Drugs & Aging

, Volume 31, Issue 6, pp 471–481 | Cite as

The Impact of a Structured Pharmacist Intervention on the Appropriateness of Prescribing in Older Hospitalized Patients

  • David O’Sullivan
  • Denis O’Mahony
  • Marie N. O’Connor
  • Paul Gallagher
  • Shane Cullinan
  • Richard O’Sullivan
  • James Gallagher
  • Joseph Eustace
  • Stephen ByrneEmail author
Original Research Article



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.


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.


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).


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.


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.


Pharmaceutical Care Medication Reconciliation Potentially Inappropriate Prescribe Computerize Decision Support System Research Pharmacist 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was funded by the Health Research Board (HRB) of Ireland. The authors of this study have no conflict of interest to declare. The authors thank the staff of the university teaching hospital in which this study was undertaken for their cooperation during the study period.


  1. 1.
    Central Statistic Office. Population and Labour Force Projections 2016–2046. Dublin: Government of Ireland; 2013. p. 2013.Google Scholar
  2. 2.
    Richardson K, Moore P, Peklar J, Galvin R, Bennett K, Kenny RA. Polypharmacy in adults over 50 in Ireland: Opportunities for cost saving and improved healthcare. Dublin: Trinity College Dublin; 2012.Google Scholar
  3. 3.
    Spinewine A, Swine C, Dhillon S, et al. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007;55(5):658–65.PubMedCrossRefGoogle Scholar
  4. 4.
    Spinewine A, Dhillon S, Mallet L, et al. Implementation of ward-based clinical pharmacy services in Belgium—description of the impact on a geriatric unit. Ann Pharmacother. 2006;40(4):720–8.PubMedCrossRefGoogle Scholar
  5. 5.
    Quelennec B, Beretz L, Paya D, et al. Potential clinical impact of medication discrepancies at hospital admission. Eur J Intern Med. 2013.Google Scholar
  6. 6.
    Galvin M, Jago-Byrne MC, Fitzsimons M, et al. Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland. Int J Clin Pharm. 2013;35(1):14–21.PubMedCrossRefGoogle Scholar
  7. 7.
    Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–9.PubMedCrossRefGoogle Scholar
  8. 8.
    Grimes TC, Duggan CA, Delaney TP, et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011;71(3):449–57.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Mueller SK, Sponsler KC, Kripalani S, et al. Hospital-based medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172(14):1057–69.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Bergkvist A, Midlov P, Hoglund P, et al. A multi-intervention approach on drug therapy can lead to a more appropriate drug use in the elderly. LIMM-Landskrona Integrated Medicines Management. J Eval Clin Pract. 2009;15(4):660–7.PubMedCrossRefGoogle Scholar
  11. 11.
    O’Connor MN, Gallagher P, O’Mahony D. Inappropriate prescribing: criteria, detection and prevention. Drugs Aging. 2012;29(6):437–52.PubMedCrossRefGoogle Scholar
  12. 12.
    Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther. 2011;89(6):845–54.PubMedCrossRefGoogle Scholar
  13. 13.
    Routledge PA, O’Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol. 2004;57(2):121–6.PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Resar R, Midelfort L. Medication reconciliation review. Boston: Institute for Healthcare Improvement; 2004.Google Scholar
  15. 15.
    World Health Organisation (WHO). Assuring Medication Accuracy at Transitions in Care. Geneva: World Health Organisation (WHO), 2007.Google Scholar
  16. 16.
    Caglar S, Henneman PL, Blank FS, Smithline HA, Henneman EA. Emergency department medication lists are not accurate. J Emerg Med. 2011;40:613–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045–51.PubMedCrossRefGoogle Scholar
  18. 18.
    Wenger NS, Shekelle PG. Assessing care of vulnerable elders: ACOVE project overview. Ann Intern Med. 2001;135(8 Pt 2):642–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. Arch Intern Med. 2003 Dec 8–22;163(22):2716–24.Google Scholar
  20. 20.
    Gallagher P, Ryan C, Byrne S, et al. STOPP (Screening Tool of Older Person’s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83.PubMedCrossRefGoogle Scholar
  21. 21.
    Holt S, Schmiedl S, Thurmann PA. Potentially inappropriate medications in the elderly: the PRISCUS list. Deutsches Arzteblatt Int. 2010;107(31–32):543–51.Google Scholar
  22. 22.
    Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012;29(6):495–510.PubMedCrossRefGoogle Scholar
  23. 23.
    Cherubini A, Ruggiero C, Gasperini B, et al. The prevention of adverse drug reactions in older subjects. Current Drug Metabol. 2011;12(7):652–7.CrossRefGoogle Scholar
  24. 24.
    Kaur S, Mitchell G, Vitetta L, et al. Interventions that can reduce inappropriate prescribing in the elderly: a systematic review. Drugs Aging. 2009;26(12):1013–28.PubMedCrossRefGoogle Scholar
  25. 25.
    Campbell F, Karnon J, Czoski-Murray C, Jones R. A systematic review of the effectiveness and costeffectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. Shellfield: The University of Sheffield, School of Health and Related Research (ScHARR); 2007.Google Scholar
  26. 26.
    Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894–900.PubMedCrossRefGoogle Scholar
  27. 27.
    Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–84.PubMedCrossRefGoogle Scholar
  28. 28.
    Drenth-van Maanen AC, Spee J, van Hensbergen L, et al. Structured history taking of medication use reveals iatrogenic harm due to discrepancies in medication histories in hospital and pharmacy records. J Am Geriatr Soc. 2011;59(10):1976–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Martin J. British National Formulary. London; 2011.Google Scholar
  30. 30.
    Cunningham G, Dodd TR, Grant DJ, et al. Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassessment. Age Ageing. 1997;26(5):375–82.PubMedCrossRefGoogle Scholar
  31. 31.
    Hanlon JT, Weinberger M, Samsa GP, et al. A randomized, controlled trial of a clinical pharmacist intervention to improve inappropriate prescribing in elderly outpatients with polypharmacy. Am J Med. 1996;100(4):428–37.PubMedCrossRefGoogle Scholar
  32. 32.
    Schmader KE, Hanlon JT, Pieper CF, et al. Effects of geriatric evaluation and management on adverse drug reactions and suboptimal prescribing in the frail elderly. Am J Med. 2004;116(6):394–401.PubMedCrossRefGoogle Scholar
  33. 33.
    Hume AL, Quilliam BJ, Goldman R, et al. Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. BMJ Qual Saf. 2011;20(10):875–84.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Raebel MA, Charles J, Dugan J, et al. Randomized trial to improve prescribing safety in ambulatory elderly patients. J Am Geriatr Soc. 2007;55(7):977–85.PubMedCrossRefGoogle Scholar
  35. 35.
    Tamblyn R, Huang A, Perreault R, et al. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. CMAJ Canadian Med Assoc J J l’Assoc Med Canadienne. 2003;169(6):549–56.Google Scholar
  36. 36.
    Kuijpers MA, van Marum RJ, Egberts AC, et al. Relationship between polypharmacy and underprescribing. Br J Clin Pharmacol. 2008;65(1):130–3.PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    van den Heuvel PM, Los M, van Marum RJ, et al. Polypharmacy and underprescribing in older adults: rational underprescribing by general practitioners. J Am Geriatr Soc. 2011;59(9):1750–2.PubMedCrossRefGoogle Scholar
  38. 38.
    Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med. 2004;140(9):714–20.PubMedCrossRefGoogle Scholar
  39. 39.
    Dunn RL, Harrison D, Ripley TL. The Beers criteria as an outpatient screening tool for potentially inappropriate medications. Consult Pharm J Am Soc Consult Pharm. 2011;26(10):754–63.CrossRefGoogle Scholar
  40. 40.
    Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison with Beers’ criteria. Age Ageing. 2008;37(6):673–9.PubMedCrossRefGoogle Scholar
  41. 41.
    Hellstrom LM, Bondesson A, Hoglund P, et al. Errors in medication history at hospital admission: prevalence and predicting factors. BMC Clin Pharmacol. 2012;12:9.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Lessard S, DeYoung J, Vazzana N. Medication discrepancies affecting senior patients at hospital admission. Am J Health System Pharm AJHP Off J Am Soc Health System Pharm. 2006;63(8):740–3.CrossRefGoogle Scholar
  43. 43.
    Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009;169(8):771–80.PubMedCrossRefGoogle Scholar
  44. 44.
    O’Sullivan DP, O’Mahony D, Parsons C, et al. A prevalence study of potentially inappropriate prescribing in Irish long-term care residents. Drugs Aging. 2013;30(1):39–49.PubMedCrossRefGoogle Scholar
  45. 45.
    Dalleur O, Spinewine A, Henrard S, et al. Inappropriate prescribing and related hospital admissions in frail older persons according to the STOPP and START criteria. Drugs Aging. 2012;29(10):829–37.PubMedCrossRefGoogle Scholar
  46. 46.
    Gallagher P, Lang PO, Cherubini A, et al. Prevalence of potentially inappropriate prescribing in an acutely ill population of older patients admitted to six European hospitals. Eur J Clin Pharmacol. 2011;67(11):1175–88.PubMedCrossRefGoogle Scholar
  47. 47.
    Conejos Miquel MD, Sánchez Cuervo M, Delgado Silveira E, et al. Potentially inappropriate drug prescription in older subjects across health care settings. Eur Geriatr Med. 2010;1(1):9–14.CrossRefGoogle Scholar
  48. 48.
    Hamilton H, Gallagher P, Ryan C, et al. Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients. Arch Intern Med. 2011;171(11):1013–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Villanyi D, Fok M, Wong RY. Medication reconciliation: identifying medication discrepancies in acutely ill hospitalized older adults. Am J Geriatr Pharmacother. 2011;9(5):339–44.PubMedCrossRefGoogle Scholar
  50. 50.
    Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Ann Pharmacother. 2012;46(4):484–94.PubMedCrossRefGoogle Scholar
  51. 51.
    Milos V, Rekman E, Bondesson A, et al. Improving the quality of pharmacotherapy in elderly primary care patients through medication reviews: a randomised controlled study. Drugs Aging. 2013;30(4):235–46.PubMedCrossRefGoogle Scholar
  52. 52.
    Miller D, Garcia D, Kreys T, Phan S, Vandenberg A, Garrison K. Evaluating the quality of performance of medication reconciliation on hospital admission. Hospital Pharm. 2012;47(7):526–31.CrossRefGoogle Scholar
  53. 53.
    Gillespie U, Alassaad A, Henrohn D, et al. A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial. Arch Intern Med. 2009;169(9):894–900.PubMedCrossRefGoogle Scholar
  54. 54.
    Fialova D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol. 2009;67(6):641–5.PubMedCentralPubMedCrossRefGoogle Scholar
  55. 55.
    Bond CA, Raehl CL, Patry R. Evidence-based core clinical pharmacy services in United States hospitals in 2020: services and staffing. Pharmacotherapy. 2004;24(4):427–40.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2014

Authors and Affiliations

  • David O’Sullivan
    • 1
  • Denis O’Mahony
    • 2
  • Marie N. O’Connor
    • 3
  • Paul Gallagher
    • 2
  • Shane Cullinan
    • 1
  • Richard O’Sullivan
    • 1
  • James Gallagher
    • 1
  • Joseph Eustace
    • 4
  • Stephen Byrne
    • 1
    Email author
  1. 1.Pharmaceutical Care Research Group, School of PharmacyUniversity College CorkCorkIreland
  2. 2.Department of Geriatric Medicine, Cork University Hospital and School of MedicineUniversity College CorkCorkIreland
  3. 3.Department of Geriatric MedicineCork University HospitalCorkIreland
  4. 4.Department of NephrologyCork University HospitalCorkIreland

Personalised recommendations