• Trine Graabaek, Ulla Hedegaard, Mikkel B Christensen, Marianne H Clemmensen, Torben Knudsen, and Lise Aagaard.
• Institute of Regional Health Sciences, University of Southern Denmark, Hospital of South West Jutland, Finsensgade 35, 6700, Esbjerg, Denmark.
• J Eval Clin Pract. 2019 Feb 1; 25 (1): 88-96.

Rationale, Aims, And ObjectivesMedication-related problems are frequent and can lead to serious adverse events resulting in increased morbidity, mortality, and costs. Medication use in frail older patients is even more complex. The aim of this study was to investigate the effect of a pharmacist-led medicines management model among older patients at admission, during inpatient stay and at discharge on medication-related readmissions.MethodA randomized controlled trial conducted at the acute admission unit in a Danish hospital with acutely admitted medical patients, randomized to either a control group or one of two intervention groups. The intervention consisted of pharmacist-led medication review and patient interview upon admission (intervention ED) or pharmacist-led medication review and patient interview upon admission, medication review during inpatient stay, and medication report and patient counselling at discharge (intervention STAY).ResultsIn total, 600 patients were included. The pharmacist identified 920 medication-related problems with 57% of the recommendations accepted by the physician. After 30 days, 25 patients had a medication-related readmission, with no statistical significant difference between the groups on either primary or secondary outcomes.ConclusionsThis study showed that a clinical pharmacist can be used to identify and solve medication-related problems, but this study did not find any effect on the selected outcomes. The frequency of medication-related readmissions was low, leaving little room for improvement. Future research should consider other study designs or outcome measures.© 2018 John Wiley & Sons, Ltd.

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