Appropriateness of medication prescribing in ambulatory elderly patients

Potentially Inappropriate Prescribing for Prostatic Hyperplasia in Older Persons

OBJECTIVES

In the context of improved medication management of older patients, we wished to evaluate the overprescription of potentially inappropriate drugs [α1-blockers and 5α-reductase inhibitors (5-ARI)] for benign prostate hyperplasia (BPH). These drugs are considered by geriatricians to increase the risk of falls and pharmacodynamic interactions, but these properties have not yet been proven.

DESIGN

This was a descriptive study of drug prescriptions in a geriatric academic center.

SETTING AND PARTICIPANTS

We included all patients older than 75 years who received a prescription for α1-blockers or 5-ARIs for 2 weeks in our hospital.

METHODS

We evaluated the prevalence of the potentially inappropriate prescription of α1-blockers and 5-ARI in older people during hospitalization using a new tool consisting of an 8-item list of explicit indicators developed using the most recent summary of product characteristics (SmPC) and latest European Association of Urology (EAU) guidelines.

RESULTS

A population of 117 patients (≥75 years) was included in the study. The median age was 84.5 (±6.3) years. The average time since urological medication prescription was 1.2 ± 1.6 years. According to explicit criteria, 84 patients (71.8%) received at least 1 potentially inappropriate urologic medication, 77 (91.7%) related to α1-blockers. Patients with a potentially inappropriate prescription for α1-blockers and/or 5-ARIs more frequently had urological assessments (P = .026), more frequently showed pharmacological interactions, with the risk of orthostatic hypotension (P = .005) or arrhythmia (P = .028), and experienced more falls in their history (P = .043). The misuse group was associated with an increased risk of falls, with an odds ratio of 3.22 (P = .039, 95% confidence interval 1.08-10.2).

CONCLUSIONS AND IMPLICATIONS

In our study, potentially inappropriate prescriptions for older individuals for BPH was close to 72% and mainly involved α1-blockers. Potentially inappropriate prescriptions for BPH were associated with a threefold higher frequency of falls.

Prevalence and Factors Associated With Polypharmacy Use Among Adult Patients in Saudi Arabia

BACKGROUND

Polypharmacy is very common in clinical practice, especially among adult patients. The use of multiple medications may increase the risk of adverse drug events, medication cost, and medication errors. In addition, polypharmacy exacerbates treatment complexity, which consequently leads to poor patients' adherence to their medications. Despite being a well-recognized problem, few studies have investigated the prevalence and predictors of polypharmacy in Saudi Arabia.

OBJECTIVES

The aims of the study were to investigate the prevalence of polypharmacy among adult patients in a tertiary teaching hospital and to determine patients' characteristics that are associated with polypharmacy.

METHODS

This was a retrospective cross-sectional study using data extracted from the electronic health records database for a period of 6 months between January and June 2016 in outpatient setting. Descriptive statistics were used to analyze the study sample. A multivariate logistic regression model was used to examine the association between different variables and polypharmacy. Statistical analysis software (SAS 9.2) was used to analyze the study data.

RESULTS

A total of 17,237 observations (67.2% females) were included in the final analysis. Of these, nearly 54% (n = 9222) of reported observations were found using up to four prescription drugs and the other 46% (n = 8015) were using five or more prescription drugs. Interestingly, the prevalence of polypharmacy use was doubled among adults with hypertension as compared with those without hypertension (odds ratio [OR] = 2.68, 95% confidence interval [CI] = 2.51-2.87). In addition, polypharmacy use was two times more prevalent among adults with diabetes as compared with those without diabetes (OR = 2.31, 95% CI = 1.99-2.28) and five times more prevalent in patient with dementia (OR = 5.57, 95% CI = 1.26-24.7). Moreover, polypharmacy in adult patients was significantly influenced by sex (OR = 1.69, 95% CI = 1.59-1.80) and nationality (OR = 2.15, 95% CI = 2.00-2.31).

CONCLUSIONS

Polypharmacy is common among adult patients especially those who are older than 60 years. Polypharmacy may affect the overall process of drug therapy. It can be a risk factor to develop undesirable adverse drug events, especially in those with chronic health conditions. A special care should be taken to manage polypharmacy among adults in Saudi Arabia.

Drug-Drug Interactions in Elderly Patients with Potentially Inappropriate Medications in Primary Care, Nursing Home and Hospital Settings: A Systematic Review and a Preliminary Study

Drug–drug interactions (DDI) occurring with potentially inappropriate medications (PIM) are additional risk factors that may increase the inappropriate character of PIM. The aim of this study was (1) to describe the prevalence and severity of DDI in patients with PIM and (2) to evaluate the DDI specifically regarding PIM. This systematic review is based on a search carried out on PubMed and Web-of-Science from inception to June 30, 2020. We extracted data of original studies that assessed the prevalence of both DDI and PIM in elderly patients in primary care, nursing home and hospital settings. Four hundred and forty unique studies were identified: 91 were included in the qualitative analysis and 66 were included in the quantitative analysis. The prevalence of PIM in primary care, nursing home and hospital were 19.1% (95% confidence intervals (CI): 15.1–23.0%), 29.7% (95% CI: 27.8–31.6%) and 44.6% (95% CI: 28.3–60.9%), respectively. Clinically significant severe risk-rated DDI averaged 28.9% (95% CI: 17.2–40.6), in a hospital setting; and were approximately 7-to-9 lower in primary care and nursing home, respectively. Surprisingly, only four of these studies investigated DDI involving specifically PIM. Hence, given the high prevalence of severe DDI in patients with PIM, further investigations should be carried out on DDI involving specifically PIM which may increase their inappropriate character, and the risk of adverse drug reactions.

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.

Prescribing issues in elderly individuals living with HIV

Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.

Influence of pharmacist intervention on drug safety of geriatric inpatients: a prospective, controlled trial

BACKGROUND

Demographic shift leads to an increasing number of geriatric patients suffering from multimorbidity and resulting polypharmacy. Polypharmacy is shown to be associated with drug-related problems (DRPs) and increased morbidity. For Germany, a hospital-based intervention may be successful optimizing of polypharmacy. The aim of this study was to reduce DRPs in geriatric inpatients by a structured pharmacist's intervention and to measure the acceptance rate of pharmaceutical recommendations.

METHODS

This study followed an open, prospective, quasi-randomized, controlled design and was conducted in a geriatric department in a teaching hospital in Germany. Patients of all sexes were included, with a minimum age of 70 years, a written informed consent and a regular intake of at least five drugs daily. Primary outcome was the percentage of patients having a DRP at admission and discharge. A DRP was defined as a prescription without indication or a relevant drug-drug interaction or prescription of a potentially inappropriate medication or presence of an adverse drug reaction. Recommendations were classified and discussed face to face. Statistical analyses were performed using a full-set analysis and a matched-pairs design.

RESULTS

Within 12 months, 411 patients were recruited with median age of 82 years (intervention: n = 209; control: n = 202). Median number of drugs at admission was 10 (range 5-24), at discharge 9 (range 3-21). In the intervention group, the percentage of patients with a DRP was reduced from 86.6% to 56.0%; in the control group, from 76.7% to 76.2% (p value < 0.001). Medication appropriateness index score was reduced by 56% in the intervention group and by 0.2% in the control group (p value < 0.001). Implementation rate of the pharmaceutical recommendation was 80%.

CONCLUSION

This prospective controlled trial showed that a pharmacist's intervention was successful in optimizing polypharmacy in geriatric inpatients.

Evaluation of Rationality of Geriatric Patients' Prescription Based On Beers Criteria in a Tertiary Care Hospital in India

AIM

Irrational prescribing for geriatric patients has become an important public health problem worldwide. Because India is one of the most populated countries having a great proportion of old people in the world, studies on the prevalence of inappropriate prescriptions can be very beneficial to increase the knowledge of health care providers and to reduce the occurrence of adverse drug events among this population.

METHODS

A group of 482 inpatients above 64 years old were enrolled in a prospective study. Chart review method was used. The data were collected from patients' prescription and medicine charts. Each prescription was checked individually for the inappropriate drug by using the AGS 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Suggestions were given to the physicians for inappropriate medications.

RESULTS

The prevalence of potentially inappropriate medication is found to be 11.66% (n = 56). Out of 56 inappropriate medications, the most frequently inappropriate medication is Digoxin (25%) followed by Sprinolactone 19.64%. This study founds age, some medication, length of stay and number of diagnosis as predictors for getting a PIM. Feedback of the physicians varies based on the suggestions.

CONCLUSION

This study concludes that the prevalence of PIMs among geriatrics patients of ≥ 65 years old is 11.66%. Some predictors have been identified for getting a PIM. This study shows that physicians' feedback is dependent on the suggestions being given.

A patient-centered deprescribing intervention for hospitalized older patients with polypharmacy: rationale and design of the Shed-MEDS randomized controlled trial

BACKGROUND

Polypharmacy is prevalent among hospitalized older adults, particularly those being discharged to a post-care care facility (PAC). The aim of this randomized controlled trial is to determine if a patient-centered deprescribing intervention initiated in the hospital and continued in the PAC setting reduces the total number of medications among older patients.

METHODS

The Shed-MEDS study is a 5-year, randomized controlled clinical intervention trial comparing a patient-centered describing intervention with usual care among older (≥50 years) hospitalized patients discharged to PAC, either a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IPR). Patient measurements occur at hospital enrollment, hospital discharge, within 7 days of PAC discharge, and at 60 and 90 days following PAC discharge. Patients are randomized in a permuted block fashion, with block sizes of two to four. The overall effectiveness of the intervention will be evaluated using total medication count as the primary outcome measure. We estimate that 576 patients will enroll in the study. Following attrition due to death or loss to follow-up, 420 patients will contribute measurements at 90 days, which provides 90% power to detect a 30% versus 25% reduction in total medications with an alpha error of 0.05. Secondary outcomes include the number of medications associated with geriatric syndromes, drug burden index, medication adherence, the prevalence and severity of geriatric syndromes and functional health status.

DISCUSSION

The Shed-MEDS trial aims to test the hypothesis that a patient-centered deprescribing intervention initiated in the hospital and continuing through the PAC stay will reduce the total number of medications 90 days following PAC discharge and result in improvements in geriatric syndromes and functional health status. The results of this trial will quantify the health outcomes associated with reducing medications for hospitalized older adults with polypharmacy who are discharged to post-acute care facilities.

TRIAL REGISTRATION

This trial was prospectively registered at clinicaltrials.gov ( NCT02979353 ). The trial was first registered on 12/1/2016, with an update on 09/28/17 and 10/12/2018.

Interprofessional Medication Management in Patients With Multiple Morbidities

BACKGROUND

Medication reviews and medication management are being used more and more around the world to improve medication safety. Both of these tools were originally conceived as pharmaceutical care activities and have recently been developed into interdisciplinary approaches. We studied the efficacy of interprofessional medication management for multimorbid patients that takes their medical conditions, but also their general living situation into account.

METHODS

A comprehensive medication management was performed, which involved the collection of information on the drugs each patient took, the way they were stored, the patient's drug intake and handling, and any problems that arose with pharmacotherapy. The interventional approach was evaluated over a period of 15 months in a cluster-randomized controlled trial with a stepped wedge design. The primary endpoint was the quality of pharmacotherapy, as assessed with the Medication Appropriateness Index (MAI). A mixed model was used to analyze efficacy.

RESULTS

162 patients were enrolled in the study; 142 were included in the intention-to-treat analysis (53.3% women, mean age 76.8 ± 6.3 years). The mean total MAI score decreased significantly (p ≤ 0.001) from the control phase (29.21, 95% CI [26.09; 32.33]) to the intervention phase (22.27 [19.00; 25.54]), with an effect strength (Cohen's d) of -0.24 [-0.36; -0.13]. The number of drug-related problems declined as well.

CONCLUSION

In this study, interprofessional collaboration increased medication safety. Working across disciplinary boundaries allowed for a decrease in drugrelated problems and brought up aspects outside the purview of the primary care physician.

Erratum to: Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta

[This corrects the article on p. 181 in vol. 10, PMID: 24155835.].

Impact of joint consultation by a clinical pharmacist and a clinical geriatrician to improve inappropriate prescribing for elderly patients

Objective

Appropriate prescribing is a key quality element in medication safety. It is unclear if therapeutic interventions resulting from medication review lead to clinically relevant improvements. The effect of medication review on prescribing appropriateness was evaluated in the setting of an outpatient consultation team, consisting of a clinical pharmacist and a clinical geriatrician, in a large non-academic teaching hospital in the Netherlands.

Method

A group of 49 elderly patients with polypharmacy was included after referral by their general practitioner for drug related problems. After a regular assessment by a clinical geriatrician and medication record review by a clinical pharmacist, a treatment plan was implemented based on the recommended interventions. The main outcome measure was the change in the Medication Appropriateness Index (MAI) before and 3 months after primary consultation.

Results

Overall 82% of the recommended interventions of the pharmacist were implemented by the geriatrician of which 63% persisted up to the last visit. Per patient an average of 6.6 interventions were carried out. The interventions showed a reduction of the MAI per patient of 50%. The number of drugs per patient was reduced from 12.1 to 11.0. The number of medications listed on the Beers list decreased from 2.3 to 1.5 and the number of drugs listed on the Hospital Admissions Related to Medication (HARM) Trigger list decreased from 2.1 to 1.5.

Conclusions

Interventions from a multidisciplinary outpatient consultation team were effective in improving appropriate prescribing in elderly outpatients with polypharmacy.

Medications associated with geriatric syndromes and their prevalence in older hospitalized adults discharged to skilled nursing facilities

BACKGROUND

More than half of the hospitalized older adults discharged to skilled nursing facilities (SNFs) have more than 3 geriatric syndromes. Pharmacotherapy may be contributing to geriatric syndromes in this population.

OBJECTIVES

Develop a list of medications associated with geriatric syndromes and describe their prevalence in patients discharged from acute care to SNFs.

DESIGN

Literature review and multidisciplinary expert panel discussion, followed by cross-sectional analysis.

SETTING

Academic medical center in the United States PARTICIPANTS: One hundred fifty-four hospitalized Medicare beneficiaries discharged to SNFs.

MEASUREMENTS

Development of a list of medications that are associated with 6 geriatric syndromes. Prevalence of the medications associated with geriatric syndromes was examined in the hospital discharge sample.

RESULTS

A list of 513 medications was developed as potentially contributing to 6 geriatric syndromes: cognitive impairment, delirium, falls, reduced appetite or weight loss, urinary incontinence, and depression. Medications included 18 categories. Antiepileptics were associated with all syndromes, whereas antipsychotics, antidepressants, antiparkinsonism, and opioid agonists were associated with 5 geriatric syndromes. In the prevalence sample, patients were discharged to SNFs with an overall average of 14.0 (±4.7) medications, including an average of 5.9 (±2.2) medications that could contribute to geriatric syndromes, with falls having the most associated medications at discharge at 5.5 (±2.2).

CONCLUSIONS

Many commonly prescribed medications are associated with geriatric syndromes. Over 40% of all medications ordered upon discharge to SNFs were associated with geriatric syndromes and could be contributing to the high prevalence of geriatric syndromes experienced by this population. Journal of Hospital Medicine 2016;11:694-700. © 2016 Society of Hospital Medicine.

Assessment of Drug-Prescribing Problems in a Multidisciplinary Primary Care Clinic

Objective:

To identify drug classes prone to prescribing problems in a multidisciplinary primary care clinic in a Department of Veterans Affairs Medical Center.

Methods:

Over a 10-week study period, the ambulatory care pharmacists reviewed the prescription profiles and medical records of every patient with an appointment in the Comprehensive Health Care Unit primary care clinic. Based on this review, the pharmacists made patient-specific consultations to the providers. They were also available during clinic hours for additional consultations and patient referrals. A standard data collection form was used to document all consultations.

Results:

The pharmacists made 1,701 consultations concerning 1,665 patients. The most problematic drug classes identified included anticoagulants, lipid-lowering agents, antiulcer agents, antihypertensive/ cardiovascular agents, chronic obstructive pulmonary disease/asthma agents, oral antidiabetic agents, nonsteroidal antiinflammatory drugs, and anticonvulsants. Anticoagulants and lipid-lowering agents were the most problematic drug classes, with most of the consultations related to dosing and monitoring requirements. Consultations had an 88.6% acceptance rate and resulted in a total monthly drug cost avoidance of $1,525.

Conclusions:

As a result of identifying the most problematic drug classes, computer programs have been developed to streamline the pharmacist review process, and clinical practice guidelines, posters, and educational handouts have been developed to promote appropriate prescribing.

Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study

In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥ 60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.

Pharmacist-Led Medication Reviews to Identify and Collaboratively Resolve Drug-Related Problems in Psychiatry - A Controlled, Clinical Trial

Aim of the study

This prospective, controlled trial aimed to assess the effect of pharmacist-led medication reviews on the medication safety of psychiatric inpatients by the resolution of Drug-Related Problems (DRP). Both the therapy appropriateness measured with the Medication Appropriateness Index (MAI) and the number of unsolved DRP per patient were chosen as primary outcome measures.

Methods

Depending on their time of admission, 269 psychiatric patients that were admitted to a psychiatric university hospital were allocated in control (09/2012-03/2013) or intervention group (05/2013-12/2013). In both groups, DRP were identified by comprehensive medication reviews by clinical pharmacists at admission, during the hospital stay, and at discharge. In the intervention group, recommendations for identified DRP were compiled by the pharmacists and discussed with the therapeutic team. In the control group, recommendations were not provided except for serious or life threatening DRP. As a primary outcome measure, the changes in therapy appropriateness from admission to discharge as well as from admission to three months after discharge (follow-up) assessed with the MAI were compared between both groups. The second primary outcome was the number of unsolved DRP per patient after completing the study protocol. The DRP type, the relevance and the potential of drugs to cause DRP were also evaluated.

Results

The intervention led to a reduced MAI score by 1.4 points per patient (95% confidence interval [CI]: 0.8–2.0) at discharge and 1.3 points (95% CI: 0.7–1.9) at follow-up compared with controls. The number of unsolved DRP in the intervention group was 1.8 (95% CI: 1.5–2.1) less than in control.

Conclusion

The pharmaceutical medication reviews with interdisciplinary discussion of identified DRP appears to be a worthy strategy to improve medication safety in psychiatry as reflected by less unsolved DRP per patient and an enhanced appropriateness of therapy. The promising results of this trial likely warrant further research that evaluates direct clinical outcomes and health-related costs.

Trial Registration

Deutsches Register Klinischer Studien (DRKS), DRKS00006358

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

Objectives

A high prevalence of potentially inappropriate prescribing (PIP) has been identified in older patients in Ireland. The impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on the medication appropriateness of acute hospitalised older patients during admission and at discharge is reported.

Methods

Uncontrolled before-after study. The study population for this study was medical patients aged ≥65 years, using ≥3 regular medicines at admission, taken from a previous before-after study. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT model involved clinical pharmacists being physician team-based, leading admission and discharge medication reconciliation and undertaking prescription review, with authority to change the prescription during admission or at discharge. The primary outcome was the Medication Appropriateness Index (MAI) score applied pre-admission, during admission and at discharge.

Results

Some 108 patients were included (48 PACT, 60 standard). PACT significantly improved the MAI score from pre-admission to admission (mean difference 2.4, 95% CI 1.0 to 3.9, p<0.005), and from pre-admission to discharge (mean difference 4.0, 95 CI 1.7 to 6.4, p<0.005). PACT resulted in significantly fewer drugs with one or more inappropriate rating at discharge (PACT 15.0%, standard 30.5%, p<0.001). The MAI criteria responsible for most inappropriate ratings were 'correct directions' (4.8% PACT, 17.3% standard), expense (5.3% PACT, 5.7% standard) and dosage (0.6% PACT, 4.0% standard). PACT suggestions to optimise medication use were accepted more frequently, and earlier in the hospital episode, than standard care (96.7% PACT, 69.3% standard, p<0.05).

Conclusions

Collaborative pharmaceutical care between physicians and pharmacists from admission to discharge, with authority for pharmacists to amend the prescription, improves medication appropriateness in older hospitalised Irish patients.

Polypharmacy and potentially inappropriate medication use in older adults with cancer undergoing chemotherapy: effect on chemotherapy-related toxicity and hospitalization during treatment

OBJECTIVES

To evaluate the prevalence of polypharmacy and potentially inappropriate medication (PIM) use and the association between these and chemotherapy-related adverse events in older adults with cancer undergoing chemotherapy.

DESIGN

Secondary analysis of prospectively collected data.

SETTING

Outpatient oncology clinics in seven academic medical centers.

PARTICIPANTS

Adults aged 65 and older with cancer undergoing chemotherapy.

MEASUREMENTS

Measures included number of daily medications (polypharmacy); PIM use based on three indices (Beers, Zhan, and Drugs to Avoid in the Elderly criteria), and use of six "high risk" medication classes for adverse drug events (anticoagulants, antiplatelet agents, opioids, insulin, oral hypoglycemics, antiarrhythmics). Using multivariate logistic regression, the relations were evaluated between these criteria and Grade 3 to 5 chemotherapy-related toxicity and between these criteria and hospitalization during chemotherapy.

RESULTS

Participants (N=500; mean age 73, 61% Stage IV disease) took a mean of 5±4 daily medications (range 0-23). PIM use was common (up to 29% according to Beers criteria). No association was found between number of daily medications (reference 0-3 medications) and toxicity (4-9 medications, odds ratio (OR)=1.34, 95% confidence interval (CI)=0.92-1.97; ≥10 medications, OR=0.82, 95% CI=0.45-1.49) or hospitalization (≥4 medications, OR=1.34, 95% CI=0.82-2.18, P=.24). There was also no association between PIM use and toxicity (P=.93) or hospitalization (P=.98). No medication class was associated with either outcome.

CONCLUSIONS

Polypharmacy and PIM use were common but were not associated with chemotherapy-related toxicity or hospitalization in older adults with cancer.

Explicit criteria for potentially inappropriate medications to reduce the risk of adverse drug reactions in elderly people: from Beers to STOPP/START criteria

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. For this reason, great efforts have been made in the search for interventions to improve efficacy, safety and appropriateness of prescriptions in this vulnerable population. Among these interventions, the avoidance of medications that are considered to be inappropriate, i.e. potentially inappropriate medications (PIMs), has been considered a valuable treatment option. The aim of the present review was to summarize evidence about the use of explicit criteria for PIMs to reduce the risk of adverse drug reactions (ADRs) in older people. A PIM is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is evidence in favour of a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs, and among these, the Beers criteria have been the most frequently applied until recently. However, evidence suggests that such criteria can not easily be applied in European countries: several drugs listed in the 2003 Beers criteria were rarely prescribed or were not available in Europe and 2003 Beers-listed PIMs were not associated with ADRs in some studies. In the past few years, START/STOPP criteria have been developed and applied in several different studies and populations showing a greater ability to predict ADRs with respect to Beers criteria and to prevent potentially inappropriate prescribing. In 2012, Beers criteria have been updated using an evidence-based approach and future studies will investigate the impact of these and other criteria coming from ongoing studies on clinical outcomes relevant to geriatric populations.

Clinical pharmacist evaluation of medication inappropriateness in the emergency department of a teaching hospital in Malta

Appropriate prescribing remains an important priority in all medical areas of practice.

Objective

The objective of this study was to apply a Medication Appropriateness Index (MAI) to identify issues of inappropriate prescribing amongst patients admitted from the Emergency Department (ED).

Methods

This study was carried out at Malta's general hospital on 125 patients following a two-week pilot period on 10 patients. Patients aged 18 years and over and on medication therapy were included. Medication treatment for inappropriateness was assessed by using the MAI. Under-prescribing was also screened for.

Results

Treatment charts of 125 patients, including 697 medications, were assessed using a MAI. Overall, 115 (92%) patients had one or more medications with one or more MAI criteria rated as inappropriate, giving a total of 384 (55.1%) medications prescribed inappropriately. The mean SD MAI score per drug was 1.78 (SD=2.19). The most common medication classes with appropriateness problems were biguanides (100%), anti-arrhythmics (100%) and anti-platelets (96.8%). The most common problems involved incorrect directions (26%) and incorrect dosages (18.5%). There were 36 omitted medications with untreated indications.

Conclusions

There is considerable inappropriate prescribing which could have significant negative effects regarding patient care.

Are nurse and pharmacist independent prescribers making clinically appropriate prescribing decisions? An analysis of consultations

OBJECTIVES

Legislation and health policy enabling nurses and pharmacists to prescribe a comprehensive range of medicines has been in place in the UK since 2006. Our objective was to evaluate the clinical appropriateness of prescribing by these professionals.

METHODS

A modified version of the Medication Appropriateness Index (MAI) was used by 10 medical, seven pharmacist and three nurse independent raters to evaluate a sample of 100 audio-recorded consultations in which a medicine was prescribed by a nurse or pharmacist. Raters were current prescribers with recognized experience in prescribing. Consultations were recorded in nine clinical practice settings in England.

RESULTS

Raters' analysis indicated that, in the majority of instances, nurses and pharmacists were prescribing clinically appropriately on all of the ten MAI criteria (indication, effectiveness, dosage, directions, practicality, drug-drug interaction, drug-disease interaction, duplication, duration, cost). Highest mean 'inappropriate' ratings were given for correct directions (nurses 12%; pharmacists 11%) and the cost of the drug prescribed (nurses 16% pharmacists 22%). Analysis of raters' qualitative comments identified two main themes: positive views on the overall safety and effectiveness of prescribing episodes; and potential for improvement in nurses' and pharmacists' history-taking, assessment and diagnosis skills.

CONCLUSIONS

Nurses and pharmacists are generally making clinically appropriate prescribing decisions. Decisions about the cost of drugs prescribed and assessment and diagnostic skills are areas for quality improvement.

Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria

Inappropriate prescribing is particularly common in older patients and is associated with adverse drug events (ADEs), hospitalization, and wasteful utilization of resources. We randomized 400 hospitalized patients aged ≥ 65 years to receive either the usual pharmaceutical care (control) or screening with STOPP/START criteria followed up with recommendations to their attending physicians (intervention). The Medication Appropriateness Index (MAI) and Assessment of Underutilization (AOU) index were used to assess prescribing appropriateness, both at the time of discharge and for 6 months after discharge. Unnecessary polypharmacy, the use of drugs at incorrect doses, and potential drug-drug and drug-disease interactions were significantly lower in the intervention group at discharge (absolute risk reduction 35.7%, number needed to screen to yield improvement in MAI = 2.8 (95% confidence interval 2.2-3.8)). Underutilization of clinically indicated medications was also reduced (absolute risk reduction 21.2%, number needed to screen to yield reduction in AOU = 4.7 (95% confidence interval 3.4-7.5)). Significant improvements in prescribing appropriateness were sustained for 6 months after discharge.

Reassessing the MAI: elderly people's opinions about medication appropriateness

Objectives

To identify the criteria that the elderly use to assess the appropriateness of their medications, rank the identified criteria in terms of importance, and compare elderly people's and clinicians' ratings of the importance of medication appropriateness index (MAI) criteria

Methods

A qualitative method was used to understand why elders' rankings of appropriateness criteria may or may not differ from clinicians'. Five focus groups with 38 elderly people were completed and content analysed. The participants also completed a written ranking of 10 criteria, indicating them as being of high importance, moderate importance or low importance

Key findings

Overall, the group discussion cited indication, effectiveness and drug-drug interactions as most important. The written ranking of the MAI criteria suggested drug-drug interactions and correct directions as being most important. Elderly people appeared to have difficulty ranking the criteria of indication and effectiveness, as there was some evidence that they took these criteria for granted. Differences among focus group participants appeared to be due to their varied medication use experience

Conclusion

These findings suggest that drug-drug interactions may be ranked highly important and practicality ranked moderately important when elderly patients' opinions are sought about medication appropriateness. Further research should be conducted to assess whether the MAI is accountable to patient viewpoints

Online detection of potential duplicate medications and changes of physician behavior for outpatients visiting multiple hospitals using national health insurance smart cards in Taiwan

OBJECTIVES

Doctor shopping (or hospital shopping), which means changing doctors (or hospitals) without professional referral for the same or similar illness conditions, is common in Hong Kong, Taiwan and Japan. Due to the lack of infrastructure for sharing health information and medication history among hospitals, doctor-shopping patients are more likely to receive duplicate medications and suffer adverse drug reactions. The Bureau of National Health Insurance (BNHI) adopted smart cards (or NHI-IC cards) as health cards in Taiwan. With their NHI-IC cards, patients can freely access different medical institutions. Because an NHI-IC card carries information about a patient's prescribed medications received from different hospitals nationwide, we used this system to address the problem of duplicate medications for outpatients visiting multiple hospitals.

METHODS

A computerized physician order entry (CPOE) system was enhanced with the capability of accessing NHI-IC cards and providing alerts to physicians when the system detects potential duplicate medications at the time of prescribing. Physician responses to the alerts were also collected to analyze changes in physicians' behavior. Chi-square tests and two-sided z-tests with Bonferroni adjustments for multiple comparisons were used to assess statistical significance of differences in actions taken by physicians over the three months.

RESULTS

The enhanced CPOE system for outpatient services was implemented and installed at the Pediatric and Urology Departments of Taipei Medical University Wan-Fang Hospital in March 2007. The "Change Log" that recorded physician behavior was activated during a 3-month study period from April to June 2007. In 67.93% of patient visits, the physicians read patient NHI-IC cards, and in 16.76% of the reads, the NHI-IC card contained at least one prescribed medication that was taken by the patient. Among the prescriptions issued by physicians, on average, there were 2.36% prescriptions containing at least one medication that might be duplicative to the prior prescriptions stored in NHI-IC cards. The rate of potential duplicate medication alerts for the Pediatric Department was higher than that for the Urology Department (2.78% versus 1.67%). However, the rate of revisions to prescriptions was higher in the Urology Department than the Pediatric Department. Overall, the rate of physicians reviewing and revising their prescriptions was 29.25%; the rate of physicians reviewing without revising their prescriptions was 43.62%; the rate of physicians turning off the alert screens right after the screens popped up (overridden) was 27.13%. Thus, physicians accepted alerts to review their prescriptions with patients in most situations (72.87%). Moreover, over the study period, the rate of total revisions made to prescriptions increased and the "overridden" rate decreased.

CONCLUSIONS

Our approach enhances the capability of CPOE systems using NHI-IC cards as a nationwide infrastructure to provide more complete patient health information and medication history sharing among hospitals in Taiwan. Thus, our system can provide a better prescribing tool to help physicians detect potential duplicate medications for frequent doctor-shopping patients and hence enhance patient safety across hospital boundaries. However, the effectiveness of detecting duplicate medications with our approach is very much dependent on the completeness of NHI-IC cards, which in turn primarily depends on physician use of the cards when prescribing.

Potentially inappropriate medication in elderly hospitalized patients

Balanced and safe prescribing is difficult to achieve in frail older adults with multiple comorbid diseases. This issue is of particular concern, especially in elderly hospitalized patients because hospitalization exposes such individuals to an increased risk of adverse drug reactions (ADRs). The avoidance of medications that are considered to be inappropriate is among the interventions for treatment options in elderly patients. A potentially inappropriate medication (PIM) is a drug in which the risk of an adverse event outweighs its clinical benefit, particularly when there is a safer or more effective alternative therapy for the same condition. Explicit criteria have been developed to identify PIMs and among these, Beers' criteria are the most frequently applied in the literature. However, evidence suggests that such criteria cannot easily be applied to elderly hospitalized people in European countries; approximately 20% of drugs listed in Beers' criteria are rarely prescribed or are not available in Europe, and Beers' listed PIMs are not associated with inhospital mortality, length of hospital stay and/or ADRs in Italian studies. On the contrary, ADRs can contribute to accelerated functional decline in elderly hospitalized patients independently of the use of Beers' listed PIMs. Therefore, we will review the evidence pertaining to the application of Beers' criteria in elderly hospitalized patients, while focusing on Italian studies that have investigated the role of PIMs as potential predictors of negative hospital outcomes. In addition, we will also review the available evidence regarding new European criteria on identifying PIMs, because clinical application in elderly hospitalized Europeans is still under investigation.

What types of inappropriate prescribing predict adverse drug reactions in older adults?

Adverse drug events happen all too often in older adults, but we still do not have a clear understanding of potentially modifiable risk factors, with the exception of polypharmacy. This paper critiques the article in this issue of The Annals entitled, "Inappropriate Prescribing Predicts Adverse Drug Events in Older Adults." A validated measure for self-reported adverse drug events was used, along with a modified measure for inappropriate prescribing that we developed nearly 2 decades ago (ie, Medication Appropriateness Index). Besides discussing the strengths and weaknesses of this article, we also recommend future research directions in this area.

Polypharmacy in older adults with cancer

The definition of "polypharmacy" ranges from the use of a large number of medications; the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication. Older adults are particularly at risk because they often present with several medical conditions requiring pharmacotherapy. Cancer-related therapy adds to this risk in older adults, but few studies have been conducted in this patient population. In this review, we outline the adverse outcomes associated with polypharmacy and present polypharmacy definitions offered by the geriatrics literature. We also examine the strengths and weaknesses of these definitions and explore the relationships among these definitions and what is known about the prevalence and impact of polypharmacy.

A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management

RATIONALE, AIMS AND OBJECTIVES

To evaluate if an integrated medicines management can lead to a more appropriate drug use in elderly inpatients.

METHOD

The study was an intervention study at a department of internal medicine in southern Sweden. During the intervention period pharmacists took part in the daily work at the wards. Systematic interventions aiming to identify, solve and prevent drug-related problems (DRPs) were performed during the patient's hospital stay by multidisciplinary teams consisting of physicians, nurses and pharmacists. DRPs identified by the pharmacist were put forward to the care team and discussed. Medication Appropriateness Index (MAI) was used to evaluate the appropriateness in the patients' drug treatment at admission, discharge and 2 weeks after discharge. In total 43 patients were included, 28 patients in the intervention group and 25 patients in the group which was used as control.

RESULTS

For the intervention group there was a significant decrease in the number of inappropriate drugs compared with the control group (P = 0.049). Indication, duration and expenses were the MAI-dimensions with most inappropriate ratings, and the drugs with most inappropriate ratings were anxiolytics, hypnotics and sedatives.

CONCLUSION

This kind of systematic approach on drug therapy can result in a more appropriate drug use in the elderly.

Drug-drug interactions in a geriatric outpatient cohort: prevalence and relevance

BACKGROUND

The prevalence of drug-drug interactions (DDIs) in a geriatric population may be high because of polypharmacy. However, wide variance in the clinical relevance of these interactions has been shown.

OBJECTIVES

To explore whether adverse drug reactions (ADRs) as a result of DDIs can be identified by clinical evaluation, to describe the prevalence of ADRs and diminished drug effectiveness as a result of DDIs and to verify whether the top ten most frequent potential DDIs known to public pharmacies are of primary importance in geriatric outpatients in the Netherlands.

METHOD

All adverse events classified by the Naranjo algorithm as being a possible ADR and drug combinations resulting in diminished drug effectiveness were identified prospectively in 807 geriatric outpatients (mean age 81 years) at their first visit. The setting was a diagnostic day clinic. The Medication Appropriateness Index (MAI) and Beers criteria were used to evaluate drug use and identify possible DDIs. The ten most frequent potential interactions, according to a 1997 national database of public pharmacies ('Top Ten') in the Netherlands, and possible adverse events as a result of other interactions, were described. The effects of changes in medication regimen were recorded by checking the medical records.

RESULTS

In 300 patients (44.5% of the 674 patients taking more than one drug), 398 potential DDIs were identified. In 172 (25.5%) of patients taking more than one drug, drug combinations were identified that were responsible for at least one ADR or which possibly resulted in reduced effectiveness of therapy. Eighty-four of the 158 possible ADRs resulting from enhanced action of drugs forming combinations listed in the 'Top Ten' were seen in 73 patients. Only four DDIs resulting in less effective therapy that involved drug combinations in the 'Top Ten' were identified. Changes in drug regimens pertaining to possible interactions were proposed or put into effect in 111 of the 172 (65%) patients with possible DDIs. Sixty-one (55%) of these patients returned for follow-up. Of these, 49 (80%) were shown to have improved after changes were made to their medication regimen.

CONCLUSION

In this study, nearly half of the geriatric outpatients attending a diagnostic day clinic who were taking more than one drug were candidates for DDIs. One-quarter of these patients were found to have possible adverse events or diminished treatment effectiveness that may have been at least partly caused by these DDIs. These potential interactions can be identified through clinical evaluation. In the majority of patients (99 of 172) the potential interactions resulting in possible ADRs or diminished effectiveness were not present in the 'Top Ten' interactions described by a national database of public pharmacies, a finding that emphasizes that the particular characteristics of geriatric patients (e.g. frequent psychiatric co-morbidities) need to be considered when evaluating their drug use. At least 7% of all patients taking more than one drug, and 80% of those with possible drug interactions whose drug regimen was adjusted, benefited from changes made to their drug regimens.

Acute hospital care for the elderly patient: its impact on clinical and hospital systems of care

A significant portion of hospital care involves elderly patients who have frequent and severe disease presentations, higher risk of iatrogenic injury during hospitalization, and greater baseline vulnerability. These risks frequently result in longer and more frequent hospitalizations. The frailty and complication rates of the elderly population underscore the importance of hospital-based programs of education and screening for cognitive and functional impairments to determine risk and needed additional care and services during hospitalization and at discharge. In addition, physicians are needed to take the lead in instituting programs of prevention and improving the systems of care. It is such a multi-tiered approach, with interventions in the areas of education, screening, prevention, and systems of care improvements, that is needed to improve the clinical care and outcomes of the hospitalized elderly patient.

Polypharmacy in elderly patients

BACKGROUND

Polypharmacy (ie, the use of multiple medications and/or the administration of more medications than are clinically indicated, representing unnecessary drug use) is common among the elderly.

OBJECTIVE

The goal of this research was to provide a description of observational studies examining the epidemiology of polypharmacy and to review randomized controlled studies that have been published in the past 2 decades designed to reduce polypharmacy in older adults.

METHODS

Materials for this review were gathered from a search of the MEDLINE database (1986-June 2007) and International Pharmaceutical Abstracts (1986-June 2007) to identify articles in people aged >65 years. We used a combination of the following search terms: polypharmacy, multiple medications, polymedicine, elderly, geriatric, and aged. A manual search of the reference lists from identified articles and the authors' article files, book chapters, and recent reviews was conducted to identify additional articles. From these, the authors identified those studies that measured polypharmacy.

RESULTS

The literature review found that polypharmacy continues to increase and is a known risk factor for important morbidity and mortality. There are few rigorously designed intervention studies that have been shown to reduce unnecessary polypharmacy in older adults. The literature review identified 5 articles, which are included here. All studies showed an improvement in polypharmacy.

CONCLUSIONS

Many studies have found that various numbers of medications are associated with negative health outcomes, but more research is needed to further delineate the consequences associated with unnecessary drug use in elderly patients. Health care professionals should be aware of the risks and fully evaluate all medications at each patient visit to prevent polypharmacy from occurring.

Medication inappropriateness for older adults receiving hospice care: a pilot survey

OBJECTIVE

To test the feasibility and reliability of a tool and methodology for evaluating expert clinicians' perceptions about the application of the Beers criteria in hospice.

DESIGN

A pilot survey.

SETTING

A national medication therapy management provider specializing in hospice care.

PARTICIPANTS

Thirty-five participants from a multidisciplinary panel were invited to complete the survey. They were selected to represent acute, long-term care, and community practice settings with various levels of experience and judgment.

INTERVENTION

Respondents were asked to complete the survey by rating their agreement or disagreement with the inappropriateness of the medications or medication classes for hospice patients, using a five-point Likert scale from strongly agree (1) to strongly disagree (5), with the midpoint (3) expressing equivocation.

MAIN OUTCOME MEASURES

Feasibility as measured by the percentage of returned and completed surveys. A secondary aim was to measure inter-rater reliability and response.

RESULTS

Twenty-four clinicians (69%) completed the survey, including 13 clinical pharmacists, 6 nurses, and 5 physicians. Twenty-nine responses (2%) were furnished by imputation methods. The intraclass correlation for medication inappropriateness for hospice patients was 0.89 (0.81-0.95), indicating "good" inter-rater reliability. Short-acting benzodiazepines, gastrointestinal antispasmodics, anticholinergics, and antihistamines were considered appropriate for use in older hospice patients, but they are considered inappropriate according to the Beers criteria.

CONCLUSION

We established a viable methodology for evaluating clinician judgment about medication inappropriateness in older hospice patients. Some medications routinely considered to be inappropriate may be appropriate at end of life; different criteria may be needed to determine medication inappropriateness in hospice care.

Inappropriate prescribing in older people

Optimal prescribing is critical to the goals of geriatric medicine of curing disease, eliminating or reducing symptoms, and improving functioning. However, prescribing decisions in older people are often complex. There is marked heterogeneity in health status and functional capacity amongst older people, who range from fit, active, independent individuals to those who are physically and mentally frail, with limited physiological reserve. Age-related changes in physiology affect drug pharmacokinetics and pharmacodynamics, and together with various pathological processes, increase the risk of adverse drug events (ADEs). This risk is heightened by prescription of multiple medications to treat multiple co-morbidities. Consequently, balancing safety and quality of prescribing for older people with appropriate treatment of all co-morbidities can be challenging.

Duplicative medications in patients who visit multiple medical institutions among the insured of a corporate health insurance society in Japan

OBJECTIVE

The objective of this paper is to describe the frequency of duplicative medication use and to estimate the drug cost associated with duplicative medications in patients who visit multiple medical institutions in Japan.

METHODS

The subjects of this study were insurants of a corporate health insurance society. We examined claims of insurants who received prescriptions from multiple medical institutions in April 2002. We examined characteristics of insurants who received duplicative medications and calculated the cost of duplicated drugs.

RESULTS

8.8% received drugs with the same mechanism of action for overlapping administration periods. In terms of comparison among three age groups, 0-19 years old, 20-69 years old, and 70 years old or older, the percentage was higher in 0-19-year-old patients than in the other age groups. The cost of duplicated drugs was found to be 0.7% or 0.5% of the total drug cost, when calculated with higher-priced drugs and lower-priced drugs, respectively.

CONCLUSIONS

This study suggests that pediatric and teenage patients as well as elderly patients require prudent management of medication to avoid duplicative medications and that at least an estimated 5.2-7.2 billion yen may be saved if duplicative medications can be completely eliminated nationwide.

Prevalence of inappropriate prescribing in primary care

OBJECTIVE

To describe the prevalence of inappropriate prescribing in primary care in Copenhagen County, according to the Medication Appropriateness Index (MAI) and to identify the therapeutic areas most commonly involved.

SETTING

A cross-sectional study was conducted among 212 elderly ( >65 years) polypharmacy patients (five or more different medications) listed to 41 general practitioners (GPs) in the County of Copenhagen.

METHOD

Patients exposed to polypharmacy were identified via the database recording the drug subsidy system of Danish pharmacies. For each patient, data were collected on subsidised medications prescribed over 3 months by the patients' own GPs. The GPs were asked to provide baseline information regarding the patients' medical history and detailed information regarding the subsidised and non-subsidised medications prescribed to the patients. A MAI was scored for medication prescribed to the patients. Topical, dermatological medications and medications not used regularly were excluded.

RESULTS

212 patients were prescribed 1621 medications by their GPs at baseline. In all, 640 (39.5%) of the medications had one or more inappropriate ratings in the 10 criteria making up the MAI. The main part of the patients (94.3%) had one or more inappropriate ratings among their medications. A total of 12.3% of the medications were rated as 'not indicated', 6% were rated as 'ineffective', 6.7% were given in an incorrect dose, 0.7% were prescribed with incorrect directions, 1.3% had impractical directions, 0.7% of the drugs had clinically significant drug-drug interactions, 8.6% had clinically significant drug-disease/condition interactions, 3.1% were unnecessary duplications, 16.5% were given in an unacceptable duration and 27.1% of the medications were not the least expensive alternative. The therapeutic groups most commonly involved in inappropriate prescribing were medications for treatment of peptic ulcer, cardiovascular medications, anti-inflammatory medications, antidepressants, hypnotics and anti-asthmatics.

CONCLUSION

The overall prescribing quality in primary care in Copenhagen County, Denmark is good. However, the majority of patients used one or more medications with inappropriate ratings. The inappropriate prescribing relates to specific therapeutic groups and criteria, which should be targeted in future interventions.

Retrospective evaluation of medication appropriateness and clinical pharmacist drug therapy recommendations for home-based primary care veterans

BACKGROUND

The Medication Appropriateness Index (MAI) has demonstrated reliability in several outpatient settings. Clinical pharmacists play key roles as members of an interdisciplinary team in determining medication appropriateness.

OBJECTIVE

The goal of this study was to examine medication appropriateness using the MAI and the degree of recommendation acceptance associated with clinical pharmacist medication reviews for veterans enrolled in the Home-Based Primary Care (HBPC) program.

METHODS

A retrospective analysis of clinical pharmacist medication reviews was performed by accessing the computerized patient medical record. Patients included in the study were enrolled in the HBPC program between March 2002 and January 2004. The data were examined to determine a total MAI score associated with medication recommendations after each review. The number and types of pharmacist recommendations, their acceptance rate, and the total number of medications discontinued were also evaluated.

RESULTS

Seventy-nine patients (mean [SD] age, 75.3 [10.3] years) identified through the pharmacy database met the inclusion criteria and were included in the study. No patients identified were excluded from the analysis. A statistically significant decrease in the overall MAI score was observed from the initial review to the end of the study (P < 0.001). Recommendations to patients' primary care providers included medication initiation/discontinuation, laboratory monitoring, dosage adjustment, and other issues associated with appropriate prescribing that could be categorized using the MAI. Recommendations to home health nurses included monitoring for medication adherence, efficacy, and adverse events. Pharmacist recommendation acceptance rates for primary care providers and home health nurses were 69% and 56%, respectively. Overall, 121 medications were discontinued during the study period.

CONCLUSIONS

By using the MAI for evaluation, pharmacist recommendations significantly improved the appropriateness of medication use among veterans receiving home health care. A majority of pharmacist recommendations were accepted.