- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04360746
The Influence of Clinical Pharmacist on the Quality of Drug Prescribing and Rehabilitation Outcomes in Post-acute Hip Fractured Patients
The influence of clinical pharmacist on various drug related outcomes was reported in different healthcare setting including the community, long term care and during acute hospitalization. Nevertheless, data on the influence of clinical pharmacist intervention on the quality of drug prescribing and rehabilitation outcomes in post-acute hip fractured patients is scarce.
The aims of the current study are to evaluate the contribution of a clinical pharmacist on the appropriateness of drug prescribing among post-acute geriatric hip fractured patients and to investigate whether this involvement can improve rehabilitation outcomes.
The investigators hypothesis is that early review of geriatric hip fractured patients medical record by a clinical pharmacist will improve the appropriateness of drug treatment and the rehabilitation outcomes among this population.
Study Overview
Status
Intervention / Treatment
Detailed Description
An Open label randomized prospective study of elderly patients (65 years old and above) admitted for rehabilitation after hip fracture. All study participants will be admitted in the same geriatric-rehabilitation department specialized in the rehabilitation of geriatric patients after hip fracture ("D" ward). This department is divided into 2 subunits (D1 and D2) with the same patient population but a different medical and nursing staff.
Randomization in this study will be based upon the admission subunit. The intervention group will include all hip fractured patients admitted to D1 subunit. This group will get a clinical pharmacist review of their medication and a pharmaceutical counseling to the medical staff in the first few days of admission (1-5 days post admission). The control group will include all hip fractured patients admitted to D2 subunit. This group will not receive any pharmacist intervention during their rehabilitation, unless the pharmacist will be asked directly to review a patient medical record by the medical or nursing staff. In this case the specific patient will be excluded from the study.
Pharmaceutical intervention will include a complete medication review by a clinical pharmacist with the following process: medication reconciliation, medication indication and dosage check, medication effectiveness and appropriateness assessment, drug-drug or drug-disease interactions check, medication duplications check, length and cost of treatment evaluation.
The pharmacist will use the following tools:
Medication appropriateness evaluation Medication appropriateness will be evaluated based upon the MAI (medication appropriateness index) score - an implicit (judgment-based) outcome measure. The MAI is a measure of prescribing appropriateness that assesses ten elements of prescribing: indication, effectiveness, dose, correct directions, practical directions, drug-drug interactions, drug-disease interactions, duplication, duration, and cost. Although based on implicit criteria, the index has operational definitions and explicit instructions, which standardize the rating process. Each medication can get a score between 0-18, with a higher score indicating inappropriateness of more drug elements. The ratings generate a weighted score that serves as a summary measure of prescribing appropriateness.
The clinical pharmacist will calculate the MAI score upon admission and discharge for each study participant.
Anticholinergic drug burden Anticholinergic drug burden will be assessed by a common anticholinergic drug scale. The medical literature describes several anticholinergic drug scales. Most of those scales were built by experts in order to generate an anticholinergic burden for a specific patient based upon his current drug treatment. Evaluation of the anticholinergic burden may predict the risk for an anticholinergic side effect in that patient.
the ACB (Anticholinergic cognitive burden) score will determine the anticholinergic burden for each patient. The ACB score was developed in order to evaluate the cognitive effects of anticholinergic medications. The tool gives points for each medication based on an ordinal scale. Each medication can get the following score: 0 = no potential for anticholinergic effect, 1 = slight anticholinergic effects, based on Evidence from in vitro data that chemical entity has antagonist activity at muscarinic receptor, 2 = moderate anticholinergic effects, based on evidence from literature, prescriber's information, or expert opinion of clinical anticholinergic effect, 3 = strong anticholinergic effects, based on evidence from literature, expert opinion, or prescribers information that medication may cause delirium.
The total ACB score will be calculated upon admission and discharge for each patient.
Underuse of medications Underuse of medications refers to the omission of a drug when there is a clear indication and no contraindications. The evaluation of underuse will be through a medication reconciliation process and by using the assessment of underutilization (AOU) index.
In the process of medication reconciliation the pharmacist will compare the current patient drug regimen to the recommended medications in the general hospital discharge letter and to the drugs prescribed/dispensed in the community. The purpose of this process is to trace any medication that was unintentionally omitted from the patient current drug list.
Drug Underutilizion will be assessed by the AOU tool. This instrument is intended for the evaluation of medications that should have been prescribed by a health care provider but were omitted. The pharmacist will review the medical file of each patient in search for any omission of a needed drug for an established active disease/condition.
A needed drug is defined as a drug that is indicated or recommended based on current practice guidelines or evidence available.
The study will involve pharmacist review of patient electronic medical records in order to collect the following data for each patient: the MAI and ACB at admission and discharge, the number of drugs added or stopped during the rehabilitation period, demographic data, functional level including pre-rehabilitation functional levels, cognitive function (via the mini-mental status exam) and clinical data including the metabolic state (admission albumin level), chronic diseases.
Likewise, other operation related factors will be collected, including: type of fracture, operation latency period, rehabilitation latency period and rehabilitation length of stay (LOS).
the rehabilitation outcomes for each patient will be register including the FIM score at admission and discharge, motor FIM , MRFS scores and the destination of the patient at the end of the rehabilitation period.
The same data for the control group will be collected retrospectively at the end of the study period.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Ran Nissan, PharmD
- Phone Number: 972544892333
- Email: Ranni@clalit.org.il
Study Contact Backup
- Name: Avital Hershkovitz, MD
- Phone Number: 97239373840
- Email: avitalhe@clalit.org.il
Study Locations
-
-
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Petah Tikva, Israel
- Beit Rivka geriatric rehabilitation center
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Description
Inclusion Criteria:
- Elderly patient (65 years of older) who were admitted for rehabilitation after hip fracture at "D" ward in beit rivka post-acute geriatric center.
Exclusion Criteria:
- Patient that did not complete the rehabilitation period due the following causes: death, acute care hospitalization or severe medical deterioration.
- In the case of D2 sub unit hospitalized patient - any request by the sub unit medical or nursing staff for pharmacist consultation/intervention.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Non-Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Clinical pharmacist intervention group
all hip fractured patients admitted to D1 subunit in "Beit rivka" geriatric rehabilitation center.
This group will get a clinical pharmacist review of their medication and a pharmaceutical counseling to the medical staff in the first few days of admission (1-5 days post admission)
|
Pharmaceutical intervention will include a complete medication review by a clinical pharmacist with the following process: medication reconciliation, medication indication and dosage check, medication effectiveness and appropriateness assessment, drug-drug or drug-disease interactions check, medication duplications check, length and cost of treatment evaluation.
The pharmacist will use the following tools: Medication appropriateness index (MAI), ACB (Anticholinergic cognitive burden) score and the using the assessment of underutilization (AOU) index.
A multidisciplinary team provided medical, nursing, physical, occupational, and social work interventions.
Rehabilitation care include: (a) individual physical therapy (PT), 2 to 3 times a week; (b) 30 to 40 min of PT in an adapted fitness room, aerobic training on a treadmill with and without partial weight support and stationary bicycles, 2 to 3 times a week ; (c) 30 to 40 min of virtual reality training by performing challenging functional tasks, 2 times a week and (d) 30 to 45 min of individual occupational therapy (OT), cognitive evaluation and stimulation, safety education, and learning to use assistive devices, 3 times a week.
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Other: control group
The control group will include all hip fractured patients admitted to D2 subunit in "Beit rivka" geriatric rehabilitation center.
This group will not receive any pharmacist intervention during their rehabilitation.
|
A multidisciplinary team provided medical, nursing, physical, occupational, and social work interventions.
Rehabilitation care include: (a) individual physical therapy (PT), 2 to 3 times a week; (b) 30 to 40 min of PT in an adapted fitness room, aerobic training on a treadmill with and without partial weight support and stationary bicycles, 2 to 3 times a week ; (c) 30 to 40 min of virtual reality training by performing challenging functional tasks, 2 times a week and (d) 30 to 45 min of individual occupational therapy (OT), cognitive evaluation and stimulation, safety education, and learning to use assistive devices, 3 times a week.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Summated Medication Appropriateness Index (MAI) score
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
|
The change from admission to discharge in the summated medication appropriateness index score.
Each medication can get a score between 0-18, with a higher score indicating inappropriateness of more drug elements.
|
Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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Anticholinergic Cognitive Burden (ACB) score
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change from admission to discharge in the anticholinergic cognitive burden score.
Each medication can get a score between 0-3, with a higher score indicating a higher anticholinergic burden.
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change in medication discrepancy
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The number of medication discrepancy and underuse of drugs
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change in overused drugs
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The number of overused or misused drugs
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change in Functional Independence measure (FIM) score
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change from admission to discharge in the Functional Independence measure score.
the score is calculated for each patient and can be between 18-126, with a higher score indicating a better functional independence status.
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change in motor functional independence measure (mFIM)
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change from admission to discharge in motor functional independence measure score.
the score is calculated for each patient and can be between 18-91, with a higher score indicating a better motor functional independence status.
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The change in Montebello Rehabilitation Factor Score (MRFS)
Time Frame: Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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The relative functional gain (motor functional independence measure effectiveness) achieved on the motor functional independence measure score.
The Montebello Rehabilitation Factor Score (MRFS) is calculated as the motor functional independence measure score change (discharge score minus admission score) divided by the motor functional independence measure maximum score (a score of 91) minus the motor functional independence measure admission score.
The Montebello Rehabilitation Factor Score can be between -80 to 100 with a higher score indicating a better motor functional independence measure effectiveness (a higher relative functional gain during rehabilitation).
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Admission (baseline value) and at discharge (approximately 5 weeks post admission)
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LOS (Length Of Stay)
Time Frame: Through study completion, an average of 1 year
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Length of rehabilitation center stay
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Through study completion, an average of 1 year
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Collaborators and Investigators
Sponsor
Publications and helpful links
General Publications
- Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189-98. doi: 10.1016/0022-3956(75)90026-6. No abstract available.
- Samsa GP, Hanlon JT, Schmader KE, Weinberger M, Clipp EC, Uttech KM, Lewis IK, Landsman PB, Cohen HJ. A summated score for the medication appropriateness index: development and assessment of clinimetric properties including content validity. J Clin Epidemiol. 1994 Aug;47(8):891-6. doi: 10.1016/0895-4356(94)90192-9.
- Somers A, Mallet L, van der Cammen T, Robays H, Petrovic M. Applicability of an adapted medication appropriateness index for detection of drug-related problems in geriatric inpatients. Am J Geriatr Pharmacother. 2012 Apr;10(2):101-9. doi: 10.1016/j.amjopharm.2012.01.003. Epub 2012 Feb 1.
- Spinewine A, Swine C, Dhillon S, Lambert P, Nachega JB, Wilmotte L, Tulkens PM. Effect of a collaborative approach on the quality of prescribing for geriatric inpatients: a randomized, controlled trial. J Am Geriatr Soc. 2007 May;55(5):658-65. doi: 10.1111/j.1532-5415.2007.01132.x.
- Hanlon JT, Schmader KE, Samsa GP, Weinberger M, Uttech KM, Lewis IK, Cohen HJ, Feussner JR. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992 Oct;45(10):1045-51. doi: 10.1016/0895-4356(92)90144-c.
- Ottenbacher KJ, Mann WC, Granger CV, Tomita M, Hurren D, Charvat B. Inter-rater agreement and stability of functional assessment in the community-based elderly. Arch Phys Med Rehabil. 1994 Dec;75(12):1297-301.
- Spinewine A, Schmader KE, Barber N, Hughes C, Lapane KL, Swine C, Hanlon JT. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007 Jul 14;370(9582):173-184. doi: 10.1016/S0140-6736(07)61091-5.
- Rolland Y, Pillard F, Lauwers-Cances V, Busquere F, Vellas B, Lafont C. Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment. Disabil Rehabil. 2004 Apr 8;26(7):425-31. doi: 10.1080/09638280410001663148.
- Heruti RJ, Lusky A, Barell V, Ohry A, Adunsky A. Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture? Arch Phys Med Rehabil. 1999 Apr;80(4):432-6. doi: 10.1016/s0003-9993(99)90281-2.
- Granger CV, Hamilton BB. The Uniform Data System for Medical Rehabilitation report of first admissions for 1992. Am J Phys Med Rehabil. 1994 Feb;73(1):51-5. No abstract available.
- Boparai MK, Korc-Grodzicki B. Prescribing for older adults. Mt Sinai J Med. 2011 Jul-Aug;78(4):613-26. doi: 10.1002/msj.20278.
- Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012 Jun 1;29(6):495-510. doi: 10.2165/11631720-000000000-00000.
- Walsh KA, O'Riordan D, Kearney PM, Timmons S, Byrne S. Improving the appropriateness of prescribing in older patients: a systematic review and meta-analysis of pharmacists' interventions in secondary care. Age Ageing. 2016 Mar;45(2):201-9. doi: 10.1093/ageing/afv190. Epub 2016 Jan 10.
- Geller AI, Nopkhun W, Dows-Martinez MN, Strasser DC. Polypharmacy and the role of physical medicine and rehabilitation. PM R. 2012 Mar;4(3):198-219. doi: 10.1016/j.pmrj.2012.02.012.
- Perez T, Moriarty F, Wallace E, McDowell R, Redmond P, Fahey T. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. BMJ. 2018 Nov 14;363:k4524. doi: 10.1136/bmj.k4524.
- Iaboni A, Rawson K, Burkett C, Lenze EJ, Flint AJ. Potentially Inappropriate Medications and the Time to Full Functional Recovery After Hip Fracture. Drugs Aging. 2017 Sep;34(9):723-728. doi: 10.1007/s40266-017-0482-6.
- Kragh Ekstam A, Elmstahl S. Do fall-risk-increasing drugs have an impact on mortality in older hip fracture patients? A population-based cohort study. Clin Interv Aging. 2016 Apr 29;11:489-96. doi: 10.2147/CIA.S101832. eCollection 2016.
- Lee JK, Alshehri S, Kutbi HI, Martin JR. Optimizing pharmacotherapy in elderly patients: the role of pharmacists. Integr Pharm Res Pract. 2015 Aug 11;4:101-111. doi: 10.2147/IPRP.S70404. eCollection 2015.
- Gillespie U, Alassaad A, Hammarlund-Udenaes M, Morlin C, Henrohn D, Bertilsson M, Melhus H. Effects of pharmacists' interventions on appropriateness of prescribing and evaluation of the instruments' (MAI, STOPP and STARTs') ability to predict hospitalization--analyses from a randomized controlled trial. PLoS One. 2013 May 17;8(5):e62401. doi: 10.1371/journal.pone.0062401. Print 2013.
- Viktil KK, Blix HS. The impact of clinical pharmacists on drug-related problems and clinical outcomes. Basic Clin Pharmacol Toxicol. 2008 Mar;102(3):275-80. doi: 10.1111/j.1742-7843.2007.00206.x. Epub 2008 Jan 30.
- Lee JK, Slack MK, Martin J, Ehrman C, Chisholm-Burns M. Geriatric patient care by U.S. pharmacists in healthcare teams: systematic review and meta-analyses. J Am Geriatr Soc. 2013 Jul;61(7):1119-27. doi: 10.1111/jgs.12323. Epub 2013 Jun 24.
- Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015 Mar 25;15:31. doi: 10.1186/s12877-015-0029-9.
- Cornu P, Steurbaut S, Leysen T, De Baere E, Ligneel C, Mets T, Dupont AG. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Ann Pharmacother. 2012 Apr;46(4):484-94. doi: 10.1345/aph.1Q594. Epub 2012 Mar 13.
- Bulloch MN, Olin JL. Instruments for evaluating medication use and prescribing in older adults. J Am Pharm Assoc (2003). 2014 Sep-Oct;54(5):530-7. doi: 10.1331/JAPhA.2014.13244.
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 0832-19-RMC
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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