Impact of joint consultation by a clinical pharmacist and a clinical geriatrician to improve inappropriate prescribing for elderly patients.

OBJECTIVE: Appropriate prescribing is a key quality element in medication safety. It is unclear if therapeutic interventions resulting from medication review lead to clinically relevant improvements. The effect of medication review on prescribing appropriateness was evaluated in the setting of an outpatient consultation team, consisting of a clinical pharmacist and a clinical geriatrician, in a large non-academic teaching hospital in the Netherlands. METHOD: A group of 49 elderly patients with polypharmacy was included after referral by their general practitioner for drug related problems. After a regular assessment by a clinical geriatrician and medication record review by a clinical pharmacist, a treatment plan was implemented based on the recommended interventions. The main outcome measure was the change in the Medication Appropriateness Index (MAI) before and 3 months after primary consultation. RESULTS: Overall 82% of the recommended interventions of the pharmacist were implemented by the geriatrician of which 63% persisted up to the last visit. Per patient an average of 6.6 interventions were carried out. The interventions showed a reduction of the MAI per patient of 50%. The number of drugs per patient was reduced from 12.1 to 11.0. The number of medications listed on the Beers list decreased from 2.3 to 1.5 and the number of drugs listed on the Hospital Admissions Related to Medication (HARM) Trigger list decreased from 2.1 to 1.5. CONCLUSIONS: Interventions from a multidisciplinary outpatient consultation team were effective in improving appropriate prescribing in elderly outpatients with polypharmacy.

Groningen frailty indicator in older patients with end-stage renal disease.

BACKGROUND: Currently over 55% of end-stage renal disease (ESRD) patients are aged ≥60 years and patients >75 years represent the fastest growing segment of the dialysis population. We aimed to assess whether the Groningen frailty indicator (GFI) can be used to distinguish fit older ESRD patients, likely able to tolerate and benefit from dialysis, from frail older patients who need further evaluation with a geriatrician's comprehensive assessment. METHODS: All patients aged ≥65 years visiting the pre-dialysis unit at the Gelre hospital between 2007 and 2013 were included and underwent the GFI (n = 65). Patients with GFI ≥ 4 (frail) were referred for geriatric consultation (n = 13). Results of the GFI and nephrologists' evaluation were compared with geriatrician's assessment. Survival rates and outcomes after one year of follow up were recorded. RESULTS: Twenty patients (32%) were identified as frail. Of the problems identified by the geriatrician in 13 patients, 55% were not reported in the nephrologists' notes. The first year after inclusion, 30% of patients with a GFI ≥ 4 died, compared to 9% of fit patients (p = 0.04). Moreover, 90% of frail patients had been hospitalized one or more times, compared to 53% in the fit group (p = 0.005). CONCLUSION: Although the GFI can be a useful instrument to identify ESRD patients at risk, both the GFI and the nephrologists' assessment failed to identify specific geriatric impairments. Further research is needed to develop a specific frailty indicator for ESRD patients and to determine the value and effect of a comprehensive geriatric assessment in ESRD patients.

Variation in diagnoses: influence of specialists' training on selecting and ranking relevant information in geriatric case vignettes.

Variation in aspects of medical practice such as diagnosis, has been studied at different levels of aggregation. At the inter-practitioner aggregation level, attention is increasingly being paid to factors explaining medical variation which are attributed to 'professional uncertainty'. The concept of 'professional uncertainty' refers to variability that is considered to be inherent to the nature and structure of medical knowledge which depend on the epistemological characteristics of medical science. In this study the relationship between specialty training and variation in diagnostic practice was examined at the inter-practitioner aggregation level. Determination of a direct relationship would support the thesis that specialization is a structuring factor in the inherent variability of medical practice. Three groups of medical specialists participated in the study: geriatricians, geriatric-psychiatrists and internists. Four case scenarios were submitted to the specialists. The cases used involved elderly patients presenting with problems in domains common to all the participating specialists. For each case the specialists were requested to select those facts they considered important for reaching diagnoses and to rank these facts in order of perceived salience. Subsequently they were asked to provide (tentative) diagnoses, ranked in order of perceived significance. The occurrence of variability in diagnostic practice due to 'professional uncertainty' and the influence of specialist specific factors and shared knowledge, respectively, are demonstrated. The results clearly show that these three groups of specialists focused on different elements of information, and formulated different diagnoses in the same case, but expressed similar ranking patterns.