title: Drug - related emergency department visits by elderly patients presenting with non-specific complaints Biases in Randomized Trials: A Conversation Between Trialists and Epidemiologists. Pharmacists in general practice: a focus on drug-related problems Coordinating resources for prospective medication risk management of older home care clients in primary care: procedure development and RCT study design for demonstrating its effectiveness Continuity and Adherence to Long-Term Drug Treatment by Geriatric Patients after Hospital Discharge Measuring adherence in a community-based elderly population. Polypharmacy Patterns: Unravelling Systematic Associations between Prescribed Medications ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions Hospital Readmission Prevalence and Analysis of Those Potentially Avoidable in Southern Italy Interdisciplinary collaboration across secondary and primary care to improve medication safety in the elderly (IMMENSE study): study protocol for a randomised controlled trial Collaboration between hospital and community pharmacists to address drug‐related problems: The HomeCoMe‐program Does the non-randomized controlled study have a place in the systematic review? A pilot study. What is a non-randomised controlled trial? A model for improving medication use in home health care patients.
abstract: Background Since drug-related emergency department ( ED ) visits are common among older adults , the objectives of our study were to identify the frequency of drug-related problems ( DRPs ) among patients presenting to the ED with non-specific complaints ( NSC ) , such as generalized weakness and to evaluate responsible drug classes . Methods Delayed type cross-sectional diagnostic study with a prospect i ve 30 day follow-up in the ED of the University Hospital Basel , Switzerl and . From May 2007 until April 2009 , all non-trauma patients presenting to the ED with an Emergency Severity Index ( ESI ) of 2 or 3 were screened and included , if they presented with non-specific complaints . After having obtained complete 30-day follow-up , two outcome assessors review ed all available information , judged whether the initial presentation was a DRP and compared their judgment with the initial ED diagnosis . Acute morbidity ( “ serious condition ” ) was allocated to individual cases according to predefined criteria . Results The study population consisted of 633 patients with NSC . Median age was 81 years ( IQR 72/87 ) , and the mean Charlson comorbidity index was 2.5 ( IQR 1/4 ) .  DRPs were identified in 77 of the 633 cases ( 12.2 % ) . At the initial assessment , only 40 % of the DRPs were correctly identified . 64 of the 77 identified DRPs ( 83 % ) fulfilled the criteria “ serious condition ” . Polypharmacy and certain drug classes ( thiazides , antidepressants , benzodiazepines , anticonvulsants ) were associated with DRPs . Conclusion Elderly patients with non-specific complaints need to be screened systematic ally for drug-related problems . Trial Registration Clinical Trials.gov : Trialists and epidemiologists often employ different terminology to refer to biases in r and omized trials and observational studies , even though many biases have a similar structure in both types of study . We use causal diagrams to represent the structure of biases , as described by Cochrane for r and omized trials , and provide a translation to the usual epidemiologic terms of confounding , selection bias , and measurement bias . This structural approach clarifies that an explicit description of the inferential goal -the intention-to-treat effect or the per- protocol effect-is necessary to assess risk of bias in the estimates . Being aware of each other 's terminologies will enhance communication between trialists and epidemiologists when considering key concepts and methods for causal inference Background Team based care has been used internationally to improve the delivery of best practice primary health care . The WentWest General Practice Pharmacist Project , involving the integration of pharmacists within general practice teams , was commissioned to improve medication management of general practice patients . A particular focus of the project was the performance of medication review to allow the detection and resolution of drug related problems ( DRPs ) . Objective The objectives of this 6-month study ( October 2016–March 2017 ) were to : ( 1 ) identify and classify the DRPs detected as a result of  pharmacist activities  within a general practice primary care setting . ( 2 ) compare the number of pharmacist recommendations and GP acceptance rates as a result of pharmacist patient consultations across multiple general practice sites . Setting 15 general practice primary care sites in Western Sydney NSW Australia . A multi-centre prospect i ve observational study conducted over a 6-month period from October 2016 to March 2017 . Main outcome measure Drug-related problems ( DRPs ) . Results Six pharmacists recorded the results from 493 patient consultations . The pharmacists identified 1124  DRPs and made 984 recommendations , of which 685 ( 70 % ) were recorded as accepted by the GP . Conclusion Pharmacists have a valuable role to play in the detection and resolution of DRP as part of the general practice team Background The magnitude of safety risks related to medications of the older adults has been evidence d by numerous studies , but less is known of how to manage and prevent these risks in different health care setting s. The aim of this study was to coordinate re sources for prospect i ve medication risk management of home care clients ≥ 65 years in primary care and to develop a study design for demonstrating effectiveness of the procedure . Methods Health care units involved in the study are from primary care in Lohja , Southern Finl and : home care ( 191 consented clients ) , the public healthcare center , and a private community pharmacy .  System based risk management theory and action research method was applied to construct the collaborative procedure utilizing each profession ’s existing re sources in medication risk management of older home care clients . An inventory of clinical measures in usual clinical practice and systematic review of rigorous study design s was utilized in effectiveness study design . Discussion The new coordinated medication management model ( CoMM ) has the following 5 stages : 1 ) practical nurses are trained to identify clinical ly significant drug-related problems ( DRPs ) during home visits and report those to the clinical pharmacist . Clinical pharmacist prepares the cases for 2 ) an interprofessional triage meeting ( 50–70 cases/meeting of 2 h ) where decisions are made on further action , e.g. , more detailed medication review s , 3 ) community pharmacists conduct necessary medication review s and each patients ’ physician makes final decisions on medication changes needed . The final stages concern 4 ) implementation and 5 ) follow-up of medication changes . R and omized controlled trial ( RCT ) was developed to demonstrate the effectiveness of the procedure . The developed procedure is feasible for screening and review ing medications of a high number of older home care clients to identify clients with severe DRPs and provide interventions to solve them utilizing existing primary care re sources .Trial registration The study is registered in the Clinical Trials.gov ( NCT02545257 ) . Registration date September 9 2015 Abstract Background : Increased life expectancy is associated with an increased prevalence of chronic diseases and drug consumption . Changes often occur in the medication regimen after hospitalization . The extent and nature of these changes and the adherence of elderly patients have not yet been fully investigated . Objective : To investigate the extent and reasons for modifications to the medication regimens of elderly patients and their adherence to treatment during the first month following hospital discharge . Methods : This was a prospect i ve cohort study of 198 patients aged ≥65 years in the Acute Geriatric Ward , Beilinson Hospital , Rabin Medical Center , Israel . Clinical , demographic and medication regimen data were recorded for all patients at an interview conducted prior to discharge . After 1 month , the patient , caregiver or general practitioner ( GP ) were interviewed regarding the extent and reasons for modifications to the medication regimen and adherence to treatment . Results : At 1-month post-discharge , on average , 36.7 % of patient medications had been modified compared with the discharge prescription . No modification was found in 16 % of patients . During the observation month , 62 % of prescribed long-term medications were taken without modification as recommended at discharge and during follow-up , 50 % of all changes were characterized by the addition of a drug or an increase in dosage , and 26 % , 16 % and 8 % consisted of cancelling , omission or switching within the same medication type , respectively . Seventy percent of medication regimen changes were based on specialists ’ recommendations or secondary to a change in the patients ’ medical state , and 13 % , 8 % , 3 % and 6 % were as a result of poor adherence , adverse effects , administrative restrictions and other reasons , respectively . There was no correlation between medication regimen change and age , gender , physical function , cognitive function and length of hospital stay . Patients discharged home experienced less regimen modification than those discharged elsewhere ( p = 0.02 ) . Patients who visited their GP only once experienced less regimen modification ( p = 0.03 ) . Regression analysis showed that the only factors affecting medication regimen changes were GP visits and chronic diseases ( p < 0.01 , R2 = 0.09 ) . The overall mean adherence among 145 home-dwelling patients was 96.7 % . Twenty-seven percent and 6 % were under- and over-adherent , respectively , to at least one drug ; under-adherence was more widespread than over-adherence . No correlation was found between the overall mean adherence and other clinical parameters or regimen change . However , non-adherence to at least one drug was associated with more medication regimen changes ( p = 0.001 ) , was more common in patients discharged with prescriptions for seven or more drug types per day ( p = 0.01 ) and was associated with failing to visit the patient ’s GP 1 month after discharge ( p = 0.02 ) . Conclusion : The majority of elderly patients experienced modifications in their medication regimen during the first month following hospital discharge . Thirty percent of patients were non-adherent to at least one drug . To improve adherence to a hospital medication regimen , patients should be encouraged to visit their GP and the number of long-term drugs should be reduced OBJECTIVE To examine the reliability and validity of the Medication Adherence Individual Review -Screening Tool ( MedAdhIR-ST ) for assessing medication adherence in a community-dwelling elderly population . DESIGN A prospect i ve , observational pilot study comparing the reliability and validity of the MedAdhIR-ST and the Medication Adherence Question naire ( MAQ ) . SETTING Independent senior-housing apartments and senior centers in Wake County , North Carolina . PARTICIPANTS Eligible subjects included individuals 60 years of age or older who were living in the community and managing their own medication regimens . INTERVENTIONS Each subject was asked to participate in two assessment visits , two weeks ( + /- 3 days ) apart , in which the questions of the MedAdhIR-ST and MAQ were administered . MAIN OUTCOME MEASURE Medication adherence . RESULTS Both tools showed moderate-to-high test/retest reliability in the study population ( correlation coefficient of 0.632 for MAQ , and 0.699 for MedAdhIR-ST ) , and moderate internal consistency ( Cronbach 's a of 0.551 and 0.584 , respectively ) . Moderate concordance in the ability to assess adherence was observed between MedAdhIR-ST and MAQ ( positive correlation coefficient of 0.450 ) . When compared with refill records , MedAdhIR-ST was slightly more sensitive ( 67 % vs. 43 % ) and specific ( 60 % vs. 50 % ) for detecting adherence and nonadherence , respectively , compared with MAQ . Exploratory factor analysis indicated that MedAdhIR-ST is multidimensional . CONCLUSION MedAdhIR-ST appears to be a reliable and valid tool for screening nonadherence in a community-dwelling elderly population Objectives The aim of this study was to demonstrate the existence of systematic associations in drug prescription that lead to the establishment of patterns of polypharmacy , and the clinical interpretation of the associations found in each pattern . Methods A cross-sectional study was conducted based on information obtained from electronic medical records and the primary care pharmacy data base in 2008 . An exploratory factor analysis of drug dispensing information regarding 79,089 adult patients was performed to identify the patterns of polypharmacy . The analysis was stratified by age and sex . Results Seven patterns of polypharmacy were identified , which may be classified depending on the type of disease they are intended to treat : cardiovascular , depression-anxiety , acute respiratory infection ( ARI ) , chronic obstructive pulmonary disease ( COPD ) , rhinitis-asthma , pain , and menopause . Some of these patterns revealed a clear clinical consistency and included drugs that are prescribed together for the same clinical indication ( i.e. , ARI and COPD patterns ) . Other patterns were more complex but also clinical ly consistent : in the cardiovascular pattern , drugs for the treatment of known risk factors — such as hypertension or dyslipidemia — were combined with other medications for the treatment of diabetes or established cardiovascular pathology ( e.g. , antiplatelet agents ) . Almost all of the patterns included drugs for preventing or treating potential side effects of other drugs in the same pattern . Conclusions The present study demonstrated the existence of non-r and om associations in drug prescription , result ing in patterns of polypharmacy that are sound from the pharmacological and clinical viewpoints and that exist in a significant proportion of the population . This finding necessitates future longitudinal studies to confirm some of the proposed causal associations . The information discovered would further the development and /or adaptation of clinical patient guidelines to patients with multimorbidity who are taking multiple drugs Non-r and omised studies of the effects of interventions are critical to many areas of healthcare evaluation , but their results may be biased . It is therefore important to underst and and appraise their strengths and weaknesses . We developed ROBINS-I ( “ Risk Of Bias In Non-r and omised Studies - of Interventions ” ) , a new tool for evaluating risk of bias in estimates of the comparative effectiveness ( harm or benefit ) of interventions from studies that did not use r and omisation  to allocate units ( individuals or clusters of individuals ) to comparison groups . The tool will be particularly useful to those undertaking systematic review s that include non-r and omised studies Background One quality indicator of hospital care , which can be used to judge the process of care , is the prevalence of hospital readmission because it reflects the impact of hospital care on the patient ’s condition after discharge . The purpose s of the study were to measure the prevalence of hospital readmissions , to identify possible factors that influence such readmission and to measure the prevalence of readmissions potentially avoidable in Italy . Methods A sample of 2289 medical records of patients aged 18 and over admitted for medical or surgical illness at one 502-bed community non-teaching hospital were r and omly selected . Results A total of 2252 patients were included in the final analysis , equaling a response rate of 98.4 % . The overall hospital readmission prevalence within 30 days of discharge was 10.2 % . Multivariate logistic regression analysis revealed that the proportion of patients readmitted within 30 days of discharge significantly increased regardless of Charlson et al. comorbidity score , among unemployed or retired patients , and in patients in general surgery . A total of 43.7 % hospital readmissions were judged to be potentially avoidable . Multivariate logistic regression analysis showed that potentially avoidable readmissions were significantly higher in general surgery , in patients referred to hospital by an emergency department physician , and in those with a shortened time between discharge and readmission . Conclusion Additional research on intervention or bundle of interventions applicable to acute inpatient population s that aim to reduce potentially avoidable readmissions is strongly needed , and health care providers are urged to implement evidence -based programs for more cost-effective delivery of health care Introduction Drug-related problems ( DRPs ) are common in the elderly , leading to suboptimal therapy , hospitalisations and increased mortality . The integrated medicines management ( IMM ) model is a multifactorial interdisciplinary methodology aim ing to optimise individual medication therapy throughout the hospital stay . IMM has been shown to reduce readmissions and drug-related hospital readmissions . Using the IMM model as a template , we have design ed an intervention aim ing both to improve medication safety in hospitals , and communication across the secondary and primary care interface . This paper presents the study protocol to explore the effects of the intervention with regard to healthcare use , health-related quality of life ( HRQoL ) and medication appropriateness in elderly patients . Methods and analysis A total of 500 patients aged ≥70 years will be included and r and omised to control ( st and ard care ) or intervention group ( 1:1 ) . The intervention comprises five steps mainly performed by pharmacists : ( 1 ) medication reconciliation at admission , ( 2 ) medication review during hospital stay , ( 3 ) patient counselling about the use of medicines , ( 4 ) a comprehensible and patient-friendly medication list with explanations in discharge summary and ( 5 ) postdischarge phone calls to the primary care level . The primary outcome is the difference between intervention and control patients in the rate of emergency medical visits ( acute readmissions and visits to emergency department ) 12 months after discharge . Secondary outcomes include length of index hospital stay , time to first readmission , mortality , hip fractures , strokes , medication changes , HRQoL and medication appropriateness . Patient inclusion started in September 2016 . Ethics and dissemination The trial was approved by the Norwegian Centre for Research Data and the Norwegian Data Protection Authority . We aim to publish the results in international peer- review ed open access journals , at national and international conferences , and as part of two PhD theses . Trial registration number NCT02816086 Background : Hospital discharge poses a significant threat to the continuity of medication therapy and frequently results in drug‐related problems post‐discharge . Therefore , establishing continuity of care by realizing optimal collaboration between hospital and community pharmacists is of utmost importance . Objective : To evaluate the collaboration between hospital and community pharmacists on addressing drug‐related problems after hospital discharge . Methods : A prospect i ve follow‐up study was conducted between November 2013–December 2014 in a general hospital and all affiliated community pharmacies . Adult patients , admitted for ≥48 h to the neurology or pulmonology ward were eligible if they used ≥3 chronic prescription drugs and lived in the community pharmacies ' service area . The HomeCoMe intervention program was comprised of medication verification and counseling at admission , medication screening by the hospital pharmacist during admission , outpatient pharmacy discharge consultation and support , and a community pharmacist home visit within one week post‐discharge . Results : The mean age of the 152 included patients was 67.0 ± 12.6 years and 56.6 % were female . A total of 745 DRPs ( 4.9 ± 2.2 DRPs per patient , range : 0–11 ) were identified with the need for additional “ Education or information ” ( 36.1 % ) and “ Compliance ” ( 16.4 % ) issues as most common DRP‐types . This led to a total of 928 recommendations ( 6.1 ± 3.0 per patient , range : 1–19 ) to solve the DRP . The majority of DRPs were identified ( 83.6 % , n = 623 ) and solved ( 91.6 % , n = 682 ) by the community pharmacist during the home visit . Furthermore , 52.5 % ( n = 64 ) of the DRPs identified during hospitalization were solved during the post‐discharge home visit . Conclusions : Collaboration between hospital and community pharmacists from hospital admission to readmission to primary care is crucial to establish continuity of care . A post‐discharge community pharmacist home visit is a valuable addition to in‐hospital transitional care to identify and solve drug‐related problems BACKGROUND A major issue in any systematic review is deciding which trials or studies to include and which to exclude . The Cochrane Collaboration and similar respected organizations have traditionally viewed the r and omized trial ( RCT ) as the only acceptable evidence on treatment outcome . However , many systematic review s are indeterminate because they include insufficient RCTs whilst they reject large numbers of non-r and omized controlled studies . This is particularly true in forensic mental health , a domain where RCT methodology can be problematic . Systematic review s could become more informative if review ers knew when , and under what circumstances , non-r and omized design s are acceptable for inclusion alongside RCTs . METHOD This pilot study explores whether good- quality , controlled , non-r and omized studies can be reliable surrogates for RCTs . We examined two published review s from the Cochrane Schizophrenia Group . We compared outcomes between ( a )  r and omized trials  ( that had been included ) and non-r  and omized studies  ( that had been excluded ) , and ( b ) between high- and low- quality studies using an established quality checklist  . RESULTS In the first review , effect scores were similar for r and omized and non-r and omized studies and relatively insensitive to study quality . In the second review , the treatment effect was considerably lower for the RCT group - here , however , studies of high- quality showed much smaller effect scores than those of low- quality on two separate outcomes . CONCLUSIONS Non-r and omized controlled studies of high quality can produce outcomes that approximate to those found in RCTs . Trial quality may have a greater impact on treatment effect size than r and omization alone , suggesting that r and omization should not be seen as a reliable proxy for overall quality . The problems and issues still to be resolved are discussed with recommendations for future research Research ers investigated whether a low cost public campaign by local health authorities reduced antibiotic prescribing for out patients . A non-r and omised controlled trial study design was used . The intervention was multifaceted and included posters , brochures , and advertisements on local media , plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists . The campaign focused primarily on the prescription of antibiotics for upper respiratory tract infections . The trial was based in Emilia-Romagna in northern Italy . The provinces of Modena and Parma ( about 1 150 000 residents ) were chosen for implementation of the intervention between November 2011 and February 2012 . The provinces where the campaign was not implemented , with no information provided to doctors and pharmacists , formed the control group ( about 3 250 000 residents ) . The primary outcome was the change in prescribing rates of antibiotics for out patients over five months.1 The research ers reported that a low cost community based public campaign targeted at residents , combined with a newsletter on local antibiotic resistance for doctors and pharmacists , was associated with a significantly decreased total rate of antibiotic prescribing . However , the campaign did not affect the participants ’ knowledge and attitudes about antibiotic resistance . Which of the following statements , if any , are true OBJECTIVES ( 1 ) To develop a model for the identification and resolution of problems associated with suboptimal medication use in elderly patients receiving home health care ; ( 2 ) To select the most important identifiable problems and develop structured procedures for their resolution . DESIGN Expert panel review , problem selection , and development of a problem resolution model and guidelines . SETTING Home health care . PARTICIPANTS A panel with expertise in home health nursing , pharmacy , clinical pharmacology , gerontology , pharmacoepidemiology , and health services research . INTERVENTIONS A list of potential problems associated with the most frequently used classes of drugs was compiled for review by the panel . Problems that were controversial or that could not be identified in the home care setting were excluded . Panel members individually ranked the remainder . Detailed procedures for identification and resolution of the 15 top-ranking problems were developed . MAIN OUTCOME MEASURES Not applicable . RESULTS Potential medication problems were defined by both drug use and symptoms or clinical signs associated with specific adverse effects , to ensure that clinical ly relevant problems would be identified . The model developed for problem assessment and resolution was centered on the drug utilization review ( DUR ) coordinator and the attending home health nurse . Following guidelines developed by the panel , the DUR coordinator advises the home health nurse about identified problems and how to resolve them . One of these practitioners , usually the nurse , then contacts the attending physician to explain their concerns , offer potential solutions , and request instructions . CONCLUSION A potentially useful model for the identification and resolution of medication problems in the home health care setting was developed . This model is currently being evaluated in a r and omized controlled trial
target: This review will provide an exhaustive view of medication management models that could be effective for polymedicated , home-dwelling older adults and will allow us to analyze their impact on managing and preventing MRPs .
background: BACKGROUND Older adults with multiple chronic diseases commonly require complex medication regimes .
  When combined with frailty , cognitive impairment , and changing pharmacological prescriptions , older adults ' polymedication regimes increase the risk of medication-related problems ( MRPs ) and hospitalization .
  Effective , well-organized medication management could avoid MRPs and their clinical outcomes .
  OBJECTIVE Identify medication management models and analyze their impact on managing and preventing MRPs for polymedicated , home-dwelling older adults .