413 General Discussion Although advanced software-assisted screening may contribute to the increased detection of patients at risk of drug-related harm, not all prescribers have expertise in medication optimisation in older people, possibly impeding the safe and successful uptake of software-generated signals, especially in a hospital setting with various experts. We found that postponed recommendations to primary care were frequently associated with attending physicians feeling ill-equipped to take responsibility for suggested medication changes beyond their area of expertise (Chapter 4.2) [44]. In addition, not all drug-related problems in older people are detectable by screening EHRs. For instance, detecting non-adherence or medication use problems and determining individual patient preferences require an implicit approach and discussion with patients by skilled professionals. Introducing a multidisciplinary geriatric pharmacotherapy team or ‘geriatric stewardship’ may be a solution to overcome patients’ and prescribers’ barriers in the transition of care and may assist the process of medication review in high-risk patients (Figure 3) [80]. Although the transfer of care is already a known risk factor for drug-related harm, our findings confirmed that one-third of all potentially preventable DRAs identified in OPERAM intervention patients occurred within two months after hospital discharge (Chapter 4.3). The role of geriatric stewardship was recently studied in older people (≥ 65 years) with polypharmacy (≥ 5 chronic drugs) and a frailty risk factor admitted to surgical and orthopaedic wards in a Dutch non-academic hospital. Patient-reported drugrelated problems were reduced compared to usual care (2.8 versus 3.3 per patient), although this reduction was not significant, which may have been caused by the small sample size (n = 127 patients) [81]. The study also showed that one-in-three initial recommendations based on EHRs were altered after input from the primary care provider and the patient. Therefore, the authors highlighted that in-hospital medication reviews require transmural collaboration and patient participation to ensure continuity of patient care. The evidence suggests that interventions designed to improve the care transition from hospital to home are effective and can reduce hospital readmission in adults, as concluded by a systematic review [82]. Such interventions preferably start in the hospital and continue after discharge rather than starting after discharge. Patient empowerment and shared decision-making, as with motivational interviewing, are key factors in the effectiveness of discharge interventions in reducing readmissions [82]. The exchange of individual treatment goals across care settings may assist all healthcare professionals in shared decision-making to meet an older patient’s needs [50]. In addition, it will likely positively affect patients’ attitudes towards medication optimisation [50]. 5
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