Impact of an enhanced pharmacy discharge service on prescribing appropriateness criteria: a randomised controlled trial

Abstract

Background: Older people are at increased risk of drug-related problems (DRPs) caused by inappropriate use or underuse of medications which may be increased during care transitions.

Objective: To examine the effects of applying a validated prescribing appropriateness criteria-set during medication review in a cohort of older (≥65 years) Australians at the time of discharge from hospital.

Setting: Private hospital and homes of older patients in Sydney, Australia.

Methods: Cognitively well English speaking patients aged 65 years or over taking five or more medications were recruited. A prescribing appropriateness criteria-set and SF-36 health-related quality of life health (HRQoL) survey were applied to all patients at discharge. Patients were then randomly assigned to receive either usual care (control, n = 91) or discharge medication counselling and a medication review by a clinical pharmacist (intervention, n = 92). Medication review recommendations were sent to the general practitioners of intervention group patients. All patients were followed up at 3 months post discharge, where the prescribing appropriateness criteria-set was reapplied and HRQoL survey repeated. MAIN OUTCOME MEASURES change in the number of prescribing appropriateness criteria met; change in HRQoL; number and causes of DRPS identified by medication review; intervention patient medication recommendation implementation rates.

Results: There was no significant difference in the number of criteria applicable and met in intervention patients, compared to control patients, between follow-up and discharge (0.09 ≤ p ≤ 0.97). While the difference between groups was positive at follow-up for SF-36 scores, the only domain that reached statistical significance was that for vitality (p = 0.04). Eighty-eight intervention patient medication reviews identified 750 causes of DRPs (8.5 ± 2.7 per patient). No causes of DRPs were identified in four patients. Of these causes, 76.4 % (573/750) were identified by application of the prescribing appropriateness criteria-set. GPs implemented a relatively low number (42.4 %, 318/750) of recommendations.

Conclusion: Application of a prescribing appropriateness criteria-set during medication review in intervention patients did not increase the number of criteria met, nor result in a significant improvement in HRQoL. Higher recommendation implementation rates may require additional facilitators, including a higher quality of collaboration.

Keywords: Australia; DRPs; Drug-related problems; Inappropriate prescribing; Overprescribing; Prescribing appropriateness criteria; Private hospital; Underprescribing.