SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
March, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Medication review is sometimes used to prevent adverse drug events in adult hospitalised patients. It can be defined as a systematic assessment of the pharmacotherapy of an individual patient that aims to optimise patient medication.
Key messages
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Using many drugs is linked to an increased risk of adverse drug events, drug interactions, poorer drug adherence, hospital admissions and even drug related deaths. Medication review is intended to improve quality of prescribing and prevention of adverse drug events. Medication review aims to evaluate and optimise patient medication by a change (or not) in prescription, either by a recommendation or by a direct change. Medication review involves evaluating the therapeutic efficacy and harms of each drug in relation to the conditions being treated. Other issues, such as adherence, interactions between different medications, biochemical monitoring and the patient’s understanding of the condition and treatment could also be considered, when appropriate.
Medication review could also include identifying the most accurate list of medications a patient is taking and using that list to provide correct pharmacotherapy, especially during transitions in care.
| Review objectives: To assess whether medication review improves health outcomes of hospitalised adult patients. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, including cluster-randomised trials, assessing medication review |
10 randomised trials were included. The medication review was performed by a pharmacist (4 trials), by a team of pharmacists and pharmacy technicians (1 trial), by a physician (2 trials), by a pharmacist or a physician (1 trial) and by a team of pharmacists and physicians (2 trials). The medication review ended with a written recommendation to the prescribing physicians, sometimes combined with drug counselling, patient education and telephone follow-up. 7 trials provided additional interventions besides medication review. |
| Participants | Hospitalised adult patients receiving medication review by a physician, pharmacist or other healthcare professional |
Participants were elderly with a mean age around 80 years in all trials except 3, in which the mean participant age was 59, 61 and 70 years. |
| Settings | Hospital setting, worldwide. |
USA (2) and Europe (Belgium, Denmark, Ireland, Northern Ireland, and Sweden) (8). |
| Outcomes | Mortality, hospital readmission, hospital emergency department contacts (all-cause and due to adverse drug events), and adverse drug events. |
Mortality (9 trials), hospital readmissions (7, with 1 due to adverse drug events), hospital emergency department contacts (4, with 1 due to adverse drug events), and adverse drug events (1). |
| Date of most recent search: May 2015 | ||
| Limitations: This is well-conducted systematic review with only minor limitations. | ||
Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev 2016; (2): CD008986.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Four trials involving a total of 2350 women were included in the review. One study was conducted at two university-affiliated hospital antenatal clinics in the USA. The second study was conducted in antenatal clinics at two military settings in the USA. The third study was conducted in health centres in Iran, and the fourth study was conducted in antenatal clinics in Sweden.
All of the included studies followed CenteringPregnancy principles. CenteringPregnancy is an approach to antenatal care by which care is provided to groups of eight to 12 women. Physical assessments are undertaken as an individual assessment alongside the group to maintain privacy. Groups integrate the usual antenatal assessment with information, education and peer support. Emphasis is placed on engaging women more fully in their own health assessments.
|
Group antenatal care versus individual antenatal care (adjusted data) for women |
|||||
|
People Pregnant women accessing prenatal care Settings 2 trials were located in the USA, 1 in Iran and 1 in Sweden Intervention Group antenatal care Comparison Individual antenatal care |
|||||
|
Outcomes |
Absolute effect* |
Relative effect (95% CI) |
Certainty of the evidence (GRADE) |
||
|
Without |
With |
||||
|
Difference (Margin of error) |
|||||
|
Preterm birth (gestational age at time of birth less than 37 weeks' gestation) |
105 per 1000 |
79 per 1000 |
RR 0.75 (0.57 to 1) |
Moderate |
|
|
Difference: 26 fewer per 1000 births (Margin of error: 45 to 0 fewer) |
|||||
|
Low birthweight (<2500 g) |
89 per 1000 |
82 per 1000 |
RR 0.92 (0.68 to 1.23) |
Moderate |
|
|
Difference: 7 fewer per 1000 births (Margin of error: 29 fewer to 20 more) |
|||||
|
Small for gestational age (less than the 10th percentile for gestation and gender) |
104 per 1000 |
96 per 1000 |
RR 0.92 (0.68 to 1.24) |
Moderate |
|
|
Difference: 8 fewer per 1000 births (Margin of error: 33 fewer to 25 more) |
|||||
|
Perinatal mortality (stillbirth or neonatal death) |
21 per 1000 |
14 per 1000 |
RR 0.63 (0.32 to 1.25) |
Low |
|
|
Difference: 7 fewer per 1000 births (Margin of error: 14 fewer to 6 more) |
|||||
|
Margin of error = Confidence interval (95% CI) RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) * The risk WITHOUT the intervention is based on the average risk across studies. The corresponding risk WITH the intervention (and the 95% confidence interval for the difference) is based on the overall relative effect (and its 95% confidence interval). |
|||||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| None of the randomised trials included in the review was conducted in a low-income country. |
Evidence from high-income countries suggests that medication review may not reduce mortality or readmissions. In addition to considering the uncertainty about the benefits of medication review found in these trials, in low-income countries the availability of resources, including pharmacists with appropriate training, and the cost of the intervention (including training) should be considered. |
| EQUITY | |
| There was no information in the included studies regarding the differential effects of the interventions for disadvantaged populations. |
Resources needed for interventions may be less available in disadvantaged settings. |
| ECONOMIC CONSIDERATIONS | |
| One trial estimated that medication review would cost between USD 1530 and USD 4760 to avoid one emergency department contact, for one patient for a year. |
Prior to implementing medication review, local costing should be undertaken. |
| MONITORING & EVALUATION | |
|
|
The impacts of medication review should be evaluated in randomised trials prior to scaling up its use.
|
|
*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: |
|
Bulloch MN, Carroll DG. When one drug affects 2 patients: a review of medication for the management of non labor-related pain, sedation, infection, and hypertension in the hospitalized pregnant patient. J Pharm Pract 2012; 25:352-67.
Holland R, Desborough J, Goodyer L, et al. Does pharmacist-led medication review help to reduce hospital admissions and deaths in older people? A systematic review and meta-analysis. Brit J Clin Pharm 2008; 65:303-16.
Nkansah N, Mostovetsky O, Yu C, et al. Effect of outpatient pharmacists' non-dispensing roles on patient outcomes and prescribing patterns. Cochrane Database Syst Rev 2010; (7): CD000336.
Alldred DP, Raynor DK, Hughes C, et al. Interventions to optimise prescribing for older people in care homes. Cochrane Database Syst Rev 2013; (2): CD009095.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
Acknowledgements
This summary has been peer reviewed by: Mercy Mulaku and Fatima Suleman.
Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev 2016; (2): CD008986.
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, medication review, older people, impatiens, pharmacist, drug therapy
