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BackgroundA patient-centred approach to medicines optimisation is considered essential. The OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial evaluated the effectiveness of medication review with shared decision-making (SDM) in older people with multimorbidity. Beyond evaluating the clinical effectiveness, exploring the patient experience facilitates a better understanding of contextual factors and mechanisms affecting medication review effectiveness.ObjectiveTo explore experiences of hospital-initiated medication changes in older people with multimorbidity.MethodsWe conducted a multicentre mixed-methods study, embedded in the OPERAM trial, combining semi-structured interviews and the Beliefs about Medicines Questionnaire (BMQ) with a purposive sample of 48 patients (70–94 years) from four European countries. Interviews were analysed using the Framework approach. Trial implementation data on SDM were collected and the 9-item SDM questionnaire was conducted with 17 clinicians.ResultsPatients generally displayed positive attitudes towards medication review, yet emphasised the importance of long-term, trusting relationships such as with their general practitioners for medication review. Many patients reported a lack of information and communication about medication changes and predominantly experienced paternalistic decision-making. Patients’ beliefs that ‘doctors know best’, ‘blind trust’, having limited opportunities for questions, use of jargon terms by clinicians, ‘feeling too ill’, dismissive clinicians, etc highlight the powerlessness some patients felt during hospitalisation, all representing barriers to SDM. Conversely, involvement of companions, health literacy, empathetic and trusting patient-doctor relationships, facilitated SDM. Paradoxical to patients’ experiential accounts, clinicians reported high levels of SDM. The BMQ showed that most patients had high necessity and low concern beliefs about medicines. Beliefs about medicines, experiencing benefits or harms from medication changes, illness perception, trust and balancing advice between different healthcare professionals all affected acceptance of medication changes.ConclusionTo meet patients’ needs, future medicines optimisation interventions should enhance information exchange, better prepare patients and clinicians for partnership in care and foster collaborative medication reviews across care settings.

Background Recommendations for individualised glycaemic management in older people with type 2 diabetes (T2D) have recently been provided in clinical practice guidelines (CPGs) issued by major scientific societies. The aim of this systematic review is to compare the content of these recommendations concerning health assessment, targets for glycaemic control, lifestyle management and glucose-lowering therapy across CPGs. Methods The CPGs on T2D management in people aged ≥65 years published in English after 2015 by major scientific societies were systematically reviewed in accordance with the PRISMA statement. The quality of the CPGs included was assessed using the AGREE-II tool. The recommendations for individualised glycaemic management were extracted, and their level of evidence (LOE) and strength of recommendation recorded. Results Three CPGs of high methodological quality were included, namely those from the American Diabetes Association 2020, the Endocrine Society 2019 and the Diabetes Canada Expert Committee 2018. They made 27 recommendations addressing individualised glycaemic management, a minority of which (40%) had a high LOE. Comparison of the 27 recommendations identified some discrepancies between CPGs, e.g. the individualised values of HbA1c targets. The 13 strong recommendations addressed 10 clinical messages, five of which are recommended in all three CPGs, i.e. assess health status, screen for cognitive impairment, avoid hypoglycaemia, prioritise drugs with low hypoglycaemic effects and simplify complex drug regimens. Conclusions Although there is a consensus on avoiding hypoglycaemia in older patients with T2D, significant discrepancies regarding individualised HbA1c targets exist between CPGs.

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient’s preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

BACKGROUND Identifying patients at high risk of drug-related hospital admission (DRA) may help to efficiently target preventive interventions. We developed a score to predict DRAs in older patients with multimorbidity and polypharmacy. METHODS We used participants from the multicenter European OPERAM trial ("Optimising PharmacothERapy in the Mutlimorbid Elderly"). We assessed the association between easily identifiable predictors and 1-year DRAs by univariable logistic regression. Variables with p-value3 points had a 40.4% predicted and 38.9% observed risk of DRA. The scaled Brier score was 0.05. Calibration showed an adequate match between predicted and observed proportions. CONCLUSION Comorbidities related to drug metabolism, specific medications, non-elective admission, and a history of hospitalization, were associated with a higher risk of DRA. Awareness of these associations and the score we developed may help identify patients most likely to benefit from preventive interventions.

Background Glucose-lowering therapy (GLT) should be individualized in older patients with type 2 diabetes (T2D) according to their health status and their life expectancy. This study aimed at assessing the inappropriateness of GLT prescribing and the one-year mortality rate in geriatric patients with T2D. Methods Retrospective cohort study of consecutive inpatients with T2D admitted to a geriatric ward of a Belgian university hospital. Inclusion criteria were age ≥ 75 years, T2D with GLT before admission, and HbA1c measurement during the hospital stay. Comorbidities and geriatric syndromes were collected. GLT agents were classified into hypoglycaemic and non-hypoglycaemic ones, and their dosages were expressed in daily defined dose (DDD). Health status (intermediate or poor) and GLT appropriateness (appropriate, overtreatment, undertreatment) were assessed according to the 2019 Endocrine Society guideline on diabetes treatment in older adults, in which GLT overtreatment requires the presence of hypoglycaemic therapy. One-year mortality was determined using the National Registry of vital status, and its associated factors were analysed using multivariable Cox’ regression. Results The 318 geriatric patients with T2D (median age 84 years; 46% female) were in intermediate (33%) or poor health (67%). These two groups reached similar low HbA1c values (median 6.9%) with similar GLT regimens. GLT overtreatment was frequent (57%) irrespectively of the geriatric features. One-year mortality rate was high (38.5%) and associated in multivariate analysis with poor health status (HR: 1.59, p = 0.033), malnutrition (HR: 1.67, p = 0.006) and GLT overtreatment (HR: 1.73, p = 0.023). Patients with GLT overtreatment had a higher mortality rate (44.5%). Conclusions GLT overtreatment was present in more than half of these geriatric patients. Many of them were in poor health status and died within one-year. Special attention should be paid to individualisation of the HbA1c goals in the geriatric patients with diabetes, and to GLT de-intensification in those being over-treated.

Background Rational use of medications and monitoring of prescriptions in elderly patients is important to decrease the number and duration of hospitalizations, emergency medical consultations, mortality, as well as medical costs. Purpose To identify potentially inappropriate medications (PIMs) and potential prescription omissions (PPOs), and determine their prevalence based on the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) v2 criteria and Screening Tool to Alert doctors to Right Treatment (START) v2 criteria for patients aged >65 years. Methods This cross-sectional study was conducted in two rural counties in Romania based on electronic prescriptions for chronic conditions (EPCCs) issued from 30 days to 90 days by a specialist or general practitioner. Collected EPCCs were evaluated by an interdisciplinary team of specialists based on 26 STOPP v2 criteria and 10 START v2 criteria. Results PIM prevalence was 25.80% and PPO prevalence was 41.72% for 646 EPCCs. The mean age of patients was 75 years and the mean number of drugs per EPCC was four. The most frequently identified PIMs were treatment duration (6.65%), theophylline administration (5.72%), drug indication (4.64%), cyclo-oxygenase-2 non-steroidal anti-inflammatory drugs (1.39%), and zopiclone prescription (0.77%). Statins (24.76%), beta-blockers (8.04%), and beta-2 agonist/antimuscarinic bronchodilators (5.88%) were the most frequently identified PPOs. Conclusion PPOs were more prevalent than PIMs for elderly populations living in the two rural counties in Romania we studied. Health practitioners (family physicians, specialists, and pharmacists) should focus on prophylactic and curative considerations when prescribing agents to decrease the morbidity and mortality of elderly rural Romanian patients.

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BACKGROUND Estimating life expectancy of older adults informs whether to pursue future investigation and therapy. Several models to predict mortality have been developed but often require data not immediately available during routine clinical care. The HOSPITAL score and the LACE index were previously validated to predict 30-day readmissions but may also help to assess mortality risk. We assessed their performance to predict 1-year and 30-day mortality in hospitalized older multimorbid patients with polypharmacy. METHODS We calculated the HOSPITAL score and LACE index in patients from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in the Multimorbid elderly) trial (patients aged �����70 years with multimorbidity and polypharmacy, admitted to hospital across four European countries in 2016-2018). Our primary and secondary outcomes were 1-year and 30-day mortality. We assessed the overall accuracy (scaled Brier score, the lower the better), calibration (predicted/observed proportions), and discrimination (C-statistic) of the models. RESULTS Within 1��year, 375/1879 (20.0%) patients had��died, including 94 deaths within 30 days. The overall accuracy was good and similar for both models (scaled Brier score 0.01-0.08). The C-statistics were identical for both models (0.69 for 1-year mortality, p��=��0.81; 0.66 for 30-day mortality, p��=��0.94). Calibration showed well-matching predicted/observed proportions. CONCLUSION The HOSPITAL score and LACE index showed similar performance to predict 1-year and 30-day mortality in older multimorbid patients with polypharmacy. Their overall accuracy was good, their discrimination low to moderate, and the calibration good. These simple tools may help predict older multimorbid patients' mortality after hospitalization, which may inform post-hospitalization intensity of care.

Background identifying drug-related hospital admissions (DRAs) in older people is difficult. A standardised chart review procedure has recently been developed. It includes an adjudication team (physician and pharmacist) screening using 26 triggers and then performing causality assessment to determine whether an adverse drug event (ADE) occurred (secondary to an adverse drug reaction, overuse, misuse or underuse) and whether the ADE contributed to hospital admission (DRA). Objective to assess the performance of those triggers in detecting DRA. Design retrospective study using data from the OPERAM (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people) trial. Settings four European medical centres. Subjects multimorbid (≥ 3 chronic medical conditions) older (≥ 70 years) inpatients with polypharmacy (≥ 5 chronic medications) were enrolled in the OPERAM trial (N = 2,008) and followed for 12 months. We included patients with ≥1 adjudicated hospitalisation during the follow-up. Methods the positive predictive value (PPV; number of DRAs identified by trigger/number of triggers) was calculated for each trigger and for the tool as a whole. Results of 1,235 hospitalisations adjudicated for 832 patients, 716 (58%) had at least one trigger; an ADE was identified in 673 (54%) and 518 (42%) were adjudicated as DRAs. The overall PPV of the trigger tool for detecting DRAs was 0.66 [0.62–0.69]. Conclusions this tool performs well for identifying DRAs in older people. Based on our results, a revised version of the tool was proposed but will require external validation before it can be incorporated into research and clinical practice.

Background: Hand Hygiene (HH) is widely recognized to be one of the most successful and cost-effective measures for reducing the incidence of healthcare-associated infections (HAIs). The hand hygiene behavior of hospital healthcare workers (HCWs) is not well-documented in Benin. Therefore, Theoretical Domains Framework (TDF) was used to identify the behavioral determinants that may impact HCWs’ hand-hygiene compliance in a public hospital. Methods: A qualitative design comprising face-to-face semi-structured interviews with nine HCWs. The interviews included questions on transmission of infections, hand-hygiene practices, problems with their implementation; and ways to improve hand hygiene compliance. Two pharmacists independently coded interviews into behavioral domains using the TDF and then subdivided them into several themes. Interview transcripts were analyzed following 3-steps approach: coding, generation of specific beliefs, and identification of relevant domains. Results: Almost all interviewees have cited the environmental context and resources (such as lack of water) as a barrier to HH practice. They also believed that role models had a significant impact on the good practices of others HCWs. Fortunately, they were confident of their capabilities to perform appropriate HH behaviors. The majority (7/9) reported having the necessary knowledge and skills and believed they could carry out appropriate HH behavior. In all cases, the participants were motivated to carry out HH behavior, and it was recognized that HH remains the cornerstone to reduce health care associated infections. Conclusion: This study identified several behavioral constructs aligned with the TDF that can be targeted and help for the development of new hand-hygiene interventions. These may increase the likelihood of a successful intervention, thereby improving HH compliance and patient safety, especially in hospitals.

BACKGROUND: Polypharmacy may result in medication-related readmissions (MRRs). Identifying MRRs is time consuming. Screening of readmissions by students could increase efficiency for healthcare professionals. Recently, two screening tools have been published: the Assessment Tool for identifying Hospital Admissions Related to Medications (AT-HARM10) tool and the Drug-Related Admission (DRA) adjudication guide. It is unknown whether pharmacy students could identify MRRs with these tools. OBJECTIVE: To compare the agreement between two pharmacy students applying the AT-HARM10 tool and DRA adjudication guide in identifying MRRs vs a multidisciplinary panel. METHODS: A retrospective study was conducted from February to July 2020 at OLVG hospital. Readmissions within 30 days after discharge from seven departments were reviewed by a multidisciplinary panel (pharmacists and physicians). MRRs were defined as readmission where medication was the main cause or medication significantly contributed to the readmission. Two 5th year pharmacy-students volunteered to blindly apply both tools individually on all MRRs and a random sample of non-MRRs. The consensus results of the students and the multidisciplinary panel were compared and displayed as a percentage and Cohen's kappa (κ). RESULTS: Three hundred sixty-six readmission cases were selected in total, consisting of 181 MRRs and 185 non-MRRs. The agreement between the students using the AT-HARM10 tool vs the multidisciplinary panel was moderate (80%, κ = 0.60 (95% confidence interval (CI): 0.52-0.68)). The DRA adjudication guide had a moderate agreement (81%, κ = 0.62 (CI: 0.54-0.70)). Students misclassified MRRs mainly because the multidisciplinary panel found disease progression more profound than a contribution of medication. CONCLUSIONS: Two students have an overall agreement of 80% in comparison with the multidisciplinary panel with a moderate Cohen's kappa. Students are more often overestimated, but they may be a good option to preselect potential MRRs to save time for healthcare professionals. However, some MRRs will be missed.

Background Thrombospondin-1 (TSP-1) is a matricellular functional protein of the extracellular matrix. As it is not constitutively present extracellularly, its secretion is enhanced in several situations, namely injury, chronic pathology, tissue remodeling, angiogenesis, and aging. Over the last decade, TSP-1 has been reported to be involved in complex and opposing biological effects on vasculature in the context of NO signaling. Several studies have reported high patient TSP-1 plasma levels, indicating that the protein can potentially serve as a prognostic marker for pulmonary arterial hypertension. Materials and methods Here, we aimed to quantify TSP-1 serum levels in hypertensive patients with endothelial dysfunction before and after one year of treatment with Perindopril (an antihypertensive drug with vasoprotective properties). Results After one year of treatment, TSP-1 levels increased in hypertensive patients compared to baseline (T0: 8061.9 ± 3684.80 vs T1: 15380±5887 ng/mL, p

Objective To examine the effect of optimising drug treatment on drug related hospital admissions in older adults with multimorbidity and polypharmacy admitted to hospital. Design Cluster randomised controlled trial. Setting 110 clusters of inpatient wards within university based hospitals in four European countries (Switzerland, Netherlands, Belgium, and Republic of Ireland) defined by attending hospital doctors. Participants 2008 older adults (≥70 years) with multimorbidity (≥3 chronic conditions) and polypharmacy (≥5 drugs used long term). Intervention Clinical staff clusters were randomised to usual care or a structured pharmacotherapy optimisation intervention performed at the individual level jointly by a doctor and a pharmacist, with the support of a clinical decision software system deploying the screening tool of older person’s prescriptions and screening tool to alert to the right treatment (STOPP/START) criteria to identify potentially inappropriate prescribing. Main outcome measure Primary outcome was first drug related hospital admission within 12 months. Results 2008 older adults (median nine drugs) were randomised and enrolled in 54 intervention clusters (963 participants) and 56 control clusters (1045 participants) receiving usual care. In the intervention arm, 86.1% of participants (n=789) had inappropriate prescribing, with a mean of 2.75 (SD 2.24) STOPP/START recommendations for each participant. 62.2% (n=491) had ≥1 recommendation successfully implemented at two months, predominantly discontinuation of potentially inappropriate drugs. In the intervention group, 211 participants (21.9%) experienced a first drug related hospital admission compared with 234 (22.4%) in the control group. In the intention-to-treat analysis censored for death as competing event (n=375, 18.7%), the hazard ratio for first drug related hospital admission was 0.95 (95% confidence interval 0.77 to 1.17). In the per protocol analysis, the hazard ratio for a drug related hospital admission was 0.91 (0.69 to 1.19). The hazard ratio for first fall was 0.96 (0.79 to 1.15; 237 v 263 first falls) and for death was 0.90 (0.71 to 1.13; 172 v 203 deaths). Conclusions Inappropriate prescribing was common in older adults with multimorbidity and polypharmacy admitted to hospital and was reduced through an intervention to optimise pharmacotherapy, but without effect on drug related hospital admissions. Additional efforts are needed to identify pharmacotherapy optimisation interventions that reduce inappropriate prescribing and improve patient outcomes. Trial registration ClinicalTrials.gov NCT02986425 .

Background Older adults with chronic conditions are at high risk of complications from influenza and pneumococcal infections. Evidence about factors associated with influenza and pneumococcal vaccination among older multimorbid persons in Europe is limited. The aim of this study was to investigate the prevalence and determinants of these vaccinations in this population. Methods Multimorbid patients aged ≥70 years with polypharmacy were enrolled in 4 European centers in Switzerland, Belgium, the Netherlands, and Ireland. Data on vaccinations, demographics, health care contacts, and comorbidities were obtained from self-report, general practitioners and medical records. The association of comorbidities or medical contacts with vaccination status was assessed using multivariable adjusted log-binomial regression models. Results Among 1956 participants with available influenza vaccination data (median age 79 years, 45% women), 1314 (67%) received an influenza vaccination within the last year. Of 1400 patients with available pneumococcal vaccination data (median age 79 years, 46% women), prevalence of pneumococcal vaccination was 21% (n = 291). The prevalence of vaccination remained low in high-risk populations with chronic respiratory disease (34%) or diabetes (24%), but increased with an increasing number of outpatient medical contacts. Chronic respiratory disease was independently associated with the receipt of both influenza and pneumococcal vaccinations (prevalence ratio [PR] 1.09, 95% confidence interval [CI] 1.03–1.16; and PR 2.03, 95%CI 1.22–3.40, respectively), as was diabetes (PR 1.06, 95%CI 1.03–1.08; PR 1.24, 95%CI 1.16–1.34, respectively). An independent association was found between number of general practitioner visits and higher prevalence of pneumococcal vaccination (p for linear trend Conclusion Uptake of influenza and particularly of pneumococcal vaccination in this population of European multimorbid older inpatients remains insufficient and is determined by comorbidities and number and type of health care contacts, especially outpatient medical visits. Hospitalization may be an opportunity to promote vaccination, particularly targeting patients with few outpatient physician contacts.

BackgroundCarbapenem-resistantAcinetobacter baumanniiis considered a top priority pathogen by the World Health Organization for combatting increasing antibiotic resistance and development of new drugs. Since it was originally reported inKlebsiella pneumoniaein 2009, the quick spread of theblaNDM-1gene encoding a New-Delhi metallo-beta-lactamase-1 (NDM-1) is increasingly recognized as a serious threat. This gene is usually carried by large plasmids and has already been documented in diverse bacterial species, includingA. baumannii. Here, we report the first detection of a NDM-1-producingA. baumanniistrain isolated in Benin.Case presentationA 31-year-old woman was admitted to a surgical unit with a diagnosis of post-cesarean hematoma. An extensively-drug resistantA. baumanniistrain solely susceptible to amikacin, colistin and ciprofloxacin, and resistant to several other antibiotics including ceftazidime, imipenem, meropenem, gentamicin, tobramycin, ceftazidime/avibactam, and sulfamethoxazole-trimethoprim, was isolated from the wound. Production of NDM-1 was demonstrated by immunochromatographic testing. Whole genome sequencing of the isolate confirmed the presence ofblaNDM-1, but also antibiotic resistance genes against multiple beta-lactamases and other classes of antibiotics, in addition to several virulence genes. Moreover, theblaNDM-1gene was found to be present in a Tn125 transposon integrated on a plasmid.ConclusionsThe discovery of this extensively-drug resistantA. baumanniistrain carryingblaNDM-1in Benin is worrying, especially because of its high potential risk of horizontal gene transfer due to being integrated into a transposon located on a plasmid. Strict control and prevention measures should be taken, once NDM-1 positiveA. baumanniihas been identified to prevent transfer of this resistance gene to other Enterobacterales. Capacity building is required by governmental agencies to provide suitable antibiotic treatment options and strategies, in combination with strengthening laboratory services for detection and surveillance of this pathogen.

Objectives We aimed to establish an explicit list of potentially clinically significant drug-drug interactions (DDIs) in people aged ≥65 years. Design A preliminary list of potentially clinically significant DDIs was compiled, based on 154 DDIs identified from literature review. Subsequently, a 2-round online Delphi survey was undertaken with a multidisciplinary expert panel. A consensus meeting and a final round were conducted to validate the final DDI list and the scope of information provided. Setting and Participants Twenty nine experts, including geriatricians and clinical pharmacists from 8 European countries. Measures For each DDI, in the first 2 rounds, experts were asked to score the severity of potential harm on a 5-point Likert-type scale. DDIs were directly included on the final list if the median score was 4 (major) or 5 (catastrophic). DDIs with a median score of 3 (moderate) were discussed at a consensus meeting and included if ≥75% of participants voted for inclusion in the final round. Results Consensus was achieved on 66 potentially clinically significant DDIs (28 had a median score of 4/5 and 48 of 3 in the Delphi survey). Most concerned cardiovascular, antithrombotic, and central nervous system drugs. The final list includes information on the mechanism of interaction, harm, and management. Treatment modification is recommended for three-quarters of DDIs. Conclusion and Implications We validated a list of potentially clinically significant DDIs in older people, which can be used in clinical practice and education to support identification and management of DDIs or to assess prevalence in epidemiologic and intervention studies. pre-print 896 KB

(N = 351) Background Drug-drug interactions (DDIs) are highly prevalent in older patients but little is known about prevalence of DDIs over time. Our main objective was to assess changes in the prevalence and characteristics of drug-drug interactions (DDIs) during a one-year period after hospital admission in older people, and associated risk factors. Methods We conducted a sub-study of the European OPERAM trial (OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people), which assessed the effects of a structured medication review (experimental arm) compared to usual care (control arm) on reducing drug-related hospital readmissions. All OPERAM patients (≥70 years, with multimorbidity and polypharmacy, hospitalized in four centers in Bern, Brussels, Cork and Utrecht between December 2016 and October 2018, followed over 1 year) who were alive at hospital discharge and had full medication data during the index hospitalization (at baseline i.e., enrolment at admission, and at discharge) were included. DDIs were assessed using an international consensus list of potentially clinically significant DDIs in older people. The point-prevalence of DDIs was evaluated at baseline, discharge, and at 2, 6 and 12 months after hospitalization. Logistic regression models were performed to assess independent variables associated with changes in DDIs 2 months after baseline. Results Of the 1950 patients (median age 79 years) included, 1045 (54%) had at least one potentially clinically significant DDI at baseline; point-prevalence rates were 58, 57, 56 and 57% at discharge, and 2, 6 and 12 months, respectively. The prevalence increased significantly from baseline to discharge (P P for trend .31). The five most common DDIs –all pharmacodynamic in nature– accounted for 80% of all DDIs and involved drugs that affect potassium concentrations, centrally-acting drugs and antithrombotics. At 2 months, DDIs had increased in 459 (27%) patients and decreased in 331 (19%). The main factor predictive of a change in the prevalence of DDIs was hyperpolypharmacy (≥10 medications). Conclusions DDIs were very common; their prevalence increased during hospitalization and tended to remain stable thereafter. Medication review may help control this increase and minimize the risk of adverse drug events.

WHAT IS KNOWN AND OBJECTIVE Prescribing errors are the leading cause of adverse drug events in hospitalized patients. Pharmaceutical validation, defined as the review of drug orders by a pharmacist, associated with clinical decision support (CDS) systems, significantly reduces these errors and adverse drug events. In Belgium, because clinical pharmacy services have limited public financial support, most pharmaceutical validations are performed at the central pharmacy instead of on-ward, by hospital pharmacists doing dispensing activities. In that context, we aimed at evaluating whether the strategy of CDS-guided central validation was the most appropriate method to improve the quality and safety of medicines' use compared to an on-ward pharmaceutical validation. METHODS Our retrospective observational study was conducted in a Belgian tertiary care hospital, in 2018-2019. Data were extracted from our validation software and pharmacists' charts. The outcomes of the study were the number of pharmaceutical interventions due to the detection of prescribing errors, reasons for interventions, their acceptance rate and their potential clinical impact (according to two blinded experts) in the central pharmacy and on-ward validation groups. RESULTS AND DISCUSSION Despite the use of the same CDS, a pharmaceutical intervention following the detection of a prescribing error was made for 2.9% (20/698) of central group patients and 13.3% (93/701) of on-ward patients (χ2 = 49.97, p

Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.

BACKGROUND Drug-drug interactions (DDIs) involving vitamin K antagonists (VKAs) constitute an important cause of in-hospital morbidity and mortality. However, the list of potential DDIs is long; the implementation of all these interactions in a clinical decision support system (CDSS) results in over-alerting and alert fatigue, limiting the benefits provided by the CDSS. OBJECTIVE To estimate the probability of occurrence of international normalized ratio (INR) changes for each DDI rule, via the reuse of electronic health records. METHODS An 8-year, exhaustive, population-based, historical cohort study including a French community hospital, a group of Danish community hospitals, and a Bulgarian hospital. The study database included 156,893 stays. After filtering against two criteria (at least one VKA administration and at least one INR laboratory result), the final analysis covered 4047 stays. Exposure to any of the 145 drugs known to interact with VKA was tracked and analyzed if at least 3 patients were concerned. The main outcomes are VKA potentiation (defined as an INR≥5) and VKA inhibition (defined as an INR≤1.5). Groups were compared using the Fisher exact test and logistic regression, and the results were expressed as an odds ratio (95% confidence limits). RESULTS The drugs known to interact with VKAs either did not have a statistically significant association regarding the outcome (47 drug administrations and 14 discontinuations) or were associated with significant reduction in risk of its occurrence (odds ratio CONCLUSIONS The probabilities of outcomes obtained were not those expected on the basis of our current body of pharmacological knowledge. The results do not cast doubt on our current pharmacological knowledge per se but do challenge the commonly accepted idea whereby this knowledge alone should be used to define when a DDI alert should be displayed. Real-life probabilities should also be considered during the filtration of DDI alerts by CDSSs, as proposed in SPC-CDSS (statistically prioritized and contextualized CDSS). However, these probabilities may differ from one hospital to another and so should probably be calculated locally.

Background and importance According to the WHO, care associated infections (CAIs) affect at least 2 million patients worldwide annually. In this African country, common CAIs are surgery site infections (SSI; 24.7% among inpatients in the south of the country). To prevent SSIs, appropriate use of antibiotics is essential. Aim and objectives To audit compliance with international recommendations of antibioprophylaxis practices in visceral surgery. Material and methods Data were prospectively collected in visceral surgery wards of five hospitals. Compliance with the antibiotic indication (administered when needed and not administered when not required), choice of molecule, dosage, timing of administration and duration were assessed in patients admitted for class 1 or 2 surgery according to Altemeier’s classification over 4 months. The international recommendation on antibiotic prophylaxis described by the SFAR (Societe Francaise d’ Anesthesie et Reanimation)1 was considered as a reference. Statistical analysis was performed using SPSS software. Results A total of 71 interventions were included the study. In 50 cases (70.4%), the administration conformed to the indication criteria (ie, 48 administrations when actually indicated and 2 abstentions when antibioprophylaxis was not required). None (0%) of the 48 patients who received the indicated antibioprophylaxis were administered the recommended molecule. Ceftriaxone was the most widely used molecule (31%). In addition, the initial dose, timing and duration of antibiotic treatment were in accordance with SFAR standards in 35%, 14% and 21% of cases, respectively. Conclusion and relevance This study highlights a problem of compliance with recommendations. This can be partly explained by the unavailability of half of the recommended molecules in the local market, the urgent character of the surgery and the lack of knowledge and training of health staff. The overuse of broad spectrum antibiotics reported in other studies may reveal a fear of SSIs by healthcare providers. These data underline the need for implementing an appropriate antibioguide based on local epidemiology and drug availability. References and/or acknowledgements 1. SFAR. Antibioprophylaxie en chirurgie et medecine interventionnelle. Reactualisation 2018;2018:1–31 [En ligne] www.cpias.fr/nosobase/.../Antibioprophylaxie-RFE-mise-a-jour-2018.pdf We thank the Academie de Recherche et d’Enseignement Superieur (ARES) for funding this work. No conflict of interest.

Aims To determine the preventability of serious adverse drug reactions (ADRs) related to the use of direct oral anticoagulants (DOACs), and to explore contributing factors to preventable ADRs. Results were compared with vitamin K antagonists (VKAs). Methods We conducted a prospective observational study in the emergency departments of two teaching hospitals from July 2015 to January 2016. Patients admitted with a thrombotic or bleeding event while under DOAC or VKA were included. Four independent reviewers assessed causality, seriousness and preventability of ADRs using pilot-tested scales. For cases of serious and potentially preventable ADRs, we performed semi-structured interviews with general practitioners to identify contributing factors to ADRs. The primary outcome was the proportion of serious ADRs that were potentially preventable. Results The analysis included 46 DOAC and 43 VKA patients (median age 79 years). Gastrointestinal (n = 34) and intracranial (n = 16) bleedings were the most frequent ADRs. Results were that 53% of DOAC- and 61% of VKA-related serious ADRs were deemed potentially preventable. Prescribing issues and inadequate monitoring were frequent for DOAC and VKA respectively. We identified many causes of preventable ADRs that applied to all oral anticoagulants, such as pharmacodynamic drug interactions and lack of communication. Conclusions More than half of serious ADRs were potentially preventable for both DOACs and VKAs. Interventions focusing on prescribing, patient education and continuity of care should help improve the use of DOACs in practice.