Stuijt Clementine C M, Franssen Eric J F, Egberts Antoine C G, Hudson Steve A
Department of Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.
Drugs Aging. 2008;25(11):947-54. doi: 10.2165/0002512-200825110-00005.
Clinically significant pharmacokinetic and pharmacodynamic changes occurring with age make older patients more prone to the consequences of inappropriate prescribing. The combination of higher use of medicines resulting from a higher disease burden with suboptimal treatment monitoring results in a higher risk of unwanted drug effects from sometimes inappropriate choice of drugs, doses and durations of treatment. Pharmacy services are increasingly being targeted to minimize the overall number of unnecessary and potential harmful medicines.
To investigate the impact of a pharmacist-led medication review on quality of prescribing by a healthcare professional team consisting of a general practitioner (GP), care home staff and a pharmacist.
This observational study compared outcome measurements before and after a pharmacist-led review of medications for patients under the care of a healthcare professional team consisting of a GP, care home staff and pharmacist. The procedure for conducting and recording the medication review consisted of the preparation of a patient medication profile, which combined the patient's medical records with his or her complete prescription record (current and previous [last 3 years] medication history) and pharmaceutical record (electronic journal entries for the patient over the same period). Laboratory values were evaluated in clinical context. Recommendations for the pharmaceutical plan were discussed at a conference involving the clinical pharmacist and other healthcare team members. Patients were recruited for medication review over the 12-month period 1 April 2003 to 1 April 2004. Medication appropriateness was assessed by an independent panel of clinical pharmacists using the Medication Appropriateness Index (MAI).
A total of 54 patients were eligible according to the inclusion criteria, of whom 24 were subsequently excluded for various reasons; thus, 30 patients were eligible for assessment on the MAI. There was a statistically significant difference between overall pre- and post-intervention summed MAI scores (p=0.013). The pharmacist identified 115 drug-related problems, and the total number of accepted recommendations was 78 (67.8%). Use of a medication review as an intervention by a clinical pharmacist was associated with an improvement in appropriateness of prescribing.
This study provides evidence supporting the formal integration of a clinical pharmacist into the healthcare team with the aim of improving prescribing appropriateness for institutionalized elderly Dutch patients. Overall MAI scores for all long-term medications used by a group of elderly patients improved significantly after a pharmacist-led medication review. This is an important finding because quality of prescribing is assuming increasing importance as a means of preventing avoidable medication-related harm.
随着年龄增长出现的具有临床意义的药代动力学和药效学变化，使老年患者更容易受到不适当处方后果的影响。较高的疾病负担导致用药增多，加上治疗监测欠佳，有时因药物、剂量和治疗时长选择不当，产生不良药物效应的风险更高。药学服务越来越多地以尽量减少不必要和潜在有害药物的总数为目标。
调查由药剂师主导的用药评估对由全科医生（GP）、养老院工作人员和药剂师组成的医疗专业团队的处方质量的影响。
这项观察性研究比较了由药剂师主导对由全科医生、养老院工作人员和药剂师组成的医疗专业团队所护理患者的用药情况进行评估前后的结果测量值。进行和记录用药评估的程序包括编制患者用药档案，该档案将患者的病历与其完整的处方记录（当前和以前[过去3年]用药史）以及药学记录（同期患者的电子日志条目）相结合。在临床背景下评估实验室值。在由临床药剂师和其他医疗团队成员参加的会议上讨论了药学计划的建议。在2003年4月1日至2004年4月1日的12个月期间招募患者进行用药评估。由独立的临床药剂师小组使用用药适宜性指数（MAI）评估用药适宜性。
根据纳入标准，共有54例患者符合条件，其中24例随后因各种原因被排除；因此，30例患者符合MAI评估条件。干预前后MAI总分存在统计学显著差异（p = 0.013）。药剂师识别出115个与药物相关的问题，接受的建议总数为78条（67.8%）。临床药剂师将用药评估用作干预措施与处方适宜性的改善相关。
本研究提供了证据，支持将临床药剂师正式纳入医疗团队，以提高荷兰机构养老老年患者的处方适宜性。在药剂师主导的用药评估后，一组老年患者使用的所有长期药物的总体MAI评分显著改善。这是一项重要发现，因为作为预防可避免的药物相关伤害的一种手段，处方质量正变得越来越重要。
