TY - JOUR
T1 - Pharmacist-driven medication recognition/ reconciliation in older medical patients
AU - the ad hoc Deprescribing Study Group
AU - Chiarelli, Maria Teresa
AU - Antoniazzi, Stefania
AU - Cortesi, Laura
AU - Pasina, Luca
AU - Novella, Alessio
AU - Venturini, Francesca
AU - Nobili, Alessandro
AU - Mannucci, Pier Mannuccio
AU - Hu, Cinzia
AU - Minonzio, Francesca
AU - Fracanzani, Anna Ludovica
AU - Iuculanno, Federica
AU - Montano, Nicola
AU - Tobaldini, Eleonora
AU - Mari, Daniela
AU - Rossi, Paolo
AU - Monzani, Valter
AU - Tantardini, Francesca
AU - Peyvandi, Flora
AU - Rossio, Raffaella
PY - 2021
Y1 - 2021
N2 - 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.
AB - 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.
KW - Deprescribing
KW - Drug related problems
KW - Multimorbidity
KW - Polypharmacy
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U2 - 10.1016/j.ejim.2020.07.011
DO - 10.1016/j.ejim.2020.07.011
M3 - Article
AN - SCOPUS:85089255835
VL - 83
SP - 39
EP - 44
JO - European Journal of Internal Medicine
JF - European Journal of Internal Medicine
SN - 0953-6205
ER -