Effectiveness of telephone counselling by a pharmacist in reducing mortality in patients receiving polypharmacy: randomised controlled trial

Abstract

Objective: To investigate the effects of compliance and periodic telephone counselling by a pharmacist on mortality in patients receiving polypharmacy.

Design: Two year randomised controlled trial.

Setting: Hospital medical clinic.

Participants: 502 of 1011 patients receiving five or more drugs for chronic disease found to be non-compliant at the screening visit were invited for randomisation to either the telephone counselling group (n = 219) or control group (n = 223) at enrollment 12-16 weeks later.

Main outcome measures: Primary outcome was all cause mortality in randomised patients. Associations between compliance and mortality in the entire cohort of 1011 patients were also examined. Patients were defined as compliant with a drug if they took 80-120% of the prescribed daily dose. To calculate a compliance score for the whole treatment regimen, the number of drugs that the patient was fully compliant with was divided by the total number of prescribed drugs and expressed as a percentage. Only patients who complied with all recommended drugs were considered compliant (100% score).

Results: 60 of the 502 eligible patients defaulted and only 442 patients were randomised. After two years, 31 (52%) of the defaulters had died, 38 (17%) of the control group had died, and 25 (11%) of the intervention group had died. After adjustment for confounders, telephone counselling was associated with a 41% reduction in the risk of death (relative risk 0.59, 95% confidence interval 0.35 to 0.97; P = 0.039). The number needed to treat to prevent one death at two years was 16. Other predictors included old age, living alone, rate of admission to hospital, compliance score, number of drugs for chronic disease, and non-treatment with lipid lowering drugs at screening visit. In the cohort of 1011 patients, the adjusted relative risk for death was 1.61 (1.05 to 2.48; P = 0.029) and 2.87 (1.80 to 2.57; P < 0.001) in patients with compliance scores of 34-66% and 0-33%, respectively, compared with those who had a compliance score of 67% or more.

Conclusion: In patients receiving polypharmacy, poor compliance was associated with increased mortality. Periodic telephone counselling by a pharmacist improved compliance and reduced mortality.

Trial registration: International Standard Randomised Controlled Trial Number Register: SRCTN48076318.

Fig 1

Flow of patients through the trial

Fig 2

Kaplan-Meier estimates of effect of telephone intervention by a pharmacist on all cause mortality in patients receiving polypharmacy (relative risk for intervention 0.59, 95% confidence interval 0.35 to 0.97, P=0.039 after adjusting for confounding factors)

Fig 3

Kaplan-Meier estimates for 1011 patients receiving polypharmacy according to compliance score at the screening visit. Relative risks and 95% confidence intervals for death in patients with compliance scores of 0-33% and 34-66% were 2.9 (1.8 to 4.6, P<0.001) and 1.8 (1.1 to 2.7, P=0.0098) compared with those who had a score of 67% or more