Identifying older adults at increased risk of medication-related readmission to hospital within 30 days of discharge: development and validation of a risk assessment tool.

OBJECTIVE: Developing and validating a risk assessment tool aiming to identify older adults (≥65 years) at increased risk of possibly medication-related readmission to hospital within 30 days of discharge. DESIGN: Retrospective cohort study. SETTING: The risk score was developed using data from a hospital in southern Sweden and validated using data from four hospitals in the mid-eastern part of Sweden. PARTICIPANTS: The development cohort (n=720) was admitted to hospital during 2017, whereas the validation cohort (n=892) was admitted during 2017-2018. MEASURES: The risk assessment tool aims to predict possibly medication-related readmission to hospital within 30 days of discharge. Variables known at first admission and individually associated with possibly medication-related readmission were used in development. The included variables were assigned points, and Youden's index was used to decide a threshold score. The risk score was calculated for all individuals in both cohorts. Area under the receiver operating characteristic (ROC) curve (c-index) was used to measure the discrimination of the developed risk score. Sensitivity, specificity and positive and negative predictive values were calculated using cross-tabulation. RESULTS: The developed risk assessment tool, the Hospitalisations, Own home, Medications, and Emergency admission (HOME) Score, had a c-index of 0.69 in the development cohort and 0.65 in the validation cohort. It showed sensitivity 76%, specificity 54%, positive predictive value 29% and negative predictive value 90% at the threshold score in the development cohort. CONCLUSION: The HOME Score can be used to identify older adults at increased risk of possibly medication-related readmission within 30 days of discharge. The tool is easy to use and includes variables available in electronic health records at admission, thus making it possible to implement risk-reducing activities during the hospital stay as well as at discharge and in transitions of care. Further studies are needed to investigate the clinical usefulness of the HOME Score as well as the benefits of implemented activities.

Obstacles and Opportunities in Information Transfer Regarding Medications at Discharge - A Focus Group Study with Hospital Physicians.

Purpose: This qualitative study aimed to investigate experiences and perceptions of hospital physicians regarding the discharging process, focusing on information transfer regarding medications. Methods: By purposive sampling three focus groups were formed. To facilitate discussions and maintain consistency, a semi-structured interview guide was used. Discussions were audio recorded and transcribed verbatim. Qualitative content analysis was used to analyze the anonymized data. A confirmatory analysis concluded that the main findings were supported by data. Results: Identified obstacles were divided into three categories with two sub-categories each: Infrastructure; IT-systems currently used are suboptimal and complex. Hospital and primary care use different electronic medical records, complicating matters. The work organization is not helping with time scarcity and lack of continuity. Distinct routines could help create continuity but are not always in place, known, and/or followed. Physician: knowledge and education in the systems is not always provided nor prioritized. Understanding the consequences of not following routines and taking responsibility regarding the medications list is important. Not everyone has the self-reliance or willingness to do so. Patient/next of kin: For patients to provide information on medications used is not always easy when hospitalized. Understanding information provided can be hard, especially when medical jargon is used and there is no one available to provide support. A central theme, "We're only human", encompasses how physicians do their best despite difficult conditions. Conclusion: There are several obstacles in transferring information regarding medications at discharge. Issues regarding infrastructure are seldom possible for the individual physician to influence. However, several issues raised by the participating physicians are possible to act upon. In doing so medication errors in care transitions might decrease and information transfer at discharge might improve.

Medication-related hospital readmissions within 30 days of discharge-A retrospective study of risk factors in older adults.

BACKGROUND: Previous studies have shown that approximately 20% of hospital readmissions can be medication-related and 70% of these readmissions are possibly preventable. This retrospective medical records study aimed to find risk factors associated with medication-related readmissions to hospital within 30 days of discharge in older adults (≥65 years). METHODS: 30-day readmissions (n = 360) were assessed as being either possibly or unlikely medication-related after which selected variables were used to individually compare the two groups to a comparison group (n = 360). The aim was to find individual risk factors of possibly medication-related readmissions focusing on living arrangements, polypharmacy, potentially inappropriate medication therapy, and changes made to medication regimens at initial discharge. RESULTS: A total of 143 of the 360 readmissions (40%) were assessed as being possibly medication-related. Charlson Comorbidity Index (OR 1.15, 95%CI 1.5-1.25), excessive polypharmacy (OR 1.74, 95%CI 1.07-2.81), having adjustments made to medication dosages at initial discharge (OR 1.63, 95%CI 1.03-2.58) and living in your own home, alone, were variables identified as risk factors of such readmissions. Living in your own home, alone, increased the odds of a possibly medication-related readmission 1.69 times compared to living in your own home with someone (p-value 0.025) and 2.22 times compared to living in a nursing home (p-value 0.037). CONCLUSION: Possibly medication-related readmissions within 30 days of discharge, in patients 65 years and older, are common. The odds of such readmissions increase in comorbid, highly medicated patients living in their own home, alone, and if having medication dosages adjusted at initial discharge. These results indicate that care planning before discharge and the provision of help with, for example, managing medications after discharge, are factors especially important if aiming to reduce the amount of medication-related readmissions among this population. Further research is needed to confirm this hypothesis.

Prospective observational study of medication reviews in internal medicine wards: evaluation of drug-related problems.

BACKGROUND: The Lund Integrated Medicines Management model offers a systematic approach for individualising and optimising patient drug treatment. Clinical, economical and humanistic outcomes have been shown as well as results from the medication reconciliation process. There is a need also to describe the medication review process. OBJECTIVE: To describe the frequency and types of drug-related problems (DRPs) identified during medication reviews and to evaluate the actions of the pharmacists and the physicians regarding the identified DRPs. METHOD: Structured medication reviews were conducted by a multi-professional team on top of standard care for 719 patients in two internal medicine wards in a Swedish University Hospital. The medication reviews were studied retrospectively to classify DRPs and actions taken. RESULTS: A total of 573 (80%) of patients had at least one actual DRP; an average of three DRPs per patient and in total 2164. Wrong drug and adverse drug reaction were the most common types of DRPs. The most frequent medication groups involved in DRPs were drugs for the cardiovascular system and the nervous system and the most frequent substances were warfarin, digoxin, furosemide and paracetamol. The 10 most common medications accounted for 27% of the actual DRPs. Of the identified DRPs, a total of 1740 (80%) were acted on. The three most common types of adjustments made were withdrawal of drug therapy, change of drug therapy and initiation of drug therapy. When the pharmacist suggested an adjustment, the physician implemented 88% (1037/1174) of the recommendations. CONCLUSION: DRPs are common among elderly patients who are admitted to hospital. Systematic identification of high-risk medications and common DRP types enables targeting of prioritised patients for medication reviews.

Risk factors for hospital readmission in older adults within 30 days of discharge - a comparative retrospective study.

BACKGROUND: The area of hospital readmission in older adults within 30 days of discharge is extensively researched but few studies look at the whole process. In this study we investigated risk factors related, not only to patient characteristics prior to and events during initial hospitalisation, but also to the processes of discharge, transition of care and follow-up. We aimed to identify patients at most risk of being readmitted as well as processes in greatest need of improvement, the goal being to find tools to help reduce early readmissions in this population. METHODS: This comparative retrospective study included 720 patients in total. Medical records were reviewed and variables concerning patient characteristics prior to and events during initial hospital stay, as well as those related to the processes of discharge, transition of care and follow-up, were collected in a standardised manner. Either a Student's t-test, χ2-test or Fishers' exact test was used for comparisons between groups. A multiple logistic regression analysis was conducted to identify variables associated with readmission. RESULTS: The final model showed increased odds of readmission in patients with a higher Charlson Co-morbidity Index (OR 1.12, p-value 0.002), excessive polypharmacy (OR 1.66, p-value 0.007) and living in the community with home care (OR 1.61, p-value 0.025). The odds of being readmitted within 30 days increased if the length of stay was 5 days or longer (OR 1.72, p-value 0.005) as well as if being discharged on a Friday (OR 1.88, p-value 0.003) or from a surgical unit (OR 2.09, p-value 0.001). CONCLUSION: Patients of poor health, using 10 medications or more regularly and living in the community with home care, are at greater risk of being readmitted to hospital within 30 days of discharge. Readmissions occur more often after being discharged on a Friday or from a surgical unit. Our findings indicate patients at most risk of being readmitted as well as discharging routines in most need of improvement thus laying the ground for further studies as well as targeted actions to take in order to reduce hospital readmissions within 30 days in this population.

A descriptive study of pain treatment and its follow-up in primary care of elderly patients after orthopaedic care.

BACKGROUND: Pain treatment post orthopaedic care in the elderly is complicated and requires careful follow-up. Current guidelines state all patients prescribed opioids should have a plan for gradual reduction, with the treatment progressively reduced and ended if any pain remains after more than three months. How this works in primary care remains to be explored.The aim was to describe pain treatment and its follow-up in primary care of elderly patients after orthopaedic care. METHODS: In this descriptive study, medical case histories were collected for patients ≥ 75 years, which were enrolled at two rural primary care units in southern Sweden, and were discharged from orthopaedic care. Pain medication follow-up plans were noted, as well as current pain medication at discharge as well as two, six and twelve weeks later. RESULTS: We included a total of 49 community-dwelling patients with medication aid from nurses in municipality care and nursing home residents, ≥ 75 years, discharged from orthopaedic care. The proportion of patients prescribed paracetamol increased from 28/49 (57%) prior to admission, to 38/44 (82%) after 12 weeks. The proportion of patients prescribed opioids increased from 5/49 (10%) to 18/44 (41%). Primary care pain medication follow-up plans were noted for 16/49 patients (33%). CONCLUSIONS: Many patients still used pain medication 12 weeks after discharge, and follow-up plans were quite uncommon, which may reflect upon lacking follow-up of these patients in primary care.

Medication Discrepancies in Discharge Summaries and Associated Risk Factors for Elderly Patients with Many Drugs.

BACKGROUND AND OBJECTIVE: Elderly patients are at high risk for medication errors in care transitions. The discharge summary aims to counteract drug-related problems due to insufficient information transfer in care transitions, hence the accuracy of its medication information is of utmost importance. The purpose of this study was to describe the medication discrepancy rate and associated risk factors in discharge summaries for elderly patients. METHODS: Pharmacists collected random samples of discharge summaries from ten hospitals in southern Sweden. Medication discrepancies, organisational, and patient- and care-specific factors were noted. Patients aged ≥ 75 years with five or more drugs were further included. Descriptive and logistic regression analyses were performed. RESULTS: Discharge summaries for a total of 933 patients were included. Average age was 83.1 years, and 515 patients (55%) were women. Medication discrepancies were noted for 353 patients (38%) (mean 0.87 discrepancies per discharged patient, 95% confidence interval 0.76-0.98). Unintentional addition of a drug was the most common discrepancy type. Central nervous system drugs/analgesics were most commonly affected. Major risk factors for the presence of discrepancies were multi-dose drug dispensing (adjusted odds ratio 3.42, 95% confidence interval 2.48-4.74), an increasing number of drugs in the discharge summary (adjusted odds ratio 1.09, 95% confidence interval 1.05-1.13) and discharge from departments of surgery (adjusted odds ratio 2.96, 95% confidence interval 1.55-5.66). By contrast, an increasing number of drug changes reduced the odds of a discrepancy (adjusted odds ratio 0.93, 95% confidence interval 0.88-0.99). CONCLUSIONS: Medication discrepancies were common. In addition, we identified certain circumstances in which greater vigilance may be of considerable value for increased medication safety for elderly patients in care transitions.

Medication errors in primary health care records; a cross-sectional study in Southern Sweden.

BACKGROUND: Drug-related problems due to medication errors are common and have the potential to cause harm. This study, which was conducted in Swedish primary health care, aimed to assess how well the medication lists in the medical records tally with the medications used by patients and to explore what type of medication errors are present. METHODS: We reviewed the electronic medical records (EMRs) at ten primary health care centers in Skåne county, Sweden. The medication lists in the EMRs were compared with the results of medication reconciliations, which were performed telephonically in a structured manner by a physician, two weeks after a follow-up visit to a general practitioner. Of 76 patients aged ≥18 years, who on a certain day in 2016 were visiting one of the included primary health care centers, a total of 56 were included. Descriptive statistics were used. The chi2-test and the Mann Whitney U-test were used for comparisons. The main outcome measure was the proportion of correctly updated medication lists. RESULTS: Following a recent visit to the general practitioner, a total of 16% of the medication lists in the medical records were consistent with the patients' actual medication use. The mean number of medication errors in the medical records was 3.8 (SD 3.8). Incorrect dose was the most common error, followed by additional drugs without indication/documentation. The most common medication group among all errors was analgesics and among dose errors the most common medication group was cardiovascular drugs. CONCLUSION: A total of 84% of the medication lists used by the general practitioners in the assessment and follow-up of the patients were not updated; this implies a great safety risk since medication errors are potentially harmful. Ensuring medication reconciliations in daily clinical practice is important for patient safety.

Elderly at risk in care transitions When discharge summaries are poorly transferred and used -a descriptive study.

BACKGROUND: Discharge summary with medication report effectively counteracts drug-related problems among elderly patients due to insufficient information transfer in care transitions. However, this requires optimal transfer and use of the discharge summaries. This study aimed to examine information transfer with discharge summaries from hospital to primary care. METHODS: A descriptive study with data consisting of discharge summaries of 115 patients, 75 years or older, using five or more drugs, collected during one week from 28 different hospital wards in Skåne county, Sweden. Two weeks after discharge, information transfer was examined via review of primary care medical records. It was noted whether the discharge summary was received (i.e. scanned to the primary care medical records), if the medication list was updated with drug changes and if a patient chart entry regarding medication or its follow-up was made in the primary care medical records. An electronic survey, which was sent to 151 primary care units in Skåne county, was used to examine experiences of the information transfer. RESULTS: Out of 115 discharge summaries, 47 (41%) were found in the primary care medical records. Patient chart entries regarding medication or its follow-up were seen in 53 (46%) cases. Drug changes during hospitalisation were seen in 51 out of 76 patients without multidose drug dispensing. In 16 (31%) out of these cases, medication lists were updated in primary care medical records. In the electronic survey, 22 (21%) out of the 107 responding primary care units reported the discharge summary was often received on the day of discharge, while 71 (66%) respondents indicated the discharge summary was always/often received but later. Medication list updates and patient chart entries in the primary care medical records were always/often done upon receipt of the discharge summary according to 61 (57%) respondents. CONCLUSION: The transfer of information was often deficient and the discharge summaries were insufficiently used. Many discharge summaries were lost, an insufficient proportion of medication lists were updated and patient chart entries were often lacking. These findings may increase the risk of medication errors and drug-related problems for elderly in care transitions.

Effects of medication reviews on use of potentially inappropriate medications in elderly patients; a cross-sectional study in Swedish primary care.

BACKGROUND: Drug use among the elderly population is generally extensive and the use of potentially inappropriate medications (PIMs) is common, which increases the risk for drug-related problems (DRP). Medication reviews are one method to improve drug therapy by identifying, preventing and solving DRPs. The aim of this study was to evaluate the effect of medication reviews on total drug use and potentially inappropriate drug use in elderly patients, as well as describe the occurrence and types of drug-related problems. METHOD: This was a cross-sectional analysis to study medication reviews conducted by trained clinical pharmacists followed by team-based discussions with general practitioners (GPs) and nurses, for elderly primary care patients in Skåne, Sweden. Included in the analysis were patients ≥75 years living in nursing homes or in their own homes with home care, who received a medication review during 2011-2012. Documented DRPs were described as both the type of DRPs and as pharmacists' recommendations to the GP. The usage of ≥3 psychotropics and PIMs (antipsychotics, anticholinergics, long-acting benzodiazepines, tramadol and propiomazine) at baseline and after medication review were also studied. RESULTS: The analysis included a total of 1720 patients. They were on average aged 87.5 years, used typically 11.3 drugs (range 1-35) and 61% of them used 10 drugs or more. Of the patients, 84% had at least one DRP with a mean of 2.2 DRPs/patient. Of the DRPs, 12% were attributable to PIMs. The proportion of patients with ≥ one PIM was reduced significantly (p < 0.001) as was the use of ≥3 psychotropics (p < 0.001). The most common DRP was unnecessary drug therapy (39%), followed by dose too high (21%) and wrong drug (20%). Drug withdrawal was the most common result. CONCLUSION: This study shows that medication reviews performed in everyday care are one way of improving drug use among elderly patients. The use of potentially inappropriate medications and use of three or more psychotropic drugs decreased after the medication review. Our study also shows that drug use is extensive in nursing home residents and elderly patients with homecare, and that unnecessary drug therapy is a common problem.

Drugs, distrust and dialogue -a focus group study with Swedish GPs on discharge summary use in primary care.

BACKGROUND: Discharge summary with medication report effectively counteracts drug-related problems due to insufficient information transfer in care transitions. The benefits of the discharge summary may be lost if it is not adequately used, and factors affecting optimal use by the GP are of interest. Since the views of Swedish GPs are unexplored, this study aimed to explore and understand GPs experiences, perceptions and feelings regarding the use of the discharge summary with medication report. METHOD: This qualitative study was based on four focus group discussion with 18 GPs and resident physicians in family medicine which were performed in 2016 and 2017. A semi-structured interview guide was used. The interviews were transcribed verbatim and analysed using qualitative content analysis. RESULTS: The analysis resulted in three final main themes: "Importance of the discharge summary", "Role of the GP" and "Create dialogue" with six categories; "Benefits for the GP and perceived benefits for the patient", "GP use of the information", "Significance of different documents", "Spider in the web", "Terminus/End station" and "Improved information transfer in care transitions". Overall, the participants described clear benefits with the discharge summary when accurate although perceived deficiencies were also quite rife. CONCLUSION: The GPs experiences and views of the discharge summary revealed clear benefits regarding mainly medication information, awareness of any plans as well as shared knowledge with the patient. However, perceived deficiencies of the discharge summary affected its use by the GP and enhanced communication was called for.

Use of Antipsychotic Drugs by Elderly Primary Care Patients and the Effects of Medication Reviews: A Cross-Sectional Study in Sweden.

BACKGROUND: Antipsychotics form a class of drugs that should be used with caution among elderly people because of a high risk of adverse events. Despite the risks and modest effects, their use is estimated to be high, especially in nursing homes. OBJECTIVE: The aim was to explore the effects of medication reviews on antipsychotic drug use for elderly primary care patients and describe the extent of, and reasons for, the prescription of antipsychotics. METHODS: In this cross-sectional study in primary care in Skåne, Sweden, patients aged ≥75 years living in nursing homes or in their own homes with home care were included. The effects of medication reviews were documented, as were the use of antipsychotics and the differences in characteristics between patients receiving or not receiving antipsychotics. RESULTS: A total of 1683 patients aged 87.6 (±5.7) years were included in the analysis. Medication reviews reduced the use of antipsychotics by 23% (p < 0.001) in this study. Of the 206 patients using antipsychotics, 43% (n = 93) had an approved indication, while for 15% (n = 32) the indication was not given. Antipsychotic drug use was more common with increasing number of drugs (p = 0.001), and in nursing home residents (p < 0.01). It was also more frequent in patients with cognitive impairment, depressive symptoms or sleeping problems. CONCLUSION: The use of antipsychotic drugs is high in elderly patients in nursing homes. They are often given for indications that are not officially approved or are poorly documented. Medication reviews appear to offer one useful strategy for reducing excessive use of these drugs.

Effects of an intervention (SÄKLÄK) on prescription of potentially inappropriate medication in elderly patients.

Background: Polypharmacy is known to increase the risk for drug-related problems, and some drugs, potentially inappropriate medications (PIMs), are especially troublesome. Objective: To analyse the effects on prescription of PIMs of the SÄKLÄK project, an intervention model created to improve medication safety for elderly patients in primary care. Method: The SÄKLÄK project was a multiprofessional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. Five Swedish primary care centres participated in the intervention and five served as comparison group. Data were collected from the Swedish Prescribed Drug Register on PIMs (long-acting benzodiazepines, anticholinergics, tramadol, propiomazine, antipsychotics and non-steroidal anti-inflammatory drugs) prescribed to patients aged 65 years and older. Total number of patients and change in patients using PIMs before and after intervention with-in groups was analysed as well as differences between intervention and comparison group. Results: A total of 32566 prescriptions of PIMs were dispensed before the intervention, 19796 in the intervention group and 12770 in the comparison group. After intervention a decrease was seen in both groups, intervention-22.2% and comparison-8.8%. All groups of PIMs decreased, except for antipsychotics in the comparison group. For the intervention group, a significant decrease in mean dose/patient was seen after the intervention but not in the comparison group. Conclusion: Our study shows this method has some effects on prescription of PIMs. The evaluation indicates this is a feasible method for improvement of medication use in primary care and the method should be tested on a larger scale.

Medication reviews in primary care in Sweden: importance of clinical pharmacists' recommendations on drug-related problems.

BACKGROUND: One way of preventing and solving drug-related problems in frail elderly is to perform team-based medication reviews. OBJECTIVE: To evaluate the quality of the clinical pharmacy service to primary care using structured medication reviews, focusing on the clinical significance of the recommendations made by clinical pharmacists. SETTING: A random sample of 150 patients (out of 1541) who received structured team based medication reviews. The patients lived at a geriatric nursing home or were ≥65 years and lived in ordinary housing with medication-related community help. METHOD: Based on information on symptoms, kidney function, blood pressure, diagnoses and the medication list, a pharmacist identified possible drug-related problems and supplied recommendations for the general practitioner to act on. Two independent physicians retrospectively ranked the clinical significance of the recommendations according to Hatoum, with rankings ranging between 1 (adverse significance) and 6 (extremely significant). Main outcome measure The clinical significance of the recommendations. Results In total 349 drug-related problems were identified, leading to recommendations. The vast majority of the recommendations (96 %) were judged to have significance 3 or higher and more than the half were judged to have significance 4 or higher. CONCLUSION: The high proportion of clinically significant recommendations provided by pharmacists when performing team-based medication reviews suggest that these clinical pharmacy services have potential to increase prescribing quality. As such, the medication reviews have the potential for contributing to a better and safer drug therapy for elderly patients.

Healthcare system intervention for safer use of medicines in elderly patients in primary care-a qualitative study of the participants' perceptions of self-assessment, peer review, feedback and agreement for change.

BACKGROUND: The elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants' perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care. METHODS: This is a qualitative study within the SÄKLÄK project. The SÄKLÄK project is a multi-professional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. A total of 17 participants from the intervention's primary care units were interviewed. Most of the interviews were done on a one-to-one basis. The interviews were recorded and transcribed verbatim. A survey was also sent to the primary care unit heads. Qualitative content analysis was used to explore the participants' perceptions. RESULTS: The analysis of the interviews yielded six categories: multi-professional co-operation, a focus on areas of improvement, the joy of sharing knowledge, disappointment with the focus of the feedback, spend time to save time and impact on work. From these categories a theme developed: "Medication safety is a large area. In order to make improvements time needs to be invested and different professions must contribute." CONCLUSIONS: This study shows that our studied intervention method is feasible to use in primary care and that the multi-professional approach was perceived as being very positive by the participants. Multi-professional co-operation was time consuming, but was also deemed as an investment and an opportunity to share knowledge. Some points of improvement of the method were identified such as simplification of the self-assessment form and clearer instructions for reviewers. In addition, to have an impact on work the focus must lie in areas within the primary care units' scope.

Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care.

BACKGROUND: Falls are the most common cause of injuries and hospital admissions in the elderly. The Swedish National Board of Health and Welfare has created a list of drugs considered to increase the fall risk (FRIDs) and drugs that might cause/worsen orthostatism (ODs). This cross-sectional study was aimed to assess FRIDs and their correlation with falls in a sample of 369 community-dwelling and nursing home patients aged ≥75 years and who were using a multi-dose drug dispensing system. METHODS: Data were collected from the patients' electronic medication lists. Retrospective data on reported falls during the previous three months and severe falls during the previous 12 months were collected. Primary outcome measures were incidence of falls as well as numbers of FRIDs and ODs in fallers and non-fallers. RESULTS: The studied sample had a high incidence of both reported falls (29%) and severe falls (17%). Patients were dispensed a mean of 2.2 (SD 1.5) FRIDs and 2.0 (SD 1.6) ODs. Fallers used on average more FRIDs. Severe falls were more common in nursing homes patients. More women than men experienced severe falls. There were positive associations between number of FRIDs and the total number of drugs (p < 0.01), severe falls (p < 0.01) and female sex (p = 0.03). There were also associations between number of ODs and both total number of drugs (p < 0.01) and being community dwelling (p = 0.02). No association was found between number of ODs and severe falls. Antidepressants and anxiolytics were the most frequently dispensed FRIDs. CONCLUSIONS: Fallers had a higher number of FRIDs. Numbers of FRIDs and ODs were correlated with the total number of drugs dispensed. Interventions to reduce falls in the elderly by focusing on reducing the total number of drugs and withdrawal of psychotropic medications might improve the quality and safety of drug treatment in primary care.

Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study.

BACKGROUND: Polypharmacy in the Swedish elderly population is currently a prioritised area of research with a focus on reducing the use of potentially inappropriate medications (PIMs). Multi-professional interventions have previously been tested for their ability to improve drug therapy in frail elderly patients. OBJECTIVE: This study aimed to assess a structured model for pharmacist-led medication reviews in primary health care in southern Sweden and to measure its effects on numbers of patients with PIMs (using the definition of the Swedish National Board of Health and Welfare) using ≥10 drugs and using ≥3 psychotropics. METHODS: This study was a randomised controlled clinical trial performed in a group of patients aged ≥75 years and living in nursing homes or the community and receiving municipal health care. Medication reviews were performed by trained clinical pharmacists based on nurse-initiated symptom assessments with team-based or distance feedback to the physician. Data were collected from the patients' electronic medication lists and medical records at baseline and 2 months after the medication review. RESULTS: A total of 369 patients were included: 182 in the intervention group and 187 in the control group. One-third of the patients in both groups had at least one PIM at baseline. Two months after the medication reviews, the number of intervention group patients with at least one PIM and the number of intervention group patients using ten or more drugs had decreased (p = 0.007 and p = 0.001, respectively), while there were no statistically significant changes in the control patients. No changes were seen in the number of patients using three or more psychotropic drugs, although the dosages of these drugs tended to decrease. Drug-related problems (DRPs) were identified in 93 % of the 182 patients in the intervention group. In total, there were 431 DRPs in the intervention group (a mean of 2.5 DRPs per patient, range 0-9, SD 1.5 at 95 % CI) and 16 % of the DRPs were related to PIMs. CONCLUSIONS: Medication reviews involving pharmacists in primary health care appear to be a feasible method to reduce the number of patients with PIMs, thus improving the quality of pharmacotherapy in elderly patients.

Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital.

OBJECTIVE: To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits. METHOD: Published data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature. RESULTS: The total cost for the LIMM model was €290 compared to €630 for standard care, in spite of a €39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part (€262) whereas only €66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%. CONCLUSIONS: The LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.

In-hospital medication reviews reduce unidentified drug-related problems.

PURPOSE: To examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting. METHODS: In a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were ≥ 65 years old, used ≥ 3 medications on a regular basis and had stayed on the ward for ≥ 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category. RESULTS: The study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st-3rd quartile 0-2), control group 9 (6-13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0-2), control group 8 (5-10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group. CONCLUSIONS: A multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients.

Errors in medication history at hospital admission: prevalence and predicting factors.

BACKGROUND: An accurate medication list at hospital admission is essential for the evaluation and further treatment of patients. The objective of this study was to describe the frequency, type and predictors of errors in medication history, and to evaluate the extent to which standard care corrects these errors. METHODS: A descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient's most accurate pre-admission medication list by conducting a medication reconciliation process shortly after admission. This list was then compared with the patient's medication list in the hospital medical records. Addition or withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered medication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional changes) were considered medication history errors. RESULTS: The final study population comprised 670 of 818 eligible patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic regression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase = 1.10; 95% CI 1.06-1.14; p < 0.0001) and the patient living in their own home without any care services (OR = 1.58; 95% CI 1.02-2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated that standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days after admission, but a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard care (OR for medication errors detected by pharmacists' medication reconciliation carried out on days 4-11 compared to days 0-1 = 0.52; 95% CI 0.30-0.91; p=0.021). CONCLUSIONS: Clinical pharmacists conducting LIMM-based medication reconciliations have a high potential for correcting errors in medication history for all patients. In an older Swedish population, those prescribed many drugs seem to benefit most from admission medication reconciliation.