Evaluation of clinical pharmacist recommendations in the geriatric ward of a Belgian university hospital

Figures & data

Table 1 Characteristics of underlying drug-related problems (n = 304)

Problem	Number (%)	Drug type
Inappropriate dose	95 (31%)	Statins, proton pump inhibitors, anti-infectives, hypnotics, ACE inhibitors, antithrombotics
Drug–drug interaction	62 (20%)	Antithrombotics, digoxin, anti-infectives, psycholeptics, psychoanaleptics
Adverse effect	46 (15%)	Diuretics, ACE inhibitors, corticosteroids, psycho(ana)leptics
Inadequate form	32 (11%)	Analgesics, psycholeptics
Unnecessary drug	22 (7%)	Miscellaneous
Wrong drug choice	22 (7%)	Cardiovascular drugs (beta blockers, diuretics, digoxin, ACE inhibitors)
Inappropriate frequency or administration time	9 (3%)	Anti-infectives, calcium/vitamin D, statins
Underuse	8 (3%)	Calcium/vitamin D
Contraindication	5 (2%)	NSAIDs, antidiabetic drugs, antibiotics, beta blockers
Inappropriate route of administration	2 (1%)	Anti-infectives

Abbreviations: ACE, angiotensin-converting enzyme; NSAID, nonsteroidal anti-inflammatory drug.

Table 2 Examples of clinical pharmacist recommendations

Problem	Drug	Recommendation	Physician decision
Recommendations assessed as having possibly moderate clinical relevance (by all four evaluators)
Unnecessary drug	Ranitidine 300 mg QD	Stop drug; no concomitant drugs with corrosive effect on the gastric mucosa. (Reason for hospital admission not related to gastrointestinal pathology).	Accepted
Inappropriate dose	Simvastatin 40 mg QD	Lower dose to 20 mg QD since cholesterol levels were excellent (TC 113 mg/dL, LDL 53 mg/dL), for woman 87 years old; no instable angina, no diabetes.	Not accepted
Recommendations assessed as having possibly important clinical relevance (by all four evaluators)
Drug–drug interaction	Haloperidol 5 drops TID	Stop drug due to interaction with amiodarone and domperidone: increased risk of QT prolongation; consider restarting after domperidone therapy as needed for agitation.	Accepted
Wrong drug choice	Carvedilol 12.5 mg QD	Patient with heart failure, ischemic heart disease, diabetes, and COPD receiving two beta blockers (nebivolol and carvedilol) but no ACE inhibitor; stop carvedilol (nonselective) and start lisinopril 10 mg QD.	Not accepted
Recommendations assessed as having possibly very important clinical relevance (by two evaluators)
Drug underuse	Calcium + vitamin D	Start calcium + vitamin D (and treatment with alendronate 70 mg weekly) for 83-year-old woman with known osteoporosis treated with methylprednisolone for several weeks.	Accepted
Contraindication	Nitrofurantoin 100 mg BID	Switch to other antibiotic (eg, levofloxacin 500 mg initially, then 250 mg QD) because of decreased renal function (calculated GFR: 35 mL/minute).	Accepted

Abbreviations: QD, once a day; TC, total cholesterol; LDL, low-density lipoprotein; TID, three times a day; COPD, chronic obstructive pulmonary disease; ACE, angiotensin-converting enzyme inhibitor; BID, twice a day; GFR, glomerular filtration rate.

Table 3 Acceptance rates of clinical pharmacist recommendations (n = 302)

	Treating physician	Physician/clinical pharmacologists		Clinical pharmacists
		Rater 1	Rater 2	Rater 3	Rater 4
Accepted	53.6%	86.1%	87.4%	86.8%	79.8%
Partially accepted	6.3%	7.0%	9.6%	7.0%	12.6%
Not accepted	40.1%	7.0%	3.0%	6.3%	7.6%

Abbreviation: n, number.

Table 4 Clinical relevance of clinical pharmacist recommendations (n = 302)

	Rater 1	Rater 2	Rater 3	Rater 4	Mean
0 – Adverse significance	0.3%	0.3%	0.3%	0.3%	0.3%
1 – No clinical relevance	1.0%	1.7%	6.3%	7.0%	4.0%
2 – Possibly low relevance	40.1%	24.8%	43.7%	43.7%	38.1%
3 – Possibly important relevance	58.6%	68.5%	43.4%	43.0%	53.4%
4 – Possibly very important relevance	0.0%	4.6%	6.3%	6.0%	4.2%
5 – Possibly life-saving	0.0%	0.0%	0.0%	0.0%	0.0%

Abbreviation: n, number.