Rationalisation of Polypharmacy by the RASP-instrument and Discharge Counselling of Geriatric Inpatients

Study Overview
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Brief Summary
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Systematic evaluation of polypharmacy in geriatric patients, through a validated list by a clinical pharmacist. The goal is reduction of potentially inappropriate medications (PIMs). A brief counseling session with the patient and/or his/her caregiver will be part of the intervention.

Detailed Description
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This project is focused on the systematic evaluation of polypharmacy in older patients admitted to the acute geriatric wards of a university hospital. Polypharmacy will be identified through a validated list by a clinical pharmacist. The goal is reduction of potentially inappropriate medications (PIMs). Before hospital discharge the hospital pharmacist will have a brief counseling session with the patient and/or his/her caregiver in order to discuss the medication list and to enhance compliance.

Official Title
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Rationalisation of Polypharmacy by the RASP-instrument (Rationalisation of Home Medication by an Adjusted STOPP-list and Discharge Counselling of Geriatric Inpatients: a Prospective, Clinical Trial

Conditions
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Polypharmacy

Intervention / Treatment
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* Procedure: Medication review and discharge counseling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Informed consent by the patient and/or his/her caregiver Admission through the emergency department of patients coming from home or a residential care facility Exclusion Criteria: Patients not speaking Dutch Patients admitted for end of life care Patients not taking any drugs on admission

Ages Eligible for Study
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Minimum Age: 75 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Supportive Care
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention group<br>In the monocentric interventional part of the study, the effect of discharge counseling on the acceptance of pharmacotherapeutic recommendations will be evaluated 1 and 3 months after discharge. | Procedure: Medication review and discharge counseling<br>* Medication reconciliation of home therapy will be performed by the clinical pharmacist through a standardized form. Next, the clinical pharmacist will perform a medication review, based on but not limited to the RASP list (Van der Linden 2014). The goal is optimization of therapy. Before discharge the clinical pharmacist will perform a second medication review, together with the treating physician and a medication reconciliation in orde to provide the best possible discharge medication list. The medication list will be provided 3 times: once for the patient and/or his/her caregiver, once for the general practitioner and once for the primary care pharmacist. Finally the clinical pharmacist will have a counseling session with the patient and/or his/her caregiver.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner. | Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner. | 1 month (30 days) after discharge | 
| Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner. | Acceptance rate of the pharmacotherapeutic recommendations, provided by the clinical pharmacist by the general practitioner. | 3 month (90 days) after discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of drug intakes at discharge versus at admission. | Number of drug intakes at discharge versus at admission. | At discharge from the index hospitalization (as mentioned in the discharge medication scheme) vs on admission (during the first 72 hours of the index hospitalization) | 
| Number of drugs at discharge versus at admission. | Number of drugs at discharge versus at admission. | At discharge from the index hospitalization (as mentioned in the discharge medication scheme) vs on admission (during the first 72 hours of the index hospitalization) | 
| Number of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list. | Number of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list. | At discharge from the index hospitalization (as mentioned in the discharge medication scheme), compared to the medication list obtained on admission (this is, during the first 72 hours of the hospitalization) | 
| Difference in number of potentially inappropriate medications identified through the RASP list on admission versus at discharge | Difference in number of potentially inappropriate medications identified through the RASP list on admission versus at discharge | At discharge from the index hospitalisation (as mentioned in the discharge medication scheme) versus on admission (medication list obtained in the first 72 hours) of the index hospitalization | 
| Number of potentially inappropriate medications on admission, at discharge and at the follow-up moments (1 and 3 months after discharge) | Number of potentially inappropriate medications on admission, at discharge and at the follow-up moments (1 and 3 months after discharge) | On admission (medication list obtained in the first 72 hours of the admission), at discharge (as mentioned in the discharge medication scheme), 1 (30 days) month after discharge, 3 months (90 days) after discharge | 
| Mortality during admission | Mortality during admission | During the index hospitalization, from admission to the emergency ward until moment of death on the geriatric ward, assessed up to 72 hours after death. | 
| Number of falls during hospitalization | Number of falls during hospitalization | During the index hospitalization, from admission on the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge. | 
| Number of fractures during hospitalization | Number of fractures during hospitalization | during the index hospitalization, from admission to the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge. | 
| Length of stay | Length of stay | During the index hospitalization, from admission to the emergency ward until discharge from the geriatric ward, assessed within 72 hours after discharge. | 
| Readmission rate 3 months after discharge | Readmission rate 3 months after discharge | 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90 | 
| Number of fractures at 3 months after discharge | Number of fractures at 3 months after discharge | 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90 | 
| Number of falls 3 months after discharge | Number of falls 3 months after discharge | 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90 | 
| Mortality at 3 months after discharge | Mortality at 3 months after discharge | 3 months (90 days) after discharge from the geriatric ward (index hospitalization), assessed at day 90 | 
| Category of potentially inappropriate medications identified through the RASP list on admission and at discharge | Category of potentially inappropriate medications identified through the RASP list on admission and at discharge | On admission (medication list obtained in the first 72 hours of the admission), at discharge (as mentioned in the discharge medication scheme) | 
| Category of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list. | Category of drugs adapted by the treating physician based on recommendations by the clinical pharmacist that are not included in the RASP list. | During the course of the index hospitalization, defined as the period between discharge from the geriatric ward and admission to the geriatric department. The outcome parameter will be assessed within 72 hours of discharge. | 
| Number of drugs at follow-up (1 month and 3 months after discharge) | Number of drugs at follow-up (1 month and 3 months after discharge) | 1 month (30 days) and 3 months (90 days) after the index hospitalization | 
| Number of drug intakes at follow-up (1 month and 3 months after discharge) | Number of drug intakes at follow-up (1 month and 3 months after discharge) | 1 month (30 days) and 3 months (90 days) after the index hospitalization |