Use of pharmacists by older people in the community

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug-related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.

OBJECTIVES

We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care.

SEARCH METHODS

We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events.

DATA COLLECTION AND ANALYSIS

Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes.

MAIN RESULTS

We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow-up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low-certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high-certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low-certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low-risk population and 12 for a high-risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results.

AUTHORS' CONCLUSIONS

We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow-up ranging from 30 days to one year, important treatment effects may have been overlooked. High-quality trials with long-term follow-up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long-term follow-up.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug related harms and poorer adherence. The concept of medication review is a key element in improving the quality of prescribing and the prevention of adverse drug events. While no generally accepted definition of medication review exists, it can be defined as a systematic assessment of the pharmacotherapy of an individual patient that aims to evaluate and optimise patient medication by a change (or not) in prescription, either by a recommendation or by a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.

OBJECTIVES

We examined whether the delivery of a medication review by a physician, pharmacist or other healthcare professional improves the health outcomes of hospitalised adult patients compared to standard care.

SEARCH METHODS

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Specialised Register (August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library 2011, Issue 8; MEDLINE (1946 to August 2011); EMBASE (1980 to August 2011); CINAHL (1980 to August 2011); International Pharmaceutical Abstracts (1970 to August 2011); and Web of Science (August 2011). In addition we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We did not apply any language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality and secondary outcomes included hospital readmission, emergency department contacts and adverse drug events.

DATA COLLECTION AND ANALYSIS

Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and additional unpublished data. We calculated relative risks for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)).

MAIN RESULTS

We identified 4647 references and included five trials (1186 participants). Follow-up ranged from 30 days to one year. We found no evidence of effect on all-cause mortality (risk ratio (RR) 0.98; 95% CI 0.78 to 1.23) and hospital readmissions (RR 1.01; 95% CI 0.88 to 1.16), but a 36% relative reduction in emergency department contacts (RR 0.64; 95% CI 0.46 to 0.89).

AUTHORS' CONCLUSIONS

It is uncertain whether medication review reduces mortality or hospital readmissions, but medication review seems to reduce emergency department contacts. However, the cost-effectiveness of this intervention is not known and due to the uncertainty of the estimates of mortality and readmissions and the short follow-up, important treatment effects may have been overlooked. Therefore, medication review should preferably be undertaken in the context of clinical trials. High quality trials with long follow-up are needed before medication review should be implemented.

Statins and the interface between patient and community pharmacist

Objective

To elicit and compare patients' and pharmacists' views on their interactions during the dispensing of prescriptions for statins.

Method

Semi-structured interviews with 25 patients who were current or previous recipients of a statin on prescription, and 20 community pharmacists. Patient interviews explored their experiences of interacting with community pharmacists when first-time or repeat prescriptions were dispensed for statins. Pharmacist interview topics included roles that pharmacists currently perform in relation to patients receiving statins on prescription, and perceived responsibilities in relation to patients receiving prescribed statins.

Key findings

Most patients said they used the same pharmacy regularly to get their prescriptions dispensed. Despite this, few patients' accounts indicated a perceived relationship with the pharmacist. Most pharmacists reported that they routinely provided information about dosage and side-effects to patients receiving a statin on prescription for the first time. In contrast, patients rarely reported that they had received such information from a pharmacist. In relation to repeat prescriptions for statins, patients' and pharmacists' accounts were similar and indicated that pharmacists rarely initiate discussions about treatment. Pharmacists' explanation for this was that they assumed the patient would already have received all the information they needed from other health professionals, and that patients would ask if they had any further queries.

Conclusions

These findings indicate a gap between pharmacists' perceptions of their interactions with patients receiving a first-time prescription for a statin and patients' reported experience. Pharmacists may perceive that they provide more information than is actually the case. Pharmacists and patients agreed that when repeat prescriptions for statins are being dispensed there is little or no discussion about the medicine. Pharmacists need to consider how they might elicit patients' needs in a more systematic way.

How do physicians conduct medication reviews?

BACKGROUND

Medication reviews are recommended annually for older patients. A medication review is a discussion of a patient's complete set of medications, but the actual content of a review is not well specified. The medical literature suggests that it is an exhaustive evaluation, but what physicians actually ask about their patients' medication regimens has been little studied.

OBJECTIVE

To describe what physicians do when they review medications in the office setting.

METHODS

Qualitative content analysis of audio-taped encounters between 100 patients aged 65 and older and 28 primary care physicians in two health care systems in Sacramento, California.

RESULTS

Physicians use a combination of non-mutually exclusive strategies when reviewing chronic medications that include: (1) efforts to obtain a complete list of patient medications (36% of visits), (2) discussion of a topic related to the management of each of a patient's chronic medications (47% of visits), and (3) sequential discussion of the majority of a patient's medications without intervening discussion (45% of visits). Of 10 medication management topics that were discussed in medication reviews, a mean of 1.5 topics (SD = 1.7, range 0-7) were mentioned for each medication, with efficacy and directions being most common. Physicians conducted a sequential discussion that included discussion of each of a patient's medications in only 32% of visits.

CONCLUSIONS

Comprehensive discussions about chronic medications are uncommon in routine practice. Practical conceptualization of what constitutes a physician-conducted medication review is needed.

Which providers should communicate which critical information about a new medication? Patient, pharmacist, and physician perspectives

OBJECTIVES

To investigate older patient, pharmacist, and physician perspectives about what information is essential to impart to patients receiving new medication prescriptions and who should provide the information.

DESIGN

Qualitative focus group discussions.

SETTINGS

Senior centers, retail pharmacies, and primary care physician offices.

PARTICIPANTS

Forty-two patients aged 65 and older, 13 pharmacists, and 17 physicians participated in eight focus groups.

MEASUREMENT

Qualitative analysis of transcribed focus group interviews and consensus through iterative review by multidisciplinary auditors.

RESULTS

Patient, pharmacist, and physician groups all affirmed the importance of discussing medication directions and side effects and said that physicians should educate about side effects and that pharmacists could adequately counsel about certain important issues. However, there was substantial disagreement between groups about which provider could communicate which critical elements of medication-related information. Some pharmacists felt that they were best equipped to discuss medication-related issues but acknowledged that many patients want physicians to do this. Physicians tended to believe that they should provide most new-medication education for patients. Patients had mixed preferences. Patients aged 80 and older listed fewer critical topics of discussion than younger patients.

CONCLUSION

Patients, pharmacists, and physicians have incongruent beliefs about who should provide essential medication-related information. Differing expectations could lead to overlapping, inefficient efforts that result in communication deficiencies when patients receive a new medication. Collaborative efforts to ensure that patients receive complete information about new medications could be explored.

Pharmacist or physician: age differences in satisfaction with medical advice

Two studies examined predictors of medical care satisfaction in communities in Eastern Canada. Both studies focused on how the roles of pharmacists and physicians are perceived by adults of different ages. Using a survey methodology, Study 1 demonstrated that middle-aged adults, older adults, and community pharmacists differ in the extent to which they rate pharmacists as being important members of the health care team. Specifically, community members value pharmacists as health care providers, and this is especially true for older adults. Using an experimental paradigm, Study 2 examined ratings of medical interaction scenarios, ratings that varied as a function of kind of health professional (pharmacist vs. physician) and type of advice (directive vs. non-directive). Results suggest that older adults may have a more complex set of expectations about their health care interactions than do younger adults and that, for older adults, the factors that determine satisfaction differ across the professions being evaluated.

Patient sources of drug information and attitudes to their provision: a corticosteroid model

AIM

To determine patient's preferred sources of drug information and their attitudes to how this is provided.

DESIGN

A quantitative evaluation via personal interviews using a formal questionnaire. SUBJECT AND SETTINGS: A group of 101 in-patients in a chest ward at the Royal Devon & Exeter Healthcare NHS Trust.

OUTCOME MEASURES

Preferred sources for medication advice; personal involvement in own treatment; adequacy of consultation period; medication compliance; post discharge sources of drug information; recalled benefits and side effects of corticosteroids.

RESULTS

Preferred source of drug information was: doctor (35%), pharmacist (11%) and nurse 4%. Sixty percent of patients wanted to be involved in the choice of their medication, thirty-nine percent leaving it totally to the doctor and one patient who wanted the final word in what was prescribed. Sufficient discussion time with GPs was reported by 66% of patients (12%, insufficient) and 53% with hospital doctors (19%, insufficient). Non-compliance with medication was reported by 66% and compliance by 24%. Medication advice sources used when at home were; community pharmacists (22%), GPs/books & magazines/specialist societies (all 18%), nurses (10%) and others less than 8%. Benefits of corticosteroids recalled by patients were: 'improving breathing' (14), 'general improvement' (9) and 'improved mobility'/'greater appetite' (both 5)' with little change' reported by 13. Knowledge of side effects was much more comprehensive with; oedema/weight gain (50), skin/hair problems (33), osteoporosis (33), bruising (12) and mood changes (10) most commonly featured in responses. Almost all patients confirmed they liked to be given printed information about their medication.

CONCLUSION

Patients sought their medication advice from a variety of sources and armed with this almost two thirds of patients wished to exercise their rights to be involved with their treatment planning. Sufficient discussion time appeared to be available to about half of the interviewees though only a few understood the intended benefits of prescribed corticosteroids used as an example in this work. A much better knowledge of drug side effects might have partly explained the high level of declared non-compliance. Although pharmacists featured as the preferred source of drug information for some patients, a much more detailed investigation is needed of patients' attitudes to the profession and to individuals' consultation and communication skills.

[A literature review on pharmacists' interventions in the use of medication by elderly patients]

The total proportional geriatric population in Brazil is projected to increase from 9.05% in 1999 to approximately 13% in 2020. Non-communicable diseases are common in this age group, and medication is used frequently. Inadequate prescription and improper use of drugs can produce undesirable outcomes, leading to avoidable hospitalization and increasing health care costs. The objective of this paper was to conduct a literature review of pharmacists' interventions and their influence on use of medication by elderly patients, based on five databases from 1970 to 1999. The sample consisted of 76 studies, of which 15 were analyzed and discussed. Research on this subject is scarce, and limited to developed countries. In general, the interventions presented favorable outcomes. Most actions were limited to counseling patients and their physicians, and there was a lack of interventions to adjust the medication to the user.