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array:24 [ "pii" => "S2254887416300017" "issn" => "22548874" "doi" => "10.1016/j.rceng.2016.01.004" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "1236" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "copyrightAnyo" => "2015" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Rev Clin Esp. 2016;216:205-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4 "PDF" => 4 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0014256516000084" "issn" => "00142565" "doi" => "10.1016/j.rce.2016.01.005" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "1236" "copyright" => "Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "ssu" "cita" => "Rev Clin Esp. 2016;216:205-21" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 293 "formatos" => array:2 [ "HTML" => 42 "PDF" => 251 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">REVISIÓN</span>" "titulo" => "Intervenciones para optimizar el tratamiento farmacológico en ancianos hospitalizados: una revisión sistemática" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "221" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Interventions to optimize pharmacologic treatment in hospitalized older adults: a systematic review" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2048 "Ancho" => 2435 "Tamanyo" => 294808 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Búsqueda en bases de datos.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Gutiérrez Valencia, N. Martínez Velilla, E. Lacalle Fabo, I. Beobide Telleria, B. Larrayoz Sola, M. Tosato" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Gutiérrez Valencia" ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Martínez Velilla" ] 2 => array:2 [ "nombre" => "E." "apellidos" => "Lacalle Fabo" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Beobide Telleria" ] 4 => array:2 [ "nombre" => "B." "apellidos" => "Larrayoz Sola" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Tosato" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2254887416300017" "doi" => "10.1016/j.rceng.2016.01.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887416300017?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256516000084?idApp=WRCEE" "url" => "/00142565/0000021600000004/v1_201605010018/S0014256516000084/v1_201605010018/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2254887415001010" "issn" => "22548874" "doi" => "10.1016/j.rceng.2015.08.007" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "1191" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Rev Clin Esp. 2016;216:222-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "formatos" => array:2 [ "HTML" => 1 "PDF" => 2 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Symposium. Heart failure</span>" "titulo" => "Prevalence and prognostic meaning of comorbidity in heart failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "222" "paginaFinal" => "228" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevalencia y significado pronóstico de la comorbilidad en la insuficiencia cardiaca" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Conde-Martel, M. Hernández-Meneses" "autores" => array:2 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Conde-Martel" ] 1 => array:2 [ "nombre" => "M." "apellidos" => "Hernández-Meneses" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256515002210" "doi" => "10.1016/j.rce.2015.08.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256515002210?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887415001010?idApp=WRCEE" "url" => "/22548874/0000021600000004/v1_201605010018/S2254887415001010/v1_201605010018/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2254887416000278" "issn" => "22548874" "doi" => "10.1016/j.rceng.2016.01.003" "estado" => "S300" "fechaPublicacion" => "2016-05-01" "aid" => "1237" "copyright" => "Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI)" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Clin Esp. 2016;216:191-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 2 "PDF" => 2 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Pulse wave velocity of the leg minus that of the arm measured with a custom device correlates to the coronary calcium quantification" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "191" "paginaFinal" => "197" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La velocidad de onda de pulso de la pierna menos brazo medida con un dispositivo propio se correlaciona con la cuantificación de calcio coronario" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1558 "Ancho" => 1633 "Tamanyo" => 132087 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Area under the curve for predicting a CCQ >100 for IMT.</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Abbreviations: CCQ, coronary calcium quantification; cfPWV, carotid-femoral pulse wave velocity measured with COMPLIOR; IMT, intima-media thickness in common carotid artery; l-a PWV, difference in maximum pulse wave velocity in the legs minus the maximum PWV in the arms measured with abiPWV.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Rico Martín, J.M. de Nicolás Jiménez, S.L. Moyano Calvente, M.V. Mogollón Jiménez, J. Vega Fernández, J.F. Calderón García, M.A. Bacaicoa Lopez de Sabando, M. Tardio, J.F. Sánchez Muñoz-Torrero" "autores" => array:9 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Rico Martín" ] 1 => array:2 [ "nombre" => "J.M." "apellidos" => "de Nicolás Jiménez" ] 2 => array:2 [ "nombre" => "S.L." "apellidos" => "Moyano Calvente" ] 3 => array:2 [ "nombre" => "M.V." "apellidos" => "Mogollón Jiménez" ] 4 => array:2 [ "nombre" => "J." "apellidos" => "Vega Fernández" ] 5 => array:2 [ "nombre" => "J.F." "apellidos" => "Calderón García" ] 6 => array:2 [ "nombre" => "M.A." "apellidos" => "Bacaicoa Lopez de Sabando" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Tardio" ] 8 => array:2 [ "nombre" => "J.F." "apellidos" => "Sánchez Muñoz-Torrero" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0014256516000096" "doi" => "10.1016/j.rce.2016.01.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0014256516000096?idApp=WRCEE" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887416000278?idApp=WRCEE" "url" => "/22548874/0000021600000004/v1_201605010018/S2254887416000278/v1_201605010018/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review</span>" "titulo" => "Interventions to optimize pharmacologic treatment in hospitalized older adults: A systematic review" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "205" "paginaFinal" => "221" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Gutiérrez Valencia, N. Martínez Velilla, E. Lacalle Fabo, I. Beobide Telleria, B. Larrayoz Sola, M. Tosato" "autores" => array:6 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Gutiérrez Valencia" "email" => array:1 [ 0 => "marta.guva@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." "apellidos" => "Martínez Velilla" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "E." "apellidos" => "Lacalle Fabo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "I." "apellidos" => "Beobide Telleria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 4 => array:3 [ "nombre" => "B." "apellidos" => "Larrayoz Sola" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Tosato" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio de Geriatría, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "IdiSNa, Navarra Institute for Health Research, Pamplona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Pamplona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Farmacia, Complejo Hospitalario de Navarra, Pamplona, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Farmacia, Fundación Matia, San Sebastián, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Centro Medicina Dell’Invecchiamento, Università Cattolica Sacro Cuore, Policlinico A. Gemelli, Roma, Italy" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intervenciones para optimizar el tratamiento farmacológico en ancianos hospitalizados: una revisión sistemática" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2048 "Ancho" => 2435 "Tamanyo" => 280376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Database search.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Drug therapy is one of the most important tools available for preserving and improving health; however, the use of medications is not without risk. The high prevalence of adverse events due to medication<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">1</span></a> is a significant public health problem, due to the significant morbidity and mortality they cause,<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">2,3</span></a> which entail a significant consumption of resources and high healthcare costs.<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">4,5</span></a> This problem is especially relevant for the elderly, who have numerous factors that contribute to a greater risk of drug iatrogenesis. These factors include age-related changes in pharmacokinetics and pharmacodynamics<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">6,7</span></a> and the combination of chronic diseases that inevitably lead to polypharmacy.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A number of studies in Spain have shown that the prevalence of polypharmacy (defined as the consumption of more than 5 drugs a day) in patients older than 65 years is approximately 50%<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">8,9</span></a> and that polymedicated patients consume a mean of almost 9 medications a day.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">8</span></a> Polypharmacy is strongly linked to drug-related adverse events, interactions and interferences between the drugs and the disease itself,<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">10,11</span></a> to lack of treatment adherence<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">12</span></a> and, ultimately, to mortality.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">13</span></a> Other patient-related factors, such as frailty, geriatric syndromes, dependence and cognitive impairment, frequently overlap, increasing the complexity of medication use, which ultimately leads to poorer health outcomes. For example, it is estimated that between 10% and 20% of hospital admissions for elderly patients in Spain are associated with medication-related adverse events,<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">14,15</span></a> which quadruple the risk when compared with younger patients.<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">16</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">All of these problems gain special relevance in elderly hospitalized patients. Hospitalization is an especially delicate situation for the elderly and is associated with higher morbidity, mortality and cognitive and functional impairment.<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">17,18</span></a> The incorporation of new prescribers and the increase in the number of drugs during hospitalization contribute to the risk of iatrogenesis and the complexity of administering drugs.<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">19,20</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The progressive aging of the population predicts that medication-related problems in the elderly will be increasingly common. Fortunately, most medication-related adverse events are considered preventable.<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">21</span></a> Improving therapeutic appropriateness could therefore help minimize the problem. The issue of prescription quality in the elderly has generated significant interest in the scientific community, which, in an attempt to define it, has coined terms such as <span class="elsevierStyleItalic">“</span>therapeutic appropriateness” and has led to the development of numerous tools to quantify it (<a class="elsevierStyleCrossRef" href="#sec0085">Appendix A</a>).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Considering the complexity of administering drugs to elderly hospitalized patients and the high prevalence of inappropriate prescriptions,<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">19,22</span></a> it seems that we need to incorporate strategies aimed at optimizing drug treatment. Although it has been previously mentioned that hospitalization is an especially appropriate period for implementing strategies for improving the quality of the use of medications,<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">23</span></a> most studies have been implemented in other healthcare settings.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this review is to summarize the evidence on interventions aimed at optimizing the drug treatment of hospitalized elderly patients.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Search strategy</span><p id="par0035" class="elsevierStylePara elsevierViewall">In August 2015, we conducted a search in the following scientific literature databases to locate primary studies, without setting any date restrictions: MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and the Cochrane Library. The search was designed with MeSH terms (Medical Subject Headings) for MEDLINE and was adapted to the other databases according to its descriptors or through keywords. We combined the following search terms: “Aged” and (“Hospitalization”, “Inpatients” or “Hospitals”); and (“Drug utilization review”, “Polypharmacy”, “Inappropriate prescribing” or “Medication therapy management”). A manual search was also conducted, reviewing the references cited in the selected studies and in relevant systematic reviews.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study selection</span><p id="par0040" class="elsevierStylePara elsevierViewall">We included studies that met the following criteria: (a) prospective studies (not necessarily controlled or randomized), (b) inclusion of interventions aimed at optimizing the drug treatment in terms of the prescription, (c) inclusion of at least 80% of the sample composed of hospitalized patients 65 years of age or older, and (d) measurement of quantifiable process variables (change in therapeutic appropriateness measured by validated tools or polypharmacy) or endpoints (clinical, use of healthcare resources, financial, humanistic, etc.).</p><p id="par0045" class="elsevierStylePara elsevierViewall">We excluded studies with the following criteria: (a) systematic reviews and meta-analyses, presentations at congresses or scientific meetings and study protocols; (b) published in languages other than English and Spanish; (c) focus on a single disease or medical condition or regarding a certain medication or therapeutic group; and (d) inclusion of interventions directed exclusively to improving treatment adherence or decreasing reconciliation errors.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection and analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">To select the studies, 2 reviewers examined the titles and abstracts of those studies identified in the search and then examined the full text of those studies that were not excluded, ultimately evaluating the ones that met the inclusion criteria. The relevant data were extracted from the selected articles, including the study design, number of participants, demographic characteristics, type of intervention and practitioner who performed it, follow-up time, degree of therapeutic appropriateness, polypharmacy, mortality, adverse reactions to medications, falls, changes in Barthel index, hospital readmissions, emergency department visits, time of admission, financial savings per patient and health-related quality of life. The main characteristics of the measurement methods for therapeutic appropriateness employed in the studies are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The quality of the prescription can be assessed using process variables (see whether the prescription coincides with the accepted standards) or results (consequences for the patient, the healthcare system and society).<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">24</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Ultimately, 2 reviewers separately assessed the included studies according to the risk of bias criteria developed by the Cochrane Effective Practice and Organization of Care group<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">25</span></a> for the main variables.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Search results</span><p id="par0065" class="elsevierStylePara elsevierViewall">A total of 794 references were identified, among which were 41 duplicates. After reviewing the titles and abstracts of 753 publications, 677 were excluded for not meeting the inclusion criteria or meeting exclusion criteria. The remaining 76 publications were assessed. Ultimately, 19 publications were selected for this review. These publications referred to 18 studies<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">26–44</span></a> that met all the defined criteria (2 studies referred to the same publication) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">37,38</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Study characteristics</span><p id="par0070" class="elsevierStylePara elsevierViewall">The number of participants in the studies varied from 43 to 3974, with a mean of 518 patients and a median of 316. Fifteen studies were conducted in Europe and the remaining 3 in the United States. Most studies had a control group, except for 2,<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">46,47</span></a> and 12 were also randomized. The follow-up time varied between the hospitalization period itself <a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">40,42–44</span></a> and 12 months.<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,32,41</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Participant characteristics</span><p id="par0075" class="elsevierStylePara elsevierViewall">The mean age of the participants ranged from 74.5<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a> to 86.6 years<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a>; 2 of the studies did not provide this datum.<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">27,28</span></a> The proportion of women ranged from 3%<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">28</span></a> to 71%<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">26</span></a>; 1 study did not provide this information.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">42</span></a> The age inclusion criteria in the studies were an age greater than 65 years in 9 studies,<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">27,28,30,31,35,36,40,43,44</span></a> greater than 70 in 4,<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,33,37,42</span></a> greater than 75 in 2<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">26,41</span></a> and greater than 80 in another.<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a> Two studies did not have age criteria for inclusion,<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">34,39</span></a> but more than 80% of the participants were older than 65 years. A number of studies also required other inclusion criteria, such as multiple diseases,<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">44</span></a> frailty<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28,41</span></a> and the consumption of more than 3 medications.<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">27,41</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Intervention characteristics</span><p id="par0080" class="elsevierStylePara elsevierViewall">The intervention was performed by pharmacists in 9 studies, by a multidisciplinary team in 3,<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28,36,41</span></a> by pharmacists and clinical pharmacologists in 1,<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">33</span></a> by geriatricians in 1,<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> by nurses in 1,<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">31</span></a> and by physicians other than the prescriber (without specifying specialty) in 2.<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">35,43</span></a> One intervention consisted of a software application used by the prescribing physician.<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">40</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">In terms of type of intervention, most of the studies (13, 72%) conducted medication reviews with subsequent recommendations by or discussions with the prescribing physician. The intervention in 2 studies was based on detecting explicit criteria such as the Screening Tool of Older Person's Potentially Inappropriate Prescriptions (STOPP)<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">35,41</span></a> and the Screening Tool to Alert Doctors to Right Treatment (START).<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a> In another study, the intervention consisted of advising a team of geriatric medicine specialists.<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">28</span></a> We also included a study with an educational approach, based on training nurses on clinical pharmacology and tools for detecting medication-related problems.<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">31</span></a> A number of studies performed other types of intervention, such as patient information, counseling and education<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">27,29,32–34,37</span></a> and medication reconciliation,<a class="elsevierStyleCrossRefs" href="#bib0565"><span class="elsevierStyleSup">36,37,39</span></a> which are beyond the scope of this review.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Variables analyzed</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Process variables</span><p id="par0090" class="elsevierStylePara elsevierViewall">Among the 14 studies that measured therapeutic appropriateness, 13 achieved an improvement in at least one of the parameters due to the intervention.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The most widely used measurement tool was the Medication Appropriateness Index (MAI),<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">45,46</span></a> which was employed in 6 studies.<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28–30,35,36,43</span></a> All 6 studies showed significant improvements in this scale after the intervention. The study by Michelek et al.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">42</span></a> used the Fit for the Aged (FORTA) system,<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">47</span></a> achieving an increase in the prescription of category A drugs (indispensable) compared with the control group, but without reaching statistical significance. Two studies<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28,35</span></a> measured medication underutilization through the Assessment of Underutilization of Medication index,<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">48</span></a> both of which achieved improvements in this criterion compared with the control group.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In terms of the explicit methods (see <a class="elsevierStyleCrossRef" href="#sec0085">Appendix A</a> in the supplementary material), the Beers criteria were employed in 4 studies,<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28,29,40,43</span></a> in its updated versions of 1997<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">49</span></a> and 2003,<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">50</span></a> but only 2 of them<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">28,40</span></a> achieved improvements after the intervention. The STOPP and START criteria<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">51</span></a> were employed to quantify therapeutic appropriateness after the intervention in 2 studies. A statistically significant improvement was observed with the STOPP criteria<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">41,43</span></a> but not in the study that applied the START criteria.<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">43</span></a> Only one study measured appropriateness using the Priscus criteria<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">43</span></a> but could not demonstrate clear improvement attributable to the intervention (42.4–40.6%) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.421). Two interventions reported in Swedish studies attempted to decrease the prevalence of inappropriate medications based on quality indicators described in Sweden,<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">52</span></a> one successfully,<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">34</span></a> the other without achieving significant differences compared with the control group.<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">31</span></a> Two studies included the Assessing Care Of Vulnerable Elders (ACOVE) criteria<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">53</span></a> to measure underprescription. While Spinewine et al.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">29</span></a> showed a marked improvement with the intervention (OR, 6.1; 95% CI 2.2–17), the improvement did not achieve statistical significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.739) in the study by O'Sullivan et al.<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">43</span></a> The studies by Delgado-Silveira et al.<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">44</span></a> and Lipton et al.<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">27</span></a> reported a reduction in medication-related problems due to the intervention.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Among the 8 studies that measured the effect of the intervention on polypharmacy,<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">26,31,36–38,40,42,43</span></a> only 1 showed better results than those of the control group.<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Outcome variables</span><p id="par0110" class="elsevierStylePara elsevierViewall">Seven of the studies analyzed the effect of the interventions on mortality after a follow-up period of 3<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">31,33</span></a> 6<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">35,38,39</span></a> or 12 months,<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,32</span></a> without conclusive results. The study by Michalek et al.<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">42</span></a> achieved a significant reduction in the number of falls in the intervention group (3.4% vs. 21.4%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) and an improved Barthel index, although that did not achieve statistical significance. In the study by Gallagher et al.,<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a> the reduction in the prevalence of falls 6 months after the intervention did not reach statistical significance (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.332).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Among the 6 studies that analyzed the influence on hospital readmissions at 3,<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">31,33,37</span></a> 6<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a> or 12 months of admission,<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,32</span></a> only the study by Legrain et al.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> achieved a statistically significant reduction (20.2% vs. 28.4%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01). Among the 4 studies that quantified emergency department visits,<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,32,33,39</span></a> only the study by Gillespie et al.<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a> achieved a 47% reduction at 1 year compared with the control group. None of the interventions achieved a significant reduction in hospital stays.<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">33,35,36,40</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In terms of the analysis of secondary costs, Gillespie et al.<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a> showed a reduction of $400 (USD) per patient when compared with the control group. This savings was due to the reduction in expenses associated with readmissions and emergency department visits ($230 less per patient when taking into account the intervention costs). Legrain et al.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> showed a reduction of €797; €519 per patient if the intervention cost was discounted.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Two studies measured the health-related quality of life using the EuroQol-5D questionnaire at 3<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">33</span></a> and 6 months.<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">34</span></a> Although the first study achieved no significant differences, the second showed an improvement in overall health, although not in the other parameters.</p><p id="par0130" class="elsevierStylePara elsevierViewall">The main characteristics and results of the studies are listed in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, which also shows the potential sources of bias.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">This review provides a summary of the evidence on various strategies for optimizing treatments for elderly hospitalized patients, aimed at reducing polypharmacy and improving therapeutic appropriateness, health results and the use of the healthcare system.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Among the analyzed variables, it is worth noting the good results regarding the improvement in therapeutic appropriateness, which appears to be independent of the personnel who perform the intervention and the type of intervention (except in the Bergqvist et al. study,<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">31</span></a> which used an educational approach).</p><p id="par0145" class="elsevierStylePara elsevierViewall">Although the majority of studies managed to improve therapeutic appropriateness in one or more of the parameters, the results differed depending on the measurement method. While all of the studies that used the MAI scale or STOPP criteria achieved an improvement, the same was not true for studies using Beers, Priscus or ACOVE criteria. These results provide an introduction to the debate on the applicability and validity of measurement tools for appropriateness. The difficulty in applying these tools in settings other than those from where the tools originate (healthcare levels, countries) has been widely commented in the literature.<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">54–56</span></a> An example of this challenge is the use of the Beers criteria in the studies by Spinewine et al.<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">29</span></a> (Belgium) and O'Sullivan et al. (Ireland),<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">43</span></a> which were not able to detect positive results in terms of therapeutic appropriateness. The usefulness of the Beers criteria in the European setting is questionable<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">57</span></a>; however, the criteria are still widely used for being one of the first tools developed. The validity of the measurement methods for appropriateness has also been the subject of controversy, given that the process variables should be related to relevant health outcomes (mortality, morbidity, medication-related adverse events and quality of life) to be valid.<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">58</span></a> Although there are studies that show a significant association between the use of inappropriate medications (according to the Beers criteria) and the health outcomes in certain healthcare settings (residence and outpatient),<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">59–61</span></a> the use of inappropriate medications for hospitalized patients is not associated with a significant increase in the risk of adverse events,<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">62</span></a> the hospital stay or mortality.<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">63,64</span></a> The degree of therapeutic appropriateness measured with the MAI scale has been shown to be related to health outcomes in the primary care setting.<a class="elsevierStyleCrossRefs" href="#bib0710"><span class="elsevierStyleSup">65,66</span></a> The use of inappropriate medications, according to the STOPP criteria, has been associated with the onset of adverse events in elderly hospitalized patients.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">67</span></a> However, a study<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">68</span></a> showed that most medication-related problems in elderly patients who live in the community are not detected using STOPP or START criteria. A number of studies that compared the Beers and STOPP criteria seem to show a lower sensitivity for the former in detecting potentially inappropriate medications<a class="elsevierStyleCrossRefs" href="#bib0730"><span class="elsevierStyleSup">69,70</span></a> or for preventing hospitalizations due to medication-related adverse events.<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">67</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In light of the fact that the available evidence on the predictive validity of explicit criteria is not definitive or the fact that the results can differ depending on the method of analysis employed, it is worth questioning the suitability of the measurement systems for therapeutic appropriateness being used and thus their published results. Given that the tools are employed both to measure results and to perform interventions, we should consider that the health endpoints can also be affected by this validity, especially if the intervention is based exclusively on detecting explicit criteria, as in the study by Gallagher et al.<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The use of explicit methods has numerous practical advantages (<a class="elsevierStyleCrossRef" href="#sec0085">Appendix A</a>), but interventions based on implicit methods (standardized or not) provide a broader vision on the patient's situation, their preferences, life expectancy and the fixed therapeutic objectives. A recent study<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">71</span></a> showed that a number of more significant causes for prescribers not modifying the treatment (according to the recommendations included in the STOPP/START criteria) are patient disability, dependence and risk of adverse events, variables that, in the elderly, can be much more important than survival itself. Regardless of the method employed, this type of information is important for adapting the intervention to each patient's needs. However, only 6<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">26,29,37,40–42</span></a> studies conducted a comprehensive geriatric assessment, and 8 studies did not record any information on the functional, cognitive and nutritional condition or on the presence of geriatric syndromes.<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">27,30,31,33,34,36,39,44</span></a> Only the study by Legrain et al.<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> recorded the patients’ preferences regarding their health. If the practitioners who conduct the intervention do not know these data, the recommendations for modifying the treatment will not correctly fit the patient's characteristics and will probably not be accepted by the prescriber.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Acceptance of these recommendations is essential to interpreting the endpoints, because the interventions need to result in treatment changes in order to affect the patient's health. Consequently, a low degree of acceptance of the recommendations can lead to a lack of improvement in the endpoints. The study by Lisby et al.,<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">33</span></a> for example, had a degree of acceptance of the recommendations of 39% and achieved no benefits in any of the study variables (hospital stay, readmissions, emergency department visits, mortality and quality of life). In contrast, those studies with a higher proportion of accepted recommendations achieved more noticeable improvements. The study by Gillespie et al.,<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a> in which 77% of the recommendations were accepted, showed a reduction in emergency department visits. The study by Legrain et al.,<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> with an acceptance of 70.9%, hospital readmissions decreased significantly.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Other factors that could have affected the health outcomes are methodological, such as the low number of participants in a number of the studies and the studies’ low power for detecting significant differences. The studies that had no statistically significant results in terms of mortality, readmissions or emergency department visits had not defined these variables as primary objectives.<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">29,33,35,39</span></a> Age is another factor worth considering. The studies with better health outcomes were those whose participants had a higher mean age,<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">32,37</span></a> which suggests that patients with greatest risk and frailty are the ones most likely to benefit from strategies that optimize the drug therapy.</p><p id="par0170" class="elsevierStylePara elsevierViewall">In terms of the impact of interventions on other significant variables such as quality of life and financial savings, it is difficult to make relevant conclusions, given the little evidence provided by the analyzed studies.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The results of this review are similar to those of other published studies. Various reviews have been conducted on the drug treatment optimization in elderly patients, not focused on the hospital setting. Two of these studies concluded that some interventions with different approaches (educational, treatment reviews, geriatric services, multidisciplinary teams, computer support systems, etc.) can improve the degree of therapeutic appropriateness.<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">72,73</span></a> In the review by Patterson et al.<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">74</span></a>, the impact of these interventions on clinical outcomes was uncertain, although benefits were demonstrated in terms of reducing inappropriate prescriptions. In the study by Holland et al.,<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">75</span></a> which examined the impact of treatment reviews performed by pharmacists on hospitalizations and mortality, also found no positive effect on these parameters. On the other hand, we found reviews on hospitalized patients, although not specifically elderly, such as the study by Christensen et al.<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">76</span></a> focusing on medical reviews, which show a reduction in emergency department visits, with no influence on mortality or hospital readmissions. Similarly, Graabaek et al.,<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">77</span></a> in a recent systematic review of medication reviews performed by clinical pharmacists, indicated a positive effect in the use and cost of medications and a number of improvements in the use of healthcare resources, which was not statistically significant.</p><p id="par0180" class="elsevierStylePara elsevierViewall">In terms of the bias of the included studies, the fact that the evaluator of the results knew which group each patient belonged to was a high risk of bias. Given the presence of several nonrandomized studies, the risks of associated bias were also frequent.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Future research should be aimed at checking the validity of the tools for measuring and improving therapeutic appropriateness, which confer a greater reliability to the studies and a greater impact of interventions for optimizing therapeutic appropriateness on health outcomes. Moreover, quality controlled clinical trials need to be developed, with sufficient sample sizes and with the necessary methodological quality to detect the expected impact on clinical variables such as hospital readmissions, emergency department visits and quality of life.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusions</span><p id="par0190" class="elsevierStylePara elsevierViewall">The analyzed studies show that the therapeutic appropriateness of elderly hospitalized patients can be improved by interventions with various approaches (systematic treatment reviews, support software for decision making and detection of explicit criteria of inappropriate prescription), implemented by various practitioners (clinical pharmacists, geriatricians, multidisciplinary teams, etc.). However, there is significant variability in the endpoints. The role of these interventions in health outcomes (the consequences for patients, healthcare system and society) is uncertain.</p><p id="par0195" class="elsevierStylePara elsevierViewall">We need to address the applicability and validity of the tools that assess therapeutic appropriateness to obtain more reliable results with greater impact on health. Explicit criteria for optimizing treatments should not be considered the gold standard, and their implementation should preferably be combined with implicit methods so as to address especially important issues for elderly patients, such as the sociofamiliar context, functional and cognitive conditions and life expectancy.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The clinical variables for elderly patients should be properly selected, given that the therapeutic objectives are often different, and the functional aspects or those related to quality of life can be more important in this population than others, such as mortality. The selection of objectives can benefit from consensus in multidisciplinary teams that include a comprehensive geriatric assessment.</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres632652" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec645361" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres632651" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec645360" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Search strategy" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study selection" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Data collection and analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Search results" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Study characteristics" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Participant characteristics" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Intervention characteristics" ] 4 => array:3 [ "identificador" => "sec0055" "titulo" => "Variables analyzed" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Process variables" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Outcome variables" ] ] ] ] ] 7 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflicts of interest" ] 10 => array:2 [ "identificador" => "xack213201" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec645361" "palabras" => array:5 [ 0 => "Elderly" 1 => "Hospitalized" 2 => "Polypharmacy" 3 => "Inappropriate prescribing" 4 => "Treatment review" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec645360" "palabras" => array:5 [ 0 => "Anciano" 1 => "Hospitalizados" 2 => "Polifarmacia" 3 => "Prescripción inadecuada" 4 => "Revisión de tratamientos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To summarise the evidence on interventions aimed at optimising the drug treatment of hospitalised elderly patients.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a search in the main medical literature databases, selecting prospective studies of hospitalised patients older than 65 years who underwent interventions aimed at optimising drug treatment, decreasing polypharmacy and improving the medication appropriateness, health outcomes and exploitation of the healthcare system.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We selected 18 studies whose interventions consisted of medication reviews, detection of predefined drugs as potentially inappropriate for the elderly, counselling from a specialised geriatric team, the use of a computer support system for prescriptions and specific training for the nursing team. Up to 14 studies assessed the medication appropriateness, 13 of which showed an improvement in one or more of the parameters. Seven studies measured the impact of the intervention on polypharmacy, but only one improved the outcomes compared with the control. Seven other studies analysed mortality, but none of them showed a reduction in that rate. Only 1 of 6 studies showed a reduction in the number of hospital readmissions, and 1 of 4 studies showed a reduction in the number of emergency department visits.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the heterogeneity of the analysed interventions and variables, we obtained better results in the process variables (especially in medication appropriateness) than in those that measured health outcomes, which had greater variability.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Resumir la evidencia sobre las intervenciones orientadas a optimizar el tratamiento farmacológico en ancianos hospitalizados.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó una búsqueda en las principales bases de datos bibliográficas, seleccionando estudios prospectivos en pacientes mayores de 65 años hospitalizados que realizaran intervenciones dirigidas a optimizar el tratamiento farmacológico, disminuir la polifarmacia y mejorar la adecuación terapéutica, los resultados en salud o el aprovechamiento del sistema sanitario.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se seleccionaron 18 estudios. Las intervenciones consistieron en revisiones de medicación, detección de medicamentos predefinidos como potencialmente inadecuados en ancianos, asesoramiento de un equipo especializado en geriatría, uso de un sistema informático de apoyo a la prescripción o formación específica al equipo de enfermería. Hasta 14 estudios evaluaron la adecuación terapéutica, demostrando 13 de ellos una mejoría en alguno de los parámetros. Siete estudios midieron el impacto de la intervención sobre la polifarmacia, pero solo uno mejoró los resultados respecto al control. Otros siete estudios analizaron la mortalidad, no demostrándose una disminución de la misma en ninguno. Solo uno de seis estudios mostró una reducción de reingresos hospitalarios y uno de cuatro estudios una disminución de las visitas a urgencias.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Pese a la heterogeneidad de las intervenciones y de las variables analizadas, se obtuvieron mejores resultados en las variables de proceso, especialmente en la adecuación terapéutica, que en aquellas que midieron resultados en salud, donde hubo una mayor variabilidad.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gutiérrez Valencia M, Martínez Velilla N, Lacalle Fabo E, Beobide Telleria I, Larrayoz Sola B, Tosato M. Intervenciones para optimizar el tratamiento farmacológico en ancianos hospitalizados: una revisión sistemática. Rev Clin Esp. 2016;216:205–221.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0220" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0090" ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2048 "Ancho" => 2435 "Tamanyo" => 280376 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Database search.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: ACOVE, Assessing Care of Vulnerable Elders; AOU, Assessment of Underutilization of Medication tool; FORTA, Fit for the Aged; MAI, Medication Appropriateness Index; START, Screening Tool to Alert Doctors to Right Treatment; STOPP, Screening Tool of Older Persons’ Potentially Inappropriate Prescriptions.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criterion (year of publication) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Years of updates \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study population \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main characteristics \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Explicit criteria</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Beers criteria (1991) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1997, 2003, 2007, 2012, 2015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• List of medicinal products to avoid<br>• List of medicinal product or therapeutic groups to avoid in certain diseases (since 1997)<br>• List of medicinal products to use with caution (since 2012)<br>• Inappropriate prescription due to drug interactions and renal function (since 2015) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>STOPP–START criteria (2008) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ireland \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• STOPP: list of potentially inappropriate medications, organized by physiological system<br>• START: underprescription criteria (health condition – indicated drug) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PRISCUS list (2010) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• List of potentially inappropriate medications. Classified by therapeutic group.<br>• Proposes therapeutic alternatives and precautions if used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>National quality indicators in the use of drug therapy for the elderly (2004) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Specific medicinal product indicators: selection, indication, dosage, polypharmacy, drug interactions, use of medicinal products with altered renal function and in the presence of certain symptoms<br>• Specific indicators of diagnosis: rational, irrational and dangerous use \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>ACOVE (1999) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2001, 2007 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years frail \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Quality indicators for improving the quality of care in various chronic conditions. Not focused exclusively on drug treatment. 35% of indicators for treatment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Criterios implícitos</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MAI (1992) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Ten questions are assigned to each medicinal product regarding the indication, effectiveness, dosage, instructions, regimen, drug–drug interactions, drug–disease interactions, duplication, duration and cost<br>• Responses based on a 3-point Likert scale (A: appropriate, C: inappropriate). Each inappropriate item scores between 1 and 3 points based on its importance. The sum of all items creates a weighted score for each drug between 0 and 18. By adding up the scores for the drugs, we can obtain an overall index<br>• Higher scores mean lower therapeutic suitability \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>FORTA (2008) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Records inappropriate prescriptions and omissions for indicated medicinal products<br>• Drugs are classified into 4 categories: A (Indispensable), B (Beneficial), C (Questionable), D (To be avoided). Based on the evidence of safety, efficacy and suitability for the age \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AOU (1999) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">All \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Measures underprescription. Requires the clinical discretion of a healthcare practitioner who compares the medical history and the list of medicinal products to establish treatment omissions \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1037750.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Methods for assessing medication appropriateness.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: AOU, assessment of underutilization of medication index; Beers CD, Beers criteria considering diagnosis; C, control group; HR, hazard ratio; I, intervention group; CI, confidence interval; PI, pharmaceutical intervention; M–M interactions, medication–medication interactions; RF, renal failure; ITT, intent-to-treat analysis; MAI, medical appropriateness index; IM, inappropriate medication; PC, primary care; PIM, potentially inappropriate medication; ns, not statistically significant; PP, per protocol analysis; PIP, potentially inappropriate prescriptions; MRP, medication-related problems; ADR, adverse drug reactions; RR, relative risk.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author<br>Year<br>Location \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Study design \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Population (I/C)<br>Inclusion criteria<br>Sample (<span class="elsevierStyleItalic">n</span>)<br>% Women<br>Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Follow-up time \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Staff who performed the intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results (P, primary variables; S, secondary variables) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High risk of bias (type: reason) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Owens 1990<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">26</span></a> USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>75 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>436 (221/215)<br>Women: 71%<br>Mean age: 83.5/83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review and recommendation to responsible team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Drug \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No. of medications at day 3: 5.3 (I) vs. 5.9 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05). No differences at 6 weeks and 3 months<br>Increase in the number of medications at day 3: 18% (I) vs. 40% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.005)<br>Medications with no apparent indication: 11% (I) vs. 19% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.025)<br>Inappropriate medications (potential adverse effects and availability of an alternative): 20% (I) vs. 37% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.005) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Owens 1992<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">27</span></a> USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years, 3 or more medications<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>236 (123/113)<br>Women: 51% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review and pharmacist counseling at discharge and for 3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical pharmacists \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with MRP: 82% (I) vs. 93% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.05)<br>Patients with suboptimal or nonindicated medication: 51 (I) vs. 68 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01). Other categories (dosage or regimen problems, M–M interactions, duplication, allergies): ns<br>Mean score differences for: prescription appropriateness: 0.59 (I) vs. 0.76 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01). Dosage: 0.09 (I) vs. 0.13 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.02). Suboptimal or nonindicated: 0.17 (I) vs. 0.24 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03). Other categories: ns \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Schmader 2004<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">28</span></a> USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years and frailty criteria<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>834<br>Women: 3/2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Geriatric assessment and intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multidisciplinary team: geriatrician, social worker, nurse, pharmacist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) ADRs (events per 1000 days): 206 (I) vs. 64 (C). RR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.85 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0001)<br>Severe ADRs (events per 1000 days): 27 (I) vs. 15 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.93)<br>(S) Difference in change of:<br>Unnecessary medications: −0.5 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001)<br>MAI score: −5.4 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001)<br>IM (Beers): −0.1 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03)<br>Medication underutilization (AOU): −0.3 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.0001) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinewine 2007<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">29</span></a> Belgium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>70 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>203(103/100)<br>Women: 71.9/66.7%<br>Mean age: 82.4/81.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review and recommendation to attending physician<br>Patient interview and information \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical pharmacist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Prescription appropriateness (at admission, at discharge and at 3 months):<br>Change in mean MAI score per patient: decreases more in intervention group: 24.1–7.1 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9.1 (95% CI 4.2–21.6)<br>IM reduction (Beers): similar I–C, OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.6 (95% CI 0.3–1.1)<br>Mean change ACOVE criteria underutilization per patient: I decreases more; OR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6.1 (95% CI 2.2–17)<br>(S) Prevalence of unnecessary medications (MAI): decreases from 87.4% to 37.5% (I) and 77.8% (C)<br>Mortality at 1 year: 22.5% (I) vs. 30.1% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.30)<br>Readmissions at 1 year: 32.6% (I) vs. 33.7% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1.0)<br>Emergency department visits at 1 year: 7.9% (I) vs. 12% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.45)<br>Satisfied with information on medications received at 1 month: 80% vs. 60.9% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blinding of evaluators to the results: unblinded evaluator<br>Contamination: physicians who treated patients in the 2 groups \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bergkvist 2009<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">30</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled nonrandomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43 (28/25)<br>Women: 61/64%<br>Mean age: 82/84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review and discussion with multidisciplinary team \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 weeks after discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Drug \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Change in MAI score (admission–discharge-after 2 weeks): ns<br>Reduction in the no. of medications with inappropriate characteristics according to MAI: less in the intervention group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.049) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Random sequence generation: nonrandomized<br>Hiding of the assignment: historical control<br>Initial imbalance: control group was older and had more inappropriate drugs at the start \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bergqvist 2009<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">31</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled nonrandomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>460(250/210)<br>Women: 56/53%<br>Mean age: 80.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurse training in clinical pharmacology for MRP detection. Tools: SYM (Symptoms Assessment Form) and JWA (Janus Web Application) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Nurses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Readmissions at 3 months: 38% (I) vs. 36% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.86)<br>(S) Proportion of inappropriate medications at discharge: ns<br>Medication-related readmissions: ns<br>Deaths: 24% (I) vs. 23.3% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.91)<br> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Random sequence generation: nonrandomized<br>Hiding of the assignment: historical control<br>Blinding of evaluators to the results: unblinded evaluator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gillespie 2009<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">32</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>80 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>400 (199/201)<br>Women: 58.7%<br>Mean age: 86.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review and recommendation to responsible physician<br>Patient counseling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Drug \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Readmissions: 217 (I) vs. 223 (C) (Estimate<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.97)<br>Medication-related readmissions: 9 (I) vs. 45 (C) (estimate<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.2)<br>Reduction in emergency department visits: 47%; 49 (I) vs. 93 (C) (Estimate<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.53)<br>Difference readmissions<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>emergency department visits: 16%; 266 (I) vs. 316 (C) (Estimate<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.84)<br>Mortality at 1 year: 57 (I) vs. 61 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.82)<br>Overall cost reduction: $400/patient (I–C)<br>Cost reduction by emergency department visits: $100/patient (I–C)<br>Cost reduction by readmissions: $300/patient (I–C)<br>Savings counting the cost of the intervention: $230/patient (I–C) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contamination: I and C same ward \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lisby 2010<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">33</span></a> Denmark \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>70 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>99 (50/49)<br>Women: 60/61%<br>Mean age: 80.2/78.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Systematic review of medication, with recommendations to the responsible physician and patient counseling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pharmacist and clinical pharmacologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Hospital stay: 239.9 (I) vs. 238.6 (C) h (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>.05)<br>(S) Time to readmission, no. of readmissions, emergency department and PC visits, death, health-related quality of life (EQ-5D): ns \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Contamination: I and C same ward \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bladh 2011<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">34</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>80% participants<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>345<br>Women: 61%<br>Mean age: 82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication review (with MiniQ tool) and feedback with physicians<br>Information at discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical pharmacist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Change in health-related quality of life (EQ-5D) at 6 months: greater in overall health 3.14 (I) vs. 2.77 (C); <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.02, but not in other parameters<br>PIP: decreases in intervention group 0.39 (admission) vs. 0.26 (discharge) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.039) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blinding of evaluators to the results: unblinded evaluator<br>Contamination: I and C same ward \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gallagher 2011<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">35</span></a> Ireland \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>382: 190/192<br>Women: 53.2/53.1%<br>Mean age: 74.5/77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">STOPP/START detection and recommendation to attending physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medical researcher \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Patients with reduction in MAI admission–discharge score: 71.1% (I) vs. 35.4% (C) (ARR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>35.7%)<br>Rate of unnecessary polypharmacy at discharge: 5.4% (I) vs. 19.8% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>All MAI criteria differ significantly between I–C at discharge and at 6 months<br>Mean MAI score decreases from 10 to 3 (I) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) and remains after 6 months (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Patients with AOU admission–discharge reduction: 31.6% (I) vs. 10.4% (C) (ARR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>21.2%) (S) Prevalence decreases after 6 months: 5.8% (I) vs. 8.4% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.332)<br>Mortality after 6 months: 5.3% (I) vs. 7.3% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.414)<br>Hospital stay: 8 (I) vs. 8.5 days (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.471)<br>Readmission rate: 67 (I) vs. 64 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.691)<br>Fewer visits to PC physician (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.063) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blinding of evaluators to the results: unblinded evaluator \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hellstrom 2011<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">36</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled nonrandomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br>(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>210)<br>Women: 60/51%<br>Mean age: 83/81.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reconciliation, medication review and monitoring \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multidisciplinary team (includes clinical pharmacist) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction in medicines with inappropriate characteristics (MAI): 51% vs. 39% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0446) ITT; 60% vs. 44% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01) PP<br>Differences in mean MAI score per patient or drug at discharge: ns<br>Medication-related readmissions or emergency department visits: 6 (I) vs. 12 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.0469)<br>Hospital stay: 16 vs. 13 days (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.09) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Random sequence generation: nonrandomized<br>Hiding of the assignment: historical control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Legrain 2011<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">37</span></a> France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>70 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>665 (317/348)<br>Women: 69.7/62.6%<br>Mean age: 86.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Review of long-term therapy, patient education, reconciliation at discharge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Geriatrician researcher (different from regular medical team) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Readmissions or emergency department visits at 3 months: 23% (I) vs. 30.5% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03) and 6 months: 35.3% (I) vs. 40.8% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.15)<br>Event-free survival at 3 months: longer in intervention group HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.72 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03); and at 6 months: HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.81 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.10)<br>(S) Readmissions at 3 months: 20.2% (I) vs. 28.4% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.01); and at 6 months: 32.5 (I) vs. 38.2 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.12).<br>Mortality at 3 months: 12% (I) vs. 13.2% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.63); and at 6 months: 17.7% (I) vs. 18.7% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.74)<br>Difference in cost at 6 months (I–C): €797/patient<br>Savings including intervention cost: €519/patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incomplete data from results: 380 excluded after randomization \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bonnet-Zamponi 2012<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">38</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Medication-related readmissions: 34.7% vs. 40.4% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.54).<br>No. of medications, polypharmacy, mean daily dose: ns<br>Difference in cost due to medication-related readmissions: €392 vs. €953.5 per patient (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.13) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Incomplete data from results: 380 excluded after randomization \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hellstrom 2012<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">39</span></a> Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled nonrandomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85%<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>3974 (1216/2758)<br>Women: 54.2/55.5%<br>Mean age: 78.3/79.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reconciliation, medication review and monitoring \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clinical pharmacist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(P) Duration of emergency department visits/readmission: HR 0.95 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.266)<br>(S) Event-free survival: HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.96 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.305)<br>Mean number of emergency department visits at 6 months: 1.02 (I) vs. 1.03 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.89)<br>Mortality at 6 months: 18.2% (I) vs. 17.3% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.55)<br>Mean number of PC visits: 1.58 (I) vs. 1.71 (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.057)<br>Patients who visited PC: 68.5% (I) vs. 70.3% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.34) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Random sequence generation: nonrandomized<br>Hiding of the assignment: historical control<br>Initial imbalance: intervention group younger than control group \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ghibelli 2013<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">40</span></a> Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled nonrandomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>134 (60/74)<br>Women: 58.3/64.8%<br>Mean age: 81.1/81.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Intercheck<span class="elsevierStyleSup">®</span> (computer support system for prescriptions) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Computer system \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction in number of patients with PIM (Beers) admission–discharge: 41.7–11.6% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Mean reduction in PIM by patient admission–discharge: 0.5–0.1 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Reduction in number of patients with potentially severe M–M interaction admission–discharge: 45–33.3% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.703)<br>Reduction in new potentially severe M–M interactions: 59–33% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Hospital stay: 10.4 (I) vs. 10.1 (C) days (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.84) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Random sequence generation: nonrandomized<br>Hiding of the assignment: historical control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dalleur 2014<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">41</span></a> Belgium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>75 years<br>Frail patients according to the ISAR scale and more than 3 medicines<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>146 (74/72)<br>Women: 63%<br>Mean age: 85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">STOPP recommendations to responsible physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Multidisciplinary team specialized in geriatric medicine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction in PIM by STOPP criteria at discharge: 39.7% (I) vs. 19.3% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Michalek 2014<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">42</span></a> Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Controlled randomized \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>70 years<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>114: 58/56<br>Mean age: 84/83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FORTA instrument and recommendations to attending physician \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Physicians other than the one responsible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with polypharmacy (>5 medications) at discharge: 84% (I) vs. 84% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.935) Increases in control and intervention<br>Category A FORTA medications at discharge: 4 vs. 3 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.051). Increases in both<br>Over and underprescription: less in intervention group (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.03 and <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.025)<br>Patients with an increased Barthel index at discharge: 76% (I) vs. 71% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.226)<br>Patients with falls: 3.4% (I) vs. 21.4% (C) (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Proportion of falls/1000 patients/year: 1.5 (I) vs. 10.6 (C) days (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.004) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">O'Sullivan 2014<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">43</span></a> Ireland \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Uncontrolled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years<br>(<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>361)<br>Women: 50.1%<br>Median age: 77 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Structured review of medication and computer support system for decision making \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Drug \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reduction in MAI score from admission to discharge: 15–12 (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). 59.3% patients with lower scores<br>Change in underprescription by ACOVE criteria admission–discharge: 28.3–26.9% (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.739)<br>Median no. of medications: 9 at admission 12 at discharge<br>Patients with 5 or more medications: 84.5% at admission and 95.8% at discharge<br>10 or more medications: 43.5% at admission and 66.8% at discharge<br>Change in STOPP criteria admission–discharge: 62.4–55.5% patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>Change in Beers CD criteria admission–discharge: 31.8–31.6% patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.282)<br>Change in Priscus criteria admission–discharge: 42.4–40.6% patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.421)<br>Change in START criteria admission–discharge: 31–31.5% patients (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.512)<br>Potential M–M interactions: 57.7% patients at admission and 63.9% at discharge (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.50)<br>Incorrect dosage in RF: 9.7% patients at admission and 7.2% at discharge (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blinding of evaluators from results: the evaluator is the same individual who performs the intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Delgado-Silveira 2015<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">44</span></a> Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Uncontrolled \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>65 years, multiple diseases [85% hospitalized]<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>287<br>53.3% women (hospitalized)<br>Mean age (hospitalized): 85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pharmaceutical intervention (clinical judgment and Checkthemeds<span class="elsevierStyleSup">®</span>) and attending physician's recommendation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Drug \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MRP: 96.4% patients<br>PI resolved 58.9% of the MRP (association PI-resolution; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001)<br>PIP for START/STOPP: 65% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blinding of evaluators from results: the individual who assesses the resolution of MRP is the one who performed the intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1037749.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Main characteristics and results of the studies.</p>" ] ] 3 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 13817 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:77 [ 0 => array:3 [ "identificador" => "bib0390" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "L.A. 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