March, 2017 - SUPPORT Summary of a systematic review | print this article |

Does medication review for hospitalised patients reduce morbidity and mortality?

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

 

  • Medication review may lead to little or no difference in mortality or hospital readmissions.
  • Medication review may reduce hospital emergency department contacts.
  • None of the studies were conducted in a low- or middle-income country.

 

Background

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.



About the systematic review underlying this summary

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.

Summary of findings

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.

 

  • In high-income countries, group antenatal care probably reduces the number of preterm births, while having little or no effect on the number of low birthweight and small for gestational age newborns. The certainty of this evidence is moderate.
  • In high-income countries, group antenatal care may have little or no effect on perinatal mortality. The certainty of this evidence is low.

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
Group antenatal care

With
Group antenatal care

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).

Relevance of the review for low-income countries

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

 

  • Medication review may reduce emergency department contacts among elderly hospitalised patients, but may have little if any effect on mortality and hospital readmissions.
  • No randomised trial evaluating the effects of medication review in a low-income country was found.

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:
www.supportsummaries.org/methods


 

Additional information

Related literature

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.

 

This summary was prepared by

Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 Acknowledgements

This summary has been peer reviewed by: Mercy Mulaku and Fatima Suleman.

This review should be cited as

Christensen M, Lundh A. Medication review in hospitalised patients to reduce morbidity and mortality. Cochrane Database Syst Rev 2016; (2): CD008986.

 

The summary should be cited as

Ciapponi A.  Does medication review for hospitalised patients reduce morbidity and mortality? March 2017. www.supportsummaries.org

 

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



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