Trine Graabæk

Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review

Suboptimal medication use may lead to morbidity, mortality and increased costs. To reduce unnecessary patient harm, medicines management including medication reviews can be provided by clinical pharmacists. Some recent studies have indicated a positive effect of this service, but the quality and outcomes vary among studies. Hence, there is a need for compiling the evidence within this area. The aim of this systematic MiniReview was to identify, assess and summarize the literature investigating the effect of pharmacist-led medication reviews in hospitalized patients. Five databases (MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library) were searched from their inception to 2011 in addition to citation tracking and hand search. Only original research papers published in English describing pharmacist-led medication reviews in a hospital setting including minimum 100 patients or 100 interventions were included in the final assessment. A total of 836 research papers were identified, and 31 publications were included in the study: 21 descriptive studies and 10 controlled studies, of which 6 were randomized controlled trials. The pharmacist interventions were well implemented with acceptance rates from 39% to 100%. The 10 controlled studies generally show a positive effect on medication use and costs, satisfaction with the service and positive as well as insignificant effects on health service use. Several outcomes were statistically insignificant, but these were predominantly associated with low sample sizes or low acceptance rates. Therefore, future research within this area should be designed using rigorous design, large sample sizes and includes comparable outcome measures for patient health outcomes.

Pharmacist-led medication review in an acute admissions unit: a systematic procedure description

Objectives Over the last decades, several papers have evaluated clinical pharmacy interventions in hospital settings with conflicting findings as results. Medication reviews are frequently a central component of these interventions. However, the term ‘medication review’ covers a plethora of principles and methodologies, and the practical procedure is seldom described in detail, which makes reproducing study findings difficult. The objective of this paper is to provide a detailed description of a procedure developed and used for pharmacist-led medication review in acute admissions units. Methods A procedure was developed based on clinical experience and inspiration from previous studies and literature on medication review models. The procedure was developed to fit the busy workflow in acute admissions units. Results The procedure consists of five steps: (1) collection of clinical patient data, (2) collection of information about the patients medical treatment, (3) patient interview, (4) critical examination of the patients medications and (5) recommendations for the hospital physician. Conclusions We have provided a detailed description of a procedure for pharmacist-led medication review. We do so, not to provide or advocate a single one-size-fits-all solution, but in an attempt to inspire a debate of the practical approach on how to execute a systematic medication review in order to develop and expand clinical pharmacy and achieve better patient outcomes.

CPC-084 Medication Reviews by Clinical Pharmacists at Hospitals Lead to Improved Patient Outcomes: A Systematic Review

Background Suboptimal use of medicines may lead to morbidity, mortality and increased costs. In order to reduce unnecessary patient harm, an increasing number of hospitals have implemented pharmaceutical care interventions such as medicines reviews. Some recent studies indicate a positive effect of pharmacist-led medicines reviews in hospitals, but the quality and outcome measures vary among studies. Hence there is a need to compile evidence within this area. Purpose To identify, assess and summarise the literature investigating the effect of pharmacist-led medicines reviews in hospitalised patients. Materials and Methods Five databases were searched from their inception to 2011: MEDLINE, EMBASE, CINAHL, Web of Science (including a citation search of relevant papers) and the Cochrane Library. Relevant systematic reviews and personal archives were also hand-searched for studies for inclusion. Only original research papers published in English describing pharmacist-led medicines reviews in a hospital setting including a minimum of 100 patients were included in the final assessment. Results A total of 836 research papers were identified and 30 publications were included in the study. Twenty studies were descriptive studies while ten studies were controlled to some extent. Only six studies were randomised controlled trials. Generally, the interventions were well implemented with acceptance rates between 39–100%. The key findings indicated positive effects on quality of prescribing, quality of life, readmission rates and emergency department visits, time to readmission and costs. However, no effect on survival rates was found in addition to several other statistically insignificant results. Conclusions Only a few papers describing pharmacist-led medicines reviews in the hospital setting were designed as randomised controlled trials and were evaluated using hard endpoints. Future research within this area should be designed using rigorous methodology and include outcome measures for patient health outcomes. No conflict of interest.

A multifaceted pharmacist intervention to support medication adherence after stroke and transient ischemic attack

43rd ESCP international symposium on clinical pharmacy patient safety: bridging the gaps Copenhagen, Denmark, 22–24 October 2014

Description of a practice model for pharmacist medication review in a general practice setting

Background Practical descriptions of procedures used for pharmacists’ medication reviews are sparse. Objective To describe a model for medication review by pharmacists tailored to a general practice setting. Methods A stepwise model is described. The model is based on data from the medical chart and clinical or laboratory data. The medication review focuses on the diagnoses of the patient instead of the individual drugs. Patient interviews are not part of the model. The model was tested in a pilot study by conducting medical reviews on 50 polypharmacy patients (i.e. receiving 7 or more drugs for regular use). Results The model contained seven main steps. Information about the patient and current treatment was collected in the first three steps, followed by identification of possible interventions related to either diagnoses or drugs in the fourth and fifth step. The sixth and seventh step concerned the reporting of interventions and the considerations of the GPs. 208 interventions were proposed among the 50 patients. The acceptance rate among the GPs was 82%. The most common interventions were lack of clinical or laboratory data (n=57, 27%) and drugs that should be discontinued as they had no indication (n=47, 23%). Most interventions were aimed at cardiovascular drugs. Conclusion We have provided a detailed description of a practical approach to pharmacists’ medication review in a GP setting. The model was tested and found to be usable, and to deliver a medication review with high acceptance rates.

Tools for Deprescribing in Frail Older Persons and Those with Limited Life Expectancy: A Systematic Review: Deprescribing tools

To summarize available tools that can assist clinicians in identifying and reducing or stopping (deprescribing) potentially inappropriate medications and that specifically consider frailty or limited life expectancy.

Pharmacist-led interventions improve quality of medicine-related healthcare service at hospital discharge

Objectives This study aims to investigate the effects on quality of the medicine-related healthcare service provided at hospital discharge after implementing a pharmacist-led patient-centred discharge service. Methods Medical in-patients ready for discharge and prescribed at least six medicines were eligible for inclusion in this descriptive intervention study. A ward-based clinical pharmacist provided a patient-centred discharge service which comprised medication review (including reconciliation if appropriate), medication counselling and verification of the medication discharge summary plans. Satisfaction with the pharmacist-led interventions was collected by questionnaires and follow-up telephone interviews. A quality audit on the medical information stated in the discharge summary plans was conducted. Results A total of 313 medical records were prospectively reviewed by the clinical pharmacist, and 745 medicine-related problems each leading to a clinical recommendation were identified. The total rate of acceptance by the physicians was found to be 84%. The quality audit revealed a significantly higher quality of the medication discharge summary plans sent to primary care regarding content of updated lists of medication after the pharmacist’s intervention. The involved physicians stated that contributions from the pharmacist had eased their workload and helped them to obtain a more rational prescribing practice. The interviewed patients felt secure and well-informed about their medicines. Conclusions Contributions from clinical pharmacists can improve both the quality of and satisfaction with the medicine-related healthcare service provided at hospital discharge and secure continuity of medical care at transitions.

Multifaceted Pharmacist-led Interventions in the Hospital Setting: A Systematic Review

Clinical pharmacy services often comprise complex interventions. In this MiniReview, we conducted a systematic review aiming to evaluate the impact of multifaceted pharmacist-led interventions in a hospital setting. We searched MEDLINE, Embase, Cochrane Library and CINAHL for peer-reviewed articles published from 2006 to 1 March 2018. Controlled trials concerning hospitalized patients in any setting receiving patient-related multifaceted pharmacist-led interventions were considered. All types of outcome were accepted. Inclusion and data extraction were performed. Study characteristics were collected, and risk of bias assessment was conducted utilizing the Cochrane Risk of Bias tools. All stages were conducted by at least two independent reviewers. The review was registered in PROSPERO (CRD42017075808). A total of 11,896 publications were identified, and 28 publications were included. Of these, 17 were conducted in Europe. Six of the included publications were multi-centre studies, and 16 were randomized trials. Usual care was the comparator. Significant results on quality of medication use were reported as positive in eleven studies (n = 18; 61%) and negative in one (n = 18, 6%). Hospital visits were reduced significantly in seven studies (n = 16; 44%). Four studies (n = 12; 33%) reported a positive significant effect on either length of stay or time to revisit, and one study reported a negative effect (n = 12; 6%). All studies investigating mortality (n = 6), patient-reported outcome (n = 7) and cost-effectiveness (n = 1) showed no significant results. This MiniReview indicates that multifaceted pharmacist-led interventions in a hospital setting may improve the quality of medication use and reduce hospital visits and length of stay, while no effect was seen on mortality, patient-reported outcome and cost-effectiveness.

INT-008 Comparison of pharmacist-led medication review at different stages during the inpatient stay

Background 5–30% of all acute admissions are caused by medication-related problems, of which many are preventable. In Denmark clinical pharmacists perform medication review both at admission and later in the inpatient stay, but no study has compared the clinical pharmacist interventions at different stages of the hospital journey. Purpose The aim of this study is to compare interventions from pharmacist-led medication review at admission and during hospital stay among elderly patients. Methods A randomised intervention study was performed from April to September 2013. 120 acutely admitted medical patients’ * 65 years of age were equally randomised to “control”, “ED” or “STAY” groups. The “control” group received standard care, the “ED” group received medication review and patient interview at admission and the “STAY” group received medication review and patient interview at admission plus medication review during hospital stay. Patient characteristics and process data for the interventions was recorded. Results 163 patients were invited to participate, whereof 43 patients declined. 120 patients with a mean age of 76 years, 51% male and a mean of 7.6 medications were included. On the emergency department, the pharmacist identified 162 medication-related problems in 73 of the 80 “ED” + ”STAY” patients, used 28 min per identified problem and achieved an acceptance rate of 54%. During inpatient stay medication review was performed for 16 of the 40 “STAY” patients, primarily because more than half of the patients were discharged directly from the emergency department. The pharmacist identified 24 medication-related problems in 14 of the 16 “STAY” patients, used 18 min per identified problem and achieved an acceptance rate of 82%. Conclusions The findings indicate the importance of pharmacist-led medication review during the entire hospital journey, because even though medication-related problems were solved at admission, the main part of the patients presented new problems later in the inpatient stay. No conflict of interest.

Validity and representativity of a national DRP database

42nd ESCP symposium on clinical pharmacy: implementation of pharmacy practice; Prague, Czech Republic, 16–18 October 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013