Reviewing Potentially Inappropriate Medication in Hospitalized Patients Over 65 Using Explicit Criteria: A Systematic Literature Review

Figures & data

Table 1 Population, Intervention, Outcome

Population	Hospitalized 65 Years and Over Patients
Intervention	Explicit tool application
Outcome	PIM reduction (primary outcome) and clinical and non-clinical outcomes (secondary outcomes)

Table 2 The Keywords Combination Used in Each Database for the Systematic Literature Review

Database	Search Term
PubMed	(((((((“Inappropriate polypharmacy“[Title/Abstract] OR polypharmacy[Title/Abstract])) OR potentially inappropriate medication list[MeSH Terms])) OR ((((“inappropriate medic*“[Title/Abstract] OR “inappropriate drug?“[Title/Abstract] OR PIM[Title/Abstract])) OR (“pharmacological inappropriateness“[Title/Abstract] OR “Potentially harmful medic*“[Title/Abstract] OR “Potentially harmful drug?“[Title/Abstract])) OR (“inappropriate prescribing”[Title/Abstract] OR PIM[Title/Abstract] OR ”inappropriate prescribing”[Title/Abstract])))) AND (((((Elderly[Title/Abstract] OR ”older people”[Title/Abstract] OR ”older patient?”[Title/Abstract] OR ”older adult?”[Title/Abstract])) OR (seniors[Title/Abstract] OR ”65 years”[Title/Abstract] OR aging[Title/Abstract]))) OR ((aged[MeSH Terms]) OR (65 years and over[MeSH Terms])))) AND (((hospital*[Title/Abstract] OR discharge[Title/Abstract])) OR (admitted[Title/Abstract] OR admission?[Title/Abstract] OR ”secondary care”[Title/Abstract])) Sorted by: best match
Scopus	(TITLE-ABS-KEY (“pharmacological inappropriateness“ OR “harmful medication“ OR “inappropriate prescribing“ OR PIM “inappropriate medication“ OR “inappropriate medicine“ OR “ inappropriate drug“) OR TITLE-ABS-KEY (pim OR PIM OR “Inappropriate polypharmacy” OR polypharmacy) AND TITLE-ABS-KEY (elderly OR ”older people” OR ”older patient” OR ”older adults” OR seniors OR ”65 years” OR aged) AND TITLE-ABS KEY (hospital OR hospitalized OR admitted OR admissions OR ”secondary care” OR hospitalization)) AND (LIMIT-TO (LANGUAGE, ”English”))
CINHAL PLUS	AB (“pharmacological inappropriateness“ OR “Potentially harmful medication“ OR ”inappropriate prescribing” OR PIM ‘inappropriate medication’ OR ‘inappropriate medicine’ OR ‘inappropriate drug’ OR PIM OR ‘Inappropriate polypharmacy’ OR Polypharmacy) AND AB (Elderly OR older people OR older adults OR seniors, 65 years and over OR aged) AND AB (Hospital OR hospitalized OR admitted OR admissions OR ”secondary care” OR hospitalization OR hospitalisation OR hospitalised)
All OVID journals, PsycINFO and Web of Science	((“Inappropriate medic*“ or “inappropriate drug“ or “pharmacological inappropriateness“ or “inappropriate prescribing“ or “inappropriate polypharmacy” or polypharmacy or PIM or PIM) and (elderly or 65 years or age* or ”older people” or ”older adults” or ”older patient” or seniors) and (hospital* or admission or admitted or discharge or ”secondary care”)).ab.
OpenGrey	“Inappropriate polypharmacy“ OR polypharmacy OR “inappropriate medic*“ OR “inappropriate drug*“ OR PIM OR “pharmacological inappropriateness“ OR “Potentially harmful medic*“ OR “Potentially harmful drug*“ OR PIM OR ”inappropriate prescrib* AND elderly OR ”older people” OR ”older adult*” OR ”older patient*” OR senior* OR ”65 years” OR aged AND admissions OR ”secondary care” OR Hospital* OR hospitali* OR admitted lang:”en

Table 3 List of Inclusion and Exclusion Criteria Applied to the Resulting Articles

Inclusion Criteria	Exclusion Criteria
● The included study can be either a qualitative or quantitative original study ● Studies included should be focused on patients 65 years and over ● The study should use an explicit tool to review potentially inappropriate medications ● The included studies should be conducted in a hospital setting	● Studies conducted in nursing homes, emergency department and primary care were excluded. ● Studies focused on terminal illness or end of life patients were excluded. ● Non- English studies were excluded.

Figure 1 Results and screening process according to PRISMA guidelines.

Note: Adapted from Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71.¹⁹

Table 4 Total of 25 Articles Included in the Synthesis in This Systematic Literature Review

Author, Year	Country	Study Design	Participants	Explicit tool Utilised	Applied by	Explicit Tool Applied in	Source of Data	Primary Outcome	Overall Quality Rating
Cossette, 2017^Citation20	Canada	Pragmatic randomised controlled trial	254 Elderly patients divided into 128 elderly patient in the control group and 126 elderly patient in the intervention group.	Exert panel selection from STOPP and Beers criteria in CAS alert system (geriatrician, internist, pharmacist).	Pharmacist checked the relevance of the CAS alert, then created a pharmacotherapeutic plan and discussed it with the treating physician to reduce PIM; blinding the pharmacist and the physician was not feasible (distribution of education material to all physicians, medical residents, and pharmacists).	During hospital stay	Electronic medical records which included clinical information and medications.	Medication change at 48 hours in the intervention group was 45.8% for drug cessation or dose reduction; 52 interventions were made. In the control group, 15.9% was associated with dose reduction or discontinue; 99 interventions were made. The mean time to analyse the patient file was 41 ± 16 minutes.	4
Dalleur, 2014^Citation21	Belgium	Randomised control study	146 Patients divided into 74 in intervention group and 72 in control group.	STOPP/START tool	Inpatient geriatric consultant team (IGCT) consisting of nurses, geriatricians, dietitian, OT, PT, speech therapist and a psychologist.	On admission screening and recommendation for PIM to be discontinued during the hospital stay.	The nurse did the initial evaluation, then the patient was referred to the team and screened for geriatric syndrome, polypharmacy and MMSE, cognitive disorders, malnutrition, and functional dependency. Recommendations were communicated orally and available on the electronic medical record.	125 PIMs were detected 68 of them found in the intervention group. Regarding stopping PIM, it was shown that the discontinuation of PIM was two times higher in the intervention group (93.7%) compared to the control group (19.3%). After 1 year follow up, the GP did not reinitiate PIM prescription in both the intervention and the control group. PIM discontinue rate of benzodiazepines in the intervention group was higher than the control group (23.1% vs 16.1%). Improvement in the drug therapy with at least one improvement was higher for the intervention group (25.7 vs 13.9%).	5
Gallagher, 2011^Citation22	Ireland	Randomised controlled trial	400 patients: 18 died before intervention. Total of 382 patients were in the study.	STOPP/START tool	Primary research physician	Within 24 hrs of hospitalisation	The information was obtained from patient or the caregiver interview and chart review. The community pharmacy is contacted if needed.	The primary research physician recommended 183 changes to 111 patients in the intervention group. 91% of the STOPP recommendation was accepted by the attending physician. 97% of the START recommendation were accepted by the attending physician.	5
Michalek, 2014^Citation23	Germany	Prospective randomised controlled trial	114 Elderly patients. 58 patients were in intervention group, and 56 patients were in control group.	FORTA list	2 physicians familiar with the FORTA list.	During hospital stay	Data collected on admission (patient and medication history, falls in the last 3 years, and Charlson index was utilized to describe the comorbidities burdens; geriatric assessment on admission, grip strength and nutritional status.	The number of medications was high in both groups; FORTA class A drugs were higher in the intervention group. It was observed that the application of FORTA had a positive impact on BI, which was pronounced in the intervention group compared to the control group. Only one patient in the intervention had a decline in BI, while 5 patients in the control group showed a decline in BI. Regarding falls during hospital stay, 2 patients in the intervention group experienced falls, and 12 patients experienced falls in control group.	4
Spinewine, 2007^Citation24	Belgium	Prospective randomised design	203 Elderly patients. 103 of the elderly patients were allocated in the intervention group, while 100 of them were in the control group.	Beers and ACOVE	Pharmaceutical care was provided from admission to discharge by a clinical pharmacist.	During hospital stay	On admission the clinical pharmacist carried out medication history and medication reviews and conducted an interview with the patient or caregiver to obtain several information related to the clinical status of the patients. The pharmacist provided both oral and written information regarding the changes medication and a copy was also written to the GP.	In the control group, less than half of the patients (34.4%) had at least one PIM on admission. In the intervention group, the prevalence of having at least one PIM on admission was 25%. Long-acting benzodiazepines were 65.1% prescribed for elderly patients on admission in the control. It was reduced at discharge to 60.3%. Long-acting benzodiazepines were prescribed to 58.6% of the patients on admission in the intervention group, and it dropped to 44.8% on discharge. After the application of Beers criteria 94% improvement in PIM prescribing in patients included in the intervention group, while only 86% improvement in PIM prescribing was noted in the patient in the control group.	4
Wehling, 2016^Citation25	Germany	Randomised controlled trial	409 Patients were randomised, 202 patients were allocated in intervention group, while 207 were in the control group.	FORTA list	Trained physician	Not stated	At baseline: patient history and detailed history of medications, physical examination, leading diagnoses, electrocardiogram, chest X-ray, supine and standing blood pressure, smoking status, pain scale from 0 to 10, basic laboratory findings. The following geriatric assessments and other tests were performed: the Barthel Index (BI) for activities of daily living (ADL), and the instrumental activities of daily life (IADL), handgrip strength, mobility tests (Timed “Up and Go”, Tinetti), cognitive tests (Mini-Mental Status according to Folstein), Morisky Score and pain scale. ADL and pain scale were repeated upon discharge, as well as blood pressure and pulse rate.	The application of FORTA tool resulted in a large difference between the intervention group and the control group on admission and on discharge. In the control the difference between PIM on admission 3.4 ± 2.3 (Median 3) to 2.4 ± 2.2 on discharge (Median 2, P < 0.0001). In the intervention group the PIM reduced from 3.5 ± 2.7 (Median 3) to 0.8 ± 1.4 (Median 0, P < 0.0001). The application of FORTA in the intervention group showed a higher reduction in both over- and undertreatment compared to the control group. The clinical impact of PIM reduction was observed in the changes in blood pressure in the hospitalized elderly patients in both the control and intervention groups. The changes in blood pressure reading were significantly different between intervention and control group at discharge groups (P < 0.05).	4
Linden, 2017^Citation26	Belgium	Monocentric prospective controlled trial	214 Elderly patients in which 97 of them in the control group and 117 in the intervention group.	RASP list	Trained clinical pharmacists (5 pharmacists)	On admission, part of medication reconciliation service and medication review during the hospital stay. The pharmacist also checked the prescription at discharge. recommendations were actively communicated to the attending physician.	On admission, reconciliation phase.	18% PIMs were stopped in the intervention group. More drugs were discontinued during hospital stay. On discharge, the number of drug discontinue in control average of 3 medications, while average of 5 medications in the intervention group. The changes in PIM were not statistically significant.	4
Lozano-Montoya, 2015^Citation27	Spain	Ambispective non-randomised study	388 Patients 42 of them died in hospital.	STOPP/START	Clinical pharmacist expert in STOPP/START; detection of PIM on admission, then the clinical pharmacist sent recommendation to the multidisciplinary team to reach a decision. The team consisted of 3 geriatricians and 2 clinical pharmacists.	On admission	Medical records in hospital and primary clinic and comprehensive medication history from patients’ caregivers.	After the application of STOPP tool, 49.1% (170 of 346) of the elderly patients had at least 1 PIM. While the STOPP criteria identified that 61.3% (212 out of 346) of the patients had at least one PPO. The total number of identified PIMs were 284 (0.8 per elderly patient). Majority of PIM were stopped (247, 87.0%), while 37 (13%) of the cases in which the PIM was not stopped. On the other hand, 33.5% of the PPO recommended by the clinical pharmacist were accepted.	4
Mattison, 2010^Citation28	USA, Boston	Prospective before and after study	All patients in the period of pre-intervention and post-intervention.	Warning system (CPOE) using specific Beer’s criteria medications; the list was generated by a geriatrician and a pharmacist, supported their choices by the literature with the final list approved by the pharmacy and therapeutic committee from Beer’s criteria.	System flagged up the PIM to the HCP who ordered it.	On admission and throughout the hospital stay.	The hospital did not support electronic medication administration records; any physician order will flag up the PIM.	Improvement in prescribing medications that were not recommended per day reduced from 11.56 (0.36) to 9.94 (0.12). Reduction in prescribing unflagged medication, however, it was not statistically significant change. Limited reduction in mediations in which the recommendation was dose reduction.	3
Urfe, 2016^Citation29	Switzerland	Before and after trial, interventional study quasi-experimental	900 Patients	STOPP/START	Not specified	On admission and checked on discharge.	Electronic medical records.	266 (31%) of the 852 elderly patients that were included in the trial had more than 1 PIM prescribed at discharge. 160 (19%) had more than 1 PPO. A 22% reduction was observed in the patients prescribed more than 1 PIM in the intervention group.	4
Vu, 2019^Citation30	Vietnam	Before and after trial	211 Medical records before intervention (4 months, 208 medical records after intervention (4 months).	Beers 2015	Pharmacist (trained on Beer’s criteria)	During hospital stay	Medical records, notebook on Beers 2015 was provided to MD for reference.	Prevalence of PIMs in patients before and after intervention were 34.1% and 23.1%, respectively. No statistical difference was noted.	4
Abbasinazari, 2020^Citation31	Iran	Prospective interventional study	240 Patients	Beer’s criteria	Clinical pharmacist	On admission (Day 1: medical history and medication reconciliation, Day 2: screening for PIM, Day 3: outcome of the recommendation checked).	Medical history and medication reconciliation.	Total of 95 PIMs were identified. 80 (33.3%) out of 240 participants had at least one PIM. The most common PIM identified were opioid and benzodiazepines. The clinical pharmacist recommendations were communicated verbally and written. There were 95 recommendations, 87 (91.5%) of which were accepted by the physician.	4
Darmawan, 2020^Citation32	Indonesia	Prospective interventional study	123 Patients	STOPP/START tool and Beer’s criteria	Hospital pharmacist	On admission	Medical record and interviews with patients or family.	According to STOPP/START tool and Beer’s criteria 54 PIMs were found in 48 patients. The recommendations were communicated verbally and written to the physician. The physician accepted 17 (31%) of the hospital pharmacist recommendations. According to STOPP tool, NSAID was the most common PIM identified. While the most common PIM identified by Beer’s criteria was benzodiazepines.	3
Hannou, 2017^Citation33	Switzerland	Prospective interventional study	102 Patients	STOPP/START	Clinical pharmacist	On admission and throughout the hospital stay.	Medication history and medication reconciliation.	The total number of the pharmacist recommendation was 697 in which 454 of them were based on routine pharmacist review. While the remaining 243 were based on STOPP/START tool. 68% global acceptance rate (78% of recommendations were accepted from the pharmacist routine review and 47% were accepted from STOPP tool 58% START tool.	4
Lang, 2012^Citation34	Switzerland	Prospective interventional study	150 Patients	French adaptation of STOPP/START tool.	A geriatrician and psychiatric provided care for elderly patient from admission to discharge. A number of HCP were also included in the team such as geriatric nurse, physical therapist, psychologist, and therapeutic recreation specialist, but not a pharmacist.	During hospital stay	A senior resident performed complete medication history, medication and patient history, lab values and renal glomerular filtration rate recorded by the attending physician. Patient functional abilities were assessed by Katz daily living scale, Charlson cumulative comorbidity index form. For dementia patients, the clinical dementia rating scale was used	The reduction of PIM decreased from 77.3% to 18.6%. The reduction of PPO was reduced from 47% to 11.2%. No change in the pharmacotherapy was done to 23 (35.1%) of elderly patients. 24 (17.9%) patients had a higher number of medications, which were mainly vitamin B6 and B12.	4
O’Sullivan, 2014^Citation35	Ireland	Prospective interventional study	361 Patients	STOPP/TART, Beers and PRISCUS.	Hospital pharmacist	48 hours of admission	Medication charts and notes of medical and nursing staff. Medication history was obtained from the patient’s caregiver and biochemical data. In order to fully reconcile elderly patient medication, either the community pharmacy or the GP were contacted. A follow up by the pharmacist was done at the 7th – 10th day of hospital stay or at patient discharge.	Total number of PIMs that were identified after using STOPP was 449. These were found in 232 (64.2%) patients. The research pharmacist recommended 1000 interventions in 296 patients, which is equal to two intervention per patients. Total of 67 patients had more than 1 PIM and total of 577 (57.7%) recommended interventions were related to medication appropriateness issues. 548 (54.8%) recommendations were accepted by the physician.	4
Alosaimy, 2019^Citation36	USA	Prospective single centre pilot study	43 Elderly patients	STOPP/START tool Beer’s criteria	Pharmacy team: six members of pharmacotherapy specialists in geriatric medication therapy management.	During hospital stay	Patient or family interview to create medication history and medication list.	52% of the elderly patients included in the study had at least one PIM. A statistical significance change in PIM number was associated with pharmacist intervention. PIMs on admission (0.84 ± 1.12) before pharmacist intervention and were (0.56 ± 0.91)after pharmacist intervention. The percentage of acceptance of the pharmacist recommendation was 36%.	4
Chandrasekhar, 2018^Citation37	India	Prospective observational study	210 Patients	STOPP/START tool	Not specified	During hospital stay	Case files, medication chart, interviews with patients’ caregivers collected in predesigned collection book. Lab values, vital parameters, prescription, and medical diagnosis; a form for data collection was created by the researcher.	The prevalence of PIM in the 1st phase was 43.5%, 40.2% in the 3rd phase. The PPO identified using START was 52.8% in the 1st phase and 53.9% in the 3rd phase. No statistical difference noted after the intervention in PIM or PPO.	3
Chu, 2014^Citation38	Taiwan	Prospective study	Number of elderly patients not stated.	Beers 2012 CPOE	There were two interventions: one with the decision support system and the other by the clinical pharmacist using Beer’s criteria.	Not specified	Not specified	Reduction of 6.42% by the CPEO and 5.47% by the clinical pharmacist. 71.4% of the recommendations generated by the CPEO were accepted and 92.5% of the pharmacist recommendation were accepted.	2
Kadri, 2017^Citation39	France	Prospective study	81 Patients	STOPP/START	Pharmacist assessed the prescription and the PIM were documented to the physician in the patient records. After discharge both the geriatrician and the pharmacist investigated the cases in which STOPP/START recommendations were not approved.	Not stated	Patient pre-admission medication history.	224 PIM were identified using STOPP, 168 (75%) were supported by the geriatrician; among 56 cases of not following the recommendation, 50 cases (90%) were justified among the PIM identified by STOPP; 94 medications identified by the physician but not STOPP supplementary medications 90. The geriatrician followed PPO identified by START 56 (62%), of which, 34 cases were not followed, 27 cases were justified; the geriatric identified medication that should be started and not in START tool.	3
Kimura, 2019^Citation40	Japan	Prospective observational study	230 Patients (201 patients were from the cardiovascular surgical department and 29 were from cardiovascular internal medicine department).	STOPP tool and STOPP-J	Clinical pharmacists that were trained to detect and correct PIM.	On admission	Medical history, medication reconciliation and laboratory findings.	After the clinical pharmacist review, 122 of the patients (53%) were prescribed at least one PIM according to STOPP-J, while 75 PIMs were detected through STOPP tool in 33% of the patients. Total of 232 PIMs were identified through STOPP-J and 133 were identified through STOPP tool. 69 PIMs were found in both criteria. STOPP-J identified statically significant (P < 0.001) more PIMs than STOPP tool. The clinical pharmacist obtained patient approval before recommending changes or discontinue to the physician. Total number of recommendations of PIMs detected by STOPP-J were 116 out of 232, 61 PIMs (26%) were recommended to be changed and 50 PIMs (22%) were recommended to be discontinued. 82% of the clinical pharmacist recommendations by STOPP-J were accepted. Total number of recommendations of PIMs detected by STOPP tool were 155 out of 133, 61 PIMs (46%) were recommended to be changes, while 54 (41%) were recommended to be discontinued. 89% of the clinical pharmacist recommendation by STOPP tool were accepted.	4
Kympers, 2019^Citation41	Belgium	Prospective observational single-centre study	60 Patients	GheOP^3s tool	Pharmacist and communicated to the geriatrician.	Not stated	Medical records and some information were obtained from the geriatrician including age, gender living status.	The number of the total number of the prescribed medication was 610. Approximately every elderly patient had 10 medications. When the GheOP3S tool was applied to the medication, 250 medications were identified as a PIM in 57 (95%) elderly patients. Only 52% of the recommendation were fully accepted by the geriatrician. While 27% of the recommendation were partially accepted and 18% of the recommendation were not accepted by the geriatrician and the reason was “insufficient reason to stop”.	4
Pandraud-Riguet, 2017^Citation42	France	Prospective observational study	1327 Patients	PIM list adopted from Beers, Laroche, and PRISCUS (Delphi panel)	Pharmacist (was trained to detect PIM) screened the prescription for PIM and sent them to the attending physician.	Not stated	Prescriptions	1036 PIMs were detected (743 PIMs and 320 PIA); of the 1327 participants, 607 had at least 1 PIM (46%), 345 had 1 PIM (26%), 140 had 2 (11%), 74 had 3 (6%) and 48 (4%) had 4 or more. After an assessment by clinical pharmacist, 78% of the PIM maintained by physician. Total of 121 medications were subjected to changes either in discontinuation, or dose reduction or switched to safer alternative. 90 PIM assessments were unknown; decrease in PIM number from 11% to 22% before assessment; the mean number of PIM was 1.8, after assessment, the mean number was 1.6	4
Brown, 2004^Citation43	USA	Retrospective case series design	99 Patients	Beers 2003	Pharmacist team	Not specified	Patients’ charts and computer database.	PIM was 10.1% on admission and reduced to 2.02% (statistically significant reduction of PIM). Patients were prescribed an average of 6.69 and 7.15 medications on admission and upon discharge, respectively. This resulted in a mean increase of 0.465 medications.	5
Cossette, 2016^Citation44	Canada	Segmented regression analysis of an interrupted time series	8622 Patients discharged from hospital in period of 2013–2014.	Intervention based on educational presentations and the PIM list adopted from Beers 2012; changes were implemented after a multidisciplinary team expert panel sent to the pharmacy department, which approved the list, then it was emailed to all physician–pharmacist medical residents.	Pharmacist review CAS alert system: evaluated their clinical relevance, developed a plan, and discussed it with the attending physician.	Not specified	CAS system embedded in medical records.	At least 1 PIM was prescribed in 19.8% elderly patients. It was observed that patients aged 75 to 84 had a higher rate being prescribed a PIM (24.0%) compared to those who are older that the age of 84 (14.4%). After reviewing elderly patient medication, a 2.55% reduction was observed in PIM. This was followed by 0.11% of PIM prescribing monthly after the intervention period. A 3.5% decrease in PIM prescribing was observed after implementing the intervention and 0.11% increase of PIM prescribing month after intervention period.	4
Ghibelli, 2013^Citation45	Italy	Two-phase retrospective studies	The observation phase included 74 elderly patients and was conducted from April to May 2012. The intervention phase included 60 elderly patients and was conducted from June to July 2012.	Beers 2002 in the InterCheck system.	Computerised system presenting alerts.	Not specified	Not specified	In the observation phase 39.1% of the elderly patients had at least one PIM on admission. While 37.8% of the elderly patients had at least one PIM on discharge. In the intervention phase 41.7% had at least one PIM on admission. While it was reduced to 11.6% upon discharge. This was statistically significant reduction of PIM number (p=0.001).	4
Kersten, 2015^Citation46	Norway	Retrospective study	250 Patients	NORGEP	In the geriatric ward, the pharmacist used to review the medications of approximately 70% of the admissions. Any medication related concerns were sent to the attending physician for evaluation. The routine clinical assessment used to be done by the nurses within 72 hours of admission.	During hospital stay	Several resources were used to obtain the medical history including the patient medical records, as well as the GP referral letter.	The mean number of medication on admission is 7.8, while the mean number of medication at discharge was 7.9. Despite the similar mean number of medications on admission and discharge, some changes were done to the medication regimens during the hospital stay. There were 133 medication removed and 102 dose reductions. Diuretics were the most common medication removed, or dose reduced or replaced. The PIM reduction during hospital stay in the geriatric ward was not statistically significant. In the geriatric ward 30% of new PIMs that were introduced included cardiovascular medications including prescribing ACE inhibitor and potassium/ potassium-sparing diuretics. However, none of the elderly patients that were prescribed these combination had hyperkalaemia. In conclusion, changes to the prescribed medication happened more often in the geriatric ward compare to other medical wards in the hospital. In addition, newly prescribed PIM was less found in geriatric ward compared to other medical wards.	5
Sennesael, 2017^Citation47	Belgium	Retrospective study in a geriatric unit consists of 4 part-time series in 1 month	120 Patients	STOPP/START tool	Clinical pharmacist.	During hospital stay	Discharge letter was used to gather the demographics, clinical and pharmaceutical information.	The prevalence of having at least one PIM on admission was 65%. The total number of PIMs that were identified on admission using the STOPP tool were 101 PIMs. These were identified in 67 elderly patients. A number of PM 49% was discontinued in 33 out of 67 patients during the hospital stay. The prevalence of PIM was reduced at discharge to 46%. After applying logistic regression to the 4^th phase, a statistically significant reduction was noted. After the application of START section, 86 PPO (51%) were identified in 61 patients. This was reduced to 39% at discharges (24/61).	4

Notes: Key characteristics are shown in the table in addition to the quality assessment that was done using MMAT tool 2018. The MMAT tool has five questions. 1 means only one question answered yes. 2 means two out of five questions answered yes. 3 means three out of five questions answered yes. 4 means four questions answered yes. 5 means all questions answered yes.

Abbreviations: PIM, potentially inappropriate medication; PPO, potential prescribing omission; CPOE, computerised physician order entry; CAS, computerised alert system; GP, general practitioner; ADL, activities of daily living; NORGEP, Norwegian General Practice; FORTA, Fit fOR The Aged; RASP, rationalisation of home medication by an adjusted STOPP-list in older patients; GheOP³s tool, Ghent older people’s Prescription community pharmacy screening; ACOVE, Assessing Care of Vulnerable Elders; STOPP-J, Screening Tool for Older Person’s Appropriate Prescriptions for Japanese.

Figure 2 Explicit tools that were utilized to review elderly patients’ medication in hospitals.

Figure 3 Percentage of PIM reduction in hospitals with the tools used.

Figure 4 Description of PIM reduction before and after tool implementation by HCP in hospitals.

Figure 5 The percentage accepting the recommendation for PIM reduction.

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