A retrospective study of drug‐related problems in Australian aged care homes: medication reviews involving pharmacists and general practitioners

Background Drug‐related problems (DRPs) in Australian aged care homes have been studied previously. However, little is known about the acceptance and implementation of pharmacists' recommendations by general practitioners (GPs) to resolve DRPs. Objectives The primary objective of this study was to investigate the number and nature of DRPs identified by accredited clinical pharmacists. The secondary objective was to study the GP acceptance and implementation of pharmacist recommendations to resolve DRPs. Methods This was a retrospective study of 500 randomly selected, de‐identified medication reviews performed by 10 accredited clinical pharmacists over 6 months across 62 aged care homes. The DRPs identified by pharmacists were subsequently classified by the drugs involved, types of problem (indication, effectiveness and safety) and medical diagnoses of the patient. GP written feedback on the medication review reports determined implementation of pharmacists' recommendations to resolve the DRPs. Results A total of 1433 DRPs were identified in 480 of the 500 residents. Potential DRPs were frequently classified as risk of adverse drug reactions, need for additional monitoring and inappropriate choice of a drug. Alimentary, cardiovascular, central nervous system and respiratory drugs were most frequently implicated, accounting for more than 75% of the DRPs. GPs' acceptance and implementation of pharmacists recommendations were 72.5% (95% CI; 70.2, 74.8) and 58.1% (95% CI; 55.5, 60.6), respectively. Conclusions Over 96% of the residents had potential DRPs identified by pharmacists. GP acceptance of pharmacists' recommendations was independent of the drug category, but not independent of the disease category.     

A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting

BACKGROUND: Little is known about the extent of drug-related problems of polypharmacy patients in Dutch nursing homes. OBJECTIVES: We investigated the feasibility of teams of hospital pharmacists and nursing home physicians carrying out medication reviews. We aimed to identify the number and nature of drug-related problems of nursing home patients receiving more than nine drugs (polypharmacy). METHODS: The study was carried out in five Dutch nursing homes (n = 742 beds) between October 2005 and May 2006. Ninety-one polypharmacy patients, (average age 80 years) were included. A medication review was carried out by teams consisting of one hospital pharmacist and the patient's nursing home physician with a follow-up meeting of the same team 6 weeks later. RESULTS: A total of 323 drug-related problems were identified (mean of 3.5 problems per patient). Sixty-two per cent of problems, in 87% of patients, were classified as 'unclear or not confirmed indication or need for review' of the prescribed drug. By the time of the follow-up, a mean of 1.7 (n = 159) problems per patient had been solved and the number of drugs per patient had decreased significantly from 13.5 to 12.7 (P < 0.0001). CONCLUSIONS: The majority of patients had at least one drug prescribed for which the indication was unknown. The intervention was accompanied by a significant decrease in the number of drugs per patient, but half of the drug-related problems remained unsolved.     

Collaborative home medicines review delays time to next hospitalization for warfarin associated bleeding in Australian war veterans

What is known and background: Unintended bleeds are a common complication of warfarin therapy. We aimed to determine the impact of general practitioner–pharmacist collaborative medication reviews in the practice setting on hospitalization‐associated bleeds in patients on warfarin. Method: We undertook a retrospective cohort study using administrative claims data for the ambulatory veteran and war widow population, Australia. Participants were veterans, war widows and their dependents aged 65 years and over dispensed warfarin. The exposed groups were those exposed to a general practitioner (GP)–pharmacist collaborative home medication review. The service includes GP referral, a home visit by an accredited pharmacist to identify medication‐related problems, a pharmacist report with follow‐up undertaken by the GP. The outcome measure was time to next hospitalization for bleeding. Results: There were 816 veterans exposed to a home medicines review and 16 320 unexposed patients, with an average age of 81·5 years, and six to seven co‐morbidities. Adjusted results showed a 79% reduction in likelihood of hospitalization for bleeding between 2 and 6 months (HR, 0·21 95% CI, 0·05–0·87) amongst those who had received a home medicines reviewed compared to the unexposed patients. No effect was seen in the time period from review to 2 months, nor in the time period 6 to 12 months post a review. What is new and conclusion: Medicines review in the practice setting delays time to next hospitalization for bleeding in those treated with warfarin in the period 2 to 6 months after the review, but is not sustained over time. Six monthly medication reviews may be required for patients on warfarin who are considered at high risk of bleeding.     

Drug-related problems and changes in drug utilization after medication reviews in nursing homes in Oslo,Norway

Objective: We describe the drug-related problems (DRPs) identified during medication reviews (MRs) and the changes in drug utilization after MRs at nursing homes in Oslo, Norway. We explored predictors for the observed changes.

Design: Observational before-after study.

Setting: Forty-one nursing homes.

Intervention: MRs performed by multidisciplinary teams during November 2011 to February 2014.

Subjects: In all, 2465 long-term care patients.

Main outcome measures: DRPs identified by explicit criteria (STOPP/START and NORGEP) and drug–drug interaction database; interventions to resolve DRPs; drug use changes after MR.

Results: A total of 6158 DRPs were identified, an average of 2.6 DRPs/patient, 2.0 for regular and 0.6 for pro re nata (prn) drugs. Of these patients, 17.3% had no DRPs. The remaining 82.7% of the patients had on average 3.0 DRPs/patient. Use of unnecessary drugs (43.5%), excess dosing (12.5%) and lack of monitoring of the drug use (11%) were the most frequent DRPs. Opioids and psychotropic drugs were involved in 34.4% of all DRPs. The mean number of drugs decreased after the MR from 6.8 to 6.3 for regular drugs and from 3.0 to 2.6 for prn drugs. Patients with DRPs experienced a decrease of 1.1 drugs after MR (0.5 for regular and 0.6 for prn drugs). The reduction was most pronounced for the regular use of antipsychotics, antidepressants, hypnotics/sedatives, diuretics, antithrombotic agents, antacid drugs; and for prn use of anxiolytics, opioids, hypnotics/sedatives, metoclopramide and NSAIDs.

Conclusion: The medication review resulted in less drug use, especially opioids and psychotropic drugs.     

Collaborative relationship in preventive home visits to older people

yamada y., vass m., hvas l., igarashi a., hendriksen c. & avlund k. (2010) Collaborative relationship in preventive home visits to older people. International Journal of Older People Nursing 6 , 33–40
doi: 10.1111/j.1748‐3743.2010.00213.x Aim. To describe what characterizes preventive home visits with collaborative relationships among non‐disabled home‐dwelling older people in Japan. Background. Preventive home visits have the potential to result in improved health outcomes among older people. Collaboration, mutual understanding and trust between visitor and the visited person seem to work as a vehicle, but little is known about which part of the encounters contributes to a collaborative relationship. Methods. We performed a retrospective qualitative analysis of visiting records written by preventive home visitors immediately after the visits were made. A collaborative relationship was predefined as a favourable change in behaviour seen in the visited person during the study period. Visitor characteristics were analysed from 248 records where 37 cases of collaborative relationships were documented. Results. The three most important elements associated with a collaborative relationship were (i) visitor communication skills i.e. mastering ‘enhancing motivation’ and ‘having patience and coping with frustrations’ in difficult and problematic situations, (ii) professionalism, which includes ‘professional instruction and guidance’ based on documented knowledge in health and social domains combined with an overall ‘caring approach’ and (iii) practical actions which imply an ‘immediate concrete response to identified needs or problems’ and ‘individually tailored advice’ to suit the older person’s daily life. Conclusions. Preventive home visitor communication skills and professionalism, and practical actions after the visits characterized cases, where favourable changes in behaviour were obtained in non‐disabled home‐dwelling older people in Japan. Relevance to clinical practice. Education should be emphasized, because preventive home visitor competence may be the most important element of proactive assessment schemes to obtain beneficial outcomes.