Continuity of medication information transfer and continuous medication supply during hospital-to-home transitions - nationwide surveys in hospital and community pharmacies after implementing new legal requirements in Germany.

BACKGROUND: While successful information transfer and seamless medication supply are fundamental to medication safety during hospital-to-home transitions, disruptions are frequently reported. In Germany, new legal requirements came into force in 2017, strengthening medication lists and discharge summaries as preferred means of information transfer. In addition to previous regulations - such as dispensing medication at discharge by hospital pharmacies - hospital physicians were now allowed to issue discharge prescriptions to be supplied by community pharmacies. The aim of this survey study was to gain first nationwide insights into how these requirements are implemented and how they impact the continuity of medication information transfer and continuous medication supply. METHODS: Two nationwide self-administered online surveys of all hospital and community pharmacies across Germany were developed and conducted from April 17th to June 30th, 2023. RESULTS: Overall, 31.0% (n = 111) of all German hospital pharmacies and 4.5% (n = 811) of all community pharmacies participated. The majority of those hospital pharmacies reported that patients who were discharged were typically provided with discharge summaries (89.2%), medication lists (59.5%) and if needed, discharge prescriptions (67.6%) and/or required medication (67.6%). About every second community pharmacy (49.0%) indicated that up to half of the recently discharged patients who came to their pharmacy typically presented medication lists. 34.0% of the community pharmacies stated that they typically received a discharge summary from recently discharged patients at least once per week. About three in four community pharmacies (73.3%) indicated that most discharge prescriptions were dispensed in time. However, one-third (31.0%) estimated that half and more of the patients experienced gaps in medication supply. Community pharmacies reported challenges with the legal requirements - such as patients´ poor comprehensibility of medication lists, medication discrepancies, unmet formal requirements of discharge prescriptions, and poor accessibility of hospital staff in case of queries. In comparison, hospital pharmacies named technical issues, time/personnel resources, and deficits in patient knowledge of medication as difficulties. CONCLUSION: According to the pharmacies´ perceptions, it can be assumed that discontinuation in medication information transfer and lack of medication supply still occur today during hospital-to-home transitions, despite the new legal requirements. Further research is necessary to supplement these results by the perspectives of other healthcare professionals and patients in order to identify efficient strategies.

Prevalence and patient-rated relevance of complexity factors in medication regimens of community-dwelling patients with polypharmacy.

PURPOSE: To describe the prevalence of complexity factors in the medication regimens of community-dwelling patients with more than five drugs and to evaluate the relevance of these factors for individual patients. METHODS: Data were derived from the HIOPP-6 trial, a controlled study conducted in 9 general practices which evaluated an electronic tool to detect and reduce complexity of drug treatment. The prevalence of complexity factors was based on the results of the automated analysis of 139 patients' medication data. The relevance assessment was based on the patients' rating of each factor in an interview (48 patients included for analysis). RESULTS: A median of 5 (range 0-21) complexity factors per medication regimen were detected and at least one factor was observed in 131 of 139 patients. Almost half of these patients found no complexity factor in their medication regimen relevant. CONCLUSION: In most medication regimens, complexity factors could be identified automatically, yet less than 15% of factors were indeed relevant for patients as judged by themselves. When assessing complexity of medication regimens, one should especially consider factors that are both particularly frequent and often challenging for patients, such as use of inhalers or tablet splitting. TRIAL REGISTRATION: The HIOPP-6 trial was registered retrospectively on May 17, 2021, in the German Clinical Trials register under DRKS-ID DRKS00025257.

Task sharing in an interprofessional medication management program - a survey of general practitioners and community pharmacists.

BACKGROUND: Pharmacist-led medication review and medication management programs (MMP) are well-known strategies to improve medication safety and effectiveness. If performed interprofessionally, outcomes might even improve. However, little is known about task sharing in interprofessional MMP, in which general practitioners (GPs) and community pharmacists (CPs) collaboratively perform medication reviews and continuously follow-up on patients with designated medical and pharmaceutical tasks, respectively. In 2016, ARMIN (Arzneimittelinitiative Sachsen-Thüringen) an interprofessional MMP was launched in two German federal states, Saxony and Thuringia. The aim of this study was to understand how GPs and CPs share tasks in MMP when reviewing the patients' medication. METHODS: This was a cross-sectional postal survey among GPs and CPs who participated in the MMP. Participants were asked who completed which MMP tasks, e.g., checking drug-drug interactions, dosing, and side effects. In total, 15 MMP tasks were surveyed using a 5-point Likert scale ranging from "I complete this task alone" to "GP/CP completes this task alone". The study was conducted between 11/2020 and 04/2021. Data was analyzed using descriptive statistics. RESULTS: In total, 114/165 (69.1%) GPs and 166/243 (68.3%) CPs returned a questionnaire. The majority of GPs and CPs reported (i) checking clinical parameters and medication overuse and underuse to be completed by GPs, (ii) checking storage conditions of drugs and initial compilation of the patient's medication including brown bag review being mostly performed by CPs, and (iii) checking side-effects, non-adherence, and continuous updating of the medication list were carried out jointly. The responses differed most for problems with self-medication and adding and removing over-the-counter medicines from the medication list. In addition, the responses revealed that some MMP tasks were not sufficiently performed by either GPs or CPs. CONCLUSIONS: Both GPs' and CPs' expertise are needed to perform MMP as comprehensively as possible. Future studies should explore how GPs and CPs can complement each other in MMP most efficiently.

The impact of a computerized physician order entry system implementation on 20 different criteria of medication documentation-a before-and-after study.

BACKGROUND: The medication process is complex and error-prone. To avoid medication errors, a medication order should fulfil certain criteria, such as good readability and comprehensiveness. In this context, a computerized physician order entry (CPOE) system can be helpful. This study aims to investigate the distinct effects on the quality of prescription documentation of a CPOE system implemented on general wards in a large tertiary care hospital. METHODS: In a retrospective analysis, the prescriptions of two groups of 160 patients each were evaluated, with data collected before and after the introduction of a CPOE system. According to nationally available recommendations on prescription documentation, it was assessed whether each prescription fulfilled the established 20 criteria for a safe, complete, and actionable prescription. The resulting fulfilment scores (prescription-Fscores) were compared between the pre-implementation and the post-implementation group and a multivariable analysis was performed to identify the effects of further covariates, i.e., the prescription category, the ward, and the number of concurrently prescribed drugs. Additionally, the fulfilment of the 20 criteria was assessed at an individual criterion-level (denoted criteria-Fscores). RESULTS: The overall mean prescription-Fscore increased from 57.4% ± 12.0% (n = 1850 prescriptions) before to 89.8% ± 7.2% (n = 1592 prescriptions) after the implementation (p < 0.001). At the level of individual criteria, criteria-Fscores significantly improved in most criteria (n = 14), with 6 criteria reaching a total score of 100% after CPOE implementation. Four criteria showed no statistically significant difference and in two criteria, criteria-Fscores deteriorated significantly. A multivariable analysis confirmed the large impact of the CPOE implementation on prescription-Fscores which was consistent when adjusting for the confounding potential of further covariates. CONCLUSIONS: While the quality of prescription documentation generally increases with implementation of a CPOE system, certain criteria are difficult to fulfil even with the help of a CPOE system. This highlights the need to accompany a CPOE implementation with a thorough evaluation that can provide important information on possible improvements of the software, training needs of prescribers, or the necessity of modifying the underlying clinical processes.

Individual factors increasing complexity of drug treatment-a narrative review.

PURPOSE: Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment. METHODS: A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients. RESULTS: Ninety-one influencing factors were identified: fourteen in "dosage forms", five in "product characteristics", twelve in "dosage schemes", nine in "additional instructions", thirty-one in "patient characteristics" and twenty in "process characteristics". CONCLUSIONS: Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Development of an algorithm to detect and reduce complexity of drug treatment and its technical realisation.

BACKGROUND: The increasing complexity of current drug therapies jeopardizes patient adherence. While individual needs to simplify a medication regimen vary from patient to patient, a straightforward approach to integrate the patients' perspective into decision making for complexity reduction is still lacking. We therefore aimed to develop an electronic, algorithm-based tool that analyses complexity of drug treatment and supports the assessment and consideration of patient preferences and needs regarding the reduction of complexity of drug treatment. METHODS: Complexity factors were selected based on literature and expert rating and specified for integration in the automated assessment. Subsequently, distinct key questions were phrased and allocated to each complexity factor to guide conversation with the patient and personalize the results of the automated assessment. Furthermore, each complexity factor was complemented with a potential optimisation measure to facilitate drug treatment (e.g. a patient leaflet). Complexity factors, key questions, and optimisation strategies were technically realized as tablet computer-based application, tested, and adapted iteratively until no further technical or content-related errors occurred. RESULTS: In total, 61 complexity factors referring to the dosage form, the dosage scheme, additional instructions, the patient, the product, and the process were considered relevant for inclusion in the tool; 38 of them allowed for automated detection. In total, 52 complexity factors were complemented with at least one key question for preference assessment and at least one optimisation measure. These measures included 29 recommendations for action for the health care provider (e.g. to suggest a dosage aid), 27 training videos, 44 patient leaflets, and 5 algorithms to select and suggest alternative drugs. CONCLUSIONS: Both the set-up of an algorithm and its technical realisation as computer-based app was successful. The electronic tool covers a wide range of different factors that potentially increase the complexity of drug treatment. For the majority of factors, simple key questions could be phrased to include the patients' perspective, and, even more important, for each complexity factor, specific measures to mitigate or reduce complexity could be defined.

Use of medication lists: A population-based approach to increase the prevalence of medication lists within a region in Germany. A pre-post study
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OBJECTIVES: Patient-centered medication lists are a useful documentation method to support safe drug treatment, but they are still inconsistently used and are of varying quality. The aim of this study was to evaluate the effects of an information campaign on the prevalence and use of medication lists. MATERIAL AND METHODS: We launched a population-based, low-threshold information campaign within a large region in Germany in order to sensitize the population to the use of medication lists. A survey was sent out at baseline and after 18 months to 5,340 citizens aged ≥ 65 years, covering ~ 4% of the region's population. RESULTS: The response rate was 49.4% (N = 2,640) at baseline and 45.4% (N = 2,427) at follow-up. Sociodemographic details of respondents were similar at both time-points as was the possession rate of a medication list among participants with regular medicine intake (51.6%, N = 1,181/2,288 vs. 51.4%, N = 1,082/2,107). Combining baseline and follow-up data, respondents indicated that their general practitioner was involved in issuing the list most often (N = 1,668/2,263, 73.7%), however, in 195 cases (8.6%), respondents indicated being solely responsible for the list. The majority (90.8%, N = 2,055/2,263) indicated having their list in use for longer than 1 year, but for only half of those, the list was updated within the last year. After the intervention, 6% of the respondents indicated being familiar with the campaign those being more likely to possess a list (69.7% N = 83/119 vs. 50.2% N = 999/1,988). CONCLUSION: The campaign did not change overall possession rate, but respondents who were familiar with the campaign were more likely to possess such a list.

[Potential Benchmarks for Successful Interdisciplinary Collaboration Projects in Germany: A Systematic Review]. / Potentielle Erfolgsindikatoren für die Durchführung von Projekten zur Arzt-Apotheker-Zusammenarbeit ­ eine systematische Übersicht.

AIM OF THE STUDY: Collaboration between general practitioners and community pharmacists is essential to ensure safe and effective patient care. However, collaboration in primary care is not standardized and varies greatly. This review aims to highlight projects about professional collaboration in ambulatory care in Germany and identifies promising approaches and successful benchmarks that should be considered for future projects. METHODS: A systematic literature search was performed based on the PRISMA guidelines to identify articles focusing on professional collaboration between general practitioners and pharmacists. RESULTS: A total of 542 articles were retrieved. Six potential premises for successful cooperation projects were identified: GP and CP knowing each other (I), involvement of both health care providers in the project planning (II), sharing of experience or concerns during regular joint meetings enabling continuing evaluation and adaption (III), ensuring (technical) feasibility (IV), particularly by providing incentives (V), and by integrating these projects into existing health care structures (VI). CONCLUSION: Only few studies have been published in scientific journals. There was no standardized assessment of how the participants perceived their collaboration and how it facilitates their daily work, even when the study aimed to evaluate GP-CP collaboration. Successful cooperation between GP and CP in daily routine care was often characterized by personal contact and longtime relationships. Therefore, collaborative teaching sessions at university might establish sympathy and mutual understanding right from the beginning. There is a strong need to establish standardized tools to evaluate collaboration in future projects and to enable comparability of different studies.

[Benefits of a Medication List from a Citizen's Perspective -A Qualitative Survey]. / Nutzen eines Medikationsplans aus Sicht der Bürger ­ eine qualitative Befragung.

BACKGROUND: Since October 2016, German patients are entitled to get a medication list if using at least 3 drugs. The patient's individual attitude to a medication list is supposed to be relevant for its use und acceptance. STUDY AIM: Because there is little known about those attitudes, this study examined which potential benefits patients see in possessing a medication list, and why certain patients might not use it. METHOD: In a qualitative survey, 375 citizens of the Rhein-Neckar region were interviewed by using a semi-standardized guide. A content analysis of the interviews was done. RESULTS: Most citizens described medication lists as having private and economic benefits such as for health care or safe drug use. But often, they combine potential benefits with requirements such as age, number of prescribed drugs, or health status. Unsatisfied individual needs, excessive demands or an attitude of rejection are possible reasons for non-use. CONCLUSION: For successful implementation of the medication list, the individual attitude of patients should be assessed to be able to provide tailored information and assistance. The views of citizens about a medication list agree with the aims of the so-called German E-Health Act, but differ particularly with regard to named requirements and prioritisation.

[Fostering medication safety by and for patients]. / Verbesserung der Arzneimitteltherapiesicherheit mit und für den Patienten.

The overall goal of all measures for medication safety is the optimization of drug treatment and the prevention of unnecessary risk that potentially endangers patients. Per definition, the goal of medication safety is a beneficial patient outcome. Particularly in primary care, the success of many medication safety strategies will depend on the active participation of patients, as in this healthcare sector the patient is responsible for many substeps of the medication process.From a healthcare systems perspective, a number of medication safety strategies have been developed that aim to support the patient in their active role in the medication process. These strategies intend to safeguard the processes of care including transfer of information, but also aim to prevent intentional and unintentional nonadherence. The prerequisites for successful implementation are targeted awareness-raising measures to sensitize all participants for potential risks in the medication process. Moreover, readily available medication safety strategies must be easily accessible and promoted both to patients and healthcare providers.

[Electronic decision support to promote medication safety]. / Elektronische Entscheidungsunterstützung zur Annäherung an eine sichere Arzneimitteltherapie.

Because of its inherent complexity, it is a considerable challenge to tailor drug treatment to a prevalent disease and its subgroups, which are increasingly defined by genomic variability (personalized medicine) and require consideration of context information such as co-morbidity, co-medication, patient preferences, and the specific characteristics of the healthcare sector. Thus, optimum treatment decisions might not be taken intuitively any longer, because decisions must be made both rapidly and increasingly based on analyses of complex relations of numerous variables that exceed the processing performance of a human brain. Hence, computer support is indispensable to ensure error-free high-performance medicine. A key step in computer-supported medication safety is to implement a computerized physician order entry (CPOE) system that compiles a patient's medication in a structured and coded format enabling the link to clinical decision support (CDS) systems. Implementing a CPOE is hence a strategic step for a hospital, which is crucial to exhaustingly and consistently prevent medication errors. Thereby, the best performance of a CPOE is achieved if it is deeply integrated into an electronic patient record thus enabling access to relevant patient information, which again has to be structured to allow processing. To efficiently support drug treatment, CDS systems must fulfill high-quality standards with regard to underlying data, integration, and user-interaction to ensure that they support but do not impede the provision of care.

[Simplifying complex drug therapies : Challenges and solutions]. / Komplexe Arzneimitteltherapien vereinfachen : Herausforderungen und Lösungsansätze.

The difficulties of managing a complex medication regimen are often underestimated in outpatient care. A large number of drugs (polypharmacy) and complicated dosage schemes or dosage forms may overstrain patients. Indeed, wrong drug administration can impair treatment success or cause adverse drug events.Patients are often unaware of the medication administration errors. Furthermore they do not voice administration problems, often because they are not aware of the potential to optimize their drug therapy. Medication regimen complexity can often be reduced by simple measures. However, feasible concepts for reducing medication regimen complexity in a structured way have been lacking in routine care so far.Electronic decision support facilitates systematic and efficient identification of factors that increase the complexity of a medication regimen. Furthermore, electronic decision aids may enable physicians and pharmacists to take appropriate measures in order to reduce medication regimen complexity. Personalizing the analysis and resulting measures to reduce medication regimen complexity might increase readiness of patients to implement changes in treatment and, thus, probably increase adherence. The first results of a prospective trial that is supported by the Federal Joint Committee (G-BA) Innovationsfonds (HIOPP-6, Komplexitätsreduktion in der Polypharmazie unter Beachtung von Patientenpräferenzen) will be available in autumn 2018 and answer these questions.

Definition of variables required for comprehensive description of drug dosage and clinical pharmacokinetics.

PURPOSE: Electronic clinical decision support systems (CDSS) require drug information that can be processed by computers. The goal of this project was to determine and evaluate a compilation of variables that comprehensively capture the information contained in the summary of product characteristic (SmPC) and unequivocally describe the drug, its dosage options, and clinical pharmacokinetics. METHODS: An expert panel defined and structured a set of variables and drafted a guideline to extract and enter information on dosage and clinical pharmacokinetics from textual SmPCs as published by the European Medicines Agency (EMA). The set of variables was iteratively revised and evaluated by data extraction and variable allocation of roughly 7% of all centrally approved drugs. RESULTS: The information contained in the SmPC was allocated to three information clusters consisting of 260 variables. The cluster "drug characterization" specifies the nature of the drug. The cluster "dosage" provides information on approved drug dosages and defines corresponding specific conditions. The cluster "clinical pharmacokinetics" includes pharmacokinetic parameters of relevance for dosing in clinical practice. A first evaluation demonstrated that, despite the complexity of the current free text SmPCs, dosage and pharmacokinetic information can be reliably extracted from the SmPCs and comprehensively described by a limited set of variables. CONCLUSION: By proposing a compilation of variables well describing drug dosage and clinical pharmacokinetics, the project represents a step forward towards the development of a comprehensive database system serving as information source for sophisticated CDSS.

Association of preventable adverse drug events with inpatients' length of stay-A propensity-matched cohort study.

PURPOSE: Using clinical administrative data (CAD) of inpatients, we aimed to identify ICD-10 codes coding for potentially preventable inhospital adverse drug events (ADE) that affect the length of hospital stay (LOS) and thus patient well-being and cost. METHODS: We retrospectively assessed CAD of all inpatient stays in 2012 of a German university hospital. Predefined ICD-10 codes indicating ADE (ADE codes) were further specified based on expert ratings of the ADE mechanism and ADE preventability in clinical routine to particularly identify preventable inhospital ADE. In a propensity-matched cohort design, we compared patients with one or more ADE codes to control patients with regard to differences in LOS for three situations: all cases with an ADE code, cases with an inhospital ADE code, and cases with a preventable inhospital ADE code. RESULTS: Out of 54 032 cases analysed, in 8.3% (N=4 462) at least one ADE code was present. Nine of 128 evaluated ADE codes were rated as preventable in clinical routine, relating to 220 inpatients (4.9% of all identified inpatients with at least one ADE code and 0.4% of the entire cohort, respectively). Out of 48 072 evaluable inpatients for propensity score matching, 7 938 controls without ADE code and 4 006 cases with ADE code were selected. In all three settings, cases showed prolonged LOS vs controls (delta 1.13 d; 0.88 d and 1.88 d, respectively), significantly exceeding the maximum LOS as defined for each Diagnosis-Related Group. CONCLUSION: Inpatients with ADE codes referring to inhospital, potentially preventable ADE exceeded the maximum hospital stay fully reimbursed by insurance companies, indicating unnecessary long and costly inpatient stays.

Working together to enhance medication safety: working group 'medication safety' of the Aktionsbündnis Patientensicherheit e.V. / Gemeinsam für mehr Arzneimitteltherapiesicherheit Die AG AMTS im Aktionsbündnis Patientensicherheit e. V.

For 12 years, the 'Aktionsbündnis Patientensicherheit e.V. (APS)' has been developing tools for improving patient safety. Experts with different professional backgrounds are working alongside patients and self-help associations in different working groups to develop and publish problem-oriented best-practice recommendations. Since its foundation in 2005, APS has published more than 20 best-practice recommendations and is one of the most important institutions for patient safety in Germany. In this article, the aims and initiatives of one working group of the APS, i.e. the medication safety working group, are presented. The standardized concept for the development of best-practice recommendations is illustrated by the example of the recommendations for medication safety in hospitals.

Limitations of the Anticholinergic Activity Assay and Assay-Based Anticholinergic Drug Scales.

OBJECTIVE: The anticholinergic activity (AA) assay is a common method to determine a patient's anticholinergic load. Several limitations, however, are expected when applying the AA assay to patients or using drug scales to estimate anticholinergic burden based on AA levels. This study aims to demonstrate common pitfalls in an experimental setting and outline their clinical consequences. METHODS: The AA was analyzed for five drugs with reported interaction with muscarinic receptors. Concentration-response curves were constructed for furosemide (weak anticholinergic), diphenhydramine (moderate anticholinergic), the strong anticholinergic amitriptyline and its metabolite nortriptyline, and the cholinergic pilocarpine. The Combination Index (CI) was used to assess the interaction of three drug combinations with amitriptyline. RESULTS: All compounds displaced the radioactive tracer from its receptor binding site in a concentration-dependent manner, and full displacement was reached for all compounds except furosemide (Emax 16%). The CI indicated that amitriptyline and thioridazine have antagonistic effects (CI = 1.46) at low and synergistic effects (CI = 0.88) at higher concentrations (p < 0.0001), whereas synergistic effects (CI = 0.47-0.48) were observed for amitriptyline in any concentration combined with pilocarpine (p < 0.001). CONCLUSION: When the patient's anticholinergic load is estimated using AA levels, the actual exposure, combination of anticholinergic drugs, their active metabolites, and also drugs with an opposite pharmacologic action will contribute to AA levels, whereas weak anticholinergic drugs in therapeutic concentrations are rather negligible.

Guidance on how to achieve comprehensible patient information leaflets in four steps.

Comprehensible information leaflets can improve a patient's knowledge. However, in clinical studies leaflets are often introduced without meticulously verifying their comprehensibility. In an attempt to provide a feasible guidance on how to design comprehensible leaflets we complied and evaluated an easy-to-use development procedure. In January 2015, a literature search was performed to identify evidence for readily available quality assurance strategies as a starting point for a standardized strategy to develop and validate written patient information. The suggested development strategy is a consecutive four-step procedure that comprised already validated distinct quality assessments: (i) an initial requirement analysis specifying the needs and constraints of the target population and evidence-based preparation of the leaflets, (ii) a readability assessment, (iii) the Suitability Assessment of Materials instrument and (iv) iterative consumer test in the target population. The consecutive combination of pertinent and previously validated quality assessments provides an easy-to-use guidance on how to create comprehensibly written patient information, particularly for small-scale research projects with time and money constraints.

The impact of pharmaceutical care interventions for medication underuse in older people: a systematic review and meta-analysis.

AIMS: The aim of the present study was to conduct a meta-analysis of controlled trials assessing the impact of pharmaceutical care interventions (e.g. medication reviews) on medication underuse in older patients (≥65 years). METHODS: The databases MEDLINE and EMBASE were searched for controlled studies, and data on interventions, patient characteristics and exposure, and outcome assessment were extracted. Risk of bias was assessed using the Cochrane Collaboration's 'risk of bias' table. Results from reported outcomes were synthesized in multivariate random effects meta-analysis, subgroup meta-analysis and meta-regression. RESULTS: From 954 identified articles, nine controlled studies, mainly comprising a medication review, were included (2542 patients). These interventions were associated with significant reductions in the mean number of omitted drugs per patient (estimate from six studies with 1469 patients: - 0.44; 95% confidence interval -0.61, -0.26) and the proportion of patients with ≥1 omitted drugs (odds ratio from eight studies with 1833 patients: 0.29; 95% confidence interval 0.13, 0.63). The only significant influential factor for improving success was the utilization of explicit screening instruments when conducting a medication review (P = 0.033). CONCLUSION: Pharmaceutical care interventions, including medication reviews, can significantly reduce medication underuse in older people. The use of explicit screening instruments alone or in combination with implicit reasoning is strongly recommendable for clinical practice.

Different methods, different results--how do available methods link a patient's anticholinergic load with adverse outcomes?

PURPOSE: Anticholinergic drugs are known to cause physical and cognitive impairment, particularly in older patients. The total of all anticholinergic influences to which a patient is exposed is referred to as anticholinergic load. Because the anticholinergic load is defined in various ways, this review aimed to describe differences in the development and evaluation of available methods calculating the anticholinergic load. METHODS: From September 2014 to August 2015, two reviewers performed a literature search in PubMed considering relevant items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We aimed to identify articles which calculated the anticholinergic load with a scale or equation and investigated its association with patient-related outcomes. From the included studies, we descriptively analyzed the identification and scoring criteria of the scales and equations with a main emphasis on their association to the reported outcomes. RESULTS: Out of 465 articles, 55 were included referring to 12 scales and one equation. Main discrepancies were located in eight different identification criteria for anticholinergic drugs, two different scoring principles, and 118 tests used for assessing outcomes. The methods most frequently detecting a significant association between the anticholinergic load and outcomes took into account the drugs' dosages and anticholinergic potencies. Interestingly, none of the methods included the patient's susceptibility for anticholinergic effects and they only rarely considered modulators of drug exposure. CONCLUSIONS: Due to hugely varying tests for assessing outcomes, the methods are scarcely comparable. For a more valuable comparison, the anticholinergic load should be calculated with all scales and the equation and correlated with patient-related outcomes.