Medication review in hospitalised patients to reduce morbidity and mortality
Abstract
Background
Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug‐related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes.
Objectives
We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care.
Search methods
We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions.
Selection criteria
We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all‐cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events.
Data collection and analysis
Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes.
Main results
We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow‐up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low‐certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high‐certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low‐certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low‐risk population and 12 for a high‐risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results.
Authors' conclusions
We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow‐up ranging from 30 days to one year, important treatment effects may have been overlooked. High‐quality trials with long‐term follow‐up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long‐term follow‐up.
PICOs
Plain language summary
Reassessment of drugs given to hospitalised adult patients to improve patients’ health
Review question
This updated Cochrane systematic review studies the evidence for performing in‐hospital medication review (defined as a systematic reassessment by a healthcare professional of an individual patients's medication with suggestions for improvement). We aimed to assess whether medication review may improve the health of adult patients.
Background
Elderly patients are often prescribed several drugs despite a generally higher risk of adverse events and sometimes lesser treatment effectiveness in this population.
Search date
To find relevant trials, we searched electronic medical literature databases up to May 2015.
Study characteristics
We included 10 randomised controlled trials with a total of 3575 participants.
Key results
We found that medication review does not seem to prevent death and hospital readmissions, but that it might reduce emergency department contacts.
Certainty of the evidence
Our confidence in results across studies ranged from low to high. We found no evidence that medication review in hospitalised patients makes a difference towards preventing mortality (low‐certainty evidence) or hospital readmissions (high‐certainty evidence), but we found that medication review may have a preventive effect on reducing the number of emergency department contacts (low‐certainty evidence). In the included trials, participants were followed for a short time (ranging from 30 days to one year). Therefore, important long‐term treatment effects may have been overlooked. We suggest that further research with long‐term patient follow‐up and examination of specific methods of medication review should be undertaken before this intervention is implemented in clinical practice.
