International Journal of Clinical Pharmacy

, Volume 37, Issue 6, pp 1194–1205 | Cite as

Impact of an enhanced pharmacy discharge service on prescribing appropriateness criteria: a randomised controlled trial

  • Benjamin J. BasgerEmail author
  • Rebekah J. Moles
  • Timothy F. Chen
Research Article


Background Older people are at increased risk of drug-related problems (DRPs) caused by inappropriate use or underuse of medications which may be increased during care transitions. Objective To examine the effects of applying a validated prescribing appropriateness criteria-set during medication review in a cohort of older (≥65 years) Australians at the time of discharge from hospital. Setting Private hospital and homes of older patients in Sydney, Australia. Methods Cognitively well English speaking patients aged 65 years or over taking five or more medications were recruited. A prescribing appropriateness criteria-set and SF-36 health-related quality of life health (HRQoL) survey were applied to all patients at discharge. Patients were then randomly assigned to receive either usual care (control, n = 91) or discharge medication counselling and a medication review by a clinical pharmacist (intervention, n = 92). Medication review recommendations were sent to the general practitioners of intervention group patients. All patients were followed up at 3 months post discharge, where the prescribing appropriateness criteria-set was reapplied and HRQoL survey repeated. Main outcome measures change in the number of prescribing appropriateness criteria met; change in HRQoL; number and causes of DRPS identified by medication review; intervention patient medication recommendation implementation rates. Results There was no significant difference in the number of criteria applicable and met in intervention patients, compared to control patients, between follow-up and discharge (0.09 ≤ p ≤ 0.97). While the difference between groups was positive at follow-up for SF-36 scores, the only domain that reached statistical significance was that for vitality (p = 0.04). Eighty-eight intervention patient medication reviews identified 750 causes of DRPs (8.5 ± 2.7 per patient). No causes of DRPs were identified in four patients. Of these causes, 76.4 % (573/750) were identified by application of the prescribing appropriateness criteria-set. GPs implemented a relatively low number (42.4 %, 318/750) of recommendations. Conclusion Application of a prescribing appropriateness criteria-set during medication review in intervention patients did not increase the number of criteria met, nor result in a significant improvement in HRQoL. Higher recommendation implementation rates may require additional facilitators, including a higher quality of collaboration.


Australia DRPs Drug-related problems Inappropriate prescribing Overprescribing Prescribing appropriateness criteria Private hospital Underprescribing 



We acknowledge the support and assistance of the Medical Board of Wolper Jewish Hospital, Woollahra, Sydney, its nursing staff, rehabilitation specialists, resident medical officers and its former Chief Executive Officer, Mr Harry Aizenberg.



Conflicts of interest

The authors declare no conflict of interest.

Supplementary material

11096_2015_186_MOESM1_ESM.docx (23 kb)
Supplementary material 1 (DOCX 22 kb)


  1. 1.
    O’Connor MN, Gallagher P, O’Mahony D. Inappropriate prescribing. Criteria, detection and prevention. Drugs Aging. 2012;29(6):437–52.CrossRefPubMedGoogle Scholar
  2. 2.
    O’Sullivan D, O’Mahony D, O’Connor MN, Gallagher P, Cullinan S, O’Sullivan R, et al. The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients. Drugs Aging. 2014;31(6):471–81.CrossRefPubMedGoogle Scholar
  3. 3.
    Ellitt GR, Engblom E, Aslani P, Westerlund T, Chen TF. Drug related problems after discharge from an Australian teaching hospital. Pharm World Sci. 2010;32(5):622–30.CrossRefPubMedGoogle Scholar
  4. 4.
    Garcia-Caballos M, Ramos-Diaz F, Jimenez-Moleon JJ, Bueno-Cavanillas A. Drug-related problems in older people after hospital discharge and interventions to reduce them. Age Ageing. 2010;39(4):430–8.CrossRefPubMedGoogle Scholar
  5. 5.
    Braund R, Coulter CV, Bodington AJ, Giles LM, Greig A-M, Heaslip LJ, et al. Drug related problems identified by community pharmacists on hospital discharge prescriptions in New Zealand. Int J Clin Pharm. 2014;36(3):498–502.CrossRefPubMedGoogle Scholar
  6. 6.
    Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Hospital-initiated transitional care interventions as a patient safety strategy. Ann Intern Med. 2013;158(5 Pt 2):433–40.CrossRefPubMedGoogle Scholar
  7. 7.
    Kahn JM, Angus DC. Going home on the right medicines. Prescription errors and transitions of care. JAMA. 2011;306(8):878–9.CrossRefPubMedGoogle Scholar
  8. 8.
    Basger BJ, Chen TF, Moles RJ. Inappropriate medication use and prescribing indicators in elderly Australians. Drugs Aging. 2008;25(9):777–93.CrossRefPubMedGoogle Scholar
  9. 9.
    Basger BJ, Chen TF, Moles RJ. Validation of prescribing appropriateness criteria for older Australians using the RAND/UCLA appropriateness method. BMJ Open doi: 10.1136/bmjopen-2012-001431. 2012. Cited 01 Jul 2015.
  10. 10.
    de Consenso Comite. Third consensus of Grenada on drug related problems (DRP) and negative outcomes associated with medicines. Ars Pharm. 2007;48:5–17.Google Scholar
  11. 11.
    Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533–43.PubMedGoogle Scholar
  12. 12.
    Van Mil JWF, Westerlund T, Hersberger T, Schaefer MA. Drug-related problem classification systems. Ann Pharmacother. 2004;38(5):859–67.CrossRefPubMedGoogle Scholar
  13. 13.
    Tarrant C, Windridge K, Baker R, Freeman G, Boulton M. Falling through gaps: primary care patients accounts of breakdowns in experienced continuity of care. Family Pract. 2015;32(1):82–7.CrossRefGoogle Scholar
  14. 14.
    Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P, Kalkman C, et al. Improving patient handovers from hospital to primary care. A syst Rev. Ann Intern Med. 2012;157(6):417–28.CrossRefGoogle Scholar
  15. 15.
    Correr CJ, Melchiors AC, de Souza TT, Rotta I, Salgado TM, Fernandez-Llimos F. A tool to characterize the components of pharmacist interventions in clinical pharmacy services: the DEPICT project. Ann Pharmacother. 2013;47(7–8):946–52.CrossRefPubMedGoogle Scholar
  16. 16.
    Patterson SM, Cadogan CA, Kerse N, Cardwell CR, Bradley MC, Ryan C, et al. Interventions to improve the appropriate use of polypharmacy for older people. Cochrane Database Syst Rev; doi: 10.1002/14651858.CD008165.pub3 2014. Cited 1 Jul 2015.
  17. 17.
    Leppin AL, Gionfriddo MR, Kessler ML, Brito JP, Mair F, Gallacher K, et al. Preventing 30-day hospital readmissions. A systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095–107.PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Basger BJ, Chen TF, Moles RJ. Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians. Int J Pharm Pract. 2012;20(3):172–82.CrossRefPubMedGoogle Scholar
  19. 19.
    Australian Institute of Health and Welfare. Australia’s Health 2012. Australia’s health series no.13. Cat. no. AUS 156. Canberra 2012. Cited 1 Jul 2015.
  20. 20.
    Department of Health and Ageing. Expenditure and prescriptions twelve months to 30 June 2013. Commonwealth Government, Canberra. Cited 1 Jul 2015.
  21. 21.
    O’Halloran J, Britt H, Valenti L, Harrison C, Pan Y, Knox S. Older patients attending general practice in Australia 2000–2002 General Practice Series No. 12, General Practice Statistics and Classification Unit. Australian Institute of Health and Welfare 1–147. Canberra. 2003. Cited 1 Jul 2015.
  22. 22.
    Britt H, Miller GC, Henderson J, Charles J, Valenti L, Harrison C, et al. A decade of Australian general practice activity 2003–2004 to 2012–2013. Bettering the Evaluation and Care of Health (BEACH) 2013. Cited 1 Jul 2015.
  23. 23.
    Malone DC, Carter BL, Billups SJ, Valuck RJ, Barnette DJ, Sintek CD, et al. Can clinical pharmacists affect SF-36 scores in veterans at high risk for medication-related problems? Med Care. 2001;39(2):113–22.CrossRefPubMedGoogle Scholar
  24. 24.
    Contopoulos-Ioannidis DG, Karvouni A, Kouri I, Ioannidis JPA. Reporting and interpretation of SF-36 outcomes in randomised trials: systematic review BMJ; doi: 10.1136/bmj.a3006. 2009. Cited 1 Jul 2015.
  25. 25.
    Burholt V, Nash P. Short Form 36 (SF-36) health survey questionnaire: normative data for Wales. J Pub Health. 2011;33(4):587–603.CrossRefGoogle Scholar
  26. 26.
    Midlov P, Bondesson A, Eriksson T, Petersson J, Minthon L, Hoglund P. Descriptive study and pharmacotherapeutic intervention in patients with epilepsy or Parkinsons disease at nursing homes in southern Sweden. Eur J Clin Pharmacol. 2002;57(12):903–10.CrossRefPubMedGoogle Scholar
  27. 27.
    Stadnyk K, Calder J, Rockwood K. Testing the measurement properties of the Short Form-36 health survey in a frail elderly population. J Clin Epidemiol. 1998;51(10):827–35.CrossRefPubMedGoogle Scholar
  28. 28.
    World Health Organisation. The High 5 s Project standard operating protocol. Assuring medication accuracy in transitions of care: medication reconciliation. 2014. Cited 1 Jul 2015.
  29. 29.
    Cotta MO, Robertson MS, Upjohn LM, Marshall C, Liew D, Buising KL. Using periodic post-prevalence surveys to assess appropriateness of antimicrobial prescribing in Australian private hospitals. Intern Med J. 2013;44(3):240–6.CrossRefGoogle Scholar
  30. 30.
    Castelino RL, Bajorek BV, Chen TF. Are interventions recommended by pharmacists during home medicines review evidence-based? J Eval Clin Pract. 2011;17(1):104–10.CrossRefPubMedGoogle Scholar
  31. 31.
    Basger BJ, Moles RJ, Chen TF. Development of an aggregated system for classifying causes of drug-related problems. Ann Pharmacother. 2015;49(4):405–18.CrossRefPubMedGoogle Scholar
  32. 32.
    Ware JE, Gandek B. Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project. J Clin Epidemiol. 1998;51(11):903–12.CrossRefPubMedGoogle Scholar
  33. 33.
    Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). Conceptual framework and item selection. Med Care. 1992;30(6):473–83.CrossRefPubMedGoogle Scholar
  34. 34.
    Ernst ME, Iyer SS, Doucette WR. Drug-related problems and quality of life in arthritis and low back pain sufferers. Value Health. 2003;6(1):51–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Frendl DM, Ware JE. Patient-reported functional health and well-being outcomes with drug therapy. A systematic review of randomised trials using the SF-36 health survey. Med Care. 2014;52(5):439–45.CrossRefPubMedGoogle Scholar
  36. 36.
    Family Medicine Research Centre. Bettering the evaluation and care of health (BEACH). The University of Sydney. 2014.; Cited 1 Jul 2015.
  37. 37.
    Australian Institute of health and Welfare 2007. Older Australia at a glance: 4th edition. 2007. Cited 1 Jul 2015.
  38. 38.
    Hill-Taylor B, Skeris I, Hayden J, Byrne S, O’Sullivan D, Christie R. Application of the STOPP/START criteria: a systematic review of the prevalence of potentially inappropriate prescribing in older adults, and evidence of clinical, humanistic and economic impact. J Clin Pharm Ther. 2013;38(5):360–72.CrossRefPubMedGoogle Scholar
  39. 39.
    Kwint H-F, Bermingham L, Faber A, Gussekloo J, Bouvy ML. The relationship between the extent of collaboration of general practitioners and pharmacists and the implementation of recommendations arising from medication review. A syst Rev. Drugs Aging. 2013;30(2):91–102.CrossRefGoogle Scholar
  40. 40.
    Geurts MM, Talsma J, Brouwers JRBJ, de Gier JJ. Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient: a systematic review. Br J Clin Pharmacol. 2012;74(1):16–33.PubMedCentralCrossRefPubMedGoogle Scholar
  41. 41.
    Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–84.CrossRefPubMedGoogle Scholar
  42. 42.
    Milos V, Rekman E, Bondesson A, Eriksson T, Jakobsson U, Westerlund T, et al. Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled trial. Drugs Aging. 2013;30(4):235–46.CrossRefPubMedGoogle Scholar
  43. 43.
    MacKeigan LD, Nissen LM. Clinical pharmacy services in the home. Dis Manage Health Outcomes. 2008;16:227–44.CrossRefGoogle Scholar
  44. 44.
    Gallagher P, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845–54.CrossRefPubMedGoogle Scholar
  45. 45.
    Gilbert AL, Roughead EE, Beilby J, Mott K, Barratt JD. Collaborative medication management services: improving patient care. Med J Aust. 2002;177(4):189–92.PubMedGoogle Scholar
  46. 46.
    Costa D, Van C, Abbott P, Krass I. Investigating general practitioner engagement with pharmacists in home medicines review. J Interprof Care. 2015;. doi: 10.3109/13561820.2015.1012253.PubMedGoogle Scholar
  47. 47.
    Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (screening tool of older person’s prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.CrossRefPubMedGoogle Scholar
  48. 48.
    National Institute of Clinical Studies. Evidence-practice gaps report Vol. 1. Australian Government. 2003; Cited 1 Jul 2015.
  49. 49.
    National Institute of Clinical Studies. Evidence-practice gaps report Vol. 2. Australian Government. 2005; Cited 1 Jul 2015.
  50. 50.
    National Institute of Clinical Studies. Evidence-practice gaps report, vol. 1. A review of developments 2004–2007. Australian Government. 2008; Cited 1 Jul 2015.
  51. 51.
    Grimes TC, Deasy E, Allen A, O’Byrne J, Delaney T, Barragry J, et al. Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study. BMJ Qual Saf. 2014;23(7):574–83.PubMedCentralCrossRefPubMedGoogle Scholar
  52. 52.
    Cherubini A, Corsonello A, Lattanzio F. Underprescription of beneficial medicines in older people: causes, consequences and prevention. Drugs Aging. 2012;29(6):463–75.CrossRefPubMedGoogle Scholar
  53. 53.
    Larsen MD, Rosholm JU, Hallas J. The influence of comprehensive geriatric assessment on drug therapy in elderly people. Eur J Clin Pharmacol. 2014;70(2):233–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Barry AR, Loewen PS, de Lemos J, Lee KG. Reasons for non-use of proven pharmacotherapeutic interventions: systematic review and framework development. J Eval Clin Pract. 2012;18(1):49–55.CrossRefPubMedGoogle Scholar
  55. 55.
    Dalleur O, Boland B, Losseau C, Henrard S, Wouters D, Speybroeck N, et al. Reduction of potentially inappropriate medications using the STOPP criteria in frail older inpatients: a randomised controlled trial. Drugs Aging. 2014;31(4):291–8.CrossRefPubMedGoogle Scholar
  56. 56.
    Cullinan S, O’Mahony D, Fleming A, Byrne S. A meta-synthesis of potentially inappropriate prescribing in older patients. Drugs Aging. 2014;31(8):631–8.CrossRefPubMedGoogle Scholar
  57. 57.
    Denneboom W, Dautzenberg MGH, Grol R, De Smet PAGM. Comparison of two methods for peforming treatment reviews by pharmacists and general practitioners for home-dwelling elderly people. J Eval Clin Pract. 2008;14(3):446–52.CrossRefPubMedGoogle Scholar
  58. 58.
    Fisher A, Bassett K, Wright JM, Brookhart MA, Freeman HJ, Dormuth CR. Prescriber preference for a particular tumour necrosis factor antagonist drug and treatment discontinuation: population-based cohort. BMJ Open. 2014;doi: 10.1136/bmjopen-2014-005532 Cited 1 Jul 2015.
  59. 59.
    de Almeida Neto AC. Chen TF. When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making. Pharm World Sci. 2008;30(1):3–8.PubMedCentralCrossRefPubMedGoogle Scholar
  60. 60.
    Dy SM, Pfoh ER, Salive ME, Boyd CM. Health-related quality of life and functional status quality indicators for older persons with multiple chronic conditions. J Am Geriatr Soc. 2013;61(12):2120–7.PubMedCentralCrossRefPubMedGoogle Scholar
  61. 61.
    Okano GJ, Malone DC, Billups SJ, Carter BL, Sintek CD, Covey D, et al. Reduced quality of life in veterans at risk for drug-related problems. Pharmacotherapy. 2001;21(9):1123–9.CrossRefPubMedGoogle Scholar
  62. 62.
    Krska J, Morecroft CW, Poole H, Rowe PH. Issues potentially affecting quality of life arising from long-term medicines use: a qualitative study. Int J Clin Pharm. 2013;35(6):1161–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Muszalik M, Kornatowski T, Zielinska-Wieczkowska H, Kedziora-kornatowska K, Dijkstra A. Functional assessment of geriatric patients in regard to health-related quality of life (HRQoL). Clin Interv Aging. 2014;10:61–7.PubMedCentralCrossRefPubMedGoogle Scholar
  64. 64.
    Scott IA. Cautionary tales in the clinical interpretation of trials assessing therapy-induced changes in health status. Int J Clin Pract. 2011;65(5):536–46.CrossRefPubMedGoogle Scholar
  65. 65.
    Sakthong P, Suksanga P, Sakulbumrungsil R, Winit-Watjana W. Development of patient-reported outcomes measure of pharmaceutical therapy for quality of life (PROMPT-QoL): a novel instrument for medication management. RSAP. 2015;11(3):315–38.PubMedGoogle Scholar
  66. 66.
    Wong FK, So C, Chau J, Law AKP, Tam SKF, McGhee S. Economic evaluation of the differential benefits of home visits with telephone calls and telephone calls only in transitional discharge support. Age Ageing. 2015;44(1):143–7.PubMedCentralCrossRefPubMedGoogle Scholar
  67. 67.
    Brazier JE, Walters SJ, Nicholl JP, Kohler B. Using the SF-36 and Euroqol on an elderly population. Qual Life Res. 1996;5(2):195–204.CrossRefPubMedGoogle Scholar
  68. 68.
    Hubbard RE, Peel NM, Scott IA, Martin JH, Smith A, Pillans PI, et al. Polypharmacy among inpatients aged 70 years or older in Australia. MJA. 2015;202(7):373–8.PubMedGoogle Scholar
  69. 69.
    Naylor MD, Aiken LH, Kurtzman ET, Olds DM, Hirschman KB. The care span: the importance of transitional care in achieving health reform. Health Aff (Millwood). 2011;30(4):746–54.CrossRefGoogle Scholar

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015

Authors and Affiliations

  • Benjamin J. Basger
    • 1
    Email author
  • Rebekah J. Moles
    • 1
  • Timothy F. Chen
    • 1
  1. 1.Faculty of PharmacyThe University of SydneySydney, CamperdownAustralia

Personalised recommendations