Evaluating a new pharmacist-led structured medication review service for older adults with frailty in secondary care

Introduction

Older adults living with frailty are at increased risk of problematic polypharmacy, adverse drug reactions and medication-related harm. Structured medication review (SMR) is recommended to support medicines optimisation but evidence supporting pharmacist-led SMR within acute secondary care remains limited. This evaluation assessed the impact of introducing a specialist pharmacist-led SMR service within an acute orthogeriatric setting.

Method

A retrospective quasi-experimental service evaluation with a non-randomised control group was conducted at a UK district general hospital. Patients aged ≥75 years with moderate to severe frailty admitted between November 2025 and January 2026 were included. Orthogeriatric ward patients received specialist pharmacist-led SMR throughout admission within multidisciplinary care, while general medical ward patients received usual care. A specialist pharmacist advanced practitioner and independent prescriber delivered the intervention. Outcomes included potentially inappropriate medicines (PIMs), medication interventions, medication and anticholinergic burden, 90-day emergency department (ED) attendances and medication-related cost savings.

Results

28 patients received SMR and 21 received usual care. The intervention group demonstrated a significantly greater reduction in PIMs at discharge (mean difference −1.06, 95% CI −1.92 to −0.20; p=0.02) and more medication interventions per patient (mean difference 1.40, 95% CI 0.39 to 2.41; p=0.01). Mean 90-day ED attendances were lower in the intervention group (0.05 versus 0.81 per patient; mean difference −0.76, 95% CI −1.09 to −0.43; p<0.001). No significant between-group differences were observed in medication or anticholinergic burden. Projected annualised medication-related savings were £12,222 (£436 per patient), compared with £1,783 (£85 per patient) under usual care.

Conclusion

Specialist pharmacist-led SMR, delivered by an advanced practitioner and independent prescriber embedded within multidisciplinary orthogeriatric care, was associated with improved prescribing appropriateness and lower post-discharge ED utilisation compared to usual care. These findings support prospective evaluation of advanced pharmacy practice models for older adults living with frailty in acute secondary care, including longer-term effectiveness, scalability and cost-effectiveness.