(285) Clinical Pharmacist-Led Medication Review in Post-Acute Care: Preliminary Results of an Observational Retrospective Study

Background: Older individuals with multimorbidity and polypharmacy face increased risks of adverse drug events, drug-drug interactions, and medication non-adherence. The setting of post-acute care hospitals represents a unique opportunity for conducting medication reviews, with clinical pharmacists playing a pivotal role in performing medication reviews, identifying potentially inappropriate medications (PIMs) and drug interactions, educating patients, and promoting rational use.

Objectives: This study aimed to assess the impact of clinical pharmacist-led medication review among older individuals with multimorbidity and polypharmacy in the identification of PIMs and drug-drug interactions, and patient health outcomes during hospitalization in a post-acute community hospital in the Romagna Area, Italy.

Methods: An observational retrospective study compared patient outcomes before and after implementing clinical pharmacist-led medication review activities. The exposed group comprised patients discharged from a community hospital between July and December 2022, while the non-exposed group included those discharged in the same months of the previous year. Clinical pharmacists conducted medication reviews using electronic medical records, identifying potential appropriateness based on Beers criteria and interactions using the UpToDate application. The outcomes included the number of medication reviews performed, the number of identified patients with PIMs and drug-drug interactions, the number of patients with medication changes approved by geriatricians, along with the evaluation of patients’ health status (re-hospitalization and mortality) and persistence to therapy three months post-hospital discharge.

Results: Preliminary analyses on 129 patients hospitalized in the post-acute community hospital during a 6-month period revealed 68 patients with PIMs, involving 81 medications, and 105 patients with potential drug-drug interactions, involving 237 medications. Medication changes recommended by the pharmacist were implemented by geriatricians in 91% of cases (117 patients), with half of them undergoing deprescription. The most common PIMs identified were promazine, delorazepam, trazodone, and doxazosin. The medications most frequently identified as potentially involved in drug-drug interactions were sodium phosphate, enoxaparin, tramadol, and furosemide.

Conclusions: Preliminary findings suggest that clinical pharmacist involvement in a post-acute community hospital's multidisciplinary team can improve medication management in older individuals with polypharmacy, reduce therapy errors during care transitions, and enhance safety.