Real-world assessment of drug related problems by medication reviews at the emergency department in older patients living with frailty

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Identifying DRPs with medication reviews is typically evaluated in restrictive clinical studies and not in a ‘real-world’ setting with organizational challenges and time-pressure. This study aims to assess the number of DRPs at the ED in older patients living with frailty, and to determine the acceptance rate of medication recommendations among physicians and the general practitioner. Additionally, practical recommendations are provided for implementing a medication review program. Methods A retrospective observational study was performed in patients ≥ 70 years living with frailty who visited the ED at Tergooi Medical Center. Medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. Also, the acceptance rate of given recommendations was assessed. Results A total of 356 ED visits were included. The mean age of patients was 83 years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients. Conclusions Our results show that medication reviews lead to better assessment of DRPs at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients. Results of our study reflect the real-life setting of conducting medication reviews at the ED for older patients living with frailty. 1. Background Adverse drug events and medication errors are important causes of emergency department (ED) visits [ 1 ]. Especially older patients are at risk of adverse drug events, hospital visits and admissions [ 2 ]. This may be due to multi-morbidities, polypharmacy and cognitive and functional decline which may influence correct use or their medications [ 2 ]. In addition, the risk of hospital-associated disability is greater in older patients [ 3 ]. This condition is defined as a loss of independence in activities of daily life following hospitalization and it affects the quality-of-life after hospital discharge. About 10% of unplanned ED visits of older patients is drug-related, of which 5% could potentially be avoided [ 4 ]. Drug-related problems (DRPs) are associated with increased healthcare costs and hospital admissions. Therefore, identifying DRPs needs consideration, especially in older patients. There are several strategies to identify DRPs in admitted patients [ 5 ], among which medication review programs. Medication review is a structured and critical evaluation of patient’s medicines with the aim to improve health outcomes [ 6 ]. Previous studies have shown the effect of in-hospital medication reviews on readmission, length of hospital stay and mortality. Although the effect on mortality was limited [ 7 ], studies have shown shorter lengths of hospital stay, fewer ED visits, increased patients satisfaction and lower healthcare costs [ 7 – 10 ]. To date, the effect of in-hospital medications reviews is well studied, but the effect of medication reviews for older patients with frailty at the ED is not. Despite the high number of drug-related ED visits and the high-risk which comes with transition of care to hospital treatment. This may be due to organizational challenges caused by the hectic environment and short ED stay. As the older patient at the ED is more prone to adverse events, it is anticipated that ED medication reviews could be beneficial for older patients. The Dutch multidisciplinary guideline on polypharmacy in older patients (≥ 70 years) and the Dutch geriatric guideline advocate medication reviews for older patients with polypharmacy (≥ 5 drugs) visiting the ED [ 11 ]. To comply with current guidelines, pharmacists at Tergooi medical center (MC) started conducting medication reviews at the ED for older patients (≥ 70 years) living with frailty as part of a larger geriatric team. In this retrospective observational study, results of these medication reviews were analysed. The aims of this study are to assess the number and type of DRPs at the ED in older patients living with frailty, and to determine the acceptance rate of recommendations among clinical physicians, general practitioners and elderly care specialists. The novelty of this study lies in the ‘real-world’ setting with organizational challenges and time-pressure. Additionally, with our acquired experience, we provide suggestions for implementing a medication review program. 1. Methods 2.1 Geriatric assessment A retrospective observational study was performed at the ED of the TergooiMC, The Netherlands. Medication reviews were performed as part of a larger geriatric assessment in routine care. This geriatric assessment was as follows: patients aged 70 years or older who visited the ED were screened for the need of geriatric co-management. Screening criteria for frailty were: presence of a cognitive disorder, presence of delirium, fall or collaps prior to ED visit or an expected care problem at discharge of the ED [ 12 ]. The ED nurse could also indicate, based on her clinical experience, the patient to be frail and the co-management of the geriatric team desirable. When one of these factors was present, the patient was seen by an advanced nurse practitioner (ANP) or physician of the geriatric department in partnership with the ED-physician. For older patients living with frailty, the pharmacist technician identified the current medication profile by talking to the patient or family members at the ED, and by consulting the medical history from the electronic patient management system. This medication profile formed the basis of the pharmacist-led medication review. The trigger tool (supplementary Table 1), Screening Tool to Alert to Right Treatment (START)- and Screening Tool of Older Persons' Prescriptions (STOPP)-criteria, Ephor, and multidisciplinary guidelines were used in the medication review for identifying DRPs [ 11 , 13 – 15 ]. DRPs were defined as any undesirable event related to medication use, and included medication errors and adverse events [ 16 ]. Potential DRPs were evaluated with the ANP or the supervising geriatrician, and relevant DRPs were documented in the electronic patient management system. For patients who were admitted to the hospital after ED visit, follow-up was performed by the treating physician. For patients directly discharged from the ED, medication recommendations were sent to the general practitioner or elderly care specialist via a discharge letter. To follow-up on recommended interventions, within six months after ED visit, patients’ general practitioners or elderly care specialists were contacted by mail. In case of no response, the physician was contacted by phone. 2.2 Study population Patients ≥ 70 years or older who visited the emergency department during the study period (7 May 2020 to 31 December 2020) and positively screened for frailty were included. Shockroom patients and suicide attempts were excluded. 2.3 Data collection The reason for ED visit and DRPs, including pharmacists’ recommendations, were collected from the electronic patient management system. The Pharmaceutical Care Network Europe (PCNE) classification system was used to classify problems (e.g., treatment effectiveness or treatment safety) and causes (e.g., no indication for a drug, drug dose too high or duration or treatment too long) [ 6 ]. In this classification system, problems with treatment effectiveness were defined as a (potential) problem with the (lack of) effect of the pharmacotherapy, and problems with treatment safety were defined as the suffering of a patient from an adverse drug event. Anatomical therapeutic chemical (ATC) codes given by the World Health Organization (WHO) Collaboration Centre for drug statistics methodology were used to define treatment domains [ 17 ]. The acceptance of recommendations rate among clinical physicians, general practitioners and elderly care specialists were determined. The acceptance rate was defined as the proportion of patients for whom at least one of the recommendations was accepted by the treating physician. A distinction was made between acceptance rate of clinical physicians and general practitioners/elderly care specialists. For patients who were admitted following the ED visit, the electronic patient management system was reviewed. For patients discharged from the ED, the discharge letter and follow-up report were reviewed. 2.4 Outcome measures The primary objective in this study was to measure the prevalence and type of DRPs among a group of older patients living with frailty visiting the ED by performing medication reviews. The second objective was to determine the acceptance rate of recommendations proposed by the clinical pharmacist among clinical physicians and general practitioners and elderly care specialists. 2.5 Statistical analyses Data were analysed using R, version 4.0.0. Categorical variables were expressed as counts with corresponding percentages, and continuous data were expressed as mean and standard deviation. The prevalence of DRPs and acceptance rate were reported using descriptive statistics. 2. Results 3.1 Patients We included 356 ED visits of older people living with frailty in our study. Demographic and drug-related patient characteristics are shown in Table 1 . Data are presented for the total population, and for patients with or without DRPs separately. 22 Patients were admitted to the ED twice during the study period and both admissions were included in data analyses. Interventions were recommended for nearly 70% of ED visits. The majority of patients were admitted to the hospital after presentation at the ED (n = 233, 66%). A fracture or fall was the main reason for ED visits (n = 192, 54%). Table 1 Demographic and drug-related patient characteristics (n = 356). Values are reported in number (n) and %, unless otherwise specified. Variable n (%) ≥ 1 DRP n (%) 0 DRPs n (%) Emergency department visits 356 (100) 270 (76) 86 (24) Age, mean (SD) 83 (6.8) 83 (6.8) 82 (6.5) Sex Male Female 139 (39) 217 (61) 105 (39) 165 (61) 34 (40) 52 (60) Number of medications per patient, mean (SD) 8 (4.7) 9 (4.5) 5 (4.0) Polypharmacy 158 (45) 127 (47) 31 (36) Cause of emergency department visit Bleeding 14 (3.9) 13 (4.8) 1 (1.2) Vomit/diarrhea 7 (2.0) 6 (2.2) 1 (1.2) Collapse/hypotension/vertigo 9 (2.5) 9 (3.3) 0 Delirium/confused/drowsy 11(3.1) 11 (4.1) 0 Electrolyte disturbances/dehydration 7 (2.0) 6 (2.2) 1 (1.2) Fracture/fall 192 (54) 142 (53) 50 (58) Heart failure 1 (0.3) 0 (0) 1 (1.2) Kidney failure 1 (0.3) 1 (0.4) 0 Obstipation/ileus 2 (0.6) 2 (0.7) 0 Disrupted blood glucose levels 2 (0.6) 2 (0.7) 0 Other † 110 (31) 78 (29) 32 (37) Hospital admission Yes No 233 (66) 123 (35) 181 (67) 89 (33) 52 (60) 34 (40) Number of DRPs No DRP 1 DRP 2 DRPs ≥3 DRPs 1.5 (1.3) 86 (24) 104 (29) 95 (27) 71 (20) 2.0 (1.1) NA 104 (38) 95 (36) 71 (26) NA NA NA NA NA † This category includes others infections, dyspnea (due to COVID-19) and unbearable pain. Declarations Declarations Ethics approval and consent to participate The study was approved by the Institutional Research Board (IRB) of TergooiMC (study number 22.36). The need for patient consent was waived by the IRB of TergooiMC, as it was a retrospective analysis. All methods were performed according to the relevant guidelines and regulations. Consent for publication Not applicable Declarations Competing interests The authors have no relevant financial or non-financial interests to disclose. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author contributions Conceptualization: MvN, MB; methodology: MvN, MB, PvdL; investigation: MVN, KV, FB; writing—original draft preparation, MVN; writing—review and editing: MB, KV, FB, VMH, AdJ, PvdL; supervision, MB, PvdL. All authors have read and agreed to the published version of the manuscript. 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Drugs Aging. 2014;31:471–81. Ravn-Nielsen LV, Duckert M-L, Lund ML, Henriksen JP, Nielsen ML, Eriksen CS, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial. JAMA Intern Med. 2018;178:375–82. Chiu P, Lee A, See T, Chan F. Outcomes of a pharmacist-led medication review programme for hospitalised elderly patients. Hong Kong medical journal. 2018;24:98–106. Unsectioned Paragraphs ORCID account: 0000-0003-1763-7334 Total number of words: 4742 Number of words abstract: 243 Number of Tables: 3 Number of Figures: 0 Number of references: 21 Abbreviations: DRP = drug related problem, NA = not applicable, SD = standard deviation. 3.2 Prevalence of DRPs A total of 548 DRPs were identified, with a mean (standard deviation, SD) of 1.5 (1.3) DRPs per patient. The mean time for performing a medication review was 10 minutes per patient. Demographic and drug-related characteristics are shown in Table 1. The majority of included patients had at least 1 DRP. The most common problem was treatment safety (44%), followed by treatment effectiveness (31%), and unnecessary treatment (20%). Causes of DRPs are presented in Table 2. From the total of 548 DRPs, the most common causes were inappropriate drug selection (72%), and dose selection (18%). Within the group of inappropriate drug selection, the most common cause was the absence of an indication (25%), followed by no treatment for the indication (14%), and drug selection according to the guidelines but contra-indicated (13%). In the group of inappropriate drug selection, the majority of DRPs were caused by drug doses being too high (9.3%), and by too frequent dosing regimens (4.6%). † This category includes, among other causes, considering a fixed dose combination and allergy registration in the electronic patient management system. Abbreviation: TDM = therapeutic drug monitoring 3.3 Treatment domains of DRPs Table 3 represents the distribution of the most common DRP causes per ATC group. The most frequently involved class of drugs differed per DRP cause. Within the group of inappropriate drugs according to guidelines (C1.1), the majority of drugs affected the nervous system (n = 41; 66%) including interventions such as stopping of tramadol and oxazepam. For the group of contra-indicated drugs (C1.2), the most common ATC group involved the cardiovascular system (n = 35; 49%). In this group, the majority of patients experienced falls while using multiple antihypertensive agents, or electrolyte imbalance during diuretic use. For drugs without an indication (C1.3), the majority of drugs affected the alimentary tract and metabolism (n = 82, 59%) which mainly involved redundant use of a proton-pump inhibitor. In the DRP group with no treatment for indication (C1.6), most drugs affected the alimentary tract and metabolism (n = 28, 37%). Here, recommended interventions included for instance the absence of vitamin D supplementation and use of laxatives during opioid treatment. Within the group of too many drugs for an indication (C1.7), the most common ATC group involved the cardiovascular system (n = 32; 91%) due to falls or low blood pressure while using multiple antihypertensive agents. For the group of inappropriate dose selection (C3), the majority of drugs affected the nervous system (n = 33; 34%). The majority of these patients received a total dose paracetamol of 4000 mg/day for chronic use instead of 3000 mg/day. In the DRP group with inadequate treatment duration (C4), the most common ATC group involved the genitourinary system (n = 13; 42%) caused by long-term tamsulosin use without previous stop attempts. † This category includes, among other causes, the absence of therapeutic drug monitoring or the use of controlled-release tablets instead of immediate release tablets. 3.4 Acceptance rates After ED visit, 169 patients with at least one DRP were admitted to the hospital. Recommended interventions were accepted by the clinical physician for 93 patients (55%) and recommendations were documented in the discharge letter to primary care for 61 patients (36%) upon discharge. Of 86 patients being discharged directly from the ED with at least one DRP, recommended interventions were included in the discharge letter to the general practitioner or elderly care specialist for 47 patients (55%). The acceptance rate of these recommendations was 32% (15 out of 47). Five patients passed away during the follow-up period. Discussion In this ’real-world’ study, 548 DRPs were identified in older patients living with frailty visiting the ED with a mean of 1.5 DRP per patient. Of identified patients, 86 patients (24%) had no DRPs, 104 patients (29%) had 1 DRP, 95 patients (27%) had 2 DRPs and 71 patients (20%) had at least 3 DRPs. The majority of DPRs were caused by inappropriate drug selection (72%) and dose selection (18%) with a diffuse distribution per ATC group. The acceptance rate or recommended interventions among clinical physicians was 55% compared to 32% among general practitioner and elderly care specialists. The prevalence of DRPs in this study was 76%. Similar percentages have been described in literature. In older patients admitted to the medical and surgical wards, DRPs were identified in 82% of patients [ 18 ]. The same percentage of 82% was found in patients ≥ 65 years visiting the ED [ 19 ]. Furthermore, the mean number of DRPs per patient was comparable [ 19 ]. These results show that by practical implementation of a medication review program at the ED, comparable DRP rates are found as in interventional trials. The acceptance rate of recommendations among general practitioners for older patients at the ED varies in clinical trials from 27–66% [ 8 , 20 ]. In admitted patients with at least one recommendation, the acceptance rate among clinical physicians varies from 55–66% [ 19 , 21 ]. In our study, the acceptance rate of recommendations among general practitioners and elderly care specialists was low (32%). This could have several explanations. First, general practitioners received recommendations via discharge letter. To our surprise, only 55% of recommendations were included in discharge letters, meaning that almost half of the DRPs were not brought to the attention of the general practitioner or elderly care specialist. This may be due to a preselection of relevant DRPs in the discharge letter by the ANP or geriatrician, or because the recommendations simply got lost in follow-up. Second, general practitioners and elderly care specialists were not informed about the geriatric assessment including a medication review, while clinical physicians were. Third, general practitioners may know of treatment indications that are unknown in the clinical setting, such as nervousness, for which medications need to be continued. A strength of this study is selection of the study population, as older patients living with frailty are prone to experiencing DRPs. Furthermore, results of this study show the prevalence and type of DRPs in a “real-life” setting of conducting medication reviews at the ED. Another strength of this study was the identification of acceptance rate in admitted patients and in patients being discharged from the ED, as most studies do not determine the acceptance rate for both patient groups. This study also has some limitations. As described, the acceptance rate for discharged patients was low. Moreover, the geriatric assessment suffered from restrictions during the Covid-19 pandemic, as general practitioners were under high pressure and workload. Additionally, the impact of medication reviews at the ED was not investigated related to clinical outcome measures. Practical recommendations We provide the following suggestions for implementing a medication review program at the ED or other departments by which we hope to stimulate other healthcare professionals to start similar projects. Before implementation, inform the surrounding healthcare network about the medication review program. This includes clinical physicians, general practitioners, elderly care specialists and pharmacists at a public pharmacy. This way, recommendations will have more support and this could potentially improve acceptance rates. Our project clearly benefited from the close collaboration with the geriatric department, resulting in higher acceptance rates in admitted patients. Select older patients living with frailty for medication reviews rather than older patients (≥ 70 years) with polypharmacy (≥ 5 drugs) as described in guidelines. Performing medication reviews is time-consuming and by adequate patient selection, the efficacy of the review process may be improved. Furthermore, vulnerable patient populations are more prone to experiencing DRPs. Include medication reviews in daily routine, as such that it is a time-efficient process done by a group of pharmacists routinely. In our experience, conducting medication reviews could be easily implemented in routine care and was well received amongst physicians. Educate treating physicians so they know what type of DRPs are often seen at your hospital. In our study, we identified drug classes that often cause DRPs at the emergency department and presented those to physicians regularly. As a result, at the end of the study period, common DRPs were already identified by the physician before the pharmacists’ consultation. If possible, include pharmacist-led patient interviews in the medication review process to identify medication related problems and patients’ experiences and wishes. This may further eliminate harmful medication use. Optimize transfer of (information about) medication recommendations in the discharge letter by including accepted and yet to be considered recommendations. Even more, we believe medication changes should be an integral part of the discharge letter, regardless of the reason for ED visit. Conclusion Our results show that pharmacy-led medication reviews in daily routine lead to better assessment of DRPs at the ED. Of included geriatric patients at the emergency department, 76% had at least one DRP, with a mean of 1.5 DRP per patient. The acceptance rate among clinical physicians in admitted patients was higher (55%) than the acceptance rate among general practitioners/ elderly care specialists in discharged patients (32%). Results of this study reflect the real-life setting of conducting medication reviews at the ED for older patients living with frailty. List of abbreviations ANP = advanced nurse practitioner ATC = anatomical therapeutic chemical DRP = drug related problem ED = emergency department PCNE = The Pharmaceutical Care Network Europe SD = standard deviation START STOPP criteria = Screening Tool to Alert to Right Treatment and Screening Tool of Older Persons' Prescriptions criteria WHO = world Health Organization Tables Table 1. Demographic and drug-related patient characteristics (n = 356). Values are reported in number (n) and %, unless otherwise specified. † This category includes others infections, dyspnea (due to COVID-19) and unbearable pain. Abbreviations: DRP = drug related problem, NA = not applicable, SD = standard deviation. Table 2. Causes of DRPs according to the Pharmaceutical Care Network Europe (PCNE) classification system. In total, 548 DRPs were identified during the study period. † This category includes, among other causes, considering a fixed dose combination and allergy registration in the electronic patient management system. Abbreviation: TDM = therapeutic drug monitoring Table 3. Distribution of causes of drug-related problems (DRPs) per anatomical therapeutic chemical (ATC) group. Numbers in bold are the highest values in each column. † This category includes, among other causes, the absence of therapeutic drug monitoring or the use of controlled-release tablets instead of immediate release tablets. Supplementary files Supplementary Table 1. Trigger tool to identify adverse events [ 11 ]. Abbreviations: ACE = angiotensine converting enzyme, AII = angiotensine II, INR = international normalized ratio, NSAIDs = non-steroidal anti-inflammatory drugs Unsectioned Tables Table 2 Causes of DRPs according to the Pharmaceutical Care Network Europe (PCNE) classification system. In total, 548 DRPs were identified during the study period. Cause n (%) C1: Drug selection 394 (72) C1.1 Inappropriate drug according to guidelines 62 (11) C1.2 According to guidelines but contra-indicated 71 (13) C1.3 No indication for drug 139 (25) C1.4 Inappropriate combination of drug, or drugs and food 2 (0.4) C1.5 Inappropriate duplication of therapeutic group or active ingredient 10 (1.8) C1.6 No treatment for indication 75 (14) C1.7 Too many drugs for indication 35 (6.4) C2: Drug form 0 (0) C2.1 Inappropriate drug form 0 (0) C3: Dose selection 97 (18) C3.1 Drug dose too low 12 (2.2) C3.2 Drug dose too high 51 (9.3) C3.3 Dose not frequent enough 5 (0.9) C3.4 Dose too frequent 25 (4.6) C3.5 Dosing time is wrong, unclear or missing 4 (0.7) C4: Treatment duration 31 (5.7) C4.1 Duration of treatment too short 0 (0) C4.2 Duration of treatment too long 31 (5.7) C5: Dispensing 0 (0) C6: Drug use 0 (0) C7: Patient related 5 (0.9) C7.1 Patient takes less or none of the drug 3 (0.5) C7.8 Patient administered/uses drug in a wrong way 2 (0.4) C8: Other causes † 21 (3.8) C8.1 No or inappropriate outcome monitoring (TDM) 7 (1.3) C8.2 Other cause 14 (2.6) Table 3 Distribution of causes of drug-related problems (DRPs) per anatomical therapeutic chemical (ATC) group. Numbers in bold are the highest values in each column. Drug selection (C1) Dose selection (C3) Treatment duration (C4) Patient related (C7) Other causes (C8) † Inappropriate drug according to guidelines (C1.1) Contra-indicated (C1.2) No indication for drug (C1.3) No treatment for indication (C1.6) Too many drugs for indication (C1.7) n = 62 n = 71 n = 139 n = 75 n = 35 n = 97 n = 31 n = 5 n = 21 ATC group Alimentary tract and metabolism (ATC group A) 3 6 82 28 22 1 1 1 Blood and blood-forming organs (ATC group B) 1 4 8 6 11 7 1 Cardiovascular system (ATC group C) 6 35 25 3 32 17 1 7 Genitourinary system and reproductive hormones (ATC group G) 2 13 1 Systemic hormonal preparations excluding reproductive hormones and insulin (ATC group H) 1 1 5 1 Anti-infective agents for systemic use (ATC group J) 1 2 2 1 2 2 Antineoplastic and immunomodulating agents (ATC group L) 1 2 1 1 Musculoskeletal system (ATC group M) 3 11 2 20 1 2 Nervous system (ATC group N) 41 8 9 8 1 33 1 6 Respiratory system (ATC group R) 3 5 2 7 2 Various (ATC group V) 4 1 3 2 2 4 4 1 3 Variable n (%) ≥ 1 DRP n (%) 0 DRPs n (%) Emergency department visits 356 (100) 270 (76) 86 (24) Age, mean (SD) 83 (6.8) 83 (6.8) 82 (6.5) Sex Male Female 139 (39) 217 (61) 105 (39) 165 (61) 34 (40) 52 (60) Number of medications per patient, mean (SD) 8 (4.7) 9 (4.5) 5 (4.0) Polypharmacy 158 (45) 127 (47) 31 (36) Cause of emergency department visit Bleeding 14 (3.9) 13 (4.8) 1 (1.2) Vomit/diarrhea 7 (2.0) 6 (2.2) 1 (1.2) Collapse/hypotension/vertigo 9 (2.5) 9 (3.3) 0 Delirium/confused/drowsy 11(3.1) 11 (4.1) 0 Electrolyte disturbances/dehydration 7 (2.0) 6 (2.2) 1 (1.2) Fracture/fall 192 (54) 142 (53) 50 (58) Heart failure 1 (0.3) 0 (0) 1 (1.2) Kidney failure 1 (0.3) 1 (0.4) 0 Obstipation/ileus 2 (0.6) 2 (0.7) 0 Disrupted blood glucose levels 2 (0.6) 2 (0.7) 0 Other † 110 (31) 78 (29) 32 (37) Hospital admission Yes No 233 (66) 123 (35) 181 (67) 89 (33) 52 (60) 34 (40) Number of DRPs No DRP 1 DRP 2 DRPs ≥3 DRPs 1.5 (1.3) 86 (24) 104 (29) 95 (27) 71 (20) 2.0 (1.1) NA 104 (38) 95 (36) 71 (26) NA NA NA NA NA Cause n (%) C1: Drug selection 394 (72) C1.1 Inappropriate drug according to guidelines 62 (11) C1.2 According to guidelines but contra-indicated 71 (13) C1.3 No indication for drug 139 (25) C1.4 Inappropriate combination of drug, or drugs and food 2 (0.4) C1.5 Inappropriate duplication of therapeutic group or active ingredient 10 (1.8) C1.6 No treatment for indication 75 (14) C1.7 Too many drugs for indication 35 (6.4) C2: Drug form 0 (0) C2.1 Inappropriate drug form 0 (0) C3: Dose selection 97 (18) C3.1 Drug dose too low 12 (2.2) C3.2 Drug dose too high 51 (9.3) C3.3 Dose not frequent enough 5 (0.9) C3.4 Dose too frequent 25 (4.6) C3.5 Dosing time is wrong, unclear or missing 4 (0.7) C4: Treatment duration 31 (5.7) C4.1 Duration of treatment too short 0 (0) C4.2 Duration of treatment too long 31 (5.7) C5: Dispensing 0 (0) C6: Drug use 0 (0) C7: Patient related 5 (0.9) C7.1 Patient takes less or none of the drug 3 (0.5) C7.8 Patient administered/uses drug in a wrong way 2 (0.4) C8: Other causes † 21 (3.8) C8.1 No or inappropriate outcome monitoring (TDM) 7 (1.3) C8.2 Other cause 14 (2.6) Drug selection (C1) Dose selection (C3) Treatment duration (C4) Patient related (C7) Other causes (C8) † Inappropriate drug according to guidelines (C1.1) Contra-indicated (C1.2) No indication for drug (C1.3) No treatment for indication (C1.6) Too many drugs for indication (C1.7) n = 62 n = 71 n = 139 n = 75 n = 35 n = 97 n = 31 n = 5 n = 21 ATC group Alimentary tract and metabolism (ATC group A) 3 6 82 28 22 1 1 1 Blood and blood-forming organs (ATC group B) 1 4 8 6 11 7 1 Cardiovascular system (ATC group C) 6 35 25 3 32 17 1 7 Genitourinary system and reproductive hormones (ATC group G) 2 13 1 Systemic hormonal preparations excluding reproductive hormones and insulin (ATC group H) 1 1 5 1 Anti-infective agents for systemic use (ATC group J) 1 2 2 1 2 2 Antineoplastic and immunomodulating agents (ATC group L) 1 2 1 1 Musculoskeletal system (ATC group M) 3 11 2 20 1 2 Nervous system (ATC group N) 41 8 9 8 1 33 1 6 Respiratory system (ATC group R) 3 5 2 7 2 Various (ATC group V) 4 1 3 2 2 4 4 1 3 Trigger Potentially associated drug Fracture/fall Psychoactive drugs/corticosteroids/antihypertensive drugs Collapse/hypotension/dizziness Antihypertensive drugs/anti-arrhythmic drugs/ Psychoactive drugs Bleeding/increased INR Anticoagulants/thrombocyte aggregation inhibitors/NSAIDs Electrolyte imbalance/dehydration Diuretics/ACE-inhibitors/AII-inhibitors/NSAIDs/antidepressants drugs Renal insufficiency ACE-inhibitors/AII-inhibitors/NSAIDs Blood sugar imbalance Glucose-lowering drugs/ corticosteroids Heart failure NSAIDs Obstipation/ileus Opioids/calcium channel blockers Vomiting/diarrhea Antibiotics Delirium/ drowsiness Psychoactive drugs//antihypertensive drugs/ anti-arrhythmic drugs/alpha blockers/ benzodiazepines Additional Declarations No competing interests reported. Supplementary Files 221101TablesBMCgeriatrics.docx 221101SuppBMCgeriatrics.docx 221101SuppBMCgeriatrics.docx Cite Share Download PDF Status: Published Journal Publication published 05 Apr, 2023 Read the published version in BMC Geriatrics → Version 1 posted Editorial decision: Major revision 06 Feb, 2023 Reviews received at journal 05 Feb, 2023 Reviewers agreed at journal 24 Jan, 2023 Reviews received at journal 26 Dec, 2022 Reviewers agreed at journal 26 Nov, 2022 Reviewers invited by journal 17 Nov, 2022 Editor assigned by journal 13 Nov, 2022 Editor invited by journal 10 Nov, 2022 Submission checks completed at journal 10 Nov, 2022 First submitted to journal 02 Nov, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2230828","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":151026908,"identity":"0e357c02-8745-4e7c-922e-ab5104c43ea8","order_by":0,"name":"Merel van Nuland","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYPACCyBOPgBhMwPxA8JaJIA4LbEBriWBOC05hg1wPj4tujOSnz0ubJOQN2fP+f7g455aOX52BrYH+LSY3UgzN57ZJmG4s+ftxsYZz44bSzYzsBvg1XLmgJk0b5sE44YbuRubeQ4cS9xwmIFNAr+W499AWuw33Mh52PyHKC3He8C2JAK1MDYzHKghSkuZNM85ieQNZ54Zzuw5cADoF8Y2/FoOs2+T5imzsd1wPPnBhx8H6uT4+Q8fk/iARws6OAzEjA0kaGBgqCNJ9SgYBaNgFIwMAADIwlCHVtQL1QAAAABJRU5ErkJggg==","orcid":"","institution":"Tergooi MC","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Merel","middleName":"van","lastName":"Nuland","suffix":""},{"id":151026909,"identity":"10d079ac-f447-44af-af47-a76266078134","order_by":1,"name":"Madelon Butterhoff","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Madelon","middleName":"","lastName":"Butterhoff","suffix":""},{"id":151026910,"identity":"543da232-408d-4346-b4e2-b76b85696a28","order_by":2,"name":"Karin Verwijmeren","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Verwijmeren","suffix":""},{"id":151026911,"identity":"3b265789-6db7-4d8d-a450-9967bb05304e","order_by":3,"name":"Florine Berger","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Florine","middleName":"","lastName":"Berger","suffix":""},{"id":151026912,"identity":"d219c4a8-e611-4b2e-8955-7686c0b80034","order_by":4,"name":"Vera M. Hogervorst","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vera","middleName":"M.","lastName":"Hogervorst","suffix":""},{"id":151026913,"identity":"5eb97b17-ad27-47bc-9060-0c4adeb605cd","order_by":5,"name":"Annemarieke de Jonghe","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Annemarieke","middleName":"","lastName":"de Jonghe","suffix":""},{"id":151026914,"identity":"a95383ba-8605-4b79-abfd-6102180e58fc","order_by":6,"name":"Paul van der Linden","email":"","orcid":"","institution":"Tergooi MC","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Paul","middleName":"van der","lastName":"Linden","suffix":""}],"badges":[],"createdAt":"2022-11-02 15:14:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2230828/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2230828/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12877-023-03942-x","type":"published","date":"2023-04-05T20:23:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":44724312,"identity":"e4d775fe-7bc5-4fa3-b911-b3f7300187dd","added_by":"auto","created_at":"2023-10-16 20:28:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":506392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2230828/v1/38b31b9d-e4c8-4a3b-b6a4-685ea18cae2c.pdf"},{"id":28987564,"identity":"b6458ebd-26fe-437f-8dbe-ea8eeb56e614","added_by":"auto","created_at":"2022-11-12 16:58:11","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":107992,"visible":true,"origin":"","legend":"","description":"","filename":"221101TablesBMCgeriatrics.docx","url":"https://assets-eu.researchsquare.com/files/rs-2230828/v1/ea558fadc9718169e19ee928.docx"},{"id":28987565,"identity":"29cfc9a9-ba2d-4dba-a6b4-40bd31c3c698","added_by":"auto","created_at":"2022-11-12 16:58:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":89665,"visible":true,"origin":"","legend":"","description":"","filename":"221101SuppBMCgeriatrics.docx","url":"https://assets-eu.researchsquare.com/files/rs-2230828/v1/164fe4c623fef32091c0be68.docx"},{"id":28987566,"identity":"d3d8e3e9-1880-4392-a55d-df2dbc3e9564","added_by":"auto","created_at":"2022-11-12 16:58:12","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":89665,"visible":true,"origin":"","legend":"","description":"","filename":"221101SuppBMCgeriatrics.docx","url":"https://assets-eu.researchsquare.com/files/rs-2230828/v1/6b76b1363a2b9d87558a7846.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Real-world assessment of drug related problems by medication reviews at the emergency department in older patients living with frailty","fulltext":[{"header":"1. Background","content":"\u003cp\u003eAdverse drug events and medication errors are important causes of emergency department (ED) visits [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Especially older patients are at risk of adverse drug events, hospital visits and admissions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This may be due to multi-morbidities, polypharmacy and cognitive and functional decline which may influence correct use or their medications [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In addition, the risk of hospital-associated disability is greater in older patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This condition is defined as a loss of independence in activities of daily life following hospitalization and it affects the quality-of-life after hospital discharge. About 10% of unplanned ED visits of older patients is drug-related, of which 5% could potentially be avoided [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Drug-related problems (DRPs) are associated with increased healthcare costs and hospital admissions. Therefore, identifying DRPs needs consideration, especially in older patients.\u003c/p\u003e \u003cp\u003eThere are several strategies to identify DRPs in admitted patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], among which medication review programs. Medication review is a structured and critical evaluation of patient\u0026rsquo;s medicines with the aim to improve health outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous studies have shown the effect of in-hospital medication reviews on readmission, length of hospital stay and mortality. Although the effect on mortality was limited [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], studies have shown shorter lengths of hospital stay, fewer ED visits, increased patients satisfaction and lower healthcare costs [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. To date, the effect of in-hospital medications reviews is well studied, but the effect of medication reviews for older patients with frailty at the ED is not. Despite the high number of drug-related ED visits and the high-risk which comes with transition of care to hospital treatment. This may be due to organizational challenges caused by the hectic environment and short ED stay. As the older patient at the ED is more prone to adverse events, it is anticipated that ED medication reviews could be beneficial for older patients.\u003c/p\u003e \u003cp\u003eThe Dutch multidisciplinary guideline on polypharmacy in older patients (\u0026ge;\u0026thinsp;70 years) and the Dutch geriatric guideline advocate medication reviews for older patients with polypharmacy (\u0026ge;\u0026thinsp;5 drugs) visiting the ED [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. To comply with current guidelines, pharmacists at Tergooi medical center (MC) started conducting medication reviews at the ED for older patients (\u0026ge;\u0026thinsp;70 years) living with frailty as part of a larger geriatric team. In this retrospective observational study, results of these medication reviews were analysed. The aims of this study are to assess the number and type of DRPs at the ED in older patients living with frailty, and to determine the acceptance rate of recommendations among clinical physicians, general practitioners and elderly care specialists. The novelty of this study lies in the \u0026lsquo;real-world\u0026rsquo; setting with organizational challenges and time-pressure. Additionally, with our acquired experience, we provide suggestions for implementing a medication review program.\u003c/p\u003e"},{"header":"1. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Geriatric assessment\u003c/h2\u003e \u003cp\u003eA retrospective observational study was performed at the ED of the TergooiMC, The Netherlands. Medication reviews were performed as part of a larger geriatric assessment in routine care. This geriatric assessment was as follows: patients aged 70 years or older who visited the ED were screened for the need of geriatric co-management. Screening criteria for frailty were: presence of a cognitive disorder, presence of delirium, fall or collaps prior to ED visit or an expected care problem at discharge of the ED [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The ED nurse could also indicate, based on her clinical experience, the patient to be frail and the co-management of the geriatric team desirable. When one of these factors was present, the patient was seen by an advanced nurse practitioner (ANP) or physician of the geriatric department in partnership with the ED-physician. For older patients living with frailty, the pharmacist technician identified the current medication profile by talking to the patient or family members at the ED, and by consulting the medical history from the electronic patient management system. This medication profile formed the basis of the pharmacist-led medication review.\u003c/p\u003e \u003cp\u003eThe trigger tool (supplementary Table\u0026nbsp;1), Screening Tool to Alert to Right Treatment (START)- and Screening Tool of Older Persons' Prescriptions (STOPP)-criteria, Ephor, and multidisciplinary guidelines were used in the medication review for identifying DRPs [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. DRPs were defined as any undesirable event related to medication use, and included medication errors and adverse events [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Potential DRPs were evaluated with the ANP or the supervising geriatrician, and relevant DRPs were documented in the electronic patient management system. For patients who were admitted to the hospital after ED visit, follow-up was performed by the treating physician. For patients directly discharged from the ED, medication recommendations were sent to the general practitioner or elderly care specialist via a discharge letter. To follow-up on recommended interventions, within six months after ED visit, patients\u0026rsquo; general practitioners or elderly care specialists were contacted by mail. In case of no response, the physician was contacted by phone.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Study population\u003c/h2\u003e \u003cp\u003ePatients\u0026thinsp;\u0026ge;\u0026thinsp;70 years or older who visited the emergency department during the study period (7 May 2020 to 31 December 2020) and positively screened for frailty were included. Shockroom patients and suicide attempts were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Data collection\u003c/h2\u003e \u003cp\u003eThe reason for ED visit and DRPs, including pharmacists\u0026rsquo; recommendations, were collected from the electronic patient management system. The Pharmaceutical Care Network Europe (PCNE) classification system was used to classify problems (e.g., treatment effectiveness or treatment safety) and causes (e.g., no indication for a drug, drug dose too high or duration or treatment too long) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In this classification system, problems with treatment effectiveness were defined as a (potential) problem with the (lack of) effect of the pharmacotherapy, and problems with treatment safety were defined as the suffering of a patient from an adverse drug event. Anatomical therapeutic chemical (ATC) codes given by the World Health Organization (WHO) Collaboration Centre for drug statistics methodology were used to define treatment domains [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe acceptance of recommendations rate among clinical physicians, general practitioners and elderly care specialists were determined. The acceptance rate was defined as the proportion of patients for whom at least one of the recommendations was accepted by the treating physician. A distinction was made between acceptance rate of clinical physicians and general practitioners/elderly care specialists. For patients who were admitted following the ED visit, the electronic patient management system was reviewed. For patients discharged from the ED, the discharge letter and follow-up report were reviewed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Outcome measures\u003c/h2\u003e \u003cp\u003eThe primary objective in this study was to measure the prevalence and type of DRPs among a group of older patients living with frailty visiting the ED by performing medication reviews. The second objective was to determine the acceptance rate of recommendations proposed by the clinical pharmacist among clinical physicians and general practitioners and elderly care specialists.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Statistical analyses\u003c/h2\u003e \u003cp\u003eData were analysed using R, version 4.0.0. Categorical variables were expressed as counts with corresponding percentages, and continuous data were expressed as mean and standard deviation. The prevalence of DRPs and acceptance rate were reported using descriptive statistics.\u003c/p\u003e \u003c/div\u003e"},{"header":"2. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Patients\u003c/h2\u003e \u003cp\u003eWe included 356 ED visits of older people living with frailty in our study. Demographic and drug-related patient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Data are presented for the total population, and for patients with or without DRPs separately. 22 Patients were admitted to the ED twice during the study period and both admissions were included in data analyses. Interventions were recommended for nearly 70% of ED visits. The majority of patients were admitted to the hospital after presentation at the ED (n\u0026thinsp;=\u0026thinsp;233, 66%). A fracture or fall was the main reason for ED visits (n\u0026thinsp;=\u0026thinsp;192, 54%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and drug-related patient characteristics (n\u0026thinsp;=\u0026thinsp;356). Values are reported in number (n) and %, unless otherwise specified.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1 DRP\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 DRPs\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency department visits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e356 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e270 (76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e82 (6.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e139 (39)\u003c/p\u003e \u003cp\u003e217 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (39)\u003c/p\u003e \u003cp\u003e165 (61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34 (40)\u003c/p\u003e \u003cp\u003e52 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of medications per patient, mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (4.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolypharmacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e158 (45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCause of emergency department visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (4.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVomit/diarrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollapse/hypotension/vertigo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium/confused/drowsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElectrolyte disturbances/dehydration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture/fall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e142 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50 (58)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKidney failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstipation/ileus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisrupted blood glucose levels\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32 (37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital admission\u003c/p\u003e \u003cp\u003eYes\u003c/p\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e233 (66)\u003c/p\u003e \u003cp\u003e123 (35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (67)\u003c/p\u003e \u003cp\u003e89 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52 (60)\u003c/p\u003e \u003cp\u003e34 (40)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of DRPs\u003c/p\u003e \u003cp\u003eNo DRP\u003c/p\u003e \u003cp\u003e1 DRP\u003c/p\u003e \u003cp\u003e2 DRPs\u003c/p\u003e \u003cp\u003e\u0026ge;3 DRPs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (1.3)\u003c/p\u003e \u003cp\u003e86 (24)\u003c/p\u003e \u003cp\u003e104 (29)\u003c/p\u003e \u003cp\u003e95 (27)\u003c/p\u003e \u003cp\u003e71 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0 (1.1)\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003e104 (38)\u003c/p\u003e \u003cp\u003e95 (36)\u003c/p\u003e \u003cp\u003e71 (26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003e\u0026dagger;\u003c/span\u003e \u003c/sup\u003e \u003cem\u003eThis category includes others infections, dyspnea (due to COVID-19) and unbearable pain.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThe study was approved by the Institutional Research Board (IRB) of TergooiMC (study number 22.36). The need for patient consent was waived by the IRB of TergooiMC, as it was a retrospective analysis. All methods were performed according to the relevant guidelines and regulations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eDeclarations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor contributions\u003c/h2\u003e \u003cp\u003eConceptualization: MvN, MB; methodology: MvN, MB, PvdL; investigation: MVN, KV, FB; writing\u0026mdash;original draft preparation, MVN; writing\u0026mdash;review and editing: MB, KV, FB, VMH, AdJ, PvdL; supervision, MB, PvdL. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHohl CM, Woo SA, Cragg A, Wickham ME, Ackerley C, Scheuermeyer F, et al. Repeat adverse drug events associated with outpatient medications: a descriptive analysis of 3 observational studies in British Columbia, Canada. CMAJ open. 2019;7:E446\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDormann H, Sonst A, M\u0026uuml;ller F, Vogler R, Patapovas A, Pfistermeister B, et al. Adverse drug events in older patients admitted as an emergency: the role of potentially inappropriate medication in elderly people (PRISCUS). Deutsches Arzteblatt international. 2013;110:213\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReichardt LA, Aarden JJ, van Seben R, van der Schaaf M, Engelbert RHH, Bosch JA, et al. Unravelling the potential mechanisms behind hospitalization-associated disability in older patients; the Hospital-Associated Disability and impact on daily Life (Hospital-ADL) cohort study protocol. BMC Geriatr. 2016;16:59.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeendertse AJ, Egberts ACG, Stoker LJ, van den Bemt PMLA, HARM Study Group. Frequency of and risk factors for preventable medication-related hospital admissions in the Netherlands. Arch Intern Med. 2008;168:1890\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHatah E, Braund R, Tordoff J, Duffull SB. A systematic review and meta-analysis of pharmacist-led fee-for-services medication review. British Journal of Clinical Pharmacology. 2014. p.\u0026nbsp;102\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClassification for drug related problems. Pharmaceutical Care Network Europe. 2017.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConroy T, Heuzenroeder L, Feo R. In-hospital interventions for reducing readmissions to acute care for adults aged 65 and over: An umbrella review. Int J Qual health care: J Int Soc Qual Health Care. 2020;32:414\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantolaya-Perr\u0026iacute;n R, Calder\u0026oacute;n-Hernanz B, Jim\u0026eacute;nez-D\u0026iacute;az G, Gal\u0026aacute;n-Ramos N, Moreno-Carvajal MT, Rodr\u0026iacute;guez-Camacho JM, et al. The efficacy of a medication review programme conducted in an emergency department. Int J Clin Pharm. 2019;41:757\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomskaug R, Skovlund E, Straand J, Molden E, Kersten H, Pitkala KH, et al. Effect of Clinical Geriatric Assessments and Collaborative Medication Reviews by Geriatrician and Family Physician for Improving Health-Related Quality of Life in Home-Dwelling Older Patients Receiving Polypharmacy: A Cluster Randomized Clinical Trial. JAMA Intern Med. 2020;180:181\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriggs S, Pearce R, Dilworth S, Higgins I, Hullick C, Attia J. Clinical pharmacist review: a randomised controlled trial. Emerg Med Australasia: EMA. 2015;27:419\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDutch College of General Practitioners. Polyfarmacie bij ouderen [polypharmacy in elderly]. 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ: Can Med Association journal = journal de l\u0026rsquo;Association medicale canadienne. 2005;173:489\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGallagher P, Ryan C, Byrne S, Kennedy J, O\u0026rsquo;Mahony D. STOPP (Screening Tool of Older Person\u0026rsquo;s Prescriptions) and START (Screening Tool to Alert doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46:72\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eExpertisecentrum pharmacotherapie bij ouderen (EPHOR). [Internet]. [cited 2021 Nov 16]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ephorapp.nl/\u003c/span\u003e\u003cspan address=\"https://www.ephorapp.nl/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eClassen DC, Resar R, Griffin F, Federico F, Frankel T, Kimmel N, et al. \u0026ldquo;Global trigger tool\u0026rdquo; shows that adverse events in hospitals may be ten times greater than previously measured. Health Aff. 2011;30:581\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Bemt PM, Egberts TC, de Jong-van den Berg LT, Brouwers JR. Drug-related problems in hospitalised patients. Drug Saf. 2000;22:321\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWHO Collaborating Centre for Drug Statistics Methodology. ATC/DDD Index 2021. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHailu BY, Berhe DF, Gudina EK, Gidey K, Getachew M. Drug related problems in admitted geriatric patients: the impact of clinical pharmacist interventions. BMC Geriatr. 2020;20:13.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Sullivan D, O\u0026rsquo;Mahony D, O\u0026rsquo;Connor MN, Gallagher P, Cullinan S, O\u0026rsquo;Sullivan R, et al. The impact of a structured pharmacist intervention on the appropriateness of prescribing in older hospitalized patients. Drugs Aging. 2014;31:471\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRavn-Nielsen LV, Duckert M-L, Lund ML, Henriksen JP, Nielsen ML, Eriksen CS, et al. Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial. JAMA Intern Med. 2018;178:375\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiu P, Lee A, See T, Chan F. Outcomes of a pharmacist-led medication review programme for hospitalised elderly patients. Hong Kong medical journal. 2018;24:98\u0026ndash;106.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Unsectioned Paragraphs","content":"\u003cp\u003eORCID account: 0000-0003-1763-7334\u003c/p\u003e\u003cp\u003eTotal number of words: 4742\u003c/p\u003e\u003cp\u003eNumber of words abstract: 243\u003c/p\u003e\u003cp\u003eNumber of Tables: 3\u003c/p\u003e\u003cp\u003eNumber of Figures: 0\u003c/p\u003e\u003cp\u003eNumber of references: 21\u003c/p\u003e\u003cp\u003eAbbreviations: DRP\u0026thinsp;=\u0026thinsp;drug related problem, NA\u0026thinsp;=\u0026thinsp;not applicable, SD\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.2 Prevalence of DRPs\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA total of 548 DRPs were identified, with a mean (standard deviation, SD) of 1.5 (1.3) DRPs per patient. The mean time for performing a medication review was 10 minutes per patient. Demographic and drug-related characteristics are shown in Table\u0026nbsp;1. The majority of included patients had at least 1 DRP. The most common problem was treatment safety (44%), followed by treatment effectiveness (31%), and unnecessary treatment (20%). Causes of DRPs are presented in Table\u0026nbsp;2. From the total of 548 DRPs, the most common causes were inappropriate drug selection (72%), and dose selection (18%). Within the group of inappropriate drug selection, the most common cause was the absence of an indication (25%), followed by no treatment for the indication (14%), and drug selection according to the guidelines but contra-indicated (13%). In the group of inappropriate drug selection, the majority of DRPs were caused by drug doses being too high (9.3%), and by too frequent dosing regimens (4.6%).\u003c/p\u003e\u003cp\u003e\u003csup\u003e \u003cb\u003e\u0026dagger;\u003c/b\u003e \u003c/sup\u003e \u003cem\u003eThis category includes, among other causes, considering a fixed dose combination and allergy registration in the electronic patient management system.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAbbreviation: TDM\u0026thinsp;=\u0026thinsp;therapeutic drug monitoring\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.3 Treatment domains of DRPs\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;3 represents the distribution of the most common DRP causes per ATC group. The most frequently involved class of drugs differed per DRP cause. Within the group of inappropriate drugs according to guidelines (C1.1), the majority of drugs affected the nervous system (n\u0026thinsp;=\u0026thinsp;41; 66%) including interventions such as stopping of tramadol and oxazepam. For the group of contra-indicated drugs (C1.2), the most common ATC group involved the cardiovascular system (n\u0026thinsp;=\u0026thinsp;35; 49%). In this group, the majority of patients experienced falls while using multiple antihypertensive agents, or electrolyte imbalance during diuretic use. For drugs without an indication (C1.3), the majority of drugs affected the alimentary tract and metabolism (n\u0026thinsp;=\u0026thinsp;82, 59%) which mainly involved redundant use of a proton-pump inhibitor. In the DRP group with no treatment for indication (C1.6), most drugs affected the alimentary tract and metabolism (n\u0026thinsp;=\u0026thinsp;28, 37%). Here, recommended interventions included for instance the absence of vitamin D supplementation and use of laxatives during opioid treatment. Within the group of too many drugs for an indication (C1.7), the most common ATC group involved the cardiovascular system (n\u0026thinsp;=\u0026thinsp;32; 91%) due to falls or low blood pressure while using multiple antihypertensive agents. For the group of inappropriate dose selection (C3), the majority of drugs affected the nervous system (n\u0026thinsp;=\u0026thinsp;33; 34%). The majority of these patients received a total dose paracetamol of 4000 mg/day for chronic use instead of 3000 mg/day. In the DRP group with inadequate treatment duration (C4), the most common ATC group involved the genitourinary system (n\u0026thinsp;=\u0026thinsp;13; 42%) caused by long-term tamsulosin use without previous stop attempts.\u003c/p\u003e\u003cp\u003e\u003csup\u003e \u003cb\u003e\u0026dagger;\u003c/b\u003e \u003c/sup\u003e \u003cem\u003eThis category includes, among other causes, the absence of therapeutic drug monitoring or the use of controlled-release tablets instead of immediate release tablets.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e3.4 Acceptance rates\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAfter ED visit, 169 patients with at least one DRP were admitted to the hospital. Recommended interventions were accepted by the clinical physician for 93 patients (55%) and recommendations were documented in the discharge letter to primary care for 61 patients (36%) upon discharge.\u003c/p\u003e\u003cp\u003eOf 86 patients being discharged directly from the ED with at least one DRP, recommended interventions were included in the discharge letter to the general practitioner or elderly care specialist for 47 patients (55%). The acceptance rate of these recommendations was 32% (15 out of 47). Five patients passed away during the follow-up period.\u003c/p\u003e\u003cp\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eDiscussion\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003c/p\u003e\u003cp\u003eIn this \u0026rsquo;real-world\u0026rsquo; study, 548 DRPs were identified in older patients living with frailty visiting the ED with a mean of 1.5 DRP per patient. Of identified patients, 86 patients (24%) had no DRPs, 104 patients (29%) had 1 DRP, 95 patients (27%) had 2 DRPs and 71 patients (20%) had at least 3 DRPs. The majority of DPRs were caused by inappropriate drug selection (72%) and dose selection (18%) with a diffuse distribution per ATC group. The acceptance rate or recommended interventions among clinical physicians was 55% compared to 32% among general practitioner and elderly care specialists.\u003c/p\u003e\u003cp\u003eThe prevalence of DRPs in this study was 76%. Similar percentages have been described in literature.\u003c/p\u003e\u003cp\u003eIn older patients admitted to the medical and surgical wards, DRPs were identified in 82% of patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The same percentage of 82% was found in patients\u0026thinsp;\u0026ge;\u0026thinsp;65 years visiting the ED [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Furthermore, the mean number of DRPs per patient was comparable [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These results show that by practical implementation of a medication review program at the ED, comparable DRP rates are found as in interventional trials.\u003c/p\u003e\u003cp\u003eThe acceptance rate of recommendations among general practitioners for older patients at the ED varies in clinical trials from 27\u0026ndash;66% [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In admitted patients with at least one recommendation, the acceptance rate among clinical physicians varies from 55\u0026ndash;66% [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In our study, the acceptance rate of recommendations among general practitioners and elderly care specialists was low (32%). This could have several explanations. First, general practitioners received recommendations via discharge letter. To our surprise, only 55% of recommendations were included in discharge letters, meaning that almost half of the DRPs were not brought to the attention of the general practitioner or elderly care specialist. This may be due to a preselection of relevant DRPs in the discharge letter by the ANP or geriatrician, or because the recommendations simply got lost in follow-up. Second, general practitioners and elderly care specialists were not informed about the geriatric assessment including a medication review, while clinical physicians were. Third, general practitioners may know of treatment indications that are unknown in the clinical setting, such as nervousness, for which medications need to be continued.\u003c/p\u003e\u003cp\u003eA strength of this study is selection of the study population, as older patients living with frailty are prone to experiencing DRPs. Furthermore, results of this study show the prevalence and type of DRPs in a \u0026ldquo;real-life\u0026rdquo; setting of conducting medication reviews at the ED. Another strength of this study was the identification of acceptance rate in admitted patients and in patients being discharged from the ED, as most studies do not determine the acceptance rate for both patient groups.\u003c/p\u003e\u003cp\u003eThis study also has some limitations. As described, the acceptance rate for discharged patients was low. Moreover, the geriatric assessment suffered from restrictions during the Covid-19 pandemic, as general practitioners were under high pressure and workload. Additionally, the impact of medication reviews at the ED was not investigated related to clinical outcome measures.\u003c/p\u003e\u003cp\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePractical recommendations\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003c/p\u003e\u003cp\u003eWe provide the following suggestions for implementing a medication review program at the ED or other departments by which we hope to stimulate other healthcare professionals to start similar projects.\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eBefore implementation, inform the surrounding healthcare network about the medication review program. This includes clinical physicians, general practitioners, elderly care specialists and pharmacists at a public pharmacy. This way, recommendations will have more support and this could potentially improve acceptance rates. Our project clearly benefited from the close collaboration with the geriatric department, resulting in higher acceptance rates in admitted patients.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e Select older patients living with frailty for medication reviews rather than older patients (\u0026ge;\u0026thinsp;70 years) with polypharmacy (\u0026ge;\u0026thinsp;5 drugs) as described in guidelines. Performing medication reviews is time-consuming and by adequate patient selection, the efficacy of the review process may be improved. Furthermore, vulnerable patient populations are more prone to experiencing DRPs.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eInclude medication reviews in daily routine, as such that it is a time-efficient process done by a group of pharmacists routinely. In our experience, conducting medication reviews could be easily implemented in routine care and was well received amongst physicians.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eEducate treating physicians so they know what type of DRPs are often seen at your hospital. In our study, we identified drug classes that often cause DRPs at the emergency department and presented those to physicians regularly. As a result, at the end of the study period, common DRPs were already identified by the physician before the pharmacists\u0026rsquo; consultation.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eIf possible, include pharmacist-led patient interviews in the medication review process to identify medication related problems and patients\u0026rsquo; experiences and wishes. This may further eliminate harmful medication use.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOptimize transfer of (information about) medication recommendations in the discharge letter by including accepted and yet to be considered recommendations. Even more, we believe medication changes should be an integral part of the discharge letter, regardless of the reason for ED visit.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003eOur results show that pharmacy-led medication reviews in daily routine lead to better assessment of DRPs at the ED. Of included geriatric patients at the emergency department, 76% had at least one DRP, with a mean of 1.5 DRP per patient. The acceptance rate among clinical physicians in admitted patients was higher (55%) than the acceptance rate among general practitioners/ elderly care specialists in discharged patients (32%). Results of this study reflect the real-life setting of conducting medication reviews at the ED for older patients living with frailty.\u003c/p\u003e\u003cp\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eList of abbreviations\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e\u003c/p\u003e\u003cp\u003eANP\u0026thinsp;=\u0026thinsp;advanced nurse practitioner\u003c/p\u003e\u003cp\u003eATC\u0026thinsp;=\u0026thinsp;anatomical therapeutic chemical\u003c/p\u003e\u003cp\u003eDRP\u0026thinsp;=\u0026thinsp;drug related problem\u003c/p\u003e\u003cp\u003eED\u0026thinsp;=\u0026thinsp;emergency department\u003c/p\u003e\u003cp\u003ePCNE\u0026thinsp;=\u0026thinsp;The Pharmaceutical Care Network Europe\u003c/p\u003e\u003cp\u003eSD\u0026thinsp;=\u0026thinsp;standard deviation\u003c/p\u003e\u003cp\u003eSTART STOPP criteria\u0026thinsp;=\u0026thinsp;Screening Tool to Alert to Right Treatment and Screening Tool of Older Persons' Prescriptions criteria\u003c/p\u003e\u003cp\u003eWHO\u0026thinsp;=\u0026thinsp;world Health Organization\u003c/p\u003e\u003cp\u003e\u003cb\u003eTables\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;1.\u003c/b\u003e Demographic and drug-related patient characteristics (n\u0026thinsp;=\u0026thinsp;356). Values are reported in number (n) and %, unless otherwise specified.\u003c/p\u003e\u003cp\u003e\u003csup\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003e\u0026dagger;\u003c/span\u003e \u003c/sup\u003e \u003cem\u003eThis category includes others infections, dyspnea (due to COVID-19) and unbearable pain.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAbbreviations: DRP\u0026thinsp;=\u0026thinsp;drug related problem, NA\u0026thinsp;=\u0026thinsp;not applicable, SD\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;2.\u003c/b\u003e Causes of DRPs according to the Pharmaceutical Care Network Europe (PCNE) classification system. In total, 548 DRPs were identified during the study period.\u003c/p\u003e\u003cp\u003e\u003csup\u003e \u003cb\u003e\u0026dagger;\u003c/b\u003e \u003c/sup\u003e \u003cem\u003eThis category includes, among other causes, considering a fixed dose combination and allergy registration in the electronic patient management system.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAbbreviation: TDM\u0026thinsp;=\u0026thinsp;therapeutic drug monitoring\u003c/p\u003e\u003cp\u003e\u003cb\u003eTable\u0026nbsp;3.\u003c/b\u003e Distribution of causes of drug-related problems (DRPs) per anatomical therapeutic chemical (ATC) group. Numbers in bold are the highest values in each column.\u003c/p\u003e\u003cp\u003e\u003csup\u003e \u003cb\u003e\u0026dagger;\u003c/b\u003e \u003c/sup\u003e \u003cem\u003eThis category includes, among other causes, the absence of therapeutic drug monitoring or the use of controlled-release tablets instead of immediate release tablets.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSupplementary files\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSupplementary Table\u0026nbsp;1.\u003c/b\u003e Trigger tool to identify adverse events [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAbbreviations: ACE\u0026thinsp;=\u0026thinsp;angiotensine converting enzyme, AII\u0026thinsp;=\u0026thinsp;angiotensine II, INR\u0026thinsp;=\u0026thinsp;international normalized ratio, NSAIDs\u0026thinsp;=\u0026thinsp;non-steroidal anti-inflammatory drugs\u003c/p\u003e"},{"header":"Unsectioned Tables","content":" \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eCauses of DRPs according to the Pharmaceutical Care Network Europe (PCNE) classification system. In total, 548 DRPs were identified during the study period.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCause\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC1: Drug selection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e394 (72)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.1 Inappropriate drug according to guidelines\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e62 (11)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.2 According to guidelines but contra-indicated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e71 (13)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.3 No indication for drug\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e139 (25)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.4 Inappropriate combination of drug, or drugs and food\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.5 Inappropriate duplication of therapeutic group or active ingredient\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (1.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.6 No treatment for indication\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e75 (14)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.7 Too many drugs for indication\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e35 (6.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC2: Drug form\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC2.1 Inappropriate drug form\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC3: Dose selection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e97 (18)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.1 Drug dose too low\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (2.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.2 Drug dose too high\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e51 (9.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.3 Dose not frequent enough\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.4 Dose too frequent\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (4.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.5 Dosing time is wrong, unclear or missing\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (0.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC4: Treatment duration\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (5.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC4.1 Duration of treatment too short\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC4.2 Duration of treatment too long\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (5.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC5: Dispensing\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC6: Drug use\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC7: Patient related\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC7.1 Patient takes less or none of the drug\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC7.8 Patient administered/uses drug in a wrong way\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC8: Other causes\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e\u0026dagger;\u003c/span\u003e\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e21 (3.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC8.1 No or inappropriate outcome monitoring (TDM)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (1.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC8.2 Other cause\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14 (2.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDistribution of causes of drug-related problems (DRPs) per anatomical therapeutic chemical (ATC) group. Numbers in bold are the highest values in each column.\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eDrug\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eselection\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(C1)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003eDose selection (C3)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003eTreatment duration (C4)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient related (C7)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther causes (C8) \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eInappropriate drug according to guidelines (C1.1)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eContra-indicated (C1.2)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo indication for drug (C1.3)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo treatment for indication (C1.6)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eToo many drugs for indication (C1.7)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;62\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;71\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;139\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;75\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;35\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;97\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;31\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;5\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;21\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eATC group\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAlimentary tract and metabolism (ATC group A)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e82\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e28\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBlood and blood-forming organs\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(ATC group B)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCardiovascular system (ATC group C)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e35\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e25\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e32\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e17\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGenitourinary system and reproductive hormones (ATC group G)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e13\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSystemic hormonal preparations excluding reproductive hormones and insulin (ATC group H)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnti-infective agents for systemic use (ATC group J)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntineoplastic and immunomodulating agents (ATC group L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMusculoskeletal system (ATC group M)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e20\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNervous system (ATC group N)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e41\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e33\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRespiratory system (ATC group R)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVarious (ATC group V)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVariable\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026ge;\u0026thinsp;1 DRP\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 DRPs\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEmergency department visits\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e356 (100)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e270 (76)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e86 (24)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge, mean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e83 (6.8)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e83 (6.8)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e82 (6.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSex\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e139 (39)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e217 (61)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e105 (39)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e165 (61)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e34 (40)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e52 (60)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of medications per patient, mean (SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8 (4.7)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (4.5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (4.0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePolypharmacy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e158 (45)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e127 (47)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (36)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCause of emergency department visit\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBleeding\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14 (3.9)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e13 (4.8)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVomit/diarrhea\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (2.0)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (2.2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCollapse/hypotension/vertigo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (2.5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (3.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDelirium/confused/drowsy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11(3.1)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (4.1)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eElectrolyte disturbances/dehydration\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (2.0)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (2.2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFracture/fall\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e192 (54)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e142 (53)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e50 (58)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHeart failure\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (1.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eKidney failure\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.3)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.4)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eObstipation/ileus\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.6)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.7)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDisrupted blood glucose levels\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.6)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.7)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e110 (31)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e78 (29)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e32 (37)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHospital admission\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e233 (66)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e123 (35)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e181 (67)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e89 (33)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e52 (60)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e34 (40)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNumber of DRPs\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNo DRP\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e1 DRP\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e2 DRPs\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026ge;3 DRPs\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1.5 (1.3)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e86 (24)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e104 (29)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e95 (27)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e71 (20)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.0 (1.1)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e104 (38)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e95 (36)\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e71 (26)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eNA\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCause\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC1: Drug selection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e394 (72)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.1 Inappropriate drug according to guidelines\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e62 (11)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.2 According to guidelines but contra-indicated\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e71 (13)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.3 No indication for drug\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e139 (25)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.4 Inappropriate combination of drug, or drugs and food\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.5 Inappropriate duplication of therapeutic group or active ingredient\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e10 (1.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.6 No treatment for indication\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e75 (14)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC1.7 Too many drugs for indication\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e35 (6.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC2: Drug form\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC2.1 Inappropriate drug form\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC3: Dose selection\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e97 (18)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.1 Drug dose too low\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (2.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.2 Drug dose too high\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e51 (9.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.3 Dose not frequent enough\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.4 Dose too frequent\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (4.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC3.5 Dosing time is wrong, unclear or missing\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4 (0.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC4: Treatment duration\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (5.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC4.1 Duration of treatment too short\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC4.2 Duration of treatment too long\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (5.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC5: Dispensing\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC6: Drug use\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e0 (0)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC7: Patient related\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC7.1 Patient takes less or none of the drug\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC7.8 Patient administered/uses drug in a wrong way\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eC8: Other causes\u003c/span\u003e\u003csup\u003e\u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003e\u0026dagger;\u003c/span\u003e\u003c/sup\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e21 (3.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC8.1 No or inappropriate outcome monitoring (TDM)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (1.3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eC8.2 Other cause\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14 (2.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eDrug\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003eselection\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(C1)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003eDose selection (C3)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003eTreatment duration (C4)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003ePatient related (C7)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther causes (C8) \u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eInappropriate drug according to guidelines (C1.1)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003eContra-indicated (C1.2)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo indication for drug (C1.3)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo treatment for indication (C1.6)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003eToo many drugs for indication (C1.7)\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;62\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;71\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;139\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;75\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;35\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;97\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;31\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;5\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003en\u0026thinsp;=\u0026thinsp;21\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eATC group\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAlimentary tract and metabolism (ATC group A)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e82\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e28\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBlood and blood-forming organs\u003c/div\u003e \u003cdiv class=\"SimplePara\"\u003e(ATC group B)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCardiovascular system (ATC group C)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e35\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e25\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e32\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e17\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGenitourinary system and reproductive hormones (ATC group G)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e13\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSystemic hormonal preparations excluding reproductive hormones and insulin (ATC group H)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnti-infective agents for systemic use (ATC group J)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntineoplastic and immunomodulating agents (ATC group L)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMusculoskeletal system (ATC group M)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e11\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e20\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNervous system (ATC group N)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e41\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003e33\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e6\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRespiratory system (ATC group R)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e7\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVarious (ATC group V)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cdiv class=\"SimplePara\"\u003e2\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cdiv class=\"SimplePara\"\u003e4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cdiv class=\"SimplePara\"\u003e1\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cdiv class=\"SimplePara\"\u003e3\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabd\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eTrigger\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePotentially associated drug\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFracture/fall\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePsychoactive drugs/corticosteroids/antihypertensive drugs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCollapse/hypotension/dizziness\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntihypertensive drugs/anti-arrhythmic drugs/ Psychoactive drugs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBleeding/increased INR\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAnticoagulants/thrombocyte aggregation inhibitors/NSAIDs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eElectrolyte imbalance/dehydration\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eDiuretics/ACE-inhibitors/AII-inhibitors/NSAIDs/antidepressants drugs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRenal insufficiency\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eACE-inhibitors/AII-inhibitors/NSAIDs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBlood sugar imbalance\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eGlucose-lowering drugs/ corticosteroids\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHeart failure\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eNSAIDs\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eObstipation/ileus\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eOpioids/calcium channel blockers\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eVomiting/diarrhea\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eAntibiotics\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDelirium/ drowsiness\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003ePsychoactive drugs//antihypertensive drugs/ anti-arrhythmic drugs/alpha blockers/ benzodiazepines\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cbr/\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2230828/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2230828/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOlder patients are at risk of drug related problems (DRPs), potentially leading to emergency department (ED) visits. Identifying DRPs with medication reviews is typically evaluated in restrictive clinical studies and not in a \u0026lsquo;real-world\u0026rsquo; setting with organizational challenges and time-pressure. This study aims to assess the number of DRPs at the ED in older patients living with frailty, and to determine the acceptance rate of medication recommendations among physicians and the general practitioner. Additionally, practical recommendations are provided for implementing a medication review program.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational study was performed in patients\u0026thinsp;\u0026ge;\u0026thinsp;70 years living with frailty who visited the ED at Tergooi Medical Center. Medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. Also, the acceptance rate of given recommendations was assessed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 356 ED visits were included. The mean age of patients was 83 years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur results show that medication reviews lead to better assessment of DRPs at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients. Results of our study reflect the real-life setting of conducting medication reviews at the ED for older patients living with frailty.\u003c/p\u003e","manuscriptTitle":"Real-world assessment of drug related problems by medication reviews at the emergency department in older patients living with frailty","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-12 16:58:07","doi":"10.21203/rs.3.rs-2230828/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-02-06T16:46:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-02-05T19:34:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"edd0954d-dfaf-434f-94e5-668160462e2c","date":"2023-01-24T20:04:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2022-12-26T08:39:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95f0fc43-0b48-4184-b7f8-3ae3dd88196d","date":"2022-11-26T20:40:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-18T01:32:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-11-13T10:00:55+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2022-11-10T11:52:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-11-10T11:46:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Geriatrics","date":"2022-11-02T15:01:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-geriatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bgtc","sideBox":"Learn more about [BMC Geriatrics](http://bmcgeriatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bgtc/default.aspx","title":"BMC Geriatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"508af090-aa6a-471f-a28d-6c8fd83e12a1","owner":[],"postedDate":"November 12th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T20:26:00+00:00","versionOfRecord":{"articleIdentity":"rs-2230828","link":"https://doi.org/10.1186/s12877-023-03942-x","journal":{"identity":"bmc-geriatrics","isVorOnly":false,"title":"BMC Geriatrics"},"publishedOn":"2023-04-05 20:23:10","publishedOnDateReadable":"April 5th, 2023"},"versionCreatedAt":"2022-11-12 16:58:07","video":"","vorDoi":"10.1186/s12877-023-03942-x","vorDoiUrl":"https://doi.org/10.1186/s12877-023-03942-x","workflowStages":[]},"version":"v1","identity":"rs-2230828","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2230828","identity":"rs-2230828","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}