Several strategies are used to monitor and optimise the use of drugs for hospitalised patients and the Cochrane review of medication review was updated in January 2023. In this podcast, one of the group’s researchers, Mikkel Christensen, talks with lead author Cille Bülow, both from Copenhagen University Hospital in Denmark, about their latest findings.
Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. Several strategies are used to monitor and optimise the use of drugs for hospitalised patients and the Cochrane review of medication review was updated in January 2023. In this podcast, one of the group's researchers, Mikkel Christensen, talks with lead author Cille Bülow, both from Copenhagen University Hospital in Denmark, about their latest findings.
Mikkel: Hello Cille, let's begin with defining the intervention. What is a medication review?
Cille: Hello Mikkel. For this review, we defined it as a structured evaluation of a patient's medication, conducted by healthcare professionals, with the aim of optimising medication use and improving health outcomes.
Mikkel: Ok, so why is it important to gather all the evidence on the effects of these medication reviews?
Cille: More and more people are treated with multiple drugs, which is known as polypharmacy. However, polypharmacy is associated with an increased risk of death, drug-related hospitalisation, emergency room visits, and a greater financial burden on society. Therefore, it's important to distinguish between appropriate and inappropriate polypharmacy. Medication reviews have the potential to make this distinction and, by reducing inappropriate medications, to ensure that patients receive the best possible pharmacotherapy.
Mikkel: That sounds promising. Did the two earlier versions of this review, in 2013 and 2016, find beneficial effects for medication reviews?
Cille: Well, no. Despite the anticipated benefits, neither of those versions found a clear beneficial effect of medication reviews on clinical outcomes but they noted the need for more research.
Mikkel: So, turning to the updated review, can you tell me about the included trials in this version?
Cille: In this review update, we include 25 randomised trials with more than 15,000 participants, most of whom were elderly patients with polypharmacy. The trials were done in different hospital settings: some were done in medical departments and others in surgical departments, and follow-up ranged from 1 to 20 months. The trials also differed in what the medication review interventions entailed and how the suggested changes were implemented. For example, how suggestions for changes were communicated to the prescribing physician.
Two trials were conducted in the US, one in Canada, one in Brazil, one in South Korea and the other 20 were from Europe. In six trials, the medication review was done using published criteria, for example, the STOPP/START criteria. In 19 trials, the intervention group received other co‐interventions in addition to a medication review, for example, discharge counselling or written information to their primary care physician.
The proportion of suggested changes to the medical treatment that were implemented by the prescribing physicians was reported in 16 trials and ranged from 15% to 93%.
Mikkel: Based on this evidence in the updated review, what can you now say about the effects of medication reviews?
Cille: We found that medication reviews for hospitalised elderly patients with polypharmacy likely reduce hospital readmissions and may reduce emergency department contacts. However, the beneficial effect of reviewing patients' medication does not seem to extend to increased survival, and the effect on quality of life is very uncertain.
Mikkel: Ok, the reduction in hospital admissions sounds important. Could you elaborate on the clinical significance of the effect?
Cille: Our results show that for every 25 patients that receive a medication review while they are in hospital, one fewer will need to be readmitted later. This is important new knowledge because hospital admissions are expensive and many hospitals face challenges with sufficient staff, so having fewer readmitted patients can also reduce the hospital's workload, in addition to benefitting the patient's health.
Mikkel: So what should happen now? How can this information be used?
Cille: Based on our data, it seems reasonable to implement medication reviews in some form for hospitalised patients to prevent readmission. However, it is uncertain which form of medication review is most effective. Our review points to where there is a lack of knowledge and need for future trials. These trials should assess the impact of different types of intervention components on the effects, and they should also have an appropriate follow‐up period. Lastly, they should ensure a high implementation rate, because we cannot expect an effect on clinical outcomes if the suggested changes to a person's polypharmacy are not implemented.
Mikkel: Thanks, Cille. If people would like to read the review, how can they get hold of it?
Cille: Thanks, Mikkel. The review is available online. If people go to Cochrane Library dot com and type the title, 'Medication review in hospitalised patients to reduce morbidity and mortality', in the search box, they'll see a link to it.