368 CHAPTER 4.3 Implementation of recommendations A change in medication regimen was recommended by the pharmacotherapy teams in one half of present MEs; however, these proposed recommendations were not implemented. Recommendations can be either intentionally or unintentionally nonimplemented and many factors affect actual implementation. Reasons for intentional non-implementation of recommendations was studied in the Dutch cohort of OPERAM intervention patients, which revealed that around 40%of all recommendations provided by the pharmacotherapy teams were disagreed upon by either the attending physician, the patient or both [54]. The main reason for disagreement was patients’ reluctance to discontinue or initiate medication. Trusting patient-physician relationships are one of the key facilitators for successful shared decision-making, as found in another multicentre mixed-methods interview study among OPERAM patients (n = 48) [55]. Therefore, whether the acute hospital setting is the most appropriate setting to conduct medication reviews from a patient’s perspective could be questioned. Future improvements in the shared decision-making process may result in a higher uptake of pharmacotherapy optimisation recommendations disagreed upon by the patient [56,57]. Physician-related factors also contributed to non-implementation, including attending physicians’ reluctance to take responsibility for suggestedmedication changes that were beyond their area of expertise [54]. Another study found that the attending physician’s implementation of STOPP/START-recommendations were significantly higher if the recommendation was discussed by a physician rather than a pharmacist [58]. Although the pharmacotherapy analysis within OPERAMwas performed jointly by a pharmacist and a physician, the discussion of recommendations with attending physicians and patientswas not always conducted by both professionals of the pharmacotherapy teams. In addition to initial non-implementation of proposed recommendations, the persistence of medication changes across health settings could be an issue as well. For example, Van der Linden et al. found that more than one-quarter of drugs that were discontinued due to an ADR in hospitalised older patients were re-prescribed after hospital discharge [59]. Another study found that about 20%of medications that were discontinued based on STOPP criteria were re-prescribed within six months after discharge from geriatric units; more than half of those resumptions occurred within a month after discharge [60]. Improvements in medication reconciliation across healthcare settings could address these unintentional re-prescriptions [61,62]. Data to distinguish between non-implementation and non-persistence of recommended drug changes were not available within the OPERAM trial. Strengths and limitations This studywas embeddedwithin a large Europeanmulticentre trial, which contributes to the external validity of the study [38]. However, despite OPERAM having few exclusion
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