241 OPERAM: cluster randomised controlled trial by providing evidence-based recommendations, it filled physicians’ knowledge gaps, and it provided the resources required for pharmacotherapy optimisation. However, it may have been less successful in addressing these barriers among GPs who received a written report of the recommendations but had no direct contact with the intervention team, and who may not have implemented recommendations or reverted medication changes. In a recent RCT involving 1,499 hospitalized Danish patients with polypharmacy, the intervention incorporated close contact with the patient and an outpatient follow-up setting with motivational patient interviews and follow-up phone calls with outpatient providers. Reduced all-cause hospital readmission rate (HR 0.75, 95%CI=0.62 to 0.90) within 180 days was observed in the extended intervention group compared to usual care [57]. However, drug-related hospital admissions were not significantly reduced (HR 0.80, 95%CI=0.59 to 1.08), although this study was not powered to detect an effect on drug-related hospital admissions. This study was not multinational and had risk of contamination bias due to lack of cluster-randomization [30]. OPERAM implemented direct interaction of physicians and pharmacists with the attending hospital physicians and patients with shared decision-making. However, several recommendations could not be implemented during the index hospitalization, as some patients wished to discuss them with their GPs at a future appointment, when there may have been additional barriers to implementation. For example, the priority may have switched to issues other than inappropriate prescribing (e.g., because of a new health problem or worsening of a chronic condition). Furthermore, similar to previous studies [58,59], there was a low implementation rate of START recommendations that are known to reduce drug-related hospital admissions such as angiotensin converting enzyme inhibitors for systolic heart failure or statins for secondary cardiovascular prevention; this was possibly due to the already high drug burden in this population with polypharmacy (Table 3). Finally, some common STRIP recommendations included common drugs that are unlikely to contribute relevantly to drug-related hospital admissions, such as regular laxatives for patients on opioids (Table 3). Implications for future research Future pharmacotherapy optimization trials will need to enforce prescribing advice implementation with greater involvement of the outpatient setting and to address more effectively physicians’ and patients’ perceived barriers to pharmacotherapy optimization. In addition, future trials might benefit from focusing on specific drug classes (e.g. benzodiazepines) to develop specific interventions combining explicit and implicit approaches with individual and patient-centred decisions, accounting for barriers/enablers that may differ between drug classes [60], or prioritizing medications that are more likely to be associated with drug-related hospital admissions. Finally, future research needs to explore when, where and with whom pharmacotherapy optimization conversations should be taking place to best engage 3
RkJQdWJsaXNoZXIy MTk4NDMw