Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT)

Lorenz Van Der Linden,Isabel Spriet,Lisa Dreessen,Julie Hias,Jos Tournoy,Johan Flamaing,Koen Milisen

doi:10.1186/s12877-018-0843-y

Abstract

BackgroundInterdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Our primary aim was to evaluate whether medication reviews increased the number of IGCT-provided drug-related recommendations. Secondary aims were to reduce the number of potentially inappropriate medications (PIMs), and to identify the acceptance rate of and determinants for the number of recommendations.MethodsA before-after study was performed in older inpatients not admitted to acute geriatric wards. The before cohort received usual care (UC); the after cohort was subjected to the intervention (I), consisting of a systematic medication review, based on but not limited to the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list. The primary outcome measure was the number of IGCT-provided drug-related recommendations. Age, sex, Charlson Comorbidity Index, creatinine clearance and serum creatinine were ascertained upon enrolment. Following variables were determined on admission and at discharge: number of drugs and number as well as type of RASP-identified PIMs. Acceptance by ward-based physicians was also determined. Poisson regression was performed to identify determinants for the primary outcome measure.ResultsFifty-nine participants were enrolled (nUC = 29; nI = 30). The intervention increased the number of drug-related recommendations from a median of 0 (IQR: 0–1) to 8 (IQR: 6.75–10) (p < 0.001). The median number of accepted recommendations differed significantly as well (UC vs. I: 0.0 (0.0–0.5) vs. 3.0 (0.0–5.3); p < 0.001). In the intervention cohort, patients were discharged with fewer drugs compared to admission (UC vs. I: 108.5%, IQR: 100.0–135.8% vs. 92%, IQR: 80.5–103.5%; p = 0.002). More RASP PIMs were discontinued in the intervention cohort, with a mean difference of 1.49 RASP PIMs (95% confidence interval (CI): 0.70, 2.23; p < 0.001). Regression analysis identified two determinants: allocation to the intervention cohort with an incidence rate ratio (IRR) of 14.1 (95% CI: 8.30, 23.8) and the number of preadmission drugs with an IRR of 1.06 (95% CI: 1.03, 1.09).ConclusionsA structured medication review as part of usual IGCT care may contribute to an increased detection of drug-related problems and help to further reduce polypharmacy in older inpatients, not admitted to acute geriatric care wards.Trial registrationNCT02165618, retrospectively registered June 17, 2014.

Highlights

Interdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients
We have developed the RASP (Rationalization of Home Medication by an Adjusted STOPP in Older Patients) list, which was subsequently investigated as part of a pharmacist-led medication review in a controlled trial which took place on several acute geriatric wards in a large teaching hospital [2, 13]
There was no difference seen in the number or type of RASP Potentially inappropriate medication (PIM) at baseline in the usual care vs. intervention patients, except a higher frequency of potentially inadequate inhalation in COPD in the intervention cohort

Summary

Introduction

Interdisciplinary geriatric consultation teams (IGCT) are regularly requested to provide comprehensive geriatric assessments in older inpatients. Most interventions have been limited to the inpatient setting, which might partially be explained by the provision of increased monitoring during hospital stay and by higher baseline risk of the hospitalized patient population for adverse (drug) events, resulting in a relatively lower needed sample size for interventional studies [9]. In several trials, such interventions relied on the addition of ward-based hospital pharmacists to the multidisciplinary care team [4]. More data are still needed to corroborate previous findings on the perceived benefit of medication review in older adults and to further confirm the perceived benefits in specific subgroups [1, 4, 11, 12]

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