Abstract
BACKGROUND: Polypharmacy and potentially inappropriate medicine use is common in older people, resulting in harm increased by lack of patient-centred care. Hospital clinical pharmacy services may reduce such harm, particularly prevalent at transitions of care. An implementation program to achieve such services can be a complex long-term process. OBJECTIVES: To describe an implementation program and discuss its application in the development of a patient-centred discharge medicine review service; to assess service impact on older patients and their caregivers. METHOD: An implementation program was begun in 2006. To assess program effectiveness, 100 patients were recruited for follow-up after discharge from a private hospital between July 2019 and March 2020. There were no exclusion criteria other than age less than 65 years. Medicine review and education were provided for each patient/caregiver by a clinical pharmacist, including recommendations for future management, written in lay language. Patients were asked to consult their general practitioner to discuss those recommendations important to them. Patients were followed-up after discharge. RESULTS: Of 368 recommendations made, 351 (95%) were actioned by patients, resulting in 284 (77% of those actioned) being implemented, and 206 regularly taken medicines (19.7 % of all regular medicines) deprescribed. CONCLUSION: Implementation of a patient-centred medicine review discharge service resulted in patient-reported reduction in potentially inappropriate medicine use and hospital funding of this service. This study was registered retrospectively on 12(th) July 2022 with the ISRCTN registry, ISRCTN21156862, https://www.isrctn.com/ISRCTN21156862 .