Shutterstock.com
A structured medication review (SMR) is an evidence-based, comprehensive and holistic evaluation of patients’ medications, where the clinician and patient work together as equals in a shared-decision making conversation to understand the risks and benefits of the medicines, taking into account the patients’ ideas, concerns and expectations.
An SMR can identify problematic polypharmacy where the potential for harm may outweigh the benefits, most commonly identifying medications that are no longer indicated, no longer recommended owing to a change in guidance, or combinations of medicines that could cause harm to the patient.
The resultant benefits of an SMR are:
- Improved quality of care and patient experience;
- Reduction in medicines-related harm, such as adverse effects and resultant hospitalisation; and
- Improved efficiencies for local healthcare systems.
Since 2019, in response to the ‘NHS long-term plan’, GP practices have been working collaboratively with other providers of community, mental health, social and hospital care within their local clusters, known as primary care networks (PCNs). The Network Contract Directed Enhanced Service (DES) specification 2020/2021 detailed the requirements of PCNs. One objective was for PCNs to deliver SMRs to all care home residents in PCN-aligned care homes using clinical pharmacists to deliver this service. Care home residents are usually high-risk vulnerable patients with varying degrees of frailty and often have complex comorbidities and medication regimens.
Analysing the impact of SMR on anticholinergic burden
The study was a case series based on a sample of 25 residents newly admitted to a residential care home in the inner west Newcastle PCN between April 2021 and March 2022. The ultimate aim of the case series was to explore the impact of a clinical pharmacist SMR on anticholinergic burden (ACB) and polypharmacy. The population sample comprised 25 consecutive new residents admitted into the care home between April 2021 and March 2022, for which no exclusion criteria were applied. The sample consisted of 8 males and 17 females with an average age of 87 years. Each resident received an SMR from a clinical pharmacist and data were collated for age, sex and anticholinergic cognitive burden before and after the SMR. The data were subsequently analysed using SPSSv13, where a valid statistical test existed.
The analysis revealed that the number of medicines taken before and after an SMR were normally distributed, so a paired-samples t-test was performed to evaluate the impact of SMR on polypharmacy in the sample. The number of medicines taken by the residents were reduced by a mean of 1.6 following an SMR (mean 7.48 pre-SMR, mean 5.88 post-SMR). This was found to be statistically significant. Cohen’s D statistic 1.05 (corrected for small sample size) showed that SMRs had a large effect size on reducing the number of medicines.
Reviewing the post-SMR intervention data revealed observable trends in deprescribing among this patient group, particularly in laxatives, diuretics, anti-hypertensives, antipsychotics, antidepressants, post-stroke anticonvulsants, bisphosphonates and overactive bladder medications.
A pharmacist-led SMR reduced the average ACB score from 1.9 to 1.1
A pharmacist-led SMR also reduced the average ACB score from 1.9 to 1.1, which was backed up by a Wilcoxon signed-rank test revealing a statistically significant reduction in ACB following SMR (Z=-2.99, P<0.001) with a large effect size (r=-0.6). In addition, a Mann-Whitney U test was performed and revealed no significant difference.
In conclusion, SMRs carried out by PCN pharmacists significantly reduced anticholinergic cognitive burden and polypharmacy in this sample of new admissions to a residential care home. From analysis of the observed deprescribing trends, overactive bladder medications were associated with significant ACB, increasing the risk of falls and adverse effects.
Going forward
The North East and Cumbria region is the highest prescriber of laxatives to care home residents and future work should explore the correlation between laxative use and admissions to secondary care owing to bowel obstruction.
Unnecessary and overprescribing of antihypertensives, antidepressants, antipsychotics and diuretics were other significant trends in deprescribing noted, reducing potential harm, falls risk and adverse effects.
Future work will be aimed at considering the impact of pharmacist-led SMRs on patient-related outcomes, such as reducing falls, improving quality of life and function. Larger samples from multiple centres randomised to intervention or control and followed up for longer may be necessary to establish adverse outcomes and to investigate the impact of factors, such as gender and comorbidity, on SMR outcome.
