414 CHAPTER 5 A recent network meta-analysis concluded that medication review in older people combined with 1) medication reconciliation and patient education and 2) medication reconciliation, patient education, professional education and transitional care were associated with a lower risk of all-cause hospital readmission compared to usual care (risk ratio (RR) 0.45, 95% CI 0.26–0.80; RR 0.64, 95% CI 0.49–0.84, respectively) [83]. These results substantiated the hypothesis that a medication review is likely more effective when integrated into a more continuous medication optimisation process following a patient’s journey across care settings, underlining the importance of patient and professional involvement. In the United States, the transmural approach for delivering older persons’ care has resulted in several restructured care models [84]. For example, the comprehensive care physician (CCP) model paired a patient with a trained hospital physician responsible for providing inpatient and outpatient care. Key factors in this programme were an integrated approach to care, a trusted physician-patient relationship, ready access to outpatient care, and a proactive interdisciplinary team tailored to patient needs. The preliminary findings based on patient-reported outcomes suggested significant improvements in patient experience and mental health status, with a 15%–20% decrease in hospitalisation, implying savings of $3000–$4000 per patient annually [85,86]. Thus, the introduction of a geriatric stewardship seems to be a promising strategy to improve care for older patients across care settings. However, a recent Swedish cluster randomised crossover trial in older (median age 81; IQR 74–87) hospitalised patients (n = 2,637) did not find a significant effect of an in-hospital medication review combined with a postdischarge follow-up on the incidence of unplanned hospital visits compared to usual care [87]. A process evaluation suggested that the follow-up was suboptimal, again highlighting the importance of successfully implementing investigated strategies to draw reliable conclusions. The authors also concluded that patient-reported outcomes, such as the health-related quality of life, might have been more suitable for capturing the potential effects of treatment changes than the primary outcome of unplanned hospital visits. One explanation for these conflicting results may be that the success or failure of these care models highly depends on the healthcare systems in which they are embedded, as addressed in the Medication Safety in Polypharmacy report by the WHO [6]. It is not unlikely that current medication optimisation strategies can be effective but first require a change in existing healthcare structures and organisational cultures. A rigorous change of healthcare structure is often unfeasible in a clinical trial setting requiring the active involvement of many stakeholders, such as policy-makers, health care professionals, managers, patients, families and caregivers.
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