Multifaceted Pharmacist-led Interventions in the Hospital Setting: A Systematic Review

Development of an innovative clinical pharmacy service in a urology surgical unit: a new initiative from Qatar

Purpose

To provide an insight into the role of a clinical pharmacy initiative in a surgical urology unit through evaluating the nature, significance, associated medications, and acceptance rate of pharmacist interventions.

Methods

A cross-sectional study was carried out at the Ambulatory Care Center (ACC), Doha, Qatar. Data related to clinical pharmacist interventions and associated rationale were classified according to the nature of the intervention using an adapted classification system. The assessment of the severity followed the National Patient Safety Agency (NPSA) Risk Matrix. Linear regression, Kruskal-Wallis, and post-hoc analyses were performed to determine the association between patient-related and medication-related characteristics on pharmacist interventions.

Results

A total of 3284 interventions (on 1486 patients) were analysed. Most patients (n = 1105; 74.4%) had 1-2 interventions. Age and gender showed a positive linear correlation with the number of interventions per patient (p < 0.01). Majority of interventions were related to pharmacological strategy (n = 1858; 56.6%) and quantity of drug (n = 821; 25%). Additional drug therapy (n = 748; 22.78%) was the most common subcategory followed by optimum dose/frequency (n = 691; 21.04%) and discontinuation of medications (n = 352, 10.72%). Anti-infectives were the most identified drug category (n = 798, 55.1%). Most interventions (59.4%) were of moderate significance; patients with moderate interventions were found to be older compared to patients with minor interventions (p = 0.032). Prescribers' acceptance rate was high (>90%), with a notable increase of 6.6% from 2021 to 2023.

Conclusion

This study showed that the clinical pharmacy service in the urology surgical field was a fruitful initiative. The clinical pharmacist's role has expanded to include not only therapeutic optimisation while ensuring medication safety across the continuum of perioperative care but also the identification and management of untreated health problems. The dynamic and complexity of the urology patient population challenge clinical pharmacists; however, the practice concepts remain the same as in any other clinical setting.

[INTERPOLAR-prospective, interventional studies as part of the Medical Informatics Initiative to improve medication therapy safety in healthcare]

Medication analyses by ward pharmacists are an important measure of drug therapy safety (DTS). Medication-related problems (MRPs) are identified and resolved with the attending clinicians. However, staff resources for extended medication analyses and complete documentation are often limited. Until now, data required for the identification of risk patients and for an extended medication analysis often had to be collected from various parts of the institution's internal electronic medical record (EMR). This error-prone and time-consuming process is to be improved in the INTERPOLAR (INTERventional POLypharmacy-Drug interActions-Risks) project using an IT tool provided by the data integration centers (DIC).INTERPOLAR is a use case of the Medical Informatics Initiative (MII) that focuses on the topic of DTS. The planning phase took place in 2023, with routine implementation planned from 2024. DTS-relevant data from the EMR is to be presented and the documentation of MRPs in routine care is to be facilitated. The prospective multicenter, cluster-randomized INTERPOLAR‑1 study serves to evaluate the benefits of IT support in routine care. The aim is to show that more MRPs can be detected and resolved with the help of IT support. For this purpose, six normal wards will be selected at each of eight university hospitals, so that 48 clusters (with a total of at least 70,000 cases) are available for randomization.

Multifaceted pharmacist-led interventions in secondary care settings between countries of various income levels: a scoping review protocol

INTRODUCTION

Clinical pharmacy services often involve multifaceted pharmacist-led interventions. However, current pharmacy practice models vary across different countries. Despite the documented benefits of clinical pharmacy services, the characteristics of pharmacist-led interventions in different countries have not yet been adequately explored and described. Therefore, this protocol outlines the methodology for a proposed scoping review aiming to investigate various types of multifaceted pharmacist-led interventions and the outcomes used to evaluate their effectiveness within secondary care settings. Additionally, the scoping review will map the current evidence surrounding the characteristics of interventions and outcomes reported across various countries of socioeconomic status.

METHODS AND ANALYSIS

The scoping review will be conducted according to the JBI Methodology for Scoping Reviews and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews. We will systematically search the following electronic databases: MEDLINE (Ovid), CINAHL (EbscoHost), Embase (embase.com), Scopus (scopus.com), Cochrane Library (cochranelibrary.com) and APA PsycInfo (Ovid). Additionally, the reference lists of identified reviews and included full texts will be searched for relevant papers. Grey literature sources, such as International Pharmaceutical Abstracts and the International Pharmaceutical Federation (FIP) website, will be searched. We will include primary studies published in the English language from January 2013 to December 2023, involving secondary care multifaceted pharmacist-led interventions. Two independent reviewers will screen studies against eligibility criteria and use a piloted data extraction form to extract relevant information. We will extract relevant data, complete a tabular summary from each included publication and analyse it.

ETHICS AND DISSEMINATION

Ethical approval is not required as we will be using data from publicly available literature sources. Findings will be disseminated in publications and presentations with relevant stakeholders. We aim to map available evidence across the breadth of studies that have reported multifaceted pharmacist-led interventions and their outcomes.

Quality indicators of hospitalized children influenced by clinical pharmacist services: A systematic review

BACKGROUND

Care for children who are hospitalized can be optimized if the pharmacist, in conjunction with the multidisciplinary team, promotes the rational use of medicines. In this sense, the evaluation of the quality of these clinical services through indicators is important in the planning, decision making of pharmacists and managers of these services.

OBJECTIVE

To characterize which health indicators were influenced by the pharmaceutical clinical services for the care of children in hospitals.

METHODS

A systematic review was performed. The search for data was made on the bases: Cochrane, Embase, Lilacs, Pubmed and Web of Science. Then, the search included studies in which evaluated the impact of pharmaceutical clinical services on clinical, economic and humanistic outcomes.

RESULTS

The search resulted in 11 included studies. In this review, four pharmaceutical clinical services were found: pharmacotherapy review, multiprofessional team interventions, antimicrobial stewardship program and pharmaceutical services at discharge hospital. The most influenced outcome indicators were length of hospital stay, with average time in the group that received the pharmacotherapy review service, and interventions multiprofessional team with a 6.45-day vs. 10.83 days in the control group; hospital readmissions with a significant reduction of non-scheduled readmission of 30 days in the ntimicrobial stewardship program; reduction of hospital costs and caregiver satisfaction.

CONCLUSION

In this study, we can highlight that pharmacotherapy review, multiprofessional team interventions and Antimicrobial Stewardship Program that significantly reduced the clinical results of length of hospital stay and hospital readmission, as well as a significant reduction of hospital costs.

Detection of Drug-Related Problems through a Clinical Decision Support System Used by a Clinical Pharmacy Team

Clinical decision support systems (CDSSs) are intended to detect drug-related problems in real time and might be of value in healthcare institutions with a clinical pharmacy team. The objective was to report the detection of drug-related problems through a CDSS used by an existing clinical pharmacy team over 22 months. It was a retrospective single-center study. A CDSS was integrated in the clinical pharmacy team in July 2019. The investigating clinical pharmacists evaluated the pharmaceutical relevance and physician acceptance rates for critical alerts (i.e., alerts for drug-related problems arising during on-call periods) and noncritical alerts (i.e., prevention alerts arising during the pharmacist’s normal work day) from the CDSS. Of the 3612 alerts triggered, 1554 (43.0%) were critical, and 594 of these 1554 (38.2%) prompted a pharmacist intervention. Of the 2058 (57.0%) noncritical alerts, 475 of these 2058 (23.1%) prompted a pharmacist intervention. About two-thirds of the total pharmacist interventions (PI) were accepted by physicians; the proportion was 71.2% for critical alerts (i.e., 19 critical alerts per month vs. 12.5 noncritical alerts per month). Some alerts were pharmaceutically irrelevant—mainly due to poor performance by the CDSS. Our results suggest that a CDSS is a useful decision-support tool for a hospital pharmacist’s clinical practice. It can help to prioritize drug-related problems by distinguishing critical and noncritical alerts. However, building an appropriate organizational structure around the CDSS is important for correct operation.

The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy: a systematic review

BACKGROUND

Polypharmacy and associated potentially inappropriate prescribing (PIP) place a considerable burden on patients and represent a challenge for general practitioners (GPs). Integration of pharmacists within general practice (herein 'pharmacist integration') may improve medications management and patient outcomes. This systematic review assessed the effectiveness and costs of pharmacist integration.

METHODS

A systematic search of ten databases from inception to January 2021 was conducted. Studies that evaluated the effectiveness or cost of pharmacist integration were included. Eligible interventions were those that targeted medications optimization compared to usual GP care without pharmacist integration (herein 'usual care'). Primary outcomes were PIP (as measured by PIP screening tools) and number of prescribed medications. Secondary outcomes included health-related quality of life, health service utilization, clinical outcomes, and costs. Randomised controlled trials (RCTs), non-RCTs, interrupted-time-series, controlled before-after trials and health-economic studies were included. Screening and risk of bias using Cochrane EPOC criteria were conducted by two reviewers independently. A narrative synthesis and meta-analysis of outcomes where possible, were conducted; the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

In total, 23 studies (28 full text articles) met the inclusion criteria. In ten of 11 studies, pharmacist integration probably reduced PIP in comparison to usual care (moderate certainty evidence). A meta-analysis of number of medications in seven studies reported a mean difference of -0.80 [-1.17, -0.43], which indicated pharmacist integration probably reduced number of medicines (moderate certainty evidence). It was uncertain whether pharmacist integration improved health-related quality of life because the certainty of evidence was very low. Twelve health-economic studies were included; three investigated cost effectiveness. The outcome measured differed across studies limiting comparisons and making it difficult to make conclusions on cost effectiveness.

CONCLUSIONS

Pharmacist integration probably reduced PIP and number of medications however, there was no clear effect on other patient outcomes; and while interventions in a small number of studies appeared to be cost-effective, further robust, well-designed cluster RCTs with economic evaluations are required to determine cost-effectiveness of pharmacist integration.

TRIAL REGISTRATION

CRD42019139679.

Effect of pharmacist intervention on antibiotic prophylaxis in orthopedic internal fixation: A retrospective study

BACKGROUND

Despite the availability of guidelines and official policies, antibiotic prophylaxis in clean surgery remains suboptimal.

OBJECTIVE

The aim of this study was to evaluate the clinical effects and cost-effectiveness of pharmacist-led intervention in the perioperative anti-infection prophylaxis of patients undergoing orthopedic internal fixation.

METHODS

We performed a retrospective analysis based on the medical records of internal fixation surgery in a tertiary hospital from July 2019 to June 2020. Data were divided into two groups based on whether a full-time pharmacist participated in the treatment. The research parameters included use of antibiotics, rationality of medication, postoperative complications, and related cost. To deal with selection bias, propensity score matching method was employed at a ratio of 1:1. Meanwhile, a cost-effectiveness analysis was used to evaluate the impact of pharmacist intervention on antibiotic prevention in internal fixation surgery.

RESULTS

A total of 537 participants were included in this study. After matching, 236 patients were comparable in each group. During the pharmacist intervention period, less pharmacologic prophylaxis (96.6% vs 100.0%, p = 0.007) and shorter prophylaxis duration (1.60 vs 2.28 days, p < 0.001) were observed. The reasonable rate increased dramatically in usage and dosage (96.6% vs 83.9%, p < 0.001), timing of administration (94.5% vs 78.4%, p < 0.001) and medication duration (64.4% vs 37.7%, p < 0.001). In addition, pharmacist intervention yielded net economic benefits. A remarkable reduction was observed in average length of stay (10.43 vs 11.14 days, p = 0.012), drug cost ($610.57 vs $706.60, p = 0.001) and defined daily doses (2.31 vs 3.27, p < 0.001). The cost-effectiveness ratios, divided drug cost savings by cost of pharmacist time, were 28:1 for drug and 2:1 for antibiotics, respectively.

CONCLUSION

Pharmacist-driven antibiotic stewardship for orthopedic internal fixation patients improved compliance with peri-procedure antibiotic prophylaxis, and reduced the cost and utilization of antibiotics. This helped to bring significant clinical and economic benefits.

Developing a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients: A collaboration between hospital and community pharmacists

Background

Patients who transfer from the hospital back to the community are at risk of experiencing problems related to their medications. Hospital pharmacists (HPs) and community pharmacists (CPs) may play an important role and provide transitional pharmaceutical care in transition of care interventions.

Objective

To describe how a pharmacist-led intervention to provide transitional pharmaceutical care for hospital discharged patients was developed, utilizing already existing pharmacist interventions in the hospital and community pharmacy.

Methods

A mixed-method approach to intervention development was applied. Existing evidence was identified through a literature review of effective transitional care interventions and existing services in the hospital and community pharmacy. Focus group interviews and a workshop were carried out with HPs and CPs to identify their perceived facilitators and uncertainties in relation to intervention development. The final intervention and the expected outcomes were developed in an expert group workshop. Finally, the hospital part of the intervention was tested in a small-scale feasibility study to assess what type of information the HP would transfer to the CP for follow up.

Results

Five components were identified through the 209 systematic reviews: pharmacist-led medication reconciliation, pharmacist-led medication review, collaboration with general practitioners (GPs), post discharge pharmacist follow up and patient counseling or education. HPs and CPs identified uncertainties related to the relevance of the information sent from the HP to the CP, identification of patients at the community pharmacy and communication. The expected outcomes for the patients receiving the intervention were an experience of increased safety and satisfaction and less use of healthcare resources. The feasibility study led to optimization of language and structure of the pharmacist referrals that were used to transfer information from the HP to the CP.

Conclusion

A patient centered intervention to provide transitional pharmaceutical care for hospital discharged patients was developed using existing evidence in transition of care, HPs and CPs, an expert group, and a small-scale feasibility study. A full-scale feasibility test of the intervention should be carried out for it to be further refined.

Assessment of the potential impact of resolving drug-related problems by clinical pharmacists in Japan: a retrospective observational study

Background

Clinical pharmacists play a role in limiting the disadvantages of pharmacotherapy for patients by detecting and resolving drug-related problems (DRPs) through medication reviews. Although their contributions to patient care have been analyzed and understood in various countries, the role of Japanese clinical pharmacists in this context remains to be clearly elucidated. Thus, in this study, we aimed to elucidate the detection of DRPs by clinical pharmacists and determine the potential impact of pharmacist interventions in Japan.

Methods

This study was conducted in a 273-bed hospital and targeted hospitalized patients over a period of 6 months. DRPs detected by clinical pharmacists during the study period were investigated and classified into 10 types. Furthermore, medications were categorized according to the Anatomical Therapeutic Chemical classification. A review committee consisting of two pharmacists independently reviewed the pharmacist interventions on a six-point scale (extremely significant, very significant, significant, somewhat significant, no significance, adverse significance) according to the potential impact on patient care.

Results

During the study period, 1711 patients (mean age: 71.2 years, 54.1% male) were included, and 2149 DRPs were detected (1.26 DRPs/patient). Pharmacists intervened in all the DRPs detected. The most common DRP was supratherapeutic dosage (19.3%), followed by untreated indication (18.1%). The most common medication classification causing DRPs was “Antiinfectives for Systemic Use” (25.1%), followed by “Alimentary Tract and Metabolism” (19.9%). Most of the pharmacist interventions (99.6%) were rated “somewhat significant” or more significant, of which 1.1% were rated “extremely significant,” and none were rated as “adverse significance.”

Conclusions

Our results show that in Japan, as in other countries, clinical pharmacists detect and resolve DRPs in hospitalized patients through medication review. Our findings also show that clinical pharmacists have a positive impact on patient care and suggest the need for their involvement.

Association between recorded medication reviews in primary care and adequate drug treatment management - a cross-sectional study

OBJECTIVE

To investigate the association between a recorded procedure code for a medication review and adequate drug treatment management, and to explore factors associated with this code.

DESIGN AND SETTING

Cross-sectional study; two primary health care centres, in Region Västra Götaland, Sweden.

SUBJECTS

A total of 302 consecutive patients (≥65 years old, 59% female; median number of drugs: six) requiring a non-urgent consultation with a physician in October-November 2017.

MAIN OUTCOME MEASURE

Adequate drug treatment management (treatment that did not require any further action), determined in consensus by two specialists in family medicine blinded to the medication review code.

RESULTS

Adequate drug treatment management was, overall, less common in those with a recorded medication review over the last year: 63% versus 73% (p = 0.047). This negative association was evident among patients aged 65-74 years: 49% versus 74% (p = 0.003), but absent in those ≥75 years old: 67% versus 70% (p = 0.77). Recommendations from consensus included the search for additional information to be able to make a decision regarding initiation or withdrawal of a drug (n = 53), withdrawal of a drug (n = 41), or ordering a laboratory test (n = 25). Factors associated with a recorded procedure code included age above the remuneration limit of 75 years (odds ratio: 9.8; 95% confidence interval 5.0-19), type 2 diabetes (3.0 (1.5-6.2)), hypertension (2.4 (1.2-4.8)), and depression (2.5 (1.02-6.0)).

CONCLUSIONS

The presence of a recorded medication review was not positively associated with adequate drug treatment management but was associated with the age limit for remuneration, and some chronic diseases.Key pointsTo improve drug treatment in older people in primary care, a remuneration system linked to recorded medication reviews has been introduced.In this study, fewer patients with than without a recorded medication review (63% versus 73%) had adequate drug treatment management.A recorded medication review was ten times more common in those ≥75 years, that is, the age limit for remuneration.Recorded codes for medication reviews were also common in those with type 2 diabetes, hypertension, and depression.

Hospital Pharmacists and Antimicrobial Stewardship: A Qualitative Analysis

Antimicrobial stewardship programmes (ASPs) in hospitals are predominantly led by specific ASP physicians and pharmacists. Limited studies have been conducted to appreciate non-ASP-trained hospital pharmacists' perspectives on their roles in antimicrobial stewardship. Focus group discussions (FGDs) were conducted with 74 pharmacists, purposively sampled from the 3 largest acute-care public hospitals in Singapore, to explore facilitators and barriers faced by them in antimicrobial stewardship. Applied thematic analysis was conducted and codes were categorised using the social-ecological model (SEM). At the intrapersonal level, pharmacists identified themselves as reviewers for drug safety before dispensing, confining to a restricted advisory role due to lack of clinical knowledge, experience, and empowerment to contribute actively to physicians' prescribing decisions. At the interpersonal level, pharmacists expressed difficulties conveying their opinions and recommendations on antibiotic therapy to physicians despite frequent communications, but they assumed critical roles as educators for patients and their caregivers on proper antibiotic use. At the organisational level, in-house antibiotic guidelines supported pharmacists' antibiotic interventions and recommendations. At the community level, pharmacists were motivated to improve low public awareness and knowledge on antibiotic use and antimicrobial resistance. These findings provide important insights into the gaps to be addressed in order to harness the untapped potential of hospital pharmacists and fully engage them in antimicrobial stewardship.

Introduction to Bayesian statistics: a practical framework for clinical pharmacists

OBJECTIVES

Most pharmaceutical investigations have relied on p values to infer conclusions from their study findings. Central to this paradigm is the concept of null hypothesis significance testing. This approach is however fraught with overuse and misinterpretations. Several alternatives have already been proposed, yet uptake remains low. In this study, we aimed to discuss the pitfalls of p value-based testing and to provide readers with the basics to apply Bayesian statistics.

METHODS

Jeffreys's Amazing Statistical Package (JASP) was used to evaluate the effect of a clinical pharmacy (CP) intervention (opposed to usual care) on the number of emergency department (ED) visits without hospital admission. Basic Bayesian terminology was explained and compared with classical p value-based testing. In the study example, a Cauchy prior distribution was used to determine the effect size with a scale parameter r=0.707 at location=0 and Bayes factors (BF) were subsequently estimated. A robustness analysis was then performed to visualise the impact of different r values on the BF value.

RESULTS

A BF of 4.082 was determined, indicating that the observed data were about four times more likely to occur under the alternative hypothesis that the CP intervention was effective. The median effect size of the CP intervention on ED visits was found to be 0.337 with a 95% credible interval of 0.074 to 0.635. A robustness check was performed and all BF values were in favour of the CP intervention.

CONCLUSION

Bayesian inference can be an important addition to the statistical armamentarium of pharmacists, who should become more acquainted with the basic terminology and rationale of such testing. To prove our point, Jeffreys' approach was applied to a CP study example, using an easy-to-use software program JASP.

The clinical pharmacist's role in enhancing the relevance of a clinical decision support system

BACKGROUND

Clinical decision support systems (CDSSs) can improve the quality of patient care by helping physicians to review their prescriptions and thus to optimize drug treatments. Nevertheless, the "alert fatigue" brought on by a large number of irrelevant alerts can decrease a CDSS's effectiveness and thus clinical value. Involving a clinical pharmacist in the development and management of a CDSS can reduce the number of irrelevant alerts presented to physicians. Clinical pharmacists screen alerts and suggest PIs for physicians, corresponding to any proposed therapeutic change about health products, only for relevant alerts could improve the relevance and the acceptance of the information given to physicians about the risks faced by their patients.

OBJECTIVE

To assess the value of involving clinical pharmacists in the development and maintenance of decision support rules for generating alerts and pharmaceutical interventions (PIs) and to describe the level of acceptance of these PIs by the physicians.

METHOD

In a retrospective, single-centre study, we evaluated the number of PIs accepted from alerts generated by the CDSS when a clinical pharmacist had developed and managed this tool. During the first 7 months of development of the CDSS, a clinical pharmacist analyzed alerts triggered by the CDSS according to its technical validity and pharmaceutical relevance. Lastly, for alerts that led to a PI, the level of acceptance by physicians was documented.

RESULTS

During the study, 1430 alerts were analysed: 186 (13%) were considered to be technically invalid - mainly due to the characteristics of the interface. Of the 1244 (87.0%) technically valid alerts, 353 (24.6%) were pharmaceutically relevant and led to a PI. The three main causes of pharmaceutical irrelevance were a lack of specificity in the CDSS (70.8%), lack of relevance with regard to the ward's habits (15.6%), and the pharmacist's decision to recommend monitoring for the patient rather than sending a PI immediately (10.8%). 64.6% of the submitted PIs were accepted by the physicians.

CONCLUSION

The standardized analysis of alerts by a clinical pharmacist appears to be a good way of improving the development of CDSS by limiting the generation of irrelevant alerts and the latter's transmission to physicians. The involvement of a clinical pharmacist in the development and implementation of a CDSS appears to be novel and may help to optimize drug treatment.

Optimization of Nutrition And Medication (OptiNAM) for acutely admitted older patients: protocol for a randomized single-blinded controlled trial

BACKGROUND

Internationally, older patients (≥65 years) account for more than 40% of acute admissions. Older patients admitted to the emergency department (ED) are frequently malnourished and exposed to inappropriate medication prescribing, due in part to the inaccuracy of creatinine-based equations for estimated glomerular filtration rate (eGFR). The overall aims of this trial are to investigate: (1) the efficacy of a medication review (MED intervention) independent of nutritional status, (2) the accuracy of eGFR equations based on various biomarkers compared to measured GFR (mGFR) based on ^99mTechnetium-diethylenetriaminepentaacetic acid plasma clearance, and (3) the efficacy of an individualized multimodal and transitional nutritional intervention (MULTI-NUT-MED intervention) in older patients with or at risk of malnutrition in the ED.

METHODS

The trial is a single-center block randomized, controlled, observer-blinded, superiority and explorative trial with two parallel groups. The population consists of 200 older patients admitted to the ED: 70 patients without malnutrition or risk of malnutrition and 130 patients with or at risk of malnutrition defined as a Mini Nutritional Assessment-Short Form score ≤11. All patients without the risk of malnutrition receive the MED intervention, which consists of a medication review by a pharmacist and geriatrician in the ED. Patients with or at risk of malnutrition receive the MULTI-NUT-MED intervention, which consists of the MED intervention in addition to, dietary counseling and individualized interventions based on the results of screening tests for dysphagia, problems with activities of daily living, low muscle strength in the lower extremities, depression, and problems with oral health. Baseline data are collected upon study inclusion, and follow-up data are collected at 8 and 16 weeks after discharge. The primary outcomes are (1) change in medication appropriateness index (MAI) score from baseline to 8 weeks after discharge, (2) accuracy of different eGFR equations compared to mGFR, and (3) change in health-related quality of life (measured with EuroQol-5D-5L) from baseline to 16 weeks after discharge.

DISCUSSION

The trial will provide new information on strategies to optimize the treatment of malnutrition and inappropriate medication prescribing among older patients admitted to the ED.

TRAIL REGISTRATION

ClinicalTrials.gov NTC03741283 . Retrospectively registered on 14 November 2018.

Medication appropriateness on an acute geriatric care unit: the impact of the removal of a clinical pharmacist

BACKGROUND

evidence is largely available indicating benefits to adding a pharmacist on acute care wards. The benefits of maintaining pharmacotherapeutic consultant services on a geriatric ward remain unexplored.

OBJECTIVES

to determine the impact of the removal of a clinical pharmacist from an acute geriatric ward on patients' Medication Appropriateness Index (MAI) scores, admission-related outcomes and drug burdens.

METHODS

researchers consulted the archives for records of patients admitted to the geriatric care unit before and after the pharmacist's withdrawal. The primary outcome of differential MAI scores and secondary outcomes of rehospitalisations, emergency department visits, durations of hospitalisation and differential drug count were compared pre- and post-intervention. An interrupted time series analysis regression model was used for the primary outcome.

RESULTS

a total of 305 patients admitted before (n = 208) and after (n = 97) the pharmacist's withdrawal were included in the study. The intervention had a significant impact on the primary outcome, increasing the relative differential MAI score (adjusted mean) by 9.3 points (95% confidence interval 3.9-14.6). As for the secondary outcomes, differences in admission-related outcomes were non-significant but the mean differential drug count significantly increased post-intervention from 0.02 to 1.36 (P < 0.001).

CONCLUSION

the removal of the pharmacist led to an increase in inappropriate drug prescription. Careful consideration should be given to decisions regarding the removal of the pharmacist from acute geriatric care teams.

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.

Pharmacist-led interventions to reduce adverse drug events in older people living in residential aged care facilities: A systematic review

AIMS

We aimed to investigate the efficacy and effectiveness of pharmacist-led interventions to reduce adverse drug events (ADEs) in older people living in residential aged care facilities (RACFs).

METHODS

We systematically searched MEDLINE via PubMed, Embase, Cochrane Central Register of Controlled Trials and PsycINFO from their inceptions to July 2020. We investigated experimental study designs that employed a control group, or quasi-experimental studies conducted in RACFs.

RESULTS

We screened 3826 records and included 23 studies. We found seven single-component and 16 multicomponent pharmacist-led interventions to reduce ADEs in older people living in RACFs. The most frequent single-component pharmacist-led intervention was medication review. Medication review and education provision to healthcare professionals were the most common components in many pharmacist-led multicomponent interventions. Thirteen studies (56%) showed no effect, whereas ten studies (43%) reported significant reductions in ADEs following pharmacist-led interventions either as a sole intervention or as a part of a multi-component intervention. Many interventions focused on reducing the incidence of falls (39%).

CONCLUSIONS

This systematic review suggests that pharmacist-led interventions have the potential to reduce the incidence of ADEs in older people living in RACFs. Medication review and educational programmes, particularly academic detailing, either as a single component or as part of multicomponent interventions were the most common approaches to reducing drug-related harm in older people living in RACFs. The lack of a positive association between interventions and ADE in many studies suggests that targeted and tailored pharmacist-led interventions are required to reduce ADEs in older people in RACFs.

Pharmacist-driven medication recognition/ reconciliation in older medical patients

BACKGROUND

In older medical patients polypharmacy is often associated with poor prescription appropriateness and harmful drug-drug interactions. An effort that jointly involved hospital pharmacists and clinicians attending multimorbid older patients acutely admitted to medical wards was implemented for medication recognition and reconciliation aided by the use of a computerized support system.

METHODS

Six internal medicine wards enrolled consecutively 90 acutely admitted multimorbid patients aged 75 years or more taking 5 or more different drugs. Two hospital pharmacists carried out the recognition of medications taken at hospital ward admission, and interacted with the clinicians in a process of drug reconciliation, using also the computerized support system to evaluate drug related problems, prescription inappropriateness or drug-drug interactions. The process was repeated at hospital discharge.

RESULTS

Among a total number of 911 drugs prescribed to 90 older medical patients at ward admission, the pharmacists identified during their recognition/reconciliation 455 drug-related problems, mainly due to prescription of medications inappropriate for older multimorbid patients and clinically harmful drug-drug interactions. When these drug-related problems were identified by the pharmacist, the attending clinicians accepted and implemented the suggestions for changes for approximately two thirds of the discrepancies, thereby leading to deprescribing the implicated drugs or at least to their closer monitoring.

CONCLUSIONS

This interventional prospective study based upon the integrated expertise of hospital pharmacists and clinicians confirms that drug-related problems are frequent in multimorbid older patients acutely admitted to hospital medical wards, and demonstrates afresh the feasibility and mutual acceptance of a trajectory of recognition/reconciliation based upon an integrated collaboration between hospital pharmacists and ward clinicians in the process of medication optimization.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

Prospective observational study of medication reviews in internal medicine wards: evaluation of drug-related problems

BACKGROUND

The Lund Integrated Medicines Management model offers a systematic approach for individualising and optimising patient drug treatment. Clinical, economical and humanistic outcomes have been shown as well as results from the medication reconciliation process. There is a need also to describe the medication review process.

OBJECTIVE

To describe the frequency and types of drug-related problems (DRPs) identified during medication reviews and to evaluate the actions of the pharmacists and the physicians regarding the identified DRPs.

METHOD

Structured medication reviews were conducted by a multi-professional team on top of standard care for 719 patients in two internal medicine wards in a Swedish University Hospital. The medication reviews were studied retrospectively to classify DRPs and actions taken.

RESULTS

A total of 573 (80%) of patients had at least one actual DRP; an average of three DRPs per patient and in total 2164. Wrong drug and adverse drug reaction were the most common types of DRPs. The most frequent medication groups involved in DRPs were drugs for the cardiovascular system and the nervous system and the most frequent substances were warfarin, digoxin, furosemide and paracetamol. The 10 most common medications accounted for 27% of the actual DRPs. Of the identified DRPs, a total of 1740 (80%) were acted on. The three most common types of adjustments made were withdrawal of drug therapy, change of drug therapy and initiation of drug therapy. When the pharmacist suggested an adjustment, the physician implemented 88% (1037/1174) of the recommendations.

CONCLUSION

DRPs are common among elderly patients who are admitted to hospital. Systematic identification of high-risk medications and common DRP types enables targeting of prioritised patients for medication reviews.

Physician's feedback on a clinical pharmacy program on geriatric wards

OBJECTIVES

As clinical pharmacy (CP) services can improve drug use and clinical outcome in older inpatients, a dedicated CP program was installed at the geriatric wards of an academic hospital. The aim of this study was to evaluate and potentially improve the CP program, by obtaining physician's feedback.

METHODS

An anonymous e-questionnaire was sent to all physicians who were active between October 2014 and March 2018 on the acute geriatric wards (80 beds) of the University Hospitals Leuven, Belgium. Thematic content analysis was applied. Six themes were defined: satisfaction with the service, time allocation of the clinical pharmacists, content and clinical relevance of pharmaceutical interventions, communication, time savings for the treating physician and future perspectives.

RESULTS

A total of 45 physicians (59%) completed the e-questionnaire. All respondents were satisfied with the content of the provided pharmaceutical recommendations. A minority (44%) found that a 0.8 full-time equivalent clinical pharmacist presence was sufficient in terms of the expected workload. The provided CP interventions improved quality of care according to 38 (84%) physicians. Oral and written communication were considered necessary by 89% and 82% of physicians, respectively. On average, an estimated 30 minutes physician time (IQR: 15-60) per patient was saved as a result of the program. The majority (87%) preferred clinical pharmacist presence for discharge support in all geriatric patients.

CONCLUSION

Physician's satisfaction with the CP service was very high. CP services in geriatric inpatients were perceived to be clinically relevant as well as time-saving by the involved physicians.

The best person (or machine) for the job: Rethinking task shifting in healthcare

Globally, health systems are faced with the difficult challenge of how to get the best results with the often limited number of health workers available to them. Exacerbating this challenge is the task of meeting ever-changing needs of service users and managing unprecedented technological advances. The process of matching skills to changing needs and opportunities is termed task shifting. It involves questioning health service goals, what health workers do, asking if it can be done in a better way, and implementing change. Task shifting in healthcare is often conceptualised as a process of transferring responsibility for 'simple' tasks from high-skilled but scarce health workers to those with less expertise and lower pay, and predominantly viewed as a means to reduce costs and promote efficiency. Here we present a position paper based on the work and expertise of the European Commission Expert Panel on Effective ways of Investing in Health. It contends that this is over simplistic, and aims to provide a new task shifting framework, informed by relevant evidence, and a series of recommendations. While far from comprehensive, there is a growing body of evidence that certain tasks traditionally undertaken by one type of health worker can be undertaken by others (or machines), in some cases to a higher standard, thus challenging the persistence of rigid professional boundaries. Task shifting has the potential to contribute to health systems strengthening when accompanied by adequate planning, resources, education, training and transparency.

Economic impact of clinical pharmaceutical activities in hospital wards: A systematic review

BACKGROUND

The positive impact of clinical pharmacy services (CPS) in improving clinical outcomes such as reduction of drug related problems is well demonstrated. Despite these results, the deployment of these activities is not systematically observed in the hospital setting.

OBJECTIVES

This systematic review first aimed to describe existing evidence regarding economic evaluation of ward-based CPS focusing on the entire treatment of a patient in a hospital setting. Secondly, the quality of economic evaluations of existing evidence was assessed.

METHODS

A comprehensive literature search was performed in PubMed/Medline, Science Direct and the NHS Economic Evaluation databases from January 2000 to March 2019. English or French language articles describing an economic evaluation of ward-based CPS on inpatients in hospital settings were included. Articles not describing a single study, dealing with a CPS not considering the entire medication regimen of the patient or presenting both inpatient and outpatient CPS were excluded. Selected articles were analyzed according to Drummond's check-list for assessing economic evaluations.

RESULTS

Forty-one studies were included. About one third were American publications. CPS implemented in ICU represented about half of the selected articles. Pharmacist-to-bed ratios varied according to countries and care unit type with the most favorable ratios in ICU and in American studies. Cost-avoidance was mostly used to express economic impact and ranged from €1579 to €3,089 328. Studies yielding the greater economic impact were conducted in the USA with implementation of full-time equivalents pharmacists or establishing of collaborative practice agreements. Only 6 articles dealt correctly with at least 7 of the 10 Drummond's checklist assessment criteria.

CONCLUSION

This review suggests that the existing evidence is not sufficient to conclude to a positive economic impact of CPS conducted according to clinical pharmacy guidelines. Funding resources, remuneration of clinical pharmacy activities and provision of standardized national clinical and economic databases appear to be essential evolutions to improve CPS development.

Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis

BACKGROUND

Irrational use of antimicrobial agents for gastrointestinal diseases deserves attention, but corresponding antimicrobial stewardship programs (ASPs) are generally not a priority for managers. We conducted this study to evaluate the effectiveness of multifaceted pharmacist-led (MPL) interventions in the gastroenterology ward (GW) to provide evidence for the efficacy of ASPs in a non-priority department.

METHODS

This was an interventional, retrospective study implemented in China. The MPL intervention lasting 1.5 years involved daily ward rounds with physicians, regular review of medical orders, monthly indicator feedback, frequent physician training, and necessary patient education. Data on all hospitalized adults receiving antibiotics was extracted from the hospital information system over a 36-month period from January 2016 to December 2018. Segmented regression analysis of interrupted time series was performed to evaluate the effect of the MPL interventions (started in July 2017) on antibiotic use and length of hospital stay, which was calculated monthly as analytical units.

RESULTS

A total of 1763 patients receiving antibiotics were enrolled. Segmented regression models showed descending trends from the baseline in the intensity of antibiotic consumption (coefficient = -0.88, p = 0.01), including a significant decline in the level of change of the proportion of patients receiving combined antibiotics (coefficient = -9.91, p = 0.03) and average length of hospital stay (coefficient = -1.79, p = 0.00), after MPL interventions. The MPL interventions led to a temporary increase in the proportion of patients receiving antibiotics (coefficient = 4.95, p = 0.038), but this was part of a declining secular trend (coefficient = -0.45, p = 0.05).

CONCLUSION

The MPL interventions led a statistically significant decline in the number of patients receiving antibiotics, the antibiotic consumption, and the average hospital stay post-intervention compared to the pre-intervention phase of the study. Health policymakers should actively practice MPL interventions by clinical pharmacists in ASPs in those departments that are not included in priority management.

The effect of inpatient pharmaceutical care on nephrotic syndrome patients after discharge: a randomized controlled trial

Background Clinical pharmacists can play an important role in chronic diseases management, but limited attention has been given to the pharmaceutical care of nephrotic syndrome patients. Objective To evaluate the impact of inpatient pharmaceutical care on medication adherence and clinical outcomes in nephrotic syndrome patients. Setting A tertiary first-class hospital in Shanxi, China. Method We conducted a randomized controlled trial on 61 patients with nephrotic syndrome. The intervention consisted of medication reconciliation, pharmacist visits every day, discharge counseling and education by 2 certificated pharmacist, while the control group received usual care. Assessments were performed at baseline, month-1, month-3 and month-6 after hospital discharge. Main outcome measure medication adherence and patients' clinical outcomes. Results 61 patient completed the trial. Baseline variables were comparable between the two groups. The decline in medication adherence of patients in the intervention group after hospital discharge was restrained effectively at month-6 (p < 0.05). However, the groups did not differ in clinical outcomes, medication discrepancies, adverse drug events and readmission rate. The rate of return visits of the pharmaceutical care group was higher at month-1 and month-6 after discharge (p < 0.05). Conclusion Pharmaceutical inpatient care improved adherence in patients with nephrotic syndrome after hospital discharge, the effect of the intervention on clinical outcomes, medication discrepancies, adverse drug events or readmission was insignificant. These results are promising but should be tested in other settings prior to broader dissemination.

Translation and psychometric validation of a Danish version of the medication-related quality of life scale

Background Generic and disease specific health-related quality of life scales have been found to be non-responsive to changes in medications in polypharmacy patients. The Taiwanese medication-related quality of life (MRQoL) scale aims to measure the effect of medication use on patients' quality of life. Objective To evaluate the psychometric properties of the Danish translation of MRQoL in a population of patients with polypharmacy. Setting Polypharmacy patients waiting for services at a community pharmacy or hospital in Denmark. Method The original MRQoL included 14 items. It was forward-translated into Danish and backward-translated into Chinese according to a modified translation protocol proposed by Sousa and Rojjanasrirrat et al. The translation was pre-tested, adjusted, and administered to polypharmacy patients. The factor structure was examined using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency reliability was evaluated, and criterion validity assessed using the beliefs about medicines questionnaire (BMQ) and SF-12v2. Known-group validity was carried out on age, number of medicines and setting. Main outcome measure Validity of the Danish version of the MRQoL-scale. Results 164 patients completed the questionnaire. EFA of all 14 items resulted in a two-factor structure, accounting for 72.8% of the total variance. The two factors were named "Energy/Concentration" (7 items) and "Feelings/Social" (7 items). Items correlating over 0.80 were removed leaving 11 items (Model 1). This model was further reduced to 8 items (Model 2) based on Cronbach's alpha. CFA confirmed the two-factor structure of both models. Model 2 fitted data without having to define covariations between error terms. Both factors showed high internal consistency reliability (Cronbachs' alpha 0.901-0.932). Ceiling effects were detected for both factors. Criterion validity was demonstrated via its significant correlations with SF-12vs2 subscales (Spearman's rho 0.340-0.353) and BMQ Concern (Spearman's rho - 0.451 to - 0.347). There was a statistically significant difference in relation to total scores of the MRQoL for age and number of drugs taken, indicating known-group validity. Conclusion The Danish translation of the MRQoL instrument showed measurement properties indicating a well-defined two-factor structure with high internal reliability, concurrent criterion validity, and known group validity. However, challenges remain with ceiling effects and efforts should be put into further development of the instrument.

A Collaborative Medication Review Including Deprescribing for Older Patients in an Emergency Department: A Longitudinal Feasibility Study

Medication review for older patients with polypharmacy in the emergency department (ED) is crucial to prevent inappropriate prescribing. Our objective was to assess the feasibility of a collaborative medication review in older medical patients (≥65 years) using polypharmacy (≥5 long-term medications). A pharmacist performed the medication review using the tools: Screening Tool of Older Persons’ potentially inappropriate Prescriptions (STOPP) criteria, a drug–drug interaction database (SFINX), and Renbase^® (renal dosing database). A geriatrician received the medication review and decided which recommendations should be implemented. The outcomes were: differences in Medication Appropriateness Index (MAI) and Assessment of Underutilization Index (AOU) scores between admission and 30 days after discharge and the percentage of patients for which the intervention was completed before discharge. Sixty patients were included from the ED, the intervention was completed before discharge for 50 patients (83%), and 39 (61.5% male; median age 80 years) completed the follow-up 30 days after discharge. The median MAI score decreased from 14 (IQR 8-20) at admission to 8 (IQR 2-13) 30 days after discharge (p < 0.001). The number of patients with an AOU score ≥1 was reduced from 36% to 10% (p < 0.001). Thirty days after discharge, 83% of the changes were sustained and for 28 patients (72%), 1≥ medication had been deprescribed. In conclusion, a collaborative medication review and deprescribing intervention is feasible to perform in the ED.

Evaluation of drug-related problems and subsequent clinical pharmacists' interventions at a Swiss university hospital

WHAT IS KNOWN AND OBJECTIVE

The evaluation of clinical pharmacy services is essential for their further development and establishment. We analysed drug-related problems (DRPs) and subsequent clinical pharmacists' interventions (PIs) at a Swiss university hospital.

METHOD

We conducted a retrospective analysis of DRPs and subsequent PIs that were identified and implemented during interdisciplinary ward rounds in internal medicine at the University Hospital Basel, Switzerland, between 2015 and 2017. We estimated the potential clinical and economic impact of PIs using a validated evaluation tool (CLEO_de ).

RESULTS AND DISCUSSION

Based on medication reviews of 5441 patients, clinical pharmacists identified 5024 DRPs, of which 2892 DRPs (57.6%) were followed by a PI that was directly accepted and implemented by the physician in charge and included in the present analysis. The leading cause and type of PIs were inappropriate dose and dose adjustment, respectively. Overall, 97.8% of DRPs were followed by PIs with an expected clinical benefit for the patients (major: 11.1%; moderate: 27.6%; minor: 59.1%). The drugs most often involved in PIs of major clinical impact were antithrombotics, acid blockers and cardiovascular drugs. With regard to the economic impact, 40.7% of DRPs implied PIs resulting in an increase of immediate therapy costs, whereas 39.3% implied PIs resulting in a decrease of immediate therapy costs. The remaining PIs were cost-neutral.

WHAT IS NEW AND CONCLUSION

This study emphasizes that clinical pharmacists may help improve the effectiveness and safety of pharmacotherapy on acute care medical wards.

The Need to Strengthen the Role of the Pharmacist in Sri Lanka: Perspectives

The role of the pharmacist in healthcare has evolved greatly over the last half-century, from dispensing to providing direct patient-oriented activities not associated with dispensing. However, pharmacist-led healthcare services in Sri Lanka must undergo reform to fully take advantage of their expertise and training in medicine management and related outcomes in Sri Lankan patients. As befits a profession's role development and value, professional and educational standards for pharmacists need ongoing development and growth. Currently, university curricula and continuing professional education in Sri Lanka require further development and optimisation to provide the theoretical and practical knowledge and skills regarding quality use of medicines and patient-oriented care. Furthermore, pharmacists' roles in Sri Lankan hospital and community pharmacist settings need to be recognised and should include the pharmacist as an integral part of the multidisciplinary healthcare team in Sri Lanka. Studies from developed countries and some developing countries have demonstrated that expanded pharmacists' roles have had a significant positive cost-effective impact on the population's health. Therefore, the availability of qualified Sri Lankan pharmacists trained to deliver expanded professional services accompanied by greater pharmacist integration into healthcare delivery is crucially important to ensure quality use of medicines within the Sri Lankan healthcare system and optimise the medication-related needs of Sri Lankans.

Medicine optimization strategy in an acute geriatric unit: The pharmacist in the geriatric team

AIM

Older patients admitted to acute geriatric units (AGU) frequently use many medications and are particularly vulnerable to adverse drug events, so specific interventions in this setting are required. In the present study, we describe a new medicine optimization strategy in an AGU, and explore its potential in reducing polypharmacy and improving medication appropriateness.

METHODS

The present prospective study included patients aged ≥75 years who were admitted to an AGU in a tertiary hospital. An intervention based on a pharmacist clinical interview, medication history and a structured medication review within a comprehensive geriatric assessment was proposed. The differences regarding polypharmacy as the primary outcome (≥5 chronic drugs), hyperpolypharmacy (≥10), number of drugs, drug-related problems and Screening Tool of Older Person's Prescription/Screening Tool to Alert Doctors to Right Treatment criteria between admission and discharge were evaluated.

RESULTS

From October 2016 to April 2017, 234 patients were enrolled, aged 87.6 years (SD 4.6 years); 143 (61.1%) were women. The intervention resulted in a statistically significant improvement in polypharmacy (-10.2%, 95% CI -15.3, -5.2), hyperpolypharmacy (-16.6%, 95% CI -22.3 -11.0), number of medications (-1.4, 95% CI -1.8, -1.0), Screening Tool of Older Person's Prescription criteria (-19.2%, 95% CI -24.9, -13.6), Screening Tool to Alert Doctors to Right Treatment criteria (-6.8%, 95% CI -10.1, -3.5) and drug-related problems (-2.7, 95% CI -2.9, -2.4; P ≤ 0.001 for all).

CONCLUSIONS

A systematic pharmacist-led intervention at hospital admission to an AGU within a comprehensive geriatric assessment was associated to a decrease in polypharmacy, drug-related problems and potentially inappropriate prescribing. Geriatr Gerontol Int 2019; 19: 530-536.