Search Results (194)

Background: Hereditary angioedema (HAE) is a rare, potentially life-threatening disease in which delayed recognition and inappropriate medication use may result in preventable morbidity and mortality. We aimed to assess physicians’ knowledge regarding HAE-related triggers, clinical features, and management strategies across multiple medical specialties. Methods: This single-center, cross-sectional survey was conducted among 350 physicians at a tertiary training and research hospital. A structured electronic questionnaire assessed knowledge of HAE pathophysiology, diagnosis, medication-related triggers, and management. A predefined composite knowledge score (0–14) was calculated. Results: Although self-reported familiarity with HAE was high, overall disease-specific knowledge was limited. Awareness of critical medication-related triggers—including angiotensin-converting enzyme inhibitors, dipeptidyl peptidase-4 inhibitors, and estrogen-containing therapies—was low across all specialties, with no significant between-group differences. Substantial knowledge gaps were identified in the recognition of clinical features, diagnostic evaluation, and acute management. In multivariable analysis, prior clinical exposure to HAE patients was the only independent predictor of higher knowledge scores (B = 1.097, p = 0.001), whereas specialty group, gender, and years of professional experience were not independently associated with knowledge scores. However, the regression model explained only a small proportion of the variance in knowledge scores. Conclusions: Significant gaps in clinically relevant HAE knowledge persist among physicians from multiple medical specialties. Prior clinical exposure was associated with higher knowledge scores, whereas specialty group, gender, and years of professional experience were not independently associated with physician knowledge. Targeted, practice-oriented educational interventions focusing on medication-related triggers and acute management may help bridge these knowledge gaps, complement experiential learning, and ultimately enhance patient safety. Full article

Background/Objectives: This study compared medication safety gaps across outpatient and inpatient care among older adults using explicit prescribing-quality criteria. Methods: We conducted an analytical cross-sectional study based on a retrospective review of 157 medical records from adults aged ≥ 60 years treated at Hospital Carlos Monge Medrano, a public referral hospital in Juliaca, Peru, in 2024. Stratified probability sampling included 73 outpatient and 84 inpatient records. Primary outcomes were Beers-defined potentially inappropriate medications, Screening Tool of Older Persons’ Prescriptions (STOPP)-defined potentially inappropriate prescribing, and Screening Tool to Alert to Right Treatment (START)-defined potential prescribing omissions. Overall medication safety gaps were assessed as a secondary exploratory composite outcome. Crude and adjusted prevalence ratios (PRs) with 95% confidence intervals (CIs) were estimated using modified Poisson regression with robust variance. Results: Overall medication safety gaps were identified in 79.0% of participants. START-defined omissions occurred in 52.9%, STOPP-defined inappropriate prescribing in 49.7%, and Beers-defined potentially inappropriate medications in 46.5%. Compared with outpatient care, hospitalization was associated with a lower prevalence of STOPP-defined inappropriate prescribing (adjusted PR = 0.74; 95% CI: 0.55–0.99) and a higher prevalence of START-defined omissions (adjusted PR = 1.39; 95% CI: 1.04–1.86). Polypharmacy and multimorbidity were independently associated with the composite outcome. Conclusions: Medication safety gaps were common but differed by care setting. Outpatient care showed more high-risk or insufficiently reviewed prescribing, whereas inpatient care showed more therapeutic omissions. These findings support prospective evaluation of medication review, reconciliation, deprescribing, and reassessment of omitted therapies in similar public referral settings. Full article

Background/Objective: Polypharmacy, conventionally defined as the concurrent use of five or more medications, has emerged as a critical public health challenge in aging populations worldwide. Polypharmacy in older adults, driven by multimorbidity and age-related physiological changes, increases the risk of adverse drug reactions, drug interactions, falls, cognitive impairment, non-adherence, and preventable hospitalization. This study aims to provide a structured narrative synthesis of the current evidence on the incidence, risk factors, and clinical management of polypharmacy in elderly patients, with particular emphasis on deprescribing strategies, interdisciplinary care models, patient education, and digital clinical decision support technologies. Methods: A structured narrative literature review was conducted across PubMed, Scopus, and Web of Science using Boolean combinations of MeSH and free text terms including ‘polypharmacy,’ ‘elderly,’ ‘deprescribing,’ and ‘medication review.’ Eligible sources were peer-reviewed primary studies published between January 2016 and June 2026 that enrolled adults aged ≥65 years and reported validated prescribing review approaches, such as the STOPP/START criteria. The review drew on 40 primary studies spanning randomized controlled trials (RCTs) and observational, qualitative, and mixed-methods designs, which were interpreted and synthesized narratively across the principal thematic domains of polypharmacy management. Results: Polypharmacy was independently and consistently associated with DDIs, preventable hospitalizations, and functional decline across diverse clinical settings. Pharmacist-led medication reviews and interdisciplinary, team-based interventions produced the most robust improvements in prescribing appropriateness and meaningful reductions in potentially inappropriate medications (PIMs). Electronic clinical decision support systems (CDSSs) have demonstrated measurable benefits for safe deprescribing at scale, although usability limitations, incomplete workflow integration, and clinician resistance are significant implementation obstacles. Conclusions: Effective management of polypharmacy in older adults requires a multicomponent, patient-centered strategy that integrates evidence-based deprescribing algorithms, principally the STOPP/START criteria, sustained interdisciplinary collaboration, structured patient education, and technology-assisted decision support. Full article

Objectives: The aging population in China presents significant challenges related to polypharmacy and potentially inappropriate medication (PIM) use among older outpatients. This study aimed to evaluate the prevalence and risk factors of PIM use in older Chinese outpatients using the 2017 Chinese criteria, 2019 AGS/Beers criteria, and 2014 STOPP criteria, and to assess the concordance among these three criteria. Methods: A cross-sectional study was conducted using outpatient prescription data from 59 hospitals across six Chinese cities between January and December 2021. Prescriptions for patients aged ≥65 years were included. PIMs were identified using the three criteria. Concordance was evaluated using weighted kappa statistics. Multivariate logistic regression was used to identify factors associated with PIM use. Results: Among 131,894 prescriptions, PIM prevalence was 29.00%, 27.77%, and 19.85% according to the Chinese, Beers, and STOPP criteria, respectively. The most common PIM was estazolam. Concordance was moderate between the Chinese and Beers criteria (kappa = 0.58), STOPP criteria (kappa = 0.625), and good between Beers and STOPP criteria (kappa = 0.73). Factors associated with PIM use included age ≥80 years, polypharmacy, full self-payment, and diagnoses such as sleep disorders and arthritis. Conclusions: PIM use is prevalent among older outpatients in China, with varying rates across different criteria and regions. Interventions targeting high-risk groups and specific drug classes may improve medication safety in this population. Full article

Therapeutic inertia has been extensively examined in chronic medical conditions but remains insufficiently conceptualized and empirically studied in psychiatry. This structured narrative review examines therapeutic inertia as a multilevel and potentially bidirectional phenomenon arising when clinically relevant care is not reconsidered or modified despite unmet therapeutic goals and the availability of a reasonable and feasible alternative. A targeted PubMed search was supplemented by backward and forward citation searching, prioritizing psychiatric evidence and foundational literature on clinical decision-making under uncertainty. The review distinguishes therapeutic inertia from appropriate caution, watchful waiting, informed refusal, structural non-access, therapeutic nihilism, medical futility, therapeutic obstinacy, and evidence-based deprescribing. Potential determinants include cognitive and emotional mechanisms, diagnostic and prognostic uncertainty, adverse-effect concerns, patient preferences and previous experiences, therapeutic relationships, resource constraints, fragmented care, guideline structures, workload, and medicolegal culture. Clozapine underutilization in treatment-resistant schizophrenia represents the most compelling psychiatric example, while direct but more limited evidence is available in major depressive and bipolar disorders; applications to anxiety, obsessive-compulsive, substance-use, and non-pharmacological care remain largely hypothesis-generating. Strategies include explicit therapeutic goals, planned reassessment, measurement-based and guideline-informed care, shared decision-making, multidisciplinary review, improved access, clinical decision support, and audit and feedback. Future research should use operational definitions, experimental and observational designs, patient-centered outcomes, and real-world data to determine when treatment non-modification is inappropriate and whether corrective interventions improve care without promoting indiscriminate escalation, coercion, polypharmacy, or premature discontinuation. Full article

Antimicrobial resistance—partly driven by inappropriate antibiotic consumption—is a major public health threat. Point-of-care (POC) procalcitonin testing can reduce antibiotic prescribing safely. Within an implementation-effectiveness trial, we conducted a two-phase participatory context analysis to identify and prioritise determinants of POC procalcitonin adoption, implementation and continued use in Swiss primary care. First, we conducted 32 semi-structured interviews with 34 participants, including physicians, representatives of medical organisations, patient representatives and other stakeholders. By coding transcripts deductively using the Consolidated Framework for Implementation Research and inductively, we identified 86 potential determinants. Second, in a focus group with ten ImpPro research team members, 15 determinants were identified as ‘not requiring change’, and ten were considered ‘unchangeable’. Among the remaining 61 determinants, 41 were prioritised through dot-voting and group discussion. These key implementation determinants were inductively grouped into eight themes. The themes with the highest priority were: (1) physicians’ awareness, knowledge, and access to education regarding POC procalcitonin, (2) scientific evidence supporting POC procalcitonin-guided antibiotic prescribing, (3) physician motivation and (4) endorsement of POC procalcitonin by credible organisations and experts. Addressing these determinants will likely require a tailored, multifaceted (combining several unique strategies), and multilevel (targeting different levels of the system) implementation strategy. Full article

Background/Objectives: Frailty is a clinically significant syndrome in older patients with ischemic heart disease, associated with adverse outcomes including hospitalization, disability, and mortality. This study aimed to evaluate the association of potentially inappropriate medication (PIM) and the Geriatric Nutrition Risk Index (GNRI) with the incidence of frailty among elderly patients with ischemic heart disease (IHD). Methods: This retrospective cohort study enrolled elderly patients with IHD between January 2018 and March 2024. Patients were grouped by PIM use and GNRI levels (<92 vs. ≥92). Cox proportional hazards models assessed the associations of PIM and GNRI with the incidence of frailty. Subgroup and sensitivity analyses evaluated the consistency and robustness of these findings. Results: PIM use was associated with a significantly higher risk of frailty (HR = 3.01, 95% CI = 2.48–3.65) than non-use. Similarly, lower GNRI increased the risk of frailty compared to higher GNRI (HR = 1.31, 95% CI = 1.12–1.54). Patients with both PIM and lower GNRI may have a higher risk of frailty, with an adjusted aHR of 4.09. Subgroup analyses showed significant interactions between GNRI and hypertension. Sensitivity analyses indicated that PIM (aHR = 2.65) and lower GNRI (aHR = 1.14) remained significantly associated with frailty, even after including those with pre-existing frailty. Conclusions: For elderly patients with IHD, both PIM and lower GNRI were significantly associated with the incidence of frailty. These findings suggest that PIM exposure and low GNRI may serve as clinically accessible markers for identifying older IHD patients at elevated risk of frailty. Full article

Background/Objectives: Polypharmacy is common in elderly nursing home residents (NHR), due to the high prevalence of chronic diseases. This practice increases the risk of clinically significant drug–drug interactions (DDIs) with serious consequences for patient health and safety. The objective of this study was to evaluate the prevalence of DDIs using the UpToDate Drug–Drug Interaction Checker, potentially inappropriate medication (PIM, as defined by the STOPP-START criteria), and their association with major clinical outcomes. Methods: Demographic data, clinical history and detailed medication records of 275 patients from Romania were collected. Potentially inappropriate medications were identified using 16 selected criteria from the 2023 STOPP/START guidelines. Statistical analysis was performed using GraphPad, R, and Python, involving Chi-squared and Fisher’s exact tests with Benjamini–Hochberg correction, linear regression, and drug-interaction network analysis to characterise interaction frequency and severity. Results: Detailed medical histories over the past year were available for 76 patients. The mean number of drugs prescribed was 9.61 ± 4.47 drugs, with an average of 10.68 ± 10.54 potential interactions per patient. The primary clinical outcome was associated with not respecting certain STOPP-START recommendations (p < 0.01). Overall, 33.1% of NHRs utilised herbal supplements, resulting in a total of 76 potential herb–drug interactions. Conclusions: The results suggest a potential impact of DDIs on clinical outcomes, underscoring the need for further studies to clarify causality. The use of STOPP/START recommendations and deprescribing could lead to better tolerability and smaller drug-related burden in the institutionalised, elderly population. Full article

Background/Objectives: Inappropriate medication storage and disposal are recognized public health concerns and represent a relevant source of environmental exposure to pharmaceutical compounds, with potential implications for ecosystem and human health. Identifying population-level determinants of these behaviors is essential to support targeted interventions and risk mitigation strategies. Methods: A cross-sectional population-based study was conducted using a structured survey administered to Brazilian adults. The questionnaire assessed medication storage practices, disposal behaviors, and prior exposure to guidance on appropriate medication handling. Descriptive statistics were used to characterize the sample, and multivariate logistic regression analysis was performed to identify independent predictors of appropriate disposal practices. Results: A total of 475 participants were included in the analysis. Although awareness of the environmental impact of improper medication disposal was high, inappropriate practices remained prevalent. Multivariate logistic regression identified educational level as the primary independent determinant of appropriate disposal practices (p < 0.001), while no significant associations were observed for age or gender (p > 0.05). Lack of prior guidance was frequent and may represent a relevant population-level exposure influencing unsafe behaviors. Conclusions: The findings highlight a gap between awareness and practice and identify key sociodemographic determinants influencing medication disposal behaviors. From an environmental epidemiology perspective, improper disposal may contribute to the dissemination of pharmaceutical residues in water systems, representing an indirect but widespread exposure pathway. Targeted public health strategies focusing on high-risk groups are needed to promote safe medication handling and reduce environmental and health risks. Full article

Background: Adverse drug reactions (ADRs) represent a major and often underestimated source of morbidity, hospitalization, and functional decline in older adults. The convergence of age-related pharmacokinetic and pharmacodynamic changes, multimorbidity, polypharmacy, and frailty creates a clinical environment in which ADR risk is not static but evolves along progressive trajectories—from mild, early manifestations toward severe, potentially irreversible outcomes. Understanding these trajectories is essential for rational geriatric prescribing. Methods: This narrative review synthesizes evidence from epidemiological studies, systematic reviews, Cochrane analyses, and clinical trials published between 2000 and 2025, focusing on adults aged 65 years and older with two or more chronic conditions. Sources were identified through a structured, non-systematic literature search of PubMed, EMBASE, Cochrane Library, Web of Science, and Scopus using the terms ‘adverse drug reactions’, ‘polypharmacy’, ‘multimorbidity’, ‘frailty’, ‘deprescribing’, and ‘pharmacokinetics’ in older adults, alone and in combination. Evidence quality was assessed narratively, distinguishing trial evidence from observational and expert consensus data. Results: ADRs in older adults are best classified using complementary frameworks—the augmented Type A to withdrawal Type E and failure-of-therapy Type F taxonomy (Types A–F), the Dose-Time-Susceptibility (DoTS) classification, and the EIDOS mechanistic scheme—which together capture the heterogeneity of drug-related harm in this population. Age-related pharmacokinetic changes (altered absorption, increased volume of distribution of lipophilic drugs, reduced hepatic and renal clearance) and pharmacodynamic shifts (heightened receptor sensitivity, baroreflex impairment, increased blood–brain barrier permeability) interact with polypharmacy and frailty to amplify ADR trajectories from mild to severe. Anticholinergic burden, prescribing cascades, and inappropriate polypharmacy function as structural accelerators of these trajectories. Medication review and deprescribing improve prescribing quality but evidence for hard outcome benefits remains of low to very low certainty. Emerging AI-enabled digital tools show promising accuracy for identifying frailty and pharmacological vulnerability, but this performance relates to frailty classification and has not yet been shown to prevent ADR trajectories; they require validation for routine clinical use. Conclusions: Recognizing ADRs in older adults as dynamic trajectories rather than isolated events repositions prescribing review and deprescribing from optional to essential clinical acts. An integrated approach combining pharmacological vigilance, comprehensive geriatric assessment, structured deprescribing, and emerging digital decision-support tools offers the most realistic pathway to reduce the trajectory-related burden of drug-related harm in complex older patients. Full article

Background: Antimicrobial resistance, driven by inappropriate use and overuse of antibiotics, is a major public health threat. Diarrhea and respiratory illness are the leading causes of pediatric healthcare visits in low- and middle-income countries like Bangladesh. Despite clear WHO guidelines recommending limited use of antibiotics for these conditions, potentially inappropriate or non-prescription antibiotic use remains a concern. Methods: We interviewed caregivers of 3025 under-5 children via cellphones to assess common illnesses, associated care-seeking practices, and antibiotic use for diarrhea and respiratory illnesses experienced by their children in the prior 14 days. Caregivers were identified through hospital outpatient screening and were contacted over the phone for the interview at least two months after that hospital visit. Results: Among the participants, 116 (3.8%) reported diarrheal disease and 570 (18.8%) experienced respiratory illness during the preceding 2-week recall period. Among the children with diarrhea, 52.6% received antibiotics, and 73.8% obtained them over the counter from pharmacies. Among those with respiratory illness, 26.3% received antibiotics, and 58% procured them from local drugstores without a prescription from a registered physician. For diarrhea, azithromycin and metronidazole were the commonly used antibiotics, while for respiratory illness, cefixime and azithromycin were frequently used. Notably, 68% of the diarrheal children either sought care from local drugstores, were self-medicated, or did not receive any formal treatment. Conventional practice, long wait times at healthcare facilities, distance, and poverty were the main reasons for not seeking care from a registered healthcare provider. Conclusions: Understanding community-level antibiotic use and care-seeking behavior is essential to strengthening antibiotic stewardship and child health programs. Our findings suggest the need for context-sensitive community education, improved access to appropriate care, and enforcement of regulations restricting the over-the-counter sale of antibiotics to curb irrational and excessive antibiotic use. Full article

Background: The COVID-19 pandemic was associated with extensive empirical antibiotic exposure despite the predominantly viral etiology of the disease. Evaluating patterns of azithromycin use, prescribing determinants, and appropriateness provides insight into real-world antibiotic use under conditions of diagnostic uncertainty. Methods: We performed a retrospective cohort study including 3200 adult patients hospitalized with laboratory-confirmed COVID-19 at the General Hospital in Ferizaj between June 2020 and June 2022. Demographic characteristics, comorbidities, markers of disease severity, laboratory parameters, and antibiotic exposure were extracted from medical records. Azithromycin prescriptions were classified as appropriate, potentially appropriate, or inappropriate based on predefined clinical and laboratory indicators suggestive of bacterial co-infection. Drug utilization patterns, temporal trends, and independent determinants of inappropriate prescribing were assessed using descriptive analyses and multivariable logistic regression modeling. Results: Among 3200 hospitalized patients, 1968 (61.5%) received azithromycin. Of these prescriptions, 612 (31.1%) were classified as appropriate, 418 (21.3%) as potentially appropriate, and 938 (47.6%) as inappropriate. The proportion of inappropriate use decreased over time, from 52.4% in 2020–2021 to 38.7% in 2022 (p < 0.001). However, a substantial proportion of prescriptions remained inappropriate throughout the study period. In multivariable analysis, absence of laboratory markers suggestive of bacterial infection (OR 2.41; 95% CI 1.98–2.93), concomitant use of more than one antibiotic (OR 1.67; 95% CI 1.32–2.11), and lower clinical severity at admission (OR 1.54; 95% CI 1.21–1.95) were independently associated with inappropriate azithromycin prescribing. Conclusions: Azithromycin use was frequent among hospitalized adults with COVID-19, and a considerable proportion of prescriptions lacked clinical or laboratory justification. Although prescribing patterns changed over time, the persistence of inappropriate use highlights ongoing challenges in aligning antibiotic use with emerging evidence. These findings contribute to the understanding of antibiotic utilization patterns in acute care settings and underscore the importance of integrating objective diagnostic indicators into antimicrobial decision-making to strengthen stewardship practice. Full article

Background: The integration of large language models (LLMs) into healthcare has rapidly expanded, particularly in the domain of patient education. However, concerns remain regarding the accuracy, adequacy, and clinical safety of AI-generated medical information. This study aimed to systematically evaluate expert-perceived quality, content appropriateness, and potential clinical risk of responses generated by a GPT-5.3–based large language model to patient-oriented questions on scoliosis. Methods: A set of patient-oriented questions was developed based on common informational needs. Responses generated by the AI model were evaluated by a panel of experts using a multidimensional assessment framework, including general appropriateness, scientific accuracy, adequacy, and clarity. Content validity was assessed using the Content Validity Ratio (CVR) and Content Validity Index (CVI). In addition, clinical risk levels were categorized, and common issues in inappropriate responses were analyzed. CVR and CVI were used to quantify expert agreement regarding perceived content appropriateness, rather than to establish definitive factual correctness or guideline concordance. Results: All responses exceeded the predefined acceptable CVR threshold, and overall CVI values were high, indicating a high level of expert agreement regarding perceived response appropriateness. Clarity received the highest scores across all dimensions, whereas adequacy and scientific accuracy were relatively lower. Most responses were classified as harmless or low risk, and no high-risk responses were identified. The most frequently reported issue in inappropriate responses was insufficient information. Conclusions: Large language models may provide understandable and generally acceptable responses in a controlled expert-evaluation setting. However, these findings reflect expert-perceived appropriateness rather than definitive clinical validity or guideline concordance. AI-generated responses should therefore be used only as supportive educational tools under clinical oversight. Full article

Background/Objectives: The accumulation of unused and expired pharmaceuticals in households is a growing public health concern with implications for patient safety, rational drug use, and environmental health. However, systematic risk characterization integrating clinical and environmental perspectives at the community level remains limited, particularly in low- and middle-income settings. This study aimed to develop and apply a composite risk index, grounded in an eco-pharmacovigilance framework, for the assessment of health risks associated with accumulated household pharmaceuticals in southeastern Mexico. Methods: A cross-sectional study was conducted in 526 randomly selected households using stratified sampling. Guided in-home medication inventories were performed with participant collaboration, and pharmaceuticals were classified according to the Anatomical Therapeutic Chemical (ATC) system. A composite risk index (CRI = Fr × PR) was developed within an eco-pharmacovigilance framework. The frequency of accumulation (Fr) for each therapeutic group was multiplied by a potential risk score (PR) derived through a structured multidisciplinary expert consensus process integrating clinical toxicity, environmental persistence, and antimicrobial resistance potential. Results: A total of 2184 pharmaceutical units were recorded during the household inventories, of which 28.7% were expired. Expired medications were primarily retained rather than actively used, representing a latent risk for inappropriate self-medication and accidental exposure. The therapeutic groups with the highest CRI values were antihypertensives (CRI = 42.3), antidiabetics (CRI = 37.8), and antibiotics (CRI = 31.5), indicating a relatively higher contribution within the composite risk index framework to overall household pharmaceutical risk. These findings highlight priority therapeutic groups driven by the combined effect of high accumulation frequency, distinct accumulation patterns, and intrinsic hazard. Conclusions: Household pharmaceutical accumulation can be characterized using a composite, eco-pharmacovigilance-based approach that integrates exposure and hazard dimensions. The proposed framework functions as a prioritization tool rather than a precise quantitative measure, enabling the identification of therapeutic groups requiring targeted intervention. Findings should be interpreted as indicative of relative risk patterns rather than precise estimates, given the exploratory design and guided data collection approach. The proposed framework provides a practical tool for prioritizing interventions aimed at improving rational drug use, reducing accumulation, and mitigating environmental impact. Further validation in diverse settings is warranted to strengthen its applicability. Full article

Older adults with type 2 diabetes mellitus (T2DM) are at high risk of polypharmacy and potentially inappropriate medication (PIM) use because of multimorbidity and complex treatment regimens. This systematic review and meta-analysis (PRISMA 2020; PROSPERO CRD420251149348) aimed to estimate the prevalence of polypharmacy and PIM use, describe PIM burden and patterns, and summarize the co-occurrence of PIMs among those with polypharmacy. On 7 September 2025, we searched PubMed, Scopus, Embase, Web of Science, and MEDLINE using a structured search strategy based on the PICO framework. Observational studies of older adults (≥65 years) with T2DM reporting polypharmacy and PIMs were included. Risk of bias was assessed using the JBI checklist, and prevalence estimates were synthesized using a random-effects meta-analysis. Five studies (13,350 participants) were included. Polypharmacy prevalence ranged from 43.6% to 95.3%, while PIM prevalence ranged from 23.4% to 74%. The co-occurrence of PIMs among polypharmacy users ranged from 39.6% to 74%. Commonly reported PIM classes included long-acting sulfonylureas, proton pump inhibitors, and benzodiazepines. Overall, polypharmacy and PIM use were frequently reported among older adults with T2DM; however, the wide variation in prevalence across studies indicates substantial clinical and methodological heterogeneity. These findings highlight the need for structured medication review and clinical context-based medication optimization beyond numerical thresholds. Full article