[Prescription appropriateness in elderly patients with polypharmacy in primary care: Cluster-randomized controlled trial PHARM-PC]

Systematic review and meta-analysis on the effectiveness of multidisciplinary interventions to address polypharmacy in community-dwelling older adults

Interventions to address polypharmacy in community-dwelling older adults often focus on medication-related outcomes. The aim was to explore the impact of multidisciplinary interventions to manage polypharmacy on clinical outcomes for community-dwelling older adults. This systematic review and meta-analysis included randomized controlled trials (RCTs) on interventions by at least a pharmacist and a physician, indexed in MEDLINE, EMBASE or CENTRAL up to January 2023. Evidence certainty was assessed using the GRADE approach. Seventeen RCTs were included. Fifteen were rated as 'high' risk of bias. No relevant benefits were found in functional and cognitive status (primary outcomes), falls, mortality, quality of life, patient satisfaction, hospital admissions, emergency department or primary care visits. Interventions reduced medication costs, improved medication appropriateness (odds ratio [OR] 0.39), reduced number of medications (mean difference [MD] -0.57), resolved medication-related problems (MD -0.45), and improved medication adherence (relative risk [RR] 1.14). There was a low or very low certainty of the evidence for most outcomes. Multidisciplinary interventions to address polypharmacy appear effective in improving multiple dimensions of medication use. However, evidence for corresponding improvements in functional or cognitive status is scarce. New efficient models of multidisciplinary interventions to address polypharmacy impacting clinical outcomes should be explored.

Primary care pharmacist-led medication review in older adult patients in coordination with general practitioners: an observational retrospective cohorts study

Background

Polypharmacy and risk of potentially inappropriate prescribing (PIP) in older adult are being continuously increased. Including a primary care pharmacist (PCP) in the healthcare team is associated with lower rates of medication-related problems (MRPs).

Objectives

To determine the impact (in terms of variation of PIP, MRPs and polymedication) of treatment reviews (TR) carried out by the PCP by comparing two cohorts: standard TR vs coordinated TR with prescribing General Practitioners (GP). To assess possible health outcomes in both groups 6 months post-TR.

Methods

This is an observational study of two retrospective cohorts (2018 to 2020). All patients who met the inclusion/exclusion criteria were analyzed. Patients ≥65 years, who underwent complete TR by the PCP were included. Patients in a situation of exitus at the time of TR and those who underwent a partial TR were excluded. Control group cohort consisted of patients who underwent standard TR, and intervention group cohort consisted of those who underwent TR coordinated with GP. Sociodemographic, clinical and pharmacological variables were analyzed.

Results

181 patients were enrolled. Mean age 84.4 ± 7.2 years, 78.5% women. Variables (GP-coordinated vs standard TRs) pre-post: decrease in drugs/patient 1.9 (95%CI: 1.4-2.4) vs 0.6 (95%CI: 0.2-1.3), p < 0.05; decrease in MRPs/patient 3.1 (95%CI: 2.8-3.4) vs 1.0 (95%CI: 0.6-1.4), p < 0.05; decrease in PIP/patient 2.0 (95% CI: 1.6-2.2) vs 0.6 (95% CI: 0.2-0.9), p < 0.05. Health outcomes: there was significant difference in average primary-care visits/patient 1.3 ± 0.5 vs 2.2 ± 1.8, p < 0.05.

Conclusions

Multidisciplinary interventions between PCP and GP, together with a systematic approach to TR can improve the quality of pharmacotherapy in the elderly. Prospective large follow-up studies are needed to demonstrate a positive trend in health outcomes.