As the population ages, more people will have comorbid disorders and polypharmacy. Medication should be reviewed regularly in order to avoid adverse drug reactions and medication-related hospital visits, but this is often not done. As part of our student-run clinic project, we investigated whether an interprofessional student-run medication review program (ISP) added to standard care at a geriatric outpatient clinic leads to better prescribing. In this controlled clinical trial, patients visiting a memory outpatient clinic were allocated to standard care (control group) or standard care plus the ISP team (intervention group). The medications of all patients were reviewed by a review panel (“gold standard”), resident, and in the intervention arm also by an ISP team consisting of a group of students from the medicine and pharmacy faculties and students from the higher education school of nursing for advanced nursing practice. For both groups, the number of STOPP/START-based medication changes mentioned in general practitioner (GP) correspondence and the implementation of these changes about 6 weeks after the outpatient visit were investigated. The data of 216 patients were analyzed (control group = 100, intervention group = 116). More recommendations for STOPP/STARTbased medication changes were made in the GP correspondence in the intervention group than in the control group (43% vs. 24%, P = < 0.001). After 6 weeks, a significantly higher proportion of these changes were implemented in the intervention group (19% vs. 9%, P = 0.001). The ISP team, in addition to standard care, is an effective intervention for optimizing pharmacotherapy and medication safety in a geriatric outpatient clinic.
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ABSTRACT Purpose: Polypharmacy is a known risk factor for potentially inappropriate prescribing. Recently there is an increasing interest in clinical decision support systems (CDSS) to improve prescribing. The objective of this study was to evaluate the impact of a CDSS, with the START-STOPP criteria as main content in the setting of a geriatric ward. Endpoints were 1) appropriateness of prescribing and 2) acceptance rate of recommendations. Methods: This prospective study comparing the use of a CDSS with usual care involved patients admitted to geriatric wards in two teaching hospitals in the Netherlands. Patients were included from January to May 2017. The medications of 64 patients in the first six weeks was assessed according to the current standard, whereas the medications of 61 patients in the second six weeks were also assessed by using a CDSS. Medication appropriateness was assessed with the Medication Appropriateness Index (MAI). Results: The medications of 125 patients (median age 83 years) were reviewed. In both the usual care group and the intervention group MAI scores decreased significantly from admission to discharge (within group analyses, p<0.001). This effect was significantly larger in the intervention group (p<0.05). MAI scores at discharge in the usual care group and the intervention group were respectively 9.95±6.70 and 7.26±5.07. The CDSS generated 193 recommendations, of which 71 concerned START criteria, 45 STOPP criteria, and 77 potential interactions. Overall, 31.6% of the recommendations were accepted. Conclusion: This study shows that a CDSS to improve prescribing has additional value in the setting of a geriatric ward. Almost one third of the software-generated recommendations were interpreted as clinically relevant and accepted, on average one per patient.
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Treatment guidelines difer signifcantly, not only between Europe and North America but also among European countries [1–4]. Reasons for these diferences include antimicrobial resistance patterns, accessibility to and reimbursement policies for medicines, and culturally and historically determined prescribing attitudes. The European Association of Clinical Pharmacology and Therapeutics’ Education Working Group has launched several initiatives to improve and harmonize European pharmacotherapy education, but international diferences have proven to be a major barrier to these eforts [5–7]. While we have taken steps to chart these diferences [6, 8], it will probably not be possible to fully resolve them. Rather than viewing these diferences as a barrier, we should perhaps see them as an opportunity for intercultural learning by providing students and teachers a valuable lesson in the context-dependent nature of prescribing medication and the diferent interpretations of evidence-based medicine. Here, we extend our experience with interprofessional student-run clinics [9, 10], to report on our first experiences with the “International and Interprofessional Student-run Clinic.” We organized three successful video meetings with medical and pharmacy students of the Amsterdam UMC, location VU University (the Netherlands), and the University of Bologna (Italy). During these meetings, one of the students presented a real-life case of a patient on polypharmacy. Then, in a 45-min session, the students split into smaller groups (break-out rooms) to review the patient’s medication, using the prescribing optimization method and STOPP/ START criteria [11, 12]. The teachers rotated between the diferent rooms and assisted the students when necessary. Teachers and students reconvened for 60 min for debriefng, with students presenting their fndings and suggestions to revise the medication list and teachers stimulating discussion and indicating how they would alter the medication list. Participation was voluntary, and the meetings were held in the evenings to accommodate students in clinical rotations. Third-to-fnal-year medical and pharmacy students participated in the three meetings (n=17, n=20, n=12, respectively). They reported learning a lot from each other, gaining an international and interprofessional perspective. Moreover, they learned to always consider the patient’s perspective, that evidence-based medicine is context-dependent, and that guidelines should be adapted to the patient’s situation.
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