The efficacy of a medication review programme conducted in an emergency department

The Impact of Pharmacist Medication Reviews on Geriatric Patients: A Scoping Review

Medication review is an intervention with the potential to reduce drug-related problems (DRPs) in the elderly. This study aimed to determine the effect of pharmacists' medication reviews on geriatric patients. This study accessed two online databases, MEDLINE Complete and Scopus, and examined all studies published in English between 2019 and 2023, except for reviews. The studies included (1) participants over 65 years of age and (2) medication reviews conducted by pharmacists. The titles, abstracts, and full texts were reviewed for data extraction to determine whether the studies satisfied the inclusion and exclusion criteria. Forty-four of the initial 709 articles were included in this study. The articles included discussions on the incidence rates of DRPs and potentially inappropriate medications (PIMs) (n=21), hospitalization (n=14), medication adherence (n=9), quality of life (QoL) (n=8), and falls (n=7). Pharmacist medication reviews were associated with a reduced incidence of DRPs and PIMs, and improved adherence to medications. Patients' overall QoL is also increasing. However, pharmacist medication reviews were not strongly associated with decreased hospitalization or falls. A pharmacist's medication review may be a feasible intervention for reducing the incidence rates of DRPs and PIMs, regardless of whether it is performed as a sole intervention or supplemented with other interventions. The intervention was also effective in increasing medication adherence and QoL.

Strategies for improving ED-related outcomes of older adults who seek care in emergency departments: a systematic review

BACKGROUND

Despite constituting 14% of the general population, older adults make up almost a quarter of all emergency department (ED) visits. These visits often do not adequately address patient needs, with nearly 80% of older patients discharged from the ED carrying at least one unattended health concern. Many interventions have been implemented and tested in the ED to care for older adults, which have not been recently synthesized.

METHODS

A systematic review was conducted to identify interventions initiated in the ED to address the needs of older adults. Embase, MEDLINE, CINAHL, Cochrane CENTRAL, the Cochrane Database of Systematic Reviews, and grey literature were searched from January 2013 to January 18, 2023. Comparative studies assessing interventions for older adults in the ED were included. The quality of controlled trials was assessed with the Cochrane risk-of-bias tool for randomized trials, and the quality of observational studies was assessed with the risk of bias in non-randomized studies of interventions tool. Due to heterogeneity, meta-analysis was not possible.

RESULTS

Sixteen studies were included, assessing 12 different types of interventions. Overall study quality was low to moderate: 10 studies had a high risk of bias, 5 had a moderate risk of bias, and only 1 had a low risk of bias. Follow-up telephone calls, referrals, geriatric assessment, pharmacist-led interventions, physical therapy services, care plans, education, case management, home visits, care transition interventions, a geriatric ED, and care coordination were assessed, many of which were combined to create multi-faceted interventions. Care coordination with additional support and early assessment and intervention were the only two interventions that consistently reported improved outcomes. Most studies did not report significant improvements in ED revisits, hospitalization, time spent in the ED, costs, or outpatient utilization. Two studies reported on patient perspectives.

CONCLUSION

Few interventions demonstrate promise in reducing ED revisits for older adults, and this review identified significant gaps in understanding other outcomes, patient perspectives, and the effectiveness in addressing underlying health needs. This could suggest, therefore, that most revisits in this population are unavoidable manifestations of frailty and disease trajectory. Efforts to improve older patients' needs should focus on interventions initiated outside the ED.

Influence of Potentially Inappropriate Medication Use on Older Australians' Admission to Emergency Department Short Stay

Older people in the emergency department (ED) often pose complex medical challenges, with a significant prevalence of polypharmacy and potentially inappropriate medicines (PIMs) in Australia. A retrospective analysis of 200 consecutive patients aged over 65 years admitted to the emergency short stay unit (ESSU) aimed to identify polypharmacy (five or more regular medications), assess PIM prevalence, and explore the link between pre-admission PIMs and ESSU admissions. STOPP/START version 2 criteria were used for the PIM assessment, with an expert panel categorizing associated risks. Polypharmacy was observed in 161 patients (80.5%), who were older (mean age 82 versus 76 years) and took more regular medications (median 9 versus 3). One hundred and eighty-five (92.5%) patients had at least one PIM, 81 patients (40.5%) had STOPP PIMs, and 177 patients (88.5%) had START omissions. Polypharmacy significantly correlated with STOPP PIM (OR 4.8; 95%CI: 1.90-12.1), and for each additional medication the adjusted odds of having a STOPP PIM increased by 1.20 (95%CI: 1.11-1.28). Nineteen admissions (9.5%) were attributed to one or more PIMs (total 21 PIMs). Of these PIMs, the expert panel rated eight (38%) as high risk, five (24%) as moderate risk, and eight (38%) as low risk for causing hospital admission. The most common PIMs were benzodiazepines, accounting for 14 cases (73.6%). Older ESSU-admitted patients commonly presented with polypharmacy and PIMs, potentially contributing to their admission.

Clinical and economic impact of partnered pharmacist medication charting in the emergency department

Introduction: Partnered pharmacist medication charting (PPMC), a process redesign hypothesised to improve medication safety and interdisciplinary collaboration, was trialed in a tertiary hospital's emergency department (ED). Objective: To evaluate the health-related impact and economic benefit of PPMC. Methods: A pragmatic, controlled study compared PPMC to usual care in the ED. PPMC included a pharmacist-documented best-possible medication history (BPMH), followed by a clinical conversation between a pharmacist and a medical officer to jointly develop a treatment plan and chart medications. Usual care included medical officer-led traditional medication charting in the ED, without a pharmacist-obtained BPMH or clinical conversation. Outcome measures, assessed after propensity score matching, were length of hospital or ED stay, relative stay index (RSI), in-hospital mortality, 30-day hospital readmissions or ED revisits, and cost. Results: A total of 309 matched pairs were analysed. The median RSI was reduced by 15.4% with PPMC (p = 0.029). There were no significant differences between the groups in the median length of ED stay (8 vs. 10 h, p = 0.52), in-hospital mortality (1.3% vs. 1.3%, p > 0.99), 30-day readmission rates (21% vs. 17%; p = 0.35) and 30-day ED revisit rates (21% vs. 19%; p = 0.68). The hospital spent approximately $138.4 for the cost of PPMC care per patient to avert at least one medication error bearing high/extreme risk. PPMC saved approximately $1269 on the average cost of each admission. Conclusion: Implementing the ED-based PPMC model was associated with a significantly reduced RSI and admission costs, but did not affect clinical outcomes, noting that there was an additional focus on medication reconciliation in the usual care group relative to current practice at our study site.

Clin-STAR corner: Practice changing advances in prescribing for geriatric emergency department patients

Reducing adverse drug events among older adults in heterogeneous and often chaotic emergency department (ED) settings requires a multidisciplinary approach. Recent research evaluates the impact of multicomponent protocols designed to reduce ED physician prescribing of potentially inappropriate medications (PIMs), including transdisciplinary training and leveraging electronic health records to provide real-time alternative safer pharmaceuticals while providing personalized feedback to prescribers. Most new research is not randomized trial data. Although this current research does not consistently demonstrate a reduction in the prescribing of PIMs, these studies provide a foundation for emergency medicine healthcare teams, geriatricians, and pharmacists to collaborate with health informatics to continue advancing the frontiers of safer medication prescribing during episodes of acute care.

STOPP/START criteria for potentially inappropriate medications/potential prescribing omissions in older people: uptake and clinical impact

INTRODUCTION

STOPP/START criteria for potentially inappropriate medications (PIMs, STOPP) and potential prescribing omissions (PPOs, START) have gained considerable interest and traction since they were first published in 2008. This review focuses on their uptake and impact in various clinical settings.

AREAS COVERED

STOPP/START criteria, now in their third iteration, are explicit criteria designed to facilitate detection of common and clinically important PIMs and PPOs during routine medication review in any clinical setting. We examine the influence of the criteria, particularly in clinical trials that focused on their impact on clinically relevant endpoints.

EXPERT OPINION

STOPP/START criteria are widely used in several countries within Europe and beyond for medication review and audit. As a discreet intervention, the criteria have been tested in several single-center and two large-scale multi-center clinical trials. The single-center trials indicate that STOPP/START criteria reduce polypharmacy, inappropriate prescribing, ADRs (adverse drug reactions), medication cost and falls. In contrast, the SENATOR and OPERAM multicentre trials did not demonstrate significant reduction in ADRs, all-cause mortality, drug-related hospital readmissions, nor any improvement in quality-of-life. Further clinical trials are required to examine whether STOPP/START criteria as an intervention can deliver significant clinical benefit in a reproducible manner in various clinical settings.

Assessment of drug-related problems at the emergency department in older patients living with frailty: pharmacist-led medication reviews within a geriatric care team

BACKGROUND

Older patients are vulnerable to experiencing drug related problems (DRPs), which may result in emergency department (ED) visits. However, it is not standard practice to conduct medications reviews during ED visit. The aim of this study was to assess the number of DRPs in older patients living with frailty at the ED, identified through pharmacist-led medication reviews within a geriatric care team, and to determine the acceptance rate of pharmacists' recommendations among hospital physicians and general practitioners or elderly care specialists.

METHODS

A retrospective observational study was performed in patients ≥ 70 years living with frailty at the ED at Tergooi Medical Center. Pharmacist-led medication reviews were conducted to identify and classify DRPs as part of a larger geriatric assessment. The acceptance rate of given recommendations was determined during follow-up.

RESULTS

A total of 356 ED visits were included. The mean (standard deviation, SD) age of patients was 83 (6.8) years. About 76% of patients had at least one DRP. In total, 548 DRPs were identified with a mean of 1.5 DRP (SD 1.3) per patient. The acceptance rate of medication recommendations in admitted patients was 55%, and 32% among general practitioners/elderly care specialists in discharged patients.

CONCLUSIONS

Pharmacist-led medication reviews as part of a geriatric care team identified DRPs in 76% of older patients living with frailty at the ED. The acceptance rate was substantially higher in admitted patients compared to discharged patients.

Medication review in hospitalised patients to reduce morbidity and mortality

BACKGROUND

A medication review can be defined as a structured evaluation of a patient's medication conducted by healthcare professionals with the aim of optimising medication use and improving health outcomes. Optimising medication therapy though medication reviews may benefit hospitalised patients.

OBJECTIVES

We examined the effects of medication review interventions in hospitalised adult patients compared to standard care or to other types of medication reviews on all-cause mortality, hospital readmissions, emergency department contacts and health-related quality of life.

SEARCH METHODS

In this Cochrane Review update, we searched for new published and unpublished trials using the following electronic databases from 1 January 2014 to 17 January 2022 without language restrictions: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). To identify additional trials, we searched the reference lists of included trials and other publications by lead trial authors, and contacted experts.

SELECTION CRITERIA

We included randomised trials of medication reviews delivered by healthcare professionals for hospitalised adult patients. We excluded trials including outpatients and paediatric patients.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed risk of bias. We contacted trial authors for data clarification and relevant unpublished data. We calculated risk ratios (RRs) for dichotomous data and mean differences (MDs) or standardised mean differences (SMDs) for continuous data (with 95% confidence intervals (CIs)). We used the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach to assess the overall certainty of the evidence.

MAIN RESULTS

In this updated review, we included a total of 25 trials (15,076 participants), of which 15 were new trials (11,501 participants). Follow-up ranged from 1 to 20 months. We found that medication reviews in hospitalised adults may have little to no effect on mortality (RR 0.96, 95% CI 0.87 to 1.05; 18 trials, 10,108 participants; low-certainty evidence); likely reduce hospital readmissions (RR 0.93, 95% CI 0.89 to 0.98; 17 trials, 9561 participants; moderate-certainty evidence); may reduce emergency department contacts (RR 0.84, 95% CI 0.68 to 1.03; 8 trials, 3527 participants; low-certainty evidence) and have very uncertain effects on health-related quality of life (SMD 0.10, 95% CI -0.10 to 0.30; 4 trials, 392 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Medication reviews in hospitalised adult patients likely reduce hospital readmissions and may reduce emergency department contacts. The evidence suggests that mediation reviews may have little to no effect on mortality, while the effect on health-related quality of life is very uncertain. Almost all trials included elderly polypharmacy patients, which limits the generalisability of the results beyond this population.

Impact of systematic medication review in emergency department on patients’ post-discharge outcomes—A randomized controlled clinical trial

Introduction

The main objective of this study was to investigate whether systematic medication review conducted by clinical pharmacists can impact clinical outcomes and post-discharge outcomes for patients admitted to the emergency department.

Method

This parallel group, non-blinded, randomized controlled trial was conducted in the emergency department, Diakonhjemmet Hospital, Oslo, Norway. The study was registered in ClinicalTrials.gov, Identifier: NCT03123640 in April 2017. From April 2017 to May 2018, patients ≥18 years were included and randomized (1:1) to intervention- or control group. The control group received standard care from emergency department physicians and nurses. In addition to standard care, the intervention group received systematic medication review including medication reconciliation conducted by pharmacists, during the emergency department stay. The primary outcome was proportion of patients with an unplanned contact with hospital within 12 months from inclusion stay discharge.

Results

In total, 807 patients were included and randomized, 1:1, to intervention or control group. After excluding 8 patients dying during hospital stay and 10 patients lacking Norwegian personal identification number, the primary analysis comprised 789 patients: 394 intervention group patients and 395 control group patients. Regarding the primary outcome, there was no significant difference in proportion of patients with an unplanned contact with hospital within 12 months after inclusion stay discharge between groups (51.0% of intervention group patients vs. 53.2% of control group patients, p = 0.546).

Conclusion

As currently designed, emergency department pharmacist-led medication review did not significantly influence clinical- or post-discharge outcomes. This study did, however pinpoint important practical implementations, which can be used to design tailored pharmacist-led interventions and workflow regarding drug-related issues in the emergency department setting.

Practice-enhancing publications about the medication-use process in 2019

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the medication-use process (MUP) from calendar year 2019 that can impact health-system pharmacy daily practice. The MUP is the foundational system that provides the framework for safe medication utilization within the healthcare environment. The MUP is defined in this article as having the following components: prescribing/transcribing, dispensing, administration, and monitoring. Articles that evaluated one of the steps were gauged for their usefulness in promoting daily practice change.

SUMMARY

A PubMed search was conducted in January 2020 for calendar year 2019 using targeted Medical Subject Headings keywords; in addition, searches of the table of contents of selected pharmacy journals were conducted. A total of 4,317 articles were identified. A thorough review identified 66 potentially practice-enhancing articles: 17 for prescribing/transcribing, 17 for dispensing, 7 for administration, and 25 for monitoring. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important within health-system pharmacy. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice; this article assists in identifying and summarizing the most impactful recently published literature in this area. Health-system pharmacists have an active role in improving the MUP in their institution, and awareness of the significant published studies can assist in changing practice at the institutional level.

Emergency department-based medication review on outpatient health services utilization: interrupted time series

Background

One in nine emergency department (ED) visits in Canada are caused by adverse drug events, the unintended and harmful effects of medication use. Medication reviews by clinical pharmacists are interventions designed to optimize medications and address adverse drug events to impact patient outcomes. However, the effect of medication reviews on long-term outpatient health services utilization is not well understood. This research studied the effect of medication review performed by clinical pharmacists on long-term outpatient health services utilization.

Methods

Data included information from 10,783 patients who were part of a prospective, multi-centre quality improvement evaluation from 2011 to 2013. Outpatient health services utilization was defined as total ED visits and physician contacts, aggregated to four physician specialty groups: general and family practitioners (GP); medical specialists; surgical specialists; and imaging and laboratory specialists. During triage, patients deemed high-risk based on their medical history, were systematically allocated to receive either a medication review (n = 6403) or the standard of care (n = 4380). Medication review involved a critical examination of a patient’s medications to identify and resolve medication-related problems and communicate these results to community care providers. Interrupted time series analysis compared the effect of the intervention on health services utilization relative to the standard of care controlling for pre-intervention differences in utilization.

Results

ED-based pharmacist-led medication review did not result in a significant level or trend change in the primary outcome of total outpatient health services utilization. There were also no differences in the secondary outcomes of primary care physician visits or ED visits relative to the standard of care in the 12 months following the intervention. Our findings were consistent when stratified by age, hospital site, and whether patients were discharged on their index visit.

Conclusion

This was the first study to measure long-term trends of physician visits following an ED-based medication review. The lack of differences in level and trend of GP and ED visits suggest that pharmacist recommendations may not have been adequately communicated to community-based providers, and/or recommendations may not have affected health care delivery. Future studies should evaluate physician acceptance of pharmacist recommendations and should encourage patient follow-up to community providers.