Hospital Pharmacy, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Scientific Direction, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
Eur J Intern Med. 2021 Jan;83:39-44. doi: 10.1016/j.ejim.2020.07.011. Epub 2020 Aug 7.
In older medical patients polypharmacy is often associated with poor prescription appropriateness and harmful drug-drug interactions. An effort that jointly involved hospital pharmacists and clinicians attending multimorbid older patients acutely admitted to medical wards was implemented for medication recognition and reconciliation aided by the use of a computerized support system.
Six internal medicine wards enrolled consecutively 90 acutely admitted multimorbid patients aged 75 years or more taking 5 or more different drugs. Two hospital pharmacists carried out the recognition of medications taken at hospital ward admission, and interacted with the clinicians in a process of drug reconciliation, using also the computerized support system to evaluate drug related problems, prescription inappropriateness or drug-drug interactions. The process was repeated at hospital discharge.
Among a total number of 911 drugs prescribed to 90 older medical patients at ward admission, the pharmacists identified during their recognition/reconciliation 455 drug-related problems, mainly due to prescription of medications inappropriate for older multimorbid patients and clinically harmful drug-drug interactions. When these drug-related problems were identified by the pharmacist, the attending clinicians accepted and implemented the suggestions for changes for approximately two thirds of the discrepancies, thereby leading to deprescribing the implicated drugs or at least to their closer monitoring.
This interventional prospective study based upon the integrated expertise of hospital pharmacists and clinicians confirms that drug-related problems are frequent in multimorbid older patients acutely admitted to hospital medical wards, and demonstrates afresh the feasibility and mutual acceptance of a trajectory of recognition/reconciliation based upon an integrated collaboration between hospital pharmacists and ward clinicians in the process of medication optimization.
在老年患者中，多种药物治疗常常与处方不当和有害的药物相互作用有关。为了识别和协调药物，我们共同努力，让医院药剂师和治疗多系统疾病的住院医师参与进来，使用计算机支持系统辅助。
连续纳入了 6 个内科病房的 90 名年龄在 75 岁及以上、服用 5 种或以上不同药物的急性多系统疾病住院患者。两名医院药剂师在识别患者入院时服用的药物时，与临床医生进行药物协调，也使用计算机支持系统评估药物相关问题、处方不当或药物相互作用。在出院时重复这个过程。
在 90 名老年住院患者入院时开具的 911 种药物中，药剂师在识别/协调过程中发现了 455 个药物相关问题，主要是由于为老年多病患者开具了不适当的药物和临床上有害的药物相互作用。当药剂师发现这些药物相关问题时，主治临床医生接受并实施了大约三分之二的差异的更改建议，从而减少了涉及药物的使用或至少加强了对其的监测。
这项基于医院药剂师和临床医生综合专业知识的干预性前瞻性研究证实，在急性住院的多系统疾病老年患者中，药物相关问题很常见，并且再次证明了在药物优化过程中，医院药剂师和病房临床医生之间的综合协作具有可行性和相互接受性。
