Reduce Medication Regimen Complexity Research Articles

Identifying opportunities for pediatric medication therapy management in children with medical complexity

BackgroundDespite potential benefits of medication therapy management (MTM) for complex pediatric patients, implementation of pediatric MTM services is rare. ObjectivesTo describe how a standardized pediatric MTM model identifies potential interventions and their impact on medication regimen complexity index (MRCI) scores in children with medical complexity (CMC) and polypharmacy. MethodsThis retrospective proof-of-concept study included pediatric patients receiving primary care in a large outpatient primary care medical home for CMC within a tertiary freestanding children’s hospital from August 2020 to July 2021. Medication profiles of established patients aged 0-18 years with at least 5 active medications at the time of the index visit were assessed for medication-related concerns, potential interventions, and potential impact of proposed interventions on MRCI scores. ResultsAmong 100 patients, an average of 3.4 ± 2.6 medication-related concerns was identified using the pediatric MTM model. Common medication-related concerns (>25% of patients) included inappropriate or unnecessary therapy, suboptimal therapy, undertreated symptom, adverse effect, clinically impactful drug-drug interaction, or duplication of therapy. A total of 97% had opportunities for 5.0 ± 2.9 potential interventions. Most common proposed interventions included drug discontinuation trial (69%), patient or caregiver education (55%), dosage form modification (51%), dose modification (49%), and frequency modification (46%). The mean baseline MRCI score was 32.6 (95% CI 29.3–35.8) among all patients. MRCI scores decreased by a mean of 4.9 (95% CI 3.8–5.9) after application of the theoretical interventions (P < 0.001). Mean potential score reduction was not significantly affected by patient age or number of complex chronic conditions. Potential impact of the proposed interventions on MRCI score was significantly greater in patients with higher baseline medication counts (P < 0.001). ConclusionMost CMC would likely benefit from a pharmacist-guided pediatric MTM service. A standardized review of active medication regimens identified multiple medication-related concerns and potential interventions for nearly all patients. Proposed medication interventions would significantly reduce medication regimen complexity as measured by MRCI. Further prospective evaluation of a pharmacist-guided pediatric MTM service is warranted.

Electronic medication monitoring versus self-reported use of inhaled corticosteroids and short-acting beta2-agonists in uncontrolled asthma

ABSTRACT Objective Current standard of care, patient self-report and clinician estimation, overestimates true inhaled corticosteroids (ICS) adherence. We compare self-reported inhaled ICS and short-acting beta 2-agonists (SABA) use with objective data from electronic medication monitors (EMMs). Methods Adults with uncontrolled asthma and prescribed ICS and SABA were enrolled. At visit one, participants’ ICS and SABA inhalers were fitted with EMMs to track real-time medication usage over 14 days. Participants were asked to complete paper diaries to self-report medication usage over the same period. Participant self-report of ICS adherence and SABA use versus objective ICS adherence and SABA use was compared using Wilcoxon signed-rank tests. Results One hundred participants (80% female, mean age 48.5 years, 60% completed college, 80% privately insured) had complete data. Participant self-report (median (IQR): 0.8 (0.0, 2.0)) was greater than objectively measured (median (IQR): 0.43 (0.1, 2.1)) SABA use, but the difference was not statistically significant (P = 0.64). Participant self-report (median (IQR): 97 (67, 100)) was significantly greater than objectively measured (median (IQR): 75 (54, 93)) ICS adherence (P = 0.002). Conclusions Significant discrepancies between self-report and objective ICS usage were observed. EMM can provide clinicians with accurate data on ICS medication taking behavior, thus reducing medication regimen complexity, side effects, and costs.

Impact of Medication Regimen Simplification on Medication Adherence and Clinical Outcomes in Patients with Long-Term Medical Conditions.

BackgroundThis study aims to identify interventions used to reduce medication regimen complexity and to assess their impact on medication adherence and clinical outcomes.MethodsA literature search was conducted using pre-defined search terms in three scientific databases, including ScienceDirect, ProQuest and MEDLINE. Original research articles published in English between 2009 and 2020 that assessed the impact of medication regimen simplification on medication adherence in patients with long-term medical conditions were eligible for inclusion. Review articles, meta-analysis studies and conference proceedings were excluded. Data charting was done in an iterative process using a study-specific extraction form.ResultsOf the 684 studies identified through initial searches, 17 studies were included in the review. Nine studies involved simplification of medication regimen related to HIV, while three studies focused on patients with diabetes with or without coronary artery disease. The remaining five studies included medications used among elderly patients or medications related to hypertension, psychiatric disorders, glaucoma and kidney diseases. Three medication regimen simplification strategies were identified; fixed-dose combination (n = 7), once-daily dosing (n = 4) and the combination of both fixed-dose and once-daily dosing (n = 6). Overall, most of the regimen simplification strategies (14 out of 17) were found to be useful in improving medication adherence. There was no assessment of clinical outcomes in four out of 17 studies. Furthermore, more than half of the studies that assessed clinical outcomes did not show any additional impact on clinical outcomes.ConclusionThe findings suggest that there was an equal utilization of the three main approaches of regimen simplifications; fixed-dose combination, once-daily dosing and a combination of both. Overall, most of the regimen simplification strategies were found to be effective in improving medication adherence. However, the associated improvement in medication adherence did not extend to improvement in the clinical outcomes.

Medication Regimen Complexity In 8 Australian Residential Aged Care Facilities: Impact Of Age, Length Of Stay, Comorbidity, Frailty, And Dependence In Activities Of Daily Living.

ObjectiveTo explore variation in medication regimen complexity in residential aged care facilities (RACFs) according to resident age, length of stay, comorbidity, dementia severity, frailty, and dependence in activities of daily living (ADLs), and compare number of daily administration times and Medication Regimen Complexity Index (MRCI) as measures of regimen complexity.MethodsThis study was a cross-sectional analysis of baseline data from the SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) cluster-randomized controlled trial. The SIMPLER study recruited 242 residents with at least one medication charted for regular administration from 8 RACFs in South Australia. Comorbidity was assessed using the Charlson Comorbidity Index (CCI). Dementia severity was assessed using the Dementia Severity Rating Scale. Frailty was assessed using the FRAIL-NH scale. Dependence in ADLs was assessed using the Katz ADL scale.ResultsThe median age of participants was 87 years (interquartile range 81–92). Over one-third of participants (n=86, 36%) had 5 or more daily medication administration times. The number of daily administration times and MRCI scores were positively correlated with resident length of stay (rs=0.19; 0.27), FRAIL-NH score (rs=0.23; 0.34) and dependence in ADLs (rs=−0.21; −0.33) (all p<0.01). MRCI was weakly negatively correlated with CCI score (rs=−0.16; p=0.013). Neither number of daily administration times nor MRCI score were correlated with age or dementia severity. In multivariate analysis, frailty was associated with number of daily administration times (OR: 1.13, 95% CI: 1.03–1.24) and MRCI score (OR: 1.26, 95% CI: 1.13–1.41). Dementia severity was inversely associated with both multiple medication administration times (OR: 0.97, 95% CI: 0.94–0.99) and high MRCI score (OR: 0.95, 95% CI: 0.92–0.98).ConclusionResidents with longer lengths of stay, more dependent in ADLs and most frail had the most complex medication regimens and, therefore, may benefit from targeted strategies to reduce medication regimen complexity.

Impact of pharmacists' interventions on the pharmacotherapy of patients with complex needs monitored in multidisciplinary primary care teams.

Recently, pharmacists have joined multidisciplinary healthcare teams within family medicine groups (FMG) in Quebec Province, Canada. This study assessed the impact of their interventions on the pharmacotherapy of patients with complex needs monitored in FMGs. We performed a pre/post real-life intervention study among patients with complex needs referred to the FMG pharmacist in four FMGs in Quebec City. Pharmacists collected data at baseline, during follow-up and up to 6months after the first encounter. They recorded all drug-related problems (DRPs) identified, interventions made and recommendations that were accepted by physicians. The researchers used the data collected to compare the medication regimen complexity index (MRCI) and medication adherence (using the proportion of days covered (PDC)) before and after the pharmacist's interventions. Descriptive statistics and paired sample t-tests were computed. Sixty-four patients (median age: 74.5years) were included; four patients were lost to follow-up. Pharmacists detected 300 DRPs (mean: 7.2 per patient) during the study period for which they made an intervention. The most common DRP was 'drug use without indication' (27%). The physicians accepted 263 (87.7%) of those interventions. The mean number of prescribed drugs per patient decreased from 13.8 (95% confidence interval (CI): 12.24 to 15.29) to 12.4 (95% CI: 10.92 to 13.90). The mean MRCI decreased from 47.18 to 41.74 (-5.44; 95% CI: 1.71 to 9.17), while the mean PDC increased from 84.4% to 90.0% (+5.6%; 95% CI: 2.7% to 8.4%). Family medicine groups pharmacists can detect and resolve DRPs and can reduce medication regimen complexity and non-adherence to treatment in patients with complex needs monitored in FMGs.

Effect of reducing medication regimen complexity on glycaemic control in patients with diabetes.

Medication Regimen complexity is an important issue of patients care that needs to be addressed. The aim of this study is the safe reduction of regimens complexities. The effect of this intervention on glycemic control was assessed in this study. Seventy eight patients were recruited to the study. The entry criteria were non optimal glycemic, non-adherence (as demonstrated by indirect tools), and polypharmacy. The only intervention was the safe reduction of medication regimen complexity. This was done in view of the best practice guidelines; to ensure that all comorbidities are treated with the optimum number of medications for the optimum duration. There was no change to hypoglycemic regimen. All patients, whose hypoglycemic regimen has changed after the recruitment, were excluded. The primary outcome measure was the change in HbA1c three months after the intervention. Reducing medications regimen complexities led to a significant improvement of HbA1c in the after phase compared to the before phase (mean HbA1c in the before phase was 7.7 ± 0.43% compared to 6.93 ± 0.4% in the after phase. Mean reduction in the HbA1c was 0.77 ± 0.23%, p values < 0.001). Medications regimen complexity constitutes a burden for patients with diabetes. Reducing such regimens might improve glycemic control in those patients. Further studies are needed to confirm this favourable effect on the glycemic control.

SImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER): study protocol for a cluster randomised controlled trial

BackgroundComplex medication regimens are highly prevalent in residential aged care facilities (RACFs). Strategies to reduce unnecessary complexity may be valuable because complex medication regimens can be burdensome for residents and are costly in terms of nursing time. The aim of this study is to investigate application of a structured process to simplify medication administration in RACFs.MethodsSImplification of Medications Prescribed to Long-tErm care Residents (SIMPLER) is a non-blinded, matched-pair, cluster randomised controlled trial of a single multidisciplinary intervention to simplify medication regimens. Trained study nurses will recruit English-speaking, permanent residents from eight South Australian RACFs. Medications taken by residents in the intervention arm will be assessed once using a structured tool (the Medication Regimen Simplification Guide for Residential Aged CarE) to identify opportunities to reduce medication regimen complexity (e.g. by administering medications at the same time, or through the use of longer-acting or combination formulations). Residents in the comparison group will receive routine care. Participants will be followed for up to 36 months after study entry. The primary outcome measure will be the total number of charted medication administration times at 4 months after study entry. Secondary outcome measures will include time spent administering medications, medication incidents, resident satisfaction, quality of life, falls, hospitalisation and mortality. Individual-level analyses that account for clustering will be undertaken to determine the impact of the intervention on the study outcomes.DiscussionEthical approval has been obtained from the Monash University Human Research Ethics Committee and the aged care provider organisation. Research findings will be disseminated through conference presentations and peer-reviewed publications. SIMPLER will enable an improved understanding of the burden of medication use in RACFs and quantify the impact of regimen simplification on a range of outcomes important to residents and care providers.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12617001060336. Retrospectively registered on 20 July 2017.

Opportunities to Reduce Medication Regimen Complexity

Numerous characteristics of a medication regimen can weaken patient adherence to drug therapy and thus impair clinical outcomes of drug therapy. The aim of the study was to investigate the prevalence of medication regimen characteristics that are known to reduce patient adherence to drug therapy. Furthermore, we assessed to what extent complex medication regimens can possibly be simplified through different strategies. We retrospectively evaluated the medication regimens of 500 consecutive patients discharged from the University Hospital of Heidelberg, Germany, in whom the dosages of all drugs were specified. The medication regimens were extracted from the discharge letters issued between 1 January 2007 and 29 December 2007. Each medication regimen was checked for the presence of seven regimen characteristics that are known to reduce patient adherence, and theoretical viable strategies to avoid four of the respective characteristics were identified. The extent of possible simplification through the identified strategies was evaluated for the overall study population and the subgroup of elderly patients (≥65 years) with polypharmacy (≥5 drugs). On average, every medication regimen in the overall study population had 2.9±1.7 (standard deviation) characteristics (range 0-7) known to impair patient adherence. In contrast, the medication regimens of elderly patients with polypharmacy contained 3.7±1.6 characteristics (range 0-7) known to impair patient adherence. The most prevalent complexity characteristics in the overall study population were prescription of ≥1 drug with multiple doses per day (441 patients), ≥3 drugs with different dosing intervals (349 patients), tablet splitting (223 patients), followed by ≥12 daily drug administrations (190 patients). Almost half of the prescribed tablet splitting could be prevented. Moreover, 17.9% of the multi-dose prescriptions could be switched to once-daily dosing, and thus reduced the number of drugs with different dosing intervals and the number of daily drug administrations. The combined intervention reduced the total number of potentially preventable complexity characteristics by 18.3% (from 2283 to 1865 characteristics) without reducing prescription quality. Almost one-fifth of all regimen complexity characteristics relevant for patient adherence were avoidable by simple modifications of the medication scheme, stressing the need for targeted interventions.

Impact of an intervention to reduce medication regimen complexity for older hospital inpatients

Hospitalisation often leads to increased medication regimen complexity for older patients; increased complexity is associated with medication non-adherence. There has been little research into strategies for reducing the impact of hospitalisation on medication regimen complexity. To investigate the impact of pharmacist medication review, together with an educational intervention targeting clinical pharmacists and junior medical officers, on the increase in medication regimen complexity that occurs during hospitalisation. Two acute general medicine wards and two subacute aged care (geriatric assessment and rehabilitation) wards at a major metropolitan public hospital in Melbourne, Australia. A before-after study involving patients aged 60 years and over was undertaken over two 5-week periods. During the pre-intervention period patients received usual care. During the intervention period, clinical pharmacists were encouraged to review patients' medication regimen complexity prior to discharge, and make recommendations to hospital medical officers to simplify regimens. Prior to the intervention period, pharmacists attended an interactive case-based education session about medication regimen simplification, and completed an assessment task. A similar, but briefer, education session was delivered to junior medical officers. The primary endpoint was change in medication regimen complexity index (MRCI) score (a validated measure of regimen complexity) between admission and discharge for regularly scheduled long-term medications, adjusted for age, length of hospital stay, number of medications and regimen complexity prior to admission. Three hundred ninety-one patients were included (mean age 80.6 years, mean 7.4 regularly scheduled long-term medications on admission). The mean increase in MRCI score between admission and discharge was significantly smaller in the 205 intervention patients than in the 186 usual care patients (2.5 vs. 4.0, p = 0.02; adjusted difference 1.6, 95 %CI 0.3, 2.9). The intervention had greatest impact in patients discharged from subacute wards (mean adjusted difference: 2.7), not using a dose administration aid after discharge (mean adjusted difference: 2.6), and not discharged to a residential care facility (mean adjusted difference: 1.9). Mean differences in MRCI scores were equivalent to ceasing one to two medications. An educational intervention and clinical pharmacist medication review reduced the impact of hospitalisation on the complexity of older patients' medication regimens.

GlaxoSmithKline Medal of Merit 2012

Journal of Pharmacy Practice and ResearchVolume 42, Issue 4 p. 305-308 AwardFree Access GlaxoSmithKline Medal of Merit 2012 Rohan A Elliott BPharm, BPharmSc (Hons), MClinPharm, CGP, FSHP, Corresponding Author Rohan A Elliott BPharm, BPharmSc (Hons), MClinPharm, CGP, FSHP Senior Pharmacist, Clinical Senior Lecturer Austin Health, Centre for Medicine Use and Safety, Monash University, Parkville, VictoriaCorresponding author: Rohan Elliott, Pharmacy Department, Heidelberg Repatriation Hospital, Heidelberg Vic. 3081, Australia. E-mail: rohan.elliott@austin.org.auSearch for more papers by this author Rohan A Elliott BPharm, BPharmSc (Hons), MClinPharm, CGP, FSHP, Corresponding Author Rohan A Elliott BPharm, BPharmSc (Hons), MClinPharm, CGP, FSHP Senior Pharmacist, Clinical Senior Lecturer Austin Health, Centre for Medicine Use and Safety, Monash University, Parkville, VictoriaCorresponding author: Rohan Elliott, Pharmacy Department, Heidelberg Repatriation Hospital, Heidelberg Vic. 3081, Australia. E-mail: rohan.elliott@austin.org.auSearch for more papers by this author First published: 13 April 2015 https://doi.org/10.1002/j.2055-2335.2012.tb00194.xCitations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1Morgan TK, Williamson M, Pirotta M, Stewart K, Myers SP, Barnes J. A national census of medicines use: a 24-hour snapshot of Australians aged 50 years and older. Med J Aust 2012; 196: 50– 3. 2Turner CD. Drug use in the elderly: results of a multicentre audit [abstract]. Proceedings of the Conference of the Victorian Branch of The Society of Hospital Pharmacists of Australia; 1992 Nov 13–15; Lorne, Victoria. 3Elliott RA. Reducing medication regimen complexity for older patients prior to discharge from hospital: feasibility and barriers. J Clin Pharm Ther 2012; 37: 637– 42. Doi:10.1111/j.1365-2710.2012.01356.x. 4Elliott RA, Thomson WA. Assessment of a nursing home medication review service provided by hospital-based clinical pharmacists. Aust J Hosp Pharm 1999; 29: 255– 60. 5Elliott RA, Woodward MC, Oborne CA. Quality of prescribing for elderly inpatients at nine hospitals in Victoria, Australia. J Pharm Pract Res 2003; 33: 101– 5. 6Sorensen L, Stokes JA, Purdie DM, Woodward M, Elliott R, Roberts MS. Medication reviews in the community: results of a randomized controlled effectiveness trial. Br J Clin Pharmacol 2004; 58: 648– 64. 7Tran T, Elliott RA, Taylor, SE, Garrett K. Development and evaluation of a hospital pharmacy generated interim residential care medication administration chart. J Pharm Pract Res 2012; 42: 100– 5. 8Elliott RA, Tran T, Taylor SE, Harvey PA, Belfrage MK, Jennings JJ, et al. Impact of a pharmacist-prepared interim residential care medication administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and postintervention study (MedGap Study). BMJ Open 2012; 2: e000918. 9Elliott R, Perera D, Garrett K, Woodward M, Szysz A, Marriott J, et al. Improving medication safety for subacute aged care patients through expanded pharmacy assistant (technician) support for clinical pharmacy services. Final report. Adelaide: Health Workforce Australia, Workforce Innovation and Reform: Caring for Older People Program; 2011. 10Elliott RA, Marriott JL. Review of instruments used in clinical practice to assess patients' ability to manage medications. J Pharm Pract Res 2010; 40: 36– 42. 11Elliott RA, Woodward MC. Medication-related problems in patients referred to aged care and memory clinics at a tertiary care hospital. Australas J Ageing 2011; 30: 124– 9. 12Elliott RA, Martinac G, Campbell S, Thorn J, Woodward MC. Pharmacistled medication review to identify medication-related problems in patients referred to an Aged Care Assessment Team: a randomised comparative study. Drugs Aging 2012; 29: 593– 605. Citing Literature Volume42, Issue4December 2012Pages 305-308 ReferencesRelatedInformation

Reducing medication regimen complexity for older patients prior to discharge from hospital: feasibility and barriers

Older hospital inpatients are often prescribed complex multi-drug regimens; increased regimen complexity is associated with poorer medication adherence and treatment outcomes. There has been little research into methods for reducing regimen complexity. The objective of this study was to explore the feasibility of incorporating medication regimen simplification into routine clinical pharmacist care for older hospital inpatients and identify barriers to regimen simplification at a major teaching hospital. Following an educational intervention, clinical pharmacists were encouraged to minimize regimen complexity for their patients by identifying potential simplifications during routine medication regimen reviews (e.g. medication chart reviews, discharge prescription reviews) and discussing these changes with hospital doctors and patients. Pharmacists completed a data collection form for patients aged 60 years or above discharged from their wards during the study period (n = 205; mean age, 81.3 years), indicating whether they had reviewed the patient's medication regimen complexity (and if not why), whether any changes to simplify the regimen were identified, and whether changes were successfully implemented (and if not why). Pharmacists reviewed medication regimen complexity for 173/205 (84.4%) patients and identified 149 potential changes to reduce regimen complexity for 79/173 (45.7%) reviewed patients. Ninety-four (63.1%) changes were successfully implemented in 54/205 (26.3%) patients. Regimens were simplified more often for patients discharged from subacute aged care (geriatric assessment and rehabilitation) wards compared with acute general medicine wards. The most commonly cited reason for not reviewing regimen complexity and not implementing identified simplification-related changes was 'lack of time'. Non-acceptance of pharmacist recommendations by patients or doctors were other common reasons for not implementing changes. This is the first study to explore pharmacist-led medication regimen simplification and barriers to regimen simplification in the hospital setting. It demonstrates that simplification of older inpatients' regimens is feasible when training in regimen simplification is provided. The main barrier to regimen simplification appears to be lack of pharmacist time.