multimorbidity and geriatric syndromes. Pharmacogenomics could allow healthcare professionals to provide optimal patient care while minimizing the risk of adverse drug events and simplifying complex medication regimens. The implementation of pharmacogenomics in geriatrics medicine requires a broad multilayered bottom-up approach. These include curriculum redesign, rethinking experiential education and patient and provider education. There are barriers associated with adopting pharmacogenomics into clinical practice. These barriers may include economic factors, workflow and informatics support. However, addressing these barriers primarily requires creating a culture of innovative practices in patient care, ongoing interprofessional continuing education and an interdisciplinary approach for patient care.

Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study

Objectives: Adverse drug events (ADE) are a common cause of morbidity and mortality in elderly patients. In this study, we assessed the impact of multidisciplinary medication review (MMR) for nursing home residents on patient safety and costs incurred by the hospital and the national health service. Methods: Medical files of residents were retrospectively assessed for medications prescribed in the previous six months. A pharmacist reviewed the prescriptions and suggested modifications to the patient's medical team. Patients were followed for six months. Trivalle's ADE geriatric risk score was calculated before and after MMR, as were number of potentially inappropriate medications, and economic impact from the perspective of the health care system and the nursing home. Results: Forty-nine patients were recruited. ADE score dropped one risk level (median score of 4 before versus 1 after, p < 0.0001). The number of patients taking at least one potentially inappropriate medication decreased from 30.6% before to 6.1% after MMR (p = 0.005). A mean saving of €232 per patient was made from the nursing home perspective following MMR (p = 0.008). Conclusion: The MMR reduced the iatrogenic drug risk for elderly residents and costs from the nursing home perspective, particularly drug expenditure.

Impact of pharmaceutical care in the orthopaedic department

WHAT IS KNOWN AND OBJECTIVE

In the mid-1960s, clinical pharmacy developed in the USA, and as the demand for pharmaceutical services continued to grow, their impact began to be taken seriously. However, the participation of clinical pharmacists as members of the multidisciplinary team in the orthopaedic department is still in its infancy, although its role in orthopaedics has not been defined. The object of this study was to identify and discuss the impact of pharmaceutical care in the orthopaedic department.

METHODS

A literature search was conducted on MEDLINE, PubMed, Web of Science, the Cochrane Library and CNKI (China National Knowledge Infrastructure) for papers published between 1998 and 2019, using the keywords pharmacy, pharmacist, and medication or drug combined with orthopaedic. Other available resources were also used to identify relevant articles.

RESULTS AND DISCUSSION

Based on the available evidence in 74 articles, it was found that clinical pharmacists play an important role in all aspects of rational use of medications, medication review and reconciliation, monitoring adverse drug events, risk assessment, and medication education and counselling. In addition, clinical pharmacy services were developed to minimize medication errors, adverse drug events and medical costs, but clinical pharmacy is still in its early stages in orthopaedics.

WHAT IS NEW AND CONCLUSION

A multidisciplinary approach should be adopted in the orthopaedic department, as pharmacist interventions can be vital for promoting the safety, effectiveness and cost-effectiveness of pharmacotherapy. Although pharmacists' contributions to orthopaedics are not yet fully recognized, pharmaceutical services can undoubtedly contribute to both clinical and societal outcomes.

Benefits, risks and impacts on quality of life of medications used in multimorbid older adults: a Delphi study

Background Multimorbidity and polypharmacy are common in older people. Despite the existence of quality criteria for medication use among this population, there is little guidance for managing the complex pharmacological arsenal in a multimorbidity context. Objective To establish consensus on benefits, risks and impacts on quality of life of medications used in an older adult with three chronic diseases that require complex pharmacotherapy. Setting International experts in pharmacology. Method A panel of experts responded to three rounds of a Delphi survey. They assessed the benefits, risks and positive impacts on quality of life of 50 different medications or medication classes that could be used by a hypothetical multimorbid older patient aged 65-75 years, with type 2 diabetes, heart failure and chronic obstructive pulmonary disease. Each aspect was evaluated on a 5-level Likert scale. Main outcome measure Percentage of agreement on each of the three aspects for all medication. Results Consensus was reached on 95% of items (166/174). Only two medication classes were associated with both the highest category of benefits and positive impacts on quality of life, and the lowest risk category: long-acting anticholinergics and long-acting beta-2-agonists. Nine other medications/classes of medications were categorized within the highest benefits level (metformin, DPP-4-inhibitors, short-acting beta-2-agonists, ACE inhibitors, beta-blockers, warfarin, non-vitamin K oral anticoagulants, nitrates and acetaminophen). Fifteen medications were included in the highest level of risks, among which warfarin and Non-vitamin K oral anticoagulants. Conclusions Medications recommended in clinical guidelines for individual diseases are generally considered positive for multimorbid older patients. Nevertheless, a non-negligible number of medications was deemed negative or very negative by our panelists. For multimorbid patients, individualizing treatment according to their preferences seems of utmost importance.

Deprescribing in Nursing Home Residents on Polypharmacy: Incidence and Associated Factors

OBJECTIVES

To assess 1-year incidence and factors related to deprescribing in nursing home (NH) residents in Europe.

DESIGN

Longitudinal multicenter cohort study based on data from the Services and Health for Elderly in Long TERm care (SHELTER) study.

SETTING

NHs in Europe and Israel.

PARTICIPANTS

1843 NH residents on polypharmacy.

METHODS

Polypharmacy was defined as the concurrent use of 5 or more medications. Deprescribing was defined as a reduction in the number of medications used over the study period. Residents were followed for 12 months.

RESULTS

Residents in the study sample were using a mean number of 8.6 (standard deviation 2.9) medications at the baseline assessment. Deprescribing was observed in 658 residents (35.7%). Cognitive impairment (mild/moderate impairment vs intact, odds ratio [OR] 1.41, 95% confidence interval [CI] 1.11-1.79; severe impairment vs intact, OR 1.60, 95% CI 1.23-2.09), presence of the geriatrician within the facility staff (OR 1.41, 95% CI 1.15-1.72), and number of medications used at baseline (OR 1.10, 95% CI 1.06-1.14) were associated with higher probabilities of deprescribing. In contrast, female gender (OR 0.76, 95% CI 0.61-0.96), heart failure (OR 0.69, 95% CI 0.53-0.89), and cancer (OR 0.64, 95% CI 0.45-0.90) were associated with a lower probability of deprescribing.

CONCLUSIONS AND IMPLICATIONS

Deprescribing is common in NH residents on polypharmacy, and it is associated with individual and organizational factors. More evidence is needed on deprescribing, and clear strategies on how to withdraw medications should be defined in the future.

Advancing precision medicine with personalized drug screening

Personalized drug screening (PDS) of approved drug libraries enables rapid development of specific small-molecule therapies for individual patients. With a multidisciplinary team including clinicians, researchers, ethicists, informaticians and regulatory professionals, patient treatment can be optimized with greater efficacy and fewer adverse effects by using PDS as an approach to find remedies. In addition, PDS has the potential to rapidly identify therapeutics for a patient suffering from a disease without an existing therapy. From cancer to bacterial infections, we review specific maladies addressed with PDS campaigns. We predict that PDS combined with personal genomic analyses will contribute to the development of future precision medicine endeavors.