Improving appropriate medication use for older people in primary care

Abstract

Clinical pharmacy interventions for older people with polypharmacy can be divided in dispensing services (aimed at support of medication management), e.g. multidose dispensing systems, and medication reviews (aimed at appropriateness of the pharmacotherapy. The objective of this thesis is to describe the effects of these clinical pharmacy interventions on the medication management and quality of pharmacotherapy of older patients with polypharmacy in primary care. Chapter 2 describes a systematic review where RCTs on medication review for community-dwelling older patients have been included. The presence of the eight key elements reflecting collaboration were scored for each intervention. This review showed an association between the number of these key elements and the implementation rate of recommendations. In Chapter 3.1 we compared the self-reported medication adherence and knowledge of older patients receiving their drugs via multidose drug dispensing (MDD-users) with patients receiving manually-dispensed drugs. We showed a higher adherence and lower knowledge for MDD-users. In Chapter 3.2 the results are presented of a pragmatic randomized controlled study on the effect of medication review for older patients using MDD on DRPs. This study with only medication records available (“prescription review”) identified a high number of potential DRPs among MDD-users which was decreased by medication review. Chapter 4.1 describes the results of a randomised controlled trial on the effect of Home Medication Review on DRPs, disease-specific outcomes and health-related quality of life in older patients. This study shows that medication review resolved a substantial number of drug-related problems and improved LDL-cholesterol, but did not lead to improvements in other disease-specific outcomes and quality of life. Chapter 4.2 focuses on the contribution of the patient interview to the identification of DRPs within the Home Medication Review. This study shows that more than a quarter of all DRPs were identified during patient interviews and were more frequently assigned a higher clinical relevance. Chapter 4.3 provides insight in the completeness of DRPs identified by community pharmacists within the Home Medication Review study. Pharmacists with clinical experience doubled the amount of DRPs identified by community pharmacists. Chapter 4.4 aims to describe the number and types of explicit STOPP (Screening Tool of Older Person’s Prescriptions)-START(Screening Tool to Alert doctors to Right Treatment) criteria present in identified potential DRPs and their implementation rate. This study shows a higher prevalence of START-criteria compared to STOPP-criteria among identified DRPs while the majority of DRPs was not associated with STOPP-START criteria. In conclusion, this thesis presented a series of studies on medication review which showed that medication review in Dutch community-dwelling older patients with polypharmacy identifies a large number of drug-related problems and some positive effects on intermediate disease-specific outcomes. An average of 1-2 problems per patient are resolved and could potentially lead to improved health outcomes. The studies presented on multidose drug dispensing systems showed high adherence, low medication knowledge and considerable inappropriateness of drugs in these systems. These findings in combination with the steep growth of MDD-users emphasize the need for sufficient pharmaceutical care around multidose drug dispensing systems, including medication review.