Medication review in hospitalised patients to reduce morbidity and mortality

Department of Clinical Pharmacology, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, Denmark, 2400.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 02/2013; 2(2):CD008986. DOI: 10.1002/14651858.CD008986.pub2
Source: PubMed

ABSTRACT Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug related harms and poorer adherence. The concept of medication review is a key element in improving the quality of prescribing and the prevention of adverse drug events. While no generally accepted definition of medication review exists, it can be defined as a systematic assessment of the pharmacotherapy of an individual patient that aims to evaluate and optimise patient medication by a change (or not) in prescription, either by a recommendation or by a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.
We examined whether the delivery of a medication review by a physician, pharmacist or other healthcare professional improves the health outcomes of hospitalised adult patients compared to standard care.
We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Group's Specialised Register (August 2011); The Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library 2011, Issue 8; MEDLINE (1946 to August 2011); EMBASE (1980 to August 2011); CINAHL (1980 to August 2011); International Pharmaceutical Abstracts (1970 to August 2011); and Web of Science (August 2011). In addition we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We did not apply any language restrictions.
We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality and secondary outcomes included hospital readmission, emergency department contacts and adverse drug events.
Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and additional unpublished data. We calculated relative risks for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)).
We identified 4647 references and included five trials (1186 participants). Follow-up ranged from 30 days to one year. We found no evidence of effect on all-cause mortality (risk ratio (RR) 0.98; 95% CI 0.78 to 1.23) and hospital readmissions (RR 1.01; 95% CI 0.88 to 1.16), but a 36% relative reduction in emergency department contacts (RR 0.64; 95% CI 0.46 to 0.89).
It is uncertain whether medication review reduces mortality or hospital readmissions, but medication review seems to reduce emergency department contacts. However, the cost-effectiveness of this intervention is not known and due to the uncertainty of the estimates of mortality and readmissions and the short follow-up, important treatment effects may have been overlooked. Therefore, medication review should preferably be undertaken in the context of clinical trials. High quality trials with long follow-up are needed before medication review should be implemented.

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Available from: Andreas Lundh, Sep 28, 2015
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    • "This makes it all the more difficult to meticulously define what it means to prescribe drugs appropriately in older people [8]. Systematically and regularly reviewing all drugs in older patients is one of several solutions, although more evidence is necessary to establish its benefits for older patients [5] [9] [10]. The use of screening tools in this regard has already been discussed previously [11] [12]. "
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    ABSTRACT: Background Inappropriate prescribing is prevalent in older people. One of the interventions is to optimize geriatric pharmacotherapy with a screening tool to detect potentially inappropriate prescribing. The aim of this study was to develop a novel instrument, the RASP list, which was adapted from The Screening Tool of Older Persons’ potentially inappropriate Prescriptions criteria. Methods Face validity, usability and time investment were determined. Content validity was verified with the Content Validity Index (CVI) and the modified kappa index (κ*). Cohen's kappa (κ) was used to determine the inter-rater reliability. Content and reproducibility validation were to be repeated if consensus (κ* ≥ 0.74) could not be reached in the first round or if new compelling evidence was published. Results Ten experts validated the content of RASP 1.0. The scale-CVI/Average (S-CVI/Ave) was 0.936, Three items did not reach κ* ≥ 0.74. Median time to complete a patient case with RASP 1.0 was 316 seconds. Inter-rater reliability was determined by 9 pharmacists (κ = 0.71) and 10 geriatricians (κ = 0.63). In a second validation round, 15 items were added to and 3 items deleted from RASP 1.0. Nine experts validated the new content of RASP 2.0. All new items but one reached a κ* ≥ 0.74. The S-CVI/Ave was 0.923. Inter-rater reliability of RASP 2.0 was performed by 14 pharmacists (κ = 0.77). The final version of the RASP list contained 76 items. Conclusions The RASP list is a reliable (κ = 0.77) and valid (S-CVI/Ave = 0.92) screening tool to identify polypharmacy in older persons. Further research concerning clinical relevancy is warranted.
    European geriatric medicine 06/2014; 5(3). DOI:10.1016/j.eurger.2013.12.005 · 0.73 Impact Factor
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    • "Benefits of ADR profiling may be confined to the specific problems identified, such as pain, stiffness, dehydration, and oral care, and not reflected in global measures. Cochrane reviews (including 1186 and 7653 patients) suggest that mortality and readmission to hospital may be insufficiently sensitive to medication review [13, 91]. Similarly, instruments, such as the CRBRS or Bartel's index [72, 92] or quality of life or behaviour measures [93], while useful when comparing populations, may be insufficiently responsive to subtle but important changes, such as improved oral care, rendering them less suitable for clinical trials. "
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    ABSTRACT: Objectives. People with dementia are susceptible to adverse effects of medicines. However, they are not always closely monitored. We explored (1) feasibility and (2) clinical impact of nurse-led medication monitoring. Design. Feasibility "before-and-after" intervention study. Setting. Three care homes in Wales. Participants. Eleven service users diagnosed with dementia, taking at least one antipsychotic, antidepressant, or antiepileptic medicine. Intervention. West Wales Adverse Drug Reaction (ADR) Profile for Mental Health Medicines. Outcome Measures. (1) Feasibility: recruitment, retention, and implementation. (2) Clinical impact: previously undocumented problems identified and ameliorated, as recorded in participants' records before and after introduction of the profile, and one month later. Results. Nurses recruited and retained 11 of 29 eligible service users. The profile took 20-25 minutes to implement, caused no harm, and supplemented usual care. Initially, the profile identified previously undocumented problems for all participants (mean 12.7 (SD 4.7)). One month later, some problems had been ameliorated (mean 4.9 (3.6)). Clinical gains included new prescriptions to manage pain (2 participants), psoriasis (1), Parkinsonian symptoms (1), rash (1), dose reduction of benzodiazepines (1), new care plans for oral hygiene, skin problems, and constipation. Conclusions. Participants benefited from structured nurse-led medication monitoring. Clinical trials of our ADR Profile are feasible and necessary.
    The Scientific World Journal 02/2014; 2014(7456):843621. DOI:10.1155/2014/843621 · 1.73 Impact Factor
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    ABSTRACT: Background Medication reviews are considered to be important to maintain a high quality of pharmacotherapy. However, there is a large variation in the quality of these reviews. Aim To evaluate the covariates that may lead to high-quality medication reviews and to establish their relative importance. Design Healthcare professionals, including community pharmacists, hospital pharmacists, nursing home physicians, general practitioners and geriatricians, were recruited in the province of Limburg, The Netherlands. Method A research group, selected for their expertise in the field of medication reviews, established covariates that could possibly affect the quality of medication reviews. An electronic questionnaire, including these covariates, was developed and was subsequently sent to the participants who rated the covariates using a 10-point scale. Finally, the research group classified the scores. Physicians and pharmacists were evaluated jointly and separately to account for possible differences. Results 29 out of 49 participants completed the study. 13 covariates were evaluated and their medians and ranges were calculated. The five most important covariates were, from most to less important, knowledge of the indication for the drug, use of guidelines, reviewer's professional field, knowledge of the medical history, and use of laboratory values. Both groups found the indication for the drug the most important covariate. Conclusions We found that the most relevant covariates that may lead to a high-quality medication review are the drug's indication, use of patients' medical history, use of guidelines, reviewer's professional field, and use of laboratory values.
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