390 CHAPTER 5 Introduction The prevalence of multimorbidity and polypharmacy is increasing in the ageing population. Multimorbidity and polypharmacy are important risk factors for drugrelated harm including drug-related hospital admissions. Previous studies have reported that 10%–30% of all hospital admissions in older people are drug-related, half of which are potentially preventable [1–4]. Consequently, healthcare professionals and patients require effective strategies to reduce drug-related harm [5,6]. Clinical practice guidelines (CPGs) focusing onmedication optimisation in older people have been developed to guide prescribers in safe and effective pharmacotherapy. In European guidelines, the Screening Tool of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert to Right Treatment (START) have been recommended to detect potentially inappropriate prescribing during medication reviews. STOPP/ START has been shown to effectively reduce potentially inappropriate prescribing, adverse drug reactions (ADRs) and lower healthcare costs in single-centre clinical trials [7–11]. However, the effect on other clinical outcomes, such as drug-related hospitalisations, remains to be established. In addition, the effectiveness of a structured medication review as a multicomponent intervention is uncertain [12,13]. This rationale was used to develop a structured, clinical decision support system (CDSS)-assisted medication review process integrating expert opinions, shared decision-making and evidence-based medication optimisation tools, such as STOPP/ START (Chapter 3.1) [14]. The effect of this in-hospital medication review on drugrelated hospital readmissions and other clinical outcomes was investigated in the multicentre OPtimising thERapy to prevent avoidable hospital Admissions in the Multimorbid elderly (OPERAM) randomised controlled trial [15,16]. OPERAM was thoroughly designed in terms of scientific standards tomaximise high-quality evidence by explicitly addressing the limitations of previous trials (e.g. short follow-up times, being underpowered, high risk of bias) [12,13]. The in-hospital medication review decreased potentially inappropriate prescribing in older people with multimorbidity and polypharmacy with no detriment to patient outcomes. However, it did not significantly alter the primary outcome of ‘drug-related hospital readmissions’ within one year after the intervention compared to usual care (Chapter 3.2) [16]. Therefore, the hypothesis that an in-hospital medication review would prevent drugrelated hospital readmissions in this vulnerable population could not be established. However, drawing conclusions about the effectiveness of medication reviews based on population-based clinical outcomes poses a risk of rejecting worthwhile interventions without critically appraising the process in which these strategies have been embedded. For instance, interventions might have failed at the level of implementation. This concern was also addressed in a recent review investigating
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