IMPLEMENTATION OF PRIORITIZATION CRITERIA IN MEDICATION REVIEW ACTIVITY IN GERIATRIC MEDICINE: AN EIGHT-MONTH STUDY
European Statement
Clinical Pharmacy Services
Author(s)
A. GHORBEL, C. KONN, J. CATROUX, J. TISSERAND, P. ROCANIERES
Why was it done?
Polypharmacy and multimorbidity make medication safety a major challenge in geriatric medicine. Medication reconciliation and review are essential but time-consuming processes that cannot be systematically performed for all patients. Prior, we made a systematic review of the French literature which identified multiple prioritization approaches – empirical, statistical, and consensus-based – but no harmonized tool. Common criteria included advanced age, polypharmacy, psychotropic use, high-risk medications, and chronic diseases such as heart failure. Then, we aimed to translate these findings into a pragmatic, locally adapted prioritization grid to improve targeting and workflow efficiency.
What was done?
An initiative was developed in the geriatric department of a French University Hospital to introduce prioritization criteria for medication review (MR) at admission. The aim was to optimize pharmacists’ clinical activity by identifying high-risk patients most likely to benefit from a MR, given the limited available resources.
How was it done?
A prospective, observational, comparative study was conducted over 13 months (early June 2024 – end June 2025) in neuro-geriatrics and onco-geriatrics. During the 8 last months, pharmacists applied a prioritization grid daily based on clinical and pharmacological criteria (≥ 5 medications, renal impairment, psychotropics, high-risk drugs). Indicators before and after its implementation were compared using a two-sample Z-test (α = 0.05).
What has been achieved?
After implementation, 295 admission and 48 discharge MR were performed (vs 272 and 31 before prioritization). The initiative allowed the targeted inclusion of patients with a mean age of 87 ± 6 years and an average of 10 ± 4 chronic medications. The most frequent prioritization criteria identified were renal impairment, use of “never-event” drugs (methotrexate, insulin, colchicine, oral chemotherapy and anticoagulant drugs), antibiotic therapy, electrolyte disorders, and diabetes. Average MR time rose (113 vs 105 min; 89 vs 47 min), reflecting higher case complexity.
What next?
Defining common prioritization criteria could support national recommendations and enable the development of digital tools integrated into hospital information systems to automatically identify high-priority patients. In the future, it is planned to use these results to create decision rules from artificial intelligence software: it could generate dynamic prioritization models based on real-time clinical, biological, and therapeutic data, embedded into dispensing software to improve patient safety and optimize pharmaceutical care.
SEMI-AUTOMATED PHARMACEUTICAL CARE CIRCUIT IN NURSING HOMES: EXCEEDING MAXIMUM DOSE PRESCRIPTIONS IN ELDERLY PEOPLE
Pdf
European Statement
Patient Safety and Quality Assurance
Author(s)
Amaia Martiarena Ayestaran, Ane Ros Olaso, Iosu Barral Juez, Cristina Saiz Martinez, Ane Latasa Berasategui.
Why was it done?
Detection of potentially inappropriate prescriptions (PIPs) exceeding maximum dose in elderly patients. Communicate these findings to nursing home´s (NH) medical staff adding information to make easier the review. Evaluate the results obtained after the pharmaceutical intervention (PI).
What was done?
Pharmaceutical care provided in NH includes systemic reviews and drug adjustments in collaboration with clinical team to enhance the rational use of drugs.
It is designed a semi-automated pharmaceutical care circuit to detect exceeding maximum dose PIPs due to high prevalence in this population. The objective of this practice is to reduce, after a PI, PIPs to improve patient’s safety.
How was it done?
Selection of the most prevalent exceeding maximum dose PIPs based on STOPP-START criteria, safety notes and technical sheets from Spanish Agency for Medicines and Health Products: omeprazole, esomeprazole and rabeprazole ≥ 40 mg/day, pantoprazole ≥ 80 mg/day, lansoprazole ≥ 60 mg/day (PPIs); zolpidem (ZLP) > 5 mg/day; acetylsalicylic acid > 100 mg/day (AAS); citalopram > 20 mg/day; escitalopram > 10 mg/day (SSRIs); iron > 200 mg/day (Fe).
Automatic data extraction.
Registration in medical records and email notification to NH´s physicians including drug and dosage, adjustment recommendation and bibliographic reference.
Results evaluation after 2 weeks.
Limitations: way of communication and drug prescribing doctor different from NH´s doctor. To solve the first issue, an email has been sent after 1 week. On the second case, no action could be taken.
What has been achieved?
155 residents with one or more exceeding maximum dose PIPs are included from 22 centers with 2,223 elderly people linked to hospital pharmacy service. The mean age is 85.3 years and 69.7% are women.
After PI, PIPs are reduced by 66.5%.
PIPs TOTAL PPI ZLP Fe SSRI AAS
INITIAL 164 73 51 18 17 5
AFTER PI 55 20 21 5 8 1
Dose reduction and prescription discontinuation are the reasons of the PIPs reductions. Physicians justify don´t change prescriptions on 8 cases.
What next?
This semi-automated circuit is focused on PIPs. That is why the tool allows easy and rapid detection of a higher amount of patients with drug safety problems at once. In the future, it will be used for other PIPs and other NH.
Development of a clinical pharmacy program for very frail elderly hospitalized patients
European Statement
Clinical Pharmacy Services
Author(s)
Baptiste Fulbert, Florian Poncelet, Marilyne Legrand, Céline Mongaret, Dominique Hettler
Why was it done?
Very frail elderly patients are a particularly high-risk population due to their frequent multi-medication and the risk of associated adverse effects.
Clinical hospital pharmacists play an increasingly important role in patient care.
What was done?
We developed a program comprising several clinical pharmacy services for very frail elderly hospitalization.
How was it done?
We conducted a 3 month prospective study in short and middle geriatric stay included patients admitted in emergency department aged at least 75 with a Short Emergency Geriatric Assessment (SEGA) frailty score above 11. We performed, as clinical pharmacy services, best possible medication history (BPMH) in the emergency department and medication reconciliation at admission (MRA) in hospital ward and medication review during hospitalization. Medication reconciliation at discharge (MRD) was carried out on a geriatric medicine unit over 2 months. All activities were performed by pharmacy students, two residents and a pharmacist.
What has been achieved?
120 patients were included. 96 BPMHs were performed : 62 in emergency department and 34 in hospital ward.
MRA was performed for 81 patients (68%), identifying 774 discrepancies of which 19 (3%) were unintentional discrepancies (UD), 6 (32%) involving Digestive Tract and Metabolism drugs. 9 (47%) of these UDs concerned omissions.
During the 163 medication reviews, pharmacist performed 98 pharmaceutical interventions (PIs) for 53 patients, with an acceptance rate of 56%. Most of drugs involved with the acceptance rate was Nervous System drugs (20;36%) and Digestive Tract and Metabolism drugs (16;29%). Among the accepted PIs, 22 (40%) relate to dosage adjustment.
Finally, MRD was performed for 25 (21%) of patients identifying 256 discrepancies, 8 of which (3%) were UDs, mainly involving Digestive Tract and Metabolism drugs (5;63%). 5 (63%) of these UDs concern omissions.
What next?
The high number and nature of the discrepancies support the idea that this population is a relevant target for a clinical pharmacy program.
This program could be applied in other hospitals with the hospital pharmacists and provide a better care for these patients.
The development of MRD in geriatric wards and collaboration between hospital pharmacists and primary care professionnals, by a discharge summary to handover the changes between the entry and the exit prescription can complete this study.