Evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study

Figures & data

Table 1 Characteristics of patients, number of medications, and DRPs

	Medication (mean ± SEM)	DRP (mean ± SEM)
Patient’s age (n=200; 80.33±0.46)	8.17±0.23	1.58±0.098
65–79 years (n=78)	7.95±0.33	1.59±0.15
≥80 years (n=122)	8.32±0.31	1.58±0.13
Patient’s gender
Male (n=69)	7.65±0.35	1.41±0.14
Female (n=131)	8.45±0.29	1.68±0.13
Renal function
eGFR >60 mL/min/1.73 m^2 (n=84)	8.45±0.36	1.42±0.13
eGFR ≤60 mL/min/1.73 m^2 (n=83)	8.13±0.36	1.76±0.17
Unknowna (n=33)	7.58±0.44	1.58±0.23
Number of medication per order
0–4 (n=25)	3.40±0.20	1.04±0.15
≥5 (n=175)	8.86±0.21	1.66±0.11b

Notes:

a Unknown at the time of medication review due to new admission of the patient and/or biochemistry results being incomplete at the time of interdisciplinary round.

b P≤0.05; Student’s t-test (number of medications per order; 0–4 vs ≥5).

Abbreviations: DRPs, drug-related problems; eGFR, estimated glomerular filtration rate; SEM, standard error of mean.

Figure 1 PCNE categories of possible drug-related problems and their frequencies.

Abbreviations: PCNE, Pharmaceutical Care Network Europe; DRPs, drug-related problems.

Table 2 PCNE categories of most encountered causes of possible DRPs and their frequencies

PCNE code	PCNE category	Total counts (n, %)
C 1.4	Inappropriate combination of drugs or drugs and herbal medication (includes intravenous incompatibility)	132 (40.12%)
C 8.1	No or inappropriate outcome monitoring	47 (14.29%)
C 3.2	Drug dose too high	41 (12.46%)
C 1.2	Inappropriate drug (within guidelines but otherwise contraindicated)	30 (9.12%)
C 8.2.1	Patient education required	28 (8.51%)
C 6.6	Drug administered via wrong route	27 (8.21%)
C 1.6	No drug treatment in spite of existing indication	23 (6.99%)
C 2.1	Inappropriate drug form (for this patient)	23 (6.99%)
C 1.1	Inappropriate drug according to guidelines/formulary	22 (6.69%)

Abbreviations: PCNE, Pharmaceutical Care Network Europe; DRPs, drug-related problems.

Figure 2 PCNE categories of interventions proposed by the pharmacist and their acceptance rates.

Abbreviation: PCNE, Pharmaceutical Care Network Europe.

Table 3 Total number of ordered medications, most frequently ordered medications, and medications with the highest number of possible DRPs in each ATC class

ATC class	Number of ordered medications	Most frequently ordered medication (n, % in related ATC group)	Medications with highest DRP (possible) counts (n, % in related ATC group)
A	314	Pantoprazole (107, 34.08%)	Pantoprazole (19, 6.05%)
B	197	Enoxaparin (60, 30.46%)	Enoxaparin (15, 4.93%)
C	304	Furosemide (57, 18.75%)	Furosemide (15, 7.61%) Metoprolol (12, 6.09%)
D	34	Silver sulfadiazine (10, 29.41%)	–
G	44	Tamsulosin (19, 43.18%)	Silodosin (3, 6.82%)
H	53	Levothyroxine (20, 37.74%)	Methylprednisolone (13, 24.53%)
J	151	Ceftriaxone (26, 17.22%)	Ciprofloxacin (11, 7.28%)
L	10	Methotrexate (2, 20.00%)	Mycophenolate (3, 30.00%)
M	11	Allopurinol (3, 27.27%)	Allopurinol (2, 18.18%) Colchicine (2, 18.18%)
N	358	Sertraline (45, 12.57%)	Quetiapine (41, 11.45%) Donepezil (27, 7.54%) Sertraline (19, 5.31%) Escitalopram (12, 3.35%)
P	2	Metronidazole (2, 100.00%)	Metronidazole (1, 50.00%)
R	65	Salbutamol + Ipratropium (26, 40.00%)	Salbutamol + Ipratropium (11, 16.92%)
S	11	Brimonidine + Timolol (4, 36.36%)	–
V	78	Enteral nutrition (61, 78.21%)	Enteral nutrition (6, 7.69%)
Total	1,632

Note: Boldface medications are the 10 medications with overall highest possible DRP counts.

Abbreviations: DRPs, drug-related problems; ATC, Anatomical Therapeutic Chemical.

Figure 3 Most frequently ordered medications and possible interaction or incompatibility risk in function of their prescription frequency. (Numbers above each bar represent total counts.)

Table S1 Types and causes of problems, proposed interventions, and acceptance status for proposed interventions

Cause	Intervention	Acceptance
Problem: none (n=44)
Problem: effect of drug treatment not optimal (n=20)
Inappropriate combination of drugs* (n=6)	Drug changed (n=1)	Fully accepted (n=1)
	Dosage changed (n=1)	Accepted; implementation unknown (n=1)
	Monitoring required (n=4)	Fully accepted (n=2)
		Not accepted: not feasible (n=1)
		Not accepted: other (n=1)
Inappropriate combination of drugs* + inappropriate timing of administration and/or dosing intervals (n=2)	Instructions for use changed (n=2)	Fully accepted (n=1)
		Partially accepted (n=1)
Inappropriate combination of drugs* + patient education required (n=5)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
	Patient (drug) counseling + instructions for use changed (n=3)	Fully accepted (n=3)
	Spoken to family member/caregiver (n=1)	Fully accepted (n=1)
Inappropriate drug form (n=1)	Drug changed (n=1)	Fully accepted (n=1)
Drug dose too low (n=1)	Dosage changed (n=1)	Fully accepted (n=1)
Drug dose too low + patient education required (n=1)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
Dosage regimen not frequent enough (n=1)	Educational discussion started during routine rounds (n=1)	Fully accepted (n=1)
Wrong drug administered (n=1)	Drug changed (n=1)	Partially accepted (n=1)
Patient stores drug inappropriately + patient education required (n=1)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
Addition of new drug might be needed due to microbial resistance (n=1)	New drug started (n=1)	Fully accepted (n=1)
Problem: effect of drug treatment not optimal + adverse drug event (possibly) occurring (n=24)
Inappropriate combination of drugs* (n=2)	Monitoring required (n=1)	Partially accepted (n=1)
	Drug stopped (n=1)	Partially accepted (n=1)
Drug administered via wrong route (n=22)	Instructions for use changed (n=22)	Fully accepted (n=22)
Problem: untreated symptoms or indication (n=20)
No drug treatment in spite of existing indication (n=20)	New drug started (n=20)	Fully accepted (n=9)
		Partially accepted (n=2)
		Not accepted: not feasible (n=5)
		Not accepted: other (n=4)
Problem: untreated symptoms or indication + adverse drug event (possibly) occurring (n=1)
Inappropriate combination of drugs* + no drug treatment in spite of existing indication (n=1)	New drug started (n=1)	Partially accepted (n=1)
Problem: adverse drug event (possibly) occurring (n=240)
Inappropriate drug according to guidelines/formulary (n=10)	Drug stopped (n=10)	Fully accepted (n=4)
		Partially accepted (n=2)
		Accepted; not implemented (n=1)
		Not accepted: other (n=2)
		Acceptance status unknown (n=1)
Inappropriate drug according to guidelines/formulary + inappropriate combination of drugs (n=5)	Drug stopped (n=2)	Partially accepted (n=2)
	Drug stopped + monitoring required (n=2)	Fully accepted (n=1)
		Partially accepted (n=1)
	Monitoring required (n=1)	Fully accepted (n=1)
Inappropriate drug according to guidelines/formulary + drug dose too high (n=5)	Dosage changed (n=2)	Partially accepted (n=2)
	Drug stopped (n=2)	Fully accepted (n=1)
		Partially accepted (n=1)
	Monitoring required (n=1)	Fully accepted (n=1)
Inappropriate drug (within guidelines but otherwise contraindicated) (n=23)	Drug changed (n=2)	Fully accepted (n=1)
		Acceptance status unknown (n=1)
	Dosage changed (n=6)	Fully accepted (n=2)
		Not accepted: not feasible (n=4)
	Instructions for use changed (n=2)	Fully accepted (n=2)
	Drug stopped (n=10)	Fully accepted (n=4)
		Partially accepted (n=2)
		Not accepted: not feasible (n=2)
		Not accepted: other (n=1)
		Acceptance status unknown (n=1)
	Monitoring required (n=3)	Fully accepted (n=3)
Inappropriate drug (within guidelines but otherwise contraindicated) + drug dose too high (n=4)	Dosage changed (n=3)	Fully accepted (n=3)
	Drug stopped (n=1)	Partially accepted (n=1)
Inappropriate drug (within guidelines but otherwise contraindicated) + drug dose too high + no or inappropriate outcome monitoring (n=1)	Dosage changed + monitoring required (n=1)	Fully accepted (n=1)
Inappropriate drug (within guidelines but otherwise contraindicated) + dosage regimen too frequent (n=1)	Drug stopped (n=1)	Fully accepted (n=1)
Inappropriate drug (within guidelines but otherwise contraindicated) + no or inappropriate outcome monitoring (n=1)	Monitoring required (n=1)	Fully accepted (n=1)
Inappropriate combination of drugs* (n=67)	Written information provided only (n=1)	Fully accepted (n=1)
	Drug changed (n=4)	Fully accepted (n=1)
		Partially accepted (n=1)
		Not accepted: not feasible (n=1)
		Acceptance status unknown (n=1)
	Drug changed + monitoring required (n=2)	Partially accepted (n=1)
		Not accepted: not feasible (n=1)
	Dosage changed (n=3)	Fully accepted (n=2)
		Not accepted: other (n=1)
	Instructions for use changed (n=2)	Fully accepted (n=1)
		Not accepted: not feasible (n=1)
	Drug stopped (n=11)	Fully accepted (n=3)
		Partially accepted (n=5)
		Not accepted: not feasible (n=1)
		Not accepted: other (n=2)
	Monitoring required (n=44)	Fully accepted (n=42)
		Not accepted: other (n=1)
		Not accepted: unknown reason (n=1)
Inappropriate combination of drugs* + too many drugs prescribed for indication (n=1)	Drug stopped + monitoring required (n=1)	Partially accepted (n=1)
Inappropriate combination of drugs* + too many drugs prescribed for indication + no or inappropriate outcome monitoring (n=2)	Drug stopped + monitoring required (n=1)	Partially accepted (n=1)
	Monitoring required (n=1)	Fully accepted (n=1)
Inappropriate combination of drugs* + drug dose too high (n=1)	Dosage changed (n=1)	Fully accepted (n=1)
Inappropriate combination of drugs* + no or inappropriate outcome monitoring (n=27)	Drug changed + monitoring required (n=1)	Fully accepted (n=1)
	Drug stopped + monitoring required (n=5)	Fully accepted (n=2)
		Partially accepted (n=3)
	Monitoring required (n=21)	Fully accepted (n=21)
Inappropriate combination of drugs* + patient education required (n=11)	Patient (drug) counseling (n=6)	Fully accepted (n=4)
		Accepted; implementation unknown (n=1)
		Acceptance status unknown (n=1)
	Spoken to family member/caregiver (n=5)	Fully accepted (n=5)
Inappropriate duplication of therapeutic group or active ingredient (n=1)	Drug stopped (n=1)	Not accepted: not feasible (n=1)
Inappropriate duplication of therapeutic group or active ingredient + too many drugs prescribed for indication (n=1)	Drug stopped (n=1)	Partially accepted (n=1)
Inappropriate duplication of therapeutic group or active ingredient + drug dose too high (n=1)	Drug stopped (n=1)	Fully accepted (n=1)
No drug treatment in spite of existing indication (n=2)	New drug started (n=2)	Fully accepted (n=1)
		Not accepted: not feasible (n=1)
Inappropriate drug form (n=19)	Drug changed (n=2)	Fully accepted (n=1)
		Not accepted: other (n=1)
	Formulation changed (n=13)	Fully accepted (n=1)
		Partially accepted (n=1)
		Accepted; not implemented (n=7)
		Accepted; implementation unknown (n=3)
		Acceptance status unknown (n=1)
	Instructions for use changed (n=4)	Fully accepted (n=2)
		Not accepted: not feasible (n=1)
		Acceptance status unknown (n=1)
Inappropriate drug form + prescribed drug not available (n=1)	Instructions for use changed (n=1)	Accepted; not implemented (n=1)
Drug dose too low (n=2)	Dosage changed (n=1)	Fully accepted (n=1)
	Dosage changed + new drug started (n=1)	Acceptance status unknown (n=1)
Drug dose too high (n=26)	Dosage changed (n=22)	Fully accepted (n=14)
		Partially accepted (n=6)
		Not accepted: other (n=1)
		Acceptance status unknown (n=1)
	Instructions for use changed (n=1)	Fully accepted (n=1)
	New drug started (n=1)	Fully accepted (n=1)
	Monitoring required (n=2)	Fully accepted (n=2)
Drug dose too high + no or inappropriate outcome monitoring (n=1)	Drug stopped + monitoring required (n=1)	Fully accepted (n=1)
Dosage regimen too frequent (n=3)	Dosage changed (n=2)	Not accepted: other (n=2)
	Instructions for use changed (n=1)	Fully accepted (n=1)
Dose timing instructions wrong, unclear or missing + no or inappropriate outcome monitoring (n=1)	Monitoring required (n=1)	Partially accepted (n=1)
Drug administered via wrong route (n=3)	Instructions for use changed (n=3)	Fully accepted (n=2)
		Acceptance status unknown (n=1)
Patient uses/takes less drug than prescribed or does not take the drug at all + patient education required (n=2)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
	Spoken to family member/caregiver (n=1)	Fully accepted (n=1)
Patient takes food that interacts + patient unable to use drug/form as directed + patient education required (n=1)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
No or inappropriate outcome monitoring (n=11)	Drug changed (n=1)	Partially accepted (n=1)
	Educational discussion started during routine rounds (n=5)	Fully accepted (n=5)
	Monitoring required (n=5)	Fully accepted (n=5)
No or inappropriate outcome monitoring + patient education required (n=2)	Patient (drug) counseling (n=1)	Fully accepted (n=1)
	Patient (drug) counseling + monitoring required (n=1)	Fully accepted (n=1)
Patient education required (n=4)	Patient (drug) counseling (n=4)	Fully accepted (n=4)
Problem: adverse drug event (possibly) occurring + unnecessary drug-treatment (n=1)
Inappropriate combination of drugs* (n=1)	Drug stopped (n=1)	Fully accepted (n=1)
Problem: unnecessary drug treatment (n=19)
Inappropriate drug according to guidelines/formulary + inappropriate combination of drugs* (n=1)	Drug stopped (n=1)	Fully accepted (n=1)
Inappropriate drug according to guidelines/formulary + patient education required (n=1)	Patient (drug) counseling + drug stopped (n=1)	Fully accepted (n=1)
No indication for drug (n=3)	Drug stopped (n=3)	Fully accepted (n=3)
Inappropriate duplication of therapeutic group or active ingredient (n=6)	Instructions for use changed (n=1)	Not accepted: other (n=1)
	Drug stopped (n=5)	Fully accepted (n=3)
		Accepted; implementation unknown (n=1)
		Not accepted: other (n=1)
Too many drugs prescribed for indication (n=4)	Drug stopped (n=4)	Fully accepted (n=4)
Drug dose too high (n=2)	Dosage changed (n=2)	Fully accepted (n=2)
Duration of treatment too long (n=2)	Monitoring required (n=2)	Fully accepted (n=2)
Problem: more suitable drug strength is available (n=2)
Inappropriate drug form (n=2)	Formulation changed (n=2)	Accepted; not implemented (n=2)
Problem: wrong administration route (n=2)
Drug administered via wrong route (n=2)	Instructions for use changed (n=2)	Fully accepted (n=2)

Note:

* Includes intravenous incompatibility.