416 CHAPTER 5 confirmed this variability could be significant: the effect on drug-related hospital admissions did not differ in prespecified subgroup analyses, except for the site of inclusion (Louvain, Belgium: hazard ratio 0.50, 95% CI 0.30–0.85, p = 0.05 for interaction) and dementia diagnosis (p = 0.04 for interaction). The current paradigm of gaining high-quality evidence by conducting RCTs may not be the most suitable model for research in older people nor for the medication review process due to variability in medication optimisation interventions and outcomes. Focusing on the effectiveness of medication optimisation related to patient-reported treatment goals may be a more suitable outcome for highly individually tailored interventions (‘n = 1’). In addition, choosing severe drug-related adverse outcomes as the primary outcome implies that such studies require large populations to reach sufficient statistical power, necessitating costly multicentre clinical trials. Indeed, sharing knowledge about failed initiatives with special attention to enablers and implementation barriers could bridge the gap between research outcomes and translating these outcomes to real-world practice [92]. In the era of electronic healthcare, using large real-world health data to obtain real-world evidence would be an interesting method to build and evaluate effective medication optimisation strategies in older people [93,94]. One condition to using real-time patient data so that feedback and learning can occur is that such data should allow for ‘following’ a patient’s journey and sharing outcomes of interest, necessitating connecting inpatient and outpatient care systems (Figure 3). Only then can the future use of real-world big data discover patterns that cannot be identified with RCTs due to sample size restrictions. Concluding remarks Medication optimisation in older people with polypharmacy and multimorbidity needs ongoing effort. Addressing appropriate prescribing and medication use in this vulnerable population should be embedded as part of a continuous process, with specific attention at the initiation, change and discontinuation of drugs, during medication review, care transitions and at changes in patients’ medical conditions. Successful implementation of medication optimisation strategies is essential to draw reliable conclusions about their (in)effectiveness. The prevention of drug-related harm on a structural basis (i.e. not only at the level of individual patients but at a population level) likely requires a system approach. This approach would involve patients, healthcare professionals, medical education developers, software developers, health care organisations, policy-makers and regulators jointly collaborating on this mutual goal.
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