Holland et al (1) describe the results of a home based medication
review by a pharmacist, after hospital discharge, that gave results that
they describe as “counter-intuitive” because the intervention appeared to
increase hospital admissions. Their results do appear to be at odds with
previous research of interventions described as “medication review”. Three
large randomised controlled trails of pharmacist conducted clinical
medication review - containing a total of 3,197 subjects - in UK general
practice (2,3,4) have not shown any affect on hospitalisation. These
studies included participants of all ages (but mostly the elderly) who
were living in the community and who were probably less acutely ill than
in this study.
However, the key issue is the definition of "medication review". The
Holland et al. paper describes their intervention as: "Two home visits by
a pharmacist .......... to educate patients and carers about their drugs,
remove out of date drugs, inform general practitioners of drug reactions
or interactions, and inform the local pharmacist if a compliance aid is
needed." We would argue however that this is not a holistic medication
review which has been defined as “a structured critical examination of
the patient’s medicines with the objective of reaching an agreement with
the patient about treatment, optimising the impact of medicines,
minimising the number of medicine-related problems and reducing waste.”
(5) Thus a large component of what is commonly understood as medication
review is to optimise the treatment regimen. This does not appear to be a
component of the intervention in this study but was an important part of
the intervention in other studies. (2,3,4)
It is arguable however, that during a hospital admission it is likely
that treatment would already have been optimised. Further rationalisation,
after discharge, would therefore usually not be necessary and therefore
the intervention may not be expected to reduce hospitalisation in this
cohort of patients.
It would be of interest to know how frequently interventions were
made by the pharmacists e.g. how frequently a recommendation on adverse
drug reactions and interventions were made to the GP; how many patients
were recommended a compliance aid; and whether patients who received an
intervention were those who subsequently had a hospital readmission or if
the admission was for an unrelated cause.
In the mean time, the results of this study should not cast doubt on
the efficacy of full pharmacist medication review, using all patient data
to optimise therapy.
Reference
1. Holland R, Lenaghan E, Harvey I, Smith R et al. Does home based
medication review keep odler people out of hospital? The HOMER randomised
controlled trial. BMJ Online bmj.com.
2. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe
CJ.Randomised controlled trial of clinical medication review by a
pharmacist of elderly patients receiving repeat prescriptions in general
practice.
BMJ. 2001 Dec 8;323(7325):1340-3.
3. Mackie CA, Lawson DH, Campbell A, Maclaren AG, Waigh R. A
randomised controlled trial of medication review in patients receiving
polypharmacy in general practice. Pharmaceutical Journal. 1999; 263: R7.
4. Krska J, Cromerty JA, Arris F, Jamieson D, Hansford D, Duffus PRS,
Downie G, Seymour DG.Pharmacist-led medication review in patients over 65:
a randomized, controlled trial in primary care. Age and Ageing.2001; 30:
205-11.
Dear Editor,
Holland et al (1) describe the results of a home based medication
review by a pharmacist, after hospital discharge, that gave results that
they describe as “counter-intuitive” because the intervention appeared to
increase hospital admissions. Their results do appear to be at odds with
previous research of interventions described as “medication review”. Three
large randomised controlled trails of pharmacist conducted clinical
medication review - containing a total of 3,197 subjects - in UK general
practice (2,3,4) have not shown any affect on hospitalisation. These
studies included participants of all ages (but mostly the elderly) who
were living in the community and who were probably less acutely ill than
in this study.
However, the key issue is the definition of "medication review". The
Holland et al. paper describes their intervention as: "Two home visits by
a pharmacist .......... to educate patients and carers about their drugs,
remove out of date drugs, inform general practitioners of drug reactions
or interactions, and inform the local pharmacist if a compliance aid is
needed." We would argue however that this is not a holistic medication
review which has been defined as “a structured critical examination of
the patient’s medicines with the objective of reaching an agreement with
the patient about treatment, optimising the impact of medicines,
minimising the number of medicine-related problems and reducing waste.”
(5) Thus a large component of what is commonly understood as medication
review is to optimise the treatment regimen. This does not appear to be a
component of the intervention in this study but was an important part of
the intervention in other studies. (2,3,4)
It is arguable however, that during a hospital admission it is likely
that treatment would already have been optimised. Further rationalisation,
after discharge, would therefore usually not be necessary and therefore
the intervention may not be expected to reduce hospitalisation in this
cohort of patients.
It would be of interest to know how frequently interventions were
made by the pharmacists e.g. how frequently a recommendation on adverse
drug reactions and interventions were made to the GP; how many patients
were recommended a compliance aid; and whether patients who received an
intervention were those who subsequently had a hospital readmission or if
the admission was for an unrelated cause.
In the mean time, the results of this study should not cast doubt on
the efficacy of full pharmacist medication review, using all patient data
to optimise therapy.
Reference
1. Holland R, Lenaghan E, Harvey I, Smith R et al. Does home based
medication review keep odler people out of hospital? The HOMER randomised
controlled trial. BMJ Online bmj.com.
2. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe
CJ.Randomised controlled trial of clinical medication review by a
pharmacist of elderly patients receiving repeat prescriptions in general
practice.
BMJ. 2001 Dec 8;323(7325):1340-3.
3. Mackie CA, Lawson DH, Campbell A, Maclaren AG, Waigh R. A
randomised controlled trial of medication review in patients receiving
polypharmacy in general practice. Pharmaceutical Journal. 1999; 263: R7.
4. Krska J, Cromerty JA, Arris F, Jamieson D, Hansford D, Duffus PRS,
Downie G, Seymour DG.Pharmacist-led medication review in patients over 65:
a randomized, controlled trial in primary care. Age and Ageing.2001; 30:
205-11.
5. Room for Review. Task Force on Medicines Partnership and The
National Collaborative Medicines Management Services Programme.
http://www.medicines-partnership.org/medication-review/room-for-review/
Competing interests:
None declared
Competing interests: No competing interests