Castelino RL, Bajorek BV, Chen TF
Ann Pharmacother. 2009;43:1096-1106
Study Summary
The objective of this review was to determine the impact of pharmacist interventions on suboptimal prescribing of medication (ie, overuse, misuse, or underuse) in the elderly. Castelino and colleagues searched databases used in several studies published between 1992 and 2008. Inclusion criteria included: patients 65 years of age or older, randomized controlled trials, intervention made by a pharmacist or team with a pharmacist, and assessment of at least 1 outcome measure of suboptimal prescribing. Studies focusing on a single drug or drug class and those that had selected patients based on a specific preexisting condition were excluded.
Twelve studies were reviewed, most of which focused on drug misuse and overuse. The studies used various methods of assessing suboptimal prescribing, both explicit (ie, rigid standards) and implicit (ie, subjective). Several studies used the implicit Medication Appropriateness Index (MAI) to assess prescribing. Nine of the 12 studies demonstrated a statistically significant improvement in prescribing after the pharmacist intervention. Interventions were usually made after medication profile review by a clinical pharmacist or during regimen review by a multidisciplinary team.
Viewpoint
The proportion of elderly patients is expected to rise significantly over the next few decades, and this group accounts for at least 30% of prescription medication costs.[1] Pharmacists can significantly improve the appropriateness of prescription drug usage, and literature reviews such as this one can help pharmacists justify their services.
Such reviews can also identify problems that deserve more attention. Studies included in this review focused on misuse and overuse of medications, while the underuse of medications in the elderly demands more research.
This problem deserves more attention in clinical practice as well. For example, the Beers criteria are often used to identify drugs that can be harmful if used in the elderly. But what about conditions that are undertreated? Clinicians should pay close attention to issues in the elderly, such as adequate pain control and management of hypertension, diabetes, and cardiovascular disease. Unfortunately, these conditions may not be maximally treated due to the belief that patients of a given age require less aggressive treatment.
Thus, pharmacists must also consider what medications may be missing from a given regimen. Is a patient receiving secondary stroke prophylaxis? Is a heart failure patient receiving a beta-blocker or angiotensin-converting enzyme (ACE) inhibitor? Clinical judgment needs to be used when weighing benefits of such things as tight low-density lipoprotein (LDL) control or tight blood pressure control. The evidence base for treatment of such diseases in the elderly is growing to help support these decisions. Trials such as PROSPER[2] and HYVET[3] demonstrated benefit of treating LDL and blood pressure in the elderly by significantly reducing negative cardiovascular outcomes.
References
1.Baum C, Kennedy DL, Forbes MB, Jones JK. Drug use in the United States in 1981. JAMA. 1984;251:1293-1297.
2.Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomized controlled trial. Lancet. 2002;360:1623-1630.
3.Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med. 2008;358:1887-1898.
Sunday, December 5, 2010
Thursday, October 28, 2010
BMJ 2001; 323 : 1340 doi: 10.1136/bmj.323.7325.1340 (Published 8 December 2001)
Abstract
Objective: To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.
Design: Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.
Setting: Four general practices.
Participants: 1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.
Intervention: Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.
Main outcome measures: Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.
Results: 590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference £4.72 per 28 days, −£7.04 to -£2.41); equivalent to £61 per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference −0.2, −0.4 to −0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.
Conclusions: A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.
What is already known on this topic
What is already known on this topic Review of patients on long term drug treatment is important but is done inadequately
Evidence from the United States shows that pharmacists can improve patient care by reviewing drug treatment
What this study adds
What this study adds Consultations with a clinical pharmacist are an effective method of reviewing the drug treatment of older patients
Review by a pharmacist results in more drug changes and lower prescribing costs than normal care plus a much higher review rate
Use of healthcare services by patients is not increased
Objective: To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.
Design: Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.
Setting: Four general practices.
Participants: 1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.
Intervention: Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.
Main outcome measures: Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.
Results: 590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference £4.72 per 28 days, −£7.04 to -£2.41); equivalent to £61 per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference −0.2, −0.4 to −0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.
Conclusions: A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.
What is already known on this topic
What is already known on this topic Review of patients on long term drug treatment is important but is done inadequately
Evidence from the United States shows that pharmacists can improve patient care by reviewing drug treatment
What this study adds
What this study adds Consultations with a clinical pharmacist are an effective method of reviewing the drug treatment of older patients
Review by a pharmacist results in more drug changes and lower prescribing costs than normal care plus a much higher review rate
Use of healthcare services by patients is not increased
Subscribe to:
Posts (Atom)