Pharmacy review rounds and medication appropriateness on a GEMU

Objectives: To evaluate the impact of weekly pharmacy review rounds and to assess medication appropriateness of patients on a Geriatric Evaluation and Management Unit (GEMU). Design: Non-randomized, observational study with no control group. Setting: Inpatient 21-bed GEMU. Participants: Ninety-eight patients discharged consecutively from June 1999 until October 2001. Intervention: Routine care provided on the GEMU consists of an interdisciplinary team under the direction of the attending geriatrician. In addition to this, weekly pharmacy review rounds were conducted. The clinical pharmacist independently reviewed all the patient charts prior to rounds and each week the pharmacist, geriatrician and nurse discussed all patients and their medications and made changes where appropriate. Medication appropriateness was determined using the Medication Appropriateness Index (MAI), retrospectively, for all admission and discharge medications for each patient. Measurements: The pharmacist collected the number and types of drug-related problems identified in a prospective manner as well as the pharmacist's recommendations and physician acceptance of these. Results: There were 669 drug-related problems (DRPs) identified independently by the pharmacist with an average of 6.82 (SD 4.09) drug problems identified per patient. The most common DRPs were lack of medication for an established diagnosis in 152 cases and drugs being used for no clear medical indication on 143 occasions. Patients were admitted on an average of 5.57 (SD 3.21) medications and discharged on 6.38 (SD 3.16). In 166 of the cases, the most common recommendation made by the pharmacist was to adjust the dosage of a medication. Physician acceptance of all of the pharmacist's recommendations was 98.5 per cent. According to the MAI, 81.6 per cent of patients were on an average of 1.6 inappropriate medications at the time of admission and no patient was on an inappropriate medication at discharge. At the time of admission, 82.7 per cent of patients had an indication for a medication they were not receiving. Only one patient had no medication changes during their admission to the GEMU. Conclusion: Within the confines of the study design, pharmacy review rounds detected many important drug-related problems in addition to those addressed in the routine clinical care of patients. The most common problems identified included lack of medication for an established diagnosis as well as no clear medical indication for a medication. Almost all of the pharmacist's recommendations were accepted by the attending physician. Medication appropriateness, assessed retrospectively by the MAI, revealed the majority of patients were on inappropriate medications at the time of admission to the unit. The average number of medications on discharge increased slightly but the appropriateness of these medications improved. A more controlled study is needed in this area to evaluate this type of intervention on a GEMU.