Ros J J W, Koekkoek T J, Kalf A, van den Bemt P M L A, Van Kan H J M
Department of Clinical Pharmacy, Gelre Hospitals, Apeldoorn, The Netherlands.
Department of Clinical Pharmacy, Rivierenland Hospital, Tiel, The Netherlands.
Eur J Hosp Pharm. 2017 Jan;24(1):26-30. doi: 10.1136/ejhpharm-2016-000916.
Appropriate prescribing is a key quality element in medication safety. It is unclear if therapeutic interventions resulting from medication review lead to clinically relevant improvements. The effect of medication review on prescribing appropriateness was evaluated in the setting of an outpatient consultation team, consisting of a clinical pharmacist and a clinical geriatrician, in a large non-academic teaching hospital in the Netherlands.
A group of 49 elderly patients with polypharmacy was included after referral by their general practitioner for drug related problems. After a regular assessment by a clinical geriatrician and medication record review by a clinical pharmacist, a treatment plan was implemented based on the recommended interventions. The main outcome measure was the change in the Medication Appropriateness Index (MAI) before and 3 months after primary consultation.
Overall 82% of the recommended interventions of the pharmacist were implemented by the geriatrician of which 63% persisted up to the last visit. Per patient an average of 6.6 interventions were carried out. The interventions showed a reduction of the MAI per patient of 50%. The number of drugs per patient was reduced from 12.1 to 11.0. The number of medications listed on the Beers list decreased from 2.3 to 1.5 and the number of drugs listed on the Hospital Admissions Related to Medication (HARM) Trigger list decreased from 2.1 to 1.5.
Interventions from a multidisciplinary outpatient consultation team were effective in improving appropriate prescribing in elderly outpatients with polypharmacy.
合理用药是药物治疗安全性的关键质量要素。目前尚不清楚药物评估所产生的治疗干预措施是否能带来临床相关改善。在荷兰一家大型非学术性教学医院，对由临床药剂师和临床老年病科医生组成的门诊咨询团队环境下药物评估对合理用药的影响进行了评估。
一组49名患有多重用药问题的老年患者经全科医生转诊因药物相关问题被纳入研究。在经过临床老年病科医生的常规评估以及临床药剂师对用药记录的审查后，根据推荐的干预措施实施了治疗方案。主要结局指标是初次咨询前和初次咨询后3个月时药物适宜性指数（MAI）的变化。
总体而言，药剂师推荐的干预措施中有82%由老年病科医生实施，其中63%持续到最后一次就诊。每位患者平均进行了6.6项干预措施。这些干预措施使每位患者的MAI降低了50%。每位患者的药物数量从12.1种减少到11.0种。列入《Beers清单》的药物数量从2.3种减少到1.5种，列入与药物相关的医院入院（HARM）触发清单的药物数量从2.1种减少到1.5种。
多学科门诊咨询团队的干预措施在改善患有多重用药问题的老年门诊患者的合理用药方面是有效的。
