Abstract
ImportanceMedication review has been proposed to achieve improved use of psychotropic drugs, but benefits have not been confirmed.ObjectiveTo synthesize evidence for focused psychotropic medication review in medication optimization.Data SourcesMedline, PsycINFO, EMBASE, and CINAHL Plus were searched from inception to February 2018 using the index terms “drug utilization review” and “psychotropic drugs” and synonyms. Additional articles were retrieved using citation tracking and reference checking.Study SelectionFull-length, peer-reviewed articles that reported focused psychotropic medication review were included. Inclusion was determined against prespecified criteria and assessed independently.Data Extraction and SynthesisStudy quality was assessed using National Institutes for Health appraisal tools and informed a structured synthesis of results. Meta-analysis using a random effects model was conducted.Main Outcomes and MeasuresChange in the number or dosage of psychotropic medications, change in clinical parameters, change in patient-reported outcomes, and economic data were collected.ResultsA total of 26 studies met the inclusion criteria. Four studies were randomized clinical trials (n = 712 participants), while the remainder were before-after studies (n = 7844 participants). Most studies were conducted in elderly individuals, people with dementia, and adults with intellectual disability. Focused psychotropic medication review is a complex intervention; the professional(s) involved, target drug, degree of integration with usual care, and participant involvement varied greatly among the studies. Meta-analysis included 3 studies (n = 652 participants). Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control (pooled odds ratio, 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment living in nursing homes. Before-after studies consistently reported a change in psychotropic drug prescribing after medication review, regardless of the population. Studies that reported the effects of psychotropic medication review on clinical outcomes failed to demonstrate benefit. Economic implications of focused psychotropic medication review were not adequately assessed. The quality of evidence is poor and studies are at risk of bias.Conclusions and RelevanceFocused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit. More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group.
Highlights
Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control in elderly participants with cognitive impairment living in nursing homes
Focused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit
More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group
Summary
The increasing worldwide use of psychotropic drugs and their application beyond licensed indications has attracted close scrutiny.[1,2,3] At least 1 in 6 adults in the United States is prescribed psychotropic medication,[4] and high levels of psychotropic drug use are demonstrated in several vulnerable groups, including elderly individuals,[5] people with dementia,[6] children and adolescents,[7] and those with neurodevelopmental disorders, including autism[8] and intellectual disability.[9,10] undoubtedly of benefit to many individuals, psychotropic drugs are associated with significant adverse drug events that can affect quality of life and result in additional service costs.[11,12] Spending on psychotropic drugs continues to grow[13,14] and a high rate of nonadherence leads to significant waste.[15]Medication optimization is a broad approach aimed at ensuring the safest and most effective use of medications.[16]. The concept has gained traction and has been applied to psychotropic drug prescribing, for example, in the Centers for Medicare & Medicaid Services’ recent efforts to reduce inappropriate antipsychotic prescribing in nursing homes.[17]
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