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
