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Background: High-quality discharge information is important to promote patient safety when patients are transferred from hospital to primary care. Patients with multiple long-term conditions are especially vulnerable to insufficient transfer of medication information, as they use many medications and have complex interactions with the healthcare services. The aim of this study was to investigate the effect of integrated medicines management provided to hospitalized multimorbid patients on the quality of the discharge medication information., Methods: Multimorbid patients ≥18 years, using a minimum of four regular medications from a minimum of two therapeutic medication classes were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a pre-specified secondary endpoint analysis of a randomized controlled trial; the difference between the intervention and control group in the quality of discharge medication information., Results: The analysis population comprised 384 patients. Integrated medicines management improved the discharge summary quality score of the medication information from 5.8 ± 1.5 to 8.6 ± 2.6 (mean difference 2.7, 95% CI 2.3-3.2, p < 0.001). In total 171 intervention patients (89%) received a patient discharge information letter, compared to 66 control patients (35%), p < 0.001. The quality score of the medication information in the patient discharge information letter was improved from 6.0 ± 1.8 in the control group to 10.0 ± 1.3 in the intervention group (mean difference 4.0, 95% CI 3.6-4.4, p < 0.001)., Conclusion: Integrated medicines management delivered to multimorbid patients during a hospital stay improved the quality of the medication information in discharge summaries as well as patient discharge information letters and ensured that a discharge information letter in lay language was prepared for almost all patients who were involved in the management of their medications after discharge., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Quality in Health Care.)

Objective: To develop and externally validate a prognostic model built on important factors predisposing multimorbid patients to all-cause readmission and/or death. In addition to identify patients who may benefit most from a comprehensive clinical pharmacist intervention., Methods: A multivariable prognostic model was developed based on data from a randomised controlled trial investigating the effect of pharmacist-led medicines management on readmission rate in multimorbid, hospitalised patients. The derivation set comprised 386 patients randomised in a 1:1 manner to the intervention group, i.e. with a pharmacist included in their multidisciplinary treatment team, or the control group receiving standard care at the ward. External validation of the model was performed using data from an independent cohort, in which 100 patients were randomised to the same intervention, or standard care. The setting was an internal medicines ward at a university hospital in Norway., Results: The number of patients who were readmitted or had died within 18 months after discharge was 297 (76.9 %) in the derivation set, i.e. the randomized controlled trial, and 69 (71.1 %) in the validation set, i.e. the independent cohort. Charlson comorbidity index (CCI; low, moderate or high), previous hospital admissions within the previous six months and heart failure were the strongest prognostic factors and were included in the final model. The efficacy of the pharmaceutical intervention did not prove significant in the model. A prognostic index (PI) was constructed to estimate the hazard of readmission or death (low, intermediate or high-risk groups). Overall, the external validation replicated the result. We were unable to identify a subgroup of the multimorbid patients with better efficacy of the intervention., Conclusions: A prognostic model including CCI, previous admissions and heart failure can be used to obtain valid estimates of risk of readmission and death in patients with multimorbidity., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: To investigate the effect of integrated medicines management provided to hospitalised multimorbid patients on the quality of drug treatment at discharge measured as the mean number of potential prescribing omissions and potentially inappropriate medicines., Methods: Multimorbid patients ≥18 years, using a minimum of four regular drugs from a minimum of two therapeutic drug classes, were recruited from the Internal Medicine ward, Oslo University Hospital, Norway, from August 2014 to March 2016 and randomly assigned, 1:1, to the intervention or control group. Intervention patients received integrated medicines management throughout the hospital stay. Control patients received standard care. This paper reports the results of a pre-specified secondary endpoint analysis of a randomised controlled trial; the difference between the intervention and control group at discharge in the mean number of potential prescribing omissions and potentially inappropriate medicines, measured with START-2 and STOPP-2 criteria, respectively. The difference between the groups was calculated using rank analysis., Key Findings: In total, 386 patients were analysed. Integrated medicines management reduced the mean number of potential prescribing omissions at discharge, compared to the control group, 1.34 versus 1.57, respectively (mean difference 0.23, 95% CI 0.07-0.38, P = 0.005, adjusted for values at admission). There was no difference in the mean number of potentially inappropriate medicines at discharge (1.84 versus 1.88, respectively; mean difference 0.03, 95% CI -0.18 to 0.25, P = 0.762, adjusted for values at admission)., Conclusions: Integrated medicines management delivered to multimorbid patients during a hospital stay led to an improvement in undertreatment. No effect on deprescribing of inappropriate treatment was seen., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Royal Pharmaceutical Society.)

Objective: Effective communication and patient empowerment before hospital discharge are important steps to ensure medication safety. Patients discharged from hospitals are often expected to assume self-management, frequently without healthcare personnel (HCP) having ensured patients' knowledge, motivation and/or skills. In this substudy of a larger study, we explore how patients experience medication communication during encounters with HCPs and how they are empowered at hospital discharge., Design: This is a qualitative case study. Data collection was done through qualitative observations of patient-HCP encounters, semistructured interviews with patients and drug reconciliation. Data were analysed using content analysis., Setting: An internal medicines ward at a university hospital in Norway., Participants: Nine patients aged 49-90 years were included close to the day of discharge., Results: The analysis revealed the following themes: (1) patient-centred care (PCC), which included 'understanding and involvement in the patient-as-person', 'establishment of a therapeutic alliance', and 'sharing power and responsibility'; and (2) biomedical (conventional) care, including the subthemes 'HCPs in power and control' and 'optimising medical outcomes, following guidelines'. Even though the elements of PCC were observed in several encounters, overall communication was not sufficiently fostering patient empowerment. Spending time with patients and building relations based on mutual trust seemed undervalued., Conclusions: The results provide a broader understanding of how patients experience medication communication at hospital discharge. Both the patients and the HCPs appear to be inculcated with biomedical traditions and are uncertain about the roles and opportunities associated with PCC. Attention should be paid to patient preferences and to the core elements of the PCC model from admission to discharge to empower patients in medication self-management., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Patients are expected to participate in the hospital discharge process, assume self-management after discharge and communicate relevant information to their general practitioner; however, patients report that they are not being sufficiently empowered to take on these responsibilities. The aim of this study was to explore and understand the discharge process with a focus on medicines communication, from the patient perspective., Methods: Patients were included at a hospital ward, observed during health-care personnel encounters on the day of discharge and interviewed 1-2 weeks after discharge. A process analysis was performed, and a content analysis combined data from observations and data from patient interviews focusing on medicines communication in the discharge process., Results: A total of 9 patients were observed on the day of discharge, equalling 67.5 hours of observations. The analysis resulted in the following themes: (a) the observed discharge process; (b) patient initiatives; and (c) the patient role. The medicines communication in the discharge process appeared unstructured. Various patient preferences and needs were revealed. The elements of the best practice structured discharge conversation were observed; however, some patients did not have a discharge conversation at all., Conclusions: The study contributes to a broader understanding of the discharge process, how patients experience it, including their role. It is evident that the discharge process is not always tailored to meet the patients' needs. More focus on early patient involvement and communication, in order to better prepare patients for self-management of their medications, is important for their health outcomes., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Objective: To investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival., Design: Parallel-group, randomised controlled trial., Setting: Recruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21-40 months., Participants: Acutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23-96) and number of diseases 7 (range 2-17)., Intervention: Intervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care., Primary and Secondary Outcome Measures: The primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint., Results: Pharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21-40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008)., Conclusions: Pharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale., Trial Registration Number: NCT02336113., Competing Interests: Competing interests: ML received Ph.D. funding from the South-Eastern Norway Regional Health Authority (grant number 12/00718)., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background/objectives: In 2004, a survey conducted in Scandinavia documented insufficient knowledge in nutrition care among doctors and nurses. The survey also revealed a significant discrepancy in nutritional practice, where Norway ranked lowest, thus leading to several actions including elaboration of national guidelines. The aim of this study was to evaluate potential changes in nutritional practice, as well as assessing barriers to nutrition therapy, 10 years after the former study., Subjects/methods: In the first half of 2014, a total of 4000 doctors and nurses received a questionnaire, similar to the one used in 2004. The questions dealt with nutritional practice, routines, knowledge, barriers, and use of clinical dietitians (CDs) in the hospitals., Results: The response rate was 22%. Routines in nutritional practice were significantly improved. The level of knowledge among respondents were increased, but lack of knowledge and lack of assignment of responsibility were still important barriers. The patients' contradiction could be a barrier to the use of enteral nutrition. CDs are used in a small amount of patients, and wards with good nutritional routines have a better cooperation with CDs than wards with insufficient routines., Conclusions: Routines in clinical nutrition have improved from 2004 to 2014. Barriers in the daily practice among health care workers like lack of knowledge and lack of assignment of responsibility are still important, and health care professionals seem to let the patient himself or herself be a barrier to the use of enteral nutrition.

Background: Previous studies, all of <20 years of follow-up, have suggested an association between lung function and the risk of fatal stroke. This study investigates the stability of this association in a cohort followed for 4 decades., Methods: The Bergen Clinical Blood Pressure Survey was conducted in Norway in 1964-1971. The risk of fatal stroke associated with forced expiratory volume after one second (FEV(1)) was estimated with Cox proportional hazards regression, making progressive adjustment for potential confounders., Results: Of 5617 (84%) participants with recorded baseline FEV(1), 462 died from stroke over 152 786 subsequent person-years of follow-up according to mortality statistics of 2005; mean (SD) follow-up was 27 (12) years. An association between baseline FEV(1) (L) and fatal stroke was observed; HR=1.38 (95% CI 1.11 to 1.71) and HR=1.62 (95% CI 1.22 to 2.15) for men and women, respectively (adjusted for age and height). The findings were not explained by smoking, hypertension, diabetes, atherosclerosis, socioeconomic status, obstructive lung disease, physical inactivity, cholesterol or body mass index and persisted in subgroups of never-smokers, subgroups without respiratory symptoms and survivors of the first 20 years of follow-up. For male survivors with a valid FEV(1) at follow-up (1988-1990) (n=953), baseline FEV(1) (L) indicated a possible strong and independent association to the risk of fatal stroke after adjustments for individual changes in FEV(1) (ml/year) (HR 1.95 (95% CI 0.98 to 3.86))., Conclusion: There is a consistent, independent and long-lasting association between lung function and fatal stroke, probably irrespective of changes during adult life.

The Bergen Clinical Blood Pressure Study in Norway was used to examine the relationship between body mass index (BMI (kg/m(2))) and total mortality in different age segments. Of 6,811 invited subjects, 5,653 (84%) participated in the study (1965-1971) and 4,520 (66%) died during 182,798 person-years of follow-up (1965-2007). Mean age at baseline was 47.5 years; range 22-75 years. BMI (kg/m(2)) was calculated from standardized measurements of body height and weight and divided into four groups (<22.0, 22.0-24.9, 25.0-27.9, > or =28.0). The 20 years cumulative risk of death related to baseline BMI was U-shaped in the elderly (aged 65-75 years), whereas the pattern was more linear in the youngest age group (20-44 years). In contrast to the younger age groups, the highest mortality in the elderly was in the lower BMI range (<22.0 kg/m(2)) (adjusted Cox proportional Hazard Ratio 1.39, 95% Confidence Interval 1.10, 1.75) compared to the BMI reference group (22.0-24.9 kg/m(2)). This pattern persisted after 72 months of early follow-up exclusion and it was robust to adjustments for a wide range of possible confounders including gender, history of cardiovascular disease, respiratory disease or hypertension, smoking habits, physical activity, socioeconomic status, physical appearance and other anthropometric measures. The study shows that a low BMI is an appreciable independent risk factor of total mortality in the elderly, and not a result of subclinical disease or confounding factors such as current or previous smoking. Awareness of this issue ought to be emphasized in advice, care and treatment of elderly subjects.

Background: Malnutrition is often over-seen in elderly acute medical patients. It is a need for a simple and robust screening tool., Objective: The aim was to evaluate, with regard to validity, the Mini Nutritional Assessment-Short Form (MNA-SF) as a screening tool for malnutrition in elderly acute medical patients., Design: This is an observational study where a nurse's scoring of MNA-SF is compared to comprehensive assessment by a clinical nutritionist (gold standard). Sixty-nine patients aged 70 years and older and admitted to a general medical department in year 2000 and 2001 were included., Results: The mean MNA-SF score was 7.8 (SD +/- 2.88, range 2 to 12). Fifty-one patients (74%) scored positive for malnutrition or risk of malnutrition (MNA-SF < 11), whereas only 21 (30%) were scored to have malnutrition by the nutritionist. Sensitivity of the MNA-SF was 1.0 and specificity 0.38, giving 0.57 correctly classified subjects. Best subset logistic regression showed BMI < 23 to be the only item explaining the gold standard. When using BMI < 23, 32 (46%) subjects screened positive for malnutrition (sensitivity 0.86, specificity 0.71), giving 0.75 correctly classified subjects., Conclusions: When screening elderly acute medical patients in general wards for malnutrition or risk of malnutrition, the MNA-SF have a high sensitivity and can be useful. The sole use of BMI < 23 may be equally effective, but will give no information leading towards an explanation. We recommend that a score of BM < 23 should be followed by MNA-SF when the aim is to identify poor nutritional status in elderly acute medical patients.

Background: Although often undiagnosed, undernutrition is prevalent among elderly patients in hospitals. The effect of undernutrition is reduced mental and pulmonary function, increased prevalence of infection, and increased morbidity and mortality., Material and Methods: This article presents an overview of the diagnosis and treatment of undernutrition in elderly patients with nonmalignant disease, based on relevant literature., Results: There are no generally accepted definitions of undernutrition. Undernutrition should be suspected clinically and screened for, using anthropometric methods (body weight, body mass index, triceps skinfold, arm muscle circumference) or functional tests (hand dynamometry, laboratory parameters). Results from several studies indicate that nutritional intervention could increase body weight and physical capacity of patients and reduce length of hospitalisation and mortality., Interpretation: Undernutrition is common in clinical practice. Hospitalised patients should be screened for risk of undernutrition. The screening should be combined with a nutrition plan, including strategies for nutrition therapy.

Background: Malnutrition is a common condition among aged, hospitalised patients, which may be due to lack of appetite in the same group. It is uncertain, however, the relationship between a reduced appetite and the nutritional status., Objective: Assess the prevalence of reduced appetite, and to study the relationship between a reduced appetite and the nutritional status., Design: A randomised population survey among elderly: one group recruited from patients recently admitted for acute disease or exacerbation of disease, and one group recruited from their homes., Results: Reduced appetite was present in 43% in the hospital group, compared to 15% in the home living group. Seventy-one % of those with reduced appetite were undernourished, while 44% with normal appetite were undernourished. The sensitivity for malnutrition was 0.55, while the positive predictive value was 0.71., Conclusion: Reduced appetite is common among aged people in hospital, and is a predictor for undernutrition.

Background: Atrophic glossitis is considered to be a marker for nutritional deficiency. Study of the tongue is part of the clinical examination. The importance of atrophic tongue has been unclear. As part of a bigger nutritional investigation in the elderly, we wanted to study the occurrence of atrophic tongue and relate this finding to other nutritional measures., Material: The presence of atrophic tongue was studied in 311 hospitalized, and in 106 randomly selected elderly at home., Results: Atrophic tongue was present in 100 of 311 hospitalized patients, and only in ten out of the 106 persons living in their own homes. Compared to those without, patients with atrophic tongue had significantly lower weight, body-mass index, triceps skinfold, arm muscle circumference and increased Katz index values for independence in daily activities. Patients with atrophic tongue had significantly reduced concentrations of serum cholesterol, ascorbic acid and calcidiol. Tongue atrophy had a sensitivity for serious malnutrition 0.30, for serious and moderate malnutrition together 0.70. The specificity for malnutrition was 0.76., Interpretation: We conclude that atrophic tongue is common in elderly people and a marker for malnutrition and reduced muscle function.

Aim: To examine the relationship between atrophic glossitis (absence of papillae in more than 50% of the tongue) and nutritional status., Design: A randomized population survey., Setting: The medical department of Aker University Hospital, and people living at home., Participants: 310 old people recently admitted to hospital and 106 randomly selected elderly people at home., Measures: The presence of atrophic glossitis and nutritional indices., Results: Atrophic glossitis occurred in 13.2% of men and 5.6% of women at home and in 26.6% of men and 37% of women in hospital. The atrophic glossitis was related to reduced weight, body mass index, triceps skinfold thickness, arm-muscle circumference, muscular strength, activities of daily living and serum concentrations of cholesterol, ascorbic acid, cholecalcidiol and B12, but not to levels of zinc or folate. In a multiple logistic regression model, atrophic glossitis was related only to cholesterol (P = 0.032), muscular strength (P = 0.018) and activities of daily living (P = 0.03)., Conclusion: Atrophic glossitis is common in elderly people and is a marker for malnutrition and reduced muscle function.

Objective: To examine the association between muscular function and the serum concentrations of 25-hydroxyvitamin D (calcidiol) and 1,25-dihydroxyvitamin D (calcitriol)., Design: A randomized population survey. Baseline measurements of serum calcidiol and calcitriol concentrations and assessment of muscular function (hand grip strength, ability to climb stairs, outdoor activity, and fall occurrence)., Setting: The Medical department, Aker University Hospital, Oslo, and subjects' homes., Participants: Two hundred forty-six recently hospitalized older patients and 103 randomly selected older people living at home., Measurements: Serum concentration of calcidiol and calcitriol in relation to muscle function., Main Results: Reduced muscle function was associated with low calcidiol levels. In both the hospital group and the home group, calcidiol concentrations correlated positively to arm muscle strength (r = .22, P < .001; r = .37, P < .001), ability to climb stairs (r = -.16, P < .05; r = -.42, P = < .001), physical activity (r = -.27, P < .001; r = -.31, P < .001), and the absence of fall occurrences (r = -.27, P < .001; r = -.31, P = .004). Calcitriol showed an association with physical activity in the hospital group (r = -.19, P < .05), and with fall last month in the home group (r = -.22, P < .05)., Conclusions: Older people with reduced muscle function often had reduced levels of calcidiol serum concentration. Low levels of calcidiol were not associated with signs of general undernutrition, such as low body mass, or with reduced arm-muscle circumference or triceps skinfold thickness. This finding may suggest a physiological role for calcidiol in muscle function. Reduced muscle strength increased disability in our older subjects, which may be improved by vitamin D supplementation in vitamin D-deficient subjects.

Vitamin D status, measured as serum calcidiol concentration, was studied in a group of 273 recently hospitalised patients at Aker University Hospital and compared to a group of 98 persons living in their own homes, all living in Oslo and all above 70 years of age. We found lower serum calcidiol concentrations in the hospital group than among people living in their own homes, in men as well as in women (mean +/- SD, 40.4 nmol/l +/- 23.2 vs 59.6 nmol/l +/- 28.9 in men and 37.5 nmol/l +/- 22.6 vs 48.5 +/- 20.3 in women). 34% of the men and 49% of the women in the hospital group had vitamin D deficiency (se. calcidiol < 20 nmol/l). There was no seasonal variation in the hospitalised group; the group living at home did show seasonal variations, with highest levels in late autumn (62.2 nmol/l) and lowest levels in February (42.7 nmol/l). The low levels of calcidiol concentration may contribute to the high prevalence of hip-fracture among elderly in Oslo.

The serum levels of intact parathyroid hormone and cholecalciferol metabolites have been measured in patients with hip fracture above 70 years of age admitted to hospital from home-living conditions and compared with serum levels in age- and sex-matched home-living control subjects. It was found that patients with hip fracture had significantly lower levels of calcidiol (29.7 +/- 15.9 vs 46.0 +/- 27.8 nmol/l) and calcitriol (63.6 +/- 25.0 vs 91.1 +/- 39.5 pmol/l) with no difference in serum levels of intact parathyroid hormone (4.7 +/- 2.1 vs 5.3 +/- 3.3 pmol/l). The data suggest that secondary hyperparathyroidism is not an important risk factor in our population of patients with hip fracture.

Objective: To determine the extent to which patients with objective signs of malnutrition had been diagnosed as such by physicians and the diagnosis documented in the medical record., Design: Cross-sectional., Subjects: All non-critically ill patients (n = 121) aged 70 years or older admitted to an Oslo hospital during a 3-week period., Methods: Compared problem list and other elements of the medical record with observations of height, weight, triceps skinfold, midarm circumference, and arm-muscle circumference made on first weekday in hospital. Serum albumin available on 66 subjects., Main Results: Nine patients had weight/height ratios below 60% of normal, 16 patients between 60% and 75%, and 41 patients between 74% and 90% of normal. Of these 66 patients, only 24 were recognized as malnourished on admission, only five received nutritional support, and none was diagnosed as having malnutrition at the time of discharge., Conclusions: Malnutrition is underdiagnosed and undertreated. The consequences of this are likely to be deleterious to health.