Interventions by health staff can cut inappropriate prescribing, study finds

Healthcare professionals can reduce inappropriate prescribing of drugs in older people who are taking four or more medicines, finds a study published in BMJ Open
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(online, 11 December 2015).

The systematic review analysed 12 studies carried out in Australia, Ireland, Belgium, Canada and the United States, looking at a total of 22,438 patients. The average patient age was 76 years and individuals were taking an average of nine medicines.

The use of multiple drugs in older people (aged 65 years and over) has the potential for negative outcomes, including adverse drug events, non-adherence and drug interactions.

The review looked at the results of interventions aimed at improving the use of polypharmacy (defined as four or more regular medicines) in older people. Prescribing appropriateness was measured using validated tools, including the Medication Appropriateness Index (MAI), Beers criteria, the Screening of Older Person’s Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START).

The review found that the interventions reduced inappropriate prescribing. “Pooled data showed a significant reduction in intervention group patients’ mean MAI score compared with control group patients,” the study says. “Assessments involving other validated tools also showed improvements in the appropriateness of prescribing.”

But there was conflicting evidence about the effect the interventions had on reducing hospital admissions and medicine-related problems.

The researchers found that the models of pharmaceutical care provided were complex and variable. For example, pharmacists conducted independent medication reviews either using patient notes or with patients during a face-to-face encounter. In other cases, recommendations from medication reviews were followed up with prescribers and other healthcare professionals.

The timing of the interventions also varied. “A number of interventions were delivered at specific time points, for example, hospital admission, attendance at outpatient clinics, nursing home visits, and hospital discharge to a nursing home,” say the researchers. “In other cases, interventions were delivered over a period of time, such as during hospital inpatient stay and at discharge.”

The researchers also point out that several of the studies focused on reducing the number of prescribed medicines without considering underprescribing, so the overall appropriateness of prescribing was not looked at. “This needs to be addressed as underprescribing is common in older populations with variable prevalence rates depending on medication classes and care settings,” they say.

They went on to point out that while the results of the review are “promising and indicate that the interventions described… were successful in improving appropriate polypharmacy, the clinical impact is not known.”

“Despite the uncertainty as to the effect of the identified interventions to improve appropriate polypharmacy on a number of outcome measures, this review provides useful guidance for the direction of future research,” they say.

Commenting on the study, Wasim Baqir, research and development pharmacist at Northumbria Healthcare NHS Foundation Trust, says: “The evidence around interventions to improve prescribing is very much about numbers and types of interventions. What we need is good quality studies to show the impact on things that matter to the health economy — for example, disease control and hospital admissions — and patients, such as improved quality [of life], [and] better pain [management].”

He says there are implications for pharmacists working in this area. “This presents pharmacists working with older people an opportunity to shape the evidence base. We know anecdotally that medication reviews, especially where there are elements of deprescribing, make a positive impact on patients and health outcomes; we just don’t measure them.”