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Clinical Pharmacy Services in Older Inpatients: An Evidence-Based Review

  • Lorenz Van der LindenEmail author
  • Julie Hias
  • Karolien Walgraeve
  • Johan Flamaing
  • Jos Tournoy
  • Isabel Spriet
Review Article

Abstract

Background

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.

Objective

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.

Methods

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.

Results

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.

Conclusions

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.

Notes

Author Contributions

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

Funding

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.

References

  1. 1.
    Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges ahead. Lancet. 2009;374(9696):1196–208.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Cohen JE. Human population: the next half century. Science. 2003;302(5648):1172–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Garfinkel D, Mangin D. Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy. Arch Intern Med. 2010;170(18):1648–54.PubMedCrossRefGoogle Scholar
  4. 4.
    Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. Med J Aust. 2014;201(7):390–2.PubMedCrossRefGoogle Scholar
  5. 5.
    Petrovic M, Somers A, Onder G. Optimization of geriatric pharmacotherapy: role of multifaceted cooperation in the hospital setting. Drugs Aging. 2016;33(3):179–88.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990;47(3):533–43.PubMedGoogle Scholar
  7. 7.
    American College of Clinical Pharmacy. The definition of clinical pharmacy. Pharmacotherapy. 2008;28(6):816–7.CrossRefGoogle Scholar
  8. 8.
    Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev. 2016;2:CD008986.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Clyne B, Fitzgerald C, Quinlan A, Hardy C, Galvin R, Fahey T, et al. Interventions to address potentially inappropriate prescribing in community-dwelling older adults: a systematic review of randomized controlled trials. J Am Geriatr Soc. 2016;64(6):1210–22.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Renaudin P, Boyer L, Esteve MA, Bertault-Peres P, Auquier P, Honore S. Do pharmacist-led medication reviews in hospitals help reduce hospital readmissions? A systematic review and meta-analysis. Br J Clin Pharmacol. 2016;82(6):1660–73.PubMedPubMedCentralCrossRefGoogle Scholar
  11. 11.
    Gray SL, Hart LA, Perera S, Semla TP, Schmader KE, Hanlon JT. Meta-analysis of interventions to reduce adverse drug reactions in older adults. J Am Geriatr Soc. 2018;66(2):282–8.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012;29(6):495–510.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Ravn-Nielsen LV, Duckert ML, Lund ML, Henriksen JP, Nielsen ML, Eriksen CS, et al. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission: a randomized clinical trial. JAMA Intern Med. 2018;178(3):375–82.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894–900.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Holland R, Desborough J, Goodyer L, Hall S, Wright D, Loke YK. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol. 2008;65(3):303–16.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Thomas R, Huntley AL, Mann M, Huws D, Elwyn G, Paranjothy S, et al. Pharmacist-led interventions to reduce unplanned admissions for older people: a systematic review and meta-analysis of randomised controlled trials. Age Ageing. 2014;43(2):174–87.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Hohl CM, Wickham ME, Sobolev B, Perry JJ, Sivilotti ML, Garrison S, et al. The effect of early in-hospital medication review on health outcomes: a systematic review. Br J Clin Pharmacol. 2015;80(1):51–61.PubMedPubMedCentralCrossRefGoogle Scholar
  18. 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
  19. 19.
    Walsh KA, O’Riordan D, Kearney PM, Timmons S, Byrne S. Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists’ interventions in secondary care. Age Ageing. 2016;45(2):201–9.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med. 2006;166(9):955–64.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    IntHout J, Ioannidis JP, Borm GF, Goeman JJ. Small studies are more heterogeneous than large ones: a meta-meta-analysis. J Clin Epidemiol. 2015;68(8):860–9.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Scott IA, Hilmer SN, Reeve E, Potter K, Le Couteur D, Rigby D, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827–34.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 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
  24. 24.
    Scullin C, Scott MG, Hogg A, McElnay JC. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13(5):781–8.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 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
  26. 26.
    Walgraeve K, Van der Linden L, Flamaing J, Fagard K, Spriet I, Tournoy J. Feasibility of optimizing pharmacotherapy in heart failure patients admitted to an acute geriatric ward: role of the clinical pharmacist. Eur Geriatr Med. 2018;9(1):103–11.CrossRefGoogle Scholar
  27. 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. 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
  29. 29.
    Lopez Cabezas C, Falces Salvador C, Cubi Quadrada D, Arnau Bartes A, Ylla Bore M, Muro Perea N, et al. Randomized clinical trial of a postdischarge pharmaceutical care program vs regular follow-up in patients with heart failure. Farm Hosp. 2006;30(6):328–42.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 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
  31. 31.
    Scott MG, Scullin C, Hogg A, Fleming GF, McElnay JC. Integrated medicines management to medicines optimisation in Northern Ireland (2000–2014): a review. Eur J Hosp Pharm Sci Pract. 2015;22(4):222–8.CrossRefGoogle Scholar
  32. 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
  33. 33.
    Hellstrom LM, Bondesson A, Hoglund P, Midlov P, Holmdahl L, Rickhag E, et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011;67(7):741–52.PubMedCrossRefGoogle Scholar
  34. 34.
    Bondesson A, Holmdahl L, Midlov P, Hoglund P, Andersson E, Eriksson T. Acceptance and importance of clinical pharmacists’ LIMM-based recommendations. Int J Clin Pharm. 2012;34(2):272–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Leendertse AJ, Egberts AC, Stoker LJ, van den Bemt PM. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med. 2008;168(17):1890–6.PubMedGoogle Scholar
  36. 36.
    Lavan A, Eustace J, Dahly D, Flanagan E, Gallagher P, Cullinane S, et al. Incident adverse drug reactions in geriatric inpatients: a multicentred observational study. Ther Adv Drug Saf. 2018;9(1):13–23.PubMedCrossRefGoogle Scholar
  37. 37.
    El Morabet N, Uitvlugt EB, van den Bemt BJF, van den Bemt P, Janssen MJA, Karapinar-Carkit F. Prevalence and preventability of drug-related hospital readmissions: a systematic review. J Am Geriatr Soc. 2018;66(3):602–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Epstein AM, Jha AK, Orav EJ. The relationship between hospital admission rates and rehospitalizations. N Engl J Med. 2011;365(24):2287–95.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Koshman SL, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure: a systematic review of randomized trials. Arch Intern Med. 2008;168(7):687–94.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Onder G, van der Cammen TJ, Petrovic M, Somers A, Rajkumar C. Strategies to reduce the risk of iatrogenic illness in complex older adults. Age Ageing. 2013;42(3):284–91.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Frontini R, Miharija-Gala T, Sykora J. EAHP survey 2010 on hospital pharmacy in Europe: parts 4 and 5. Clinical services and patient safety. Eur J Hosp Pharm. 2013;20:69–73.CrossRefGoogle Scholar
  42. 42.
    Van der Linden L, Hias J, Walgraeve K, Flamaing J, Spriet I, Tournoy J. Clinical pharmacy services on geriatric care wards: catch 22 of implementation and research. Drugs Aging. 2018;35(5):375–7.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Somers A, Spinewine A, Spriet I, Steurbaut S, Tulkens P, Hecq JD, et al. Development of clinical pharmacy in Belgian hospitals through pilot projects funded by the government. Acta Clin Belg. 2019;74(2):75–81.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Rodakowski J, Rocco PB, Ortiz M, Folb B, Schulz R, Morton SC, et al. Caregiver integration during discharge planning for older adults to reduce resource use: a metaanalysis. J Am Geriatr Soc. 2017;65(8):1748–55.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Kempen TGH, Bertilsson M, Lindner KJ, Sulku J, Nielsen EI, Hogberg A, et al. Medication Reviews Bridging Healthcare (MedBridge): study protocol for a pragmatic cluster-randomised crossover trial. Contemp Clin Trials. 2017;61:126–32.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Tan ECK, Sluggett JK, Johnell K, Onder G, Elseviers M, Morin L, et al. Research priorities for optimizing geriatric pharmacotherapy: an international consensus. J Am Med Dir Assoc. 2018;19(3):193–9.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Lipton HL, Bird JA. The impact of clinical pharmacists’ consultations on geriatric patients’ compliance and medical care use: a randomized controlled trial. Gerontologist. 1994;34(3):307–15.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients: a randomized controlled trial. Age Ageing. 2001;30(1):33–40.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54(6):657–64.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Naunton M, Peterson GM. Evaluation of home-based follow-up of high-risk elderly patients discharged from hospital. J Pharm Pract Res. 2003;33(3):176–82.CrossRefGoogle Scholar
  51. 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
  52. 52.
    Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007;55(5):658–65.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Triller DM, Hamilton RA. Effect of pharmaceutical care services on outcomes for home care patients with heart failure. Am J Health Syst Pharm. 2007;64(21):2244–9.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Makowsky MJ, Koshman SL, Midodzi WK, Tsuyuki RT. Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676]. Med Care. 2009;47(6):642–50.PubMedCrossRefPubMedCentralGoogle Scholar
  55. 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
  56. 56.
    Eggink RN, Lenderink AW, Widdershoven JW, van den Bemt PM. The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure. Pharm World Sci. 2010;32(6):759–66.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Lisby M, Thomsen A, Nielsen LP, Lyhne NM, Breum-Leer C, Fredberg U, et al. The effect of systematic medication review in elderly patients admitted to an acute ward of internal medicine. Basic Clin Pharmacol Toxicol. 2010;106(5):422–7.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Bladh L, Ottosson E, Karlsson J, Klintberg L, Wallerstedt SM. Effects of a clinical pharmacist service on health-related quality of life and prescribing of drugs: a randomised controlled trial. BMJ Qual Saf. 2011;20(9):738–46.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 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
  60. 60.
    Scullin C, Hogg A, Luo R, Scott MG, McElnay JC. Integrated medicines management: can routine implementation improve quality? J Eval Clin Pract. 2012;18(4):807–15.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Barker A, Barlis P, Berlowitz D, Page K, Jackson B, Lim WK. Pharmacist directed home medication reviews in patients with chronic heart failure: a randomised clinical trial. Int J Cardiol. 2012;159(2):139–43.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Marusic S, Gojo-Tomic N, Erdeljic V, Bacic-Vrca V, Franic M, Kirin M, et al. The effect of pharmacotherapeutic counseling on readmissions and emergency department visits. Int J Clin Pharm. 2013;35(1):37–44.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Eisenhower C. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. Ann Pharmacother. 2014;48(2):203–8.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    Basger BJ, Moles RJ, Chen TF. Impact of an enhanced pharmacy discharge service on prescribing appropriateness criteria: a randomised controlled trial. Int J Clin Pharm. 2015;37(6):1194–205.PubMedCrossRefPubMedCentralGoogle Scholar
  65. 65.
    Khalil H, Bell B, Chambers H, Sheikh A, Avery AJ. Professional, structural and organisational interventions in primary care for reducing medication errors. Cochrane Database Syst Rev. 2017;10:CD003942.PubMedPubMedCentralGoogle Scholar
  66. 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. 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
  68. 68.
    Roblek T, Deticek A, Leskovar B, Suskovic S, Horvat M, Belic A, et al. Clinical-pharmacist intervention reduces clinically relevant drug-drug interactions in patients with heart failure: a randomized, double-blind, controlled trial. Int J Cardiol. 2016;15(203):647–52.CrossRefGoogle Scholar
  69. 69.
    Cossette B, Ethier JF, Joly-Mischlich T, Bergeron J, Ricard G, Brazeau S, et al. Reduction in targeted potentially inappropriate medication use in elderly inpatients: a pragmatic randomized controlled trial. Eur J Clin Pharmacol. 2017;73(10):1237–45.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Gustafsson M, Sjolander M, Pfister B, Jonsson J, Schneede J, Lovheim H. Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia: a randomized controlled trial. Eur J Clin Pharmacol. 2017;73(7):827–35.PubMedPubMedCentralCrossRefGoogle Scholar
  71. 71.
    Nielsen TRH, Honore PH, Rasmussen M, Andersen SE. Clinical effects of a pharmacist intervention in acute wards: a randomized controlled trial. Basic Clin Pharmacol Toxicol. 2017;121(4):325–33.PubMedCrossRefGoogle Scholar
  72. 72.
    Bonetti AF, Bagatim BQ, Mendes AM, Rotta I, Reis RC, Favero MLD, et al. Impact of discharge medication counseling in the cardiology unit of a tertiary hospital in Brazil: a randomized controlled trial. Clinics (Sao Paulo). 2018;73:e325.CrossRefGoogle Scholar
  73. 73.
    Rottman-Sagebiel R, Cupples N, Wang CP, Cope S, Pastewait S, Braden H, et al. A pharmacist-led transitional care program to reduce hospital readmissions in older adults. Fed Pract. 2018;35(12):42–50.PubMedPubMedCentralGoogle Scholar
  74. 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
  75. 75.
    Topinkova E, Baeyens JP, Michel JP, Lang PO. Evidence-based strategies for the optimization of pharmacotherapy in older people. Drugs Aging. 2012;29(6):477–94.PubMedCrossRefGoogle Scholar
  76. 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
  77. 77.
    Van der Linden L, Hias J, Spriet I, Walgraeve K, Flamaing J, Tournoy J. Medication review in older adults: importance of time to benefit. Am J Health Syst Pharm. 2019;76(4):247–50.PubMedCrossRefGoogle Scholar
  78. 78.
    Kini V, Ho PM. Interventions to improve medication adherence: a review. JAMA. 2018;320(23):2461–73.PubMedCrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Pharmacy DepartmentUniversity Hospitals LeuvenLeuvenBelgium
  2. 2.Department of Pharmaceutical and Pharmacological SciencesKU LeuvenLeuvenBelgium
  3. 3.Department of Geriatric MedicineUniversity Hospitals LeuvenLeuvenBelgium
  4. 4.Department of Chronic Diseases, Metabolism and AgeingKU LeuvenLeuvenBelgium

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