Effect of a Collaborative Approach on the Quality of Prescribing for Geriatric Inpatients: A Randomized, Controlled Trial

Abstract

OBJECTIVES: To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management (GEM) care on the appropriateness of prescribing. DESIGN: Randomized, controlled trial, with the patient as unit of randomization. SETTING: Acute GEM unit. PARTICIPANTS: Two hundred three patients aged 70 and older. INTERVENTION: Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients. MEASUREMENTS: Appropriateness of prescribing on admission, at discharge, and 3 months after discharge, using the Medication Appropriateness Index (MAI), Beers criteria, and Assessing Care of Vulnerable Elders (ACOVE) underuse criteria and mortality, readmission, and emergency visits up to 12 months after discharge. RESULTS: Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge (odds ratio (OR)=9.1, 95% confidence interval (CI)=4.2–21.6 and OR=6.1, 95% CI=2.2–17.0, respectively). The control and intervention groups had comparable improvements in the Beers criteria. CONCLUSION: Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge. This is an important finding, because only limited data exist on the effect of various strategies to improve medication use in elderly inpatients. The present approach has the potential to minimize risk and improve patient outcomes.

Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits

“…In agreement with these results, a previous study showed a reduction in the number of drugs with at least one inappropriate rating after implementation of the LIMM model [10]. A number of earlier controlled studies on pharmaceutical care, integrated medicines management or other collaborative approaches in hospitalised patients have also shown improvements in the appropriateness of medications (decrease in the MAI scores) [9,28,29].…”

“…Nonetheless, we have presented the MAI scores in this study in order to facilitate comparison with previous studies. In our study, the average patient MAI score in the intervention group at discharge was lower than that in most other studies (indicating more appropriate prescribing) [9,10,28,29]. However, because the control group also had a very low patient MAI score, there were no apparent differences between the groups.…”

“…When the per-protocol population and the nonblinded MAI assessment were analysed, the difference between the groups was larger, suggesting that the effect of the intervention may have been underestimated in the main analysis. The use of a blinded outcome assessment, as in our study and two other hospital-based MAI studies [29,31], strengthens the validity of the MAI ratings in comparison with those from other studies, which used reviewers who were not blind to group allocation [9,10,28].…”

“…This measure has also previously been used by others [20,28]. By using that measure we could avoid summing or subtracting scores, which is generally not recommended when dealing with ordered categorical data (i.e.…”

Potentially Inappropriate Home Medications Among Older Patients With Cardiovascular Disease Admitted to a Cardiology Service in Usa

“…Strategies that were shown to be effective in reducing the use of PIMs include provider education and detailed assessment of home medication lists upon hospital admission by a multidisciplinary team, which involves geriatricians and specialized clinical pharmacists [22][23][24][25]. Polypharmacy should provoke attempts to stop unnecessary medications and drugs that are prone to be prescribed inappropriately; CNS-active drugs, PPIs, NSAIDs, NOACs, diuretics, and digoxin should be carefully evaluated and monitored.…”