396 CHAPTER 5 2. The process of in-hospital medication review Amedication review can be defined as ‘a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medicationrelated problems and reducing waste [author’s emphasis]’ [42]. By definition, a medication review is an individually tailored intervention involving many healthcare professionals considering different treatment options that should be separately weighed with the patient. Older people with polypharmacy and multimorbidity are, in particular, a diverse patient population, with patient-specific treatment goals, patient preferences, contra-indications and drug-drug interactions that affect treatment decisions and, therefore, the medication review outcome. This variability is contrary to the relative homogeneity of ideal study designs where all potential factors that might affect the outcome are minimised, except for the usually highly standardised investigated intervention. The randomised controlled trial is still considered the gold standard in the hierarchy of evidence-based medicine [43]. Although the cluster randomisation design of the OPERAM trial limited allocation contamination and balanced general baseline characteristics of the study population between intervention and control patients, polypharmacy optimisation in each older person with multimorbidity could be considered as an n = 1 experiment, with each medication review, or even each recommendation for a medication change as an n = 1 intervention. Thus, it is challenging to establish a causal relationship between reducing inappropriate prescribing with a cross-sectional medication review and outcomes over a predefined time window. The process of in-hospital medication review as investigated in the OPERAM trial was evaluated in detail in three descriptive substudies in Chapter 4. The studies aimed to better understand the decisions made during the in-hospital medication review process and the consequences of these decisions. To elucidate our findings presented in Chapter 4, we introduced two illustrative examples for potentially inappropriate prescribing in the same polypharmacy patient using a benzodiazepine (Boxes 1–3, Example 1) and a direct anticoagulant (DOAC) combined with acetylsalicylic acid (Boxes 1–3, Example 2). In the next paragraphs, we reflect on 1) the implementation of medication optimisation recommendations (within the OPERAM trial) and 2) perspectives on improving the implementation of medication optimisation recommendations.
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