| The National
Service Framework for Older People recommends regular medication
reviews for older people to maximise the benefit they receive from their
drugs and minimise the risk of the drugs causing harm. A number of UK
studies have shown that medication reviews conducted in general practice
by a pharmacist can be an effective method of reviewing older patients’ drug
treatments and studies in other countries have shown that pharmacists’ reviews
of long-term prescriptions in community practice benefit patients and
reduce both hospital admissions and deaths outside hospitals.
A study published last week, however, found that home-based medication
review by pharmacists increased hospital admissions, decreased patients’ quality
of life and failed to have a significant impact on mortality (BMJ
Online First; PJ, 22 January, p71).
The study
Richard Holland, senior lecturer in public
health medicine at the University of East Anglia, and his colleagues
studied the effect
of pharmacists’ medication reviews on 872 patients aged
over 80 years, who had been admitted to hospital as an emergency
and
who had been prescribed two or more drugs on discharge.
Pharmacists then visited the patients’ homes to carry out
medication reviews and returned six to eight weeks later to reinforce
the original
advice. The control group received usual care and so may also have
received medication reviews.
The primary outcome that the researchers measured was the total
number of emergency admissions to hospital over six months. The
numbers
of deaths in each group were not significantly different in the
intervention and control groups. However, the intervention group
readmissions
were 30 per cent higher, their home visits by GPs were 43 per cent
higher and their quality of life, as measured on the visual analogue
health scale, fell significantly more.
The pharmacists who took part all either held a postgraduate qualification
in pharmacy practice or had recently done continuing professional
development in therapeutics. They took part in a two-day training
course, which included lectures on adverse drug reactions, prescribing
in elderly people, improving concordance and communication skills.
The initial referral for a medication review in the trial included
a copy of the patient’s discharge letter. The pharmacist
then:
· Arranged home visits at times when they could meet patients
and carers
· Assessed patients’ ability to self medicate
· Assessed patients’ drug adherence
· Educated the patient and carer about the patient’s drugs
· Removed any out-of-date drugs
· Reported any possible adverse drug reactions and interactions
to the patient’s GP
· Reported any requirements for compliance aids to the local pharmacist
· Conducted a follow-up visit six to eight weeks later |
“We are at the crossroads of introducing medication review in community
pharmacy through the new contract,” says Maria Christou, education
pharmacist at the University of East Anglia’s academic pharmacy
practice unit and one of the authors of the study. “So we need
as much information as possible about the impact of such community-based
medication reviews. One clear message that this study sends out is that
community pharmacy is not yet geared up in terms of information technology
or other means of collaborative working with GP practices to undertake
informed medication reviews.”
The pharmacists in the study carried out interventions similar to those
in other studies. So why were the results the exact opposite of what
would be expected?
Richard Holland, senior lecturer in public health medicine at the University
of East Anglia and lead author of the study, offers three main explanations
for the finding that medication reviews increased hospital readmissions.
“The first is that we had done some good, that pharmacists had
helped patients understand their condition better and that these patients
had
then been able to recognise problems more quickly and so seek medical
attention earlier,” he says. Another explanation is that educating
patients about their medicines may have led to increased adherence which,
in turn, led to an increase in
iatrogenic disease. “A final explanation is that pharmacists’ visits
may simply have added to the complexity of the patients’ treatment,
increasing their anxiety and dependence on health services and left them
in a worse state than before.” Difficulties
Christine Bond, professor of primary care, University of Aberdeen,
thinks it may not be possible to prise these explanations apart. “This
is a very complex intervention, and there’s a lot going on,” Professor
Bond comments. “There’s a black box between the pharmacist
walking into the house to undertake the medication review, and the
outcome of hospital admission,” she adds. “We need to look
into the detail of this to explain the results.”
Unfortunately that may not be possible from the data of this study.
The authors set out to achieve a particular goal in a particular patient
group. They chose a clear and definite primary outcome (hospital admission)
and limited their patients to a group in which that outcome was likely
to occur (those over 80 years old and taking two or more medicines).
This part of the study’s design may have, in fact, limited the
impact of the pharmacists’ reviews.
“The patients were all recruited on the basis of an earlier emergency
admission,” Professor Bond explains. “If these admissions
were not drug-related, then it may not be surprising that the pharmacists’ medication
reviews did not reduce readmission rates.”
Another design issue that may have made the reviews less effective than
they would otherwise have been was that pharmacists had no access to
the patients’ full clinical histories.
Duncan Petty, of the pharmacy practice and medicines management research
group at the University of Leeds, says: “The main limitation with
the study is that the pharmacists who took part were really restricted
in terms of the information they had. I just wonder whether, if they’d
had more information, the study would have produced better outcomes.” Focusing in
What this study clearly shows is that more research is needed in order
to establish what the effect of community-based medication reviews
by pharmacists is. “This study tells us that we need to look
in a bit more detail at what works and what doesn’t,” Professor
Bond says. In particular we need, she believes, a greater understanding
of the group of patients who are likely to benefit from medication
reviews.
Dr Holland agrees and is now looking at whether community-based medication
reviews by pharmacists can reduce hospital admissions in heart failure
patients. Such interventions have been shown to be effective when carried
out by community nurses, he says, but whether the same will be the case
if they are carried out by pharmacists remains to be seen. If they are
not, then Dr Holland’s study may have opened up a whole new set
of questions about community pharmacists’ role in reviewing medication. |
The
Pharmaceutical Journal