This study (1) showed that pharmacist home based medication review
was associated with increased hospital admission rates in older people
suggesting that these patients were somehow disadvantaged by pharmacist
home visits. There are some key issues, discussed below, that we believe
may affect the interpretation of these results.
It is unclear what additional training pharmacists conducting the
interventions obtained, what their specific area of practice was and
whether they were assessed for competency prior to undertaking these
reviews. The work by Stewart et al (2) in Australia was associated with
reduced hospital admissions and mortality and participating pharmacists
were required to undertake a specific qualification in medication reviews
to be included in the study. It is worth noting that Zermansky (3), who
showed benefits of medication review in GP practices was a pharmacist with
a clinical diploma.
We are not told what constituted a medication review in this study,
nor if there was a standard questionnaire or assessment used which was
validated or had been used in some of the other trial work cited.
Pharmacists did not appear to have full access to patient records from the
GP surgery or from previous hospital admissions, in contrast with the
Zermansky work (3). It was not stated whether the discharge medication
list the pharmacists were given had been verified as correct with no
omissions.
As highlighted by other respondents, the groups were not well matched
for diseases, especially for dementia patients. There were a large number
of drop-outs in the control group and 67 did not receive a medication
review. The authors suggest that pharmacists in this trial were
encouraging patient adherence to medication however no measure of
adherence was made to support this claim.
We feel some concern that the study is vague about the
recommendations made by the pharmacists; how many were actioned by the
GPs? Were the pharmacists instrumental in prompting the additional GP
visits or did this happen after prescribing changes had been made?
Home based medication reviews by pharmacists, or indeed pharmacist home
visits, may identify vulnerable elderly people with unmet clinical needs.
This may explain the much higher rate of GP visits and higher readmission
rates in this group, reflecting an attempt to meet those needs. It is also
unclear whether a few patients having multiple-readmissions may have
distorted the results.
There is no measure of appropriateness of readmission, number of
multiple admissions for particular patients or comparison of re-admission
rates in these two groups with usual readmission rates for over 80 year
olds recently discharged in the locality.
In summary, it is difficult to draw any firm conclusions without
knowing the reasons for the emergency admissions and how many of them were
iatrogenic.
References
1. Richard Holland, Elizabeth Lenaghan, Ian Harvey, Richard Smith, Lee
Shepstone, Alistair Lipp, Maria Christou, David Evans, and Christopher
Hand
Does home based medication review keep older people out of hospital? The
HOMER randomised controlled trial
BMJ, Feb 2005; 330: 293
2. Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based
intervention on unplanned readmissions and out-of-hospital deaths. J Am
Geriatr Soc 1998;46: 174-80
3. Arnold G Zermansky, Duncan R Petty, David K Raynor, Nick Freemantle,
Andy Vail, and Catherine J Lowe
Randomised controlled trial of clinical medication review by a pharmacist
of elderly patients receiving repeat prescriptions in general practice
BMJ, Dec 2001; 323: 1340
Competing interests:
None declared
Competing interests:
No competing interests
09 March 2005
Caroline S Bowyer
Senior Pharmacist Elderly Care
Gary Todd Care of the Elderly Practice Interest Group UKCPA and Nina Barnett, Pharmacy Adviser for Older People, London SE and Eastern Specialist Pharmacy services
Care of the Elderly Practice Interest Group, United Kingdom Clinical Pharmacy Association (UKCPA)
This study (1) showed that pharmacist home based medication review
was associated with increased hospital admission rates in older people
suggesting that these patients were somehow disadvantaged by pharmacist
home visits. There are some key issues, discussed below, that we believe
may affect the interpretation of these results.
It is unclear what additional training pharmacists conducting the
interventions obtained, what their specific area of practice was and
whether they were assessed for competency prior to undertaking these
reviews. The work by Stewart et al (2) in Australia was associated with
reduced hospital admissions and mortality and participating pharmacists
were required to undertake a specific qualification in medication reviews
to be included in the study. It is worth noting that Zermansky (3), who
showed benefits of medication review in GP practices was a pharmacist with
a clinical diploma.
We are not told what constituted a medication review in this study,
nor if there was a standard questionnaire or assessment used which was
validated or had been used in some of the other trial work cited.
Pharmacists did not appear to have full access to patient records from the
GP surgery or from previous hospital admissions, in contrast with the
Zermansky work (3). It was not stated whether the discharge medication
list the pharmacists were given had been verified as correct with no
omissions.
As highlighted by other respondents, the groups were not well matched
for diseases, especially for dementia patients. There were a large number
of drop-outs in the control group and 67 did not receive a medication
review. The authors suggest that pharmacists in this trial were
encouraging patient adherence to medication however no measure of
adherence was made to support this claim.
We feel some concern that the study is vague about the
recommendations made by the pharmacists; how many were actioned by the
GPs? Were the pharmacists instrumental in prompting the additional GP
visits or did this happen after prescribing changes had been made?
Home based medication reviews by pharmacists, or indeed pharmacist home
visits, may identify vulnerable elderly people with unmet clinical needs.
This may explain the much higher rate of GP visits and higher readmission
rates in this group, reflecting an attempt to meet those needs. It is also
unclear whether a few patients having multiple-readmissions may have
distorted the results.
There is no measure of appropriateness of readmission, number of
multiple admissions for particular patients or comparison of re-admission
rates in these two groups with usual readmission rates for over 80 year
olds recently discharged in the locality.
In summary, it is difficult to draw any firm conclusions without
knowing the reasons for the emergency admissions and how many of them were
iatrogenic.
References
1. Richard Holland, Elizabeth Lenaghan, Ian Harvey, Richard Smith, Lee
Shepstone, Alistair Lipp, Maria Christou, David Evans, and Christopher
Hand
Does home based medication review keep older people out of hospital? The
HOMER randomised controlled trial
BMJ, Feb 2005; 330: 293
2. Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based
intervention on unplanned readmissions and out-of-hospital deaths. J Am
Geriatr Soc 1998;46: 174-80
3. Arnold G Zermansky, Duncan R Petty, David K Raynor, Nick Freemantle,
Andy Vail, and Catherine J Lowe
Randomised controlled trial of clinical medication review by a pharmacist
of elderly patients receiving repeat prescriptions in general practice
BMJ, Dec 2001; 323: 1340
Competing interests:
None declared
Competing interests: No competing interests