Post-discharge adjustment of medication in geriatric patients : A prospective cohort study

Pharmacist-led hospital intervention reduces unintentional patient-generated medication discrepancies after hospital discharge

Background

Medication reconciliation can significantly reduce clinically important medication errors at hospital discharge, but its impact on post-discharge medication management has not been investigated. We aimed to investigate the incidence of patient-generated medication discrepancies 30 days after hospital discharge and the impact of a pharmacist-led medication reconciliation coupled with patient counselling on clinically important discrepancies caused by patients.

Methods

A pragmatic, prospective, controlled clinical trial was conducted at the University Clinic Golnik, Slovenia. Adult patients were divided into an intervention group and a control group. The intervention group received pharmacist-led medication reconciliation at admission and discharge, plus patient counselling at discharge. Medication discrepancies were identified by comparing the therapy prescribed in the discharge letters with the therapy 30 days after discharge, obtained through telephone patient interviews. Discrepancies were classified as intentional or unintentional, and their clinical importance was assessed.

Results

The study included 254 patients (57.9% male, median age 71 years), with 136 in the intervention group and 118 in the control group. Discrepancies occurred with a quarter of the medicines (617/2,441; 25.3%) at 30 days after hospital discharge, and patients themselves caused half of the discrepancies (323/617; 52.4%), either intentionally (171/617; 27.7%) or unintentionally (152/617; 24.6%). Clinically important discrepancies occurred in 18.7% of intentional and 45.4% of unintentional patient-generated changes. The intervention significantly reduced the likelihood of clinically important unintentional patient-generated discrepancies (OR 0.204; 95%CI: 0.093-0.448), but not clinically important intentional patient-generated discrepancies (OR 2.525; 95%CI: 0.843-7.563). The latter were more frequent among younger, male patients and patients hospitalized for respiratory diseases.

Conclusion

The study emphasizes the importance of addressing discrepancies made by patients after hospital discharge, which can result in potentially harmful outcomes. It also shows that a pharmacist-led hospital intervention can significantly reduce discrepancies in the early post-discharge period. These findings can guide the development of future services to improve patient support for medication management after hospitalization.

Barriers and Facilitators to Medication Adherence among the Vulnerable Elderly: A Focus Group Study

Poor medication adherence is a significant public health issue, especially among the vulnerable elderly, leading to increased morbidity, mortality, and healthcare costs. This study aimed to explore, identify, and understand the barriers and facilitators to medication adherence among vulnerable elderly individuals. We conducted a qualitative study using focus group interviews with 31 participants, including community nurses, social care services, volunteers from non-governmental organizations, patient association members, and informal caregivers, using semi-structured questions and inductive content analysis to gather and analyze qualitative data. Two main categories, "Perceived barriers" and "Facilitative interventions" were developed. The findings revealed multiple barriers, including medication-related barriers, patient-related barriers and barriers related to the healthcare system and healthcare personnel. Participants also highlighted the importance of facilitating interventions like medication management, health education, supportive social networks, and ensuring continuity of care. The study underscores the need for targeted strategies to improve medication adherence among the vulnerable elderly.

What do older patients know about their medication? A cross-sectional, interview-based pilot study

PURPOSE

This study sought to analyze the medication knowledge and awareness of medication adjustment options during intercurrent illness (sick day rules) of patients ≥ 70 years treated at a hospital for geriatric medicine in northern Germany.

METHODS

The study was designed as a cross-sectional, interview-based pilot study, was approved by the Ethics Committee of Hannover Medical School (No. 10274_BO_K_2022; date of approval: 11 March 2022), and enrolled a convenience sample of 100 patients between May and December 2022.

RESULTS

The median of the average medication knowledge score in the study population (median age 82 years (IQR 75-87); 71% female) was 5 on a scale from 0 to 6 (IQR 3.8-5.6). Women achieved higher average medication knowledge scores than men (median 5.1 (IQR 4-5.6) vs. median 4.3 (IQR 3.6-5.1); p = 0.012), and patients < 80 years achieved higher average medication knowledge scores than patients ≥ 80 years (median 5.4 (IQR 4.9-5.7) vs. median 4.3 (IQR 3.2-5.3); p < 0.001). Sick day rules were known for only 1.1% of drugs for which sick day rules were applicable. Fifty-two percent of the patients reported that their general practitioner contributed most to their medication knowledge, and 66% considered their daily number of drugs to take adequate.

CONCLUSION

Our study showed that medication knowledge of older patients was overall satisfying. Awareness of sick day rules, however, was poor. Future studies should evaluate the clinical benefits of sick day rules and ways of better communicating sick day rules to patients. In this regard, general practitioners may play a decisive role.

Patterns and Predictors of Medication Change after Discharge from Hospital: An Observational Study in Older Adults with Neurological Disorders

BACKGROUND

Medication is often changed after inpatient treatment, which affects the course of the disease, health behavior and adherence. Thus, it is important to understand patterns of medication changes after discharge from hospital.

METHODS

Inpatients at the Department of Neurology received a comprehensive assessment during their stay, including adherence, depression, cognition, health and sociodemographic variables. A month after being discharged, patients were contacted to enquire about post-discharge medication changes.

RESULTS

910 older adults aged 70 ± 8.6 years participated, of which 204 (22.4%) reported medication changes. The majority of changes were initiated by physicians (n = 112, 56.3%) and only 25 (12.6%) patients reported adjusting medication themselves. Reasons for medication changes differed between patients and doctors (p < 0.001), with side effects or missing effects cited frequently. Sociodemographic and patient-related factors did not significantly predict medication changes.

CONCLUSION

Patients reported less post-discharge medication changes than expected, and contrary to previous literature on nonadherence, only a fraction of those changes were performed by patients themselves. Socioeconomic and clinical parameters regarding personality, mood and cognition were poorly associated with post-discharge medication changes. Instead, individual health-related factors play a role, with patient factors only indirectly influencing physicians' decisions.

Patient Safety in a Box: Implementation and Evaluation of the Emergency Box in Geriatric and Parkinson Patients

In an industrial society, the proportion of geriatric people increases with rising age. These people are likely to use polypharmacy and experience medical emergencies. However, their emergency care can be complicated by unclear comorbidities and medication. The aim of this prospective interventional study was to assess the demand for a drug safety tool in clinical practice and to analyze whether the emergency box can improve acute care in a geriatric cohort. Therefore, emergency room (ER) doctors in a German tertiary hospital recorded the number of geriatric patients lacking medical information and its impact on diagnostics/treatment. Furthermore, the emergency box was distributed to patients on the neurological ward and their current drug safety concepts were assessed. After 6 months, we evaluated in a follow-up whether the tool was helpful in emergency cases. Our study revealed that 27.4% (n = 28) of the patients came to the ER without their medical information, which caused a relevant delay or possible severe complications in 11.8% (n = 12). The emergency box was perceived as easily manageable and 87.9% (n = 109) of the participants wanted to keep it after the study. Subjectively, participants benefitted in emergencies. In conclusion, the emergency box is a cheap tool that is easy to use. It can save valuable time in emergencies and increases the safety of geriatric patients.

Exploring pharmacist involvement in the discharge medicines reconciliation process and information transfer to primary care: an observational study

Background Medication errors can occur because of incomplete or poorly communicated information at the transition from hospital to community. Following an audit in 2016, a project was undertaken to determine if pharmacists could improve the quality of medication information in discharge summaries by introducing a discharge medication reconciliation process. Pharmacists recorded any changes to the patient's medication in the electronic prescribing system during their inpatient stay and summarised these changes on discharge. Objective To compare medication information in discharge summaries with recognised standards for the clinical structure and content of patient records, and to assess the impact of the pharmacist process on compliance with certain elements of these standards. Setting A 750 bed teaching district general hospital in England. Method A retrospective observational study examining all patient discharge summaries over a 1 week period for compliance to national standards. Main outcome measure The main outcome measures were compliance with standards for medication started, stopped or changed in hospital and any differences between extent of recording this information by doctors and pharmacists. Results Data were collected and analysed for 243 patients, of whom 94 (38.7%) attracted a discharge medicines reconciliation process by a pharmacist. Discharge summaries were compliant with basic standards for changed medication in 42% of patients or 51.4% with the input of a pharmacist. This increase of 9.4% was statistically significant (p = 0.0365). At an enhanced level, pharmacists increased compliance from 39.1 to 46.5%, this did not represent a significant increase (p = 0.0989). Conclusion Pharmacists undertaking a discharge medication reconciliation process significantly improves the quality of discharge summaries.

Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions

Background Medication reconciliation prevents medication errors at care transition points. This process improves communication with general practitioners regarding the reasons for therapeutic changes, allowing those changes to be maintained after hospital discharge. Objective To investigate the impact of medication reconciliation in geriatrics on the sustainability of therapeutic optimization after hospital discharge. Setting This study was conducted in a geriatric unit in a University Hospital Centre in France. Method This was a retrospective study. For 6 months, all patients over 65 years who underwent the process of medication reconciliation performed by a clinical hospital pharmacist and a physician at admission and discharge, were included. A comparison between drug prescriptions at hospital discharge and the first prescription made outside the hospital was made to identify any differences. Main outcome measure The main outcome measures were the provision of the results of the medication reconciliation performed in the hospital to the relevant general practitioner, the subsequent acceptance of that information, the type of medication discrepancies one month after discharge and the therapeutic classes affected by the modifications. Results Among the 112 patients, medication reconciliation allowed us to identify and correct 87 unintentional discrepancies at admission (88% corrected) and 54 at discharge (92% corrected). Patients were discharged to homes or nursing homes (61%), geriatric rehabilitation units (38%) or psychiatric clinics (1%). A general practitioner wrote the first prescription renewal a mean of 36 ± 23 days after discharge, having been made aware of the medication reconciliation in only 24% of the cases (received and taken into account). The impact was a decrease in the number of patients with at least one discrepancy. Twenty-five percent of general practitioners who were aware about the medication reconciliation process accepted all therapeutic changes, while only 7% of those who were not informed did so (p = 0.02). The number of medication discrepancies observed was correlated with the number of medications for which prescriptions were renewed (p < 0.01). Conclusion Medication reconciliation involving therapeutic optimization and the justification of changes is essential to ensure the safety of the prescriptions written for patients. However, its impact after discharge is hampered by the fact that the results are often not received or taken into account by general practitioners. Taking medication reconciliation into account was associated with a significant increase in prescriptions that maintained therapeutic changes made in the hospital, confirming the positive impact of communication between care providers on therapeutic optimization.