Background At discharge of elderly patients, improving reconciliation information and transmission to general practitioners (GP) on therapeutic optimisation is an important issue, especially in relation to potentially inappropriate medications (PIMs). Since November 2014, all patients have received daily pharmaceutical care (PC) in a geriatric medicine ward.
Purpose The objectives of the study were to describe implementation of pharmaceutical discharge letters (PDL) targeted on PIMs and to collect GP opinion.
Material and methods From March to September 2015, every patients received a PC from admission to discharge. A standardised PDL was written with modifications or to stop PIMs during hospitalisation. PDL included: a letter arguing the benefits/risks of treatment modification with bibliographic arguments and a summary reconciliation table. Hospitalisation reports were enclosed and sent to the GP. In September 2015, the implicated GPs were called to collect their feelings about these letters.
Results For 7 months, PC was performed for 419 patients characterised by: mean age of 85.7 years old (± 6), an average of 7 drugs prescribed at admission and 6.5 at discharge. At least one PIM was prescribed at admission for 32%, and 11% at discharge (p < 0.05).
41 PDL (10% of PC) were sent to 42 doctors (36 GPs, 4 rehabilitation setting, 2 nursing home). They had a mean age of 86 years (±6), an average of 8.5 drugs prescribed at admission and 6.5 at discharge, and for all, 59 PIMs on admission and 8 at discharge. PDL concerned: anticholinergic drugs (35%), full dose of zolpidem or zopiclone (23%), long half-life benzodiazepines (17%), central antihypertensive treatment (6%) and more than 3 antihypertensive agents (5%). 12 GPs were interviewed; all called this strategy useful and relevant for continuity of care between hospital and home care. Some modifications were suggested about, for example, adding implementation treatment date.
Conclusion This approach tended to reduce PIMs at discharge and to be careful about them. Collaborative reconciliation and therapeutic optimisation targeting PIMs with PDL could be a real help to limit errors, to re-evaluate prescriptions and to prevent renewal when patients are back at home. As GPs seems to be satisfied, a goal is to send PDL to community pharmacists.
References and/or Acknowledgements STOPP-START criteria.
No conflict of interest.
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