Interprofessional Medication Management in Patients With Multiple Morbidities

Abstract

Background: Medication reviews and medication management are being used more and more around the world to improve medication safety. Both of these tools were originally conceived as pharmaceutical care activities and have recently been developed into interdisciplinary approaches. We studied the efficacy of interprofessional medication management for multimorbid patients that takes their medical conditions, but also their general living situation into account.

Methods: A comprehensive medication management was performed, which involved the collection of information on the drugs each patient took, the way they were stored, the patient's drug intake and handling, and any problems that arose with pharmacotherapy. The interventional approach was evaluated over a period of 15 months in a cluster-randomized controlled trial with a stepped wedge design. The primary endpoint was the quality of pharmacotherapy, as assessed with the Medication Appropriateness Index (MAI). A mixed model was used to analyze efficacy.

Results: 162 patients were enrolled in the study; 142 were included in the intention-to-treat analysis (53.3% women, mean age 76.8 ± 6.3 years). The mean total MAI score decreased significantly (p ≤ 0.001) from the control phase (29.21, 95% CI [26.09; 32.33]) to the intervention phase (22.27 [19.00; 25.54]), with an effect strength (Cohen's d) of -0.24 [-0.36; -0.13]. The number of drug-related problems declined as well.

Conclusion: In this study, interprofessional collaboration increased medication safety. Working across disciplinary boundaries allowed for a decrease in drugrelated problems and brought up aspects outside the purview of the primary care physician.

Figure

Alteration of Medication Appropriateness Index Scores over the study period, separated according to changeover groups Explanation of documentation time points:

eFigure 1

Definition of medication review (from Pharmaceutical Care Network Europe) (12)

eFIGURE 2

CONSORT flowchart MAI, medication appropriateness index; T, timing of documentation Documentation times: T0, baseline collection at inclusion into study; T1, data collection at end of recruitment period; T2, 3 months after end of recruitment period; T3, 6 months after end of recruitment period; T4, 9 months after end of recruitment period; T5, 12 months after end of recruitment period; T6, 15 months after end of recruitment period Explanations regarding study drop-out at patients’ own volition, unrelated to the intervention, according to exit questionnaire: move into care home/moving in with children and therefore changing primary care physicians; change in family situation (for example, death of spouse) and no more time for the study; extended inpatient stays including rehabilitation. From the reasons given in the exit questionnaires we were not able to establish any connection to the intervention. Definition of the intention-to-treat (ITT) group: all randomized patients whose written consent had been filed, who met all inclusion and exclusion criteria, and for whom the MAI score was determined at least at baseline were included in the ITT analysis. All patients in this group were evaluated within the group they had been randomized to. Definition of the per protocol (PP) group: all patients within the ITT set who had received medication management according to the cluster they had been randomized to, and for whom, in addition to the baseline MAI score, at least two further MAI scores had been collected after the change from control group to intervention group.