Older inpatients with multimorbidity often experience polypharmacotherapy, which can lead to more frequent adverse events, drug-drug interactions and other drug-related problems. Involving a clinical pharmacist through a medication review is an effective approach to improve treatment quality and reduce risks for patients. The aim of this study was to evaluate the impact of clinical pharmacist's recommendations in a medication review process on the optimization of pharmacotherapy in elderly patients with polypharmacy. We evaluated the impact of therapy optimization on the occurrence of medication-related problems, such as reduction in the number of medications, the number of potentially inappropriate medications (PIMs), the number of potential interactions, and improving adherence to treatment guidelines after medication review. A retrospective, non-interventional study was conducted at the Psychiatric Hospital Ormož, where we considered patients who were referred for a medication review between January 2013 and December 2018. We included patients aged 65 years or older who were receiving at least five medications and received at least one suggestion for a therapy modification related to heart failure, arterial hypertension or diabetes. Potential X and D interactions were evaluated using the Lexicomp Online database. PIMs were identified based on Priscus list 2.0 and the 2023 Beers Criteria. We also evaluated the economic impact using a cost-benefit analysis. We included 100 patients with a mean age of 78.1 years (SD=6.8). On average, they received 11.4 medications (median=11), which decreased to 10.7 medications (median=11) after medication review. The total number of medications decreased by 6.6% (from 1,144 to 1,068; p<0.001). Of 559 pharmacist recommendations, 59.2% were accepted. Potential X interactions decreased by 75.8% (from 33 to 8; p<0.001) and potential D interactions decreased by 56.9% (from 188 to 81; p<0.001). The number of PIMs also decreased, with a reduction of 29.5% (from 308 to 217) based on the Priscus List and 17.5% (from 343 to 283) according to the Beers Criteria. For the diseases considered, the results showed a significant improvement in adherence to treatment guidelines. Employing a pharmacist and implementing medication review services was financially justified, resulting in a total reduction of € 217,033.60 in unnecessary costs. The results of this study demonstrate that interventions provided by clinical pharmacists through the medication review process significantly contributed to the optimization of drug treatment at the Psychiatric Hospital Ormož. These findings confirm that the involvement of clinical pharmacist in treatment contributes to improving the quality and safety of treatment.
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