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Table. Proportion of Patients With an Increased, Unchanged, or Decreased Number of DRPS After Follow-up in the Intervention and Control Groups
Table. Proportion of Patients With an Increased, Unchanged, or Decreased Number of DRPS After Follow-up in the Intervention and Control Groups
Research Letter
Sep 24, 2012

Effect of a Pharmacist Medication Review in Elderly Patients Discharged From the Hospital

Author Affiliations

Author Affiliations: Departments of Clinical Pharmacology and Pharmacy (Ms Ahmad and Dr Hugtenburg), General Practice (Dr Nijpels), and Epidemiology and Biostatistics (Drs Dekker and Kostense), EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, the Netherlands.

Arch Intern Med. 2012;172(17):1346-1347. doi:10.1001/archinternmed.2012.2816

During hospital admission, several changes in a patient's drug regimen are often introduced. After discharge, patients frequently do not know which drugs to take, and 20% of the patients experience an adverse event.1,2 Medication review is a successful intervention to improve medication safety.3 We studied the effect of medication review consisting of medication analysis, treatment analysis, patient interview, and counseling by community pharmacists and pharmacy technicians on the occurrence of drug-related problems (DRPs) among elderly patients discharged from the hospital.


We performed a randomized, controlled intervention study in patients 60 years or older using at least 5 prescribed drugs and discharged from the hospital, with DRPs as the main outcome measure. The method has been described in detail previously.4 Pharmacies were electronically randomized as a control or intervention pharmacy.

Intervention and Control Groups

Twenty-four community pharmacists at the intervention pharmacies performed a medication review, including medication analysis, treatment analysis, patient interview, and counseling. Two clinical pharmacologists (J.G.H.) developed a checklist of different types of DRPs, which has been developed based on review of the literature and experts in the field. A face-validity procedure was performed by 12 clinical pharmacologists. Drug-related problems were categorized using the Pharmaceutical Care Network Europe DRP-score form.5 A general practitioner was consulted about the chronic diseases of the patient and the DRPs identified. Pharmacy technicians interviewed and counseled patients at discharge from the hospital. The effects and adverse effects of the medication were inventoried by means of a semistructured protocol.

In the control group, identified DRPs were registered by the 2 clinical pharmacologists at baseline and after 1 year. Control pharmacies provided usual care according to the Dutch Pharmacy Standard.4

Statistical Analysis

Linear regression analyses were performed adjusting for confounders. Subgroup analyses were used to investigate the effectiveness of the intervention in specific patient groups. P < .05 was considered statistically significant.


Of the 489 eligible patients, 340 (69.5%) agreed to participate. We included 180 and 160 patients in the intervention and control group, respectively. There were no significant differences in patient characteristics between the 2 groups. At baseline, there were more patient perceived DRPs in the intervention group. At the 12-month follow-up, 13 and 8 patients in the intervention and control group, respectively, did not have an interview or DRP assessment.

Effect on the Occurrence of DRPs

The total number of DRPs at baseline and at follow-up were 253 and 437, respectively, in the control group and 271 and 689, respectively, in the intervention group. The mean number of DRPs identified with the medication analysis decreased from baseline to follow-up in the intervention group from 1.51 to 1.37. In the control group, the number of DRPs increased from 1.58 (baseline) to 1.62 (follow-up). The mean number of DRPs identified with the patient interview in the intervention group decreased from 3.88 (baseline) to 2.33 (follow-up). In the control group, the mean number of DRPs increased from 2.73 (baseline) to 2.80 (follow-up).

The proportion of patients with an increased, unchanged, or decreased number of DRPs after follow-up (compared with baseline) in the intervention group was significantly different from the control group (Table). This effect was also significant for the specific DRPs “clear indication but no medication” and “fear of adverse effects” (Table).

Regression and Subgroup Analyses

Linear regression analysis show that both medication analysis and patient interview resulted in a significant reduction of DRPs after follow-up. After adjusting for age, sex, number of drugs, and baseline DRPs, the reduction of DRPs identified with the patient interview was not significant.

Subgroup analyses showed that the reduction of DRPs identified with medication analysis was significantly more pronounced among patients with hypertension (P = .01) and heart failure (P = .001). The reduction of DRPs identified with patient interview was significantly more pronounced among patients with hypertension (P = .04).


We demonstrated that pharmacist-led medication review is an effective method to reduce DRPs, in particular “no drug but clear indication” and “fear of adverse effects,” among elderly patients discharged from the hospital. The beneficial effect of the medication analysis was more pronounced in patients with heart failure or hypertension.

Medication review, patient counseling, and telephone follow-up reduced the rate of adverse effects in this patient population.2,6,7 However, the effect on specific patient-perceived DRPs after hospital discharge has not been studied.

Although the checklist was not validated, it was developed on the basis of literature search and a face validity procedure with experts. Patient-perceived DRPs at baseline were significantly higher in the intervention group than in the control group. We adjusted for this difference in our analysis. Control pharmacists could have become more conscious of the possibility of DRPs, thereby becoming more observant and active in resolving DRPs. This may have led to an underestimation of the effect of the intervention.

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Article Information

Correspondence: Ms Ahmad, Department of Clinical Pharmacology and Pharmacy, VU University Medical Center, Van Der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands (a.ahmad@vumc.nl).

Published Online: August 6, 2012. doi:10.1001/archinternmed.2012.2816

Author Contributions:Study concept and design: Ahmad, Nijpels, Dekker, and Hugtenburg. Acquisition of data: Ahmad and Hugtenburg. Analysis and interpretation of data: Ahmad, Nijpels, Kostense, and Hugtenburg. Drafting of the manuscript: Ahmad and Hugtenburg. Critical revision of the manuscript for important intellectual content: Nijpels, Dekker, Kostense, and Hugtenburg. Statistical analysis: Ahmad, Nijpels, and Kostense. Obtained funding: Hugtenburg. Administrative, technical, and material support: Ahmad. Study supervision: Nijpels, Dekker, and Hugtenburg.

Financial Disclosure: None reported.

Trial Registration: trialregister.nl Identifier: NTR1194

Previous Presentation: This manuscript was presented at the International Conference on Pharmacoepidemiology and Therapeutic Risk Management; August 14-17, 2011; Chicago, Illinois.

Additional Contributions: Maria Ruth Mast, MSc, assisted with data collection and in the development of a checklist of different types of drug-related problems used in the study.

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