Abstract
Background Polypharmacy in older patients can lead to potentially inappropriate prescribing. The risk of the latter calls for effective medication review to ensure proper medication usage and safety. Objective Provide insight on the similarities and differences of medication review done in multiple ways that may lead to future possibilities to optimize medication review. Setting This study was conducted in Zuyderland Medical Centre, the second largest teaching hospital in the Netherlands. Method This descriptive study compares the quantity and content of remarks identified by medication review performed by a geriatrician, outpatient pharmacist, and Clinical Decision Support System. The content of remarks is categorized in seven categories of possible pharmacotherapeutic problems: ‘indication without medication’, ‘medication without indication’, ‘contra-indication/interaction/side-effect’, ‘dosage problem’, ‘double medication’, ‘incorrect medication’ and ‘therapeutic drug monitoring’. Main outcome measure Number and content of remarks on medication review. Results The Clinical Decision Support System (1.8 ± 0.8 vs. 0.9 ± 0.9, p < 0.001) and outpatient pharmacist (1.8 ± 0.8 vs. 0.9 ± 0.9, p = 0.045) both noted remarks in significantly more categories than the geriatricians. The Clinical Decision Support System provided more remarks on ‘double medication’, ‘dosage problem’ and ‘contraindication/interaction/side effects’ than the geriatrician (p < 0.050), while the geriatrician did on ‘medication without indication’ (p < 0.001). The Clinical Decision Support System noted significantly more remarks on ‘contraindication/interaction/side effects’ and ‘therapeutic drug monitoring’ than the outpatient pharmacist, whereas the outpatient pharmacist reported more on ‘indication without medication’ and ‘medication without indication’ than the Clinical Decision Support System (p ≤ 0.007). Conclusion Medication review performed by a geriatrician, outpatient pharmacist, and Clinical Decision Support System provides different insights and should be combined to create a more comprehensive report on medication profiles.
Highlights
As the general population ages, the number of older patients (≥ 65 years) in hospitals increases [1,2,3,4,5]
The Clinical rule reporter (CRR) is a Clinical Decision Support Systems (CDSSs) that is developed in the Zuyderland Medical Centre
Categorizing medication to ATC code, we see ≥ 40% of the patients use pump inhibitors (PPIs), vitamin D, anticoagulants, diuretics, beta blocking agents, agents acting on the renin–aldosterone–angiotensin system (RAAS), and statins (“Appendix 1”)
Summary
As the general population ages, the number of older patients (≥ 65 years) in hospitals increases [1,2,3,4,5]. These (ill) older patients make for a vulnerable group This vulnerability is caused by factors such as reduced selfreliance due to multimorbidity, reduced cognitive skills, malnutrition, and physical constraints [6,7,8]. Because of their multimorbidity, polypharmacy (≥ 5 medicines) is common in this group. The risk of the latter calls for effective medication review to ensure proper medication usage and safety
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