Development and Application of Comprehensive Medication Review Procedure to Community-Dwelling Elderly

Populations in Western countries are ageing. At the same time, use of medications is increasing among older people. Age-related changes in the body make the elderly vulnerable to adverse drug events. Thus, ensuring medication safety among this patient group is a growing health care concern. For this purpose, several criteria to indicate inappropriate prescribing among the aged have been developed. Also, different types of medication review procedures have been created in several countries to identify drug-related problems (DRPs). The aim of this study was to develop a collaborative Comprehensive Medication Review (CMR) procedure applicable to the Finnish health care system and evaluate its usefulness as a means to improve the appropriateness of pharmacotherapy among community-dwelling elderly. The specific aims were 1) to determine the prevalence of potentially inappropriate medication use according to the Beers 2003 criteria among Finnish non-institutionalized population aged ≥65 years; 2) to describe the development and assess participant satisfaction on the CMR accreditation training; 3) to describe the development of the CMR procedure and related documentation, and to assess CMR training participants’ satisfaction on the documentation; and 4) to assess the DRPs pharmacists report to collaborating physicians during CMR and the resulting interventions among outpatients aged ≥65 years. This study applied both quantitative and qualitative methods. The prevalence of potentially inappropriate drug use according to the Beers criteria was studied by using the drug reimbursement register of the Finnish Social Insurance Institution covering the entire non-institutionalized population aged ≥65 years in 2007 (n=841 509, Study I). The development of the CMR procedure and accreditation training involved a review of literature and medication review procedures used in other countries as well as pilot testing by 26 experienced pharmacists undergoing the CMR training in 2005– 2006 (Studies II, III). Participants’ satisfaction on the CMR training (n=38) and documentation (n=27) were assessed by surveys completed by pharmacists attending CMR training in 2006–2007 (Studies II, III). The DRPs identified and reported to the collaborating physicians during CMR were studied by a retrospective review of CMR case reports (n=121) by 26 community pharmacists attending the CMR training in 2006–2007 (Study IV). Approximately 15% of the entire non-institutionalized population aged ≥65 years used potentially inappropriate medications in Finland in 2007. This prevalence is low compared to studies in other countries. The most worrying finding was the common use of benzodiazepines: one third of the potentially inappropriate drug use involved these drugs, particularly high-dose temazepam. The 1.5year CMR accreditation training for practicing pharmacists combines distance learning and face-to-face learning and consists of 5 modules: 1) Multidisciplinary Collaboration; 2) Clinical Pharmacy and Pharmacotherapy; 3) Rational Pharmacotherapy; 4) CMR Tools; and 5) Optional Studies. The participating pharmacists’ satisfaction with the training was high but several factors prevent them from conducting CMRs after the training. The collaborative CMR procedure involves access to clinical patient information, home visit with patient interview, a case conference with the collaborating physician and extensive documentation to support the process. The procedure covers four main dimensions critical for safe and appropriate pharmacotherapy for the aged: Aging and Safety; CoMorbidities; Polypharmacy; and Adherence. When using the CMR procedure, pharmacists reported to collaborative physicians an average of 6.5 DRPs per patient. Most common DRPs were inappropriate drug selection, especially involving psychotropic drugs, and undertreatment. Also treatment of pain was often found to need improvement. Approximately half of the pharmacists’ recommendations led to medication changes, i.e., to an average of 3 changes/patient. The most common agreed change was to stop hypnotics or sedatives. The results of this study confirm many well-known problems in elderly pharmacotherapy: prescribing of inappropriate drugs, undertreatment, and issues related to inadequate management of pain. The CMR procedure could be beneficial for improving pharmacotherapy among older outpatients as a large portion of DRPs identified by pharmacists led to medication changes. Actions to facilitate implementation of the model to Finnish health care system are needed. Also, further studies are needed to evaluate the effects of CMR on clinical, humanistic and economic outcomes.