Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice: a randomised controlled trial

Harmonizing the definition of medication reviews for their collaborative implementation and documentation in electronic patient records: A Delphi consensus study

BACKGROUND

Medication review practices have evolved internationally in a direction in which not only physicians but also other healthcare professionals conduct medication reviews according to agreed practices. Collaborative practices have increasingly highlighted the need for electronic joint platforms where information on medication regimens and their implementation can be documented, kept updated, and shared.

OBJECTIVE

The aim of this study was to harmonize the definition of medication reviews and create a unified conceptual basis for their collaborative implementation and documentation in electronic patient records (definition appellation: collaborative medication review).

METHODS

The study was conducted using the Delphi consensus survey with three interprofessional expert panel rounds in September-December 2020. The consensus rate was set at 80%. Experts assessed the proposed definition of collaborative medication review based on an international and national inventory of medication review definitions. The expert panel (n = 41) involved 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals. The range of response rates for the rounds was 63-88%.

RESULTS

The experts commented on which of the pre-selected items (n = 75) characterizing medication reviews should be included in the definition of collaborative medication review. The items were divided into the following five themes and 51 of them reached consensus: 1) Actions included in the collaborative medication review (n = 24/24), 2) Settings where the review should be conducted (n = 5/5), 3) Situations where the review should be considered as needed and carried out (n = 10/11), 4) Prioritization of top five benefits to be achieved by the review and 5) Prioritization of top five patient groups to whom the review should be targeted.

CONCLUSIONS

A strong interprofessional consensus was reached on the definition of collaborative medication review. The most challenging was to identify individual patient groups benefiting from the review.

Medication Review: What's in a Name and What Is It about?

BACKGROUND

Medication review is a multifaceted service aimed at optimizing the use of medicines and enhancing the health outcomes of patients. Due to its complexity, it is crucial to clearly describe the service, its variants, and its components to avoid confusion and ensure a better understanding of medication review among healthcare providers.

AIM

This study aims to bring clarity to the origins, definitions, abbreviations, and types of medication reviews, together with the primary criteria that delineate key features of this service.

METHOD

A narrative review approach was employed to clarify the diverse terminology associated with "medication review" services. Relevant references were initially identified through searches on PubMed and Google Scholar, complementing the existing literature known to the authors.

RESULTS

The study uncovers a complicated and sometimes convoluted history of "medication review" in different regions around the world. The initial optimization of medicine use had an economic purpose before evolving subsequently into a more patient-oriented approach. A selection of abbreviations, definitions, and types were outlined to enhance the understanding of the service.

CONCLUSIONS

The study underscores the urgent need for comprehensive information and standardization regarding the content and quality of the services, collectively referred to as "medication review".

Medicine-related problems: A recurrent issue among residents living in nursing homes

Aim: To examine the incidence and nature of medicine-related problems over time experienced by nursing home residents.

Method: We analyzed records collected in the Reducing Medicine-Induced Deterioration and Adverse Events (ReMInDAR) trial. The trial pharmacists provided services to reduce medicine-induced deterioration and adverse reactions for residents every 8-weeks over a year. The problems identified by the pharmacists were documented in reports and subsequently classified independently by research pharmacists using the D.O.C.U.M.E.N.T system. The number and type of problems at each service and time to develop a new problem post first session were assessed. All analyses were performed using R software (Version 4.1.1).

Results: The cohort was 115 nursing home residents who received 575 services. In the 12-months, a total of 673 medicine-related problems or symptom reports were identified in 112 residents. Most residents (75%) experienced a new medicine-related problem by the fourth month post the first assessment. After the first session, the proportion of residents with a new medicine-related problem or symptom report declined at each repeated pharmacy session (59% at visit 2 vs. 28% at visit 6, p < 0.01).

Conclusion: Residents living in nursing homes frequently experience medicine-related problems. Our results suggest clinical pharmacist services performed every 4-months may have the potential to reduce the medicine-related problems in nursing homes.

Development, validation and evaluation of an online medication review tool (MedReview)

Objectives

To develop, validate and evaluate a computerized clinical decision support system (MedReview) that aids medication reviewers with pharmacological decision-making.

Methods

This study included three phases; the development phase included computerizing a consolidated medication review algorithm (MedReview), followed by validation and evaluation of MedReview and responding to a web-based survey designed using patient scenarios. Participants had to be ‘fully registered’ with the Malaysian Pharmacy Board and work full-time at a community pharmacy.

Results

MedReview was developed as a web app. It was validated among 100 community pharmacists from May-July 2021 using the Technology Acceptance Model (TAM). There was acceptable content validity and fair inter-rater agreement, and good convergent and discriminant validity. Exploratory factor analysis resulted in five domains to determine the attitude of pharmacists about using MedReview: perceived ease of use, perceived usefulness, intention to use, trust, and personal initiatives and characteristics; the total variance explained by five factors was 76.36%. The survey questionnaire had a high overall reliability value of 0.96. Evaluation of MedReview was based on mean scores of survey items. Of all items included in the survey, the highest mean score (out of 7) was achieved for ‘I could use MedReview if it is meaningful/relevant to my daily tasks’ (5.78 ± 1.10), followed by ‘I could use MedReview if I feel confident that the data returned by MedReview is reliable’ (5.77 ± 1.21), and ‘I could use MedReview if it protects the privacy of its users’ (5.73 ± 1.20).

Conclusion

Community pharmacists generally had a positive attitude towards MedReview. They found that MedReview is trustworthy and they had the intention to use it when conducting medication reviews. The adaptation of the TAM in the survey instrument was reliable and internally valid.

Pharmacotherapy and the Role of Pharmacists in Rehabilitation Medicine

Pharmacotherapy is important in older patients undergoing rehabilitation because such patients, especially those with frailty and physical disabilities, are susceptible to drug-related functional impairment. Drug-related problems include polypharmacy, potentially inappropriate medications (PIMs), and potential prescription omissions. These problems are associated with adverse drug events such as dysphagia, depression, drowsiness, falls and fractures, incontinence, decreased appetite, and Parkinson's syndrome, leading to impaired improvement in activities of daily living (ADL), quality of life (QOL), and nutritional status. Moreover, the anticholinergic burden is associated with impaired physical and cognitive functions. Therefore, pharmacist-centered multidisciplinary pharmacotherapy should be performed to maximize rehabilitation outcomes. Pharmacotherapy includes a review of all medications, the assessment of drug-related problems, goal setting, correction of polypharmacy and PIMs, monitoring of drug prescriptions, and reassessment of drug-related problems. The goal of pharmacotherapy in rehabilitation medicine is to optimize drug prescribing and to maximize the improvement of ADL and QOL as patient outcomes. The role of pharmacists during rehabilitation is to treat patients as part of multidisciplinary teams and as key members of nutritional support teams. In this review, we aim to highlight existing evidence regarding pharmacotherapy in older adults, including drug-related functional impairment and the association between pharmacotherapy and functional, cognitive, and nutritional outcomes among patients undergoing rehabilitation. In addition, we highlight the important role of pharmacists in maximizing improvements in rehabilitation outcomes and minimizing drug-related adverse effects.

Budget Impact Analysis of Pharmacist-Led Medication Management in Cardiovascular and Type 2 Diabetic Patients

The paper aims to identify and measure the costs and savings associated with the delivery of Comprehensive Medication Management (CMM) services in Croatia in patients diagnosed with hypertension accompanied by at least one additional established cardiovascular disease (CVD) and/or type 2 diabetes mellitus (DMT2) who use five or more medicines daily. The budget impact analysis (BIA) employed in this study compares the total costs of CMM to the cost reductions expected from CMM. The cost reductions (or savings) are based on the reduced incidence of unwanted clinical events and healthcare service utilisation rates due to CMM. The BIA model is populated by data on medication therapy costs, labour, and training from the pilot CMM intervention introduced in Zagreb’s main Health Centre, while relevant international published sources were used to estimate the utilisation, incidence, and unwanted clinical events rates. Total direct costs, including pharmacists’ labour and training (EUR 2,667,098) and the increase in the cost of prescribed medication (EUR 5,182,864) amounted to EUR 7,849,962 for 3 years, rendering the cost per treated patient per year EUR 57. CMM is expected to reduce the utilisation rates of healthcare services and the incidence of unwanted clinical events, leading to a total 3-year reduction in healthcare costs of EUR 7,787,765. Given the total CMM costs of EUR 7,849,962, CMM’s 3-year budget impact equals EUR 92,869, rendering per treated patient an incremental cost of CMM EUR 0.67. Hence, CMM appears to be an affordable intervention for addressing medication mismanagement and irrational drug use.

Pharmacy services and role development in UK general practice: a cross-sectional survey

Background

The ‘Clinical Pharmacists in General Practice’ (CPGP) pilot provided a template for general practice pharmacy professionals’ (GPPPs) roles encouraging NHS England to fund >2000 practice-based pharmacists. However, many GPPPs work outside the CPGP initiative and little is known about the services they provide.

Objectives

To explore services provided by all UK GPPPs (pharmacists/pharmacy technicians), including the types of services, perceived benefits and barriers to role development.

Methods

A 26-item electronic questionnaire was developed using SurveyMonkey and piloted during cognitive interviews. A cross-sectional survey was conducted via social media, primary care organisations and emails to CPGP pilot sites between November 2018 and March 2019. Three reminders were sent 1 week apart.

Key findings

Ninety-one complete responses were received (81 pharmacists; 10 technicians). Over 80% of pharmacists provided clinical services, such as medication reviews or management of long-term conditions. More pharmacists within CPGP pilot managed repeat prescribing requests (P = 0.035). Technicians took responsibility for primarily non-clinical roles, including commissioning or safety alerts/drug recalls. A third of GPPPs wished to develop care home services. Perceived benefits of GPPPs’ services included improved utilisation/development of professional skills, identifying medicines-related issues and reduction in medication waste. Respondents were satisfied with professional relationships but reported workload issues, limited patient awareness of their roles and restricted opportunities to contribute to service development, which was associated with unsatisfactory support/mentorship (P < 0.001).

Conclusion

General practice pharmacy professionals deliver clinical and non-clinical services which may benefit patients, general practice and the healthcare system. General practices and national organisations should provide GPPPs with tailored support and exploit the combined strengths of pharmacists and pharmacy technicians to tackle increased workload.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Pharmacy-based management for depression in adults

BACKGROUND

It is common for peoples not to take antidepressant medication as prescribed, with around 50% of people likely to prematurely discontinue taking their medication after six months. Community pharmacists may be well placed to have a role in antidepressant management because of their unique pharmacotherapeutic knowledge and ease of access for people. Pharmacists are in an ideal position to offer proactive interventions to people with depression or depressive symptoms. However, the effectiveness and acceptability of existing pharmacist-based interventions is not yet well understood. The degree to which a pharmacy-based management approach might be beneficial, acceptable to people, and effective as part of the overall management for those with depression is, to date, unclear. A systematic review of randomised controlled trials (RCTs) will help answer these questions and add important knowledge to the currently sparse evidence base.

OBJECTIVES

To examine the effects of pharmacy-based management interventions compared with active control (e.g. patient information materials or any other active intervention delivered by someone other than the pharmacist or the pharmacy team), waiting list, or treatment as usual (e.g. standard pharmacist advice or antidepressant education, signposting to support available in primary care services, brief medication counselling, and/or (self-)monitoring of medication adherence offered by a healthcare professional outside the pharmacy team) at improving depression outcomes in adults.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMD-CTR) to June 2016; the Cochrane Library (Issue 11, 2018); and Ovid MEDLINE, Embase, and PsycINFO to December 2018. We searched theses and dissertation databases and international trial registers for unpublished/ongoing trials. We applied no restrictions on date, language, or publication status to the searches.  SELECTION CRITERIA: We included all RCTs and cluster-RCTs where a pharmacy-based intervention was compared with treatment as usual, waiting list, or an alternative intervention in the management of depression in adults over 16 years of age. Eligible studies had to report at least one of the following outcomes at any time point: depression symptom change, acceptability of the intervention, diagnosis of depression, non-adherence to medication, frequency of primary care appointments, quality of life, social functioning, or adverse events.  DATA COLLECTION AND ANALYSIS: Two authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment (including GRADE). We discussed disagreements within the team until we reached consensus. Where data did not allow meta-analyses, we synthesised results narratively.  MAIN RESULTS: Twelve studies (2215 participants) met the inclusion criteria and compared pharmacy-based management with treatment as usual. Two studies (291 participants) also included an active control (both used patient information leaflets providing information about the prescribed antidepressant). Neither of these studies reported depression symptom change. A narrative synthesis of results on acceptability of the intervention was inconclusive, with one study reporting better acceptability of pharmacy-based management and the other better acceptability of the active control. One study reported that participants in the pharmacy-based management group had better medication adherence than the control participants. One study reported adverse events with no difference between groups. The studies reported no other outcomes. Meta-analyses comparing pharmacy-based management with treatment as usual showed no evidence of a difference in the effect of the intervention on depression symptom change (dichotomous data; improvement in symptoms yes/no: risk ratio (RR), 0.95, 95% confidence interval (CI) 0.86 to 1.05; 4 RCTs, 475 participants; moderate-quality evidence; continuous data: standard mean difference (SMD) -0.04, 95% CI -0.19 to 0.10; 5 RCTs, 718 participants; high-certainty evidence), or acceptability of the intervention (RR 1.09, 95% CI 0.81 to 1.45; 12 RCTs, 2072 participants; moderate-certainty evidence). The risk of non-adherence was reduced in participants receiving pharmacy-based management (RR 0.73, 95% CI 0.61 to 0.87; 6 RCTs, 911 participants; high-certainty evidence). We were unable to meta-analyse data on diagnosis of depression, frequency of primary care appointments, quality of life, or social functioning.

AUTHORS' CONCLUSIONS

We found no evidence of a difference between pharmacy-based management for depression in adults compared with treatment as usual in facilitating depression symptom change. Based on numbers of participants leaving the trials early, there may be no difference in acceptability between pharmacy-based management and controls. However, there was uncertainty due to the low-certainty evidence.

Optimising pharmacotherapy in older cancer patients with polypharmacy

OBJECTIVE

Polypharmacy is frequent among older cancer patients and increases the risk of potential drug-related problems (DRPs). DRPs are associated with adverse drug events, drug-drug interactions and hospitalisations. Since no standardised polypharmacy assessment methods for oncology patients exist, we aimed to develop one that can be integrated into routine care.

METHODS

Based on the Systematic Tool to Reduce Inappropriate Prescribing (STRIP), we developed OncoSTRIP, which includes a polypharmacy anamnesis, a concise geriatric assessment, a polypharmacy analysis taking life expectancy into account and an optimised treatment plan. Patients ≥65 years with ≥5 chronic drugs visiting our outpatient oncology clinic were eligible for the polypharmacy assessment.

RESULTS

OncoSTRIP was integrated into routine care of our older cancer patients. In 47 of 60 patients (78%), potential DRPs (n = 101) were found. In total, 85 optimisations were recommended, with an acceptance rate of 41%. It was possible to reduce the number of potential DRPs by 41% and the number of patients with at least one potential DRP by 30%. Mean time spent per patient was 71 min.

CONCLUSIONS

Polypharmacy assessment of older cancer patients identifies many pharmacotherapeutic optimisations. With OncoSTRIP, polypharmacy assessments can be integrated into routine care.

Cost Effectiveness of Advanced Pharmacy Services Provided in the Community and Primary Care Settings: A Systematic Review

BACKGROUND

Pharmacists working in community and primary care are increasingly developing advanced skills to provide enhanced services, particularly in dealing with minor acute illness. These services can potentially free-up primary care physicians' time; however, it is not clear whether they are sufficiently cost effective to be recommended for wider provision in the UK.

OBJECTIVE

The aim of this study was to review published economic evaluations of enhanced pharmacy services in the community and primary care settings.

METHODS

We undertook a systematic review of economic evaluations of enhanced pharmacy services to inform NICE guidelines for emergency and acute care. The review protocol was developed and agreed with the guideline committee. The National Health Service Economic Evaluation Database, Health Technology Assessment Database, Health Economic Evaluations Database, MEDLINE and EMBASE were searched in December 2016 and the search was updated in March 2018. Studies were assessed for applicability and methodological quality using the NICE Economic Evaluation Checklist.

RESULTS

Of 3124 records, 13 studies published in 14 papers were included. The studies were conducted in the UK, Spain, The Netherlands, Australia, Italy and Canada. Settings included community pharmacies, primary care/general practice surgeries and patients' homes. Most of the studies were assessed as partially applicable with potentially serious limitations. Services provided in community and primary care settings were found to be either dominant or cost effective, at a £20,000 per quality-adjusted life-year threshold, compared with usual care. Those delivered in the patient's home were not found to be cost effective.

CONCLUSIONS

Advanced pharmacy services appear to be cost effective when delivered in community and primary care settings, but not in domiciliary settings. Expansion in the provision of these services in community and primary care can be recommended for wider implementation.

Patient-perceived barriers and facilitators to the implementation of a medication review in primary care: a qualitative thematic analysis

BACKGROUND

Although polypharmacy can cause adverse health outcomes, patients often know little about their medication. A regularly conducted medication review (MR) can help provide an overview of a patient's medication, and benefit patients by enhancing their knowledge of their drugs. As little is known about patient attitudes towards MRs in primary care, the objective of this study was to gain insight into patient-perceived barriers and facilitators to the implementation of an MR.

METHODS

We conducted a qualitative study with a convenience sample of 31 patients (age ≥ 60 years, ≥3 chronic diseases, taking ≥5 drugs/d); in Hesse, Germany, in February 2016. We conducted two focus groups and, in order to ensure the participation of elderly patients with reduced mobility, 16 telephone interviews. Both relied on a semi-structured interview guide dealing with the following subjects: patients' experience of polypharmacy, general design of MRs, potential barriers and facilitators to implementation etc. Interviews were audio-recorded, transcribed verbatim, and analysed by two researchers using thematic analysis.

RESULTS

Patients' average age was 74 years (range 62-88 years). We identified barriers and facilitators for four main topics regarding the implementation of MRs in primary care: patient participation, GP-led MRs, pharmacist-led MRs, and the involvement of healthcare assistants in MRs. Barriers to patient participation concerned patient autonomy, while facilitators involved patient awareness of medication-related problems. Barriers to GP-led MRs concerned GP's lack of resources while facilitators related to the trusting relationship between patient and GP. Pharmacist-led MRs might be hindered by a lack of patients' confidence in pharmacists' expertise, but facilitated by pharmacies' digital records of the patients' medications. Regarding the involvement of healthcare assistants in MRs, a potential barrier was patients' uncertainty regarding the extent of their training. Patients could, however, imagine GPs delegating some aspects of MRs to them.

CONCLUSIONS

Our study suggests that patients regard MRs as beneficial and expect indications for their medicines to be checked, and possible interactions to be identified. To foster the implementation of MRs in primary care, it is important to consider barriers and facilitators to the four identified topics.

Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions

OBJECTIVE

This study aimed to determine whether pharmacist-provided home-based medication review (HBMR) can reduce readmissions in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Patient's home.

PARTICIPANTS

Records of patients referred to a care transition program from March 2011 through March 2015 were reviewed. Patients aged 60 years and older taking more than 5 medications and had at least 2 unplanned admissions within 3 months preceding the first home visit were included.

INTERVENTION

Pharmacist-provided HBMR.

MAIN OUTCOME MEASURES

Primary outcome was readmission rate over 6 months after the first home visit. Secondary outcomes included emergency department (ED) visits, outpatient visits and mortality. Drug-related problems (DRPs) were reported for the HBMR group. Multivariate incidence rate ratios (IRR) and hazard ratio (HR) were calculated with adjustments for covariates.

RESULTS

The study included 499 patients (97 HBMR, 402 no HBMR). Pharmacist-provided HBMR reduced readmissions by 26% (IRR = 0.74, 95% CI: 0.59-0.92, P = 0.007), reduced ED visits by 20% (IRR = 0.80, 95% CI: 0.66-0.98, P = 0.030) and increased outpatient visits by 16% (IRR = 1.16, 95% CI: 0.95-1.41, P = 0.150). There were 8 and 44 deaths in the HBMR and no HBMR groups respectively (HR = 0.73, 95% CI: 0.29-1.81, P = 0.492). Pharmacists identified 464 DRPs, with 169 (36.4%) resolved within 1 month after the home visit.

CONCLUSIONS

The study suggests that pharmacist-provided HBMR is effective in reducing readmissions and ED visits in the elderly. More studies in the Asian population are needed to determine its long term benefits and patient's acceptability.

Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Medication review is often recommended to optimize medication use. In clinical practice it is mostly operationalized as an intervention without co-interventions during a short term intervention period. However, most systematic reviews also included co-interventions and prolonged medication optimization interventions. Furthermore, most systematic reviews focused on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). Therefore, the objective of this study is to assess the effectiveness of medication review as an isolated short-term intervention, irrespective of the patient population and the outcome measures used.

METHODS

A literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. Randomized controlled trials (RCTs) with medication review as isolated short term intervention (<3 months) were included. There were no restrictions with regard to patient characteristics and outcome measures. One reviewer extracted and a second checked data. The risk of bias of studies was evaluated independently by two reviewers. A best evidence synthesis was conducted for every outcome measure used in more than one trial. In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect.

RESULTS

Thirty-one RCTs were included in this systematic review (55% low risk of bias). A best evidence synthesis was conducted for 22 outcome measures. No effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning), except a decrease in the number of falls per patient. However, in a sensitivity analysis using a more stringent threshold for risk of bias, the conclusion for the effect on the number of falls changed to inconclusive. Furthermore no effect was found on quality of life and evidence was inconclusive about the effect on economical outcome measures. However, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs.

CONCLUSIONS

An isolated medication review during a short term intervention period has an effect on most drug-related outcomes, minimal effect on clinical outcomes and no effect on quality of life. No conclusion can be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care.

Interventions to improve adherence to lipid-lowering medication

BACKGROUND

Lipid-lowering drugs are widely underused, despite strong evidence indicating they improve cardiovascular end points. Poor patient adherence to a medication regimen can affect the success of lipid-lowering treatment.

OBJECTIVES

To assess the effects of interventions aimed at improving adherence to lipid-lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO and CINAHL up to 3 February 2016, and clinical trials registers (ANZCTR and ClinicalTrials.gov) up to 27 July 2016. We applied no language restrictions.

SELECTION CRITERIA

We evaluated randomised controlled trials of adherence-enhancing interventions for lipid-lowering medication in adults in an ambulatory setting with a variety of measurable outcomes, such as adherence to treatment and changes to serum lipid levels. Two teams of review authors independently selected the studies.

DATA COLLECTION AND ANALYSIS

Three review authors extracted and assessed data, following criteria outlined by the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of the evidence using GRADEPro.

MAIN RESULTS

For this updated review, we added 24 new studies meeting the eligibility criteria to the 11 studies from prior updates. We have therefore included 35 studies, randomising 925,171 participants. Seven studies including 11,204 individuals compared adherence rates of those in an intensification of a patient care intervention (e.g. electronic reminders, pharmacist-led interventions, healthcare professional education of patients) versus usual care over the short term (six months or less), and were pooled in a meta-analysis. Participants in the intervention group had better adherence than those receiving usual care (odds ratio (OR) 1.93, 95% confidence interval (CI) 1.29 to 2.88; 7 studies; 11,204 participants; moderate-quality evidence). A separate analysis also showed improvements in long-term adherence rates (more than six months) using intensification of care (OR 2.87, 95% CI 1.91 to 4.29; 3 studies; 663 participants; high-quality evidence). Analyses of the effect on total cholesterol and LDL-cholesterol levels also showed a positive effect of intensified interventions over both short- and long-term follow-up. Over the short term, total cholesterol decreased by a mean of 17.15 mg/dL (95% CI 1.17 to 33.14; 4 studies; 430 participants; low-quality evidence) and LDL-cholesterol decreased by a mean of 19.51 mg/dL (95% CI 8.51 to 30.51; 3 studies; 333 participants; moderate-quality evidence). Over the long term (more than six months) total cholesterol decreased by a mean of 17.57 mg/dL (95% CI 14.95 to 20.19; 2 studies; 127 participants; high-quality evidence). Included studies did not report usable data for health outcome indications, adverse effects or costs/resource use, so we could not pool these outcomes. We assessed each included study for bias using methods described in the Cochrane Handbook for Systematic Reviews of Interventions. In general, the risk of bias assessment revealed a low risk of selection bias, attrition bias, and reporting bias. There was unclear risk of bias relating to blinding for most studies.

AUTHORS' CONCLUSIONS

The evidence in our review demonstrates that intensification of patient care interventions improves short- and long-term medication adherence, as well as total cholesterol and LDL-cholesterol levels. Healthcare systems which can implement team-based intensification of patient care interventions may be successful in improving patient adherence rates to lipid-lowering medicines.

Supervised pharmacy student-led medication review in primary care for patients with type 2 diabetes: a randomised controlled pilot study

OBJECTIVE

To pilot and feasibility-test supervised final year undergraduate pharmacy student-led medication reviews for patients with diabetes to enable definitive trial design.

METHOD

Third year pharmacy students were recruited from one UK School of Pharmacy and trained to review patient's medical records and provide face-to-face consultations under supervision while situated within the patient's medical practice. Patients with type 2 diabetes were recruited by postal invitation letter from their medical practice and randomised via automated system to intervention or usual care. Diabetes-related clinical data, quality of life, patient reported beliefs, adherence and satisfaction with medicines information were collected with validated tools at baseline and 6 months postintervention. The process for collecting resource utilisation data was tested. Stakeholder meetings were held before and after intervention to develop study design and learn from its implementation. Recruitment and attrition rates were determined plus the quality of the outcome data. Power calculations for a definitive trial were performed on the different outcome measures to identify the most appropriate primary outcome measure.

RESULTS

792 patients were identified as eligible from five medical practices. 133 (16.8%) were recruited and randomised to control (n=66) or usual care (n=67). 32 students provided the complete intervention to 58 patients. Initial data analysis showed potential for impact in the right direction for some outcomes measured including glycated haemoglobin, quality of life and patient satisfaction with information about medicines. The intervention was found to be feasible and acceptable to patients. The pilot and feasibility study enabled the design of a future full randomised controlled trial.

CONCLUSIONS

Student and patient recruitment are possible. The intervention was well received and demonstrated some potential benefits. While the intervention was relatively inexpensive and provided an experiential learning opportunity for pharmacy students, its cost-effectiveness remains to be determined.

TRIAL REGISTRATION NUMBER

ISRCTN26445805; Results.

Public perceptions of pharmacist expanded scope of practice services in Nova Scotia

BACKGROUND

Community pharmacists have been transitioning from traditional dispensing roles toward a much broader scope of practice. The objective of this research was to explore public perceptions of expanded scope of practice (ESOP) services as they relate to pharmacy and pharmacist characteristics.

METHODS

The Survey on New Services Offered by Nova Scotia Pharmacists was developed and deployed using in-pharmacy intercept surveys and online public surveys in Nova Scotia. The survey focused on 4 key ESOP elements/services: 1) prescribing for minor ailments (ambulatory conditions), 2) injections and vaccinations, 3) prescription renewals and 4) medication reviews. Data were analyzed using comparisons between groups (multivariate analysis of variance) and principal component analysis.

RESULTS

A total of 385 surveys were obtained from the public regarding their perceptions and use of ESOP services (online n = 237, in-pharmacy intercept n = 148). A number of significant differences were found on the basis of respondent sex, age and the location of survey deployment.

DISCUSSION

Overall, public perceptions of pharmacists' knowledge and skills in providing ESOP services are positive. A pharmacist's ability to communicate, protect confidentiality and provide quality information regarding medications is important to the public.

CONCLUSION

Respondents who already have a good relationship with their pharmacist are more likely to see value in ESOP services. Future public education strategies should focus on factors positively affecting the public's perceptions of ESOP services and should encourage public use of these services through intentional patient education of the benefits of ESOP services and strengthening of the patient-provider relationship.

Health care consumers' perspectives on pharmacist integration into private general practitioner clinics in Malaysia: a qualitative study

BACKGROUND

Pharmacists are considered medication experts but are underutilized and exist mainly at the periphery of the Malaysian primary health care team. Private general practitioners (GPs) in Malaysia are granted rights under the Poison Act 1952 to prescribe and dispense medications at their primary care clinics. As most consumers obtain their medications from their GPs, community pharmacists' involvement in ensuring safe use of medicines is limited. The integration of a pharmacist into private GP clinics has the potential to contribute to quality use of medicines. This study aims to explore health care consumers' views on the integration of pharmacists within private GP clinics in Malaysia.

METHODS

A purposive sample of health care consumers in Selangor and Kuala Lumpur, Malaysia, were invited to participate in focus groups and semi-structured interviews. Sessions were audio recorded and transcribed verbatim and thematically analyzed using NVivo 10.

RESULTS

A total of 24 health care consumers participated in two focus groups and six semi-structured interviews. Four major themes were identified: 1) pharmacists' role viewed mainly as supplying medications, 2) readiness to accept pharmacists in private GP clinics, 3) willingness to pay for pharmacy services, and 4) concerns about GPs' resistance to pharmacist integration. Consumers felt that a pharmacist integrated into a private GP clinic could offer potential benefits such as to provide trustworthy information on the use and potential side effects of medications and screening for medication misadventure. The potential increase in costs passed on to consumers and GPs' reluctance were perceived as barriers to integration.

CONCLUSION

This study provides insights into consumers' perspectives on the roles of pharmacists within private GP clinics in Malaysia. Consumers generally supported pharmacist integration into private primary health care clinics. However, for pharmacists to expand their capacity in providing integrated and collaborative primary care services to consumers, barriers to pharmacist integration need to be addressed.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Medication reviews

Recent years have seen a formalization of medication review by pharmacists in all settings of care. This article describes the different types of medication review provided in primary care in the UK National Health Service (NHS), summarizes the evidence of effectiveness and considers how such reviews might develop in the future. Medication review is, at heart, a diagnostic intervention which aims to identify problems for action by the prescriber, the clinician conducting the review, the patient or all three but can also be regarded as an educational intervention to support patient knowledge and adherence. There is good evidence that medication review improves process outcomes of prescribing including reduced polypharmacy, use of more appropriate medicines formulation and more appropriate choice of medicine. When 'harder' outcome measures have been included, such as hospitalizations or mortality in elderly patients, available evidence indicates that whilst interventions could improve knowledge and adherence they did not reduce mortality or hospital admissions with one study showing an increase in hospital admissions. Robust health economic studies of medication reviews remain rare. However a review of cost-effectiveness analyses of medication reviews found no studies in which the cost of the intervention was greater than the benefit. The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care. Medication reviews can be more effectively deployed in the future by targeting, multi-professional involvement and paying greater attention to medicines which could be safely stopped.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Retrospective cohort study highlighted outcome reporting bias in UK publicly funded trials

OBJECTIVE

To assess outcome reporting bias and dissemination bias in trials funded by the National Health System (NHS) Health Technology Assessment (HTA) program.

STUDY DESIGN AND SETTING

A retrospective cohort study of HTA monographs and corresponding journal publications including all clinical effectiveness randomized controlled trials published as HTA monographs between 1999 and 2005 by the NHS HTA program.

RESULTS

There was a higher median P-value (P=0.33, interquartile range [IQR]: 0.02-0.54) among trials without a journal publication compared with those with a journal publication (P=0.14, IQR: 0.007-0.43), although the difference was not statistically significant (Mann-Whitney U test, z=-0.70; P=0.48). A higher proportion of statistically significant findings were reported in journal articles when compared with the outcomes reported in the HTA monographs. Trials published in general medical journals tended to have smaller P-values (median: 0.05, IQR: 0.001-0.22) than those published in more specialist journals (median: 0.33 IQR: 0.008-0.58), although this result was not significant (Mann-Whitney U test, z=-1.63; P=0.10).

CONCLUSIONS

Among journal-published trials, there were a greater proportion of statistically significant findings included in the journal reports compared with those in the HTA monographs.

The General Practitioner–Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy

Objectives

There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for ‘medication reviews’ there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine-related therapeutic outcomes for patients.

Methods

A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed-up 3-monthly. The control group received usual care. The main outcome measures were Quality of Life (SF-36) and Medication Appropriateness Index.

Key findings

A total of 498 patients were enrolled in the study. The quality-of-life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study.

Conclusion

Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.

Pharmacist-led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives

To ascertain general practitioners' views of a pharmacist-led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems.

Method

Semi-structured interviews with a purposive sample of six GPs informed the development of a self-completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free-text responses were sought on benefits, problems and areas for future improvement.

Key findings

The response rate was 84% for GPs (93% of practices were represented). Ninety-five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP-pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP-pharmacist communication and extended pharmacist roles.

Conclusion

The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.

Drug-related problems in elderly general practice patients receiving pharmaceutical care†

Objective

To describe the types of drug-related problems identified by pharmacists providing pharmaceutical care to elderly patients in the primary care or general medicine setting, and the impact of their recommendations on drug-related outcomes.

Methods

Searches of the MEDLINE, EMBASE, CINAHL, HealthSTAR, and International Pharmaceutical Abstracts electronic databases from 1990 to 2002 were conducted and a manual search of references from retrieved articles and references on file was performed. Large (n&gt; 100) randomised, controlled studies comparing the provision of pharmaceutical care to usual care in seniors in primary care or general medicine settings were included. Two reviewers evaluated articles based on inclusion criteria and extracted data from the intervention arm of each study, resolving discrepancies by consensus. Nine original articles were included for analysis.

Key findings

The mean number of drug-related problems (DRPs) identified per patient was 3.2 and the mean number of recommendations made per patient was 3.3. The most common DRP identified was not taking/receiving a prescribed drug appropriately (35.2%, range 4.7–49.3%). The most common recommendations made involved patient education (37.2%, range 4.6–48.2%). Implementation rates were generally high for all types of recommendations, with the highest being for provision of patient education (81.6%). The small number of studies available examining measures of drug utilisation and costs, health services utilisation, and patient outcomes produced inconsistent results, making it difficult to draw conclusions.

Conclusions

Substantial numbers and a wide range of DRPs were identified by pharmacists who provided pharmaceutical care to seniors in the primary care and general medicine setting. Pharmacists' drug-therapy recommendations were well accepted; however, further study is needed to determine the impact of these recommendations on health-related outcomes.

Medication therapy management services: definitions and outcomes

In the US, the Medicare Modernization Act of 2003 required that Medicare Part D insurers provide medication therapy management (MTM) services (MTMS) to selected beneficiaries, with the goals of providing education, improving adherence, or detecting adverse drug events and medication misuse. These broad goals and variety in MTM programmes available make assessment of these programmes difficult. The objectives of this article are to review the definitions of MTMS proposed by various stakeholders, and to summarize and evaluate the outcomes of MTMS consistent with those that may be offered in Medicare Part D or reimbursed by State Medicaid programmes. MTM programmes are approved by the Centers for Medicare and Medicaid Services (CMS). Pharmacy, medical and insurance organizations have provided guidelines and definitions for MTM programmes, distinguishing them from other types of community pharmacy activities. MTM has been distinguished from disease state management because of the focus on medications and multiple conditions. It differs from patient counselling because it is delivered independent of dispensing and involves collaboration with patients and providers. There is no consensus on the recommended mode of delivery (i.e. face-to-face or by telephone) for MTM. A MEDLINE search was conducted to identify articles published after 2000 using the search terms 'medication therapy management' and 'medication management'. Studies with outcomes evaluating community-based programmes consistent with MTMS, regardless of MTMS reimbursement source, were included in the review. Seven publications describing four MTMS were identified. For each of the identified articles, we describe the study design, service setting, inclusion criteria and outcomes. An additional three surveys describing multiple MTMS were identified and are summarized. Finally, ongoing efforts by CMS to evaluate the success of MTMS in the US are described. To date, there are limited outcomes available for MTMS. The wide variety of MTMS offered means that evaluations of individual programmes are necessary. Despite the potential benefits of MTMS, there are numerous challenges to providing MTMS, including reimbursement, justification of the service and stakeholder acceptance of the services. There remains a need for adequately funded, prospective, controlled studies of MTM programmes using strong designs to advance our knowledge of the effectiveness of various interventions and methods of delivery, and for naturalistic studies assessing the impact of CMS approved MTM programmes.

Promoting Appropriate Drug Use Through the Application of the Spanish Drug-Related Problem Classification System in the Primary Care Setting

Background:

According to the Second Consensus of Granada (2002), the term drug-related problem (DRP) is defined as a health problem resulting from pharmacotherapy and is considered a negative clinical outcome (ie, a therapeutic objective is not achieved or adverse effects are reported). DRP classification systems used in primary care settings can be useful tools to detect, evaluate, and resolve DRPs.

Objective:

To encourage appropriate drug use in the ambulatory clinical setting through DRP detection and evaluation by means of the Spanish DRP classification system, and to document how pharmacists can help resolve DRPs through interventions with both general practitioners (GPs) and patients.

Methods:

Four pharmacists investigated DRPs in polymedicated patients over a 6-month period. All detected DRPs were grouped into 3 major categories: necessity, effectiveness, and safety. To resolve DRPs, pharmacists performed interventions on GPs and patients. GPs received verbal and written information about DRPs; patient interventions were in the form of private meetings on health education.

Results:

Four hundred twenty-two patients, 80% of whom were aged 65 years or older, were included in the study. Each patient was taking a mean ± SD of 8.1 ± 2.4 medications. Three hundred four medications were associated with 245 DRPs; medications indicated for digestive/metabolic or cardiovascular pathologies were the most prevalent. Most (60%) of the identified DRPs belonged to the effectiveness category, whereas safety issues accounted for 28.6%. The most frequently reported DRP was pathology resistant to treatment (19.6%), followed by nonadherence (16.3%). Of the 215 interventions carried out to resolve these DRPs, 173 (80.5%) were addressed to GPs, who agreed to change therapy regimens on 90.2% of the occasions. Forty-two (19.5%) interventions were addressed to patients. Furthermore, the interventions accepted by GPs and patients resolved 176 (82%) DRPs.

Conclusions:

The current Spanish DRP classification system is a useful tool to systematically detect and document DRPs in daily general practice, in addition, the interventions addressed by pharmacists to GPs and patients resolved most of the detected DRPs.

Care home medicine in the UK--in from the cold

The quality of care within care homes comes under frequent media scrutiny, and is underpinned by the medical support to the staff. In the UK, medical care to care homes is provided by general practitioners. A GP is likely to have patients in many homes, and each home relates to many GPs. The growing complexity of patients in care requires proactive models of care delivered by those with an understanding of care home medicine. A range of innovative models of medical care are emerging across the UK which have the potential to improve the standard of care in homes, and reduce inappropriate use of secondary care admissions. These models are described, and the need for them to be subjected to evaluation.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Prevalence of self-reported risk factors for medication misadventure among older people in general practice

OBJECTIVE

To describe the prevalence of risk factors for medication misadventures among older people in general practice.

DESIGN

Descriptive cross-sectional analysis.

SETTING

General practices, New South Wales, Australia.

PARTICIPANTS

Twenty general practitioners in 16 practices recruited 849 practice attendees aged 65 years and over.

OUTCOME MEASURE

Risk factors for medication misadventures.

RESULTS

Almost all participants (95%) had used at least one medication for more than 6 months. More than half of the participants had more than one doctor involved in their care (59%), had three or more health conditions (57%), or used five or more medicines (54%). With regard to potential adverse drug reactions, in the last month 39% of participants experienced difficulties sleeping, one-third felt drowsy or dizzy (34%), and about a quarter had a skin rash (28%), leaked urine (27%), had stomach problems (22%) or had been constipated (22%). The most common compliance problems were experiencing side effects (14%) and having difficulties opening bottles or packets/applying the medicine (10%).

CONCLUSION

Risk factors for medication misadventure remain a substantial problem among older people. A Medication Risk Assessment Form completed by patients can be used as an aid to increase general practitioners' awareness of a variety of problem areas associated with medication use in a compact way, and could be used as part of a system for medication review to determine whether actions are required to improve quality use of medicines.

Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis

We set out to determine the effects of pharmacist-led medication review in older people by means of a systematic review and meta-analysis covering 11 electronic databases. Randomized controlled trials in any setting, concerning older people (mean age > 60 years), were considered, aimed at optimizing drug regimens and improving patient outcomes. Our primary outcome was emergency hospital admission (all cause). Secondary outcomes were mortality and numbers of drugs prescribed. We also recorded data on drug knowledge, adherence and adverse drug reactions. We retrieved 32 studies which fitted the inclusion criteria. Meta-analysis of 17 trials revealed no significant effect on all-cause admission, relative risk (RR) of 0.99 [95% confidence interval (CI) 0.87, 1.14, P = 0.92], with moderate heterogeneity (I(2) = 49.5, P = 0.01). Meta-analysis of mortality data from 22 trials found no significant benefit, with a RR of mortality of 0.96 (95% CI 0.82, 1.13, P = 0.62), with no heterogeneity (I(2) = 0%). Pharmacist-led medication review may slightly decrease numbers of drugs prescribed (weighted mean difference = -0.48, 95% CI -0.89, -0.07), but significant heterogeneity was found (I(2) = 85.9%, P < 0.001). Results for additional outcomes could not be pooled, but suggested that interventions could improve knowledge and adherence. Pharmacist-led medication review interventions do not have any effect on reducing mortality or hospital admission in older people, and can not be assumed to provide substantial clinical benefit. Such interventions may improve drug knowledge and adherence, but there are insufficient data to know whether quality of life is improved.

A Quality Use of Medicines program for general practitioners and older people: a cluster randomised controlled trial

OBJECTIVE

To investigate the effectiveness of an educational Quality Use of Medicines program, delivered at the level of general practice, on medicines use, falls and quality of life in people aged > or = 65 years.

DESIGN

Cluster randomised controlled trial conducted in 2002.

SETTING

General practices in the Hunter Region, New South Wales, Australia.

PARTICIPANTS

Twenty general practitioners recruited 849 patients to participate in the study.

INTERVENTION

Education (academic detailing, provision of prescribing information and feedback); medication risk assessment; facilitation of medication review; financial incentives.

MAIN OUTCOME MEASURES

PRIMARY MEASURES

a composite score reflecting use of benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs) and thiazide diuretics; secondary measures: use of medication reviews, occurrence of falls, quality of life (as assessed by SF-12 and EQ-5D survey scores.

RESULTS

Compared with the control group, participants in the intervention group had increased odds of having an improved medication use composite score (odds ratio [OR], 1.86; 95% CI, 1.21-2.85) at 4-month follow-up but not at 12 months. At 4-month follow-up, the intervention group had reduced odds of using NSAIDs (OR, 0.62; 95% CI, 0.39-0.99) and showed a non-significant reduction in use of benzodiazepines (OR, 0.51; 95% CI, 0.20-1.30) and thiazide diuretics (OR, 0.70; 95% CI, 0.48-1.01). Changes in drug use were not significant at 12-month follow-up. At 12 months, intervention-group participants had lower adjusted ORs (AORs) for having a fall (AOR, 0.61; 95% CI, 0.41-0.91), injury (AOR, 0.56; 95% CI, 0.32-0.96), and injury requiring medical attention (AOR, 0.46; 95% CI, 0.30-0.70). Quality-of-life scores were unaffected by the intervention.

CONCLUSION

Education and systems for medication review conducted by GPs can be used to improve use of medicines. These interventions are associated with a reduction in falls among older people, without adverse effects on quality of life.

Home-based medication review in a high risk elderly population in primary care--the POLYMED randomised controlled trial

OBJECTIVE

To assess whether home-based medication review by a pharmacist for at-risk older patients in a primary care setting can reduce hospital admissions.

DESIGN

Randomised controlled trial comparing home-based medication review with standard care.

SETTING

Home-based medication review of 136 patients registered with one general practice.

METHOD

Study participants were over 80 years of age, living at home, taking four or more medicines, and had at least one additional medicines-related risk factor. The intervention comprised two home visits by a community pharmacist who educated the patient/carer about their medicines, noted any pharmaceutical care issues, assessed need for an adherence aid, and subsequently met with the lead GP to agree on actions.

MAIN OUTCOME MEASURE

Total non-elective hospital admissions within 6 months. Secondary outcomes included number of deaths, care home admissions and quality of life (EQ-5d). Impact on number of medicines prescribed was also assessed.

RESULTS

At 6 months, no difference in hospital admissions (21 intervention versus 20 control P = 0.80), and no difference in care home admissions or deaths were detected between groups. There was a small (non-significant) decrease in quality of life in the intervention group. There was a statistically significant reduction in the mean number of medicines prescribed ( -0.87 items in favour of the intervention group, 95% confidence interval -1.66 to -0.08, P = 0.03).

CONCLUSIONS

No positive impact on clinical outcomes or quality of life was demonstrated, however, this intervention did appear to reduce prescribing. This is in line with other evidence and suggests that this form of intervention may not have a clear health gain, but may lead to modest savings in terms of reduced prescribing. Future research should focus on whether such a prescribing effect would make this type of intervention cost effective.

Survey of pharmacists' attitudes towards interchangeable use of dry powder inhalers

BACKGROUND

It is a common cost-containment practice in some countries to dispense a cheaper, generic version of a prescribed medication. This presents few problems for most medications. However, dry powder inhalers used in asthma and COPD vary markedly in design and method of operation, so generic substitution may not be acceptable to patients or healthcare professionals. Patients dispensed an unfamiliar device in which they have received no training, risk poor inhalation technique with the potential for inadequate dosing and loss of disease control.

OBJECTIVE

To assess the views of pharmacists towards interchangeable use of dry powder inhalers.

SETTING

Community pharmacists in Australia, Canada, France, Germany, and the UK.

METHOD

Following exploration of the key issues with international opinion leaders in respiratory management, a structured web questionnaire was developed for use in computer assisted web interviews. Fieldwork was carried out in March and April 2005.

MAIN OUTCOME MEASURE

Responses to the web questionnaire were analysed by percentage of respondents or by mean or median score, as appropriate to the question.

RESULTS

A total of 254 pharmacists were included in the study. Just 6% of pharmacists considered that dry powder inhalers are interchangeable, with a high level of concern shown about interchangeable use (median score of 6 on a scale of 1, not at all concerned, to 7, extremely concerned). Patient confusion was the main concern, expressed by 77% of respondents. Pharmacists also envisaged substitution having an adverse impact on pharmacy stock levels (72%), patient device handling (70%), pharmacist workload (63%), patient compliance (56%) and outcomes for the patient (51%), with pharmacists in Germany having a particularly negative view and those in France generally the most positive. Despite the generally negative view of pharmacists about interchangeable use of dry powder inhalers, overall only 22% would contact the prescribing physician often/very often for approval of the substitution.

CONCLUSION

The study showed that only a small minority of pharmacists believe that dry powder inhalers can be used interchangeably, with the majority concerned about generic substitution of these products. Pharmacists in Germany were particularly negative about the interchangeable use of dry powder inhalers.

Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial

OBJECTIVE

to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.

DESIGN

randomised controlled trial of clinical medication review by a pharmacist against usual care.

SETTING

sixty-five care homes for the elderly in Leeds, UK.

PARTICIPANTS

a total of 661 residents aged 65+ years on one or more medicines.

INTERVENTION

clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care.

MAIN OUTCOME MEASURES

primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE).

RESULTS

the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (pounds sterling 42.24 and pounds sterling 42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented.

CONCLUSIONS

general practitioners do not review most care home patients' medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients' medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.

Preventing drug related morbidity: a process for facilitating changes in practice

AIM

To describe how quantitative data obtained from applying a series of indicators for preventable drug related morbidity (PDRM) in the electronic patient record in English general practice can be used to facilitate changes aimed at helping to improve medicines management.

DESIGN

A multidisciplinary discussion forum held at each practice facilitated by a clinical researcher.

SUBJECTS AND SETTING

Eight English general practices.

OUTCOME MEASURES

Issues discussed at the multidisciplinary discussion forum and ideas generated by practices for tackling these issues. Progress made by practices after 1, 3, and 6 months.

RESULTS

A number of clinical issues were raised by the practices and ideas for moving them forward were discussed. The issues that were easiest and most straightforward to deal with (for example, reviewing specific patient groups) were quickly addressed in most instances. Practices were less likely to have taken steps towards addressing issues at a systems level.

CONCLUSIONS

Data generated from applying PDRM indicators can be used to facilitate practice-wide discussion on medicines management. Different practices place different priority levels on the issues they wish to pursue. Individual practice "ownership" of these, together with having a central committed figure at the practice, is key to the success of the process.

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Repeat prescriptions: refill adherence in relation to patient and prescriber characteristics, reimbursement level and type of medication

BACKGROUND

Repeat prescribing used in long-term pharmacotherapy is often associated with inadequate patient medication, including non-adherence. In this paper we explore patients' drug refill adherence with repeat prescriptions and relate refill data to patient age and gender, type of prescriber, type of prescribed drug, and reimbursement level.

METHODS

During one week of 2002, copies of 3636 repeat prescriptions filled at 16 large Swedish pharmacies were collected. Satisfactory refill adherence was defined as dispensed refills covering 80-120% of the prescribed treatment time. Under- and oversupplying were defined as <80% and >120% coverage, respectively.

RESULTS

The average level of refill adherence was 57%, and the level of under- and oversupplying 21% and 22%, respectively. There was no gender difference. Patients who were exempt from payment had higher oversupplies than others (33% versus 19%), and patients of general practitioners had higher refill adherence than patients of hospital physicians. The highest refill adherence was observed for contraceptives (81%) and the lowest for anti-asthmatics, proton pump inhibitors and non-steroidal anti-inflammatory drugs (30-40%).

CONCLUSIONS

Refill non-adherence includes both under- and oversupplying and may vary due to different attitudes between prescribers and between patients. Different therapeutic indications and reimbursement systems are other apparent causes. These observations should be considered in programs aiming to assist patients in following medication prescriptions.

Repeat prescribing: scale, problems and quality management in ambulatory care patients

The reported scale of repeat prescriptions ranges from 29% to 75% of all items prescribed, depending on the definition of repeat prescribing and other variables. It is likely that a substantial part of repeat prescribing by general practitioners (GPs) occurs without direct doctor-patient contact. While this reduces the workload for the GP and is convenient for the patient, it does not provide the adequate control that is needed to ensure that every repeat prescription is still appropriate, effective and well tolerated, and that it is still being viewed upon and taken by the patient as intended. Infrequent therapy reviews may lead to failure to prevent, identify and solve drug-related problems and drug wastage, and may, thereby, have a negative impact on the effectiveness, safety or cost of the medications prescribed. Studies evaluating the repeat prescribing process have shown that GPs and medical practices vary widely in their degree of administrative and clinical control of repeat prescriptions. Contrary to the opinion that GPs cannot change prescribing behaviour when the prescription is initiated by a medical specialist, GPs have their own responsibility for controlling the repeats of such prescriptions. Intervention studies suggest that a medication review by a pharmacist can help to reduce drug-related problems with repeat prescriptions, and the effectiveness of the intervention may be increased by combining the medication review with a consultation of the patient's medical records and a patient interview. In several studies, such an intervention was relatively inexpensive and, therefore, feasible. However, these conclusions should be viewed with appropriate caution because a number of caveats pertain. There is still no evidence that these types of intervention improve health-related quality of life or reduce healthcare cost, and so far only a few trials have produced any evidence of clinical improvement. As implicit and explicit screening criteria have their own benefits and limitations, a combined application may offer a more thorough assessment but may also be more complex and time consuming. Further studies on the development and evaluation of repeat prescription management models are needed, preferably focussing on improving clinical, humanistic and economic outcomes. New studies should investigate the effects of: different types of interventions; different organisational models; different target populations; and selecting and training different types of healthcare professionals. Future studies should also assess whether results are sustained, the optimal time interval between reviews of repeat prescriptions, and the possibilities offered by new computerised support technologies.

Interventions to improve adherence to lipid lowering medication

BACKGROUND

Lipid lowering drugs are still widely underused, despite compelling evidence about their effectiveness in the treatment and prevention of cardiovascular disease. Poor patient adherence to medication regimen is a major factor in the lack of success in treating hyperlipidaemia. In this review we focus on interventions, which encourage patients at risk of heart disease or stroke to take lipid lowering medication regularly.

OBJECTIVES

To assess the effect of interventions aiming at improved adherence to lipid lowering drugs, focusing on measures of adherence and clinical outcomes.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycInfo and CINAHL. Date of most recent search was in February 2003. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of adherence-enhancing interventions to lipid lowering medication in adults for both primary and secondary prevention of cardiovascular disease in an ambulatory setting.

DATA COLLECTION AND ANALYSIS

Two reviewers extracted data independently and assessed studies according to criteria outlined by the Cochrane Reviewers' Handbook.

MAIN RESULTS

The eight studies found contained data on 5943 patients. Interventions could be stratified into four categories : 1. simplification of drug regimen, 2. patient information/education, 3. intensified patient care such as reminding and 4. complex behavioural interventions such as group sessions. Change in adherence ranged from -3% to 25% (decrease in adherence by 3% to increase in adherence by 25%). Three studies reported significantly improved adherence through simplification of drug regimen (category 1), improved patient information/education (category 2) and reminding (category 3). The fact that the successful interventions were evenly spread across the categories, does not suggest any advantage of one particular type of intervention. The methodological and analytical quality was generally low and results have to be considered with caution. Combining data was not appropriate due to the substantial heterogeneity between included randomised controlled trials (RCTs).

REVIEWERS' CONCLUSIONS

At this stage, no specific intervention aimed at improving adherence to lipid lowering drugs can be recommended. The lack of a gold standard method of measuring adherence is one major barrier in adherence research. More reliable data might be achieved by newer methods of measurement, more consistency in adherence assessment and longer duration of follow-up. Increased patient-centredness with emphasis on the patient's perspective and shared-decision-making might lead to more conclusive answers when searching for tools to encourage patients to take lipid lowering medication.