title: The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients.
abstract: BACKGROUND
  Throughout the literature, drug-related problems (DRPs), such as medication reconciliation issues and potentially inappropriate prescribing, have been reported to be associated with adverse outcomes in older individuals. Both structured pharmacist review of medication (SPRM) interventions and computerized decision support systems (CDSSs) have been shown to reduce DRPs.
  
  
  OBJECTIVE
  The objectives of this study were to (i) evaluate the impact of a specially developed SPRM/CDSS intervention on the appropriateness of prescribing in older Irish hospital inpatients, and (ii) examine the acceptance rates of these recommendations.
  
  
  METHODS
  We prospectively reviewed 361 patients, aged ≥65 years who were admitted to an Irish university teaching hospital over a 12-month period. At the point of admission, the patients received a SPRM/CDSS intervention, which screened for DRPs. Any DRPs that were identified were then communicated in writing to the attending medical team. The patient's medical records were reviewed again at 7-10 days, or at the point of discharge (whichever came first).
  
  
  RESULTS
  Of the 361 patients reviewed, 181 (50.1 %) were female; the median age was 77 years [interquartile range (IQR) 71-83 years). A total of 3,163 (median 9, IQR 6-12) and 4,192 (median 12, IQR 8-15) medications were prescribed at admission and discharge, respectively. The SPRM generated 1,000 recommendations in 296 patients. Of the 1,000 recommendations, 548 (54.8 %) were implemented by the medical teams accordingly. The SPRM/CDSS intervention resulted in an improvement in the appropriateness of prescribing as defined by the medication appropriateness index (MAI), with a statistically significant difference in the median summated MAI at admission (15, IQR: 7-21) and follow-up (12, IQR: 6-18); p < 0.001. However, the SPRM did not result in an improvement in appropriateness of underprescribing as defined by a modified set assessment of care of vulnerable elders (ACOVE) criteria.
  
  
  CONCLUSIONS
  This study indicated that DRPs are prevalent in older Irish hospitalized inpatients and that a specially developed SPRM intervention supported by a CDSS can improve both the appropriateness and accuracy of medication regimens of older hospitalized inpatients.
authors.affiliation: Pharmaceutical Care Research Group, School of Pharmacy, University College Cork, Cork, Ireland, dos1984ucc@gmail.com.
authors.forename: David
authors.initials: D
authors.lastname: O'Sullivan
authors.forename: Denis
authors.initials: D
authors.lastname: O'Mahony
authors.forename: Marie N
authors.initials: MN
authors.lastname: O'Connor
authors.forename: Paul
authors.initials: P
authors.lastname: Gallagher
authors.forename: Shane
authors.initials: S
authors.lastname: Cullinan
authors.forename: Richard
authors.initials: R
authors.lastname: O'Sullivan
authors.forename: James
authors.initials: J
authors.lastname: Gallagher
authors.forename: Joseph
authors.initials: J
authors.lastname: Eustace
authors.forename: Stephen
authors.initials: S
authors.lastname: Byrne
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D020000:Decision Support Systems, Clinical; D017723:Drug Utilization Review / Q000379:methods*; D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control; D055695:Electronic Prescribing; D005260:Female; D006784:Hospitals, Teaching; D006801:Humans; D057970:Inappropriate Prescribing / Q000706:statistics & numerical data*; D007494:Ireland; D008297:Male; D010595:Pharmacists / Q000592:standards*; D010607:Pharmacy Service, Hospital / Q000592:standards*; D015995:Prevalence; D024382:Professional Role; D011446:Prospective Studies