Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

Selection of outcome measurement instruments for a core outcome set for trials aimed at improving appropriate polypharmacy in older people in primary care: a Delphi consensus study

BACKGROUND

Despite developing a polypharmacy core outcome set (COS) in primary care, it is not clear how these outcomes should be measured.

AIM

To select outcome measurement instruments (OMIs) for a COS targeting appropriate polypharmacy in older patients in primary care.

METHOD

Following the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) guideline, OMIs were identified from a Cochrane review focusing on appropriate polypharmacy. The quality of OMIs was assessed using a published checklist. Subsequently, two rounds of Delphi questionnaires were conducted via the SoGoSurvey® platform, engaging stakeholders (researchers, clinicians and journal editors specialising in geriatric primary care) to achieve consensus on OMIs using a scale encompassing "agree", "disagree", or "unsure". Consensus was achieved if 70% or more participants chose "agree" and 15% or fewer chose "disagree."

RESULTS

The quality of 20 OMIs identified from the Cochrane review was evaluated. Seven OMIs were selected based on meeting the COSMIN guideline's minimum requirements. Out of 188 potential participants, 57 (30.3%) consented to participate. Rounds 1 and 2 of Delphi exercises were completed by 50 respondents, achieving agreement on three OMIs: 'number of serious adverse drug reactions (ADRs)' (98%), 'number of deaths' (76%), and 'number of patients who fell' (70%) for measuring 'serious ADRs,' 'mortality,' and 'falls,' respectively. No agreement was reached for 'medication appropriateness,' 'medication side-effects,' 'quality of life,' and 'medication regimen complexity.'

CONCLUSION

OMIs were selected for a limited number of outcomes in the polypharmacy COS. Future research should identify suitable OMIs for the remaining four outcomes.

Persistence in the Methadone Maintenance Program and Its Relationship with the Medication Regimen Complexity Index in Opioid-Dependent Patients

It has been shown that the Medication Regimen Complexity Index (MRCI) is a useful and reliable tool for calculating the complexity of the pharmacotherapeutic regimen (CPR). Furthermore, a high MRCI is associated with lower adherence. However, the MRCI of opioid-dependent patients (ODP) has not been studied. The aim of this study is to calculate the Methadone Maintenance Program (MMP) persistence and the MRCI score in a ODP cohort. Second, to analyze its relationship and association with other variables. To accomplish this research, an observational study including adults with a confirmed diagnosis of opiate-dependency according to the DSM-5 in a MMP center was carried out. To define MMP-persistence, a group was created by the researchers who defined five weighted items according to their agreed importance. Our first contribution was to create a new definition of MMP-persistence. This study also identified age, comorbidities, and received methadone maintenance doses as successful predictors for MMP-persistence. We have also shown that the MRCI does not seem to be a useful tool to determine MMP-persistence, probably because there are multiple factors that influence it in addition to the CPR. It is necessary to continue searching for more precise selection and stratification tools for ODP to improve their persistence.

Effect of Multi-Dose Dispensing on Medication Regimen Complexity: A Real-World Study

(1) Background: Older patients frequently require dosing aids, such as multi-dose medication dispensing (MMD) when they experience medication regimen complexity (MRC) with increased drug use. However, the evaluations of the efficacy of MMD alterations remain limited. (2) Methods: A total of 1120 patients were included in the study who were discharged from hospital during the study period of January to March 2019. The Medication Regimen Complexity Index (MRCI) score, a validated 65-item tool in Korea (MRCI-K), was used to quantify MRC. The original MRCI-K scores, representing the typical administration based on prescription information, were compared to recalculated MRCI-K scores measured following MMD during the hospital dispensing period. Differences in MRCI-K across the top four wards based on the numbers of discharge prescription medications were assessed, and the overall scores were categorized into quartiles to identify MMD's impact within each group. We confirmed the effect of MMD based on the patient's admission diagnosis depending on MRCI. (3) Results: The mean (standard deviation) of original MRCI scores was 26.2 (13.4), which decreased to 18.9 (8.8) after applying MMD. The decrease in MRCI scores after MMD was statistically significant in all four wards, with the Orthopedic Surgery ward showing the biggest decrease. The patients with MRCI scores in the highest quartile group demonstrated the greatest improvement as a result of the implementation of MMD. Respiratory diseases exhibited the highest baseline MRCI scores due to formulation complexity, and ear, nose, and throat patients demonstrated the most significant reduction in MRC after MMD, depending on the diagnostic criteria at administration. (4) Conclusions: We confirmed the reduction in MRC after applying MMD, as a significant decrease in MRCI-K scores. This study highlights the need to deliver effective pharmacist-led services to identify patients who would benefit from MMD.

Clinical pharmacy in hospital palliative medicine: non-randomised clinical trial

OBJECTIVE

To assess the impact of pharmaceutical care on hospital indicators and clinical outcomes of palliative care (PC) patients admitted to a secondary hospital.

METHODS

A non-randomised clinical trial was carried out in the PC ward of a secondary hospital in São Paulo, Brazil. Pharmaceutical care for all patients aged 18 and above, admitted between October 2021 and March 2022, with stays exceeding 48 hours, was provided. The interventions required were performed in collaboration with healthcare teams, patients and caregivers. Assessments occurred at admission and discharge, using PC performance scales and pharmacotherapy tools, with Research Ethics Committee approval.

RESULTS

Over 6 months, 120 hospitalisations were analysed, primarily involving women (58.9%), averaging 71.0 years, with neoplasm diagnoses (20.5%). A total of 170 drug-related problems were identified in 68.3% of patients. Following assessment, 361 interventions were performed, with a 78.1% acceptance rate, including medication dose adjustments, additions and discontinuations. Addressing unintentional pharmacotherapy discrepancies at admission led to reduced hospital stays (p<0.05). Pharmaceutical interventions also decreased pharmacotherapy complexity (p<0.001), inappropriate medications for the older people (p<0.001) and improved symptom management, such as pain (p<0.05).

CONCLUSIONS

Pharmaceutical care services integrated within the multiprofessional health team contributed to reducing drug-related problems associated with polypharmacy as well as improved the management PC symptoms in end-of-life patients, which reduced hospitalisation time.

Organ-Retentive Osmotically Driven System (ORODS): A Novel Expandable Platform for in Situ Drug Delivery

Drug delivery systems capable of being retained within hollow organs allow the entire drug dose to be delivered locally to the disease site or to absorption windows for improved systemic bioavailability. A novel Organ-Retentive Osmotically Driven System (ORODS) was here proposed, obtained by assembling drug-containing units having prolonged release kinetics with osmotic units used as increasing volume compartments. Particularly, prototypes having H-shape design were conceived, manufactured and evaluated. Such devices were assembled by manually inserting a tube made of regenerated cellulose (osmotic unit) into the holes of two perforated hydrophilic tableted matrices containing paracetamol as a tracer drug. The osmotic unit was obtained by folding and gluing a plain regenerated cellulose membrane and loading sodium chloride inside. When immersed in aqueous fluids, this compartment expanded to approximately 80% of its maximum volume within 30 min of testing, and a plateau was maintained for about 6 h. Subsequently, it slowly shrank to approximately 20% of the maximum volume in 24 h, which would allow for physiological emptying of the device from hollow organs. While expanding, the osmotic unit acquired stiffness. Drug release from H-shaped ORODSs conveyed in hard-gelatin capsules was shown to be prolonged for more than 24 h.

Medication Regimen Complexity Index Score at Admission as a Predictor of Inpatient Outcomes: A Machine Learning Approach

BACKGROUND

In the intensive care unit, traditional scoring systems use illness severity and/or organ failure to determine prognosis, and this usually rests on the patient's condition at admission. In spite of the importance of medication reconciliation, the usefulness of home medication histories as predictors of clinical outcomes remains unexplored.

METHODS

A retrospective cohort study was conducted using the medical records of 322 intensive care unit (ICU) patients. The predictors of interest included the medication regimen complexity index (MRCI) at admission, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Sequential Organ Failure Assessment (SOFA) score, or a combination thereof. Outcomes included mortality, length of stay, and the need for mechanical ventilation. Machine learning algorithms were used for outcome classification after correcting for class imbalances in the general population and across the racial continuum.

RESULTS

The home medication model could predict all clinical outcomes accurately 70% of the time. Among Whites, it improved to 80%, whereas among non-Whites it remained at 70%. The addition of SOFA and APACHE II yielded the best models among non-Whites and Whites, respectively. SHapley Additive exPlanations (SHAP) values showed that low MRCI scores were associated with reduced mortality and LOS, yet an increased need for mechanical ventilation.

CONCLUSION

Home medication histories represent a viable addition to traditional predictors of health outcomes.

Medication Complexity Among Older Adults with HF: How Can We Assess Better?

Medical management of heart failure (HF) has evolved and has achieved significant survival benefits, resulting in highly complex medication regimens. Complex medication regimens create challenges for older adults, including nonadherence and increased adverse drug events, especially associated with cognitive impairment, physical limitations, or lack of social support. However, the association between medication complexity and patients' health outcomes among older adults with HF is unclear. The purpose of this review is to address how the complexity of HF medications has been assessed in the literature and what clinical outcomes are associated with medication regimen complexity in HF. Further, we aimed to explore how older adults were represented in those studies. The Medication Regimen Complexity Index was the most commonly used tool for assessment of medication regimen complexity. Rehospitalization was most frequently assessed as the clinical outcome, and other studies used medication adherence, quality of life, healthcare utilization, healthcare cost, or side effect. However, the studies showed inconsistent results in the association between the medication regimen complexity and clinical outcomes. We also identified an extremely small number of studies that focused on older adults. Notably, current medication regimen complexity tools did not consider a complicated clinical condition of an older adult with multimorbidity, therapeutic competition, drug interactions, or altered tolerance to the usual dose strength of the medications. Furthermore, the outcomes that studies assessed were rarely comprehensive or patient centered. More studies are required to fill the knowledge gap identifying more comprehensive and accurate medication regimen complexity tools and more patient-centered outcome assessment.

Evaluating the Medication Regimen Complexity Score as a Predictor of Clinical Outcomes in the Critically Ill

Background: Medication Regimen Complexity (MRC) refers to the combination of medication classes, dosages, and frequencies. The objective of this study was to examine the relationship between the scores of different MRC tools and the clinical outcomes. Methods: We conducted a retrospective cohort study at Roger William Medical Center, Providence, Rhode Island, which included 317 adult patients admitted to the intensive care unit (ICU) between 1 February 2020 and 30 August 2020. MRC was assessed using the MRC Index (MRCI) and MRC for the Intensive Care Unit (MRC-ICU). A multivariable logistic regression model was used to identify associations among MRC scores, clinical outcomes, and a logistic classifier to predict clinical outcomes. Results: Higher MRC scores were associated with increased mortality, a longer ICU length of stay (LOS), and the need for mechanical ventilation (MV). MRC-ICU scores at 24 h were significantly (p < 0.001) associated with increased ICU mortality, LOS, and MV, with ORs of 1.12 (95% CI: 1.06−1.19), 1.17 (1.1−1.24), and 1.21 (1.14−1.29), respectively. Mortality prediction was similar using both scoring tools (AUC: 0.88 [0.75−0.97] vs. 0.88 [0.76−0.97]. The model with 15 medication classes outperformed others in predicting the ICU LOS and the need for MV with AUCs of 0.82 (0.71−0.93) and 0.87 (0.77−0.96), respectively. Conclusion: Our results demonstrated that both MRC scores were associated with poorer clinical outcomes. The incorporation of MRC scores in real-time therapeutic decision making can aid clinicians to prescribe safer alternatives.

Prevalence and patient-rated relevance of complexity factors in medication regimens of community-dwelling patients with polypharmacy

Purpose

To describe the prevalence of complexity factors in the medication regimens of community-dwelling patients with more than five drugs and to evaluate the relevance of these factors for individual patients.

Methods

Data were derived from the HIOPP-6 trial, a controlled study conducted in 9 general practices which evaluated an electronic tool to detect and reduce complexity of drug treatment. The prevalence of complexity factors was based on the results of the automated analysis of 139 patients’ medication data. The relevance assessment was based on the patients’ rating of each factor in an interview (48 patients included for analysis).

Results

A median of 5 (range 0–21) complexity factors per medication regimen were detected and at least one factor was observed in 131 of 139 patients. Almost half of these patients found no complexity factor in their medication regimen relevant.

Conclusion

In most medication regimens, complexity factors could be identified automatically, yet less than 15% of factors were indeed relevant for patients as judged by themselves. When assessing complexity of medication regimens, one should especially consider factors that are both particularly frequent and often challenging for patients, such as use of inhalers or tablet splitting.

Trial registration

The HIOPP-6 trial was registered retrospectively on May 17, 2021, in the German Clinical Trials register under DRKS-ID DRKS00025257.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-022-03314-1.

Pharmacists' Role in Older Adults' Medication Regimen Complexity: A Systematic Review

Medication regimen complexity (MRC) may influence health outcomes, such as hospitalisation, hospital readmission and medication adherence. Pharmacists have been referred to as health professionals with the opportunity to act on MRC reduction. This study aimed to investigate pharmacists' role in studies about older adults' medication regimen complexity. A literature search was performed in PubMed, Web of Science and the Cochrane Library-CENTRAL-up to October 2019. Out of 653 potentially relevant studies, 17 articles met the inclusion criteria for this review. Most studies used the 65-item medication regimen complexity index (MRCI) to assess medication complexity. Pharmacists' role was mainly confined to data collection. It seems that pharmacists' active role in older adults' medication complexity has not been studied in depth so far. However, the few existing interventional ones suggest that, after previous training, regimen simplification is feasible.

Complexity of Medication Regimens for Children With Neurological Impairment

IMPORTANCE

Parents of children with severe neurological impairment (SNI) manage complex medication regimens (CMRs) at home, and clinicians can help support parents and simplify CMRs.

OBJECTIVE

To measure the complexity and potentially modifiable aspects of CMRs using the Medication Regimen Complexity Index (MRCI) and to examine the association between MRCI scores and subsequent acute visits.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was conducted between April 1, 2019, and December 31, 2020, at a single-center, large, hospital-based, complex care clinic. Participants were children with SNI aged 1 to 18 years and 5 or more prescribed medications.

EXPOSURE

Home medication regimen complexity was assessed using MRCI scores. The total MRCI score is composed of 3 subscores (dosage form, dose frequency, and specialized instructions).

MAIN OUTCOMES AND MEASURES

Patient-level counts of subscore characteristics and additional safety variables (total doses per day, high-alert medications, and potential drug-drug interactions) were analyzed by MRCI score groups (low, medium, and high score tertiles). Associations between MRCI score groups and acute visits were tested using Poisson regression, adjusted for age, complex chronic conditions, and recent health care use.

RESULTS

Of 123 patients, 73 (59.3%) were male with a median (interquartile range [IQR]) age of 9 (5-13) years. The median (IQR) MRCI scores were 46 (35-61 [range, 8-139]) overall, 29 (24-35) for the low MRCI group, 46 (42-50) for the medium MRCI group, and 69 (61-78) for the high MRCI group. The median (IQR) counts for the subscores were 6 (4-7) dosage forms per patient, 7 (5-9) dose frequencies per patient, and 5 (4-8) instructions per patient, with counts increasing significantly across higher MRCI groups. Similar trends occurred for total daily doses (median [IQR], 31 [20-45] doses), high-alert medications (median [IQR], 3 [1-5] medications), and potential drug-drug interactions (median [IQR], 3 [0-6] interactions). Incidence rate ratios of 30-day acute visits were 1.26 times greater (95% CI, 0.57-2.78) in the medium MRCI group vs the low MRCI group and 2.42 times greater (95% CI, 1.10-5.35) in the high MRCI group vs the low MRCI group.

CONCLUSIONS AND RELEVANCE

Higher MRCI scores were associated with multiple dose frequencies, complicated by different dosage forms and instructions, and associated with subsequent acute visits. These findings suggest that clinical interventions to manage CMRs could target various aspects of these regimens, such as the simplification of dosing schedules.

Risk factors associated with drug therapy among elderly people with Alzheimer's disease: a cross-sectional study

BACKGROUND

Improving knowledge and establishing strategies and policies for better patient safety are worldwide priorities.

OBJECTIVE

To evaluate drug safety among elderly people with Alzheimer's disease (AD).

DESIGN AND SETTING

Cross-sectional study among elderly people within the National AD Assistance Protocol (PCDTDA/MS) who were living in the municipality of Araraquara, Brazil, in 2017.

METHODS

Through interviews conducted with relatives/caregivers of elderly people with diagnoses of AD, the following variables were evaluated: comorbidities, drug therapy used, use of potentially inappropriate medications for the elderly (PIMs), presence of potentially inappropriate interactions (PIIs) and medication regimen complexity index. Factors associated with AD severity were also evaluated. Multivariate and simple logistic regressions were applied.

RESULTS

143 elderly people enrolled in PCDTDA/MS were analyzed. The majority were women (67.1%); assisted only through the public healthcare system (75.5%); polymedicated (57.4%); using at least one PIM (63.6%); presenting at least one PII (63.6%); and under drug therapy of low to medium complexity (92.2%). No semi-annual monitoring of the effectiveness of PCDTDA/MS drugs was identified. The proportion using AD drug therapy at daily doses differing from those recommended by the World Health Organization was 75.6%. However, these doses were not associated with drug risk.

CONCLUSION

The data from this study raise the hypothesis that use of polypharmacy might show a correlation with severity of AD. The drug safety risk may be associated with comorbidities of the metabolic syndrome, anxiety and off-label use of PIMs, such as risperidone and quetiapine, and benzodiazepines (i.e. clonazepam and flunitrazepam).

Medication Complexity among Disadvantaged African American Seniors in Los Angeles

Background. Several publications highlight data concerning multiple chronic conditions and the medication regimen complexity (MRC) used in managing these conditions as well as MRCs’ association with polypharmacy and medication non-adherence. However, there is a paucity of literature that specifically details the correlates of MRC with multimorbidity, socioeconomic, physical and mental health factors in disadvantaged (medically underserved, low income) African American (AA) seniors. Aims. In a local sample in South Los Angeles, we investigated correlates of MRC in African American older adults with chronic disease(s). Methods. This was a community-based survey in South Los Angeles with 709 African American senior participants (55 years and older). Age, gender, continuity of care, educational attainment, multimorbidity, financial constraints, marital status, and MRC (outcome) were measured. Data were analyzed using linear regression. Results. Higher MRC correlated with female gender, a higher number of healthcare providers, hospitalization events and multimorbidity. However, there were no associations between MRC and age, level of education, financial constraint, living arrangements or health maintenance organization (HMO) membership. Conclusions. Disadvantaged African Americans, particularly female older adults with multimorbidity, who also have multiple healthcare providers and medications, use the most complex medication regimens. It is imperative that MRC is reduced particularly in African American older adults with multimorbidity.

Practical Barriers to Medication Adherence: What Do Current Self- or Observer-Reported Instruments Assess?

Introduction

Practical adherence barriers (e.g., medication frequency) are generally more amenable to intervention than perceptual barriers (e.g., beliefs). Measures which assess adherence barriers exist, however these tend to measure a mix of factors. There is a need to identify what practical barriers are captured by current measures.

Aim

To identify and synthesise the practical adherence barriers which are assessed by currently available self- or observer-report adherence measures.

Methods

A search for systematic reviews of self- or observer-report report adherence measures was conducted. Three electronic databases (Embase, Ovid Medline, and PsycInfo) were searched using terms based on adherence, adherence barriers and measures. Systematic reviews reporting on adherence measures which included at least one self- or observer-report questionnaire or scale were included. Adherence measures were extracted and coded on whether they addressed perceptual or practical barriers, or both. Practical items were then analysed thematically.

Results

Following screening of 272 initial abstracts, 20 full-text papers were reviewed. Four were excluded after full-text review, leaving 16 systematic reviews for data extraction. From these, 187 different adherence measures were extracted and coded, and 23 unique measures were identified as assessing practical barriers and included in the final analysis. Seven key themes were identified: formulation; instructions for use; issues with remembering; capability—knowledge and skills; financial; medication supply and social environment.

Conclusion

Existing adherence measures capture a variety of practical barriers which can be grouped into seven categories. These findings may be used to inform the development of a measure of practical adherence barriers.

Impact of Medication Regimen Simplification on Medication Administration Times and Health Outcomes in Residential Aged Care: 12 Month Follow Up of the SIMPLER Randomized Controlled Trial

In the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial, we evaluated the impact of structured medication regimen simplification on medication administration times, falls, hospitalization, and mortality at 8 residential aged care facilities (RACFs) at 12 month follow up. In total, 242 residents taking ≥1 medication regularly were included. Opportunities for simplification among participants at 4 RACFs were identified using the validated Medication Regimen Simplification Guide for Residential Aged CarE (MRS GRACE). Simplification was possible for 62 of 99 residents in the intervention arm. Significant reductions in the mean number of daily medication administration times were observed at 8 months (-0.38, 95% confidence intervals (CI) -0.69 to -0.07) and 12 months (-0.47, 95%CI -0.84 to -0.09) in the intervention compared to the comparison arm. A higher incidence of falls was observed in the intervention arm (incidence rate ratio (IRR) 2.20, 95%CI 1.33 to 3.63) over 12-months, which was primarily driven by a high falls rate in one intervention RACF and a simultaneous decrease in comparison RACFs. No significant differences in hospitalizations (IRR 1.78, 95%CI 0.57-5.53) or mortality (relative risk 0.81, 95%CI 0.48-1.38) over 12 months were observed. Medication simplification achieves sustained reductions in medication administration times and should be implemented using a structured resident-centered approach that incorporates clinical judgement.

Individual factors increasing complexity of drug treatment-a narrative review

Purpose

Complexity of drug treatment is known to be a risk factor for administration errors and nonadherence promoting higher healthcare costs, hospital admissions and increased mortality. Number of drugs and dose frequency are parameters often used to assess complexity related to the medication regimen. However, factors resulting from complex processes of care or arising from patient characteristics are only sporadically analyzed. Hence, the objective of this review is to give a comprehensive overview of relevant, patient-centered factors influencing complexity of drug treatment.

Methods

A purposeful literature search was performed in MEDLINE to identify potential complexity factors relating to the prescribed drug (i.e. dosage forms or other product characteristics), the specific medication regimen (i.e. dosage schemes or additional instructions), specific patient characteristics and process characteristics. Factors were included if they were associated to administration errors, nonadherence and related adverse drug events detected in community dwelling adult patients.

Results

Ninety-one influencing factors were identified: fourteen in “dosage forms”, five in “product characteristics”, twelve in “dosage schemes”, nine in “additional instructions”, thirty-one in “patient characteristics” and twenty in “process characteristics”.

Conclusions

Although the findings are limited by the non-systematic search process and the heterogeneous results, the search shows the influence of many factors on the complexity of drug treatment. However, to evaluate their relevance for individual patients, prospective studies are necessary.

Electronic supplementary material

The online version of this article (10.1007/s00228-019-02818-7) contains supplementary material, which is available to authorized users.

Factors associated with high medication regimen complexity in primary care older adults in Brazil

PURPOSE

Complex medication regimens are common among older adults and contribute to the occurrence of undesirable health outcomes. This study aims to investigate the factors associated with high medication regimen complexity in older people.

METHODS

A cross-sectional study was conducted with older adults selected from two primary healthcare units. Medication regimen complexity was measured using the Brazilian version of the Medication Regimen Complexity Index. The Pearson's Chi square test was used to analyse the individual association of each independent variable with high medication regimen complexity. The backward stepwise method was used to obtain the final multivariate logistic regression model.

RESULTS

We included 227 older adults with a median age of 70 years who were mostly females (70.9%). The median total Medication Regimen Complexity Index was 20.8 for high complexity and 10.5 for patients that were not using high complexity regimens. The Medication Regimen Complexity Index section with higher median scores in both groups was dosing frequency, followed by additional instructions. High complexity was associated with diabetes (OR 5.42; p = 0.00 2.69-10.93) and asthma/Chronic Obstructive Pulmonary Disease (OR 2.96(1.22-7.18); p = 0.02).

CONCLUSIONS

Older people in primary care with diabetes and respiratory disease were most likely to have complex medication regimens. Dosing frequency and additional instructions were medication regime complexity index components that most contributed to the high complexity in medication regime of older adults.

Are Clinical Outcomes Associated With Medication Regimen Complexity? A Systematic Review and Meta-analysis

Background: Current evidence of the influence of the medication regimen complexity (MRC) on the patients’ clinical outcomes are not conclusive. Objective: To systematically and analytically assess the association between MRC measured by the Medication Regimen Complexity Index (MRCI) and clinical outcomes. Methods: A search was carried out in the databases Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science to identify studies evaluating the association between MRC and clinical outcomes that were published from January 1, 2004, to April 2, 2018. The search terms included outcome assessment, drug therapy, and medication regimen complexity index and their synonyms in different combinations for case-control and cohort studies that used the MRCI to measure MRC and related the MRCI with clinical outcomes. Odds ratios (ORs), hazard ratios (HRs), and mean differences (WMDs) were calculated, and heterogeneity was assessed using the I2 test. Results: A total of 12 studies met the eligibility criteria. The meta-analysis showed that MRC is associated with the following clinical outcomes: hospitalization (HR = 1.20; 95% CI = 1.14 to 1.27; I2 = 0%) in cohort studies, hospital readmissions (WMD = 7.72; 95% CI = 1.19 to 14.25; I2 = 84%) in case-control studies, and medication nonadherence (adjusted OR = 1.05; 95% CI = 1.02 to 1.07; I2 = 0%) in cohort studies. Conclusion and Relevance: This systematic review and meta-analysis gathered relevant scientific evidence and quantified the combined estimates to show the association of MRC with clinical outcomes: hospitalization, hospital readmission, and medication adherence.

Medication regimen complexity on hospital admission in patients with advanced chronic conditions in need of palliative care

Objectives

To evaluate characteristics of the medication complexity, risk factors associated with high medication complexity and their clinical consequences in patients with advanced chronic conditions.

Methods

A 10-month cross-sectional study was performed in an acute-hospital care Geriatric Unit. Patients with advanced chronic conditions were identified by the NECPAL test. Medication complexity was established using the Medication Regimen Complexity Index (MRCI) tool. Demographic, pharmacological and clinical patient data were collected with the objective of determining risk factors related to high medication complexity. Measured clinical outcomes were hospital length of stay, destination on hospital discharge, in-hospital mortality and 2-year survival.

Results

Two hundred and thirty-five patients (mean age 86.8, SD 5.37; 65.5% female) were recruited. MRCI's mean score was 38 points (SD 16.54, rank: 2.00-98.50), with 57.9% of patients with high medication complexity (MRCI >35 points).

Medication Regimen Complexity In 8 Australian Residential Aged Care Facilities: Impact Of Age, Length Of Stay, Comorbidity, Frailty, And Dependence In Activities Of Daily Living

Objective

To explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.

Methods

This study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.

Results

The median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (r_s=0.19; 0.27), FRAIL-NH score (r_s=0.23; 0.34) and dependence in ADLs (r_s=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (r_s=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).

Conclusion

Residents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.

Development and validation of the Korean version of the medication regimen complexity index

The medication regimen complexity index (MRCI), originally developed in English, is a reliable and valid tool to assess the complexity of pharmacotherapy. This study aimed to validate the Korean version of MRCI (MRCI-K). A cross-cultural methodological study comprising 335 discharged patients of a tertiary hospital in Korea was conducted. The translation process included translation into Korean by two clinical pharmacists, back translation by two native speakers, and a pretest of the tool, culminating in the Korean version of MRCI-K. Reliability analysis was assessed using inter-rater and test–retest reliability with 25 randomly selected patients. Convergent and discriminant validity analyses were conducted by correlating MRCI scores with medication number, age, sex, adverse drug reaction (ADR) reports, and length of stay. The criterion validity was confirmed through evaluation by a nine-member expert panel that subjectively ranked these regimens. The reliability analysis demonstrated excellent internal consistency (Cronbach’s α = 0.977), and the intraclass correlation coefficient exceeded 0.90 for all cases. The correlation coefficient for the number of medications was 0.955 (P < 0.001). Weak significant correlations were observed with age and length of stay. The MRCI-K group with ADR reports scored higher (mean, 31.8) than the group without ADR reports (mean, 27.3). The expert panel’s ranking had a stronger correlation with the MRCI ranking than the medication number ranking. MRCI-K has similar reliability and validity as MRCI and is useful for analyzing therapeutic regimens with potential applications in both practice and research in Korea.

Electronic Medication Regimen Complexity Index at admission and complications during hospitalization in medical wards: a tool to improve quality of care?

Objective

Adverse events during hospitalization are a major worry considering their frequency and their burden. Many could be avoided by immediate identification of at-risk patients at admission and adapted prevention. The complexity of a patient's medication regimen immediately available at admission is a good indicator of the complexity of the patient's condition. This study aims to determine whether the electronic Medication Regimen Complexity Index (MRCI) at admission is associated with complications during hospitalization.

Design

We performed a multilevel logistic regression model, adjusted for age and sex.

Setting

Premier Perspective™ database, a clinical and financial information system from 417 US hospitals.

Participants

Adults hospitalized for more than 3 days in a medical ward and included in Premier's Perspective™ database for 2006.

Intervention(s)

Multilevel logistic regression.

Main Outcome Measure

Association of the MRCI and complications during hospitalization, defined as in-hospital death, hospital-acquired infection, pressure ulcers; and need for highly technical healthcare, identified as the secondary introduction of catecholamines.

Results

In total, 1 592 383 admissions were included. The median MRCI at admission was 13 [interquartile range: 9-19]. The higher the MRCI, the higher the adjusted odds ratio of the following: in-hospital mortality, hospital-acquired infections, pressure ulcers and the secondary introduction of catecholamines.

Conclusions

Our results suggested that the MRCI at admission was correlated with patient complexity, independent of age. Considering that patients with complex conditions pose a heavier workload for staff, measuring MRCI at admission could be used to allocate resources in medical wards at an institutional level. The MRCI might be a useful tool to assess the management of care.

The association between polypharmacy and medication regimen complexity and antibiotic use in bronchiectasis

Background Polypharmacy is associated with an increased risk of adverse drug events, inappropriate prescribing and medication errors. People with bronchiectasis have frequent pulmonary exacerbations that require antibiotic therapy. Objective This study aimed to measure polypharmacy and medication regimen complexity in bronchiectasis patients and to explore associations between these factors and oral and intravenous (IV) antibiotic use for suspected pulmonary exacerbations. Setting Patients were sampled from the Regional Bronchiectasis Clinic at the Belfast Health and Social Care Trust, Northern Ireland. Method Data on medicines were collected from patients’ records and used to measure polypharmacy using three thresholds (≥ 4, ≥ 10, and ≥ 15 medicines’). Medication regimen complexity was calculated using the medication regimen complexity index (MRCI). Data analysis investigated differences in outcomes across polypharmacy thresholds and correlations with MRCI. Main outcome measure Primary outcomes were prescriptions for oral antibiotics and IV antibiotics, in the past 6 months and 2 years, respectively. Results Over three-quarters of the sample (N = 95) were prescribed ≥ 4 medicines (n = 74; 77.9%), 31 patients were prescribed ≥ 10 medicines (33.0%), and 12 patients (12.8%) were prescribed ≥ 15 medicines. The median MRCI was 26. Patients prescribed ≥ 10 medicines were over three times more likely to have had an IV antibiotic in the past 2 years (adjusted odd ratio 3.44, 95% confidence intervals 1.15–10.31). Conclusion There were significant differences in all outcomes across the ‘≥ 10 medicines’ threshold. MRCI was positively correlated with oral and IV antibiotic usage. These findings also suggest a possible link between polypharmacy and medicines regimen complexity, and poorer outcomes.

Medication Regimen Complexity Measured by MRCI: A Systematic Review to Identify Health Outcomes

Objective: To perform a systematic review to identify health outcomes related to medication regimen complexity as measured by the Medication Regimen Complexity Index (MRCI) instrument. Data Sources: Cochrane Library, LILACS, PubMed, Scopus, EMBASE, Open Thesis, and Web of Science were searched from January 1, 2004, until April 02, 2018, using the following search terms: outcome assessment, drug therapy, and Medication Regimen Complexity Index and their synonyms in different combinations. Study Selection and Data Extraction: Studies that used the MRCI instrument to measure medication regimen complexity and related it to clinical, humanistic, and/or economic outcomes were evaluated. Two reviewers independently carried out the analysis of the titles, abstracts, and complete texts according to the eligibility criteria, performed data extraction, and evaluated study quality. Data Synthesis: A total of 23 studies met the inclusion criteria; 18 health outcomes related to medication regimen complexity were found. The health outcomes most influenced by medication regimen complexity were hospital readmission, medication adherence, hospitalization, adverse drug events, and emergency sector visit. Only one study related medication regimen complexity with humanistic outcomes, and no study related medication regimen complexity to economic outcomes. Most of the studies were of good methodological quality. Relevance to Patient Care and Clinical Practice: Health care professionals should pay attention to medication regimen complexity of the patients because this may influence health outcomes. Conclusion: This study identified some health outcomes that may be influenced by medication regimen complexity: hospitalization, hospital readmission, and medication adherence were more prevalent, showing a significant association between MRCI increase and these health outcomes.

Why current drug adherence programs fail: addressing psychological risk factors of nonadherence

PURPOSE OF REVIEW

To provide an overview of a selection of largely neglected psychological risk factors for nonadherence, and to offer new approaches to improve medication adherence.

RECENT FINDINGS

Current adherence research and intervention programs focus on a few risk factors for nonadherence, such as complexity of the drug regimen. In addition, other important risk factors of nonadherence are neglected or insufficiently addressed. There is good evidence for the significant role of the quality of the patient-healthcare provider relationship. Other risk factors like the individual history of nonadherence, the lack of acceptance of having a treatable disorder, fear of side-effects, comorbid depression, and cognitive impairment have been broadly neglected in adherence programs, although they offer a powerful key to improve adherence-oriented interventions.

SUMMARY

Current research on determinants of nonadherence has focused on a few risk factors, while neglecting crucial psychological predictors of nonadherence. The personalized consideration of a multiplicity of risk factors offers a new basis for the development and evaluation of interventions to better promote adherence.

Association between medication regimen complexity and pharmacotherapy adherence: a systematic review

PURPOSE

The purpose of this study was to systematically review evidence regarding the association between regimen complexity and adherence.

METHODS

Articles were searched in MEDLINE, LILACS, Cochrane, CINAHL, PsycINFO and references of included studies. Search terms included medication regimen complexity, medication adherence and their synonyms. Randomized clinical trials, cross-sectional, cohort or case-control studies published until March 2016 in English, Portuguese or Spanish were eligible if quantitatively examined the association between complexity and adherence in patients of any age and sex, under any type of medication therapy. Complexity was defined according to the strategy used to assess it in the individual studies. All types of instruments used to assess complexity and adherence were considered. Data extraction was performed using an electronic spreadsheet. Quality assessment was conducted independently using standard scales. The data were qualitatively synthesized.

RESULTS

Fifty-four studies were included: 37 cross-sectional and 17 cohorts. Most were conducted in outpatient setting. Most frequently, studies were carried out with HIV-infected individuals or patients with chronic conditions. The most frequent methods used to assess complexity and adherence were complexity index (19) and self-report (27), respectively. Complexity was associated with adherence in 35 studies. Most of them (28) identified that participants with more complex regimens were less likely to adhere to pharmacotherapy; seven studies found a direct correlation. The others found inconclusive results or no association between complexity and adherence. The studies had low to moderate-methodological quality.

CONCLUSION

Although there was variability regarding the association between complexity and adherence, most studies showed that an increased regimen complexity reduces medication adherence.

Practical Considerations for the Use of Subcutaneous Treatment in the Management of Dyslipidaemia

Suboptimal drug adherence represents a major challenge to effective primary and secondary prevention of cardiovascular disease. While adherence is influenced by multiple considerations, polypharmacy and dosing frequency appear to be rate-limiting factors in patient satisfaction and subsequent adherence. The cardiovascular and metabolic therapeutic areas have recently benefited from a number of advances in drug therapy, in particular protease proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and incretin-based therapies, respectively. These drugs are administered subcutaneously and offer efficacious treatment options with reduced dosing frequency. Whilst patients with diabetes and diabetologists are well initiated to injectable therapies, the cardiovascular therapeutic arena has traditionally been dominated by oral agents. It is therefore important to examine the practical aspects of treating patients with these new lipid-lowering agents, to ensure they are optimally deployed in everyday clinical practice.

Evaluation of pharmacotherapy complexity in residents of long-term care facilities: a cross-sectional descriptive study

BACKGROUND

Polypharmacy is a reality in long-term care facilities. However, number of medications used by the patient should not be the only predictor of a complex pharmacotherapy. Although the level of complexity of pharmacotherapy is considered an important factor that may lead to side effects, there are few studies in this field. The aim of this study was to evaluate the complexity of pharmacotherapy in residents of three long-term care facilities.

METHODS

A cross-sectional study was performed to evaluate the complexity of pharmacotherapy using the protocols laid out in the Medication Regimen Complexity Index instrument in three long-term care facilities in northeastern Brazil. As a secondary result, potential drug interactions, potentially inappropriate medications, medication duplication, and polypharmacy were evaluated. After the assessment, the association among these variables and the Medication Regimen Complexity Index was performed.

RESULTS

In this study, there was a higher prevalence of women (64.4%) with a high mean age among the study population of 81.8 (±9.7) years. The complexity of pharmacotherapy obtained a mean of 15.1 points (±9.8), with a minimum of 2 and a maximum of 59. The highest levels of complexity were associated with dose frequency, with a mean of 5.5 (±3.6), followed by additional instructions of use averaging 4.9 (±3.7) and by the dosage forms averaging 4.6 (±3.0).

CONCLUSIONS

The present study evaluated some factors that complicate the pharmacotherapy of geriatric patients. Although polypharmacy was implicated as a factor directly related to complexity, other indicators such as drug interactions, potentially inappropriate medications, and therapeutic duplication can also make the use of pharmacotherapy in such patients more difficult.

Medication Regimen Complexity and Low Adherence in Older Community-Dwelling Adults With Substantiated Self-Neglect

Objective: Determine whether medication regimen complexity predicts medication adherence levels in a sample of community-dwelling adults 65 years and older with Adult Protective Services–substantiated self-neglect. Methods: A cross-sectional analysis of baseline data ( N = 31 participants) from a pilot intervention to increase medication adherence among the target group was performed. The Medication Regimen Complexity Index (MRCI) and the 8-item Morisky Medication Adherence Scale (MMAS-8)™ were the primary independent and dependent measures, respectively. A multivariable linear regression analysis, adjusting for potential confounders, was conducted to estimate the association between complexity and adherence. Results: Regimen complexity was high (mean MRCI = 19.6) and adherence was low (mean MMAS = 5.1). Even after controlling for confounders, increased complexity was significantly associated with lower adherence. Discussion: Older community-dwelling adults who self-neglect have complex medication regimens that contribute to low medication adherence. Medication regimen complexity may be a modifiable contributor to low adherence that can be targeted by future interventions to reduce self-neglect and its consequences.

Medication regimen complexity in ambulatory older adults with heart failure

PURPOSE

Heart failure prevalence is increasing in older adults, and polypharmacy is a major problem in this population. We compared medication regimen complexity using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool in "young-old" (60-74 years) versus "old-old" (75-89 years) patients with heart failure. We also compared pMRCI between patients with ischemic cardiomyopathy (ISCM) versus nonischemic cardiomyopathy (NISCM).

PATIENTS AND METHODS

Medication lists were retrospectively abstracted from the electronic medical records of ambulatory patients aged 60-89 years with heart failure. Medications were categorized into three types - heart failure prescription medications, other prescription medications, and over-the-counter (OTC) medications - and scored using the pMRCI tool.

RESULTS

The study evaluated 145 patients (n=80 young-old, n=65 old-old, n=85 ISCM, n=60 NISCM, mean age 73±7 years, 64% men, 81% Caucasian). Mean total pMRCI scores (32.1±14.4, range 3-84) and total medication counts (13.3±4.8, range 2-30) were high for the entire cohort, of which 72% of patients were taking eleven or more total medications. Total and subtype pMRCI scores and medication counts did not differ significantly between the young-old and old-old groups, with the exception of OTC medication pMRCI score (6.2±4 young-old versus 7.8±5.8 old-old, P=0.04). With regard to heart failure etiology, total pMRCI scores and medication counts were significantly higher in patients with ISCM versus NISCM (pMRCI score 34.5±15.2 versus 28.8±12.7, P=0.009; medication count 14.1±4.9 versus 12.2±4.5, P=0.008), which was largely driven by other prescription medications.

CONCLUSION

Medication regimen complexity is high in older adults with heart failure, and differs based on heart failure etiology. Additional work is needed to address polypharmacy and to determine if medication regimen complexity influences adherence and clinical outcomes in this population.

Clinical Outcomes Associated with Medication Regimen Complexity in Older People: A Systematic Review

OBJECTIVES

To systematically review clinical outcomes associated with medication regimen complexity in older people.

DESIGN

Systematic review of EMBASE, MEDLINE, International Pharmaceutical Abstracts, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane library.

SETTING

Hospitals, home, and long-term care.

PARTICIPANTS

English-language peer-reviewed original research published before June 2016 was eligible if regimen complexity was quantified using a metric that considered number of medications and at least one other parameter, regimen complexity was calculated for participants' overall regimen, at least 80% of participants were aged 60 and older, and the study investigated a clinical outcome associated with regimen complexity.

MEASUREMENTS

Quality assessment was conducted using an adapted version of the Joanna Briggs Institute critical appraisal tool.

RESULTS

Sixteen observational studies met the inclusion criteria. Regimen complexity was associated with medication nonadherence (2/6 studies) and higher rates of hospitalization (2/4 studies). One study found that participants with less-complex medication administration were more likely to stop medications when feeling worse. One study each identified an association between regimen complexity and higher ability to administer medications as directed, medication self-administration errors, caregiver medication administration hassles, hospital discharge to non-home settings, postdischarge potential adverse drug events, all-cause mortality, and lower patient knowledge of their medication. Regimen complexity had no association with postdischarge medication modification, change in medication- and health-related problems, emergency department visits, or quality of life as rated by nursing staff.

CONCLUSION

Research into whether medication regimen complexity is associated with nonadherence and hospitalization has produced inconsistent results. Moderate-quality evidence from four studies (two each for nonadherence and hospitalization) suggests that medication regimen complexity is associated with nonadherence and higher rates of hospitalization.

Evaluating Patient-Level Medication Regimen Complexity Over Time in Heart Transplant Recipients

BACKGROUND

Medication regimen complexity describes multiple characteristics of a patient's prescribed drug regimen. Heart transplant recipients must comply with a lifelong regimen that consists of numerous medications. However, a systematic assessment of medication regimen complexity over time has not been conducted in this, or any other, transplant population.

OBJECTIVE

The objective of this study was to quantify patient-level medication regimen complexity over time following primary heart transplantation and heart retransplantation, using the validated patient-level Medication Regimen Complexity Index (pMRCI) tool.

METHODS

Medication lists were reviewed at transplant discharge and years 1, 3, and 5 post-primary heart transplant, and at transplant discharge and years 1 and 3 post-heart retransplantation. Medications were categorized as transplant-specific, other prescription, and over-the-counter (OTC).

RESULTS

In primary heart transplant recipients (n = 60), mean total medication count was 14.3 ± 3.4 at transplant discharge and did not change significantly over time ( P = 0.64). Transplant-specific medication count decreased significantly from discharge (2.9 ± 0.4) to year 5 (2.3 ± 0.6); P = 0.02. However, 32% of patients were taking 16 or more total medications at year 5 posttransplant. More than 70% of the pMRCI score was attributed to other prescription and OTC medications, which was largely driven by dosing frequency in this cohort. Medication complexity did not differ significantly between heart retransplant recipients (n = 11) and matched primary heart transplant controls (n = 22).

CONCLUSION

Together, these data highlight the substantial medication burden after heart transplantation and reveal opportunities to address medication regimen complexity in this, and other, transplant populations.

Medication Complexity, Medication Number, and Their Relationships to Medication Discrepancies

Background: Medication reconciliation to identify discrepancies is a National Patient Safety Goal. Increasing medication number and complex medication regimens are associated with discrepancies, nonadherence, and adverse events. The Medication Regimen Complexity Index (MRCI) integrates information about dosage form, dosing frequency, and additional directions. Objective: This study evaluates the association of MRCI scores and medication number with medication discrepancies and commissions, a discrepancy subtype. Methods: This was a retrospective cohort study of a convenience sample of 104 ambulatory care patients seen from April 2010 to July 2011 within the Department of Veterans Affairs. Primary outcomes included any medication discrepancy and commissions. Primary exposures included MRCI scores and medication number. Multivariable logistic regression models associated MRCI scores and medication number with discrepancies. Receiver operating characteristic (ROC) curves provided discrepancy thresholds. Results: For the 104 patients analyzed, the median MRCI score was 25 (interquartile range [IQR] = 14-43), and the median medication number was 8 (IQR = 5-13); 60% of patients had any discrepancy, whereas 36% had a commission. In adjusted analyses, patients with MRCI scores ≥25 or medication number ≥8 were more likely to have commissions (odds ratio [OR] = 3.64, 95% CI = 1.41-9.41; OR = 4.51, 95% CI = 1.73-11.73, respectively). The unadjusted ROC threshold for commissions was 36 for MRCI (sensitivity, 59%; specificity, 82%) and 9 for medication number (sensitivity 68%; specificity 67%). Conclusion: Patients with either MRCI scores ≥25 or ≥8 medications were more likely to have commissions. Given equal performance in predicting discrepancies, the efficiency and simplicity of medication number supports its use in identifying patients for intensive medication review beyond medication reconciliation.

Medication regimen complexity in adults and the elderly in a primary healthcare setting: determination of high and low complexities

Background:

The complexity of a medication regimen is related to the multiple characteristics of the prescribed regimen and can negatively influence the health outcomes of patients.

Objective:

To propose cut-off points in the complexity of pharmacotherapy to distinguish between patients with low and high complexities seen in a primary health care (PHC) setting to enable prioritization of patient management.

Methods:

This is a cross-sectional study, which included 517 adult and elderly patients, analyzing different cut-off points to define the strata of low and high pharmacotherapy complexities based on percentiles of the population evaluated. Data collection began with the solicitation of prescriptions, followed by a questionnaire that was administered by an interviewer. The complexity of a medication regimen was estimated from the Medication Regimen Complexity Index (MRCI). High complexity pharmacotherapy scores were analyzed from patient profiles, the use of health services, and pharmacotherapy. The criteria for subject inclusion in the sample population were as follows: inhabitant of the area covered by the municipality, 18 years or older, and being prescribed at least one drug during the collection period. Exclusion criteria at the time of collection were the use of any medication whose prescription was not available. All medications were accessed through the Primary Healthcare Service (PHS).

Results:

The median total pharmacotherapy complexity score was 8.5. High MRCI scores were correlated with age, medications taken with in the Brazilian PHS, having at least one potential drug-related problem, receiving up to eight years of schooling, number of medications and polypharmacy (five or more medicines), number of medical conditions, number of medical appointments, and number of cardiovascular diseases and endocrine metabolic diseases. We suggest different complexity tracks according to age (e.g., adult or elderly) that consider the pharmacotherapy and population coverage characteristics as high complexity limits. For the elderly patients, the tracks were as follows: MRCI≥25.4, MRCI≥20.9, MRCI≥17.5, MRCI≥15.7, MRCI≥14.0, and MRCI≥13.0. For adult patients, the limits of high complexity were MRCI≥25.1; MRCI ≥ 23.8; MRCI≥21.0; MRCI≥17.0; MRCI≥16.5; and MRCI≥15.5.

Conclusion:

The medication regimen complexity is associated with the patient’s illness profile and problems with the use of drugs; therefore, the proposed scores can be useful in prioritizing patients for clinical care by pharmacists and other health professionals.

Discrepancies on Medication Plans detected in German Community Pharmacies

RATIONALE, AIMS AND OBJECTIVES

A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients.

METHODS

Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication.

RESULTS

Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives.

CONCLUSION

Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.

Factors associated with medication regimen complexity in older people: a cross-sectional population-based study

PURPOSE

There is a lack of population-based research about factors associated with medication regimen complexity. This study investigated factors associated with medication regimen complexity in older people, and whether factors associated with regimen complexity were similar to factors associated with number of medications.

METHODS

This cross-sectional population-based study included 3348 people aged ≥ 60 years. Medication regimen complexity was computed using the validated 65-item Medication Regimen Complexity Index (MRCI). Multinomial logistic regression was used to compute unadjusted and adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) for factors associated with regimen complexity. Multivariable quantile regression was used to compare factors associated with regimen complexity and number of medications.

RESULTS

In adjusted analyses, participants in the highest MRCI quintile (MRCI > 20) were older (OR = 1.04, 95 % CI 1.02;1.05), less likely to live at home (OR = 0.35, 95 % CI 0.15;0.86), had greater comorbidities (OR = 2.17, 95 % CI 1.89;2.49), had higher cognitive status (OR = 1.06, 95 % CI 1.01;1.11), a higher prevalence of self-reported pain (OR = 2.85, 95 % CI 2.16;3.76), had impaired dexterity (OR = 2.39, 95 % CI 1.77;3.24) and were more likely to receive help to sort their medications (OR = 4.43 95 % CI 2.39;8.56) than those with low regimen complexity (MRCI > 0-5.5). Similar factors were associated with both regimen complexity and number of medications.

CONCLUSION

Older people with probable difficulties managing complex regimens, including those with impaired dexterity and living in institutional settings, had the most complex medication regimens even after adjusting for receipt of help to sort medications. The strong correlation between regimen complexity and number of medications suggests that clinicians could use a person's number of medications to target interventions to reduce complexity.

Validation of a patient-level medication regimen complexity index as a possible tool to identify patients for medication therapy management intervention

Background

The Medication Regimen Complexity Index (MRCI) is a 65-item instrument that can be used to quantify medication regimen complexity at the patient level, capturing all prescribed and over-the-counter medications. Although the MRCI has been used in several studies, the narrow scope of the initial validation limits application at a population or clinical practice level.

Purpose

To conduct a MRCI validation pertinent to the desired clinical use to identify patients for medication therapy management interventions.

Methods

An expert panel of clinical pharmacists ranked medication regimen complexity for two samples of cases: a single-disease cohort (diabetes mellitus) and a multiple-disease cohort (diabetes mellitus, hypertension, human immunodeficiency virus infection, geriatric depression). Cases for expert panel review were selected from 400 ambulatory clinic patients, and each case description included data that were available via claims or electronic medical records (EMRs). Construct validity was assessed using patient-level MRCI scores, medication count, and additional patient data. Concordance was evaluated using weighted κ agreement statistic, and correlations were determined using Spearman rank-order correlation coefficient (ρ) or Kendall τ.

Results

Moderate to good concordance between patient-level MRCI scores and expert medication regimen complexity ranking was observed (claims data, consensus ranking: single-disease cohort 0.55, multiple disease cohort 0.63). In contrast, only fair to moderate concordance was observed for medication count (single-disease cohort 0.33, multiple-disease cohort 0.48). Adding more-detailed administration directions from EMR data did not improve concordance. MRCI convergent validity was supported by strong correlations with medication count (all cohorts 0.90) and moderate correlations with morbidity measures (e.g., all cohorts; number of comorbidities 0.46, Chronic Disease Score 0.46). Nonsignificant correlation of MRCI scores with age and gender (all cohorts 0.08 and 0.06, respectively) supported MRCI divergent validity.

Limitations

This study used cross-sectional, retrospective patient data for a small number of patients and clinical pharmacists from only two universities; therefore, results may have limited generalizability.

Conclusions

The patient-level MRCI is a valid tool for assessing medication regimen complexity that can be applied by using data commonly found in claims and EMR databases and could be useful to identify patients who may benefit from medication therapy management.

What older complex chronic patients need to know about their everyday medication for safe drug use

OBJECTIVE

To determine whether elderly patients with complex drug regimens have enough information to ensure safe drug use.

METHODS

A cross-sectional study was conducted in Spain based on interviews of a random sample of 265 patients aged over 65 and taking at least five drugs for multiple comorbidities. General practitioners reported on diagnoses, drugs, dosage and biochemical laboratory results. Patients were asked about the medications they were taking (with higher scores indicating greater knowledge).

RESULTS

The patients took an average of 7.9 medications (SD 3.0). The mean scores were low for precautions (mean 0.3, SD 0.7) and how to properly store medications (mean 2.0, SD 3.0). Scores were significantly higher when physicians regularly provided patients with information (F-test 3.3, p = 0.039) and were not related to gender, years of treatment or health status. Frequent changes in medication adversely affected the scores (p = 0.03). Higher scores were related to a smaller number of medication errors (t-test 2.2, p = 0.032, CI 95% of the difference 0.6 - 1.2).

CONCLUSIONS

Older complex chronic patients are unaware of the precautions they must adopt to use their medications safely. Patient knowledge does contribute to reducing medication errors. When physicians change prescriptions, modify doses or introduce new medications, more information needs to be provided for safe use of the drugs.