Medication review in hospitalised patients to reduce morbidity and mortality

Abstract

Background: Pharmacotherapy in the elderly population is complicated by several factors that increase the risk of drug-related harms and less favourable effectiveness. The concept of medication review is a key element in improving the quality of prescribing and in preventing adverse drug events. Although there is no generally accepted definition of medication review, it can be broadly defined as a systematic assessment of pharmacotherapy for an individual patient that aims to optimise patient medication by providing a recommendation or by making a direct change. Medication review performed in adult hospitalised patients may lead to better patient outcomes. Objectives: We examined whether delivery of a medication review by a physician, pharmacist or other healthcare professional leads to improvement in health outcomes of hospitalised adult patients compared with standard care. Search methods: We searched the Specialised Register of the Cochrane Effective Practice and Organisation of Care (EPOC) Group; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to November 2014, as well as International Pharmaceutical Abstracts and Web of Science to May 2015. In addition, we searched reference lists of included trials and relevant reviews. We searched trials registries and contacted experts to identify additional published and unpublished trials. We applied no language restrictions. Selection criteria: We included randomised controlled trials (RCTs) of medication review in hospitalised adult patients. We excluded trials of outclinic and paediatric patients. Our primary outcome was all-cause mortality, and secondary outcomes included hospital readmissions, emergency department contacts and adverse drug events. Data collection and analysis: Two review authors independently included trials, extracted data and assessed trials for risk of bias. We contacted trial authors for clarification of data and for additional unpublished data. We calculated risk ratios for dichotomous data and mean differences for continuous data (with 95% confidence intervals (CIs)). The GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to assess the overall certainty of evidence for the most important outcomes. Main results: We identified 6600 references (4647 references in our initial review) and included 10 trials (3575 participants). Follow-up ranged from 30 days to one year. Nine trials provided mortality data (3218 participants, 466 events), with a risk ratio of 1.02 (95% CI 0.87 to 1.19) (low-certainty evidence). Seven trials provided hospital readmission data (2843 participants, 1043 events) with a risk ratio of 0.95 (95% CI 0.87 to 1.04) (high-certainty evidence). Four trials provided emergency department contact data (1442 participants, 244 events) with a risk ratio of 0.73 (95% CI 0.52 to 1.03) (low-certainty evidence). The estimated reduction in emergency department contacts of 27% (with a CI ranging from 48% reduction to 3% increase in contacts) corresponds to a number needed to treat for an additional beneficial outcome of 37 for a low-risk population and 12 for a high-risk population over one year. Subgroup and sensitivity analyses did not significantly alter our results. Authors' conclusions: We found no evidence that medication review reduces mortality or hospital readmissions, although we did find evidence that medication review may reduce emergency department contacts. However, because of short follow-up ranging from 30 days to one year, important treatment effects may have been overlooked. High-quality trials with long-term follow-up (i.e. at least up to a year) are needed to provide more definitive evidence for the effect of medication review on clinically important outcomes such as mortality, readmissions and emergency department contacts, and on outcomes such as adverse events. Therefore, if used in clinical practice, medication reviews should be undertaken as part of a clinical trial with long-term follow-up.