Optimization of Medication by Pharmacists in Older People With Multimorbidity for Improved Outcomes-Mirage or Reality?

Abstract

Multimorbidity commonly leads to polypharmacy in old age, and polypharmacy in turn engenders inappropriate prescribing, which is a major risk factor for adverse drug events (ADEs).1 Medicationrelated morbidity is increasingly a public health problem in most countries where aging populations are now presenting the predominant challenge to health services provision and funding. Not surprisingly, interventions that are seen as potential moderators of medication-related morbidity have been the subject of a variety of studies over the last decade, including large-scale randomized clinical trials. Interventions that are shown to attenuate hard end points, such as unscheduled hospitalization, hospital length of stay, and overall health care use in the community, have the potential to be highly important for older people with multimorbidity by reducing avoidable morbidity. The same interventions, if effective, also represent a transferrable and internationally relevant means of reducing health care expenditures. The importance of such interventions is reflected in the 2017 World Health Organization Medication Without Harm initiative,2 with its target of reducing medication-related harm internationally by 50% by 2022. The results of the Medication Reviews Bridging Healthcare (MedBridge) trial by Kempen et al3 are interesting and important for several reasons. The trial team went to considerable lengths to examine the effects of 2 well-constructed pharmacist interventions designed to optimize medication of older patients with multimorbidity in 4 Swedish hospitals in 1 region compared with usual pharmaceutical care. The first intervention was a comprehensive medication review (CMR), the second was CMR with detailed and structured postdischarge follow-up. The trial design was appropriately cluster-randomized and adequately powered to properly test the impact of the extended CMR among older adults admitted to the 4 hospitals. The primary end point, unplanned hospital visits (emergency department [ED] attendances and admissions) within 12 months of randomization, was highly relevant. Secondary end points were also important: medication-related admissions, primary care physician visits, time to first unscheduled hospital visit, all-cause mortality, and hospitalization care costs. The MedBridge trial3 was sufficiently large scale, randomizing 2644 older people with multimorbidity with associated polypharmacy to 1 of 3 trial arms. The drop-out rate was very small—only 7 patients. Results showed no significant difference among the 2 intervention groups and control group in terms of the composite primary outcome; counterintuitively, the CMR with postdischarge follow-up group showed a significant 29% increase in ED visits in isolation compared with the usual care group.3 None of the secondary outcomes showed significant difference among the 2 intervention groups and the control group. That is, neither of the pharmacistdelivered CMR interventions significantly reduced any of the primary or secondary outcomes.3 The MedBridge trial3 results align with another US randomized clinical trial by Gurwitz et al4 examining a multifaceted pharmacist intervention focused on particularly high-risk medications (ie, anticoagulants, antidiabetic drugs and opioids) in older patients with multimorbidity (ie, aged >50 years, mean age, 68.9 years).4 The 2 end points in the study by Gurwitz et al4 were adverse drugrelated incidents and clinically important medication errors, including actual ADEs and potential ADEs. The pharmacist intervention encompassed detailed assessment of the patients and their medications at home, education of the patients using evidence-based teaching resources, focused communication of actual and potential problems with patients’ primary care teams, and telephone follow-up with the patients (and caregivers, when necessary). Once again, the carefully designed + Related article