Impact of an intervention to reduce medication regimen complexity for older hospital inpatients

Abstract

Background Hospitalisation often leads to increased medication regimen complexity for older patients; increased complexity is associated with medication non-adherence. There has been little research into strategies for reducing the impact of hospitalisation on medication regimen complexity. Objective To investigate the impact of pharmacist medication review, together with an educational intervention targeting clinical pharmacists and junior medical officers, on the increase in medication regimen complexity that occurs during hospitalisation. Setting Two acute general medicine wards and two subacute aged care (geriatric assessment and rehabilitation) wards at a major metropolitan public hospital in Melbourne, Australia. Methods A before-after study involving patients aged 60 years and over was undertaken over two 5-week periods. During the pre-intervention period patients received usual care. During the intervention period, clinical pharmacists were encouraged to review patients’ medication regimen complexity prior to discharge, and make recommendations to hospital medical officers to simplify regimens. Prior to the intervention period, pharmacists attended an interactive case-based education session about medication regimen simplification, and completed an assessment task. A similar, but briefer, education session was delivered to junior medical officers. Main outcome measure The primary endpoint was change in medication regimen complexity index (MRCI) score (a validated measure of regimen complexity) between admission and discharge for regularly scheduled long-term medications, adjusted for age, length of hospital stay, number of medications and regimen complexity prior to admission. Results Three hundred ninety-one patients were included (mean age 80.6 years, mean 7.4 regularly scheduled long-term medications on admission). The mean increase in MRCI score between admission and discharge was significantly smaller in the 205 intervention patients than in the 186 usual care patients (2.5 vs. 4.0, p = 0.02; adjusted difference 1.6, 95 %CI 0.3, 2.9). The intervention had greatest impact in patients discharged from subacute wards (mean adjusted difference: 2.7), not using a dose administration aid after discharge (mean adjusted difference: 2.6), and not discharged to a residential care facility (mean adjusted difference: 1.9). Mean differences in MRCI scores were equivalent to ceasing one to two medications. Conclusion An educational intervention and clinical pharmacist medication review reduced the impact of hospitalisation on the complexity of older patients’ medication regimens.

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References

  1. 1.

    Haslbeck JW, Schaeffer D, Haslbeck JW, Schaeffer D. Routines in medication management: the perspective of people with chronic conditions. Chronic Illn. 2009;5:184–96.

    PubMed  Article  Google Scholar 

  2. 2.

    Manias E, Claydon-Platt K, McColl GJ, Bucknall TK, Brand CA. Managing complex medication regimens: perspectives of consumers with osteoarthritis and healthcare professionals. Ann Pharmacother. 2007;41:764–71.

    PubMed  Article  Google Scholar 

  3. 3.

    Travis SS, McAuley WJ, Dmochowski J, Bernard MA, Kao HS, Greene R. Factors associated with medication hassles experienced by family caregivers of older adults. Patient Educ Counsel. 2007;66:51–7.

    Article  Google Scholar 

  4. 4.

    Ingersoll KS, Cohen J, Ingersoll KS, Cohen J. The impact of medication regimen factors on adherence to chronic treatment: a review of literature. J Behav Med. 2008;31:213–24.

    PubMed  Article  Google Scholar 

  5. 5.

    Corsonello A, Pedone C, Lattanzio F, Lucchetti M, Garasto S, Carbone C. Regimen complexity and medication nonadherence in elderly patients. Ther Clin Risk Manag. 2009;5:209–16.

    PubMed  Article  Google Scholar 

  6. 6.

    Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther. 2001;23:1296–310.

    PubMed  Article  CAS  Google Scholar 

  7. 7.

    Maddigan SL, Farris KB, Keating N, Wiens CA, Johnson JA. Predictors of older adults’ capacity for medication management in a self-medication program: a retrospective chart review. J Aging Health. 2003;15:332–52.

    PubMed  Article  Google Scholar 

  8. 8.

    Choudhry NK, Fischer MA, Avorn J, Liberman JN, Schneeweiss S, Pakes J. The implications of therapeutic complexity on adherence to cardiovascular medications. Arch Intern Med. 2011;171:814–22.

    PubMed  Article  Google Scholar 

  9. 9.

    Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA. 2005;294:716–24.

    PubMed  Article  CAS  Google Scholar 

  10. 10.

    Tinetti ME, Bogardus ST, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351:2870–4.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Elliott RA, O’Callaghan CJ. Impact of hospitalisation on the complexity of older patients’ medication regimens and potential for regimen simplification. J Pharm Pract Res. 2011;41:21–5.

    Google Scholar 

  12. 12.

    Mansur N, Weiss A, Beloosesky Y. Relationship of in-hospital medication modifications of elderly patients to postdischarge medications, adherence, and mortality. Ann Pharmacother. 2008;42:783–9.

    PubMed  Article  Google Scholar 

  13. 13.

    Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol. 2006;63:187–95.

    PubMed  Article  Google Scholar 

  14. 14.

    George J, Phun YT, Bailey MJ, Kong DC, Stewart K. Development and validation of the medication regimen complexity index. Ann Pharmacother. 2004;38:1369–76.

    PubMed  Article  Google Scholar 

  15. 15.

    Centre for Home Care Policy and Research. Medication regimen complexity in home health care. New York: Visiting Nurse Service of New York, 2011. http://toolkit.techandaging.org/2011/03/08/medication-regime-complexity-in-home-health-care/ Accessed 2012 Sept 27.

  16. 16.

    Kripalani S, Yao X, Haynes RB. Interventions to enhance medication adherence in chronic medical conditions: a systematic review. Arch Intern Med. 2007;167:540–9.

    PubMed  Article  Google Scholar 

  17. 17.

    Bangalore S, Kamalakkannan G, Parkar S, Messerli FH. Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med. 2007;120:713–9.

    PubMed  Article  Google Scholar 

  18. 18.

    Richter A, Anton SE, Koch P, Dennett SL. The impact of reducing dose frequency on health outcomes. Clin Ther. 2003;25:2307–35.

    PubMed  Article  Google Scholar 

  19. 19.

    George J, Elliott RA, Stewart D. A systematic review of interventions to improve medication taking in elderly patients prescribed multiple medications. Drugs Aging. 2008;25:307–24.

    PubMed  Article  Google Scholar 

  20. 20.

    Muir AJ, Sanders LL, Wilkinson WE, Schmader K. Reducing medication regimen complexity: a controlled trial. J Gen Intern Med. 2001;16:77–82.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Steinman MA, Hanlon JT. Managing medications in clinically complex elders: “there’s got to be a happy medium”. JAMA. 2010;304:1592–601.

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Elliott RA. Problems with medication use in the elderly: an Australian perspective. J Pharm Pract Res. 2006;36:58–66.

    Google Scholar 

  23. 23.

    The Society of Hospital Pharmacists of Australia Committee of Specialty Practice in Clinical Pharmacy. Standards of practice for clinical pharmacy. Journal of Pharmacy Practice and Research 2005; 35:122–146.

    Google Scholar 

  24. 24.

    The Society of Hospital Pharmacists of Australia. Standards of practice for the provision of medication reconciliation. J Pharm Pract Res. 2007;37:231–3.

    Google Scholar 

  25. 25.

    Masoudi FA, Baillie CA, Wang Y, Bradford D, Steiner JF, Havranek EP, et al. The complexity and cost of drug regimens of older patients hospitalized with heart failure in the United States, 1998–2001. Arch Intern Med. 2005;165:2069–76.

    PubMed  Article  Google Scholar 

  26. 26.

    Huang ES, Basu A, Finch M, Frytak J, Manning W. The complexity of medication regimens and test ordering for patients with diabetes from 1995 to 2003. Curr Med Res Opin. 2007;23:1423–30.

    PubMed  Article  Google Scholar 

  27. 27.

    Elliott RA. Reducing medication regimen complexity for older patients prior to discharge from hospital: feasibility and barriers. J Clin Pharm Ther; published online 21 May 2012: DOI: 10.1111/j.1365-2710.2012.01356.x.

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Acknowledgments

The assistance of Patricia Ooi and Victoria Tran (pharmacy students, Monash University) and Dhineli Perera (clinical pharmacist, Austin Health) with the conduct of this study is acknowledged.

Funding

The study received no external funding or sponsorship.

Conflicts of interest

The authors have no competing interests to declare.

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Correspondence to Rohan A. Elliott.

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Elliott, R.A., O’Callaghan, C., Paul, E. et al. Impact of an intervention to reduce medication regimen complexity for older hospital inpatients. Int J Clin Pharm 35, 217–224 (2013). https://doi.org/10.1007/s11096-012-9730-3

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Keywords

  • Australia
  • Education
  • Geriatrics
  • Hospital inpatients
  • Medication review
  • Pharmacists
  • Prescribing
  • Regimen complexity