Clinical Pharmacy Services in Older Inpatients: An Evidence-Based Review
Hospital admissions in older adults are frequently drug related and avoidable. Clinical pharmacy interventions during hospital stay might reduce drug-related harm and reduce hospital visits. Moreover, several recent positive clinical pharmacy investigations incorporated a transitional care component to further improve medication use after discharge. It is currently unclear what the strength of evidence is and what the exact components should be of such clinical pharmacy interventions in older adults.
An evidence-based review was performed to determine the status of the evidence and also to explore whether a clinical pharmacy intervention incorporating transitional care was associated with reduced hospital visits after discharge.
Prospective controlled investigations were included if they contained a clinical pharmacy intervention that was initiated before discharge in older inpatients. Relevant quasi-experimental and randomized controlled trials were searched in MEDLINE. First, an evidence-based review was performed, including a description of the study design, characteristics, and outcomes. Major components of successful clinical pharmacy interventions were described and potential implications for clinical practice and research were determined. Second, the Fisher’s exact test was used to explore the association between transitional care and reduced hospital visits. Third, based on these findings, a medication review proposal was developed to improve medication use in older adults.
Thirty-five studies were included, with 26 randomized controlled trials. Median patient follow-up after discharge was 90 days (interquartile range 37–180 days) and investigators enrolled a median of 210 (interquartile range 110–498) study participants. On average, patients were aged 77.5 years (interquartile range 73–82.2 years). Nine randomized controlled trials had sufficient power to detect a reduction in hospital visits after discharge; this was reduced in three randomized controlled trials. Post-discharge follow-up was not associated with reduced post-discharge hospital visits (20 randomized controlled trials: follow-up vs. no follow-up: 6/11 vs. 1/9, p = 0.070). There was a significant reduction in post-discharge hospital visits in patients aged 75 years or older (12 randomized controlled trials: follow-up vs. no follow-up: 5/7 vs. 0/5, p = 0.028). A medication review proposal was developed, consisting of six steps.
Three powered randomized controlled trials were identified that found a significant association between a pharmacist-led intervention in older adults and a reduction in post-discharge hospital visits. In clinical practice, an intervention consisting of medication reconciliation, review, counseling, and post-discharge follow-up should be provided to such high-risk inpatients. Regarding research priorities, large, multi-center randomized controlled trials should be performed to generate more evidence on the impact of clinical pharmacy interventions on the patient trajectory and economic outcomes.
All authors contributed to the manuscript. The first draft was written by the first author (LVDL) and all authors commented on previous versions of the manuscripts. All authors read and approved the final manuscript.
Compliance with Ethical Standards
Lorenz Van der Linden and Isabel Spriet have received a clinical scholarship from the Clinical Research Fund of UZ Leuven.
Conflict of interest
Lorenz Van der Linden, Julie Hias, Karolien Walgraeve, Johan Flamaing, Jos Tournoy, and Isabel Spriet have no conflicts of interest that are directly relevant to the content of this article.
- 18.Cheema E, Alhomoud FK, Kinsara ASA, Alsiddik J, Barnawi MH, Al-Muwallad MA, et al. The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2018;13(3):e0193510.PubMedPubMedCentralCrossRefGoogle Scholar
- 23.Drenth-van Maanen AC, Leendertse AJ, Jansen PAF, Knol W, Keijsers C, Meulendijk MC, et al. The Systematic Tool to Reduce Inappropriate Prescribing (STRIP): combining implicit and explicit prescribing tools to improve appropriate prescribing. J Eval Clin Pract. 2018;24(2):317–22.PubMedCrossRefPubMedCentralGoogle Scholar
- 25.Guiding principles for the care of older adults with multimorbidity: an approach for clinicians: American Geriatrics Society Expert Panel on the Care of Older Adults with Multimorbidity. J Am Geriatr Soc. 2012;60(10):E1–25.Google Scholar
- 27.Van der Linden L, Hias J, Dreessen L, Milisen K, Flamaing J, Spriet I, et al. Medication review versus usual care to improve drug therapies in older inpatients not admitted to geriatric wards: a quasi-experimental study (RASP-IGCT). BMC Geriatr. 2018;18(1):155.PubMedPubMedCentralCrossRefGoogle Scholar
- 28.Van der Linden L, Decoutere L, Walgraeve K, Milisen K, Flamaing J, Spriet I, et al. Combined use of the Rationalization of Home Medication by an Adjusted STOPP in Older Patients (RASP) list and a pharmacist-led medication review in very old inpatients: impact on quality of prescribing and clinical outcome. Drugs Aging. 2017;34(2):123–33.PubMedCrossRefPubMedCentralGoogle Scholar
- 30.Rasmussen MK, Ravn-Nielsen LV, Duckert ML, Lund ML, Henriksen JP, Nielsen ML, et al. Cost-consequence analysis evaluating multifaceted clinical pharmacist intervention targeting patient transitions of care from hospital to primary care. JACCP. 2019;2(2):123–30.Google Scholar
- 32.Johansen JS, Havnes K, Halvorsen KH, Haustreis S, Skaue LW, Kamycheva E, et al. Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial. BMJ Open. 2018;8(1):e020106.PubMedPubMedCentralCrossRefGoogle Scholar
- 51.Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2(4):257–64.PubMedCrossRefPubMedCentralGoogle Scholar
- 55.Koehler BE, Richter KM, Youngblood L, Cohen BA, Prengler ID, Cheng D, et al. Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J Hosp Med. 2009;4(4):211–8.PubMedCrossRefPubMedCentralGoogle Scholar
- 59.Elliott RA, Tran T, Taylor SE, Harvey PA, Belfrage MK, Jennings RJ, et al. Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open. 2012;2(3):e000918.PubMedPubMedCentralCrossRefGoogle Scholar
- 66.O’Sullivan D, O’Mahony D, O’Connor MN, Gallagher P, Gallagher J, Cullinan S, et al. Prevention of adverse drug reactions in hospitalised older patients using a software-supported structured pharmacist intervention: a cluster randomised controlled trial. Drugs Aging. 2016;33(1):63–73.PubMedCrossRefPubMedCentralGoogle Scholar
- 67.Tong EY, Roman C, Mitra B, Yip G, Gibbs H, Newnham H, et al. Partnered pharmacist charting on admission in the general medical and emergency short-stay unit: a cluster-randomised controlled trial in patients with complex medication regimens. J Clin Pharm Ther. 2016;41(4):414–8.PubMedCrossRefPubMedCentralGoogle Scholar
- 74.Graabaek T, Hedegaard U, Christensen MB, Clemmensen MH, Knudsen T, Aagaard L. Effect of a medicines management model on medication-related readmissions in older patients admitted to a medical acute admission unit: a randomized controlled trial. J Eval Clin Pract. 2019;25(1):88–96.PubMedCrossRefGoogle Scholar
- 76.Wauters M, Elseviers M, Vaes B, Degryse J, Dalleur O, Vander Stichele R, et al. Too many, too few, or too unsafe? Impact of inappropriate prescribing on mortality, and hospitalization in a cohort of community-dwelling oldest old. Br J Clin Pharmacol. 2016;82(5):1382–92.PubMedPubMedCentralCrossRefGoogle Scholar