415 General Discussion The proportion of drug-related hospital admissions (10%) in the Netherlands did not change over five years after the appearance of the HARM-Wrestling report in 2009. However, the absolute number has increased over the past years [88,89]. Therefore, we wonder if we should continue to search for scientific proof of effective medication optimisation strategies, or rethink our current delivery of care systems. Future research perspectives Although this thesis adds valuable insights to better understand the complexity of medication optimisation interventions in older people and measuring the effectiveness on clinical outcomes, some questions remain unanswered. The limited availability of risk prediction models, interventions with proven effectiveness based on current scientific standards, and the ongoing search for appropriate outcome measures highlight many opportunities for future research in medication optimisation in older people at risk of medication-related harm [90]. The application of a STOPP/START-based CDSS-assisted medication review – similarly to the applied intervention in OPERAM but in a primary care setting – is currently under investigation in the Optimising PharmacoTherapy In the multimorbid elderly in primary CAre (OPTICA) trial and may provide insights whether primary care is a more appropriate setting for conducting structured medication reviews in older people. In the Netherlands, the recently initiated cluster randomised controlled trial ‘Less Is More: Optimised pharmacotherapy with improved coNtinuity of CarE in hospitaLised oLder peOple (LIMONCELLO)’ [91] will focus on transitional multidisciplinary pharmacotherapeutic care consisting of four steps: a structured medication review, a transitional multidisciplinary discussion, a pharmacotherapeutic care discharge interview and discussion with the patient and a pharmacotherapeutic care plan incorporated in the discharge note. The primary outcome will be the proportion of patients with drug-related hospital readmissions in the first month after discharge, and secondary outcomes will include a costeffectiveness analysis. Several limitations of the OPERAM study will be addressed in the design of this clinical trial. For instance, the pharmacotherapy optimisation process will be better integrated into the usual care process, focusing on transitional care instead of a cross-sectional in-hospital medication review within 72 hours of admission as investigated in OPERAM. However, the short-term follow-up time in LIMONCELLO will impede measuring the advantages of long-term outcomes of medication optimisation in underuse and overuse of preventative, chronic medications. Another potentially important difference compared to OPERAM is that LIMONCELLO only includes Dutch hospitals, eliminating differences between countries. OPERAM 5
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