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Using telehealth to enable collaboration of pharmacists and geriatricians in residential medication management reviews
Abstract
Background Practical issues impede optimum collaboration between pharmacists and other clinical specialists in the current Australian residential medication review services which potentially affect efficiency, timeliness and quality of outcomes. Objective This mixed methods study aimed to explore the potential value of an existing telehealth platform to enable collaboration of pharmacists and geriatricians in residential medication reviews. Setting Long term care facilities in Australia. Method Twenty vignettes of aged care residents were prepared and independently reviewed by five pharmacists and five geriatricians using a telehealth platform to record their recommendations for medications. The geriatricians were subsequently asked to re-consider their recommendations after being provided with a pharmacist’s report. Main outcome measure The level of agreement between pharmacists and between geriatricians, changes in the mean number of medications after pharmacists’ and geriatricians’ reviews, number of changes in geriatricians’ recommendations after viewing a pharmacist’s report, and pharmacists’ and geriatricians’ feedback. Results Both pharmacists and geriatricians had fair agreement about their recommendations for medications (kappa of 0.30 and 0.31 respectively). The mean number of medications over 20 cases was significantly reduced from a baseline of 14.9 to 13.4 by pharmacists, and to 12.3 by geriatricians after their reviews. There was disagreement between geriatricians and pharmacists on 430/1485 (29%) recommendations on medications; after viewing a pharmacist’s report, geriatricians changed their mind in 51 occasions. Geriatricians found the pharmacist report useful in 72% of the cases. The majority of the pharmacists (4/5) were prepared to use the online system routinely. Conclusion The tested telehealth platform has the potential of being used as a part of routine practice to improve accessibility of the service and to enable synchronous collaboration among healthcare professionals.
... Fourteen quantitative, seven qualitative and five mixed methods studies were reviewed. The Western countries studied included the United States, 29-32 the United Kingdom, [33][34][35] Australia, [36][37][38][39] Sweden, 40,41 Canada, 42 Germany 43 and France. 44,45 Studies on Asian countries included those on Hong Kong Special Administrative Region of the People's Republic of China, 46-50 Japan 51 and Singapore. ...
... 31,34,43 One study investigated a hybrid model: videoconferencing integrated with a clinical database. 37 ...
... 31 In one study, various medical specialists were involved. 42 Geriatric assessment was the most common scope of service provided, 35,40,44,53 followed by wound assessment and monitoring, 47,52,54 vital signs monitoring, 31,34,43 medication review 37 and staff and resident education. 46 Four studies - ...
Objective:
To consolidate existing evidence on experiences and perspectives of healthcare providers involved in telemedicine services in long-term residential care.
Methods:
A scoping review was conducted. A systematic search for articles published in 2000-2021 was performed in CINAHL, Web of Science, PubMed, EMBASE and Scopus; further, relevant journals and grey literature websites were hand searched. Key search terms included 'telemedicine', 'telehealth' and 'nursing homes'.
Results:
Twenty-six articles were included. A narrative synthesis of evidence was conducted. The review identified four themes: (1) Presence of multidisciplinary care, (2) perceived usefulness of telemedicine, (3) perceived ease of use and (4) expanded role of nursing home staff. The presence of multidisciplinary care providers provided a wide range of telemedicine services to residents and promoted interprofessional collaboration between acute and long-term care. Telemedicine was perceived to increase timely onsite management by remote specialists, which enabled care quality improvement. However, technical problems associated with equipment usage reduced the ease of use of telemedicine. Concerns emerged from the expanded role of nursing home staff, which could negatively affect clinical decision-making and create medico-legal risks.
Conclusion and implications:
Telemedicine is valuable in distance-based care, especially in the current 2019 coronavirus pandemic, for supporting continuity of care to nursing home residents. This review provided evidence from multiple healthcare providers' perspectives. Further research can elucidate their specific roles and responsibilities in telemedicine and challenges in work processes, which will facilitate developing evidence-based competencies and improving technical infrastructure, thus contributing to personal and organisational readiness for telemedicine integration.
... In contrast, the features of unusefulness or uncertainty of using smart technologies in the coping process were reported to affect the user acceptability negatively, such as the unusefulness [129,149], difficulty in use or to learn [101,208], and lacking supportive resources [169,177] or tech-support in applying technologies [178]. Some HCPs perceived new technologies as a burden to disrupt routines or added workloads, and it may cause reducing their time to provide essential nursing care for the residents, for example, initiating a new information system requiring manual input of residents' health records into the system caused frustrations among the HCPs [71,181]. ...
... Integrating medical services could achieve clinical efficiency and overcome the limited access to healthcare for the older adults who live in rural area [213]. Electronic clinical information, telemedicine, and mHealth have shown the feasibility in overcoming shortages of medical resources and improving healthcare access in nursing homes [169]. The scoping review found that clinical information management and remote clinical services, especially telemedicine, have been broadly implemented in some nursing homes and they were accepted by many stakeholders [147]. ...
Background and objectives
Smart technology in nursing home settings has the potential to elevate an operation that manages more significant number of older residents. However, the concepts, definitions, and types of smart technology, integrated medical services, and stakeholders’ acceptability of smart nursing homes are less clear. This scoping review aims to define a smart nursing home and examine the qualitative evidence on technological feasibility, integration of medical services, and acceptability of the stakeholders.
Methods
Comprehensive searches were conducted on stakeholders’ websites (Phase 1) and 11 electronic databases (Phase 2), for existing concepts of smart nursing home, on what and how technologies and medical services were implemented in nursing home settings, and acceptability assessment by the stakeholders. The publication year was inclusive from January 1999 to September 2021. The language was limited to English and Chinese. Included articles must report nursing home settings related to older adults ≥ 60 years old with or without medical demands but not bed-bound. Technology Readiness Levels were used to measure the readiness of new technologies and system designs. The analysis was guided by the Framework Method and the smart technology adoption behaviours of elder consumers theoretical model. The results were reported according to the PRISMA-ScR.
Results
A total of 177 literature (13 website documents and 164 journal articles) were selected. Smart nursing homes are technology-assisted nursing homes that allow the life enjoyment of their residents. They used IoT, computing technologies, cloud computing, big data and AI, information management systems, and digital health to integrate medical services in monitoring abnormal events, assisting daily living, conducting teleconsultation, managing health information, and improving the interaction between providers and residents. Fifty-five percent of the new technologies were ready for use in nursing homes (levels 6–7), and the remaining were proven the technical feasibility (levels 1–5). Healthcare professionals with higher education, better tech-savviness, fewer years at work, and older adults with more severe illnesses were more acceptable to smart technologies.
Conclusions
Smart nursing homes with integrated medical services have great potential to improve the quality of care and ensure older residents’ quality of life.
... In contrast, appraisals of unusefulness or uncertainty of usefulness of a smart solution (120,142), not easy to use or to learn (190,191), lacking in supportive resources (132,172) or tech-support (167) were reported to negatively affect the user acceptability. Some HCPs perceived new technologies as a burden when they disrupted routines or brought added workloads, reducing their time to provide essential nursing care for the residents. ...
... The integration of medical services is a network of healthcare services and advanced technologies, and it could achieve clinical e ciency or overcome the limited access to healthcare (196). Electronic clinical information, telemedicine, and mHealth were increasingly used and shown to be successful to some extent in overcoming shortages of medical resources and improving healthcare access and the standards of clinical practices in nursing homes (132). From our scoping review, clinical information management and remote clinical services, especially telemedicine have been broadly implemented in some nursing homes, and these services were reported to be acceptable to many stakeholders (146). ...
Background and objectives:
Smart technology in nursing home settings has potential to elevate an operation that manages a larger number of elderly residents. However, the concepts, definitions and scopes of ‘smartness’, integrated medical services and stakeholders’ acceptability of a smart nursing home are less clear. This scoping review aims to define a smart nursing home and examine the qualitative evidence on technological feasibility, integration of medical services and acceptability of the stakeholders.
Methods:
Comprehensive searches were conducted on stakeholders’ websites and 11 electronic databases for existing concepts of a smart nursing home (Phase 1), and on what and how technologies and medical services were implemented in nursing home settings, as well as acceptability assessment by the stakeholders (Phase 2). The publication year was inclusive of January 1999 to September 2021. The language was limited to English and Chinese. Included articles must report nursing home settings and related to older adults ≥ 60 years old with or without medical demands but not bed-bound. New technology developments and system designs were measured by Technology Readiness Levels. The analysis was guided by Framework Method and the smart technology adoption behaviours of elder consumers theoretical model, and reported according to the PRISMA-ScR.
Results:
A total of 177 literature (13 website documents and 164 journal articles) were selected. Smart nursing homes are technology-assisted nursing homes that allow life enjoyment of its residents. They used IoT, computing technologies, cloud computing, big data and AI, information management systems, and digital health to integrate medical services in monitoring abnormal events, assisting daily living, teleconsultation, health information management, and improving interaction between providers and residents. Fifty-five percent of the new technologies were proven ready for use in nursing homes (level 6-7), and the remaining were proven of implementation feasibility (level 1-5). Providers with higher education, tech-savviness, fewer years at work, and older adults with more severe illnesses were more acceptable to smart technologies.
Conclusions:
Smart nursing homes with integrated medical services have great potential to improve the quality of care and ensure elderly residents’ quality of life.
... Providing on-site medication reviews might also be more resource-intensive for GPs with patients in different institutions. Telemedicine might not only reduce travel time for physicians, but also facilitate interprofessional integration of specialist staff like pharmacists [33]. ...
Background
Around 86% of Switzerland’s nursing home (NH) residents have polypharmacy (≥ 5 concomitant medications); almost 80% use a potentially inappropriate medication increasing their risk of medication-related problems. Medication reviews can optimize medication safety by fostering interprofessional collaboration, leading to medication therapy adjustments; they are currently being considered as a future national quality indicator of NH performance in Switzerland.
The present study aimed to survey current medication-use infrastructure and processes and medication review practices in NHs in the German-speaking part of Switzerland. It also aimed to explore the barriers to, facilitators of, and prerequisites for medication review to become a national NH quality indicator.
Methods
We took a rapid appraisal approach. Between February and August 2022, we distributed a structured online questionnaire to the participating NHs assessing the infrastructure and processes surrounding medication use, analyzing them quantitatively and descriptively. We followed up with 60-minute, in-depth, interprofessional, online group interviews, using a semi-structured interview guide, focusing on interprofessional collaboration and medication reviews. Data analysis was done iteratively in a descriptive manner.
Results
Fourteen NHs in German-speaking regions of Switzerland completed the questionnaire, with 31 professionals from eleven of these NHs participating in group interviews.
Almost half of the NHs (42.9%) had a cantonal license to run an in-house pharmacy, and in two-thirds of these, the legally responsible specialist was an external pharmacist. Community pharmacies supplied 92.9% of NHs with their medicines, mostly stored on the wards and prepared by nurses (57.1%). Accordingly, pharmacists were predominantly tasked with logistics, but were also key contacts for medication information. A clinical pharmacist participated in monthly ward rounds in just one NH. Medication verification occurred predominantly in the presence of physicians and sometimes nurses, mostly in the form of discussions during ward rounds or medication checks subsequent to an adverse event, rather than as part of comprehensive, proactive, interprofessional medication reviews.
Interviewees identified numerous prerequisites before medication review could be used as a national NH quality indicator.
Conclusions
None of our participants contested the importance of medication safety and quality in NHs; they mostly favored regular medication reviews. However, interviewees expected that the nationwide introduction of medication reviews would require a standardized guide about its content, execution, analysis, and documentation, as well as interprofessional collaboration and some form of financial incentive. Promoting the use of medication reviews in NHs will have to involve interprofessional stakeholders in developing a specific implementation approach and defining the quality assessment requirements of an indicator. Further research into these topics would be highly relevant to ensure acceptance and success.
... The study reported the expectations and possibly unmet needs of older adults for a ubiquitous healthcare service system, including various aspects such as health monitoring, health report generation, call-out services, referral services, and personalized treatment [10]. Previous research has demonstrated the potential benefits of nursing homes that utilize smart technologies and integrated medical services, as they can improve the efficiency of nursing services and enhance the effectiveness of medical care for both residents and healthcare professionals (HCPs) [11,12]. For example, the implementation of teleconsultations through videoconferencing has proven valuable in overcoming the lack of local medical resources, increasing healthcare accessibility for residents, and facilitating remote consultations with specialists. ...
Purpose:
This study aims to explore the expectations and acceptability of a smart nursing home model among Chinese older adults and their family members based on a scoping review that defines the concept of smart nursing homes.
Methods:
A qualitative case study was employed for this research. Semi-structured in-depth interviews and focus group discussions were conducted on WeChat. Participants were purposively sampled through snowball sampling in Hainan and Dalian, China. A total of 28 older adults aged 60-75 and six adult children were interviewed until data saturation was achieved, followed by a thematic analysis.
Results:
The expectations of smart nursing homes include 1) quality of care supported by governments and societies; 2) smart technology applications; 3) the presence of a skilled healthcare professional team; 4) access and scope of basic medical services; and 5) integration of medical services. The acceptability of smart nursing homes included factors such as stakeholders' perceived efficaciousness, usability, and collateral damages of using smart technologies, and the coping process of adoption was influenced by factors such as age, economic status, health status, education, and openness to smart technologies among older adults.
Conclusion:
Chinese older adults and their family members hold a positive perception of the smart nursing home model. The qualitative evidence regarding their expectations and acceptability of smart nursing homes contributes valuable insights for a wide range of stakeholders involved in the planning and implementation of smart nursing homes.
... A study by Shafiee et al looked at the collaboration of pharmacists and geriatricians via telehealth. 12 This study used an on-line platform for pharmacists to share recommendations for changes in medication therapy of longterm care facility residents. Pharmacists were asked to conduct medication reviews of the charts of 20 long-term care facility residents. ...
The COVID-19 pandemic created care continuity challenges for older adults in the ambulatory care setting. Similarly, maintaining the multidisciplinary team concept of geriatric care among healthcare practitioners working from home presented several logistical difficulties. It became apparent there was a need to address these problems to avoid care gaps in this vulnerable population. Realizing that in-person clinics could put vulnerable older adults at increased risk of contracting COVID-19, a workflow was proactively developed to convert a traditional in-person multidisciplinary geriatric clinic to a telemedicine-based model. A video patient encounter option within our electronic health record along with a secure on-line meeting platform was used to maintain a team-based approach to care. This resulted not only in a high level of efficiency in care delivery, but also ensured the safety of older adult patients served by the clinic. This model provides a template for the continued use of telemedicine as a strategy for the care of vulnerable older adults who experience challenges with attending in-person clinics.
Introduction
New and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.
Methods
This is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.
Ethics and dissemination
Ethical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.
Older adults are particularly susceptible to iatrogenic disease and communicable diseases, such as influenza. Prescribing in the residential aged care population is complex, and requires ongoing review to prevent medication misadventure. Pharmacist-led medication review is effective in reducing medication-related problems; however, current funding arrangements specifically exclude pharmacists from routinely participating in resident care. Integrating an on-site clinical pharmacist into residential care teams is an unexplored opportunity to improve quality use of medicines in this setting. The primary objective of this pilot study is to investigate the feasibility of integrating a residential care pharmacist into the existing care team. Secondary outcomes include incidence of pharmacist-led medication review, and incidence of potential medication problems based on validated prescribing measures. This is a cross-sectional, non-randomised controlled trial with a residential care pharmacist trialled at a single facility, and a parallel control site receiving usual care and services only. The results of this hypothesis-generating pilot study will be used to identify clinical outcomes and direct future larger scale investigations into the implementation of the novel residential care pharmacist model to optimise quality use of medicines in a population at high risk of medication misadventure.
PurposeTo assess whether comprehensive medication reviews conducted by clinical pharmacists as part of a healthcare team reduce drug-related hospital readmission rates among people with dementia or cognitive impairment. Methods
This randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. Patients aged ≥65 years with dementia or cognitive impairment admitted to three wards at two hospitals located in Northern Sweden were included. ResultsOf the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization. The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis.During the 180 days of follow-up, 18.9% (40/212) of patients in the intervention group and 23.0% (50/217) of those in the control group were readmitted for drug-related reasons (HR = 0.80, 95% CI = 0.53–1.21, p = 0.28, univariable Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder and an interaction term, multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR = 0.49, 95% CI = 0.27–0.90, p = 0.02). A post-hoc analysis showed a significantly reduced risk of 30-day readmissions due to drug-related problems in the total sample (without adjustment for heart failure). Conclusion
Participation of clinical pharmacists in healthcare team conducting comprehensive medication reviews did not significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment; however, post-hoc and subgroup analyses indicated significant effects favoring the intervention. More research is needed. Trial registration: Clinical trials NCT01504672.
The use of information and telecommunication technologies has expanded at a rapid rate, which has a strong influence on healthcare delivery in many countries. Rural residents and communities, however, often lack easy access to healthcare services due to geographical and demographical factors. Telepharmacy, a more recent concept that refers to pharmaceutical service provision, enables healthcare services, such as medication review, patients counseling, and prescription verification, by a qualified pharmacist for the patients located at a distance from a remotely located hospital, pharmacy, or healthcare center. Telepharmacy has many recognizable benefits such as the easy access to healthcare services in remote and rural locations, economic benefits, patient satisfaction as a result of medication access and information in rural areas, effective patient counseling, and minimal scarcity of local pharmacist and pharmacy services. Telepharmacy undoubtedly is a great concept, but it is sometimes challenging to put into practice. Inherent to the adoption of these practices are legal challenges and pitfalls that need to be addressed. The start-up of telepharmacy (hardware, software, connectivity, and operational cost) involves considerable time, effort, and money. For rural hospitals with fewer patients, the issue of costs appears to be one of the biggest barriers to telepharmacy services. Moreover, execution and implementation of comprehensive and uniform telepharmacy law is still a challenge. A well-developed system, however, can change the practice of pharmacy that is beneficial to both the rural communities and the hospitals or retail pharmacies that deliver these services.
Importance
As older adults living in nursing homes are at a high risk of adverse drug-related events, medications with a poor benefit/risk ratio or with a safer alternative should be avoided.
Objectives
To systematically evaluate the prevalence of potentially inappropriate medication use in nursing home residents.
Evidence review
We searched in PubMed and EMBASE databases (1990–2015) for studies reporting the prevalence of potentially inappropriate medication use in people ≥60 years of age living in nursing homes. The risk of bias was assessed with an adapted version of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.
Findings
A total of 91 articles were assessed for eligibility, and 48 met our inclusion criteria. These articles reported the findings from 43 distinct studies, of which 26 presented point prevalence estimates of potentially inappropriate medication use (227,534 nursing home residents). The overall weighted point prevalence of potentially inappropriate medication use in nursing homes was 43.2% [95% confidence interval (CI) 37.3%–49.1%], increasing from 30.3% in studies conducted during 1990–1999 to 49.8% in studies conducted after 2005 (P < .001). Point prevalence estimates reported in European countries were found to be higher (49.0%, 95% CI 42.5–55.5) than those reported in North America (26.8%, 95% CI 16.5–37.1) or in other countries (29.8%, 95% CI 19.3–40.3). In addition, 18 studies accounting for 326,562 nursing home residents presented 20 distinct period prevalence estimates ranging from 2.3% to 50.3%. The total number of prescribed medications was consistently reported as the main driving factor for potentially inappropriate medications use.
Conclusions and relevance
This systematic review shows that almost one-half of nursing home residents are exposed to potentially inappropriate medications and suggests an increase prevalence over time. Effective interventions to optimize drug prescribing in nursing home facilities are, therefore, needed.
Older people are often prescribed multiple medicines and have a high prevalence of polypharmacy. Polypharmacy is associated with an increased risk of inappropriate use of medicines and drug-related problems. As experts in pharmacotherapy, pharmacists are well placed to review complex medication regimens and identify causes of drug-related problems and recommend solutions to prevent or resolve them. Involvement in medication review services represents a major philosophical shift and paradigm change in the way pharmacists practice, in that the focus is shifted away from the dispensing of prescription medicines to the provision of a professional service for a patient, in collaboration with their general practitioner (GP). In Australia, there are two established medication review programs: Home Medicines Review (HMR) and Residential Medication Management Review (RMMR). The objectives of this article were to describe the process of government-funded medication review services in Australia and to evaluate the contribution of pharmacists to HMR and RMMR, using evidence-based measures, such as the Drug Burden Index (DBI) and the Medication Appropriateness Index (MAI). This review found that there is good evidence to support the role of pharmacists in delivering medication review services across different settings. Although the positive impact of such services has been demonstrated using a variety of validated measures (DBI, MAI), there remains a need to also evaluate actual clinical outcomes and/or patient-reported outcomes.
Clinical medication review (CMR) is a structured and collaborative service aimed at identifying and resolving medication-related problems (MRPs). This is the first systematic review of CMR research in Australia.
To systematically review the processes and outcomes of CMR in community-settings in Australia.
MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library and the grey literature were searched from 2000 to February 2015. All study designs were considered. Data extraction and quality assessment were performed independently by two investigators.
Nine controlled studies, 34 observational and uncontrolled studies, 11 qualitative studies (focus groups and interviews) and nine survey studies were included. The CMRs resulted in identification of MRPs (n = 15 studies, mean 3.6 MPRs per CMR) and improved adherence (n = 3). Reductions in numbers of medications prescribed (n = 3 studies), hospitalizations (n = 3), potentially inappropriate prescribing (n = 3) and costs (n = 6) were demonstrated. Comparisons to a control group, predominately non-recipients of CMR, were made in eleven of 43 studies. Evidence supports additional models that promote interprofessional collaboration and timely referral following hospital discharge. Qualitative research identified low awareness of CMR among eligible non-recipients, while benefits were perceived to outweigh barriers to implementation. Underserved populations include indigenous and culturally and linguistically diverse people, recipients of palliative care, those recently discharged from hospital, people with poor medication adherence, those in rural and remote areas, older males, and younger people with long-term, persistent or serious health problems.
The available evidence suggests CMR is beneficial in improving the quality use of medications and health outcomes. However, lack of comparator groups in many observational studies limited the strength of conclusions in relation to the impact on clinical outcomes. Addressing access gaps for underserved populations, implementing additional referral pathways, and facilitating greater collaboration between the health professionals represent opportunities for further improvement.
Copyright © 2015 Elsevier Inc. All rights reserved.
In Australian residential aged care facilities (RACFs), the use of certain classes of high-risk medication such as antipsychotics, potent analgesics, and sedatives is high. Here, we examined the prescribed medications and subsequent changes recommended by geriatricians during comprehensive geriatric consultations provided to residents of RACFs via videoconference.
This is a prospective observational study.
Four RACFs in Queensland, Australia, are included.
A total of 153 residents referred by general practitioners for comprehensive assessment by geriatricians delivered by video-consultation.
Residents' mean (standard deviation, SD) age was 83.0 (8.1) years and 64.1% were female. They had multiple comorbidities (mean 6), high levels of dependency, and were prescribed a mean (SD) of 9.6 (4.2) regular medications. Ninety-one percent of patients were taking five or more medications daily. Of total medications prescribed (n=1,469), geriatricians recommended withdrawal of 9.8% (n=145) and dose alteration of 3.5% (n=51). New medications were initiated in 47.7% (n=73) patients. Of the 10.3% (n=151) medications considered as high risk, 17.2% were stopped and dose altered in 2.6%.
There was a moderate prevalence of potentially inappropriate high-risk medications. However, geriatricians made relatively few changes, suggesting either that, on balance, prescription of these medications was appropriate or, because of other factors, there was a reluctance to adjust medications. A structured medication review using an algorithm for withdrawing medications of high disutility might help optimize medications in frail patients. Further research, including a broader survey, is required to understand these dynamics.
Older people in nursing and residential homes often have complex disabilities and behavioural disturbances. Recent publicity has highlighted the dangers of medication in this group, and controls over prescribing have been suggested.
To investigate the effect of a review of medication by a pharmacist.
An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.
The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).
This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality.
to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.
randomised controlled trial of clinical medication review by a pharmacist against usual care.
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.
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).
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.
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.
For long the medical literature has shown that patients do not always receive appropriate care, including pharmacotherapeutic treatment. To achieve improved patient care, a number of physician-oriented interventions are being delivered internationally in an attempt to implement evidence based medicine in routine daily practice of medical practitioners. The pharmacy profession has taken an active role in the delivery of intervention strategies aimed at promoting evidence based prescribing and improved quality and safety of medicine use. However, the medical literature also supports the notion that valid clinical care recommendations do not always have the desired impact on physician behaviour. We argue that the well-established theory of psychological reactance might at least partially explain instances when physicians do not act upon such recommendations. Reactance theory suggests that when recommended to take a certain action, a motivational state compels us to react in a way that affirms our freedom to choose. Often we choose to do the opposite of what the recommendation is proposing that we do or we just become entrenched in our initial position. The basic concepts of psychological reactance are universal and likely to be applicable to the provision of recommendations to physicians. Making recommendations regarding clinical care, including pharmacotherapy, may carry with it implied threats, as it can be perceived as an attempt to restrict one's freedom of choice potentially generating reactance and efforts to avoid them. By identifying and taking into account factors likely to promote reactance, physician-oriented interventions could become more effective.
Background
Older adults living with dementia may have a higher risk of medication toxicity than those without dementia. Optimising prescribing in this group of people is a critically important yet challenging process.
Objective
Our aim was to systematically review the evidence for the effectiveness of interventions for optimising prescribing in older people with dementia.
Methods
This systematic review searched the Pubmed, Embase, CINAHL, PsycINFO and Cochrane Library electronic databases for studies that evaluated relevant interventions. Experimental, quasi-experimental and observational studies published in English prior to August 2018 were included. Data were synthesised at a narrative level.
Results
The 18 studies accepted for review included seven randomised, two nonrandomised controlled, five quasi-experimental and four observational studies. Half the studies were conducted in nursing homes and the other half in hospital and community settings. There was great variability in the interventions and outcomes reported and a meta-analysis was not feasible. The three randomised and four nonrandomised studies examining medication appropriateness all reported improvements on at least one measure of the outcome. Six studies reported on interventions that identified and resolved drug-related problems. The results for other outcomes, including the number of medications (10 studies), healthcare utilisation (7 studies), mortality (7 studies), quality of life (3 studies) and falls (3 studies), were mixed and difficult to synthesise because of variability in the study design and measures used.
Conclusion
Emerging evidence suggests that interventions in older people with dementia may have positive effects on medication appropriateness and resolution of drug-related problems; however, whether optimisation of medication results in clinically meaningful outcomes remains uncertain.
Objectives: The primary objective of this study was to investigate the impact of RMMRs on medication regimen complexity, as assessed by a validated measure.
Methods: Retrospective analysis of RMMRs pertaining to 285 aged care residents aged ≥ 65 years in Sydney, Australia. Medication regimen complexity was measured using the Medication Regimen Complexity Index (MRCI) at baseline, after pharmacists’ recommendations (assuming that all of the pharmacists’ recommendations were accepted by the General Practitioner (GP)), and after the actual uptake of pharmacists’ recommendations by the GP. Differences in the regimen complexity was measured using the Wilcoxon sign rank test.
Results: Pharmacists made 764 recommendations (average 2.7 recommendations per RMMR), of which 569 (74.5%) were accepted by GPs. The median MRCI at baseline in the sample was 25.5 (IQR = 19.0–32.5). No statistically significant differences were demonstrated in the MRCI scores after pharmacists’ recommendations (p = 0.53) or after GPs’ acceptance of these recommendations (p = 0.07) compared to the baseline.
Conclusion: Our study revealed high acceptance of pharmacists’ recommendations by GPs. This suggests that RMMRs are useful for identifying and resolving drug-related issues among residents of ACFs. However, our study failed to show a significant effect of RMMRs in reducing the medication regimen complexity, as measured by the MRCI. Further studies are needed to establish the association of medication regimen complexity and clinical outcomes in residents of ACFs.
Background: Inappropriate prescribing (IP) is prevalent among elderly people in aged care facilities. Little has been published on the effect of pharmacists performing residential medication management reviews (RMMRs) in aged care, on the appropriateness of prescribing. RMMRs represents a key strategy for achieving quality use of medicines, by assisting residents in aged care facilities and their carers to better manage their medicines. However, the structure of RMMR has moved from annual to every two years for each resident.
Objectives: The primary objective of this study was to investigate the impact of the effect of pharmacists performing RMMRs on medication use appropriateness, as measured by the Medication Appropriateness Index (MAI).
Methods: Retrospective analysis of RMMRs pertaining to 223 aged care residents aged ≥65 years in Sydney, Australia. The MAI was applied on two RMMR cohorts; newer cohort (n = 111, 2015) i.e. following the recent changes to the RMMR funding and older cohort (n = 112, 2012) at baseline, after pharmacists’ recommendations (assuming all pharmacists’ recommendations were accepted by the General Practitioner (GP)), and after the actual uptake of pharmacists’ recommendations by the GP. Differences in the inappropriate prescribing were measured using the Wilcoxon sign rank test.
Results: Overall, all patients in study (n = 223) had at least one inappropriate rating at baseline (median MAI score of 26 for the old cohort and 27 for the newer cohort). The median cumulative MAI scores were significantly lower post the RMMRs by pharmacists (15.5 and 20 for the old and new cohort respectively, p < 0.001) and following the uptake of recommendations by the GP, indicating an increased appropriateness of drug regimen after the medication review (20 and 22 for the old and new cohort respectively, P < 0.001).
Conclusion: This study shows that pharmacist-led medication reviews are effective in reducing inappropriate prescribing among aged care residents, as demonstrated by the reduction in MAI scores. Future studies should focus on the impact of such a decrease on patient outcomes.
Objectives:
To determine whether geriatric triage decisions made using a comprehensive geriatric assessment (CGA) performed online are less reliable than face-to-face (FTF) decisions.
Design:
Multisite noninferiority prospective cohort study. Two specialist geriatricians assessed individuals sequentially referred for an acute care geriatric consultation. Participants were allocated to one FTF assessment and an additional assessment (FTF or online (OL)), creating two groups-two FTF (FTF-FTF, n = 81) or online and FTF (OL-FTF, n = 85).
Setting:
Three acute care public hospitals in two Australian states.
Participants:
Admitted individuals referred for CGA.
Intervention:
Nurse-administered CGA, based on the interRAI Acute Care assessment system accessed online and other online clinical data such as pathology results and imaging enabling geriatricians to review participants' information and provide input into their care from a distance.
Measurements:
The primary decision subjected to this analysis was referral for permanent residential care. Geriatricians also recorded recommendations for referrals and variations for medication management and judgment regarding prognosis at discharge and after 3 months.
Results:
Overall percentage agreement was 88% (n = 71) for the FTF-FTF group and 91% (n = 77) for the OL-FTF group. The difference in agreement between the FTF-FTF and OL-FTF groups was -3%, indicating that there was no difference between the methods of assessment. Judgements made regarding diagnoses of geriatric syndromes, medication management, and prognosis (with regard to hospital outcome and location at 3 months) were found to be equally reliable in each mode of consultation.
Conclusion:
Geriatric assessment performed online using a nurse-administered structured CGA system was no less reliable than conventional assessment in making clinical triage decisions.
Background:
Aging is often associated with various underlying comorbidities that warrant the use of multiple medications. Various interventions, including medication reviews, to optimize pharmacotherapy in older people residing in aged care facilities have been described and evaluated. Previous systematic reviews support the positive impact of various medication-related interventions but are not conclusive because of several factors.
Objectives:
The current study aimed to assess the impact of medication reviews in aged care facilities, with additional focus on the types of medication reviews, using randomized controlled trials (RCTs) and observational studies.
Methods:
A systematic searching of English articles that examined the medication reviews conducted in aged care facilities was performed using the following databases: PubMed, CINAHL, IPA, TRiP, and the Cochrane Library, with the last update in December 2015. Extraction of articles and quality assessment of included articles were performed independently by 2 authors. Data on interventions and outcomes were extracted from the included studies. The SIGN checklist for observational studies and the Cochrane Collaboration's tool for assessing risk of bias in RCTs were applied. Outcomes assessed were related to medications, reviews, and adverse events.
Results:
Because of the heterogeneity of the measurements, it was deemed inappropriate to conduct a meta-analysis and thus a narrative approach was employed. Twenty-two studies (10 observational studies and 12 controlled trials) were included from 1141 evaluated references. Of the 12 trials, 8 studies reported findings of pharmacist-led medication reviews and 4 reported findings of multidisciplinary team-based reviews. The medication reviews performed in the included trials were prescription reviews (n = 8) and clinical medication reviews (n = 4). In the case of the observational studies, the majority of the studies (8/12 studies) reported findings of pharmacist-led medication reviews, and only 2 studies reported findings of multidisciplinary team-based reviews. Similarly, 6 studies employed prescription reviews, whereas 4 studies employed clinical medication reviews. The majority of the recommendations put forward by the pharmacist or a multidisciplinary team were accepted by physicians. The number of prescribed medications, inappropriate medications, and adverse outcomes (eg, number of deaths, frequency of hospitalizations) were reduced in the intervention group.
Conclusion:
Medication reviews conducted by pharmacists, either working independently or with other health care professionals, appear to improve the quality of medication use in aged care settings. However, robust conclusions cannot be drawn because of significant heterogeneity in measurements and potential risk for biases.
Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality.
To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of healthcare professionals, health policy, and consumer representatives.
Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n=19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level.
Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were ‘implementation of a pharmacist-led medication reconciliation service for new residents’, ‘conduct facility-level audits and feedback to staff and healthcare professionals’, ‘develop deprescribing scripts to assist clinician-resident discussion’, ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs’, ‘implement electronic medication charts and records’ and ‘better support Medication Advisory Committees (MACs) to address medication appropriateness’.
This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.
Objectives:
The primary objective of this study was to investigate the impact of Residential Medication Management Reviews (RMMRs) on anticholinergic burden quantified by seven anticholinergic risk scales.
Design:
Retrospective analysis.
Setting:
Accredited pharmacists conducted RMMRs in aged-care facilities (ACF) in Sydney, Australia.
Participants:
RMMRs pertaining to 814 residents aged 65 years or older.
Measurements:
Anticholinergic burden was quantified using seven scales at baseline, after pharmacists' recommendations and after the actual GP uptake of pharmacists' recommendations. Change in the anticholinergic burden was measured using the Wilcoxon sign rank test.
Results:
At baseline, depending on the scale used to estimate the anticholinergic burden, between 36 and 67% of patients were prescribed at least one regular anticholinergic medication (ACM). Anticholinergic burden scores were significantly (p<0.001) lower after pharmacists' recommendations as determined by each of the seven scales. The reduction in anticholinergic burden was also significant (p<0.001) after GPs' acceptance of the pharmacists' recommendations according to all scales with the exception of one scale which reached borderline significance (p = 0.052).
Conclusion:
Despite the limitations of the retrospective design and differences in the estimation of anticholinergic burden, this is the first study to demonstrate that RMMRs are effective in reducing ACM prescribing in ACF residents, using a range of measures of anticholinergic burden. Future studies should focus on whether a decrease in anticholinergic burden will translate into improvement in clinical outcomes.
Older adults with dementia commonly have multiple chronic conditions that prompt clinicians to prescribe medications. While dementia is a life-limiting disease, progression from mild cognitive impairment to end stage dementia is a process that can occur over many years and may not take a predetermined course. Therefore aligning pharmacological treatment with changing goals of care can be challenging. The aim of this narrative review was to explore barriers to optimising prescribing and deprescribing (withdrawing) of medications as the goal of care shifts from prolonging life to optimising quality of life. Optimising pharmacological treatment to help people with dementia achieve their goals of care often requires deprescribing of medications that are inappropriate, as well as initiating appropriate medications. Medical practitioner, system, patient and carer related barriers to optimisation of medications in older adults with multiple morbidities have been identified including: inadequate guidelines, incomplete medical histories, lack of time, avoidance of negative consequences, established beliefs in the benefits and harms of medication use and others. Optimising prescribing for older people with dementia is further complicated by diminished decision making capacity, difficulties with comprehension and communication, increasing involvement of carers and difficulties establishing goals of care. Further research is required into the attitudes, beliefs and preferences of people with dementia and their carers regarding prescribing and deprescribing.
Objective:
The objective of the study was to investigate the prevalence of, and factors associated with, polypharmacy in long-term care facilities (LTCFs).
Methods:
MEDLINE, EMBASE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library were searched from January 2000 to September 2014. Primary research studies in English were eligible for inclusion if they fulfilled the following criteria: (1) polypharmacy was quantitatively defined, (2) the prevalence of polypharmacy was reported or could be extracted from tables or figures, and (3) the study was conducted in a LTCF. Methodological quality was assessed using an adapted version of the Joanna Briggs Institute Critical Appraisal Checklist.
Results:
Forty-four studies met the inclusion criteria and were included. Polypharmacy was most often defined as 5 or more (n = 11 studies), 9 (n = 13), or 10 (n = 11) medications. Prevalence varied widely between studies, with up to 91%, 74%, and 65% of residents taking more than 5, 9, and 10 medications, respectively. Seven studies performed multivariate analyses for factors associated with polypharmacy. Positive associations were found for recent hospital discharge (n = 2 studies), number of prescribers (n = 2), and comorbidity including circulatory diseases (n = 3), endocrine and metabolic disorders (n = 3), and neurological motor dysfunctioning (n = 3). Older age (n = 5), cognitive impairment (n = 3), disability in activities of daily living (n = 3), and length of stay in the LTCF (n = 3) were inversely associated with polypharmacy.
Conclusions:
The prevalence of polypharmacy in LTCFs is high, varying widely between facilities, geographical locations and the definitions used. Greater use of multivariate analysis to investigate factors associated with polypharmacy across a range of settings is required. Longitudinal research is needed to explore how polypharmacy has evolved over time.
Background:
Drug-related problems (DRPs) are common in aged care facilities and few studies have been conducted to determine the impact of the pharmacist-conducted medication review services. Studies determining the prevalence of chronic kidney disease (CKD) and data regarding inappropriate prescribing of renally cleared medications in aged care facilities in Australia are also lacking.
Objectives:
To investigate the number and nature of DRPs identified and recommendations made by pharmacists in residents of aged care facilities. To determine the prevalence of CKD and estimate the magnitude of inappropriate prescribing of renally cleared medications in residents of aged care facilities.
Methods:
DRPs identified and recommendations made by pharmacists were classified using the adapted version of the DOCUMENT classification system. The modification of diet in renal disease formula was used to estimate the prevalence of CKD, and the Cockcroft-Gault formula was used to estimate the magnitude of inappropriate prescribing of renally cleared medications.
Results:
Over 98 % of residents of aged care facilities had at least one DRP. Most (83.8 %) recommendations made by accredited pharmacists to resolve DRPs were accepted by general practitioners. CKD was prevalent in 48 % of residents, and inappropriate prescribing of renally cleared medications was identified in 28 (16 %) residents with CKD.
Conclusions:
DRPs are common in aged care facilities and the impact of medication review services appears to be high. CKD is also common among residents of aged care facilities, and inappropriate prescribing of renally cleared medications was also prevalent, warranting attention to regular renal function monitoring and appropriate drug and dose selection in residents of aged care facilities.
Medication use in nursing homes is often suboptimal. This study investigated the impact of a pharmacist-conducted medication review on the appropriateness of prescribing for Belgian nursing home residents. We conducted a 6-month controlled, non-randomized study in two nursing homes (one intervention and one control nursing home). Sixty-nine residents completed the study in the intervention group (92 residents were included). For the control group, that were 79 residents (100 residents were included). Primary outcome was the appropriateness of prescribing, assessed by a set of validated quality indicators. At baseline, this study detected three main problems associated with the appropriateness of medication use: (i) the Medication Appropriateness Index (MAI) could be improved (continuation of no longer indicated medication was the most common problem), (ii) potential overuse was present in about half of the group, and (iii) potential underuse was present in about 30% of the sample. Despite this, our pharmacist-conducted medication review only modestly improved the appropriateness of prescribing. This may be attributed to the low implementation rate of the pharmacist recommendations.
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.
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.
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.
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.
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.
Background:
The Drug Burden Index (DBI) is an evidence-based tool that associates medication exposure with functional outcomes in older people. Accredited clinical pharmacists performing medication reviews could consider including the DBI in their medication reviews to optimize prescribing in older people.
Objective:
To examine the impact of residential medication management reviews (RMMRs) performed by accredited clinical pharmacists on DBI in older people living in aged-care homes.
Methods:
A retrospective analysis was performed of a random sample of 500 de-identified RMMR reports from residents aged (mean +/- SD) 84 +/- 9.0 years who had medication reviews conducted by ten accredited clinical pharmacists from 1 January 2008 through 30 June 2008. The data on medication use were collected over 8 months across 62 aged-care homes. DBI scores were calculated at baseline, after the recommendations had been made by the pharmacist and after uptake of pharmacist recommendations by the general practitioner (GP).
Results:
A statistically significant decrease (p < 0.001) in median DBI score was observed as a result of uptake of pharmacist recommendations by the GP. GPs were more likely to take up recommendations made by pharmacists that resulted in a decrease in DBI score than recommendations that resulted in an increase in DBI score (60.7% vs 34.6%, respectively). The mean decrease in DBI as a result of pharmacist recommendations was 0.12 (95% CI 0.09, 0.14) representing a 20% decrease in mean baseline DBI for residents. When GPs implemented pharmacists' recommendations, DBI decreased by a mean of 12% from baseline (mean decrease 0.07; 95% CI 0.05, 0.08). Most of the recommendations proposed by the pharmacists involved withdrawing benzodiazepines or reducing antipsychotic drug dosage.
Conclusions:
This is the first study in which DBI has been used as a tool to evaluate the impact of RMMRs conducted by accredited clinical pharmacists. The study demonstrates that pharmacist-conducted medication reviews can reduce prescribing of sedative and anticholinergic drugs in older people, resulting in a significant decrease in the DBI score.
This paper describes a system designed to enable comprehensive geriatric assessment to be performed at distant locations. A structured assessment incorporating the interRAI Acute Care assessment tool is administered by a specifically trained nurse assessor onsite. Data are entered and processed by web-based software that incorporates a clinical decision support system. It enables a geriatrician to review and report the assessment online. The assessment and report can be viewed by authorised clinicians inside and outside the hospital via the Internet. The system can also be used to support in person geriatric consultation and whole of episode ward-based geriatric care. Preliminary evaluation suggests the system to be reliable, safe, efficient and appealing to clinicians.
This paper presents a general statistical methodology for the analysis of multivariate categorical data arising from observer reliability studies. The procedure essentially involves the construction of functions of the observed proportions which are directed at the extent to which the observers agree among themselves and the construction of test statistics for hypotheses involving these functions. Tests for interobserver bias are presented in terms of first-order marginal homogeneity and measures of interobserver agreement are developed as generalized kappa-type statistics. These procedures are illustrated with a clinical diagnosis example from the epidemiological literature.