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 clinican 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.     

Home-based medication review in older people: is it cost effective?

BACKGROUND: Medication review by pharmacists is increasingly being implemented in the primary care setting and has been incorporated into the new pharmacy contract in the UK. This study aims to determine the cost effectiveness of home-based medication review in older people. METHODS: This economic evaluation was based on a randomised controlled trial (the HOMER [HOME-based medication Review] trial). Patients aged >80 years (n = 872) were recruited if admitted as an emergency to an acute or community hospital in Norfolk or Suffolk (any cause), returning to their own home or warden-controlled accommodation, and taking two or more drugs daily on discharge. Patients randomised to the intervention group received two home visits by a pharmacist within 2 and 8 weeks of discharge to educate patients and carers about their drugs, remove out-of-date drugs, inform GPs of drug reactions or interactions and inform the local pharmacist if an adherence aid was needed. The control arm received usual care. Economic evaluation was performed from the UK NHS perspective, with follow-up for 6 months and cost data from 2000. Resource use data were collected from hospital episode statistics and from a sample of GP records of trial participants. Intervention, hospital, ambulance and general practice costs were considered to determine average costs and incremental cost-effectiveness ratios. Use of the EQ-5D questionnaire permitted outcomes to be expressed as QALYs. Probabilistic sensitivity analysis was employed to calculate cost-effectiveness acceptability curves. RESULTS: Mortality and admission data were available for 829 of 855 patients included in the study (415 intervention and 414 control patients). Of those patients randomised to the intervention group, 358 had a medication review at a total intervention cost of 51,622 pound (or 124 pound per randomised patient). The intervention did not reduce hospital admissions. The average cost per intervention group patient was 1695 pound compared with 1424 pound for control patients. The incremental cost per life year gained through the intervention was 33,541 pound. The incremental cost per QALY gained in the intervention was 54,454 pound. Sensitivity analysis suggested a 25% probability that home-based medication review is cost effective using a threshold of 30,000 pound per QALY. CONCLUSION: The current policy imperative for implementing medicines review needs to be reconsidered in the light of the findings of this study: a small, non significant gain in quality of life, no reduction in hospital admissions and a low probability of cost effectiveness.     

The cost‐effectiveness of macrogol 3350 compared to lactulose in the treatment of adults suffering from chronic constipation in the UK

Background It is unknown whether macrogol 3350 (Movicol) affords the UK’s National Health Service (NHS) a cost‐effective addition to the current range of laxatives. Aim To estimate the cost‐effectiveness of macrogol 3350 compared with lactulose in the treatment of chronic constipation, from the perspective of the UK’s NHS. Methods A decision model depicting the management of chronic constipation was constructed using clinical outcomes and resource use values derived from patients suffering from chronic constipation in The Health Independent Network (THIN) database. The model was used to estimate the cost‐effectiveness of a GP prescribing macrogol 3350 instead of lactulose to treat adults ≥18 years of age suffering from chronic constipation. Results Sixty‐eight percent of patients given macrogol 3350 were successfully treated within 6 months after starting treatment compared to 60% of patients given lactulose.Patients’ health status at 6 months was estimated to be 0.458 and 0.454 quality‐adjusted life years (QALYs) in the macrogol 3350 and lactulose groups respectively. The total 6‐monthly NHS cost of initially treating patients with macrogol 3350 or lactulose was estimated to be £420 (US $688) and £419 (US $686) respectively. Hence, the cost per QALY gained with macrogol 3350 was estimated to be £250 (US $410). Conclusion Macrogol 3350 affords the NHS a cost‐effective addition to the range of laxatives available for this potentially resource‐intensive condition. Aliment Pharmacol Ther 31 , 302–312     

Antibiotic prescribing control by pharmacists within UK NHS hospitals

Objective To identify the role of clinical pharmacists in antibiotic prescribing control. Method A self‐completion postal questionnaire was sent to the chief pharmacist at 465 UK National Health Service hospitals in 2001/2002. It contained questions covering hospital demographics and the role of pharmacists in ensuring adherence with the recommendations on antibiotic prescribing contained in hospital prescribing documents. Key findings Fifty‐four per cent of questionnaires (n=253) were completed. Of these, 93% (n=235) of the responding hospitals had at least one of the following prescribing control documents: antibiotic formulary, antibiotic policy and antibiotic guidelines. Pharmacists routinely performed clinical review of adherence with prescribing recommendations (antibiotic prescribing control) in 83% of the responding hospitals but only in approximately two‐thirds of hospitals (64%) was this review performed on every ward. The antibiotic prescribing control process appeared to be thorough, with five review activities performed by pharmacists in the majority of hospitals (74%), and proactive, with pharmacists undertaking routine daily visits to all wards (or selected units) in 85% of responding hospitals. Nearly three‐quarters (71%) of hospitals had performed an audit of antibiotic prescribing; the majority had done so within the past two years. Pharmacists had been involved in these audits in 92% of responding hospitals. Conclusions Where performed, antibiotic prescribing control appeared to be a thorough process. Key areas for service improvement are extension of antibiotic prescribing control to all wards and the standardisation of intervention documentation. Barriers preventing the provision of a comprehensive clinical pharmacy service are discussed and future strategies identified.     

Pharmaceutical care for adult asthma patients: A controlled intervention one‐year follow‐up study

Asthma is a clinical problem with social, psychological and economic burdens. To improve patient disease management, different education programmes have been developed. Challenges in asthma management may be partially attributed to non‐adherence or improper use of inhalers. This study aimed to implement and assess hospital‐based pharmaceutical care services for asthmatic patients. A 12‐month, single‐centre, randomized, controlled study was initiated in asthmatic adult patients who had been divided into either a control or intervention group. Patients in the control group received the usual care, and patients in the intervention group received patient counselling per study protocol that covered asthma knowledge, control, adherence to treatment and inhalation techniques. The main variables compared measurements at baseline with those at 6 and 12 months. A total of 192 patients completed the study protocol: 90 in the control group and 102 in the intervention group. The control group included 90 patients, and the intervention group included 102 patients. Over the course of the 12‐month follow‐up period, a significant difference was observed between intervention and control groups with respect to asthma control (38.2% vs 10.0%; P < .001), mean correct inhalation technique (confidence interval [CI]: 8.1, 7.8‐8.5 vs CI: 6.1; 5.6‐6.6; P = .01) and good medication adherence (60.7% vs 50.0%, P = .02). There were 34% and 25% decreases in emergency room visits and hospital admissions, respectively, in the intervention group compared to the control group. This study emphasizes the importance of patient counselling in asthma management and the significant contribution that the pharmacist's intervention can have on asthma control.     

How effective are pharmacists who work with medical practitioners? A study of interventions intended to influence prescribing

Objective — This study was designed to describe the interventions made by pharmacists working within different therapeutic areas in medical practices in primary care and to estimate the effects on prescribing. Method — All medical practices and community pharmacists in one health authority area in England were invited to participate. Pharmacists were allocated to work with specific practices and training was provided in musculoskeletal, respiratory and anxiolytic/hypnotic (sedative) prescribing. Pharmacists negotiated and agreed with their medical practice the type of interventions which would meet the practice's needs. Pharmacists were remunerated to provide a maximum of eight three‐hour sessions in each medical practice on each therapeutic area over a 12‐month period. Details of all interventions were recorded by each pharmacist and countersigned by a practice GP. A summary form was then sent to the health authority. Analysis of prescribing data before and after intervention in all practices was carried out using a predictive model to calculate estimated costs. Key findings — Twenty‐seven pharmacists working with 39 medical practices participated in the study. Pharmacist interventions resulted in 165 dose changes, 368 drug changes, 470 drug discontinuations and 1,042 patient reviews. On average, £3.99 was saved for each musculoskeletal intervention made. This compared with an additional cost of £15.50 and £17.92 for each intervention in sedative and respiratory prescribing, respectively. Analysis of prescribing data showed that the total spend in musculoskeletal and sedative prescribing in participating practices one year after intervention was lower than that predicted. Conclusion — Accurate recording of individual interventions with reasons, outcomes and direct cost consequences allows purchasers to make more informed decisions about the potential benefits of practice pharmacists. This method may, however, underestimate the pharmacist's indirect impact on prescribing since it does not take into account any educational effect on prescribers.     

A multifaceted intervention to reduce guideline non-adherence among prescribing physicians in Dutch hospitals

Background Despite the potential of clinical practice guidelines to improve patient outcomes, adherence to guidelines by prescribers is inconsistent. Objective The aim of the study was to determine whether an approach of introducing an educational programme for prescribers in the hospital combined with audit and feedback by the hospital pharmacist reduces non-adherence of prescribing physicians to key pharmacotherapeutic guidelines. Setting This prospective intervention study with a before–after design evaluated patients at surgical, urological and orthopaedic wards. Method An educational program covering pain management, antithrombotics, fluid and electrolyte management, prescribing in case of renal insufficiency, application of radiographic contrast agents and surgical antibiotic prophylaxis was presented to prescribers on the participating wards. Hospital pharmacists performed medication safety consultations, combining medication review of patients who are at risk for drug related problems with visits to ward physicians. Main outcome measure The outcome measure was the proportion of the admissions of patients in which the physician did not adhere to one or more of the included guidelines. Difference was expressed in odds ratios (OR) with 95% confidence intervals (CI). Multivariable logistic regression analysis was performed. Results 1435 Admissions of 1378 patients during the usual care period and 1195 admissions of 1090 patients during the intervention period were included. Non-adherence was observed significantly less often during the intervention period [21.8% (193/886)] as compared to the usual care period [30.5% (332/1089)]. The adjusted OR was 0.61 (95% CI 0.49–0.76). Conclusion This study shows that education and support of the prescribing physician can reduce guideline non-adherence at surgical wards.     

Implementation of a community liaison pharmacy service: a randomised controlled trial

Objective The aim of this study was to provide a pharmacy service to improve continuity of patient care across the primary‐secondary care interface. Setting The study involved patients discharged from two acute‐care tertiary teaching hospitals in Melbourne, Australia, returning to independent living. Methods Consecutive patients admitted to both hospitals who met the study criteria and provided consent were recruited. Recruited patients were randomised to receive either standard care (discharge counselling, provision of compliance aids and communication with primary healthcare providers when necessary) or the intervention (standard care and a home visit from a community liaison pharmacist (CLP) within 5 days of discharge). Participant medication was reviewed during the visit according to set protocols and compliance and medication understanding was measured. All participants were telephoned 8–12weeks after discharge to assess the impact of the intervention on adherence and medication knowledge. Key findings The CLP visited 142 patients with a mean time of 4.2 days following hospital discharge (range = 1–14 days). Consultations lasted 15–105 min (mean, 49 min; SD, ± 21 min). The CLPs retrospectively coded 766 activities and interventions that occurred during home visits, subsequently categorised into three groups: counselling and education, therapeutic interventions and other interventions. No statistical difference was detected in the number of medications patients reported taking at follow‐up: the mean value was 7.72 (SD, ± 3.27) for intervention patients and 7.55 (SD, ± 3.27) for standard‐care patients (P = 0.662). At follow‐up self‐perceived medication understanding was found to have improved in intervention patients (P < 0.001) and significant improvements from baseline in medication adherence were found in both standard‐care (P < 0.022) and intervention (P < 0.005) groups; however, adherence had improved more in intervention patients. Conclusion The community liaison pharmacy service provided critical and useful interventions and support to patients, minimising the risk of medication misadventure when patients were discharged from hospital to home.     

Impact of community pharmacist intervention discussing patients’ beliefs to improve medication adherence

Background Adherence to evidence based medicines in patients who have experienced a myocardial infarction remains low. Individual’s beliefs towards their medicines are a strong predictor of adherence and may influence other factors that impact on adherence. Objective To investigate if community pharmacists discussing patients’ beliefs about their medicines improved medication adherence at 12 months post myocardial infarction. Setting This study included 200 patients discharged from a public teaching hospital in Queensland, Australia, following a myocardial infarction. Patients were randomised into intervention (n = 100) and control groups (n = 100) and followed for 12 months. Method All patients were interviewed between 5 to 6 weeks, at 6 and 12 months post discharge by the researcher using the repertory grid technique. This technique was used to elicit the patient’s individualised beliefs about their medicines for their myocardial infarction. In the intervention group, patients’ beliefs about their medicines were communicated by the researcher to their community pharmacist. The pharmacist used this information to tailor their discussion with the patient about their medication beliefs at designated time points (3 and 6 months post discharge). The control group was provided with usual care. Main outcome measure The difference in non-adherence measured using a medication possession ratio between the intervention and control groups at 12 months post myocardial infarction. Results There were 137 patients remaining in the study (intervention group n = 72, control group n = 65) at 12 months. In the intervention group 29 % (n = 20) of patients were non-adherent compared to 25 % (n = 16) of patients in control group. Conclusion Discussing patients’ beliefs about their medicines for their myocardial infarction did not improve medication adherence. Further research on patients beliefs should focus on targeting non-adherent patients whose reasons for their non-adherence is driven by their medication beliefs.     

Implementation of statin prescribing guidelines: a cost effectiveness analysis

□ The evidence that statins reduce coronary heart disease mortality and morbidity is strong yet these drugs are under‐utilised in the UK □ Statin prescribing guidelines were implemented in five general medical practices using academic detailing, audit, feedback and written materials □ Statin prescribing increased following introduction of the guidelines, to a greater extent than predicted by regression analysis in the absence of intervention, with an additional 102 patients being treated 12 months after intervention □ Assuming benefits in this patient group are equivalent to those seen in the major trials, this equates to an additional 3.6 major coronary events and 1.5 coronary deaths prevented □ Including both the cost of guideline introduction and the additional statin drug costs, the cost per event prevented was 28,063 for major coronary events and £67,351 for coronary deaths.     

Is hospital admission a sufficiently sensitive outcome measure for evaluating medication review services? A descriptive analysis of admissions within a randomised controlled trial

Objective The aims of the study were: to describe and assess hospital admissions occurring during a randomised controlled trial (RCT) of a pharmacist‐led medication review service; to describe the admissions in terms of emergency status and main cause; to estimate the potential contribution of pharmaceutical care issues (PCIs) to admission; and to assess the proportion of admissions that could be influenced by a pharmacist intervention. Setting Within the context of a RCT of pharmacists providing medication review for 332 elderly patients living at home, taking at least four repeat medicines, carried out in one region of Scotland. Method Hospital data were obtained for all admissions occurring during the 9‐month period studied, summarised and evaluated by two independent medical reviewers for the contribution of PCIs to admission. Two pharmacists assessed the extent to which PCIs were preventable by pharmacist intervention. Key findings Approximately two‐thirds of the 77 admissions were unplanned, and two‐thirds were to medical wards. Only 17 (22%) of all admissions were considered to be related to PCIs and 10 (13%) possibly preventable by pharmacist intervention. Although the majority of surgical admissions were considered to be unrelated to PCIs (26/29), both unplanned and planned medical admissions were related to PCIs. One of these occurred as a direct result of the pharmacist's recommendation. Conclusion The overall numbers of hospital admissions, medical admissions and unplanned admissions may not be sufficiently sensitive outcome measures for evaluating the impact of pharmacist interventions. Consideration could be given to developing categories of admission that are related to medicines or are likely to be preventable as more relevant measures. Including more details of hospital admissions in future studies may be useful.     

Outcomes of pharmacist-provided medication review in collaborative care for adult Singaporeans receiving hemodialysis

Background Patients receiving hemodialysis are predisposed to drug related problems (DRPs). While collaborative care (CC) models with pharmacist involvement can reduce DRP occurrence, few have examined its impact on clinical and economic outcomes. Objective To determine whether a CC model with pharmacist-provided medication review can reduce unplanned admissions and healthcare utilization in patients receiving hemodialysis, compared to usual care (UC). Setting Outpatient nephrology clinic of a tertiary hospital in Singapore. Method In this retrospective observational study, patients who were taking more than 10 medications or had prior unplanned admissions were included. Patients were identified as being managed under CC (n = 134) if they received comprehensive pharmacist-provided review, or under the UC (n = 190) if they did not. Those perceived to be at greater risk were given priority for receiving CC. All outcomes analyses were adjusted for covariates. Main outcome measure The primary outcome was incidence of unplanned admissions within 6 months post index visit. Secondary outcomes included length of stay (LOS), mortality and healthcare utilization cost. Results CC reduced unplanned admissions by 27% (IRR 0.73, 95% CI 0.54–0.99, p = 0.047) and shortened mean LOS by 1.3 days [6.7 (2.6) vs. 8.0 (3.2), p < 0.001] compared to UC. There were no significant differences in mortality (p = 0.189) or mean healthcare utilization cost (p = 0.165) between groups. Pharmacists identified 515 DRPs with 429 (83.3%) resolved after review. Conclusion The CC model with pharmacist-provided medication review reduced unplanned admissions and LOS in patients receiving hemodialysis. Further studies are warranted to confirm reductions in mortality and healthcare utilization.