Medication reviews in the community: results of a randomized, controlled effectiveness trial

Abstract

Aims: To examine the effectiveness of a multidisciplinary service model delivering medication review to patients at risk of medication misadventure in the community.

Methods: The study was carried out in three Australian states; Queensland, New South Wales and Western Australia, and conducted as a randomized, controlled effectiveness trial with the general practitioner (GP) as the unit of randomization. In total, 92 GPs, 53 pharmacists and 400 patients enrolled in the study. The multidisciplinary service model consisted of GP education, patient home visits, pharmacist medication reviews, primary healthcare team conferences, GP implementation of action plans in consultation with patients, and follow-up surgery visits for monitoring. Effectiveness was assessed using the four clinical value compass domains of (i) functional status, (ii) clinical outcomes, (iii) satisfaction and (iv) costs. The domains of functional status (assessed by the health-related quality of life measure SF-36 subscales) and clinical outcomes (as assessed by adverse drug events (ADEs), number of GP visits, hospital services and severity of illness) were measured at baseline and endpoint. Satisfaction was measured by success in implementation and by participant satisfaction at endpoint, and costs (as assessed using medication and healthcare service costs, less intervention costs) were measured preintervention and during the trial. In addition, process evaluation was conducted for intervention patients, in which problems and recommendations from the medication reviews were described.

Results: The model was successfully implemented with 92% of intervention GPs suggesting that the model had improved the care of participating patients, a view shared by 94% of pharmacists. In addition, positive trends in clinical outcomes (ADEs and severity of illness) and costs (an ongoing trend towards reduction in healthcare service costs) were evident, although the trial was limited to a 6-month intervention time. No differences between intervention and control groups were identified for the health-related quality of life domain. The cost-effectiveness ratio for the intervention based on cost savings, reduced adverse events and improved health outcomes was small. The most common problems identified in the medication reviews were potential adverse drug reactions, suboptimal monitoring and adherence/lack of concordance issues. In total, 54.4% of recommendations were enacted, and 23.9% were implemented precisely as recommended in the medication review. Follow-up evaluation showed that 70.9% of actions had a positive outcome, 15.7% no effect and 3.7% had a negative outcome.

Conclusions: Most studies emphasize efficacy and the best achievable clinical outcomes rather than whether an intervention will be effective in practice. The current trial showed that three of the four domains in the clinical value compass showed trends of improvement or were indeed improved in the relatively short follow-up period of the trial, suggesting that a service based on this model could achieve similar benefits in practice. A domiciliary medication review programme similar to this model has now been implemented into national Australian practice, where GPs and pharmacists are reimbursed by the Australian government for the provision of these services.

Figure 1

Intervention model. *An accredited pharmacist was a pharmacist accredited by the Australian Association of Consultant Pharmacy to perform medication reviews (after completion of training and assessment). Accredited pharmacists could be the community pharmacist or an independent practitioner separate from the community pharmacy

Figure 2

Flow diagram of the progress of the trial. *It was not possible to identify how many potential participants had been reached by the promotional material. **One hundred and forty conducted by pharmacists, 12 by GPs. ***Ninety-three completed by community pharmacists, 57 by noncommunity pharmacists. IC, Inclusion criteria; FU, follow-up. The figure is based on the CONSORT guidelines [42]. Note that 150 out of 177 medication reviews were conducted but only 110 were made available to the study team

Figure 3

Health outcomes for (A) Duke's severity of illness (DUSOI-A). Control (n = 186) (), intervention (n = 100) (), and (B) patient-reported adverse drug events. Control (n = 180) (), intervention (n = 94) ()

Figure 4

Cumulative cost per person (AUS$) for (A) medication and (B) medical services. 1, Start of patient enrolments; 2, start of home visits; 3, start of medication reviews; 4, Start of Primary Health Care Team (PHCT) conferences; 5, start of follow-up visits