A review of the ways that healthcare professionals can improve the use of suitable medicines for older people

What is the aim of this review?

The aim of this Cochrane Review was to find out which types of approaches can improve the use of suitable medicines in older people. Researchers collected and analysed all relevant studies to answer this question and included 32 trials in the review.

Key messages

Taking medicine to treat symptoms of chronic illness and to prevent worsening of disease is common in older people. However, taking too many medicines can cause harm.

What was studied in the review?

This review examines studies in which healthcare professionals have taken action to make sure that older people are receiving the most effective and safest medicines for their illness. Actions taken included providing a service, known as pharmaceutical care, which involves promoting the correct use of medicines by identifying, preventing and resolving medication-related problems. Another strategy which we were interested in was using computerised decision support, which involves a programme on the doctor’s computer that aids the selection of appropriate treatment(s).

What are the main results of the review?

Review authors found 32 relevant trials from 12 countries that involved 28,672 older people. These studies compared interventions aiming to improve the appropriate use of medicines with usual care. It is uncertain whether the interventions improved the appropriateness of medicines (based on scores assigned by expert professional judgement), reduced the number of potentially inappropriate medicines (medicines in which the harms outweigh the benefits), reduced the proportion of patients with one or more potentially inappropriate medications, or reduced the proportion of patients with one or more potential prescribing omissions (cases where a useful medicine has not prescribed) because the certainty of the evidence is very low. The interventions may lead to little or no difference in hospital admissions or quality of life, however, the interventions may slightly decrease the number of potential prescribing omissions.

How up-to-date is this review?

Review authors searched for studies that had been published up to February 2018.

Authors' conclusions: 

It is unclear whether interventions to improve appropriate polypharmacy, such as reviews of patients’ prescriptions, resulted in clinically significant improvement; however, they may be slightly beneficial in terms of reducing potential prescribing omissions (PPOs); but this effect estimate is based on only two studies, which had serious limitations in terms of risk bias.

Read the full abstract...
Background: 

Inappropriate polypharmacy is a particular concern in older people and is associated with negative health outcomes. Choosing the best interventions to improve appropriate polypharmacy is a priority, hence interest in appropriate polypharmacy, where many medicines may be used to achieve better clinical outcomes for patients, is growing. This is the second update of this Cochrane Review.

Objectives: 

To determine which interventions, alone or in combination, are effective in improving the appropriate use of polypharmacy and reducing medication-related problems in older people.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers up until 7 February 2018, together with handsearching of reference lists to identify additional studies.

Selection criteria: 

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series. Eligible studies described interventions affecting prescribing aimed at improving appropriate polypharmacy in people aged 65 years and older, prescribed polypharmacy (four or more medicines), which used a validated tool to assess prescribing appropriateness. These tools can be classified as either implicit tools (judgement-based/based on expert professional judgement) or explicit tools (criterion-based, comprising lists of drugs to be avoided in older people).

Data collection and analysis: 

Two review authors independently reviewed abstracts of eligible studies, extracted data and assessed risk of bias of included studies. We pooled study-specific estimates, and used a random-effects model to yield summary estimates of effect and 95% confidence intervals (CIs). We assessed the overall certainty of evidence for each outcome using the GRADE approach.

Main results: 

We identified 32 studies, 20 from this update. Included studies consisted of 18 randomised trials, 10 cluster randomised trials (one of which was a stepped-wedge design), two non-randomised trials and two controlled before-after studies. One intervention consisted of computerised decision support (CDS); and 31 were complex, multi-faceted pharmaceutical-care based approaches (i.e. the responsible provision of medicines to improve patient’s outcomes), one of which incorporated a CDS component as part of their multi-faceted intervention. Interventions were provided in a variety of settings. Interventions were delivered by healthcare professionals such as general physicians, pharmacists and geriatricians, and all were conducted in high-income countries. Assessments using the Cochrane 'Risk of bias' tool, found that there was a high and/or unclear risk of bias across a number of domains. Based on the GRADE approach, the overall certainty of evidence for each pooled outcome ranged from low to very low.

It is uncertain whether pharmaceutical care improves medication appropriateness (as measured by an implicit tool), mean difference (MD) -4.76, 95% CI -9.20 to -0.33; 5 studies, N = 517; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the number of potentially inappropriate medications (PIMs), (standardised mean difference (SMD) -0.22, 95% CI -0.38 to -0.05; 7 studies; N = 1832; very low-certainty evidence). It is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PIMs, (risk ratio (RR) 0.79, 95% CI 0.61 to 1.02; 11 studies; N = 3079; very low-certainty evidence). Pharmaceutical care may slightly reduce the number of potential prescribing omissions (PPOs) (SMD -0.81, 95% CI -0.98 to -0.64; 2 studies; N = 569; low-certainty evidence), however it must be noted that this effect estimate is based on only two studies, which had serious limitations in terms of risk bias. Likewise, it is uncertain whether pharmaceutical care reduces the proportion of patients with one or more PPOs (RR 0.40, 95% CI 0.18 to 0.85; 5 studies; N = 1310; very low-certainty evidence). Pharmaceutical care may make little or no difference in hospital admissions (data not pooled; 12 studies; N = 4052; low-certainty evidence). Pharmaceutical care may make little or no difference in quality of life (data not pooled; 12 studies; N = 3211; low-certainty evidence). Medication-related problems were reported in eight studies (N = 10,087) using different terms (e.g. adverse drug reactions, drug-drug interactions). No consistent intervention effect on medication-related problems was noted across studies.

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