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Improving the Quality of Pharmacotherapy in Elderly Primary Care Patients Through Medication Reviews: A Randomised Controlled Study

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Abstract

Background

Polypharmacy in the Swedish elderly population is currently a prioritised area of research with a focus on reducing the use of potentially inappropriate medications (PIMs). Multi-professional interventions have previously been tested for their ability to improve drug therapy in frail elderly patients.

Objective

This study aimed to assess a structured model for pharmacist-led medication reviews in primary health care in southern Sweden and to measure its effects on numbers of patients with PIMs (using the definition of the Swedish National Board of Health and Welfare) using ≥10 drugs and using ≥3 psychotropics.

Methods

This study was a randomised controlled clinical trial performed in a group of patients aged ≥75 years and living in nursing homes or the community and receiving municipal health care. Medication reviews were performed by trained clinical pharmacists based on nurse-initiated symptom assessments with team-based or distance feedback to the physician. Data were collected from the patients’ electronic medication lists and medical records at baseline and 2 months after the medication review.

Results

A total of 369 patients were included: 182 in the intervention group and 187 in the control group. One-third of the patients in both groups had at least one PIM at baseline. Two months after the medication reviews, the number of intervention group patients with at least one PIM and the number of intervention group patients using ten or more drugs had decreased (p = 0.007 and p = 0.001, respectively), while there were no statistically significant changes in the control patients. No changes were seen in the number of patients using three or more psychotropic drugs, although the dosages of these drugs tended to decrease. Drug-related problems (DRPs) were identified in 93 % of the 182 patients in the intervention group. In total, there were 431 DRPs in the intervention group (a mean of 2.5 DRPs per patient, range 0–9, SD 1.5 at 95 % CI) and 16 % of the DRPs were related to PIMs.

Conclusions

Medication reviews involving pharmacists in primary health care appear to be a feasible method to reduce the number of patients with PIMs, thus improving the quality of pharmacotherapy in elderly patients.

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References

  1. Shi S, Morike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol. 2008;64(2):183–99.

    Article  PubMed  Google Scholar 

  2. Noble RE. Drug therapy in the elderly. Metabolism. 2003;52(10 Suppl 2):27–30.

    Article  PubMed  CAS  Google Scholar 

  3. Midlov P, Eriksson T, Kragh A. Drug-related problems in the elderly [online] Chapter 1, Aging and Drugs 2009: 4. Available from URL: http://www.springerlink.com.ludwig.lub.lu.se [Accessed 2012 Nov 19].

  4. Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. 2007;5(4):345–51.

    Article  PubMed  Google Scholar 

  5. Strand LM, Morley PC, Cipolle RJ, Ramsey R, Lamsam GD. Drug-related problems: their structure and function. DICP. 1990;24(11):1093–7.

    PubMed  CAS  Google Scholar 

  6. American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2012;60(4):616–31.

    Article  Google Scholar 

  7. The Swedish National Board of Health and Welfare. Indikatorer för god läkemedelsterapi hos äldre (publication no.: 2010-6-29) [in Swedish]. Available from URL: http://www.socialstyrelsen.se [Accessed 2012 Nov 16].

  8. Johnell K, Fastbom J. Multi-dose drug dispensing and inappropriate drug use: a nationwide register-based study of over 700,000 elderly. Scand J Prim Health Care. 2008;26(2):86–91.

    Article  PubMed  Google Scholar 

  9. Ruths S, Straand J, Nygaard HA. Multidisciplinary medication review in nursing home residents: what are the most significant drug-related problems? The Bergen District Nursing Home (BEDNURS) study. Qual Saf Health Care. 2003;12(3):176–80.

    Article  PubMed  CAS  Google Scholar 

  10. Midlov P, Bondesson A, Eriksson T, et al. Effects of educational outreach visits on prescribing of benzodiazepines and antipsychotic drugs to elderly patients in primary health care in southern Sweden. Fam Pract. 2006;23(1):60–4.

    Article  PubMed  Google Scholar 

  11. Midlov P, Deierborg E, Holmdahl L, et al. Clinical outcomes from the use of Medication Report when elderly patients are discharged from hospital. Pharm World Sci. 2008;30(6):840–5.

    Article  PubMed  Google Scholar 

  12. Bernsten C, Bjorkman I, Caramona M, et al. Improving the well-being of elderly patients via community pharmacy-based provision of pharmaceutical care: a multicentre study in seven European countries. Drugs Aging. 2001;18(1):63–77.

    Article  PubMed  CAS  Google Scholar 

  13. Pharmaceutical Care Network Europe. PCNE Guidelines for Retrospective Medication Review in Pharmacy V0, The official PCNE definition 2012. Available from: http://www.pcne.org 2012 [Accessed 2012 June 15].

  14. Westerlund T, Marklund B. Assessment of the clinical and economic outcomes of pharmacy interventions in drug-related problems. J Clin Pharm Ther. 2009;34(3):319–27.

    Article  PubMed  Google Scholar 

  15. Roberts MS, Stokes JA, King MA, et al. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Br J Clin Pharmacol. 2001;51(3):257–65.

    Article  PubMed  CAS  Google Scholar 

  16. Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm. 2011;33(3):549–57.

    Article  PubMed  Google Scholar 

  17. Kragh A. Two out of three persons living in nursing homes for the elderly are treated with at least ten different drugs. A survey of drug prescriptions in the northeastern part of Skane [in Swedish]. Lakartidningen. 2004;101(11): 994–6, 9.

    Google Scholar 

  18. Hellstrom LM, Bondesson A, Hoglund P, et al. Impact of the Lund Integrated Medicines Management (LIMM) model on medication appropriateness and drug-related hospital revisits. Eur J Clin Pharmacol. 2011;67(7):741–52.

    Article  PubMed  Google Scholar 

  19. Schmidt I, Claesson CB, Westerholm B, et al. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46(1):77–82.

    PubMed  CAS  Google Scholar 

  20. Hedström MLB, Hulter Åsberg K. PHASE-20: a new instrument for assessment of possible therapeutic drug-related symptoms among elderly in nursing homes [in Swedish]. Nord J Nurs Res Clin Stud/Vård i Norden. 2009;29(4):9–14.

    Google Scholar 

  21. Anatomical Therapeutic Chemical Classification System [online]. Available from URL: http://www.who.int/classifications/atcddd/en/ [Accessed 2012 6th June].

  22. Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice. New York: McGraw-Hill; 1998.

    Google Scholar 

  23. Bennett DA. How can I deal with missing data in my study? Aust N Z J Public Health. 2001;25(5):464–9.

    PubMed  CAS  Google Scholar 

  24. Crotty M, Halbert J, Rowett D, et al. An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing. Age Ageing. 2004;33(6):612–7.

    Article  PubMed  Google Scholar 

  25. Davidsson M, Vibe OE, Ruths S, et al. A multidisciplinary approach to improve drug therapy in nursing homes. J Multidiscip Healthc. 2011;4:9–13.

    PubMed  Google Scholar 

  26. Liu GG, Christensen DB. The continuing challenge of inappropriate prescribing in the elderly: an update of the evidence. J Am Pharm Assoc (Wash). 2002;42(6):847–57.

    Article  Google Scholar 

  27. Finkers F, Maring JG, Boersma F, et al. A study of medication reviews to identify drug-related problems of polypharmacy patients in the Dutch nursing home setting. J Clin Pharm Ther. 2007;32(5):469–76.

    Article  PubMed  CAS  Google Scholar 

  28. Higashi T, Shekelle PG, Solomon DH, et al. The quality of pharmacologic care for vulnerable older patients. Ann Intern Med. 2004;140(9):714–20.

    Article  PubMed  Google Scholar 

  29. Steinman MA, Landefeld CS, Rosenthal GE, et al. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc. 2006;54(10):1516–23.

    Article  PubMed  Google Scholar 

  30. Meredith S, Feldman P, Frey D, et al. Improving medication use in newly admitted home healthcare patients: a randomized controlled trial. J Am Geriatr Soc. 2002;50(9):1484–91.

    Article  PubMed  Google Scholar 

  31. Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–84.

    Article  PubMed  Google Scholar 

  32. Mallet L, Spinewine A, Huang A. The challenge of managing drug interactions in elderly people. Lancet. 2007;370(9582):185–91.

    Article  PubMed  CAS  Google Scholar 

  33. Holland R, Desborough J, Goodyer L, et al. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Br J Clin Pharmacol. 2008;65(3):303–16.

    Article  PubMed  Google Scholar 

  34. Gallagher P, Barry P, Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32(2):113–21.

    Article  PubMed  CAS  Google Scholar 

  35. Bondesson A, Holmdahl L, Midlov P, et al. Acceptance and importance of clinical pharmacists’ LIMM-based recommendations. Int J Clin Pharm. 2012;34(2):272–6.

    Article  PubMed  Google Scholar 

  36. Bergkvist Christensen A, Holmbjer L, et al. The process of identifying, solving and preventing drug related problems in the LIMM-study. Int J Clin Pharm. 2011;33(6):1010–8.

    Article  PubMed  Google Scholar 

  37. Zermansky AG, Alldred DP, Petty DR, et al. Clinical medication review by a pharmacist of elderly people living in care homes—randomised controlled trial. Age Ageing. 2006;35(6):586–91.

    Article  PubMed  Google Scholar 

  38. Stuijt CC, Franssen EJ, Egberts AC, et al. Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review. Drugs Aging. 2008;25(11):947–54.

    Article  PubMed  Google Scholar 

  39. Halvorsen KH, Ruths S, Granas AG, et al. Multidisciplinary intervention to identify and resolve drug-related problems in Norwegian nursing homes. Scand J Prim Health Care. 2010;28(2):82–8.

    Article  PubMed  Google Scholar 

  40. Chen TF, de Almeida Neto AC. Exploring elements of interprofessional collaboration between pharmacists and physicians in medication review. Pharm World Sci. 2007;29(6):574–6.

    Article  PubMed  Google Scholar 

  41. de Almeida Neto AC, Chen TF. When pharmacotherapeutic recommendations may lead to the reverse effect on physician decision-making. Pharm World Sci. 2008;30(1):3–8.

    Article  PubMed  Google Scholar 

  42. Bernabei R, Gambassi G, Lapane K, et al. Characteristics of the SAGE database: a new resource for research on outcomes in long-term care. SAGE (Systematic Assessment of Geriatric drug use via Epidemiology) Study Group. J Gerontol A Biol Sci Med Sci. 1999;54(1):M25–33.

    Article  PubMed  CAS  Google Scholar 

  43. Kragh A, Rekman E. Remote drug-review for better use of pharmaceuticals among the elderly [in Swedish]. Lakartidningen. 2005;102(15):1143, 5–6, 9.

    Google Scholar 

  44. Holland R, Smith R, Harvey I. Where now for pharmacist led medication review? J Epidemiol Community Health. 2006;60(2):92–3.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

The authors especially want to thank the four pharmacists who performed the medication reviews (Annika Dobszai, Karin Fält, Martina Haggren and Krister Karlsson), the pharmacist student who initially collected the data (Susan Wong) and the municipal care nurses. We are indebted to Stephen Gilliver for his expertise and invaluable advice in proofreading the manuscript.

Conflict of interest

None declared

Disclaimer

The opinions or assertions in this article are the views of the authors and are not to be construed as official or as necessarily reflecting the views of the Swedish Medical Products Agency, where one of the authors is employed.

Funding

The study was conducted with government funding for projects involving improvement of drug therapy in the elderly.

Author information

Authors and Affiliations

  1. Laröd Health Care Centre, Helsingborg, Sweden

    Veronica Milos

  2. Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University/Region Skåne, Malmö, Sweden

    Veronica Milos, Ulf Jakobsson & Patrik Midlöv

  3. Brösarp Health Care Centre, Brösarp, Sweden

    Eva Rekman

  4. Department of Medicines Management and Informatics, Kristianstad, Region Skåne, Sweden

    Åsa Bondesson

  5. Clinical Pharmacology, Department of Laboratory Medicine, Lund University, Lund, Sweden

    Åsa Bondesson & Tommy Eriksson

  6. Apoteket Farmaci AB, Stockholm, Sweden

    Tommy Eriksson

  7. Medical Products Agency, Department of Rational Use of Medicines, Uppsala, Sweden

    Tommy Westerlund

  8. Sahlgrenska Academy, Institute of Medicine, Department of Public Health and Community Medicine, Unit of Social Medicine, University of Gothenburg, Gothenburg, Sweden

    Tommy Westerlund

  9. Faculty of Medicine, Lund University Department of Clinical Sciences Malmö Clinical Research Centre (CRC), Building 28, Floor 11, Jan Waldenströms gata 35, Skåne University Hospital, 205 02, Malmö, Sweden

    Veronica Milos

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  1. Veronica Milos
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Correspondence to Veronica Milos.

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Milos, V., Rekman, E., Bondesson, Å. et al. Improving the Quality of Pharmacotherapy in Elderly Primary Care Patients Through Medication Reviews: A Randomised Controlled Study. Drugs Aging 30, 235–246 (2013). https://doi.org/10.1007/s40266-013-0057-0

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  • DOI: https://doi.org/10.1007/s40266-013-0057-0

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