Interventions to optimise prescribing for older people in care homes

David P Alldred; Mary‐Claire Kennedy; Carmel Hughes; Timothy F Chen; Paul Miller

doi:10.1002/14651858.CD009095.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Interventions to optimise prescribing compared with usual GP care for care home residents
Patient or population: older people (aged 65 years or older) living in care homes Settings: Institutionalised care facilities in Australia, Finland, Israel, Netherlands, New Zealand, Spain, Sweden, United Kingdom, and USA and Canada Intervention: Intervention to optimise prescribing (single or multicomponent intervention) Comparison: Usual care by general practitioner
Outcomes	Impact	No of Participants (studies)	Quality of the evidence (GRADE)
Adverse drug events	There was no evidence of an effect on adverse drug events	1228 in 87 care homes (2 studies)	⊕⊕⊝⊝ low
Hospital admissions	It is uncertain whether medication review reduces hospital admissions	7606 in 309 care homes (8 studies)	⊕⊕⊝⊝ low
Mortality	There was no evidence of an effect on mortality	6805 in 188 care homes (6 studies)	⊕⊕⊝⊝ low
Quality of life	It is uncertain whether medication review improves quality of life	586 in 21 care homes (2 studies)	⊕⊕⊝⊝ low
Medication‐related problems	Medication review may lead to the identification and resolution of medication‐related problems	6640 in 251 care homes (7 studies)	⊕⊕⊝⊝ low
Medication appropriateness	Medication review may lead to an improvement in medication appropriateness	1566 in 152 care homes (5 studies)	⊕⊕⊝⊝ low
Medicine costs	It is uncertain whether medication review decreases medication costs	4734 in 142 care homes (5 studies)	⊕⊝⊝⊝ very low
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
Quality assessment of evidence for each outcome was based on study design, risk of bias, inconsistency, indirectness and imprecision. The evidence was downgraded from high to low for adverse drug events (Crotty 2004b; Gurwitz 2008) due to a serious risk of bias and imprecision. The evidence was downgraded from high to low for hospital admissions (Furniss 2000; Roberts 2001; Crotty 2004b; Zermansky 2006; Frankenthal 2014; Garcia‐Gollarte 2014; Pitkala 2014; Connolly 2015), mortality (Furniss 2000; Roberts 2001; Zermansky 2006; Frankenthal 2014; Pitkala 2014; Connolly 2015), quality of life (Frankenthal 2014; Pitkala 2014) and medication appropriateness (Crotty 2004a; Crotty 2004b; Frankenthal 2014; Garcia‐Gollarte 2014; Pitkala 2014) due to a serious risk of bias and inconsistency. The evidence for medicines costs (Furniss 2000; Roberts 2001; Crotty 2004a; Zermansky 2006; Frankenthal 2014 was downgraded from high to very low due to a serious risk of bias, inconsistency and imprecision. The evidence for medicine‐related problems (Strikwerda 1994; Claesson 1998; Furniss 2000; Roberts 2001; Crotty 2004b; Zermansky 2006; Frankenthal 2014 was reduced from high to low due to design, risk of bias and imprecision.

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Table 1. Summary of study characteristics

Study,Country, Design	Participants	Intervention	Outcome measures	Duration
Claesson 1998 Sweden Cluster‐RCT	1854 residents in 33 nursing homes	Multidisciplinary meetings with physician, pharmacist and nurse(s)	Medication‐related problems	14 months
Connolly 2015 Australia Cluster‐RCT	1998 residents in 36 nursing homes	Multidisciplinary meetings with study geriatrician, a GP, a pharmacist and a nurse manager. Education of nurses and care‐givers	Hospital admissions Mortality	14 months
Crotty 2004a Australia Cluster‐RCT	154 residents in 10 nursing homes	Multidisciplinary case conferencing with GP, a geriatrician, a pharmacist, residential care staff and an Alzheimer's Association representative	Medication Appropriateness Index	3 months
Crotty 2004b Australia Patient‐RCT	110 patients discharged to 85 long‐term care facilities	Pharmacist transition co‐ordinator. Transfer of medicines information to nursing staff, family physician and community pharmacist plus medication review and case conferencing	Adverse drug events Hospital admissions Medication‐related problems Medication Appropriateness Index	8 weeks
Frankenthal 2014 Israel Patient‐RCT	359 residents in 1 chronic care geriatric facility	Medication review by the study pharmacist	Hospital admissions Mortality Quality of life Medication appropriateness (STOPP‐START) Medication‐related problems Medicine costs	12 months
Furniss 2000 UK Cluster‐RCT	330 residents in 14 nursing homes	Medication review by a single pharmacist	Hospital admissions Mortality Medication‐related problems Medicine costs	8 months
Garcia‐Gollarte 2014 Spain Cluster‐RCT	716 residents in 36 nursing homes	Physician educational programme followed by on‐demand support (prescription advice) by phone	Hospital admissions (total number of days spent in hospital) Medication appropriateness (STOPP‐START)	6 months
Gurwitz 2008 USA/Canada Cluster‐RCT	1118 residents in 29 units in 2 long‐term care facilities	Computerised provider order entry with clinical decision support	Adverse drug events	12 months
Pitkala 2014 Finland Cluster‐RCT	227 residents in 20 assisted living facilities	Nurse training and education	Hospital admissions Mortality Health‐related Quality of Life Medication appropriateness (Beer's criteria plus others)	12 months
Roberts 2001 Australia Cluster‐RCT	3230 residents in 52 nursing homes	Introduction of new professional role, nurse education and medication review by pharmacists	Hospital admissions Mortality Medication‐related problems Medicine costs	24 months
Strikwerda 1994 Netherlands Cluster‐RCT	196 residents in 1 nursing home	Feedback on GP prescribing from community pharmacist	Medication‐related problems	6 weeks
Zermansky 2006 UK Patient‐RCT	661 residents in 65 care homes	Medication review by a single pharmacist	Hospital admissions Mortality Medication‐related problems Medicine costs	6 months

Table 1. Summary of study characteristics

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