Systematic evaluation of polypharmacy in geriatric patients, through a validated list by a clinical pharmacist. The goal is reduction of potentially inappropriate medications (PIMs). A brief counseling session with the patient and/or his/her caregiver will be part of the intervention.
This project is focused on the systematic evaluation of polypharmacy in older patients admitted to the acute geriatric wards of a university hospital. Polypharmacy will be identified through a validated list by a clinical pharmacist. The goal is reduction of potentially inappropriate medications (PIMs). Before hospital discharge the hospital pharmacist will have a brief counseling session with the patient and/or his/her caregiver in order to discuss the medication list and to enhance compliance.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
SUPPORTIVE_CARE
Masking
NONE
Medication reconciliation of home therapy will be performed by the clinical pharmacist through a standardized form. Next, the clinical pharmacist will perform a medication review, based on but not limited to the RASP list (Van der Linden 2014). The goal is optimization of therapy. Before discharge the clinical pharmacist will perform a second medication review, together with the treating physician and a medication reconciliation in orde to provide the best possible discharge medication list. The medication list will be provided 3 times: once for the patient and/or his/her caregiver, once for the general practitioner and once for the primary care pharmacist. Finally the clinical pharmacist will have a counseling session with the patient and/or his/her caregiver.
UZLeuven
Leuven, Belgium
Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner.
Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner.
Time frame: 1 month (30 days) after discharge
Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner.
Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner.
Time frame: 3 month (90 days) after discharge
Number of drug intakes at discharge versus at admission.
Number of drug intakes at discharge versus at admission.
Time frame: At discharge from the index hospitalization (as mentioned in the discharge medication scheme) vs on admission (during the first 72 hours of the index hospitalization)
Number of drugs at discharge versus at admission.
Number of drugs at discharge versus at admission.
Time frame: At discharge from the index hospitalization (as mentioned in the discharge medication scheme) vs on admission (during the first 72 hours of the index hospitalization)
Number of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list.
Number of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list.
Time frame: At discharge from the index hospitalization (as mentioned in the discharge medication scheme), compared to the medication list obtained on admission (this is, during the first 72 hours of the hospitalization)
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Difference in number of potentially inappropriate medications identified through the RASP list on admission versus at discharge
Difference in number of potentially inappropriate medications identified through the RASP list on admission versus at discharge
Time frame: At discharge from the index hospitalisation (as mentioned in the discharge medication scheme) versus on admission (medication list obtained in the first 72 hours) of the index hospitalization
Number of potentially inappropriate medications on admission, at discharge and at the follow-up moments (1 and 3 months after discharge)
Number of potentially inappropriate medications on admission, at discharge and at the follow-up moments (1 and 3 months after discharge)
Time frame: On admission (medication list obtained in the first 72 hours of the admission), at discharge (as mentioned in the discharge medication scheme), 1 (30 days) month after discharge, 3 months (90 days) after discharge
Mortality during admission
Mortality during admission
Time frame: During the index hospitalization, from admission to the emergency ward until moment of death on the geriatric ward, assessed up to 72 hours after death.
Number of falls during hospitalization
Number of falls during hospitalization
Time frame: During the index hospitalization, from admission on the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge.
Number of fractures during hospitalization
Number of fractures during hospitalization
Time frame: during the index hospitalization, from admission to the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge.
Length of stay
Length of stay
Time frame: During the index hospitalization, from admission to the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge.
Readmission rate 3 months after discharge
Readmission rate 3 months after discharge
Time frame: 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90
Number of fractures at 3 months after discharge
Number of fractures at 3 months after discharge
Time frame: 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90
Number of falls 3 months after discharge
Number of falls 3 months after discharge
Time frame: 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90
Mortality at 3 months after discharge
Mortality at 3 months after discharge
Time frame: 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90
Category of potentially inappropriate medications identified through the RASP list on admission and at discharge
Category of potentially inappropriate medications identified through the RASP list on admission and at discharge
Time frame: On admission (medication list obtained in the first 72 hours of the admission), at discharge (as mentioned in the discharge medication scheme)
Category of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list.
Category of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list.
Time frame: During the course of the index hospitalization, defined as the period between discharge from the geriatric ward and admission to the geriatric department. The outcome parameter will be assessed within 72 hours of discharge.
Number of drugs at follow-up (1 month and 3 months after discharge)
Number of drugs at follow-up (1 month and 3 months after discharge)
Time frame: 1 month (30 days) and 3 months (90 days) after the index hospitalization
Number of drug intakes at follow-up (1 month and 3 months after discharge)
Number of drug intakes at follow-up (1 month and 3 months after discharge)
Time frame: 1 month (30 days) and 3 months (90 days) after the index hospitalization