***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective Heart failure patients are regularly admitted to hospital and frequently use multiple medication . Besides intentional changes in pharmacotherapy , unintentional changes may occur during hospitalisation . The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure . Setting A general teaching hospital in Tilburg , the Netherl and s. Method An open r and omized intervention study was performed comparing an intervention group , with a  control group receiving regular care by doctors and nurses .  The clinical pharmacist discharge service consisted of review of discharge medication , communicating prescribing errors with the cardiologist , giving patients information , preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication . Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured . Main outcome measure The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined . Results Forty-four patients were included in the control group and 41 in the intervention group . Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39 % in the intervention group ( RR 0.57 ( 95 % CI 0.37–0.88 ) ) . The percentage of medications with a discrepancy or prescription error in the control group was 14.6 % and in the intervention group it was 6.1 % ( RR 0.42 ( 95 % CI 0.27–0.66 ) ) . Conclusion This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge Background Older people are at increased risk of drug-related problems ( DRPs ) caused by inappropriate use or underuse of medications which may be increased during care transitions . Objective To examine the effects of applying a vali date d prescribing appropriateness criteria -set during medication review in a cohort of older ( ≥65 years ) Australians at the time of discharge from hospital . Setting Private hospital and homes of older patients in Sydney , Australia . Methods Cognitively well English speaking patients aged 65 years or over taking five or more medications were recruited . A prescribing appropriateness criteria -set and SF-36 health-related quality of life health ( HRQoL ) survey were applied to all patients at discharge . Patients were then r and omly assigned to receive either usual care ( control , n = 91 ) or discharge medication counselling and a medication review by a clinical pharmacist ( intervention , n = 92 ) . Medication review recommendations were sent to the general practitioners of intervention group patients . All patients were followed up at 3 months post discharge , where the prescribing appropriateness criteria -set was reapplied and HRQoL survey repeated . Main outcome measures change in the number of prescribing appropriateness criteria met ; change in HRQoL ; number and causes of DRPS identified by medication review ; intervention patient medication recommendation implementation rates . Results There was no significant difference in the number of criteria applicable and met in intervention patients , compared to control patients , between follow-up and discharge ( 0.09 ≤ p ≤ 0.97 ) . While the difference between groups was positive at follow-up for SF-36 scores , the only domain that reached statistical significance was that for vitality ( p = 0.04 ) . Eighty-eight intervention patient medication review s identified 750 causes of DRPs ( 8.5 ± 2.7 per patient ) . No causes of DRPs were identified in four patients . Of these causes , 76.4 % ( 573/750 ) were identified by application of the prescribing appropriateness criteria -set . GPs implemented a relatively low number ( 42.4 % , 318/750 ) of recommendations . Conclusion Application of a prescribing appropriateness criteria -set during medication review in intervention patients did not increase the number of criteria met , nor result in a significant improvement in HRQoL. Higher recommendation implementation rates may require additional facilitators , including a higher quality of collaboration OBJECTIVES To evaluate the effect of pharmaceutical care provided in addition to acute Geriatric Evaluation and Management ( GEM ) care on the appropriateness of prescribing . DESIGN R and omized , controlled trial , with the patient as unit of r and omization . SETTING Acute GEM unit . PARTICIPANTS Two hundred three patients aged 70 and older . INTERVENTION Pharmaceutical care provided from admission to discharge by a specialist clinical pharmacist who had direct contacts with the GEM team and patients . MEASUREMENTS Appropriateness of prescribing on admission , at discharge , and 3 months after discharge , using the Medication Appropriateness Index ( MAI ) , Beers criteria , and Assessing Care of Vulnerable Elders ( ACOVE ) underuse criteria and mortality , readmission , and emergency visits up to 12 months after discharge . RESULTS Intervention patients were significantly more likely than control patients to have an improvement in the MAI and in the ACOVE underuse criteria from admission to discharge ( odds ratio (OR)=9.1 , 95 % confidence interval (CI)=4.2 - 21.6 and OR=6.1 , 95 % CI=2.2 - 17.0 , respectively ) . The control and intervention groups had comparable improvements in the Beers criteria . CONCLUSION Pharmaceutical care provided in the context of acute GEM care improved the appropriate use of medicines during the hospital stay and after discharge . This is an important finding , because only limited data exist on the effect of various strategies to improve medication use in elderly in patients . The present approach has the potential to minimize risk and improve patient outcomes Background Polypharmacy and potentially inappropriate drugs have been associated with negative outcomes in older adults which might be reduced by pharmacist interventions . Objectives Our objective was to evaluate the effect of a pharmacist intervention , consisting of the application of the Rationalization of home medication by an Adjusted STOPP in older Patients ( RASP ) list and a pharmacist-led medication review on polypharmacy , the quality of prescribing , and clinical outcome in geriatric in patients . Methods A monocentric , prospect i ve controlled trial was undertaken at the geriatric wards of a large university hospital . Pharmacists applied the RASP list to the drugs reconciled on admission and additionally performed an expert-based medication review , upon which recommendations were provided to the treating physicians . The primary outcome was the composite endpoint of drug discontinuation and dose reduction of drugs taken on admission . Secondary outcomes included RASP-identified potentially inappropriate medications ( PIMs ) , the number of Emergency Department ( ED ) visits and quality of life ( QOL ) registered up to 3 months after discharge . Results On average , patients ( n = 172 ) took 10 drugs on admission and were 84.5 years ( st and ard deviation 4.8 ) of age . More drugs were discontinued or reduced in dose in the intervention group { control vs. intervention : median ( interquartile range [ IQR ] ) 3 ( 2–5 ) vs. 5 ( 3–7 ) ; p < 0.001}. More PIMs were discontinued in the intervention group , leading to less PIM at discharge [ control vs. intervention : median ( IQR ) 2 ( 1–3 ) vs. 0.5 ( 0–1 ) ; p < 0.001 ] . No signal of harm was seen , and a significant improvement of QOL and less ED visits without hospitalization were observed . Conclusions The combined intervention safely reduced drug use in very old in patients and outperformed usual geriatric care . An increased QOL was seen , as well as a trend towards less ED visits . Clinical Trials.gov Identifier : NCT01513265 Purpose To examine the impact of systematic medication reconciliations upon hospital admission and of a medication review while in hospital on the number of inappropriate medications and unscheduled drug-related hospital revisits in elderly patients . Methods This was a prospect i ve , controlled study in 210 patients , aged 65 years or older , who were admitted to one of three internal medicine wards at a University Hospital in Sweden . Intervention patients received the complete Lund Integrated Medicines Management model ( medication reconciliation upon admission and discharge , and medication review and monitoring ) provided by a multi-professional team , including a clinical pharmacist . Control patients received st and ard care and medication reconciliation upon discharge . Blinded review ers evaluated the appropriateness of the prescribing ( using the Medication Appropriateness Index ) on admission and discharge , and assessed the probability that a drug-related problem was the reason for any patient readmitted to hospital or visiting the emergency department within 3 months of discharge ( using World Health Organisation causality criteria ) . Results There was a greater decrease in the number of inappropriate drugs in the intervention group than in the control group for both the intention-to-treat population { 51 % [ 95 % confidence interval ( CI ) 43–58 % ] vs. 39 % ( 95 % CI 30–48 % ) ; p = 0.0446 } and the per- protocol population [ 60 % ( 95 % CI 51–67 % ) vs. 44 % ( 95 % CI 34–52 % ) ; p = 0.0106 ) ] . There were six revisits to hospital in the intervention group which were judged as ‘ possibly , probably or certainly drug-related ’ , compared with 12 in the control group ( p = 0.0469 ) . Conclusions In this study , medication reconciliation and review provided by a clinical pharmacist in a multi-professional team significantly reduced the number of inappropriate drugs and unscheduled drug-related hospital revisits among elderly patients Importance Hospital readmissions are common among patients receiving multiple medications , with considerable costs to the patients and society . Objective To determine whether a multifaceted pharmacist intervention based on medication review , patient interview , and follow-up can reduce the number of readmissions and emergency department ( ED ) visits . Design , Setting , and Participants This r and omized clinical multicenter study ( Odense Pharmacist Trial Investigating Medication Interventions at Sector Transfer [ OPTIMIST ] ) enrolled patients from September 1 , 2013 , through April 23 , 2015 , with a follow-up of 6 months completed on October 31 , 2015 . Consecutive medical patients in an acute admission ward who were 18 years or older and who used 5 or more medications were invited to participate . Of 1873 patients invited to participate , 1499 ( 80.0 % ) accepted . The medication review and patient interview were conducted in the hospital and followed up in collaboration with primary care . Analysis was based on intention to treat . Interventions The patients were r and omized into 3 groups receiving usual care ( no intervention ) , a basic intervention ( medication review ) , and an extended intervention ( medication review , 3 motivational interviews , and follow-up with the primary care physician , pharmacy , and nursing home ) . Main Outcomes and Measures The prespecified primary outcomes were readmission within 30 or 180 days and ED visits within 180 days . The primary composite end point was readmission or an ED visit within 180 days . Secondary outcomes were drug-related readmissions within 30 and 180 days after inclusion , and all-cause mortality and drug-related mortality . Results A total of 1467 patients ( 679 men [ 46.3 % ] and 788 women [ 53.7 % ] ; median age , 72 years ; interquartile range , 63 - 80 years ) were part of the primary analysis , including 498 r and omized to usual care , 493 r and omized to the basic intervention , and 476 r and omized to the extended intervention . The extended intervention had a significant effect on the numbers of patients who were readmitted within 30 days ( hazard ratio [ HR ] , 0.62 ; 95 % CI , 0.46 - 0.84 ) or within 180 days ( HR , 0.75 ; 95 % CI , 0.62 - 0.90 ) after inclusion and on the number of patients who experienced the primary composite end point ( HR , 0.77 ; 95 % CI , 0.64 - 0.93 ) . The study showed a nonsignificant reduction in drug-related readmissions within 30 days ( HR , 0.65 ; 95 % CI , 0.39 - 1.09 ) and within 180 days ( HR , 0.80 ; 95 % CI , 0.59 - 1.08 ) after inclusion and in deaths ( HR , 0.83 ; 95 % CI , 0.22 - 3.11 ) . The number needed to treat to achieve the primary composite outcome for the extended intervention ( vs usual care ) was 12 . Conclusions and Relevance A multifaceted clinical pharmacist intervention may reduce the number of ED visits and hospital readmissions . Trial Registration clinical trials.gov Identifier : PURPOSE The effects of an integrated medicines management ( IMM ) program on medication appropriateness are discussed . METHODS Patients enrolled in an IMM project within a hospital were r and omly allocated to either a control or an intervention group . Patients in the control group received st and ard pharmaceutical care , while the intervention patients received the IMM service . The appropriateness of the medications prescribed was estimated on admission and discharge using the Medicines Appropriateness Index ( MAI ) , which ranged from 0 ( no prescribing problems ) to 18 ( most prescribing problems ) . 
    Output:
    
This Mini Review indicates that multifaceted pharmacist-led interventions in a hospital setting may improve the quality of medication use and reduce hospital visits and length of stay , while no effect was seen on mortality , patient-reported outcome and cost-effectiveness