MEDICATION CHANGES & RECOMMENDATIONS IN A CLINICAL GERONTOLOGY SERVICE
The purpose of this prospective study was to assess medication changes instituted during geriatric assessment and to determine compliance with medication recommendations three months post-discharge. Additional information to be studied included physicians' opinions of a Clinical Gerontology Service (CGS) discharge summary and the impact of the addition of a pharmacist-prepared medication discharge summary. Patients who underwent geriatric assessment had their medication regimens assessed on admission, discharge, and three months post-discharge. As an intervention, a pharmacist-prepared medication discharge section was added to the multidisciplinary discharge summary. A questionnaire was used to determine referring and primary care physicians' opinions of the CGS discharge summary. A total of 104 patients (two patients with readmissions, therefore 106 study cases) participated. The mean age of the study population was 80.6 (SD=6.8) years. Patients were admitted on an average of 5.5 (SD=3.3) total medications. They were discharged on an average of 4.3 (SD=2.3) and were again on an average of 5.5 (SD=2.9) total medications by three months post-discharge. There were no significant differences in scheduled medication costs between admission, discharge, and follow-up. Numerous drug additions, discontinuations, dose and administration interval changes occurred during and after assessment. There were also many changes in the choice of therapeutic agents prescribed. A number of variables were identified which were significantly correlated with the number of medication changes which occurred. The overall response rate for the questionnaires was 67.5%. For two of the three CGS study sites, physicians reported that discharge summaries were not received within a desirable time period. The overall quality of the discharge summary and the quality of the medication information provided received median rank scores of 4 (on a five point Likert scale labelled as 1=poor and 5=excellent). Physicians rated as "very important" the inclusion of information in discharge summaries about discharge medications along with their therapeutic rationale, changes in dose and reasons for this change, medications discontinued and reasons for the discontinuations, and medications added and reasons for the additions. The pharmacy discharge summary had no significant impact on decreasing medication numbers, costs, or changes between discharge and follow-up. Because the control group may have been sicker (possible selection bias), it was not possible to determine if polypharmacy occurred less frequently in intervention patients, or whether the more favorable questionnaire responses from physicians of these patients were actually due to the presence of the pharmacy discharge summary.
Medicine, Chemistry, Gerontology
Master of Science (M.Sc.)
Pharmacy and Nutrition