Clinical Pharmacy Services in Older Inpatients: An Evidence-Based Review

Prevalence and trends in polypharmacy and excessive polypharmacy: a retrospective national database analysis (2012-2021)

BACKGROUND

Polypharmacy is a growing concern, impacting patient safety and healthcare costs. Monitoring its prevalence and temporal trends is essential for effective healthcare management.

AIM

This study aimed to determine prevalence and trends of polypharmacy and excessive polypharmacy in Belgium.

METHOD

Utilizing a federal claims database, medication data were analyzed from 2012 to 2021. Polypharmacy (≥ 5 medications) and excessive polypharmacy (≥ 10 medications) were evaluated, with prevalence calculated per 1000 inhabitants, and reported per year, age group and region. Linear regression estimated the impact of age and year on polypharmacy prevalence.

RESULTS

In 2021, polypharmacy and excessive polypharmacy were reported in 135/1000 and 31/1000 Belgians respectively. Prevalence of both increased steadily from 2012 to 2021, with excessive polypharmacy rising more prominently. Among adults aged ≥ 65 years, prevalence rates were higher, with polypharmacy at 434/1000 and excessive polypharmacy at 106/1000. Regional variations were observed, with prevalence highest in the Walloons region. Patient age and year (2012-2021) were associated with both polypharmacy and excessive polypharmacy (p < 0.001).

CONCLUSION

We observed increases in polypharmacy and excessive polypharmacy over a decade in Belgium, particularly among older adults. Efforts to monitor, manage, and optimize medication use are imperative to ensure safe and effective healthcare delivery.

Impact of the Clinical Pharmacist in Rheumatology Practice: A Systematic Review

This is a systematic literature review on the impact of pharmacists in rheumatology, conducted using the PubMed®, CINAHL®, Cochrane Library®, and Web of science® databases and using the PRISMA 2020 checklist. This review was conducted from 2000 to June 2024. A quality analysis was performed. The selection of articles, as well as all analyses, including quality analyses, were conducted by a pair of pharmacists with experience in rheumatology, and included 24 articles. This study highlights the growth of clinical pharmacy activities in rheumatology and the positive influence of clinical pharmacists on patient care. The implementation of such initiatives has the potential to improve medication adherence, reduce medication-related risks, and optimize associated healthcare costs. All these pharmaceutical interventions aim to make the patient care journey smoother and safer. Additionally, the diversity of available pharmaceutical services caters to the varied needs of rheumatology. Furthermore, outpatient clinical pharmacy is also explored in this field and garners interest from patients. The vast majority of studies demonstrate significant improvement in patient care with promising performance outcomes when pharmacists are involved. This review highlights the diverse range of interventions by clinical pharmacists in rheumatology, which is very promising. However, to better assess the benefits of clinical pharmacists, this activity needs further development and evaluation through controlled and randomized clinical research programs.

Developing Medication Reviews to Improve the Aruban Healthcare System: A Mixed-Methods Pilot Study

This study investigated whether and how medication reviews (MRs) conducted by pharmacists and general practitioners (GPs) with patient involvement can be performed on the island of Aruba (Dutch Caribbean). In this mixed-methods pilot study (both qualitative and quantitative), constructive and observational methodologies were combined. Healthcare providers' and patients' views on MRs and aspects of Aruban healthcare and culture relevant to MRs were examined. These insights were used to develop a protocol for conducting and implementing MRs in Aruba. Surveys were distributed and semi-structured interviews were held among Aruban community pharmacists and GPs, and a pilot program was created in which MRs were carried out with four Aruban patients and their GPs. According to the included healthcare providers, the main purpose of MRs is to optimize the patient experience and achieve concordance. Even though pharmacists and GPs consider their partnership equal, they have different views as to who should bear which responsibility in the MR process in matters regarding patient selection and follow-up. Common Aruban themes that were mentioned by the healthcare providers and deemed relevant for conducting MRs included behaviour/culture, healthcare, lifestyle, and therapy compliance. Anamnesis should be concise during the MR, and questions about medication storage, concerns, beliefs, and practical problems, as well as checks for limited health literacy, were considered important. In the pilot, at least three to, maximally, eight pharmacotherapy-related problems (PRPs) were detected per MR consultation, such as an incorrect dosage of acetylsalicylic acid, an inappropriate combination tablet for blood pressure regulation, and the absence of important laboratory values. All patients considered their consultation to be positive and of added value. In addition, it was observed that an MR can potentially generate cost savings. The information obtained from the healthcare providers and patients, together with the basic principles for MRs, as applied in the Netherlands, led to a definitive and promising MR format with practical recommendations for community pharmacists in Aruba: in comparison with the Dutch MR approach, GPs and pharmacists in Aruba could collaborate more on patient selection for MRs and their follow-up, because of their specific knowledge regarding the medications patients are taking chronically (pharmacists), and possible low levels of health literacy (GPs). Taking into account the Aruban culture, pharmacists could ask extra questions during MRs, referring to lifestyle (high prevalence of obesity), readability of medication labels (limited literacy), and herbal product use (Latin American culture). GPs and medical specialists sometimes experience miscommunication regarding the prescription of medication, which means that pharmacists must carefully take into account possible duplicate medications or interactions.

The pharmacists' interventions after a Drug and Therapeutics Committee (DTC) establishment during the COVID-19 pandemic

Introduction

Healthcare systems in developing countries faced significant challenges during COVID-19, grappling with limited resources and staffing shortages. Assessment of the impact of pharmaceutical care expertise, particularly in critical care units during the pandemics, in developing countries remains poorly explored. The principal aim of our study was to assess the impact of the Drug and Therapeutics Committee (DTC), comprising clinical pharmacists, on the incidence, types, and severity of medication errors and associated costs in using COVID-19 medications, especially antibiotics.

Methods

An interventional pre-post study was carried out at a public isolation hospital in Egypt over 6 months.

Results

Out of 499 medication orders, 238 (47.7%) had medication errors, averaging 2.38 errors per patient. The most frequent were prescribing errors (44.9%), specifically incorrect drug choice (57.9%), excessive dosage (29.9%), treatment duplication (4.5%), inadequate dosage (4.5%), and overlooked indications (3.6%). Linezolid and Remdesivir were the most common medications associated with prescribing errors. Pharmacists intervened 315 times, primarily discontinuing medications, reducing doses, introducing new medications, and increasing doses. These actions led to statistically significant cost reductions (p < 0.05) and better clinical outcomes; improved oxygen saturation, decreased fever, stabilised respiratory rates, and normalised white blood cell counts. So, clinical pharmacist interventions made a notable clinical and economic difference (66.34% reduction of the expenses) in antibiotics usage specifically and other medications used in COVID-19 management during the pandemic.

Conclusion

Crucially, educational initiatives targeting clinical pharmacists can foster judicious prescribing habits.

Pharmacist-Led Medication Management in Acute Geriatric Medicine and Its Associations with Rehospitalizations: A Cohort Study

INTRODUCTION

Hospitalization and discharge in older patients are critical and clinical pharmacists have shown to ameliorate risks. Our objective was to assess their benefit as part of the geriatric team regarding rehospitalizations and related outcomes after discharge focusing on general practitioners' decision to continue or change discharge medication (GPD).

METHODS

Prospective implementation study with 6-month follow-up in an acute geriatric clinic. Patients ≥70 years with comorbidities, impairments, and a current drug therapy were consecutively assigned to three groups: control group (CG), implementation group (IG), and wash-out group (WG). CG only received medication reconciliation (MR) at admission; IG and their hospital physicians received a pharmaceutical counseling and medication management; during WG, pharmaceutical counseling except for MR was discontinued. We used a negative-binomial model to calculate rehospitalizations and days spent at home as well as a recurrent events survival model to investigate recurrent rehospitalizations.

RESULTS

One hundred thirty-two patients (mean age 82 years, 76 women [57.6%]) finished the project. In most of the models for rehospitalizations, a positive GPD led to fewer events. We also found an effect of pharmaceutical counseling on rehospitalizations and recurrent rehospitalizations in the CG versus WG but not in the CG versus IG models. 95.3% of medication recommendations by the pharmacist in the clinic setting were accepted. While the number of positive GPDs in CG was low (38%), pharmaceutical counseling directly to the GP in IG led to a higher number of positive GPDs (60%).

DISCUSSION

Although rehospitalizations were not directly reduced by our intervention in the CG versus IG, the pharmacist's acceptance rate in the hospital was very high and a positive GPD led to fewer rehospitalization in most models.

Introducing a pharmacist-led transmural care program to reduce drug-related problems in orthogeriatric patients: a prospective interventional study

BACKGROUND

Orthogeriatric patients have an increased risk for complications due to underlying comorbidities, chronic drug therapy and frequent treatment changes during hospitalization. The clinical pharmacist (CP) plays a key role in transmural communication concerning polypharmacy to improve continuity of care by the general practitioner (GP) after discharge. In this study, a pharmacist-led transmural care program, tailored to orthogeriatric patients, was evaluated to reduce drug related problems (DRPs) after discharge.

METHODS

An interventional study was performed (pre-period: 1/10/2021-31/12/2021; post-period: 1/01/2022-31/03/2022). Patients (≥ 65 years) from the orthopedic department were included. The pre-group received usual care, the post-group received the pharmacist-led transmural care program. The DRP reduction rate one month after discharge was calculated. Associated factors for the DRP reduction rate were determined in a multiple linear regression analysis. The GP acceptance rate was determined for the proposed interventions, as well as their clinical impact using the Clinical, Economic and Organizational (CLEO) tool. Readmissions one month after discharge were evaluated.

RESULTS

Overall, 127 patients were included (control n = 61, intervention n = 66). The DRP reduction rate was statistically significantly higher in the intervention group compared to the control group (p < 0.001). The pharmacist's intervention was associated with an increased DRP reduction rate (+ 1.750, 95% confidence interval 1.222-2.278). In total, 141 interventions were suggested by the CP, of which 71% were accepted one month after discharge. In both periods, four patients were readmitted one month after discharge. 58% of the interventions had a clinical impact (≥ 2 C level using the CLEO-tool) according to the geriatrician and for the CP it was 45%, indicating that they had the potential to avoid patient harm.

CONCLUSIONS

The pharmacist-led transmural care program significantly reduced DRPs in geriatric patients from the orthopedic department one month after discharge. The transmural communication with GPs resulted in a high acceptance rate of the proposed interventions.

Improving the impact of pharmacy interventions in hospitals

The clinical and pharmaceutical interventions of pharmacy professionals are considered impactful inputs towards optimised patient care and safety, by rationalising prescriptions, enhancing therapeutic choices and reducing and preventing medication errors and adverse effects. Pharmacy interventions (PIs), related to the identification, prevention and resolution of drug-related problems, should be recorded for optimal clinical governance and potential health outcomes.Between October 2020 and October 2021, the community hospitals at Powys Teaching Health Board recorded 158 PIs, corresponding to 0.4 interventions per staff per week. Only two members of the team were recording these PIs. Poor indicative PIs can result in lost opportunities for medication optimisation and prescribing rationalisation, increased costs and unidentified training potential.The aims of this project were (1) to record 180 interventions between 22 November 2021 and 8 April 2022 (20 weeks), corresponding to an average threefold increase, compared to the interventions recorded between October 2020 and October 2021 (52 weeks); (2) to have all hospital pharmacy staff recording at least one intervention during the same period.The number of interventions recorded and the number of pharmacy staff recording each intervention were two process measures. The project was completed through two Plan-Do-Study-Act cycles and applied theory on managing change in healthcare.The most successful intervention influencing positively the process measures was the implementation of a new Pharmacy Intervention Record Tool (xPIRT) toolkit that included an online recording tool (xPIRT) and an interactive panel with up-to-date results from all interventions recorded (xPIRT Dashboard). Motivating change was proven to be one of the best determinants of user satisfaction and engagement that contributed to meet the project's targets. xPIRT Dashboard provided staff the capacity to act on possible personal motivators and the possibility to improving care with medicines on their wards. The implementation of xPIRT toolkit was able to increase the representativity and significance of PIs recorded by the hospital pharmacy team, and it is expected to be used for personal professional development, demonstrating team activity and impact, service planning, prescribing practice optimisation and to identify education/training needs. This toolkit can be easily applied and adapted to other health organisations, settings and services.

Implementation of the standardized process of Pharmacotherapeutic evaluation in inpatients and outpatients

OBJECTIVES

The Pharmacotherapeutic follow-up program (PFU) carried out by the clinical pharmacist can be categorized within 3 fundamental activities; identification, resolution and prevention of adverse drug events. These must be adjusted to the requirements and resources of each institution, developing procedures to increase PFU efficiency and to guarantee patient safety. The clinical pharmacists of UC-CHRISTUS Healthcare Network developed a Standardized Pharmacotherapeutic Evaluation Process (SPEP). The main goal of our study is to evaluate the impact of this tool through the pharmacist evaluation number and pharmacist interventions number. Secondarily to determine the potential and direct cost savings associated with the pharmacist interventions in an Intensive care unit (ICU).

METHODS

A quasi-experimental study evaluated the frequency and type of pharmacist evaluation and pharmacist interventions performed by clinical pharmacists in adult patients units of UC-CHRISTUS Healthcare Network, before and after the implementation of SPEP. The distribution of variables was evaluated using the Shapiro-Wilk test and the association between the use of SPEP and the pharmacist evaluation and pharmacist interventions number was performed using the Chi-square test. The cost evaluation associated with pharmacist interventions in the ICU was carried out using methodology proposed by Hammond et al. RESULTS: A total number of 1,781 patients was evaluated before and 2,129 after the SPEP. The pharmacist evaluation and pharmacist interventions number in the before-SPEP period were 5,209 and 2,246. In the after-SPEP period were 6,105 and 2,641, respectively. The increase in both the pharmacist evaluation and pharmacist interventions number was significant only in critical care patients. The potential cost saving in after-SPEP period in the ICU was USD 492,805. Major adverse drug events prevention was the intervention that generated the most savings with a reduction of 60.2%. The total direct savings for sequential therapy was USD 8,072 in the study period.

CONCLUSIONS

This study shows a clinical pharmacist developed tool called SPEP that increased the pharmacist evaluation and pharmacist interventions number in multiple clinical scenarios. These were significant only in critical care patients. Future investigations should make effort to evaluate the quality and clinical impact of these interventions.

[Translated article] Implementation of the standardized process of drug therapy evaluation in inpatients and outpatients

OBJECTIVES

The Pharmacotherapeutic follow-up program (PFU) carried out by the clinical pharmacist can be categorized within 3 fundamental activities; identification, resolution and prevention of adverse drug events. These must be adjusted to the requirements and resources of each institution, developing procedures to increase PFU efficiency and to guarantee patient safety. The clinical pharmacists of UC-CHRISTUS Healthcare Network developed a Standardized Pharmacotherapeutic Evaluation Process (SPEP). The main goal of our study is to evaluate the impact of this tool through the pharmacist evaluation number and pharmacist interventions number. Secondarily to determine the potential and direct cost savings associated with the pharmacist interventions in an Intensive care unit (ICU).

METHODS

A quasi-experimental study evaluated the frequency and type of pharmacist evaluation and pharmacist interventions performed by clinical pharmacists in adult patients units of UC-CHRISTUS Healthcare Network, before and after the implementation of SPEP. The distribution of variables was evaluated using the Shapiro-Wilk test and the association between the use of SPEP and the pharmacist evaluation and pharmacist interventions number was performed using the Chi-square test. The cost evaluation associated with pharmacist interventions in the ICU was carried out using methodology proposed by Hammond et al. RESULTS: A total number of 1781 patients was evaluated before and 2129 after the SPEP. The pharmacist evaluation and pharmacist interventions number in the before-SPEP period were 5209 and 2246. In the after-SPEP period were 6105 and 2641, respectively. The increase in both the pharmacist evaluation and pharmacist interventions number was significant only in critical care patients. The potential cost saving in after-SPEP period in the ICU was USD 492,805. Major adverse drug events prevention was the intervention that generated the most savings with a reduction of 60.2%. The total direct savings for sequential therapy was USD 8072 in the study period.

CONCLUSIONS

This study shows a clinical pharmacist developed tool called SPEP that increased the pharmacist evaluation and pharmacist interventions number in multiple clinical scenarios. These were significant only in critical care patients. Future investigations should make effort to evaluate the quality and clinical impact of these interventions.

Clinical and economic impact of clinical oncology pharmacy in cancer patients receiving injectable anticancer treatments: a systematic review

PURPOSE

Clinical pharmacy can reduce drug-related iatrogenesis by improving the management of adverse effects of drugs, limiting drug-drug interactions, and improving patient adherence. Given the vulnerability of cancer patients and the toxicity of injectable anticancer drugs, clinical pharmacy service (CPS) could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on clinical pharmacy's impact on patients treated with intravenous anticancer drugs.

METHODS

A comprehensive search was performed in the PubMed/Medline database from January 2000 to December 2021, associating the keywords: clinical pharmacy, pharmaceutical care, pharmacist, oncology, and chemotherapy. To be eligible for inclusion, studies have to report clinical pharmaceutical services for patients treated with intravenous chemotherapy with a clinical and/or economic impact.

RESULTS

Forty-one studies met the selection criteria. Various CPS were reported: medication reconciliation, medication review, and pharmaceutical interview with patient. There was a lack of randomized study (n = 3; 7.3%). In one randomized controlled trial, pharmaceutical intervention significantly improved quality of life of patients receiving pharmaceutical care during injectable anticancer drugs courses. Economical results appear to show positive impact of clinical pharmacy with cost savings reported from 3112.87$ to 249 844€. Although most studies were non-comparative, they highlighted that clinical pharmacy tend to limit chemotherapy side effects and drug-related problems, improve quality of life and satisfaction of patients and healthcare professional, and a positive economic impact.

CONCLUSION

Clinical pharmacy can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness

Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.

The impact of a pharmacist intervention on post-discharge hypnotic drug discontinuation in geriatric inpatients: a before-after study

BACKGROUND

Chronic use of hypnotic agents is prevalent in older adults, who as a result are at increased risk for certain adverse events, such as day-time drowsiness and falls. Multiple strategies to discontinue hypnotics have been tested in geriatric patients, but evidence remains scarce. Hence, we aimed to investigate a multicomponent intervention to reduce hypnotic drug use in geriatric inpatients.

METHODS

A before-after study was performed on the acute geriatric wards of a teaching hospital. The before group (= control group) received usual care, while intervention patients (= intervention group) were exposed to a pharmacist-led deprescribing intervention, comprising education of health care personnel, access to standardized discontinuation regimens, patient education and support of transitional care. The primary outcome was hypnotic drug discontinuation at one month after discharge. Secondary outcomes among others were sleep quality and hypnotic use at one and two weeks after enrolment and at discharge. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) upon inclusion, two weeks after enrolment and one month after discharge. Determinants for the primary outcome were identified using regression analysis.

RESULTS

A total of 173 patients were enrolled, with 70.5% of patients taking benzodiazepines. Average age was 85 years (interquartile range 81-88.5) and 28.3% were male. A higher discontinuation rate at one month after discharge was observed in favour of the intervention (37.7% vs. 21.9%, p = 0.02281). No difference in sleep quality was found between both groups (p = 0.719). The average sleep quality was 8.74 (95% confidence interval (CI): 7.98-9.49) and 8.57 (95% CI: 7.75-9.39) in the control and intervention groups respectively. Determinants for discontinuation at one month were: the intervention (odds ratio (OR) 2.36, 95% CI: 1.14-4.99), fall on admission (OR 2.05; 95% CI: 0.95-4.43), use of a z-drug (OR 0.54, 95% CI: 0.23-1.22), PSQI score on admission (OR 1.08, 95% CI: 0.97-1.19) and discontinuation prior to discharge (OR 4.71, 95% CI: 2.26-10.17).

CONCLUSIONS

A pharmacist-led intervention in geriatric inpatients was associated with a reduction of hypnotic drug use one month after discharge, without any loss in sleep quality.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05521971 (retrospectively registered on 29^th of August 2022).

Effect of Pharmacist-Led Intervention in Elderly Patients through a Comprehensive Medication Reconciliation: A Randomized Clinical Trial

PURPOSE

Polypharmacy can cause drug-related problems, such as potentially inappropriate medication (PIM) use and medication regimen complexity in the elderly. This study aimed to investigate the feasibility and effectiveness of a collaborative medication review and comprehensive medication reconciliation intervention by a pharmacist and hospitalist for older patients.

MATERIALS AND METHODS

This comprehensive medication reconciliation study was designed as a prospective, open-label, randomized clinical trial with patients aged 65 years or older from July to December 2020. Comprehensive medication reconciliation comprised medication reviews based on the PIM criteria. The discharge of medication was simplified to reduce regimen complexity. The primary outcome was the difference in adverse drug events (ADEs) throughout hospitalization and 30 days after discharge. Changes in regimen complexity were evaluated using the Korean version of the medication regimen complexity index (MRCI-K).

RESULTS

Of the 32 patients, 34.4% (n=11/32) reported ADEs before discharge, and 19.2% (n=5/26) ADEs were reported at the 30-day phone call. No ADEs were reported in the intervention group, whereas five events were reported in the control group (p=0.039) on the 30-day phone call. The mean acceptance rate of medication reconciliation was 83%. The mean decreases of MRCI-K between at the admission and the discharge were 6.2 vs. 2.4, although it was not significant (p=0.159).

CONCLUSION

As a result, we identified the effect of pharmacist-led interventions using comprehensive medication reconciliation, including the criteria of the PIMs and the MRCI-K, and the differences in ADEs between the intervention and control groups at the 30-day follow-up after discharge in elderly patients.

TRIAL REGISTRATION

(Clinical trial number: KCT0005994).

Pharmacist-Driven Geriatric Medication Assessment at an Acute Care Teaching Hospital

Older patients are often prescribed many medications and are at higher risk for medication-related problems. Pharmacists can help to identify potentially inappropriate medication use that may precipitate adverse drug events resulting in mental status changes, falls, and hospitalization. A Pharmacist-Driven Geriatric Medication Assessment program was established by clinical pharmacists to evaluate medication use in older patients admitted to a pilot unit of an acute care hospital as part of an Age-Friendly Care initiative. This article describes the implementation of this program and the types of medication interventions pursued by the pharmacists. Pharmacist recommendation acceptance rate by the health care team was greater than 90% overall for medication reconciliation, potentially inappropriate medications, and other medication interventions.

Uptake of pharmacist recommendations by patients after discharge: Implementation study of a patient-centered medicines review service

BACKGROUND

Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process.

OBJECTIVES

To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers.

METHOD

An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge.

RESULTS

Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed.

CONCLUSION

Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12^th July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .

Age is just a number: the concept of time to benefit in older adults

A female nursing home resident aged >70 years was admitted to the geriatric ward with de novo dysphagia 6 days after being discharged from the stroke unit. Metformin and ezetimibe had been added to her treatment regimen which already consisted of clopidogrel, atorvastatin, denosumab, calcium and vitamin D. At the geriatric ward a multidisciplinary team involving clinical pharmacists reviewed all treatments and appraised the time to benefit, ascertaining whether there was sufficient time left to experience therapeutic benefits. As a result, metformin, ezetimibe, denosumab, calcium and vitamin D were discontinued. This case report illustrates that both mortality risk assessment and evaluation of the time to benefit should be part of any medication review in frail older adults. Conversely, with limited available data pertaining to the concept of time to benefit, we advocate a broader awareness among pharmacists and a systematic assessment in future clinical trials.

Using xPIRT to Record Pharmacy Interventions: An Observational, Cross-Sectional and Retrospective Study

Medication errors and omissions can potentially cause harm, prolong a hospital stay, lead to co-morbidities and even death. Pharmacy interventions (PI) ensure that these errors are identified and addressed, leading to improved patient safety and prescriber practice. Particularly in community hospitals, many only having general practitioners and not specialist doctors in their medical teams, PIs assume a strategic role. The PIs recorded throughout 8 months (between November 2021 and June 2022) in the community hospital wards in Powys, Wales, UK, using xPIRT (Pharmacy Intervention Recording Tool), a new pharmacy intervention record toolkit, were subjected to a retrospective analysis. The data were organised by location, drug, severity, acceptance, cost avoidance and intervention type. Significant prescribing errors were identified, which can potentially be different from those recorded in acute settings. Our results also informed on the need for integrated electronic prescribing systems paired with a PI recording tool to address effectively prescribing inaccuracies. Overall, this study was able to identify pharmacy teams as key to improve patient safety and care while contributing to significant cost-savings, through the recording of PI using xPIRT.

Consensus validation of a screening tool for cardiovascular pharmacotherapy in geriatric patients: the RASP_CARDIO list (Rationalization of Home Medication by an Adjusted STOPP list in Older Patients)

PURPOSE

Cardiovascular agents commonly used in geriatric patients, are linked to potentially avoidable harm and might hence be a suitable substrate for medication review practices. Therefore, we sought to update and validate the content of the cardiovascular segment of the previously published Rationalization of Home Medication by an Adjusted STOPP list in Older Patients (RASP) List.

METHODS

A three-step study was conducted by the pharmacy department in collaboration with the geriatric medicine and cardiology department at the University Hospitals Leuven, Belgium. First, the cardiovascular segment of the RASP list version 2014 was updated taking into account published research, other screening tools and the input of end-users. Secondly, this draft was reviewed during three panel discussions with five expert cardiologists and three clinical pharmacists, all of whom had relevant expertise in geriatric pharmacotherapy. Thirdly, the content was validated using a modified Delphi Technique by a panel of European hospital pharmacists, cardiologists, geriatricians and an internal medicine physician.

RESULTS

After the first and second step, the RASP_CARDIO list comprised 94 statements. Consensus (≥ 80% agreement) of all statements and one new statement about gliflozins in heart failure was achieved by a panel of seventeen experts across four European countries after two validation rounds. The final construct comprised a list of 95 statements related to potentially inappropriate prescribing of cardiovascular agents.

CONCLUSION

The RASP_CARDIO list is an updated and validated explicit screening tool to optimize cardiovascular pharmacotherapy in geriatric patients.

Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (The IMMENSE study) - a randomized controlled trial

Background

Suboptimal medication use contributes to a substantial proportion of hospitalizations and emergency department visits in older adults. We designed a clinical pharmacist intervention to optimize medication therapy in older hospitalized patients. Based on the integrated medicine management (IMM) model, the 5-step IMMENSE intervention comprise medication reconciliation, medication review, reconciled medication list upon discharge, patient counselling, and post discharge communication with primary care. The objective of this study was to evaluate the effects of the intervention on healthcare use and mortality.

Methods

A non-blinded parallel group randomized controlled trial was conducted in two internal medicine wards at the University Hospital of North Norway. Acutely admitted patients ≥ 70 years were randomized 1:1 to intervention or standard care (control). The primary outcome was the rate of emergency medical visits (readmissions and emergency department visits) 12 months after discharge.

Results

Of the 1510 patients assessed for eligibility, 662 patients were asked to participate, and 516 were enrolled. After withdrawal of consent and deaths in hospital, the modified intention-to-treat population comprised 480 patients with a mean age of 83.1 years (SD: 6.3); 244 intervention patients and 236 control patients. The number of emergency medical visits in the intervention and control group was 497 and 499, respectively, and no statistically significant difference was observed in rate of the primary outcome between the groups [adjusted incidence rate ratio of 1.02 (95% CI: 0.82–1.27)]. No statistically significant differences between groups were observed for any of the secondary outcomes, neither in subgroups, nor for the per-protocol population.

Conclusions

We did not observe any statistical significant effects of the IMMENSE intervention on the rate of emergency medical visits or any other secondary outcomes after 12 months in hospitalized older adults included in this study.

Trial registration

The trial was registered in clinicaltrials.gov on 28/06/2016, before enrolment started (NCT02816086).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08648-1.

Patient satisfaction with inpatient pharmacy services at tertiary care setting—a meta-analysis of recent literature

Objectives

This study aimed to determine patient satisfaction with the following pharmacist-led services for inpatients in tertiary care hospitals.

Methods

Studies were identified from different databases from 2012 to 2020. A total of 1910 articles were identified using the search strategies out of which 1153 were rejected based on the review of titles and abstracts. The search criteria were the roles of inpatient pharmacists and patient satisfaction with inpatient pharmacy services. Multiple keywords were used such as ‘patient satisfaction’/‘inpatient pharmacist’/‘pharmacist hospital services’/‘clinical pharmacist roles’. The quality of each study was measured using the mixed methods appraisal tool, and the same was used to evaluate the risk of bias as well.

Key findings

A total of 11 cross-sectional studies were included in the evidence synthesis of this meta-analysis. Three studies tested the satisfaction of patients with inpatient counselling with a sample size of n = 742. The odd ratio (OR) was 215.33 (141.77 to 327.05) [95% confidence interval (CI)] showed a significant patient satisfaction (P = 0.00001) with the pharmacist’s inpatient counselling (I2 = 0%). Studies showed a statistically significant satisfaction of patients with discharge counselling P &lt; 0.00001 and OR 55.74 (35.93 to 86.49) and heterogeneity I2 = 0%. In a total of five studies, the healthcare professional (HCP) satisfaction with pharmacist services was reported, and satisfied and unsatisfied HCPs were n = 801 and n = 362, respectively. Results showed high satisfaction (P &lt; 0.00001) and OR 4.62 (95% CI, 3.89 to 5.48).

Conclusion

This meta-analysis concluded that clinical pharmacist services in an inpatient setting have a significant impact on increasing patient satisfaction with their treatment. The clinical pharmacist services are not very well implemented and are limited in some hospitals, but patients who have received these services were highly satisfied and expected to receive them more often.

Optimizing pharmacotherapy on geriatric hospital units in Belgium - a national survey

OBJECTIVE

Inappropriate prescribing remains highly prevalent on geriatric units. The aim of this investigation, initiated by the Belgian College for Geriatrics, was to evaluate the implementation of strategies to optimize pharmacotherapy on geriatric units in Belgium.

METHODS

A literature search was performed to identify strategies to support the appropriate use of medications in very old inpatients. These strategies were subsequently validated based on Delphi consensus rounds and a national survey was developed. Experts were selected by the research team in collaboration with the Belgian College for Geriatrics. The survey was sent to the heads of the geriatric departments of all Belgian hospitals (n = 100).

RESULTS

After 3 months a response rate of 55% was achieved. Strategies that were implemented more frequently were the use of electronic prescribing (85%), performing a structured medication review (69%) and providing patient education (76%). In a minority (24%) of hospitals, a clinical pharmacist was directly involved in the multidisciplinary geriatric team. Implementation of clinical decisions support systems (CDSS) was reported by 36% of the hospitals. Educational strategies for healthcare professionals and strategies to optimize transitional care were variable.

CONCLUSION

Taking into account the current body of evidence, strategies that include transitional care components, CDSS or ward-based clinical pharmacy services should be further promoted on Belgian geriatric units.

SGLT2 Inhibitors in Older Adults with Heart Failure with Preserved Ejection Fraction

Heart failure is an important medical condition that is prevalent in older adults. Multiple therapies have been identified that improve clinical outcome in heart failure with a reduced ejection fraction. Conversely, this has not been the case in heart failure with preserved ejection fraction (HFpEF). Until now, empagliflozin is the first therapy that has convincingly been shown to improve clinical outcome in HFpEF. Importantly, some key points should be considered to better understand the impact of empagliflozin on the patient trajectory, particularly in older adults with HFpEF. In this current opinion article, we have therefore provided more information on how to translate the findings of the EMPEROR-Preserved trial to the setting of older adults, with a focus on the impact of empagliflozin on hospitalizations, both heart failure-related and all-cause. To better understand the importance of EMPEROR-Preserved findings, we compared these findings with previous relevant HFpEF and heart failure with reduced ejection fraction (HFrEF) trials and provided information on ongoing trials in the HFpEF setting.

Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist-led interdisciplinary intervention to improve medication safety in older hospitalized patients

WHAT IS KNOWN AND OBJECTIVE

The majority of hospitalized older patients experience medication-related problems (MRPs), and there is a call for interventions to solve MRPs and improve clinical outcomes like medical visits. The IMMENSE study is a randomized controlled trial investigating the impact of a pharmacist-led interdisciplinary intervention on emergency medical visits. Its multistep intervention is based on the integrated medicines management methodology and includes a follow-up step with primary care. This study aims to describe how the intervention in the IMMENSE study was delivered and its process outcomes.

METHODS

The study includes the 221 intervention patients in the per-protocol group of the IMMENSE study. Both intervention delivery, reasons for not performing interventions and process outcomes were registered daily by the study pharmacists in a Microsoft Access^® database. Process outcomes were medication discrepancies, MRPs and how the team solved these.

RESULTS AND DISCUSSION

A total of 121 (54.8%) patients received all intervention steps if appropriate. All patients received medication reconciliation (MedRec) and medication Review (MedRev) (step 1 and 2), while between 10% and 20% of patients were missed for medication list in discharge summary (step 3), patient counselling (step 4), or communication with general practitioner and nurse (step 5). A total of 437 discrepancies were identified in 159 (71.9%) patients during MedRec, and 1042 MRPs were identified in 209 (94.6%) patients during MedRev. Of these, 292 (66.8%) and 700 (67.2%), respectively, were communicated to and solved by the interdisciplinary team during the hospital stay.

WHAT IS NEW AND CONCLUSION

The fidelity of the single steps of the intervention was high even though only about half of the patients received all intervention steps. The impact of the intervention may be influenced by not implementing all steps in all patients, but the many discrepancies and MRPs identified and solved for the patients could explain a potential effect of the IMMENSE study.

Contextualising the Perceptions of Pharmacists Practicing Clinical Pharmacy in South Africa-Do We Practice what We Preach?

The National Department of Health published their Quality Standards for Healthcare Establishments in South Africa and introduced the National Health Insurance, with the pilot phase that commenced in 2012. The system requires an adequate supply of pharmaceutical personnel and the direct involvement of clinical pharmacists throughout the medication-use process to ensure continuity of care, minimised risk with increasing improvement of patient outcomes. The study aimed to provide insight into the pressing issues of clinical pharmacy practice in South Africa, and sets out to contextualise the current profile of the pharmacist performing clinical functions. The study used a quantitative, explorative, cross-sectional design. The population included pharmacists from private and public tertiary hospitals. A questionnaire was administered, using Typeform™. Ethics approval was obtained from Sefako Makgatho Health Sciences University, National Department of Health and Private Healthcare groups. Categorical data were summarised using frequency counts and percentages; continuous data were summarised by mean values and standard deviations. The sample size included 70 pharmacists practicing clinical pharmacy (private sector n = 59; public sector n = 11). Most participants hold a BPharm degree (busy with MPharm qualification) (64%; n = 70). No statistical significance was found between participants in private and public practice. Most pharmacist agreed (32% (private); n = 59) and strongly agreed (45% (public); n = 11) to have sufficient training to perform pharmaceutical care. The majority respondents felt that interventions made by the pharmacist improved the rational use of medicine (47% (private); 55% (public). Pharmacist interventions influence prescribing patterns (42% (private); 64% (public); and reduce polypharmacy (41% (private); 55% (public). The clinical functions mostly performed were evaluation of prescriptions (private 90%; public 82%), while the top logistical function is daily ordering of medication (40.7%; private), and checking of ward stock (36%; public). Although not all pharmacists appointed in South Africa has completed the MPharm degree in clinical pharmacy, the pharmacists at ward level perform numerous clinical functions, even if only for a small part of their workday. This paper sets the way to standardise practices of clinical pharmacy in South Africa, with a reflection on the differences in practice in different institutions.

Interventions to improve medicines optimisation in frail older patients in secondary and acute care settings: a systematic review of randomised controlled trials and non-randomised studies

Background: Frailty is a geriatric syndrome in which physiological systems have decreased reserve and resistance against stressors. Frailty is associated with polypharmacy, inappropriate prescribing and unfavourable clinical outcomes. Aim: To identify and evaluate randomised controlled trials (RCTs) and non-randomised studies of interventions designed to optimise the medications of frail older patients, aged 65 years and over, in secondary or acute care settings. Method: Literature searches were conducted across seven electronic databases and three trial registries from the date of inception to October 2021. All types of interventional studies were included. Study selection, data extraction, risk of bias and quality assessment were conducted by two independent reviewers. Results: Three RCTs were eligible for inclusion; two employed deprescribing as the intervention, and one used comprehensive geriatric assessment. All reported significant improvements in prescribing appropriateness. One study investigated the effect of the intervention on clinical outcomes including hospital presentations, falls, fracture, quality of life and mortality, and reported no significant differences in these outcomes, but did report a significant reduction in monthly medication cost. Two of the included studies were assessed as having ‘some concerns’ of bias, and one was judged to be at ‘high risk’ of bias. Conclusion: This systematic review demonstrates that medicines optimisation interventions may improve medication appropriateness in frail older inpatients. However, it highlights the paucity of high-quality evidence that examines the impact of medicines optimisation on quality of prescribing and clinical outcomes for frail older inpatients. High-quality studies are needed to address this gap.

Effects of hospital pharmacist interventions on health outcomes in older polymedicated inpatients: a scoping review

PURPOSE

To identify the evidence that supports the effect of interventions made by hospital pharmacists, individually or in collaboration with a multidisciplinary team, in terms of healthcare outcomes, a more effective utilization of resources and lower costs in older polymedicated inpatients.

METHODS

We searched the following databases: MEDLINE, EMBASE and the Cochrane Library. We also conducted a hand search by checking the references cited in the primary studies and studies included in reviews identified during the process of research. Four review authors working by pairs searched for studies, extracted data, and drew up the results tables.

RESULTS

Twenty-six studies were included in the review. In 13 of them pharmacists carried out their intervention exclusively while the patients were in hospital, whereas in 13 interventions were delivered during admission and after hospital discharge. Outcomes identified were mortality, length of stay, visits to the emergency department, readmissions and reported quality of life, among others. Pharmacist interventions were found to be beneficial in fifteen studies, specifically on hospital readmissions, visits to the emergency department and healthcare costs.

CONCLUSION

There is no hard evidence demonstrating the effectiveness of hospital pharmacist interventions in older polymedicated patients. Mortality does not show as a relevant outcome. Other health care outcomes, such as hospital readmissions, visits to the emergency department and healthcare costs, seem to be more relevant and amenable to change. Interventions that include pharmacists in multidisciplinary geriatric teams seem to be more promising that isolated pharmacist interventions. Interventions prolonged after hospital discharge seem to be more appropriate that interventions delivered only during hospital admission. Better-designed studies should be conducted in the future to provide further insight into the effect of hospital pharmacist interventions.

Polypharmacy and excessive polypharmacy in community-dwelling middle aged and aged adults between 2011 and 2015

AIMS

We aimed to assess the prevalence, components and evolution of polypharmacy and to evaluate risk factors associated with polypharmacy.

METHODS

A retrospective dynamic cohort study was performed, using a primary healthcare database comprising Flemish community-dwelling adults aged ≥40 years between 2011 and 2015. Polypharmacy and excessive polypharmacy were defined as the use of 5-9 or minimum 10 different medications during 1 year, respectively. Temporal changes were analysed using an autoregressive error model. Risk factors for polypharmacy were evaluated using logistic regression.

RESULTS

In total, 68 426 patients were included in the analysis. The prevalence of polypharmacy was 29.5% and 16.1% for excessive polypharmacy in 2015. The age-standardised prevalence rate of patients using minimum five medications increased with 1.3% per year (95% confidence interval (CI): 0.1968-2.4279). The mean number of unplanned hospital admissions was 0.07 (standard deviation (SD) 0.33) for polypharmacy patients and 0.19 (SD 0.53) for excessive polypharmacy patients. Four risk factors were found to be significantly correlated with polypharmacy: age (odds ratio (OR) 1.015; 95% CI: 1.013-1.017), female gender (OR 1.161; 95% CI: 1.108-1.216), number of chronic diseases (OR 1.126; 95% CI: 1.114-1.139) and number of general practitioner contacts (OR 1.283; 95% CI: 1.274-1.292).

CONCLUSION

The prevalence of polypharmacy increased between 2011 and 2015. Polypharmacy and excessive polypharmacy patients appeared to differ based on our observations of characteristics, drug therapy and outcomes. Age, female gender, number of chronic diseases and number of general practitioner contacts were associated with polypharmacy.

Mapping of drug-related problems among older adults conciliating medical and pharmaceutical approaches

PURPOSE

To lay the fundamentals of drug-related problems (DRPs) in older adults, and to organize them according to a logical process conciliating medical and pharmaceutical approaches, to better identify the causes and consequences of DRPs.

MATERIALS AND METHODS

A narrative overview.

RESULTS

The causes of DRPs may be intentional or unintentional. They lie in poor prescription, poor adherence, medication errors (MEs) and substance use disorders (SUD). Poor prescription encompasses sub-optimal or off-label drug choice; this choice is either intentional or unintentional, often within a polypharmacy context and not taking sufficiently into account the patient's clinical condition. Poor adherence is often the consequence of a complicated administration schedule. This review shows that MEs are not the most frequent causes of DRPs. SUD are little studied in older adults and needs to be more investigated because the use of psychoactive substances among older people is frequent. Prescribers, pharmacists, nurses, patients, and caregivers all play a role in different causes of DRPs. The potential deleterious outcomes of DRPs result from adverse drug reactions and therapeutic failures. These can lead to a negative benefit-risk ratio for a given treatment regimen.

DISCUSSION/CONCLUSION

Interdisciplinary pharmacotherapy programs show significant clinical impacts in preventing or resolving adverse drug events and, suboptimal responses. New technologies also seem to be interesting solutions to prevent MEs. Better communication between healthcare professionals, patients and their caregivers would ensure greater safety and effectiveness of treatments.

Impact of pharmacist interventions during transition of care in older adults to reduce the use of healthcare services: A scoping review

BACKGROUND

Current literature has shown increasing risk of error in transition of care between different healthcare settings, especially in the older population. Moreover, drug-related hospital readmission has been reported due to lack of appropriate communication. However, the literature is not clear about the impact of pharmacist interventions during transition of care of older adults on the reduction in use of healthcare services.

OBJECTIVE

The goal of the scoping review was to describe the impact of pharmacist interventions during transitions of care for older adults on the use of healthcare services.

METHODS

MEDLINE was searched for randomized controlled trials and controlled studies that analyzed pharmacist interventions during transition of care of older adults with regard to use of healthcare services. Four reviewers, grouped in pairs, independently screened all references published from 1990 to 2019 and extracted and analyzed the data. A pharmaceutical model of 8 pharmacist-led interventions was adapted from literature to compare the included studies.

RESULTS

There were 1527 publications screened, 17 of which met inclusion criteria. Pharmacist-led interventions decreased the use of healthcare services in 11 of these studies. The majority of studies were of very good or good quality based on Mixed Methods Appraisal Tool. Pharmacist were implicated at all times during the transition of care process (i.e. admission/during stay, discharge and post-discharge) in 4 of the effective studies, whereas none did in the not effective studies. More interventions were accomplished by pharmacists in studies with positive outcomes.

CONCLUSION

By diversifying their interventions at different moments throughout transition of care, pharmacists can reduce the use of healthcare services for older adults during transition of care. This scoping review also shows the need to better understand key components of post-discharge interventions and to have a dynamic pharmaceutical model accepted by the scientific community.

Clinical pharmacy services in Brazil, particularly cardiometabolic diseases: a systematic scoping review and meta-analyses

OBJECTIVE

To map the clinical pharmacy services conducted in Brazil, their characteristics, outcomes, and process measures in general population, as well as the assessment of the clinical impact on people with cardiometabolic diseases (cardiovascular diseases and metabolic diseases).

METHODS

A systematic scoping review and meta-analysis were conducted. The electronic searches were re-run in March 2020. To the clinical impact assessment, meta-analyses of cardiometabolic outcomes (i.e., change of systolic (SBP) and diastolic blood pressure (DBP), triglycerides, total cholesterol, glycated hemoglobin (HbA1c), fasting glycemia, LDL-, and HDL-cholesterol) were led. The risk of bias was assessed with the Cochrane Collaboration tools.

RESULTS

71 studies were identified (7,402 patients), being the majority quasi-experimental studies (n=41) and published by research groups of Southeast Brazil (n=33). Medication therapy management (n=62) was the most frequent clinical pharmacy service, performed on outpatient setting (n=45), with adults or elderly people (n=58) with hypertension (n=18) or diabetes (n=10). Process measures (n=58) (e.g. resolution of drug related-problem) were widely used as indicator, followed by clinical (n=44) (e.g. change in SBP), humanistic (n=12) (e.g. change in quality-of-life score assessed by Short-Form 36 Health Survey Questionnaire), and economic outcomes (n=3) (incremental cost-effectiveness ratio for reduction in HbA1c). Regarding the assessment of clinical impact of the services, 20 studies were included in meta-analyses, showing improvement in most cardiometabolic outcomes when considered individual studies. However, the evidence presents high risk of bias, high heterogeneity (median 67-90%) and imprecision, contributing to wide prediction intervals and low reliability.

CONCLUSIONS

A predominance of studies on cardiometabolic diseases, process measures, and clinical outcomes were identified. Considering the assessment of the clinical impact of clinical pharmacy services in cardiometabolic diseases, an improvement in most cardiometabolic outcomes was showed, however, with low confidence and wide prediction interval. Therefore, development of larger studies with low risk of bias and major homogeneity is necessary for a better comprehension of clinical pharmacy service characteristics, benefits, and the population groups most benefited.