To examine the effect of a cross-sectoral medication review intervention to admitted multi-morbid, polypharmacy patients aged 65+ at SHS in two settings; an acute admission unit (typical admission time \< 48 hours) and a medical outpatient setting (patients routinely visits for follow-up, diagnosis or treatment, but do require a bed or overnight care).
all hospitalized patients who are prescribed at least seven medications specified in the Electronic Patient Journal (EPJ) at admission
terminal patients or patients with a short life expectancy, patients residing in another region, patients who are discharged on the day of inclusion, and finally patients who do not speak Danish.
Parallel
Clinical pharmacist
Other interventionThe clinical pharmacist calls the patients' GP 90 days after discharge for follow-up
Readmission and emergency department rate.
The number of acute readmissions and emergency department visits between 4 hours and 30 days after discharge from the index hospital stay in the intervention group compared with the control group. As a "yes" or "no" and a time-to-event. Potential readmissions are assessed through the electronic patient journal.
Acute admission
Time to first acute admission after discharge from index hospital stay for the intervention and control group (up to 90 days follow-up). As a "yes" or "no" and a time-to-event. Potential acute admissions are assessed through the electronic patient journal.
Mortality
The mortality rate after 30 and 90 days respectively after discharge will be evaluated. As a "yes" or "no" and a time-to-event. The mortality will be identified from patient journals.
GP contacts
The GP visit rate (number) will be identified at a follow-up telephone contact with the GP 90 days after discharge. As a "yes" or "no" to GP contact within the time frame and a time-to-event related to "yes".
Implementation rate
The implementation rate (number) of pharmacist recommendations and potential medication changes from the medication review made by the GP will be identified, 30 and 90 days respectively after index hospital stay. Each recommendation will be evaluated as a "yes", "no", "partly" or "unsure", where "partly" or "unsure" requires additional free text information to support the evaluation. The information will be obtained from the patients' shared medication record
Patient satisfaction with the intervention
Patients' satisfaction and experience with the medication review and intervention are explored through a smaller sample of intervention patients (approx. 25%, 50 patients) using an evaluation survey and a 5-likert scale. The evaluation will be conducting through telephone by the project manager, who will follow a structured evaluation survey and register the patients reply continuously in an online survey form in RedCap.
Evaluation of the collaboration among clinical pharmacists, medical specialists, and GPs
The evaluation of the collaboration will be explored through a survey to clinical pharmacists, medical specialists, and GPs. The main focus are the collaboration with the GP and medical doctors; potential barriers to a fruitful collaboration in the team of clinical pharmacist, medical specialist and the GP; the feasibility of the intervention with pharmacist-led medication review to admitted patients, and the experience with the optimized discharge summary containing pharmacist interventions from medication reviews. A 5-likert scale will be used.
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