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Pharmacist-led interventions to improve medication use and safety in older people who access hospital inpatient and aged care services
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posted on 16.02.2017by Elliott, Rohan
Older people (over 65 years) are at increased risk of medication-related problems (MRPs) and
adverse medication events compared with younger adults. Within the older population, there is a
very high risk subgroup: those who access hospital inpatient and aged care services. They are, on
average, at the extreme end of age (over 80 years), with high disease-burden (more than four comorbidities) and high medication use (more than eight medications); they are often frail and
The research presented in this thesis comes from three projects that explored MRPs and
deficiencies in medication management processes in this high risk subgroup, and investigated the
impact of pharmacist-led interventions to improve medication use and safety. The projects
focused on areas in which there has been little research previously conducted in Australia or
Project 1 (medication regimen complexity in hospitalised older people) explored the impact of
hospitalisation on the complexity of older patients' medication regimens, and strategies to reduce
complexity prior to hospital discharge. In a prospective study of 186 older patients admitted to
general medicine and aged care wards, it was observed that multiple medication changes were
made during hospitalisation, and the complexity of medication regimens increased by 32%. Most
medication regimens had potential to be simplified without altering the therapeutic intent.
Therefore an intervention was designed and tested. During the intervention period, hospital
pharmacists who had received training in regimen simplification reviewed 205 patients'
medications prior to discharge, in consultation with hospital doctors, to identify ways to reduce
complexity. The outcome was that the increase in regimen complexity between admission and
discharge was significantly smaller following the intervention. The difference in regimen
complexity was equivalent to prescribing at least one less medication, and up to two or three
medications for some patients. Barriers to reducing regimen complexity were identified,
including lack of pharmacist time to review and simplify medication regimens, and nonacceptance
by patients or doctors of some pharmacist recommendations.
Project 2 (continuity of medication management after discharge from hospital to residential
care) explored gaps in the continuity of medication management when patients were discharged
to residential care facilities (RCF), and evaluated strategies to improve the continuity of care. In
a prospective observational study of 202 patients, 20% were exposed to a medication
administration error in the 24 hours after hospital discharge, and 33% required a locum doctor to
write a medication chart at the RCF. To address these issues, a pharmacist-prepared 7-day
interim residential care medication administration chart was developed, with patient and
medication data auto-populated onto the chart from hospital pharmacy dispensing software. The
impact of the chart on medication administration errors and use of locum doctors after hospital
discharge was investigated in a prospective pre- and post-intervention study (n = 428 patients).
Provision of the chart reduced the incidence of missed and delayed medication doses from 18%
to 2% and the use of locum medical services from 33% to II%. RCF nurses and doctors were
highly satisfied with the chart. Provision of interim medication charts by hospital pharmacists
was reliable and accurate, with more than 95% of patients receiving one on discharge, and a 1%
discrepancy rate between the charts and discharge prescriptions.
Project 3 (medication-related problems in people referred to aged care outpatient clinics and
assessment services) explored the accuracy of medication histories, the prevalence of MRPs, and
the impact of pharmacist-conducted medication reviews in 46 patients referred to aged care
outpatient clinics in a cross-sectional study, and 80 patients referred to an aged care assessment
team (ACAT) in a randomised comparative study. A tool for assessing the risk associated with
unresolved MRPs was developed and validated. Despite deteriorating health and functional
decline, fewer than 7% of patients had received a Home Medicines Review (HMR) in the 12
months prior to referral, in both studies. Medication histories recorded by aged care clinicians
were usually inaccurate, and many MRPs were not identified prior to pharmacist-conducted
reviews. In the ACAT study, referral of patients to their general practitioner for a HMR resulted
in 18% receiving a pharmacist-conducted medication review within 4 weeks; referral to a
hospital outreach pharmacist resulted in 90% receiving a medication review within 4 weeks. A
median of three unresolved MRPs per patient were identified via hospital outreach pharmacist
review; more than three-quarters of these were rated as having moderate, high or extreme risk of
adverse outcome if not addressed. Just over 50% of pharmacist recommendations led to changes
to patients' medication management. General practitioners and aged care clinicians reported that
pharmacist-conducted medication reviews were useful.
Together, these three projects have identified a range of problems with medication use and safety
in a very old, high-risk subset of the Australian population. The projects provide evidence to
guide implementation of strategies to improve medication use in this population. Pharmacist-led
interventions resulted in significant improvements in various aspects of medication management.
Although the impact on long-term clinical outcomes was not assessed, the MRPs that were
prevented or resolved were assessed by experts as having significant risk of adverse outcomes if
not addressed, and have been associated with adverse outcomes in previous studies.
Nevertheless, further studies are needed to confirm that the interventions described lead to
improved clinical outcomes.
In conclusion, complex medication regimens on discharge from hospital, medication errors after
discharge from hospital to RCFs, and MRPs in patients referred to hospital-based ambulatory
aged care services are common. Pharmacist-led interventions can improve medication use and