328 CHAPTER 4.2 admissions (DRAs) in multimorbid (≥3 chronic conditions) older people (≥70 years) with polypharmacy (≥5 chronic medications). In-hospital patients were recruited in Switzerland (Bern), Belgium (Louvain), Ireland (Cork) and the Netherlands (Utrecht) i.e. one centre per country. All patients were admitted to the participating hospitals, either electively or non-electively through the emergency department and were recruited in both surgical and medical wards. Geriatric specialist wards were excluded from the OPERAM trial to avoid contamination of the trial arising from routine medication reconciliation and optimisation in such wards. Only data from the Dutch intervention patients were eligible for the present study, as data regarding agreement with the recommendations and reasons for disagreement by both patients and physicians were only systematically collected at the St. Antonius Hospital, a large non-academic teaching hospital, located in Utrecht and Nieuwegein. Data were collected between January 2017 and October 2018 during the recruitment phase of the OPERAM trial. Baseline characteristics were registered in and extracted from the electronic Case Report Form (eCRF) deployed in each randomised patient. Intervention The intervention within the OPERAM trial consisted of a structured medication review based on the software-supported Systematic Tool to Reduce Inappropriate Prescribing (STRIP) method performed by a pharmacotherapy team (PT), consisting of a physician and a pharmacist, both experienced with geriatric pharmacotherapy optimisation and trained by standardised operating procedures in all trial sites [7,16]. The Dutch PT consisted of one physician/pharmacist pair performing the intervention throughout the trial. The intervention consisted of five consecutive steps and occurred within 72 hours after trial enrolment: 1) Structured History taking of Medication use (SHiM) [17] and collection of patient data including medical conditions, laboratory data and clinical parameters; 2) digitalized screening of pharmacotherapy supported by a Clinical Decision Support System (CDSS) with integrated STOPP/START criteria (version 2) [18,19]; START and STOPP signals generated by the CDSS were based on the patient data and current pharmacotherapy; 3) pharmacotherapy analysis resulted in a report with individualised recommendations: the CDSS-generated STOPP/START signals were assessed for appropriateness for the individual patient by the PT based on additional information from the patient’s medical records, such as prior use and effectiveness, side-effects or known drug allergies; 4) discussion of individualised medication optimisation recommendations with the patient and attending physician by the PT. Recommendations were first discussed with the patient. The recommendations agreed upon by the patient were then suggested to the attending physician. In case the attending physician did not agree or did not feel qualified to adjust the medication, these recommendations were then transferred to the GP in case
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