Clinical impact of a pharmacist-led medication review with follow up for aged polypharmacy patients: A cluster randomized controlled trial

Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis

INTRODUCTION

Pharmacist-led medication reviews are an established intervention to support patients prescribed multiple medicines or with complex medication regimes. For this systematic review, a medication review was defined as 'a consultation between a pharmacist and a patient to review the patient's total medicines use with a view to improve patient health outcomes and minimise medicines-related problems'. It is not known how varying approaches to medication reviews lead to different outcomes.

AIM

To explore the common themes associated with positive outcomes from pharmacist-led medication reviews.

METHOD

Randomised controlled trials of pharmacist-led medication reviews in adults aged 18 years and over were included. The search terms used in MEDLINE, EMBASE and Web of Science databases were "medication review", "pharmacist", "randomised controlled trial" and their synonyms, time filter 2015 to September 2023. Studies published before 2015 were identified from a previous systematic review. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Descriptions of medication reviews' components, implementation and outcomes were narratively synthesised to draw out common themes. Results are presented in tables.

RESULTS

Sixty-eight papers describing 50 studies met the inclusion criteria. Common themes that emerged from synthesis include collaborative working which may help reduce medicines-related problems and the number of medicines prescribed; patient involvement in goal setting and action planning which may improve patients' ability to take medicines as prescribed and help them achieve their treatment goals; additional support and follow-up, which may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems.

CONCLUSION

This systematic review identified common themes and components, for example, goal setting, action planning, additional support and follow-up, that may influence outcomes of pharmacist-led medication reviews. Researchers, health professionals and commissioners could use these for a comprehensive evaluation of medication review implementation.

PROSPERO REGISTRATION NUMBER

CRD42020173907.

Evaluation of an enhanced service for medication review with follow up in Swiss community pharmacies: Pre-post study protocol

BACKGROUND

In Switzerland, 20,000 people are hospitalized each year as result of drug related problems (DRPs). The sources of DRPs can be related to patients' behavior (i.e., wrong administration) or to health processes (i.e., drug-drug interaction). No community pharmacy (CP) service focus on DRPs related to patients' behavior is currently recognized or remunerated in Switzerland. A medication review with follow up (MRF) has been developed to evaluate prescription and non-prescription medication.

OBJECTIVE

To evaluate the impact of MRF service for the identification and management DRPs associated to patients' behavior and to describe pharmaceutical interventions carried out through MRF.

METHODS

A pre-post intervention study with a cluster design and one intervention group will be carried out in CPs in the canton of Vaud (Switzerland) for 15 months. Volunteer pharmacists will be trained on the identification and management of DRPs related to patients' behavior. After training, they will include randomly selected adults taking four or more chronic drugs prescribed for at least three months prior to recruitment. Then, they will conduct three pharmacist-patient face-to-face consultations at 6-month intervals. Tasks will be differentiated by pharmacy technician or pharmacist to triage expired medication or to manage DRPs in a structured manner, respectively. The primary outcome is the identification of DRPs associated to patients' behavior. Secondary outcomes are to assess patients' medication knowledge, number of expired medications, interventions carried out by pharmacists and pharmacists' satisfaction. The study will begin in April 2023 in 19 to 35 pharmacies that will recruit at least 162 patients. A sub analysis will be carried out for patients with 65 years old or over.

CONCLUSIONS

The MRF intervention features a training designed for an enhanced evaluation of patient's behavior towards their medication. The study will allow the assessment and management of DRPs in Swiss CPs with the support of the local health authorities and pharmacist association.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05348538.

The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy: a systematic review

BACKGROUND

Polypharmacy and associated potentially inappropriate prescribing (PIP) place a considerable burden on patients and represent a challenge for general practitioners (GPs). Integration of pharmacists within general practice (herein 'pharmacist integration') may improve medications management and patient outcomes. This systematic review assessed the effectiveness and costs of pharmacist integration.

METHODS

A systematic search of ten databases from inception to January 2021 was conducted. Studies that evaluated the effectiveness or cost of pharmacist integration were included. Eligible interventions were those that targeted medications optimization compared to usual GP care without pharmacist integration (herein 'usual care'). Primary outcomes were PIP (as measured by PIP screening tools) and number of prescribed medications. Secondary outcomes included health-related quality of life, health service utilization, clinical outcomes, and costs. Randomised controlled trials (RCTs), non-RCTs, interrupted-time-series, controlled before-after trials and health-economic studies were included. Screening and risk of bias using Cochrane EPOC criteria were conducted by two reviewers independently. A narrative synthesis and meta-analysis of outcomes where possible, were conducted; the certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

In total, 23 studies (28 full text articles) met the inclusion criteria. In ten of 11 studies, pharmacist integration probably reduced PIP in comparison to usual care (moderate certainty evidence). A meta-analysis of number of medications in seven studies reported a mean difference of -0.80 [-1.17, -0.43], which indicated pharmacist integration probably reduced number of medicines (moderate certainty evidence). It was uncertain whether pharmacist integration improved health-related quality of life because the certainty of evidence was very low. Twelve health-economic studies were included; three investigated cost effectiveness. The outcome measured differed across studies limiting comparisons and making it difficult to make conclusions on cost effectiveness.

CONCLUSIONS

Pharmacist integration probably reduced PIP and number of medications however, there was no clear effect on other patient outcomes; and while interventions in a small number of studies appeared to be cost-effective, further robust, well-designed cluster RCTs with economic evaluations are required to determine cost-effectiveness of pharmacist integration.

TRIAL REGISTRATION

CRD42019139679.

Effects of the Full Coverage Policy of Essential Medicines on Inequality in Medication Adherence: A Longitudinal Study in Taizhou, China

The full coverage policy for essential medicines (FCPEMs) was proposed and implemented in Taizhou city of Zhejiang Province, China, to promote equal access and adherence to medicines. This study aimed to examine the effects of FCPEMs on the income-related inequality in medication adherence among local patients with hypertension or diabetes. We collected electronic health records of patients with hypertension or diabetes of three districts of Taizhou from 2011 to 2016. As the implementation schedule of the FCPEMs varied across districts, we applied a retrospective longitudinal study design and assigned records from 1 year before to 3 years following the implementation of FCPEMs as baseline and follow-up data. We thus generated a dataset with 4-year longitudinal data. The concentration index (CI) and its decomposition method were employed to measure factors contributing to inequality in medication adherence and the role played by FCPEMs. The sample size rose from 264,836 at the baseline to 315,677, 340,512, and 355,676 by each follow-up year, and the proportion of patients taking free medicines rose from 17.6 to 25.0 and 29.8% after FCPEMs implementation. The proportion of patients with high adherence increased from 39.9% at baseline to 51.6, 57.2, and 60.5%, while CI decreased from 0.073 to −0.011, −0.029, and −0.035. The contribution of FCPEMs ranked at 2nd/13, 7th/13, and 2nd/13 after the implementation of FCPEMs. Changes in CI of medication adherence for every 2 years were −0.084, −0.018, and −0.006, and the contribution of FCPEMs was −0.006, 0.006, and 0.007, ranking at 2nd/13, 2nd/13, and 1st/13, respectively. Most changes in CI of medication adherence can be attributed to FCPEMs. The medication adherence of patients with hypertension or diabetes improved after the implementation FCPEMs in Taizhou, although inequality did not improve consistently. In general, FCPEMs could be a protective factor against income-related inequalities in access and adherence to medicines. Future research is needed to investigate the change mechanism and the optimal design of similar interventions.

Clinical and Humanistic Outcomes of Community Pharmacy-Based Healthcare Interventions Regarding Medication Use in Older Adults: A Systematic Review and Meta-Analysis

This review and meta-analysis aimed to determine the clinical and humanistic outcomes of community pharmacy-based interventions on medication-related problems of older adults at the primary care level. We identified randomized controlled trials (RCTs) examining the impact of various community pharmacy-based interventions from five electronic databases (namely, MEDLINE (Ovid), EMBASE (Ovid), CINAHL, APA PSYInfo, and Scopus) from January 2010 to December 2020. Consequently, we assessed these interventions’ clinical and humanistic outcomes on older adults and compared them with non-intervention. We included 13 RCTs in the current review and completed a meta-analysis with six of them. The included studies had a total of 6173 older adults. Quantitative analysis showed that patient education was significantly associated with an increase in the discontinuation of sedative–hypnotics use (risk ratio 1.28; 95% CI (1.20, 1.36) I2 = 0%, p < 0.00001). Moreover, the qualitative analysis showed that medication reviews and education with follow-ups could improve various clinical outcomes, including reducing adverse drug events, reducing uncontrolled health outcomes, and improving appropriate medication use among the elderly population. However, medication review could not significantly reduce the number of older adults who fall (risk ratio 1.25; 95% CI (0.78, 1.99) I2 = 0%, p = 0.36) and require hospitalization (risk ratio 0.72; 95% CI (0.47, 1.12) I2 = 45%, p = 0.15). This study showed that community pharmacy-based interventions could help discontinue inappropriate prescription medications among older adults and could improve several clinical and humanistic outcomes. However, more effective community pharmacy-based interventions should be implemented, and more research is needed to provide further evidence for clinical and humanistic outcomes of such interventions on older adults.

Polypharmacy among older Brazilians: prevalence, factors associated, and sociodemographic disparities (ELSI-Brazil)

Background:

Polypharmacy has become an increasingly public health issue as population age and novel drugs are developed. Yet, evidence on low- and middle-income countries (LMIC) is still scarce.

Objective:

This work aims to estimate the prevalence of polypharmacy among Brazilians aged 50 and over, and investigate associated factors.

Methods:

A cross-sectional study was conducted using data from the baseline assessment of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), a nationally representative study of persons aged 50 years and older (n=9,412). Univariate and bivariate analyses described the sample. Robust Poisson regression was used to estimate prevalence ratios and predict probabilities of polypharmacy.

Results:

Prevalence of polypharmacy was estimated at 13.5% among older adults in Brazil. Important disparities were observed in regard to gender (16.1% among women and 10.5% among men), race (16.0% among whites and 10.1% among blacks) and geographic region (ranging from 5.1% in the North to 18.7% in the South). The multivariate analysis showed that polypharmacy is associated with various sociodemographic/individual factors (age, gender, race, education, region, health status, body mass index) as well as with several variables of healthcare access/utilization (number of visits, same physician, provider’s knowledge of patient’s medications, gate-keeper, and difficulty managing own medication). Overall, the more utilization of health services, the higher the probability of polypharmacy, after adjusting for all other model covariates.

Conclusions:

Polypharmacy prevalence is relatively low in Brazil, compared to European countries. After controlling for variables of healthcare need and demographic characteristics, there is still substantial residual variance in polypharmacy prevalence. Policies to identify inappropriate prescribing and reduce regional discrepancies are necessary.