A Clinical Medication Review Focused on Deprescribing in Older Patients With Hyperpolypharmacy: A Mixed-Methods Feasibility Study.

Organisational problems still prevent widespread implementation of clinical medication reviews. The Opti-Med2 method was developed to facilitate the process of performing clinical medication reviews. The method includes patient involvement by means of a questionnaire and expert teams of community pharmacists and general practitioners (GPs) to perform pharmacotherapeutic analyses, providing the patients' own GP with pharmacotherapeutic advice. There is a supporting role of community pharmacy technicians and general practice nurses/assistants in the process. To gain insight into the implementation of the Opti-Med2 method within the framework of pharmacotherapeutic audit meeting groups in the Netherlands. A mixed-methods implementation study in seven groups of primary care healthcare providers. Quantitative data were collected using study forms. Semi-structured interviews with 8 GPs, 5 community pharmacists and 2 community pharmacy technicians were held. Interviews were transcribed verbatim and were analysed using the extended Normalization Process Theory. Only one group provided sufficient quantitative data for analysis. Of the pharmacotherapeutic advice given by the expert team, 72% was adopted by the GPs of which 85% resulted in an intervention with the patient. In general, the healthcare providers were satisfied with using the Opti-Med2 method. The use of expert teams was appreciated by most GPs and community pharmacists. All healthcare providers were very satisfied with the use of the patient questionnaire. Although full implementation of Opti-Med2 method as a whole was not achieved, the structured organisation of conducting CMRs and the use of questionnaires was deemed successful.

Research on the benefits of clinical medication reviews (CMRs) performed by pharmacists has been conducted mostly in controlled settings and has been widely published. Less is known of the effects after large scale implementation in community pharmacies. An online CMR tool enabled the systematic registration of drug-related problems (DRPs) and implemented interventions derived from CMRs in daily practice. To describe the effects of CMRs on pharmacy practice after large-scale implementation in the Netherlands. 268 community pharmacies. Pharmacists were trained on CMRs with a patient centred approach. Retrospective analyses of DRPs, pharmacists' proposals and implemented interventions recorded between January 1st and September 1st 2012. Frequencies of DRPs, intervention proposals, implemented interventions, and drugs involved. 4,579 CMRs were analysed. On average 2.9 (SD 2.1) DRPs per review were identified. 4,123 (31%) of the DRPs led to medication changes. Stopping a drug (16%) was more frequent than starting a drug (8.1%). Drugs related to cardiovascular risk management, diabetes and osteoporosis were most frequently involved. This study is the largest analysis of pharmacists-initiated CMRs in the Netherlands to date. The findings demonstrate the potential to reduce medication-related errors through pharmacist involvements in complex pharmacotherapy and the positive impact on the quality of drug therapy through making necessary medication changes. The data also support the need for large-scale implementation of pharmacists-initiated CMRs in the presence of proper training programmes.

BackgroundInappropriate drug use has been identified as one of the most important problems affecting the quality of care in older people. Inappropriate drug use may increase the risk of the occurrence of ‘geriatric giants’ such as immobility, instability, incontinence and cognitive impairment. There are indications that clinical medication reviews (CMR) can reduce inappropriate drug use. However, CMRs have not yet been implemented at a large scale in primary care. An innovative medication review program in primary care will be developed which tackles the most important obstacles for a large scale implementation of CMRs. The aim of this study is to assess whether this CMR program is (cost-) effective compared with usual general practice care for older patients with geriatric symptoms with regard to quality of life and geriatric symptoms.MethodsA cluster randomised controlled trial will be performed in 20 Dutch general practices including 500 patients. Patients of 65 years and older are eligible if they newly present with pre-specified geriatric symptoms in general practice and chronic use of at least one prescribed drug. GP practices will be stratified by practice size and randomly allocated to control (n = 10) or intervention group (n = 10). The intervention consists of CMRs which will be facilitated and prepared by an expert team consisting of a GP and a pharmacist. Primary outcome measures are patient’s quality of life and the presence of self-reported geriatric symptoms during a follow-up period of 6 months. Secondary outcomes are costs of healthcare utilisation, feasibility, number of drug related problems, medication adherence and satisfaction with medication.DiscussionThis study is expected to add evidence on the (cost-) effectiveness of an optimally facilitated, prepared and structured CMR in comparison with usual care in older patients who present a geriatric symptom to their GP. The strength of this study is that it will be conducted in daily clinical practice. This improves the possibilities to implement the CMRs in the primary care setting on a large scale.Trial registrationNetherlands Trial register: NTR4264Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2318-14-116) contains supplementary material, which is available to authorized users.

BackgroundPolypharmacy is common in chronic medication users, which increases the risk of drug related problems. A suitable intervention is the clinical medication review (CMR) that was introduced in the Netherlands in 2012, but the effectiveness might be hindered by limited implementation in community pharmacies. Therefore our aim was to describe the current implementation of CMRs in Dutch community pharmacies and to identify barriers to the implementation.MethodsAn online questionnaire was developed based on the Consolidated Framework for Implementation Research (CFIR) and consisted of 58 questions with open ended, multiple choice or Likert-scale answering options. It was sent out to all Dutch community pharmacies (n = 1,953) in January 2021. Descriptive statistics were used.ResultsA total of 289 (14.8%) community pharmacies filled out the questionnaire. Most of the pharmacists agreed that a CMR has a positive effect on the quality of pharmacotherapy (91.3%) and on medication adherence (64.3%). Pharmacists structured CMRs according to available selection criteria or guidelines (92%). Pharmacists (90%) believed that jointly conducting a CMR with a general practitioner (GP) improved their mutual relationship, whereas 21% believed it improved the relationship with a medical specialist. Lack of time was reported by 43% of pharmacists and 80% (fully) agreed conducting CMRs with a medical specialist was complicated. Most pharmacists indicated that pharmacy technicians can assist in performing CMRs, but they rarely do in practice.ConclusionsLack of time and suboptimal collaboration with medical specialists are the most important barriers to the implementation of CMRs.

Background Drug-related problems (DRP) following hospital discharge may cause morbidity, mortality and hospital re-admissions. It is unclear whether a clinical medication review (CMR) and counseling at discharge is a cost-effective method to reduce DRP. Objective To assess the effect of a CMR on health care utilization and to investigate whether CMR is a cost-effective method to reduce DRP in older polypharmacy patients discharged from hospital. Setting 24 community pharmacies in the Netherlands. Method A cluster-randomized controlled trial with an economic evaluation. Community pharmacies were randomized to those providing a CMR, counseling and follow-up at discharge and those providing usual care. Main outcome measures Change in the number of DRP after 1 year of follow-up and costs of health care utilization during follow-up. In 216 patients the use of health care was prospectively assessed. Missing data on effects and costs were imputed using multiple imputation techniques. Bootstrapping techniques were used to estimate the uncertainty around the differences in costs and incremental cost-effectiveness ratios. Results CMR resulted in a small reduction of DRP. The proportion of patients readmitted to the hospital during 6 months of follow-up was significantly higher in the intervention group than in the control group (46.4 vs. 20.9%; p < 0.05). Health care costs were higher in the intervention group, although not statistically significant. The costs of reducing one DRP by a CMR amounted to €8270. Conclusion A CMR in vulnerable older patients at hospital discharge led to a small reduction in DRP. Because of a significantly higher use of health care and higher number of re-hospitalisations post CMR, the present study data indicate that performing the intervention in this patient population is not cost-effective.

To analyze the impact of clinical medication reviews (CMR) on reducing unplanned hospitalizations owing to polypharmacy among older adults using an intervention. Our meta-analysis complied with PRISMA guidelines. The literature review comprised a search for articles published between January 1972 and March 2017 on MEDLINE and Google Scholar. We identified randomized controlled trials focusing on CMR that evaluated unplanned hospitalization and re-hospitalization among older adults as a primary outcome. The keywords used were "CMR" or "medication review" in their titles, and the phrases "elderly" or "older adults" or "geriatric" and "polypharmacy." The randomized controlled trials selected were divided according to the three types of CMR to analyze the characteristics of each review. We included nine randomized controlled trials that examined the impact of CMR of polypharmacy in older patients. Five trials corresponded to CMR type I (prescription only review) or II (adherence review), whereas four corresponded to type III (comprehensive clinical evaluation for disease management). Type I/II increased the number of unplanned hospitalizations (RR 1.22, 95% CI 1.07-1.38, P = 0.002), whereas type III decreased hospital admissions (RR 0.86, 95% CI 0.79-0.95, P = 0.001). The present findings show the need for an intervention standardization for CMR, particularly for type III in older adults with polypharmacy, to decrease hospitalizations. Geriatr Gerontol Int 2019; 19: 1275-1281.

BackgroundDeprescribing inappropriate cardiovascular and antidiabetic medication has been shown to be feasible and safe. Healthcare providers often perceive the deprescribing of cardiovascular and antidiabetic medication as a challenge and therefore it is still not widely implemented in daily practice.AimThe aim was to assess whether training focused on conducting a deprescribing-oriented clinical medication review (CMR) results in a reduction of the inappropriate use of cardiovascular and antidiabetic medicines.MethodA cluster randomized controlled trial involving 20 community pharmacists, who conducted a clinical medication review in 10 patients. The intervention group received training on deprescribing. Patients 70 years or older with polypharmacy having a systolic blood pressure below 140 mmHg and using antihypertensive medication and/or an HbA1c level below 54 mmol/mol and using antidiabetic medication, were included. Follow-up took place within 4 weeks (T1) and after 3 months (T2). The primary outcome measure was the proportion of patients with one or more cardiovascular and antidiabetic medicine deprescribed within 3 months after the CMR (T2).ResultsA total of 71 patients in the intervention group and 69 patients in the control group were included. At T2, 32% of patients in the intervention group and 26% in the control group (OR 1.4, CI 0.65–2.82, p = 0.413) had one or more cardiovascular or antidiabetic medicines discontinued. Regarding any medication, these percentages were 51% and 36%, (OR 1.8, CI 0.92–3.56, p = 0.085) respectively.ConclusionIncreased awareness and ability of community pharmacists to deprescribe medication and use of general practitioners’ data, led community pharmacists and general practitioners to successfully conduct a more deprescribing-focused CMR in daily practice. Further research is needed to assess the necessity of additional training to optimize the deprescribing of cardiovascular and antidiabetic medication.The study was registered at The Netherlands Trial Register (registration no: NL8082).

BackgroundClinical medication reviews (CMRs) are increasingly performed in older persons with multimorbidity and polypharmacy to reduce drug-related problems (DRPs). However, there is limited evidence that a CMR can improve clinical outcomes. Little attention has been paid to patients’ preferences and needs. The aim of this study was to investigate the effect of a patient-centred CMR, focused on personal goals, on health-related quality of life (HR-QoL), and on number of health problems.Methods and findingsThis study was a randomised controlled trial (RCT) performed in 35 community pharmacies and cooperating general practices in the Netherlands. Community-dwelling older persons (≥70 years) with polypharmacy (≥7 long-term medications) were randomly assigned to usual care or to receive a CMR. Randomisation was performed at the patient level per pharmacy using block randomisation. The primary outcomes were HR-QoL (assessed with EuroQol [EQ]-5D-5L and EQ-Visual Analogue Scale [VAS]) and number of health problems (such as pain or dizziness), after 3 and 6 months. Health problems were measured with a self-developed written questionnaire as the total number of health problems and number of health problems with a moderate to severe impact on daily life. Between April 2016 and February 2017, we recruited 629 participants (54% females, median age 79 years) and randomly assigned them to receive the intervention (n = 315) or usual care (n = 314). Over 6 months, in the intervention group, HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval [CI] 0.94 to 5.8; p = 0.006), and the number of health problems with impact on daily life decreased by 12% (difference at 6 months −0.34; 95% CI −0.62 to −0.044; p = 0.024) as compared with the control group. There was no significant difference between the intervention group and control group for HR-QoL measured with EQ-5D-5L (difference at 6 months = −0.0022; 95% CI −0.024 to 0.020; p = 0.85) or total number of health problems (difference at 6 months = −0.30; 95% CI −0.64 to 0.054; p = 0.099). The main study limitations include the risk of bias due to the lack of blinding and difficulties in demonstrating which part of this complex intervention (for example, goal setting, extra attention to patients, reducing health problems, drug changes) contributed to the effects that we observed.ConclusionsIn this study, we observed that a CMR focused on personal goals improved older patients’ lives and wellbeing by increasing quality of life measured with EQ-VAS and decreasing the number of health problems with impact on daily life, although it did not significantly affect quality of life measured with the EQ-5D. Including the patient’s personal goals and preferences in a medication review may help to establish these effects on outcomes that are relevant to older patients’ lives.Trial registrationNetherlands Trial Register; NTR5713

Background and Objective: Overtreatment with cardiometabolic medication is a common phenomenon in older patients. Up to 20% of these patients may be eligible for deprescribing. Deprescribing may decrease the risk of adverse drug events and is indicated when a drug may lead to more harm than benefits. The LeMON study aims to develop, implement and evaluate a standardized template for the performance of clinical medication reviews (CMR) using evidence based tools and training to support deprescribing of cardiometabolic medication. Method: A clustered randomized controlled study involving twenty community pharmacists (CP). CP will be asked to conduct a CMR in ten patients. The intervention group will receive training on the background of deprescribing cardiometabolic medication and the use of tools and the control group will perform a CMR according to standard practice. Follow-up will take place within four weeks (T1) and after three months (T2) following the CMR. Patients 70 years or older; polypharmacy and chronic use of at least one blood pressure medicine and having a systolic blood pressure below 140 mmHg, or chronic use of glucose lowering medication and HbA1c level below 54 mmol/ mol were included. Discussion: The LeMON study will assess whether a primary care-based intervention educating CPs about deprescribing cardiometabolic medication reduces the number of cardiometabolic medication used by older patients with a blood pressure or HbA1c lower than the treatment targets tment. The use of algorithms including information on blood pressure and/or HbA1c and cardiometabolic medication use has not been studied previously.

Drug-related problems (DRPs) may result in adverse drug reactions causing hospital admissions (5-17%); older patients in particular may experience such reactions during a hospital stay (6-17%). While community pharmacists can identify DRPs through clinical medication reviews, little is known about how well they perform in providing such reviews. To assess trained community pharmacists' performance in writing care plans and referrals when providing clinical medication reviews to elderly patients as part of a patient outcome-focused Medicines Management project. In the south of England, 43 community pharmacists were recruited from 80 local community pharmacies; 37 completed clinical pharmacy training to provide medication reviews for elderly patients who were receiving prescriptions for 4 or more medicines from local general practices. Eleven trained pharmacists withdrew and did not provide any reviews. As part of quality assurance, a clinical pharmacist reviewed all care plans and referrals written by the community pharmacists and, if required, amended referrals before they were sent to the patients' family physicians with recommendations. The referrals written by the community pharmacists were compared with those written by the clinical pharmacist and were deemed to be accurate or incomplete (the community pharmacists could provide verbal information to the physicians) if the observations of DRPs and suggestions to solve them were beneficial to patients. Incorrect or missing observations and suggestions were considered nonbeneficial to patients. The performance assessment was based on a sample of 244 referrals written by 20 community pharmacists. The clinical pharmacist identified 908 DRPs and suggested 1489 solutions; the community pharmacists beneficially identified 75% of these DRPs (1% were incorrectly identified and 24% were missed) and suggested 58% of the solutions (6% were incorrectly suggested and 36% were missed). The community pharmacists beneficially identified most DRPs and suggested many solutions. However, the assessment may underestimate the community pharmacists' abilities, as it relied on the records they kept and was based on a gold standard. While the pharmacists were self-selected, this study provides valuable insight into trained community pharmacists' clinical medication review performance.

Background Knowledge of drug-related problems (DRPs) identified in the medication of home-dwelling elderly patients with polypharmacy has been based predominantly on medication reviews conducted in research settings rather than in daily practice. Objective To evaluate the prevalence of DRPs identified by means of a clinical medication review (CMR) and the implementation rate of proposed interventions in a large group of older patients with polypharmacy in the daily practice of community pharmacies. Setting 318 Dutch community pharmacies. Method A cross-sectional study based on CMR-data of 3807 older patients (≥65 years) with polypharmacy (≥5 drugs) completed between January and August 2012. Data were extracted from community pharmacists’ databases and entailed: year of birth, gender, dispensing data, number and nature of identified DRPs, consultations performed, proposed and implemented interventions. Main outcome measure Prevalence of DRPs, drug classes involved in overtreatment and undertreatment, and proposed and implemented interventions. Results A median of two DRPs (interquartile range 1–4; mean 3.0) was identified per patient. The DRP-categories overtreatment (25.5 %) and undertreatment (15.9 %) were found most frequently. 46.2 % of the proposed interventions to solve DRPs were implemented as proposed, in 22.4 % of cases, the intervention differed from the proposal. In 31.3 % of cases no intervention was implemented. Conclusion By conducting a CMR community pharmacists identified a median of two DRPs in older patients with polypharmacy. Overtreatment and undertreatment accounted for 41.4 % of the DRPs identified. In dealing with DRPs, pharmacists proposed a variety of interventions of which the majority (69.9 %) was either implemented or led to alternative interventions. A set of explicit criteria should be applied during a CMR to solve and prevent DRPs.

BackgroundDrug-related problems are prevalent among older patients, and substantially increase the risk of morbidity, (re-)hospitalisation and mortality. To detect drug-related problems and optimize treatment primary caregivers should periodically review the medication of older patients. The aim was to develop a structured, comprehensive but practicable tool to facilitate and support the reviewing of medication of older patients with a chronic disease by pharmacists and general practitioners.MethodsA tool facilitating clinical medication review by community pharmacists was developed on the basis of treatment guidelines, literature data on drug-related problems. For the identification of drug-related problems from the patient’s perspective, a script for structured interviews was developed. The tool was optimized by means of a Delphi method with an expert panel and testing in a trial.ResultsThe medication review tool consists of a comprehensive checklist of 124 drug-related problems divided by 20 sections according to physiological systems and diseases, and includes a structured interview script for a patient interviews.ConclusionA structured, comprehensive and practical tool to assist pharmacists and general practitioners to perform clinical medication review including a list of potential drug-related problems in older patients with chronic disease, as well as a script for structured patient interviews, was developed.Electronic supplementary materialThe online version of this article (doi:10.1186/s13104-015-1566-1) contains supplementary material, which is available to authorized users.

Inappropriate drug use is a frequent problem in older patients and associated with adverse clinical outcomes and an important determinant of geriatric problems. Clinical medication reviews (CMR) may reduce inappropriate drug use. The aim of this study is to investigate the effectiveness of CMR on quality of life (QoL) and geriatric problems in comparison with usual care in older patients with geriatric problems in the general practice. We performed a cluster randomised controlled trial in 22 Dutch general practices. Patients of ≥65 years were eligible if they newly presented with pre-specified geriatric symptoms in general practice and the chronic use of ≥1 prescribed drug. The intervention consisted of CMRs which were prepared by an independent expert team and discussed with the patient by the general practitioner. Primary outcomes: QoL and the presence of self-reported geriatric problems after a follow-up period of 6 months. 518 patients were included. No significant differences between the intervention and control group and over time were found for QoL, geriatric problems, satisfaction with medication and self-reported medication adherence. After 6 months the percentage of solved Drug Related Problems (DRPs) was significantly higher in the intervention group compared to the control group [B 22.6 (95%CI 14.1-31.1), P < 0.001]. The study intervention did not influence QoL and geriatric problems. The higher percentage of solved DRPs in the intervention group did not result in effects on the patient's health. CMRs on a large scale seem not meaningful and should be reconsidered.

The use of goal attainment scaling during clinical medication review in older persons with polypharmacy.

The impact of several pharmaceutical interventions to reduce the use of potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) has been recently studied. We aimed to determine whether clinical medication review (CMR) (i.e. a systematic and patient-centred clinical assessment of all medicines currently taken by a patient) performed by a geriatrician and a pharmacist added to standard pharmaceutical care (SPC) (i.e. medication reconciliation and regular prescription review by the pharmacist) resulted in more appropriate prescribing compared to SPC among older inpatients. A retrospective observational single-centre study was conducted in a French geriatric ward. Six criteria for appropriate prescribing were chosen: the number of PIMs and POMs as defined by the STOPP/STARTv2 list, the total number of drugs prescribed, the number of administrations per day and the number of psychotropic and anticholinergic drugs. These criteria were compared between CMR and SPC group using linear and logistic regression models weighted on propensity scores. There were 137 patients included, 66 in the CMR group and 71 in the SPC group. The mean age was 87years, the sex ratio was 0.65, the mean number of drugs prescribed was 9, the mean MMSE was 21 and at admission 242 POMs, and 363 PIMs were prescribed. Clinical medication review did not reduce the number of PIMs at discharge compared to SPC (beta = - 0.13 [- 0.84; 0.57], p = 0.71) nor did it reduce the number of drugs prescribed (p = 0.10), the number of psychotropic drugs (p = 0.17) or the anticholinergic load (p = 0.87). Clinical medication review resulted in more POMs being prescribed than in standard pharmaceutical care (beta = - 0.39 [- 0.72; - 0.06], p = 0.02). Cardiology POMs were more implemented in the medication review group (p = 0.03). Clinical medication review did not reduce the number of PIMs but helped clinicians introduce underused drugs, especially cardiovascular drugs, which are known to be associated with morbidity and mortality risk reduction.