Furthermore, different types of medication reviews (for example, treatment review or CMR) are performed in different settings (for example, primary care, nursing homes, or hospital wards), implying that interventions performed during medication review are often heterogeneous. However, hospitalizations are rare in primary care, where a focus on the general health problems of older persons may be more important. Preventing hospital (re)admissions is a very relevant goal of medication review, especially in high-risk patients after a recent hospital stay.
A large proportion of these community-dwelling older persons might have had a relatively good quality of life and a low probability for clinical events such as hospital admissions. First, the selection criteria for persons invited for medication review may have been too broad, for example, in participants aged ≥65 years and using ≥5 long-term medications. Several factors may contribute to the lack of clear evidence regarding the effect of CMR on clinical outcomes. However, evidence for the effect of CMR on clinical outcomes, for example, hospital admissions and health-related quality of life (HR-QoL), is limited. It has been established that a CMR can identify and reduce drug-related problems (DRPs) and can have positive effects on other intermediate outcomes, such as low-density lipoprotein (LDL) cholesterol or HbA1c. There are different types of medication reviews, ranging from a prescription review (which is basically an evaluation of the list of prescribed medicines) to a clinical medication review (CMR with the availability of all clinical data and an extensive patient interview).
Medication reviews are increasingly performed and recommended by guidelines for older persons with multimorbidity and long-term medication use. 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. 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). Over 6 months, in the intervention group, HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval 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. 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). 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. The primary outcomes were HR-QoL (assessed with EuroQol -5D-5L and EQ-Visual Analogue Scale ) and number of health problems (such as pain or dizziness), after 3 and 6 months. Randomisation was performed at the patient level per pharmacy using block randomisation. Community-dwelling older persons (≥70 years) with polypharmacy (≥7 long-term medications) were randomly assigned to usual care or to receive a CMR.
32 lives trial trial#
This study was a randomised controlled trial (RCT) performed in 35 community pharmacies and cooperating general practices in the Netherlands.