Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
Drugs Aging. 2020 Mar;37(3):161-174. doi: 10.1007/s40266-019-00733-1.
Hospital admissions in older adults are frequently drug related and avoidable. Clinical pharmacy interventions during hospital stay might reduce drug-related harm and reduce hospital visits. Moreover, several recent positive clinical pharmacy investigations incorporated a transitional care component to further improve medication use after discharge. It is currently unclear what the strength of evidence is and what the exact components should be of such clinical pharmacy interventions in older adults.
An evidence-based review was performed to determine the status of the evidence and also to explore whether a clinical pharmacy intervention incorporating transitional care was associated with reduced hospital visits after discharge.
Prospective controlled investigations were included if they contained a clinical pharmacy intervention that was initiated before discharge in older inpatients. Relevant quasi-experimental and randomized controlled trials were searched in MEDLINE. First, an evidence-based review was performed, including a description of the study design, characteristics, and outcomes. Major components of successful clinical pharmacy interventions were described and potential implications for clinical practice and research were determined. Second, the Fisher's exact test was used to explore the association between transitional care and reduced hospital visits. Third, based on these findings, a medication review proposal was developed to improve medication use in older adults.
Thirty-five studies were included, with 26 randomized controlled trials. Median patient follow-up after discharge was 90 days (interquartile range 37-180 days) and investigators enrolled a median of 210 (interquartile range 110-498) study participants. On average, patients were aged 77.5 years (interquartile range 73-82.2 years). Nine randomized controlled trials had sufficient power to detect a reduction in hospital visits after discharge; this was reduced in three randomized controlled trials. Post-discharge follow-up was not associated with reduced post-discharge hospital visits (20 randomized controlled trials: follow-up vs. no follow-up: 6/11 vs. 1/9, p = 0.070). There was a significant reduction in post-discharge hospital visits in patients aged 75 years or older (12 randomized controlled trials: follow-up vs. no follow-up: 5/7 vs. 0/5, p = 0.028). A medication review proposal was developed, consisting of six steps.
Three powered randomized controlled trials were identified that found a significant association between a pharmacist-led intervention in older adults and a reduction in post-discharge hospital visits. In clinical practice, an intervention consisting of medication reconciliation, review, counseling, and post-discharge follow-up should be provided to such high-risk inpatients. Regarding research priorities, large, multi-center randomized controlled trials should be performed to generate more evidence on the impact of clinical pharmacy interventions on the patient trajectory and economic outcomes.
老年人住院的原因常常与药物有关，且这些住院是可以避免的。在住院期间开展临床药学干预可能会减少药物相关伤害并降低住院次数。此外，最近的一些积极的临床药学研究纳入了过渡护理的组成部分，以进一步改善出院后的药物使用情况。目前尚不清楚此类针对老年人的临床药学干预的证据强度和具体组成部分是什么。
进行了一项基于证据的综述，以确定证据的现状，并探讨是否将包含过渡护理的临床药学干预与出院后的住院次数减少有关。
如果前瞻性对照研究包含在老年住院患者出院前开始的临床药学干预，则将其纳入。在 MEDLINE 中搜索了相关的准实验和随机对照试验。首先，进行了基于证据的综述，包括研究设计、特征和结局的描述。描述了成功的临床药学干预的主要组成部分，并确定了其对临床实践和研究的潜在影响。其次，使用 Fisher 确切检验探讨了过渡护理与减少住院次数之间的关系。然后，根据这些发现，制定了药物审查建议，以改善老年人的药物使用情况。
共纳入 35 项研究，其中包括 26 项随机对照试验。出院后患者的中位随访时间为 90 天（四分位距 37-180 天），研究纳入的中位患者数为 210 例（四分位距 110-498 例）。患者平均年龄为 77.5 岁（四分位距 73-82.2 岁）。9 项随机对照试验有足够的效能来检测出院后住院次数的减少，但在 3 项随机对照试验中这种效能降低了。出院后随访与出院后住院次数减少无关（20 项随机对照试验：随访 vs. 无随访：6/11 例 vs. 1/9 例，p=0.070）。年龄在 75 岁及以上的患者出院后住院次数显著减少（12 项随机对照试验：随访 vs. 无随访：5/7 例 vs. 0/5 例，p=0.028）。制定了一项药物审查建议，包含六个步骤。
确定了 3 项具有效能的随机对照试验，发现老年患者中由药剂师主导的干预与出院后住院次数减少之间存在显著关联。在临床实践中，应为此类高危住院患者提供包括药物重整、审查、咨询和出院后随访的干预措施。关于研究重点，应开展大型多中心随机对照试验，以产生更多关于临床药学干预对患者轨迹和经济结果影响的证据。
