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Peer-reviewed

Research Article

Pharmacist-participated medication review in different practice settings: Service or intervention? An overview of systematic reviews

Contributed equally to this work with: Rafaella de Oliveira Santos Silva, Luana Andrade Macêdo, Genival Araújo dos Santos Júnior, Patrícia Melo Aguiar, Divaldo Pereira de Lyra Júnior

Roles Conceptualization, Formal analysis, Investigation, Writing – original draft, Writing – review & editing

Affiliation Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Department of Pharmacy, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil

Roles Conceptualization, Formal analysis, Investigation

Roles Conceptualization, Supervision, Writing – original draft

Affiliation Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil

Roles Conceptualization, Project administration, Supervision, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

• Rafaella de Oliveira Santos Silva, 
• Luana Andrade Macêdo, 
• Genival Araújo dos Santos Júnior, 
• Patrícia Melo Aguiar, 
• Divaldo Pereira de Lyra Júnior

• Published: January 10, 2019
• https://doi.org/10.1371/journal.pone.0210312
• Reader Comments

Introduction

Medication review (MR) is a pharmacy practice conducted in different settings that has a positive impact on patient health outcomes. In this context, systematic reviews on MR have restricted the assessment of this practice using criteria such as methodological quality, practice settings, and patient outcomes. Therefore, expanding research on this subject is necessary to facilitate the understanding of the effectiveness of MR and the comparison of its results.

To examine the panorama of systematic reviews on pharmacist-participated MR in different practice settings.

A literature search was undertaken in Biblioteca Virtual em Saúde (BVS), Embase, PubMed, Scopus, The Cochrane Library, and Web of Science databases through January 2018 using keywords for "medication review", "systematic review", and "pharmacist". Two independents investigators screened titles, abstracts, full texts; assessed methodological quality; and, extracted data from the included reviews.

Seventeen systematic reviews were included, of which sixteen presented low to moderate methodological quality. Most of reviews were conducted in Europe (n = 7), included controlled primary studies (n = 16), elderly patients (n = 9), and long-term care facilities (n = 8). Seven reviews addressed MR as an intervention and thirteen reviews cited collaboration between physicians and pharmacists in the practice of MR. In addition, thirteen terminologies for MR were used and the main objective was to identify and solve drug-related problems and/or optimize the drug use (n = 11).

There is considerable heterogeneity in practice settings, population, definitions, terminologies, and approach of MR as well as poor description of patient care process in the systematic reviews. These facts may limit the comparison, summarization and understanding of the results of MR. Furthermore, the methodological quality of most systematic reviews was below ideal. Thus, international agreement on the MR process is necessary to assess, compare and optimize the quality of care provided.

Citation: Silva RdOS, Macêdo LA, Santos GAd Júnior, Aguiar PM, de Lyra DP Júnior (2019) Pharmacist-participated medication review in different practice settings: Service or intervention? An overview of systematic reviews. PLoS ONE 14(1): e0210312. https://doi.org/10.1371/journal.pone.0210312

Editor: Robert K. Hills, University of Oxford, UNITED KINGDOM

Received: December 30, 2017; Accepted: December 20, 2018; Published: January 10, 2019

Copyright: © 2019 Silva et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Medication Review (MR) has been defined as a structured assessment of patients’ pharmacotherapy whose aim is to optimize the drug use and to improve health outcomes [ 1 ]. Despite that concept, MR is used as a generic term and its practice can be performed by some health professionals, such as physicians, nurses and pharmacists, causing confusion regarding its characterization and effectiveness. In the MR, pharmacists play an important role in the detection and resolution of drug-related problems (DRPs) through interaction with patients and/or healthcare professionals [ 2 ].

The MR conducted by pharmacists may be classified into three types: Prescription Review, Concordance and Compliance Review (Adherence Support Review), and Clinical Medication Review (with or without prescribing) [ 3 , 4 ]. This practice, the last type particularly, must be conducted in collaboration with health professionals [ 5 ]. There are models of MR performed by pharmacists with collaboration of other health professionals in countries where pharmaceutical education is clinic-oriented as well as in those where pharmacists have no formal clinical education [ 6 – 11 ].

In Australia, there are examples of MR in which after the pharmacist assesses the patient’s pharmacotherapy, he sends a report with recommendations to the patient’s physician. After agreement with the pharmacist, the physician discusses the proposed recommendations with the patient [ 8 , 9 ]. The implementation of these recommendations made by the pharmacist may be influenced by some factors such as: a good working relationship between the pharmacist and the health care team [ 2 ], the type of communication between the pharmacist and the team (verbal or written) [ 2 , 10 , 11 ] and the clinical relevance of the recommendations [ 10 , 11 ].

In this context, studies show that pharmacist-participated MR has a positive impact on patients in practice settings such as community pharmacies [ 12 , 13 ], long-term care facilities [ 14 , 15 ], outpatient clinic [ 16 ], home care [ 17 , 18 ] and hospitals [ 19 , 20 ]. Besides the identification and resolutions of DRPs [ 21 – 23 ], the studies highlight benefits such as increase in quality of life [ 24 ], decrease of hospitalizations and health costs [ 25 , 26 ]. In order to achieve such results, the implementation of MR demands changes in pharmacists’ professional and social behaviour [ 18 ].

Although a previous overview of systematic reviews has corroborated the importance of MR for the improvement of patients’ health outcomes, it restricted relevant aspects such as methodological quality, practice settings, and assessed outcomes [ 27 ]. Moreover, the mentioned overview didn’t focus on concepts, terminologies and approach (as service or practice component) of MR as well as the professionals involved in this practice (interprofessional collaboration). The study of these variables is necessary to facilitate the understanding of the effectiveness of MR and to compare results.

Taking this into consideration, the present overview aimed to examine: 1) the panorama of systematic reviews on pharmacist-participated MR in different practice settings; 2) methodological quality of systematic reviews included in this overview; 3) the concepts, terminologies, and MR approach as well as the interprofessional collaboration in MR.

This overview of systematic reviews was performed according to the tool “A MeaSurement Tool to Assess systematic Reviews” (AMSTAR) [ 28 ].

Definitions

This overview of systematics reviews adopted the following concepts:

• Systematic reviews: studies that: (i) present a clear research question and/or eligibility criteria used to select primary studies; (ii) describe all information sources and the keywords used in the search; (iii) present the number of primary studies found in the information sources and included in the final sample of systematic review.
• Medication Review: critical and structured assessment of patients’ drugs with the objective of coming to an agreement of their pharmacotherapy, improving treatment, decreasing DRPs and costs with healthcare systems [ 29 ]. MR can be classified in Prescription Review, Concordance and Compliance Review (Adherence Support Review), and Clinical Medication Review (with or without prescribing) depending on their objective, patient’s presence, access to information and drugs and/or patient’s clinical conditions [ 3 , 4 ],

Literature search

A comprehensive literature search was conducted on the following databases: Biblioteca Virtual em Saúde (BVS), Embase, PubMed, Scopus, The Cochrane Library, and Web of Science for systematic reviews with or without meta-analysis published until 31 January 2018. To that end, Medical Subject Headings (MESH) vocabulary [ 30 ] and non-standard terms (text words) were used. Full search strategy can be seen in S1 Table . This overview has not been registered on PROSPERO International prospective register of systematic reviews.

Systematic reviews selection

Systematic reviews were selected in four stages: 1) exclusion of repeated articles; 2) title and abstract screening; 3) full-text screening; and, 4) manual screening of references of the systematic reviews included after reading full articles. Systematic reviews were independently selected by two investigators (R.O.S.S. and L.A.M.) and divergences were solved by a third investigator (G.A.S.J.). If articles were not available in full, authors were contacted via ResearchGate ( www.researchgate.net ) and e-mail. The stages 1, 2, and 3 of the study selection were performed using the Rayyan QCRI tool [ 31 ].

The included systematic reviews attended the following criteria: (i) they were published in English, Portuguese or Spanish; (ii) they were systematic reviews followed or not by meta-analysis; (iii) they examined MR (focused on MR or included different pharmaceutical services/interventions, but the results were presented by type of service/intervention); (iv) they adopted terminology for MR adopted in the search strategy; and (vi) pharmacist-participated MR in all primary studies with or without collaboration of other health professionals. Systematic reviews that did not present the definition of MR were included only if the interventions described in primary studies accorded to the concept of MR adopted.

In this overview, other systematic reviews were excluded because: i) full text was unavailable; (ii) MR was performed collaboratively by pharmacist and other health professionals but the pharmacist’s role within the team was not clearly defined in the primary studies included.

Data extraction

Two investigators (R.O.S.S. and L.A.M.) extracted independently the following data: authors, publication year, main author’s country, aim, country of primary studies, study design, practice setting, and population, number of primary studies included in the systematic review and meta-analysis, number of primary studies related to MR, assessed outcomes related to the drug use process, and economic, clinical, and human outcomes (ECHO model) [ 32 ], main results, concepts, terminologies, and approach (service or intervention) of MR, interprofessional collaboration, structure, processes, and outcomes variables [ 33 , 34 ] described in the systematic reviews as well as limitations or biases. Except for the number of primary studies included in the systematic reviews and meta-analysis, all data were extracted only from primary studies on MR. In case of data absence or clear pieces of information, it was considered that authors did not report such variable. Discrepancies among investigators were solved by consensus.

Study design, practice setting and population were determined according to the authors of systematic reviews. Regarding terminologies of MR, the words used in the search strategies of the included systematic reviews were not considered. If the review presented different MR definitions, the one presented in the methodology was adopted. Moreover, in the absence of a clear definition, components or objectives of MR were extracted. Interprofessional collaboration was considered present if at least one primary study reported it.

Quality assessment

Two investigators (R.O.S.S. and L.A.M.) analyzed independently the methodological quality, and discrepancies were solved by consensus. To achieve that, the AMSTAR tool [ 28 ] was used, which is composed by 11 criteria, each one judged as “yes,” “no,” “cannot answer,” or “not applicable”. Total score was obtained by the attribution of one point to “yes” answers and zero to other answers, varying score from 0 to 11. The score was ranged according to Mikton and Butchart (2009) [ 35 ]: i) score 0–4, low quality; ii) 5–8, moderate quality; and, iii) 9–11, high quality.

Agreement between investigators

Cohen’s Kappa index (k) was used to measure degree of agreement between the two investigators (R.O.S.S. and L.A.M.) in the title, abstract and full text screenings as well as in the assessment of methodological quality. Degree of agreement was stratified: i) k < 0.10, no agreement; ii) k < 0.40, weak agreement; iii) 0.40 < k < 0.75, good agreement; and, iv) k > 0.75, excellent agreement [ 36 ].

Selection of systematic reviews

The literature search identified 3,053 articles, from which 2,950 were excluded mainly because of: i) simultaneous indexation in two or more databases; ii) language; iii) they were not a systematic review; and/or, iv) they did not examine MR. Thus, 103 articles were selected to full-text screening, from which 17 reviews met the inclusion criteria. Their references were revised manually, and 68 were identified as potentially relevant. From these, none met the inclusion criteria. Excluded full texts and their reasons for exclusion are summarized in S2 Table .

From 17 articles included, 10 focus on MR [ 37 – 46 ] and seven include other services/interventions besides MR [ 47 – 53 ]. Fig 1 illustrates the selection process.

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https://doi.org/10.1371/journal.pone.0210312.g001

Degree of agreement between the two investigators (R.O.S.S. and L.A.M.) was excellent for title and abstract screenings (k1 = 0.942) and full-text screening (k2 = 0.805).

Scores of methodological quality after consensus are presented in Table 1 . The percentage of reviews that met each item of AMSTAR is presented in Fig 2 . Score varied from 2 to 9, presenting average 4.82 ± 2.09. Degree of agreement between the two investigators (R.O.S.S. and L.A.M.) was excellent (k = 0.802). Among the 17 reviews, eight were categorized as low quality [ 37 , 39 , 47 – 49 , 51 – 53 ]; eight as moderate quality [ 38 , 40 – 43 , 44 , 46 , 50 ]; and one review presented high quality [ 45 ]. Seven articles that presented from moderate to high quality were published from 2013 to 2017 [ 40 – 46 ]. Seven reviews with meta-analysis presented AMSTAR score between 4–8 [ 37 , 40 – 42 , 44 , 49 , 53 ].

https://doi.org/10.1371/journal.pone.0210312.t001

https://doi.org/10.1371/journal.pone.0210312.g002

Item six (characteristics about participants, interventions, and results) was presented by all reviews [ 37 – 54 ]. Most of reviews performed literature search in at least two databases and supplementary search (item 3) [ 37 , 38 , 42 – 49 , 51 , 53 ] and performed the quality assessment of systematic reviews (item 7) [ 37 , 38 , 40 – 45 , 50 ]. On the other hand, only two reviews registered the protocol for systematic review (item 1) [ 40 , 42 ] and presented the assessment of publication bias (item 10) [ 41 , 45 ].

Characteristics of systematic reviews

Characteristics of systematic reviews are described in Table 1 . All reviews were published in English between 2005 and 2016. The main authors of the included systematic reviews were from four continents: America, Asia, Europe, and Oceania. Most of reviews had their main authors from Europe (seven reviews; 41.17%) [ 30 – 33 , 40 , 41 , 43 , 48 ], Asia (four reviews; 23.53%) [ 40 , 44 , 46 , 52 ], and Oceania (four reviews; 23.53%) [ 41 , 43 , 47 , 49 ], especially Australia (three reviews; 17,64%) [ 43 , 47 , 49 ]. Primary studies were performed in 28 different countries, and Australia (n = 13) [ 37 – 39 , 41 , 43 – 46 , 48 – 51 ] and the United Kingdom (n = 13) [ 37 , 38 , 41 , 43 – 51 ] were the most frequent countries. No primary study of the systematic reviews was found in Latin America.

Most reviews included controlled studies [ 37 – 43 , 44 – 47 , 49 – 53 ]. Six reviews included only controlled randomized trials [ 37 , 39 , 45 , 50 , 53 ] and five reviews included primary studies of different design as observational, descriptive, qualitative, surveys, and controlled study [ 38 , 43 , 46 , 48 , 52 ]. Regarding population, most reviews included elderly patients [ 37 , 39 , 44 – 46 , 49 – 53 ].

Most frequent primary studies settings were long-term care facilities [ 37 , 46 , 47 , 49 – 52 ], hospitals [ 37 , 38 , 42 , 44 , 45 , 52 ], primary care or clinics [ 37 , 39 – 42 , 45 ], pharmacies [ 37 , 39 , 40 , 41 , 44 ], and patient’s home [ 37 , 41 , 44 , 47 ].

Number of primary studies in the systematic reviews, meta-analysis, and related to MR; assessed outcomes, main results; and structure, processes and outcomes variables

Number of primary studies in the systematic reviews, meta-analysis and related to MR as well as assessed outcomes and main results are presented in Table 2 . Number of primary studies included in the reviews varied from 5 [ 40 ] to 69 [ 52 ]. The minimum and maximum number of primary studies in the systematic reviews related to MR was 4 [ 44 , 51 – 53 ] and 63, respectively [ 43 ]. Only seven of these reviews performed meta-analysis [ 37 , 40 , 41 , 44 , 45 , 47 , 49 ], in which the number of primary studies varied from 3 to 25 [ 37 , 40 ].

https://doi.org/10.1371/journal.pone.0210312.t002

Primary and secondary outcomes assessed were: mortality [ 37 , 41 , 42 , 45 , 50 , 51 ], hospital visits (admissions, readmissions, hospitalizations and emergency department visits) [ 37 , 41 , 42 , 45 , 46 , 50 ], drug use [ 37 , 41 , 46 , 49 , 51 ], and quality of life [ 37 , 40 , 44 , 45 ]. Regarding the assessment of impact of MR in the meta-analyses, significant impact was not shown in any systematic review of mortality [ 37 , 41 , 42 , 45 ], hospitalizations [ 37 , 41 ], length of hospital stay [ 42 , 45 ], readmission [ 45 ], readmission and/or emergency department visits [ 45 ], and revisits to emergency department [ 42 ]. MR presented significantly positive impact (p<0.05) on the all-cause emergency department visits [ 45 ], blood pressure [ 41 ], drug-related readmissions [ 45 ] intensity of pain [ 40 ], low density lipoprotein [ 41 ], number of drugs prescribed [ 37 ], quality of life [ 44 ], patients’ satisfaction [ 40 ], and physical functioning [ 40 ].

Regarding Structure variables described in the systematic reviews, the most frequent were “pharmacists qualified to provide MR” [ 39 , 40 , 42 , 43 , 44 , 48 ], “access to medical records” [ 37 – 38 , 40 , 42 ], “number of pharmacists” [ 37 , 39 , 42 , 44 ], and “remuneration system” [ 41 , 43 , 48 ]. Concerning the Process variables, “number of drugs used” [ 37 – 39 , 41 , 43 , 46 , 47 , 49 – 52 ], “number of interventions” [ 38 – 40 , 43 , 46 , 51 ], and “accepted interventions” [ 38 , 40 , 43 , 44 , 46 , 52 ] were the most common. The most recurrent Outcomes variables, in turn, were “mortality” [ 37 – 39 , 41 – 43 , 45 – 47 , 49 – 52 ], “quality of life” [ 37 – 45 , 47 , 49 , 50 ], “ economy of costs related to drugs” [ 37 , 38 , 41 , 43 , 44 , 46 , 47 , 51 ], “number of hospital visits” [ 37 , 41 , 42 , 45 , 46 , 50 , 51 ], and “patients’ satisfaction” [ 37 , 38 , 40 , 43 , 47 ].

Definitions, terminologies, MR approach, and interprofessional collaboration

Definitions of MR had the objective of identifying and solving DRPs and/or optimizing the drug use ( Table 3 ) [ 37 – 39 , 41 – 46 , 48 , 49 ]. Four systematic reviews presented components of MR, in which the most cited were: assessment of drug use history, review of patient’s medications, and health education [ 41 , 42 , 47 ].

https://doi.org/10.1371/journal.pone.0210312.t003

The terminology “Medication Review” was used in all reviews ( Table 3 ). Nine reviews used “ Clinical Medication Review ” [ 38 , 39 , 41 , 45 – 47 , 49 , 51 , 52 ] and five reviews, “Prescription Review” [ 38 , 39 , 41 , 42 , 46 ]. Moreover, 52.94% (n = 9) considered it as “intervention” [ 37 , 40 , 41 , 44 – 46 , 50 – 52 ], whilst 47.06% (n = 8) of systematic reviews considered MR as service [ 38 , 39 , 41 , 43 , 47 – 49 , 53 ]. All reviews that used only one terminology considered MR as “intervention” [ 37 , 40 , 42 , 43 , 44 ].

Systematic reviews that reported interprofessional collaboration ( Table 3 ) presented different collaborative models. Collaboration and communication occurred through direct and/or indirect contact, such as letters. The most cited health professionals were the physicians [ 37 – 40 , 42 , 43 , 44 , 46 , 47 , 49 – 52 ] and nurses [ 39 , 43 , 46 , 47 , 49 – 52 ].

Limitations declared by systematic reviews

Main limitations described were: absence of search in grey literature [ 37 , 39 , 41 , 46 , 50 , 53 ]; possibility of loss and exclusion of primary studies during search and screening processes [ 39 , 40 , 50 ]; number [ 39 , 42 , 45 , 49 ] and design of included primary studies [ 37 , 43 , 45 , 46 ]; impossibility of performing meta-analysis or limited meta-analysis due to heterogeneity of primary studies [ 42 – 44 ]; and restriction of language in the selection of primary studies [ 38 , 40 , 44 , 46 , 51 , 53 ].

Most reviews had main authors and primary studies from Australia, which includes research with elderly people in community pharmacies, long-term care facilities and hospitals. Australia is one of the first countries to incorporate MR in primary outpatient care and has remuneration programs to accredited pharmacists who offer such service [ 54 – 57 ]. Furthermore, elderly people are some of the priority patients of this practice according to international guidelines as well as children and pregnant women [ 55 – 60 ]. Regarding the practice settings, Bulajeva et al. (2014) [ 54 ] corroborate our results when reported that in Europe, MR has been performed in community environments, hospitals, and long-term care facilities.

Terminologies for MR are not standardized in literature. Among the most well-known are: Home Medicines Review , Medication Use Review and Residential Medication Management Review , in Australia [ 61 – 63 ]; Revisión de la medicación and Revisión sistemática de la medicación , in Spain [ 64 , 65 ]; Medication Review and Comprehensive Medication Review , in the United States [ 66 , 67 ]; Comprehensive Medication Review , in Finland [ 68 , 69 ]; and Medicines Use Review in the United Kingdom [ 70 , 71 ]. These terminologies result from the differences in patient complexity and characteristics of each country and practice setting where MR is performed [ 72 – 74 ].

In pharmacy, there is no consensus among concepts and terminologies of clinical practice [ 75 – 79 ]. Linguistic and cultural questions as well as the overlapping between “what we do” and “how we do” can be causes of these divergences. Consequently, lack of standardization of definitions and terminologies can confuse researchers and professionals who aim to compare results and to confirm the practice effectiveness [ 75 , 78 ]. Thus, definitions and terminologies internationally standardized can benefit the assessment of impact of MR [ 80 ]. Moreover, modelling of clinical pharmacy services should be used since it facilitates the standardization and comparison of MR and provides a holistic approach to the decision-making process and organizational change [ 81 – 85 ]. Therefore, establishing minimum quality standards for MR is important for comparison of the practice as well as for the optimization of the care provided and, consequently, of the patients’ health outcomes.

Regardless of the terminology adopted in systematic reviews, the objective of MR, both as service as well as intervention, is to identify and solve DRPs, implement changes in patients’ pharmacotherapy and improve health outcomes. This objective agreed with guidelines of the countries where this practice is more frequent. In this regard, interprofessional collaboration is necessary to reach this objective [ 55 – 60 , 86 , 87 ]. Collaborations among healthcare professionals declared in the systematic reviews can be seen as a positive factor to achieve better clinical, economic, and humanistic outcomes.

Interprofessional collaboration can be encouraged through specializations, since they motivate information sharing and communication between healthcare professionals. Furthermore, appropriate training of these professionals, such as pharmacists, is essential to develop abilities to the clinical practice, for example, critical thinking and collaborative interpersonal practice [ 88 ]. In Australia, only pharmacists who are trained and go through assessments are accredited and can provide MR [ 89 ]. In the United States, post-graduate pharmacist residency training, as well as physician residency training, has become a requirement for entry-level health-system pharmacy practice [ 90 ]. In this same country, the Accreditation Council for Pharmacy Education (ACPE) (2016) [ 91 ] established interprofessional collaboration as one of the accreditation standards for the professional program in Pharmacy leading to the Doctor of Pharmacy degree. According to this institution, the curriculum should prepare students to provide entry-level, patient-centered care in different practice settings as member of an interprofessional team (with prescribers or other healthcare professional). Thus, literature supports our finding of "pharmacists qualified to provide MR" as a frequently described structure variable.

In this context, MR can be performed by physicians, nurses, and pharmacists. Despite using the same terminology, for physicians and nurses, MR is usually a component of clinical practice whose process has not been well described in literature [ 92 , 93 ]. In pharmacy, studies and guidelines of different countries described MR as a clinical pharmacy service or intervention [ 13 , 16 , 94 – 100 ]. In this overview, the systematic reviews who presented practice components of MR (e.g. assessment of drug use history, health education, and review of patient’s medications) addressed it as service or intervention. However, the discrepancy between the MR approach as an intervention and the concept of the intervention present in the literature is noticeable.

According to the Society of Hospital Pharmacists of Australia, “intervention” is “any action performed by a clinical pharmacist that directly results in the change of patient management or therapy” [ 101 ]. Suggett and Marriott (2016) [ 102 ], in turn, define “intervention” as a process in which the pharmacist identifies and makes recommendations in an attempt to prevent or resolve DRPs. The authors emphasize that the definition of “ intervention ” does not include MR without recommendations for changes in treatment.

In Brazil, “intervention” is a “professional action planned , documented and performed by the pharmacist for optimization of pharmacotherapy , promotion , protection and recovery of health , prevention of diseases and other health problems” [ 103 ]. Thus, we understand "pharmacist intervention" as an action whose goal is to improve patient health outcomes and that may result in changes in pharmacotherapy. In addition, "intervention" is a result of the situational analysis of the patient, and is part of the care plan, step of the patient care process.

Considering the patient care process, three stages are recommended in several health professions, including pharmacists: initial assessment, care plan, and assessment of outcomes. The first stage is a situational analysis in which the pharmacist gathers, analyzes and interprets information about patient’s clinical conditions and pharmacotherapy, aiming to evaluate his or her drug-related needs. The second stage is the care plan whose purpose is to agree with the patient the actions necessary to manage his or her clinical conditions successfully with pharmacotherapy. The care plan includes goals of therapy, interventions (e.g. inclusion of new drug therapy, patient education, and referrals to other health professionals), and a schedule for assessment of outcomes. In the third stage, patient outcomes are assessed, documented, and compared to the goals of therapy [ 104 ].

From the presented patient care process, the most appropriate MR approaches are as "service" or "practice component" . As a service, MR should include all steps of the patient care process. As a practice component, MR is part of other health services, such as medication reconciliation, and consists of the situational analysis of the patient’s pharmacotherapy. Hence, future studies need to describe if MR is a clinical pharmacy service or a practice component. Only then, it will be possible to compare the impact of its results and assure the robustness of this practice.

Regardless of the MR approach, access to medical records is important for the clinical practice. Literature has reported that pharmacists should rely on medical records and technical drug information to make decisions based on evidences and provides the best possible patient care [ 105 , 106 ]. Guidelines highlight the need to obtain patient information from different sources, such as interviews with patient and caregiver, clinical laboratory tests, and medical records, considering that they are complementary [ 55 – 60 ]. Therefore, describing access to medical records as a structure variable is relevant, since the limitation of access to any sources of information can result in the restriction of clinical activities of pharmacists.

Although there is no standardization for terminologies and approaches of MR, there are variables related to the care process that are commonly used in this practice, such as: “number of drugs” and “number of interventions” . Considering the objective of MR, literature confirms that the analysis of the number of drugs is necessary to the assessment of the impact of MR, especially because it can involve vulnerable patients which present polypharmacy, therapeutic duplication, drug interactions, and contraindications [ 55 – 60 ]. Thus, Cipolle et al. (2012) highlight that interventions related to the resolution of DRPs, usually in interprofessional collaboration, may result in the reduction of the number of drugs [ 104 ].

Despite Jokanovic et al. (2016) [ 27 ] mentioning the positive impact of MR in primary studies performed in community environments (e.g. blood pressure control, quality of life, and healthcare costs), some reviews included in our study show that MR results were contradictory, had little significant or were inconclusive. A systematic review conducted by Huiskes et al. (2017) [ 107 ] showed positive and negative effects for some outcomes variables described in our overview. According to the authors, the different results found may be a reflection of factors such as: 1) selection of patients, which may not fit the objective of MR; 2) how MR is performed in the clinical practice, since there is heterogeneity in the work processes and there is no gold standard on how it should be performed; and 3) outcomes and time of follow-up used to assess the impact of MR, variables that should be chosen according to the objective of MR and being more specific to diseases and drugs. Thus, heterogeneity of processes can affect the method of data analysis as well as the sensitivity and specificity of results, such as mortality, economy of drugs costs, hospital readmissions, quality of life and patients’ satisfaction.

Another factor that influences the impact analysis of MR is the methodological quality of the reviews. Although systematic reviews are considered a key element used to the practices of patient care, low quality of reviews have limited processes of decision making and performance of healthcare systems. Our findings were corroborated by literature that has reported low methodological quality of systematic reviews on clinical pharmacy practice. Melchiors et al. (2012) [ 108 ] assessed the quality of 31 systematic reviews, in which 24 presented low and moderate quality. In overview of seven systematic reviews, Aguiar et al. (2014) [ 109 ] noticed that 71.4% of the reviews had low and moderate quality. Rotta et al. (2015) [ 110 ], in turn, found in overview of 49 systematic reviews that no review met all AMSTAR criteria. Therefore, future systematic reviews should value high methodological quality to result in more reliable evidences of real impact of clinical services.

Strengths and limitations

Strengths of this overview include: research in six different databases as well as manual search in the references of the included systematic reviews; use of MESH terms and text words for the literature search; use of 15 different terminologies to MR in the literature search; title, abstract, and full text screenings as well as quality assessment performed by two independent investigators. Moreover, systematic reviews were not excluded based on methodological quality, study design, practice setting, and population. Thus, our study presents a panorama of systematic reviews about pharmacist-participated MR. This overview comprised variables little explored in overviews of systematic reviews on MR, such as definitions and terminologies of MR; interprofessional collaboration; MR approach as well as structure, processes, and outcomes variables described in the systematic reviews.

This overview also presents limitations. Search in the grey literature was not performed. As most systematic reviews are found in databases, the inclusion of only indexed reviews may not have influenced the final sample. Data extraction and analysis of the variables studied were based on systematic reviews rather than primary studies, which may have resulted in overlapping of primary studies in the evaluation of results of MR. Many included reviews did not provide clear information or presented few details on primary studies’ design, population, and practice setting; definitions of MR; and impact of MR, this might have compromised data extraction. Moreover, AMSTAR limitations, such as the subjectivity of items “no” and “cannot answer” and the dependence of quality of reports [ 111 , 112 ], could have influenced the assessment of methodological quality of systematic reviews included in this overview.

Toward a future research agenda

This overview of systematic reviews is a starting point to analyze the panorama of literature on pharmacist-participated MR in different practice settings regarding to the concepts, terminologies and approach of MR as well as interprofessional collaboration. From the findings of this overview, it is possible to identify the need for future systematic reviews and primary studies to clarify these variables. The lack of clarity about concepts, terminologies and MR approach as well as interprofessional collaboration extracted from the primary studies of the included systematic reviews may be due to the summarization of the results found in these primary studies and/or to the lack of clarity of the primary studies themselves. Thus, future systematic reviews should analyze these variables in the primary studies in order to reinforce the need to standardize concepts, terminologies and approach of MR in the literature. Moreover, the findings of this overview should also be addressed in future primary studies since any systematic review is only as good as the primary studies that compose it. That is, having in the literature high quality of systematic reviews is just as important as having high quality primary studies. Therefore, future studies, both systematic reviews and primary studies, should clearly present the variables studied in this manuscript in order to facilitate the understanding of effectiveness of MR and the comparison of its results.

In this overview, considerable heterogeneity of systematic reviews about MR was evidenced, especially regarding practice setting, population, MR approach and terminology. Description of patient care process of the primary studies is not clear in some reviews. These facts may limit the comparison, summarization and understanding of MR results. “Medication Review” was the most used terminology, whose main objective is the identification and resolution of DRPs to optimize the drug use. MR practice is mostly comprehended as “intervention” , and its main collaborator is the physician. Moreover, methodological quality of most systematic reviews was below ideal. In the light of what was mentioned, it is necessary to come to an international agreement regarding the work process of MR, as a clinical service or practice component, improving, then, the assessment, comparison and optimization of care quality given to patients.

Supporting information

S1 table. search strategy in databases..

https://doi.org/10.1371/journal.pone.0210312.s001

S2 Table. List of excluded studies and reasons for exclusion.

Abbreviation: MR—Medication Review.

https://doi.org/10.1371/journal.pone.0210312.s002

S1 Checklist. PRISMA checklist.

Abbreviations: NA: Not Applicable; U: Unrealized.

https://doi.org/10.1371/journal.pone.0210312.s003

Acknowledgments

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—Finance Code 001. The authors thanks specially to the researchers of the Laboratory of Teaching and Research in Social Pharmacy (LEPFS) for their contribution to this manuscript.

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• Research article
• Open access
• Published: 10 November 2021

Development of a model of medication review for use in clinical practice: Bristol medication review model

• D. McCahon 1 ,
• R. E. Denholm 1 ,
• A. L. Huntley 1 ,
• S. Dawson 1 ,
• P. Duncan 1 &
• R. A. Payne 1  

BMC Medicine volume  19 , Article number:  262 ( 2021 ) Cite this article

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Medication review is a core aspect of medicine optimisation, yet existing models of review vary substantially in structure and content and are not necessarily easy to implement in clinical practice. This study aimed to use evidence from the existing literature to identify key medication review components and use this to inform the design of an improved review model.

A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of stand-alone medication review in adults (18+ years). The review updated that by Huiskes et al. (BMC Fam Pract. 18:5, 2017), using the same search strategy implemented in MEDLINE and Embase. Studies were assessed using the Cochrane risk of bias tool. Key review components were identified, alongside relevant clinical and health service outcomes. A working group (patients, doctors and pharmacists) developed the model through an iterative consensus process (appraisal of documents plus group discussions), working from the systematic review findings, brief evidence summaries for core review components and examples of previous models, to agree on the main purpose of the review model, overarching model structure, review components and supporting material.

We identified 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes. The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision-making and implementation. Most key components identified in the literature were included. The final model was considered to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice.

Conclusions

The Bristol Medication Review Model provides a framework for standardised delivery of structured reviews. The model has the potential for use by all healthcare professionals with relevant clinical experience and is designed to offer flexibility of implementation not limited to a particular healthcare setting.

Peer Review reports

Medicines are a fundamental intervention used by health services to improve health and well-being. In patients with long-standing or several health problems, the use of multiple medicines—polypharmacy—is commonplace [ 1 ]. If used appropriately, polypharmacy may lead to improvements in clinical outcomes [ 2 ]. However, it may also be associated with a range of adverse consequences including hazardous prescribing [ 3 ] and reduced quality of life [ 4 ].

The process of medicine optimisation serves to ensure medicines are used in the most effective and safe manner possible [ 5 ]. The Royal Pharmaceutical Society describes four guiding principles to achieve this, applicable to both front-line care and service development: understanding the patient’s experience, ensuring evidence-based choice of medicines, ensuring the safety of medicines use and embedding medicine optimisation in routine practice [ 6 ]. Medication review forms a critical part of the process. It has been defined by the UK’s National Institute for Health and Care Excellence (NICE) as “a structured, critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medicine-related problems and reducing waste” [ 7 ]. Other definitions may be more focused; for example, the Pharmaceutical Care Network of Europe considers reviews to “entail detecting drug-related problems and recommending interventions” [ 8 ]. The structure and content of reviews also vary depending on the nature of clinical information available and the involvement (or otherwise) of the patient in the review process [ 8 ]. In addition, clinical guidance differs in how it specifies the way a review should be carried out: the WHO technical report on medicine safety in polypharmacy describes a seven-step model [ 9 ], whereas the NICE medicine optimisation guideline does not outline a particular approach [ 7 ].

Some studies have demonstrated medication review to be associated with improvements in certain clinical outcomes in specific patient groups. For example, significant reductions in drug-related problems have been achieved with medication review in people with diabetes [ 10 ] and heart failure [ 11 ]. In addition, complex interventions, incorporating elements such as clinical informatics and education, have been shown to reduce problematic prescribing [ 12 , 13 ]. However, a systematic review of the literature found a majority of pharmacist-led interventions in residential aged care facilities, of which medication review was a common component, were ineffective [ 14 ]. Another review focusing on older people with multimorbidity and polypharmacy found mixed effects on outcomes [ 15 ]. A further systematic review by Huiskes et al. found that an isolated medication review had minimal impact on clinical outcomes and no effect on the quality of life, attributing this in part to the insufficient standardisation of reviews and differing review objectives, and going as far to suggest such reviews should not be part of standard care [ 16 ]. Nevertheless, structured review is widely used internationally, despite significant inconsistencies in approach including in both service design and clinical issues addressed [ 17 , 18 ].

The aim of the current study was to review the existing literature to identify the active elements of a medication review and use the findings to develop an evidence-based, structured model of medication review for use in clinical practice.

Systematic review study design

The protocol for the systematic review has been published on PROSPERO (reference CRD42018109788) [ 19 ]. The purpose of the literature review was to establish the structure and components commonly included within medication review strategies. This was done by updating an existing review [ 16 ], to which revised inclusion/exclusion criteria were additionally applied.

The starting point was a systematic review published in 2017 by Huiskes et al. [ 16 ], the aim of which was to summarise the evidence of medication review as a stand-alone short-term intervention (e.g. as performed in clinical practice), irrespective of the patient population and the outcome measures. Huiskes et al. identified 33 randomised controlled trials (RCTs) published before September 2015 investigating the effectiveness of medication review.

Data sources and searches

An updated literature search, using the same search strategy as Huiskes et al. for the period 2015 to 2018, was also performed in MEDLINE and Embase databases. Reference lists and citations of included papers were also examined for relevant articles. The search strategy is presented in Additional File 1 : Appendix 1. Papers were managed in EndNote.

Study selection

The study selection criteria were modified slightly from that of Huiskes et al., to increase relevance in terms of informing the development of a new review model. We applied these revised inclusion/exclusion criteria both to the new studies identified and to the previous studies identified in the Huiskes’ review. Consistent with the approach taken by Huiskes, we applied no restrictions to the outcome measures.

All RCTs investigating the effectiveness of medication review (including protocol papers) were considered for inclusion, where the intervention was subjectively judged by the research team to meet the definition of medication review as stated by the NICE guidelines for medicine optimisation [ 7 ]. The study design needed to include a cross-sectional intervention delivered within a primary or secondary care setting, by any healthcare professional, with the intervention involving patient participation in the form of provision of information and/or involvement in the discussion and decision-making. The study population was restricted to adults, aged 18 years or over.

Studies were excluded where the medication review (1) targeted a specific disease, condition or a single class of drug; (2) aimed to solely improve patient knowledge and adherence or reduce costs; (3) formed part of a complex intervention or included a co-intervention (e.g. discharge counselling, non-pharmacological intervention, professional education); (4) was conducted within a palliative care setting; or (5) involved no direct patient participation. We also excluded articles in languages other than English.

Reviewer DM ran the database searches. The titles and abstracts were screened by DM and RP/RD independently. Full-text screening was conducted independently by DM and RD. Disagreement between reviewers was resolved through discussion with RP.

Data extraction and risk of bias assessment

The characteristics of the study (e.g. setting, population, outcomes), medication review components (e.g. clinical areas, question types, review facilitators), underpinning behavioural change theory (which could be used to inform specific approaches to model design) and outcome data were extracted from the full-text articles into a data recording proforma by one reviewer and checked by a second reviewer.

The risk of bias in eligible studies was independently assessed by two of the three reviewers (DM, RD, RP) using the Cochrane risk of bias tool [ 20 ], with disagreements resolved through discussion with a third reviewer.

Thematic analysis was used by DM to develop a framework to classify the components of the different medication review strategies. RD piloted the framework in a random selection of 25% of studies. Comparison to identify disagreements was undertaken with discrepancies being discussed with RP to agree and refine the framework and improve face validity. The finalised framework (Additional File 1 : Appendix 2) was used independently by DM and RD to code all included studies.

Outcomes were categorised into five main overarching groups, following discussion between DM, RD and RP based on the experience of the topic area: safety, efficacy, service use, patient experience and mortality. The latter two categories were added as it was apparent that the first three categories prespecified by the protocol did not capture the full range of outcomes being reported. P -values of < 0.05 were considered statistically significant.

Each intervention component was mapped against corresponding study outcomes, with a view to conducting a meta-regression of the two.

Stakeholder working group

The medication review model was constructed through an iterative process through consultation via meetings and offline work with a UK-based stakeholder working group comprising clinical (RP) and non-clinical (DM) members of the research team, two GPs, a geriatrician, two clinical pharmacists with roles in medicine optimisation and two patients with experience in patient and public engagement with medicine optimisation research. The group was recruited through existing networks and selected to ensure diversity of membership across professions and clinical settings, whilst being small enough to maximise within-group efficiency and ensure consensus could be reached. The two 2-hour meetings of the group were facilitated by RP, a clinical pharmacologist and GP with expertise in medicine optimisation. Additional work was conducted remotely, and the group members were reimbursed for their time. Formal ethical permissions were not required.

Meetings and group work employed a standard approach to group decision-making, involving discussion, followed by formation and modification of proposals, and checking agreement of participants. Meetings were structured around a clear agenda, with all group members afforded equal input. Outside of meetings, individual participants’ comments on materials and specific preferences were collated and then shared with the group as a whole prior to further decisions being taken.

To begin, individuals in the group were provided by email with a summary of the systematic review findings, along with brief evidence summaries for each of the clinical themes and core elements of the process and delivery themes (healthcare professional interaction, follow-up, review facilitators) identified by the review, and examples of previous review models. Independent comments were then shared with the group. The initial meeting was used to agree on the main purpose of the review model, to identify potential overarching model structures and to recommend potential review components and supporting material. Following the first meeting, three draft review models were drawn up by the research team (RP, DM, RD), informed by the framework developed from the systematic review, previous sample review models and recommendations from the working group. These draft models were circulated via email to group members for review and comment. A further draft model was drawn up based on resulting feedback and shared along with comments with the group. A second meeting was then held during which the overall model structure was agreed, and further decisions made about the content and supporting materials. The final model was agreed upon by all participants and finalised via email following the third round of refinement and comment.

Patient and public involvement

Our departmental Patient and Public Involvement in Research advisory group, with specific interests in medicines and prescribing research and comprising patients of a diverse mix of ages, gender and ethnicity, was consulted on the design and purpose of the study. Patients also contributed to the model development as part of the stakeholder working group.

Systematic review

The abstracts of 1498 scientific papers were identified by the updated search, in addition to the original 33 records from Huiskes’ review. Following full-text assessment, a total of 32 articles representing 28 trials met the selection criteria and were included (PRISMA flow diagram, Fig. 1 ; Additional File 1 : Appendices 3 and 4).

PRISMA flow diagram of the literature search and study selection process

The components identified in the different medication review strategies are reported in Table 1 . The most frequently used review components were medicines reconciliation (26/28 studies, e.g. determining actual drug use by the patient), an assessment of medicine safety (22 studies, e.g. assessment of side effects, potential for anticholinergic drug effects, contraindications and/or drug-drug interactions), assessment of suboptimal treatment (19 studies, e.g. presence of a valid clinical indication, unnecessary medicines use or undertreatment) and evaluation of patient-orientated issues (18 studies, e.g. patient knowledge and understanding of medicines, patient values and preferences and practical issues pertaining to taking medicines). Less frequently used review components were assessment of medication adherence (14 studies), over-the-counter therapy (13 studies), drug monitoring (10 studies, e.g. drug levels and other biomarkers), one or more drug appropriateness tools (9 studies, e.g. STOPP/START criteria) and drug costs (8 studies).

The vast majority of reviews (25/28) involved a face-to-face consultation with the patient, although the exact nature of communication was often not reported (Table 1 ). Most medication reviews involved input from more than one healthcare profession (25/28) and all but two included pharmacist involvement. Where review decisions were not being actioned by the reviewer themselves, the treatment plan was discussed with another healthcare professional in 15 studies, and written information was provided in 13 studies. Active follow-up formed part of the review process in 11 studies. A number of potential review facilitators were identified, including supplying providers with financial incentives, training and supporting resources.

The outcomes assessed in each study are reported in Table 2 . Overall, 15 studies investigated the impact of the medication review intervention on unplanned hospital admissions, 13 examined the total number of medicines prescribed and 11 assessed the outcome of generic drug-related problems. Fifteen studies examined an outcome—quality of life—which forms part of a proposed core outcome set for polypharmacy medication review [ 21 ]. Few studies assessed the impact of the medication review strategy on cognitive function (3), number of falls (2), mortality (1) or medication efficacy (1); further analyses of these outcomes were therefore considered inappropriate. Two of 11 studies demonstrated statistically significant improvements in generic drug-related problems, 3 of 9 showed improvements in adherence, 7 of 13 studies reported significant reductions in the number of medicines and 1 of 15 studies showed an improvement in quality of life. A further study showed an increase in unplanned hospital admissions in the intervention group. Due to heterogeneity in intervention design and outcome measures, it was not possible to undertake a meta-analysis or meta-regression of outcomes on review components.

The summary results of the risk of bias assessment are reported in Fig. 2 (individual study risk of bias is reported in Additional File 1 : Appendix 5). Overall, included studies had a moderate risk of bias. There was a lack of detail provided by some studies to fully assess bias, particularly methods of randomisation and allocation concealment. It was not possible to blind participants in this type of intervention, and this question was therefore rated as high risk in most cases, although some studies did blind outcome assessors thereby reducing detection bias. Two studies were only available as protocol papers; review components and intended outcomes were extracted but not results.

Overall risk of bias

Model development

The final model is presented in Fig. 3 ; the final version with accompanying supporting materials is provided in Additional File 1 : Appendix 6.

Bristol Medication Review Model

At the initial meeting, the working group agreed that the resulting structured medication review model should be simple and pragmatic and one that can be used across professions and settings, applied in a flexible way, and include relatively “high-level” detail only.

The group expressed a number of key views about the overarching review model structure, based on the examples presented to it prior to the first meeting, and these informed the subsequent draft models developed by the research team. Firstly, the defined start (patient values and preferences) and end (decision making and implementation) was considered to be more in-keeping with traditional consultation structure and patient expectation, and thus aiding implementation in clinical practice. Secondly, the group felt that the parallel information gathering and evaluation stages facilitated a more holistic approach, making it easier to capture the broader patient story, with the former stage focused more on patient problems and the latter stage on medications. Thirdly, the model was considered by the group to emphasise the importance of patient-centredness.

The first meeting also provided an opportunity to agree on the review components. Whilst acknowledging that all the medication review components identified from the literature were relevant, the working group took a decision to exclude medication cost reduction, on the basis it was less relevant to patient-facing clinical interaction. In addition, the use of potentially inappropriate prescribing tools (e.g. STOPP/START, Beers) was excluded on the basis that these are already captured by other review components. The group also felt that the use of non-pharmacological therapies, and the concept of drug cascade, should be explicitly mentioned by the model.

The second meeting focused on refining the review model and agreeing on the supporting materials. The working group advocated the use of slightly more “technical” terms in the model to aid brevity, given the clinical audience. However, to improve understanding, there was strong backing for additional inclusion of a list of definitions for the terminology used, in turn supported by example open questions suitable for use in clinical practice. Although there was an agreement that the use of the review model should remain flexible and not be limited to a single approach, the group did make several recommendations for implementation. These included advocating the use of pre-review preparation, a preference for in-person face-to-face interaction, use of various review facilitators (e.g. training, dedicated time, financial incentives) and taking care to avoid clinical informatics support (e.g. decision support tools or computerised data-recording templates) or review monitoring processes unduly impairing the clinical process.

It has been possible to use existing studies to develop a new, patient-centred model of review that is potentially suitable for clinical practice which incorporates established components of medication review. There is heterogeneity in the design of various models of medication review that have been studied in clinical trials, and despite patient-centredness being considered core to many medication models, patient perspectives are not captured by around a third of models. The studies identified are not of high quality, do not report the content and structure of interventions in detail and are inconsistent in the outcome measures they examine. Nevertheless, a number of consistent components exist which are appropriate for use in practice, with recurring themes including safety, suboptimal treatment and broader medication use considerations such as adherence. The current study provides some evidence that medication reviews may reduce total numbers of medications and cost and more limited evidence for improvements in adherence and drug-related problems. However, there is no clear evidence that particular elements of these are associated with improvements in specific clinical outcomes. Nonetheless, it has been possible to draw on the existing literature to inform a new review model which is more comprehensive than other published models, has the potential to reduce heterogeneity in existing approaches [ 16 ] and may help address barriers to implementation such as complexity and applicability [ 22 ].

Strengths and limitations

The use of formal systematic review methodology has helped ensure the model is comprehensive in terms of its content. The involvement of a range of clinicians together with patients has helped improve acceptability and generalisability. However, there are limitations. In order to isolate the effect of medication review, we restricted studies to those of medication review alone by excluding more complex interventions, and this may have resulted in the omission of important studies. We only extended our search to 2018, and this may again have omitted relevant trials, although we do not believe more recent literature is likely to significantly alter our analytical framework or the resulting model development. We were also unable to use quantitative methods to synthesise our findings as originally proposed in our protocol, due to heterogeneity in the nature of the interventions and in the outcomes reported. This makes it difficult to determine which elements of the review model are most likely to be effective in practice. In addition, our initial intention had been to use the information on the behavioural theory basis of the various interventions to inform the model design, but we were unable to extract this due to insufficient published detail. The stakeholder working group was also relatively small but reflects a trade-off between ensuring representativeness and avoiding difficulties of achieving consensus in a larger group. Finally, further work is required to test acceptability, feasibility and effectiveness in practice.

Comparison with literature and implications for practice

Others have observed substantial variations in the content of medication reviews [ 17 ], and this is reflected in the variability of intervention design we observed in our own study. Our model sought to capture most of the key components identified in our review of the literature, and these correspond with, and indeed are arguably more comprehensive than, those set out by recommendations made in various national and international guidance and standards documents [ 7 , 9 , 23 , 24 ]. Although medication costs are considered in some review models, our decision to exclude this is consistent with others’ views that this is less relevant from a clinical and patient perspective [ 25 ].

The design of the model emphasises the importance of patient-centredness. This is considered central to medicine optimisation [ 6 ] and can improve patient satisfaction and adherence [ 26 ]. The structure is also consistent with familiar traditional consultation frameworks such as the Calgary-Cambridge approach [ 27 ], which may facilitate implementation in practice. At the same time, the design is flexible enough to allow for the contrasting approaches of doctors and pharmacists, the latter perceived as providing more medication-focused as opposed to person-focused care [ 28 ].

It is not possible to say whether the proposed model is effective at optimising the use of medicines in practice, and further evaluation is required. Nevertheless, the model and accompanying example questions and supporting information are consistent with relevant behaviour change theory, addressing psychological capability and both reflective and automatic motivations of the clinician to engage with the medication review process, by providing an easy-to-use resource which supports the development of knowledge and skills, as well as facilitating the planning and delivery of the review process [ 29 ]. Flexibility in design is also likely to aid implementation, given it has been argued elsewhere that restrictive guidance may not be well suited to the complexity of clinical practice [ 30 ]. There is also evidence to support the recommendations for implementation such as financial incentivisation [ 31 ] and provision of relevant training [ 32 ]. Several potential barriers to the implementation of guidance have additionally been identified by previous research, including lack of evidence, implausibility, complexity, poor layout, lack of applicability and generalizability [ 12 ]. By addressing these issues, we can have greater confidence in the acceptability of the proposed model.

The Bristol Medication Review Model has been developed by integrating common themes identified in existing studies with a patient-centred approach. The model addresses deficits in existing approaches, emphasising the importance of capturing patient values and preferences. The framework enables reviews to be conducted in a consistent manner, potentially reducing variation in standards of existing reviews. The model is designed to offer flexibility of implementation, with the potential for use by all healthcare professionals with relevant clinical experience across healthcare settings. Evaluation of the acceptability, feasibility and effectiveness of the model will be the subject of future study.

Availability of data and materials

Data from the systematic review can be shared on request.

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Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service (NSQHS) Standards. Action 4.10: Medication review. 2019. Available at: https://www.safetyandquality.gov.au/standards/national-safety-and-quality-health-service-nsqhs-standards/medication-safety-standard/continuity-medication-management/action-410

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Funding for the working group was provided by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group

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RP conceived the study. DM acquired funding. DM, RD and RP designed the study and undertook the data collection and analysis. AH and SD advised further on the methodology. All authors contributed to the interpretation of the findings. RP and PD advised on the clinical aspects of the design and interpretation. The initial manuscript was drafted by DM, RD and RP. All authors commented on the final version. All authors read and approved the final manuscript.

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Additional file 1:..

Appendix 1. Search strategy and full electronic search. Appendix 2. Medication review framework and definitions. Appendix 3. Reference list of included articles, grouped by study intervention. Appendix 4. Excluded articles and reasons for exclusion. Appendix 5. Risk of bias within each study. Appendix 6. Bristol Medication Review Model – practice document.

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McCahon, D., Denholm, R.E., Huntley, A.L. et al. Development of a model of medication review for use in clinical practice: Bristol medication review model. BMC Med 19 , 262 (2021). https://doi.org/10.1186/s12916-021-02136-9

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DOI : https://doi.org/10.1186/s12916-021-02136-9

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Medication review

Medication review is a systematic assessment of a patient's medication management with the aim of optimising the quality use of medicines and minimising medication-related problems.

It is a multidisciplinary responsibility that ensures the ongoing safe and effective use of medicines at all stages of the medication management pathway. 1,2

Types of Medication Review

Medication Order Review

A review of individual medication orders and / or prescription validity. It may take place without the patient present.

Medication Adherence Review

A review of a patient's medicine taking behaviour (how they actually take their medicines and what their beliefs about medicines are).

Clinical Medication Review

A comprehensive review of a patient's medicines in the context of their clinical conditions. It considers the management of the conditions being treated and the appropriateness and continuing need of each medication, as well as potential gaps in therapy. Partnering with the patient/carer is essential when undertaking a clinical medication review.

Medication Review and Medication Reconciliation

Medication Review and Medication Reconciliation are distinct but interrelated processes.

Medication review involves an evaluation of a patient’s medicines with the aim of optimising the quality use of medicines. A medication review will often result in the identification of actual or potential medication-related problems and recommendations to optimise medicines use.

Medication Reconciliation involves ensuring accurate and complete medicines information is communicated at all transfers of care. Medication reconciliation will often result in identification of medication discrepancies (e.g. differences between the documented medication history and the admission medication orders) which may be intentional or unintentional. Visit the Medication Reconciliation page for more information.

Why is medication review important?

Conducting evidence-based medication reviews can optimise the medications used and reduce medicine-related problems.

ACSQHC Medication Safety Standard

The Australian Commission on Safety and Quality in Health Care's (ACSQHC) National Safety and Quality Health Service (NSQHS) Standards (second edition) require health service organisations to have processes:

• To perform medication reviews for patients, in line with evidence and best practice.
• To prioritise medication reviews, based on a patient's clinical needs and minimising the risk of medication-related problems.
• That specify the requirements for documentation of medication reviews, including actions taken as a result. 1

How to conduct a Medication Review?

Medication review is a multidisciplinary responsibility which ensures the ongoing safe and effective use of medicines at all stages of the medication management pathway.

The delivery models for medication review may vary across health service organisations. Patients with a higher risk of experiencing medication-related harm should be given priority. 1,2 Risk assessment and stratification should be based on evidence and local organisational priorities. 3

A Guide to Medication Reviews for NSW Health Services 2019

In partnership with the Medication Review Working Group, a subgroup of the Continuity of Medication Management Expert Advisory Group (CMMEAG), the CEC has developed a Guide to Medication Reviews as a resource for health service organisations and clinicians to develop systems and processes to conduct medication reviews for patients.

Further information

The guide specifically supports action 4.10a of the NSQHS Standards by providing advice on evidence and what constitutes best practice when performing medication reviews.

The guide encourages health service organisations to consider:

• the purpose of medication review
• the importance of partnering with patients, carers and their families
• roles, responsibilities and training requirement of clinicians
• development of a consistent and effective method for performing medication reviews, including how it can be built into existing work practices and how it relates to other medication management processes such as medication reconciliation.

With the majority of NSW Health services utilising electronic medication management systems, the development of electronic tools to assist with risk stratification as well as documentation and monitoring requirements for medication review and other medication management processes have become possible. The CEC is committed to working towards safe, user friendly electronic solutions to meet the needs of health services.

Polypharmacy review

Inappropriate polypharmacy in older people is common and contributes substantially to adverse drug events, drug-drug interactions, medication non-adherence and reduced functional capacity. 4

Translational research projects funded by NSW Health and Sydney Health Partners, led by Prof Sarah Hilmer from Northern Sydney LHD, with associate investigators from Sydney LHD, NSW Therapeutic Advisory Group (TAG), the University of Sydney and Macquarie University, developed and piloted a polypharmacy intervention bundle to facilitate review of polypharmacy in routine care.

Polypharmacy in Older Inpatients e-Learning module

The HETI module (course code: 183595643) is suitable for all clinical staff involved in the care of older inpatients. It provides information and tools to review polypharmacy, prioritisation of patient review and resources for deprescribing.

Resource kit

The Resource kit for Measuring Strategies to Reduce Harm from Polypharmacy in Australian Hospitals contains Quality Use of Medicines (QUM) indicators, Patient Reported Experience Measures (PREMs) and Risk Stratification Tools.

It has been designed to provide a set of tools to evaluate processes involved in identification of medication-related harm in older hospitalised patients and the management of inappropriate polypharmacy. The PREMs evaluate patients' experiences in the decision-making process of deprescribing in hospital.

• Deprescribing guides and consumer leaflets

There are several deprescribing guides and consumer leaflets available . The Deprescribing Guides support clinicians in deprescribing. The Consumer Information Leaflets support communication of deprescribing decisions to patients and/or carers.

• Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards Guide for Hospitals. Sydney: ACSQHC.
• Clyne, W., Blenkinsopp, A. and Seal R. (2008). A Guide to Medication Review. [online] Liverpool, UK: National Prescribing Centre. Available at: http://www.cff.org.br/userfiles/52%20-%20CLYNE%20W%20A%20guide%20to%20medication%20review%202008.pdf [Accessed 26 Feb. 2020].
• Society of Hospital Pharmacists of Australia. (2015). Risk Factors for Medication-Related Problems: fact sheet. Melbourne: SHPA.
• Maher RL, Hanlon J, Hajjar ER. (2013). Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf13(1):57–65. 10.1517/14740338.2013.827660
• Guide to Medication Reviews for NSW Health Services
• Polypharmacy in Older Inpatients module
• Polypharmacy resource kit

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Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes

NICE guideline [NG5] Published: 04 March 2015

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1 Recommendations

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Terms used in this guideline

• 1.1 Systems for identifying, reporting and learning from medicines‑related patient safety incidents

1.2 Medicines-related communication systems when patients move from one care setting to another

1.3 medicines reconciliation, 1.4 medication review, 1.5 self-management plans, 1.6 patient decision aids used in consultations involving medicines, 1.7 clinical decision support, 1.8 medicines-related models of organisational and cross-sector working.

People have the right to be involved in discussions and make informed decisions about their care, as described in  NICE's information on making decisions about your care .

Making decisions using NICE guidelines  explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

Adverse drug reaction This is a response to a medicinal product which is noxious and unintended. Response in this context means that a causal relationship between a medicinal product and an adverse event is at least a reasonable possibility. See also Medicines and Healthcare Products Regulatory Agency for further information.

Complementary medicine Treatments that fall outside of mainstream healthcare. These medicines and treatments range from acupuncture and homeopathy to aromatherapy.

'Fair blame' culture In health and social care, this enables open and honest reporting of mistakes that are treated as an opportunity to learn to improve care.

Over‑the‑counter medicines Medicines that can be bought without a prescription.

Person's baseline risk Patient decision aids illustrate the absolute benefits and risks of interventions, assuming a particular baseline risk. It is important to take into account the person's likely starting or baseline risk when using a patient decision aid. Even though the relative risk is the same regardless of the person's baseline risk, people with a lower baseline risk than that illustrated in a patient decision aid will have a lower absolute chance of benefiting and a lower residual risk. People with a greater baseline risk than that illustrated will have a greater absolute chance of benefiting but also a greater residual risk.

PINCER (pharmacist‑led information technology intervention for medication errors) Method for reducing a range of medication errors in general practices with computerised clinical records.

Polypharmacy Use of multiple medicines by a person.

Preference‑sensitive decision Decisions about treatment made based on the person's preferences and personal values of each treatment option presented. Decisions should be made only after patients have enough information to make an informed choice, in partnership with the prescriber.

Robust and transparent Robust and transparent processes, including sharing of information and appropriate collaboration with relevant stakeholders, aims to improve the consistency of decision‑making about medicines and ensure that patient safety is not compromised. This should reduce inappropriate variation in patient care when decisions are made due to inconsistent, inadequate or unsafe processes and policies. However, even with robust and transparent processes in place, legitimate variation will remain. Organisations will make decisions within their local governance arrangements that are based on local priorities and the needs of their local population.

1.1 Systems for identifying, reporting and learning from medicines‑related patient safety incidents

Improving learning from medicines‑related patient safety incidents is important to guide practice and minimise patient harm. Medicines‑related patient safety incidents are unintended or unexpected incidents that are specifically related to medicines use, which could have or did lead to patient harm. These include potentially avoidable medicines‑related hospital admissions and re‑admissions, medication errors, near misses and potentially avoidable adverse events.

1.1.1 Organisations should support a person‑centred, 'fair blame' culture that encourages reporting and learning from medicines‑related patient safety incidents.

1.1.2 Health and social care practitioners should explain to patients, and their family members or carers where appropriate, how to identify and report medicines‑related patient safety incidents.

1.1.3 Organisations should ensure that robust and transparent processes are in place to identify, report, prioritise, investigate and learn from medicines‑related patient safety incidents, in line with national patient safety reporting systems – for example, the National Reporting and Learning System .

1.1.4 Organisations should consider using multiple methods to identify medicines‑related patient safety incidents – for example, health record review, patient surveys and direct observation of medicines administration. They should agree the approach locally and review arrangements regularly to reflect local and national learning.

1.1.5 Organisations should ensure that national medicines safety guidance, such as patient safety alerts, are actioned within a specified or locally agreed timeframe.

1.1.6 Organisations should consider assessing the training and education needs of health and social care practitioners to help patients and practitioners to identify and report medicines‑related patient safety incidents.

1.1.7 Health and social care practitioners should report all identified medicines‑related patient safety incidents consistently and in a timely manner, in line with local and national patient safety reporting systems, to ensure that patient safety is not compromised.

1.1.8 Organisations and health professionals should consider applying the principles of the PINCER intervention to reduce the number of medicines‑related patient safety incidents, taking account of existing systems and resource implications. These principles include:

using information technology support

using educational outreach with regular reinforcement of educational messages

actively involving a multidisciplinary team, including GPs, nurses and support staff

having dedicated pharmacist support

agreeing an action plan with clear objectives

providing regular feedback on progress

providing clear, concise, evidence‑based information.

1.1.9 Consider using a screening tool – for example, the STOPP/START tool in older people – to identify potential medicines‑related patient safety incidents in some groups (STOPP, Screening Tool of Older Persons' potentially inappropriate Prescriptions; START, Screening Tool to Alert to Right Treatment). These groups may include:

adults, children and young people taking multiple medicines ( polypharmacy )

adults, children and young people with chronic or long‑term conditions

older people.

1.1.10 Organisations should consider exploring what barriers exist that may reduce reporting and learning from medicines‑related patient safety incidents. Any barriers identified should be addressed – for example, using a documented action plan.

1.1.11 Health and social care organisations and practitioners should:

ensure that action is taken to reduce further risk when medicines‑related patient safety incidents are identified

apply and share learning in the organisation and across the local health economy, including feedback on trends or significant incidents to support continuing professional development. This may be through a medicines safety officer, controlled drugs accountable officer or other medicines safety lead.

Relevant information about medicines should be shared with patients, and their family members or carers, where appropriate, and between health and social care practitioners when a person moves from one care setting to another, to support high‑quality care. This includes transfers within an organisation – for example, when a person moves from intensive care to a hospital ward – or from one organisation to another – for example, when a person is admitted to hospital, or discharged from hospital to their home or other location.

Recommendations in this section update and replace recommendation 1.4.2 in NICE's guideline on medicines adherence .

1.2.1 Organisations should ensure that robust and transparent processes are in place, so that when a person is transferred from one care setting to another:

the current care provider shares complete and accurate information about the person's medicines with the new care provider and

the new care provider receives and documents this information, and acts on it. Organisational and individual roles and responsibilities should be clearly defined. Regularly review and monitor the effectiveness of these processes. See also section 1.3 on medicines reconciliation. Take into account the 5 rules set out in the Health and Social Care Information Centre's guide to confidentiality in health and social care when sharing information.

1.2.2 For all care settings, health and social care practitioners should proactively share complete and accurate information about medicines:

ideally within 24 hours of the person being transferred, to ensure that patient safety is not compromised and

in the most effective and secure way, such as by secure electronic communication, recognising that more than one approach may be needed.

1.2.3 Health and social care practitioners should share relevant information about the person and their medicines when a person transfers from one care setting to another. This should include, but is not limited to, all of the following:

contact details of the person and their GP

details of other relevant contacts identified by the person and their family members or carers where appropriate – for example, their nominated community pharmacy

known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see NICE's guideline on drug allergy )

details of the medicines the person is currently taking (including prescribed, over-the-counter and complementary medicines ) – name, strength, form, dose, timing, frequency and duration, how the medicines are taken and what they are being taken for

changes to medicines, including medicines started or stopped, or dosage changes, and reason for the change

date and time of the last dose, such as for weekly or monthly medicines, including injections

what information has been given to the person, and their family members or carers where appropriate

any other information needed – for example, when the medicines should be reviewed, ongoing monitoring needs and any support the person needs to carry on taking the medicines. Additional information may be needed for specific groups of people, such as children.

1.2.4 Health and social care practitioners should discuss relevant information about medicines with the person, and their family members or carers where appropriate, at the time of transfer. They should give the person, and their family members or carers where appropriate, a complete and accurate list of their medicines in a format that is suitable for them. This should include all current medicines and any changes to medicines made during their stay.

1.2.5 Consider sending a person's medicines discharge information to their nominated community pharmacy, when possible and in agreement with the person.

1.2.6 Organisations should consider arranging additional support for some groups of people when they have been discharged from hospital, such as pharmacist counselling, telephone follow‑up, and GP or nurse follow‑up home visits. These groups may include:

Medicines reconciliation, as defined by the Institute for Healthcare Improvement, is the process of identifying an accurate list of a person's current medicines and comparing them with the current list in use, recognising any discrepancies, and documenting any changes, thereby resulting in a complete list of medicines, accurately communicated. The term 'medicines' also includes over‑the‑counter or complementary medicines, and any discrepancies should be resolved. The medicines reconciliation process will vary depending on the care setting that the person has just moved into – for example, from primary care into hospital, or from hospital to a care home.

1.3.1 In an acute setting, accurately list all of the person's medicines (including prescribed, over‑the‑counter and complementary medicines) and carry out medicines reconciliation within 24 hours or sooner if clinically necessary, when the person moves from one care setting to another – for example, if they are admitted to hospital.

1.3.2 Recognise that medicines reconciliation may need to be carried out on more than one occasion during a hospital stay – for example, when the person is admitted, transferred between wards or discharged.

1.3.3 In primary care, carry out medicines reconciliation for all people who have been discharged from hospital or another care setting. This should happen as soon as is practically possible, before a prescription or new supply of medicines is issued and within 1 week of the GP practice receiving the information.

1.3.4 In all care settings organisations should ensure that a designated health professional has overall organisational responsibility for the medicines reconciliation process. The process should be determined locally and include:

organisational responsibilities

responsibilities of health and social care practitioners involved in the process (including who they are accountable to)

individual training and competency needs.

1.3.5 Organisations should ensure that medicines reconciliation is carried out by a trained and competent health professional – ideally a pharmacist, pharmacy technician, nurse or doctor – with the necessary knowledge, skills and expertise including:

effective communication skills

technical knowledge of processes for managing medicines

therapeutic knowledge of medicines use.

1.3.6 Involve patients and their family members or carers, where appropriate, in the medicines reconciliation process.

1.3.7 When carrying out medicines reconciliation, record relevant information on an electronic or paper‑based form. See section 1.2 on medicines‑related communication systems.

Medication review can have several different interpretations and there are also different types which vary in their quality and effectiveness. Medication reviews are carried out in people of all ages. In this guideline medication review is defined as 'a structured, critical examination of a person's medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication‑related problems and reducing waste'. See also recommendation 1.6.3 .

1.4.1 Consider carrying out a structured medication review for some groups of people when a clear purpose for the review has been identified. These groups may include:

1.4.2 Organisations should determine locally the most appropriate health professional to carry out a structured medication review, based on their knowledge and skills, including all of the following:

therapeutic knowledge on medicines use

effective communication skills. The medication review may be led, for example, by a pharmacist or by an appropriate health professional who is part of a multidisciplinary team.

1.4.3 During a structured medication review, take into account:

the person's, and their family members or carers where appropriate, views and understanding about their medicines

the person's, and their family members' or carers' where appropriate, concerns, questions or problems with the medicines

all prescribed, over-the-counter and complementary medicines that the person is taking or using, and what these are for

how safe the medicines are, how well they work for the person, how appropriate they are, and whether their use is in line with national guidance

whether the person has had or has any risk factors for developing adverse drug reactions (report adverse drug reactions in line with the yellow card scheme )

any monitoring that is needed.

Self‑management plans can be patient‑led or professional‑led and they aim to support people to be empowered and involved in managing their condition. Different types of self‑management plan exist and they vary in their content depending on the needs of the individual person. Self‑management plans can be used in different settings. In this guideline self‑management plans are structured, documented plans that are developed to support a person's self management of their condition using medicines. People using self‑management plans can be supported to use them by their family members or carers who can also be involved when appropriate during discussions – for example, a child and their parents using a self‑management plan.

1.5.1 When discussing medicines with people who have chronic or long‑term conditions, consider using an individualised, documented self‑management plan to support people who want to be involved in managing their medicines. Discuss at least all of the following:

the person's knowledge and skills needed to use the plan, using a risk assessment if needed

the benefits and risks of using the plan

the person's values and preferences

how to use the plan

any support, signposting or monitoring the person needs. Record the discussion in the person's medical notes or care plan as appropriate.

1.5.2 When developing an individualised, documented self‑management plan, provide it in an accessible format for the person and consider including:

the plan's start and review dates

the conditions being managed

a description of medicines being taken under the plan (including the timing)

a list of the medicines that may be self‑administered under the plan and their permitted frequency of use, including any strength or dose restrictions and how long a medicine may be taken for

known drug allergies and reactions to medicines or their ingredients, and the type of reaction experienced (see the NICE guideline on drug allergy )

arrangements for the person to report suspected or known adverse reactions to medicines

circumstances in which the person should refer to, or seek advice from, a health professional

the individual responsibilities of the health professional and the person

any other instructions the person needs to safely and effectively self‑manage their medicines.

1.5.3 Review the self‑management plan to ensure the person does not have problems using it.

Many people wish to be active participants in their own healthcare, and to be involved in making decisions about their medicines. Patient decision aids can support health professionals to adopt a shared decision‑making approach in a consultation, to ensure that patients, and their family members or carers where appropriate, are able to make well‑informed choices that are consistent with the person's values and preferences. More information is available in NICE's guidelines on decision-making and mental capacity and shared decision making .

1.6.1 Offer all people the opportunity to be involved in making decisions about their medicines. Find out what level of involvement in decision‑making the person would like and avoid making assumptions about this.

1.6.2 Find out about a person's values and preferences by discussing what is important to them about managing their conditions and their medicines. Recognise that the person's values and preferences may be different from those of the health professional and avoid making assumptions about these.

1.6.3 Apply the principles of evidence‑based medicine when discussing the available treatment options with a person in a consultation about medicines. Use the best available evidence when making decisions with or for individuals, together with clinical expertise and the person's values and preferences.

1.6.4 In a consultation about medicines, offer the person, and their family members or carers where appropriate, the opportunity to use a patient decision aid (when one is available) to help them make a preference-sensitive decision that involves trade‑offs between benefits and harms. Ensure the patient decision aid is appropriate in the context of the consultation as a whole.

1.6.5 Do not use a patient decision aid to replace discussions with a person in a consultation about medicines.

1.6.6 Recognise that it may be appropriate to have more than one consultation to ensure that a person can make an informed decision about their medicines. Give the person the opportunity to review their decision, because this may change over time – for example, a person's baseline risk may change.

1.6.7 Ensure that patient decision aids used in consultations about medicines have followed a robust and transparent development process, in line with NICE's Standards framework for shared-decision-making support tools, including patient decision aids or the International Patient Decision Aid Standards criteria .

1.6.8 Before using a patient decision aid with a person in a consultation about medicines, read and understand its content, paying particular attention to its limitations and the need to adjust discussions according to the person's baseline risk.

1.6.9 Ensure that the necessary knowledge, skills and expertise have been obtained before using a patient decision aid. This includes:

relevant clinical knowledge

effective communication and consultation skills, especially when finding out patients' values and preferences

effective numeracy skills, especially when explaining the benefits and harms in natural frequencies, and relative and absolute risk

explaining the trade‑offs between particular benefits and harms.

1.6.10 Organisations should consider training and education needs for health professionals in developing the skills and expertise to use patient decision aids effectively in consultations about medicines with patients, and their family members or carers where appropriate.

1.6.11 Organisations should consider identifying and prioritising which patient decision aids are needed for their patient population through, for example, a local medicines decision‑making group. They should agree a consistent, targeted approach in line with local pathways and review the use of these patient decision aids regularly.

1.6.12 Organisations and health professionals should ensure that patient decision aids prioritised for use locally are disseminated to all relevant health professionals and stakeholder groups, such as clinical networks.

Clinical decision support software is a component of an integrated clinical IT system providing support to clinical services, such as in a GP practice or secondary care setting. These integrated clinical IT systems are used to support health professionals to manage a person's condition. In this guideline the clinical decision support software relates to computerised clinical decision support, which may be active or interactive, at the point of prescribing medicines.

1.7.1 Organisations should consider computerised clinical decision support systems (taking account of existing systems and resource implications) to support clinical decision‑making and prescribing, but ensure that these do not replace clinical judgement.

1.7.2 Organisations should ensure that robust and transparent processes are in place for developing, using, reviewing and updating computerised clinical decision support systems.

1.7.3 Organisations should ensure that health professionals using computerised clinical decision support systems at the point of prescribing have the necessary knowledge and skills to use the system, including an understanding of its limitations.

1.7.4 When using a computerised clinical decision support system to support clinical decision‑making and prescribing, ensure that it:

identifies important safety issues

includes a system for health professionals to acknowledge mandatory alerts. This should not be customisable for alerts relating to medicines-related 'never events'

reflects the best available evidence and is up‑to‑date

contains useful clinical information that is relevant to the health professional to reduce 'alert fatigue' (when a prescriber's responsiveness to a particular type of alert declines as they are repeatedly exposed to that alert over time).

The introduction of skill mixing of various health and social care practitioners to meet the needs of different groups of people has led to different types of models of care emerging across health and social care settings. Cross‑organisational working further provides seamless care during the patient care pathway when using health and social care services. The type of model of care used will be determined locally based on the resources and health and social care needs of the population in relation to medicines.

1.8.1 Organisations should consider a multidisciplinary team approach to improve outcomes for people who have long‑term conditions and take multiple medicines ( polypharmacy ).

1.8.2 Organisations should involve a pharmacist with relevant clinical knowledge and skills when making strategic decisions about medicines use or when developing care pathways that involve medicines use.

• Research article
• Open access
• Published: 17 January 2017

Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials

• Victor Johan Bernard Huiskes 1 ,
• David Marinus Burger 2 ,
• Cornelia Helena Maria van den Ende 3 &
• Bartholomeus Johannes Fredericus van den Bemt 1 , 2 , 4  

BMC Family Practice volume  18 , Article number:  5 ( 2017 ) Cite this article

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Medication review is often recommended to optimize medication use. In clinical practice it is mostly operationalized as an intervention without co-interventions during a short term intervention period. However, most systematic reviews also included co-interventions and prolonged medication optimization interventions. Furthermore, most systematic reviews focused on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). Therefore, the objective of this study is to assess the effectiveness of medication review as an isolated short-term intervention, irrespective of the patient population and the outcome measures used.

A literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. Randomized controlled trials (RCTs) with medication review as isolated short term intervention (<3 months) were included. There were no restrictions with regard to patient characteristics and outcome measures. One reviewer extracted and a second checked data. The risk of bias of studies was evaluated independently by two reviewers. A best evidence synthesis was conducted for every outcome measure used in more than one trial. In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect.

Thirty-one RCTs were included in this systematic review (55% low risk of bias). A best evidence synthesis was conducted for 22 outcome measures. No effect of medication review was found on clinical outcomes (mortality, hospital admissions/healthcare use, the number of patients falling, physical and cognitive functioning), except a decrease in the number of falls per patient. However, in a sensitivity analysis using a more stringent threshold for risk of bias, the conclusion for the effect on the number of falls changed to inconclusive. Furthermore no effect was found on quality of life and evidence was inconclusive about the effect on economical outcome measures. However, an effect was found on most drug-related problems: medication review resulted in a decrease in the number of drug-related problems, more changes in medication, more drugs with dosage decrease and a greater decrease or smaller increase of the number of drugs.

Conclusions

An isolated medication review during a short term intervention period has an effect on most drug-related outcomes, minimal effect on clinical outcomes and no effect on quality of life. No conclusion can be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care.

Peer Review reports

In order to reduce the number of preventable adverse drug events and hospital admissions, medication review is often recommended, incorporated in several guidelines and also frequently reimbursed by health care insurers in various countries [ 1 – 10 ]. Medication review is defined by the Pharmaceutical Care Network Europe (PCNE) as “a structured evaluation of a patient‘s medicines with the aim of optimising medicines use and improving health outcomes. This entails detecting drug related problems and recommending interventions” [ 11 ]. In clinical practice, for each individual patient, medication review is mostly operationalized as an isolated intervention during a short term intervention period [ 5 , 6 , 9 , 12 , 13 ].

Several systematic reviews and meta-analyses already examined the effectiveness of medication review and these did not unequivocally prove the effectiveness of medication review [ 14 – 23 ]. However, these systematic reviews did not only include trials assessing the effect of medication review in terms of how it is mostly operationalized in practice: an isolated cross-sectional assessment of total medication use during a short term intervention period less than 3 months. Most trials in the systematic reviews assessed the effect of medication review as part of multi-faceted pharmaceutical care interventions, consisting of for instance transitional care, adherence counseling and education of patients and healthcare professionals, besides medication review. Such interventions also often last longer than 3 months. Furthermore, most systematic reviews focus on specific patient groups (e.g. polypharmacy, elderly, hospitalized) and/or on specific outcome measures (e.g. hospital admissions and mortality). As a result, more insight is necessary in the effectiveness of medication review as an isolated short-term intervention on clinical outcomes, quality of life, drug-related and economical outcomes.

Therefore, this systematic review aims to summarize the evidence of medication reviews as performed in clinical practice, irrespective of patient characteristics, setting and outcome measures.

This systematic review, assessing the effectiveness of medication review, irrespective of the outcome measures used, follows the PRISMA-guidelines [ 24 , 25 ].

Data sources and searches

A literature search was performed in MEDLINE, EMBASE and Web of Science from their inception through September 2015. For the development of the search strategy and the full electronic search, see Additional file 1 .

Study selection

The inclusion criteria were operationalized based on the PICO model. No restrictions were set concerning the P (patients) and O (outcome measures): interventions could be conducted in any setting and there were no restrictions with regard to patient characteristics and outcome measures. The I (intervention) had to be medication review, which was defined as follows: a structured cross-sectional assessment of a patient’s total medication use leading to recommendations that had to be discussed with the patient and/or clinician within 3 months, in order to improve safety, efficacy or cost-effectiveness. Medication review had to be the single intervention; co-interventions with potential impact on the outcome measures (e.g. discharge counseling, transitional care, non-pharmacological interventions) were not allowed. The C (comparison) was defined as usual care. In addition to PICO the following study selection criteria were formulated: trials had to be randomized controlled trials (RCTs) and only full-length articles were considered for inclusion in this review. Two reviewers independently selected titles/abstracts and the corresponding full text articles to be included in this systematic review. Discrepancies in judgment were discussed in order to reach consensus (VH-BvdB) about final inclusion.

Data extraction and risk of bias assessment

Relevant data on study characteristics and outcomes were extracted by one reviewer (VH) and checked by a second reviewer (NW). P -values ≤0.05 were considered as statistically significant.

Two reviewers independently assessed the risk of bias of the studies eligible for inclusion by using the checklist with criteria for risk of bias from the Cochrane Back Review Group [ 26 , 27 ]. To determine whether a study had a low risk of bias (LRB) or a high risk of bias (HRB), a consensus (VH-BvdB) based scorings method was developed based on the risk of bias assessment.

The twelve Cochrane criteria [ 26 , 27 ] were designated essential (4) or non-essential (8) in relation to research on medication review by a consensus discussion (VH-BvdB). Essential criteria were: was the method of randomization adequate?; Was the drop-out rate described and acceptable?; Were the groups similar at baseline regarding the most important prognostic indicators?; Were co-interventions avoided or similar?. To be considered a study with a low risk of bias, all the essential Cochrane criteria had to be scored positive, whereas a total of at least 6 of the 12 criteria (50%) had to be scored positive. A cutoff of 50% was chosen, as it is not feasible for medication review trials to score positive on certain criteria, like: “was the patient blinded to the intervention”; “was the care provider blinded to the intervention”; “was the outcome assessor blinded to the intervention”. Discrepancies in judgment were discussed in order to reach consensus (VH-BvdB) about the designation of low or high risk of bias for each criterion for each study. If for a specific study an “unclear risk of bias” was scored for the same criterion by both reviewers, the criterion was designated “high risk of bias. The inter-rater agreement of the assessment of risk of bias was assessed by calculating the Cohen’s kappa.

A sensitivity analysis was performed regarding a more stringent cut-off point for risk of bias. The actually used cut-off point for risk of bias was compared with a threshold of ≥8 (2/3 of the attainable 12) of the criteria to be scored positive for a study to be considered a study with a low risk of bias.

Data synthesis and analysis

An adapted version from previously published best evidence syntheses [ 28 , 29 ] was conducted for every outcome measure used in more than one trial, combining a) the percentage of intervention patients included in studies showing effect on the outcome measure and b) the risk of bias of the set of trials using the outcome measure.

The following methodology was used for this purpose:

First, for each outcome measure, the percentage of intervention patients included in studies showing effect on the outcome measure was calculated

The risk of bias of a set of studies per outcome measure was subsequently determined as follows: if 50% or more of the intervention patients included in trials using the outcome measure had a low risk of bias, the set of studies was designated overall low risk of bias

Finally, both the percentage of intervention patients included in studies showing effect on the outcome measure and the risk of bias score for the set of trials per outcome measure were combined to conclude whether medication review has effect on the outcome measure by using the method depicted in Fig.  1 .

Schematic representation of the best evidence synthesis. Schematic representation of the best evidence synthesis, combining a ) the percentage of intervention patients included in studies showing effect on the outcome measure and b ) the risk of bias of the set of trials using the outcome measure. For details: see Additional file 4

In case of binary variables a meta-analysis was performed in addition to the best evidence synthesis, to quantify the effect. In these meta-analyses, effect sizes of binary variables were pooled using their weighted average for the treatment effect (using a random-effect meta-analysis method). Forest plots were created with STATA version 13.1 to summarize the risk ratio (RR) and the 95% confidence interval (CI). Heterogeneity across studies was assessed using I 2 statistics (studies with an I 2  > 50% were considered heterogeneous). Outcome measures reported in only one trial were reported descriptively.

A sensitivity analysis was performed with regard to the impact of large trials with a high risk of bias, on every individual outcome measure. In this sensitivity analysis, large trials with a high risk of bias, with a number of intervention patients greater than the median number of intervention patients per outcome measure, were excluded from the best evidence synthesis.

The literature search provided a total of 13,870 potentially relevant publications which were screened for eligibility. After screening titles and abstracts, 154 articles were left for full text screening. After this screening, 31 RCTs met the inclusion criteria and were included in this systematic review. A flow diagram of the literature search is represented in Fig.  2 .

Flow diagram of the literature search and study selection process

An overview of the study characteristics of the included studies is depicted in Table  1 . Most studies were conducted in primary care (52%), sample size ranged from 64 to 2014 patients, the observation period ranged from 0 to 12 months and 17 (58%) of the trials were conducted in Europe and 7 (23%) in the United States. Patients were involved in the medication reviews in 21 of the 31 studies, the mean age (as reported in 24/31 trials) and the number of drugs (as reported in 18/31 studies) of the intervention patients in each trial ranged from 51.4 to 87.0 years and from 4 to 14 drugs, respectively.

Seventeen studies (55%) met the criteria for low risk of bias. The inter-rater agreement between the two assessors of risk of bias was 0.74 (Cohen’s Kappa). Most common reasons for designating studies high risk of bias were methodological shortcomings on “compliance”, “treatment allocation concealment”, “blindness of patient, care provider and outcome assessor”, “randomization”, “similarity of study groups at baseline” and “drop-out rate”.

• Clinical outcomes

As summarized in Fig.  3 , no effect of medication review was found on clinical outcomes, except for a decrease in the number of falls.

Effect of medication review on clinical outcome measures as assessed in more than 1 trial. The percentage of intervention patients is shown on the y-axis. The black part of the bar represents the percentage of intervention patients included in a trial with a positive effect on a specific outcome measure. The outcome measures, the number of trials using the specific outcome measure, the overall risk of bias of the set of evidence per outcome measure and the conclusion of the best evidence synthesis are shown on the x –axis. T = trials; LRB = low risk of bias; HRB = High risk of bias; inconcl. = inconclusive

Eleven trials (overall low risk of bias, including 2403 intervention patients) assessed the effect of medication review on mortality (for details, see Additional file 2 : Table S1). Data were pooled in a meta-analysis (Additional file 2 : Figure S1) and with a RR of 0.94 (CI, 0.76–1.17) no effect of medication review on mortality was found. Moderate heterogeneity was found between the trials (I 2  = 22.0%, P  = 0.234).

Hospital admissions and healthcare use

Data of 11 trials (Additional file 2 : Table S2), including 2041 intervention patients, showed evidence with a low risk of bias for no effect of medication review on the number of hospital admissions (including emergency admissions and visits). Meta-analysis of data from five trials with overall low risk of bias, including 2000 intervention patients, assessing the effect of medication review on the number of patients admitted to the hospital revealed no effect, with a RR of 0.94 (0.82, 1.08) and with moderate heterogeneity (I 2  = 42.3%, P  = 0.139) (Additional file 2 : Figure S2 and Table S3). The same applies to the time to first (re)admission in three trials with low risk of bias, including 518 intervention patients, except for a subgroup with only emergency department visits or a low baseline risk for hospital admission (Additional file 2 : Table S4) [ 30 , 31 ]. In addition, no effect of medication review was found on the length of hospital stay in seven trials with overall high risk of bias, including 1330 intervention patients and the number of emergency admissions/visits in seven trials with overall low risk of bias, including 1243 intervention patients (Additional file 2 : Tables S5 to S6). Furthermore, no effect of medication review was demonstrated on the number of General Practitioner (GP) visits in 6 trials with low risk of bias including 1582 intervention patients and on the number of outpatient visits in four trials with overall low risk of bias, including 1144 intervention patients (Additional file 2 : Tables S7 to S8). The meta-analysis of data of 2 trials with overall high risk of bias, including 825 intervention patients, found no effect on the number of patients admitted to residential homes with a RR of 1.17 (0.79, 1.74), with limited heterogeneity (I 2  = 0.0%, p  = 0.997) (Additional file 2 : Figure S3 and Table S9).

No best evidence synthesis could be conducted for a variety of other healthcare use related outcome measures used in only one trial. In six trials no effect was found on these outcome measures [ 30 , 32 – 37 ], whereas in two trials an effect was found only in a subdomain of healthcare use related outcome measures or a subgroup of patients [ 32 , 38 ] and in one trial a positive effect was found in favor of patients receiving usual care [ 30 ].

It was observed in two trials with overall low risk of bias, including 467 intervention patients, that medication review decreases the number of falls per patient (Additional file 2 : Table S10). Data of four trials with overall low risk of bias, including 929 intervention patients, were pooled in a meta-analysis (Additional file 2 : Figure S4). This meta-analysis suggested that medication review decreases the number of patients falling (RR 0.68 (0.52, 0.90); I 2  = 41.0%, p  = 0.166). However, the best evidence synthesis was inconclusive about the effect on the number of patients falling (Additional file 2 : Table S11). Furthermore, a significant lower fall rate per 1000 patient days (only assessed by Michalek et al) due to medication review was found [ 39 ].

Health status, physical and cognitive outcome measures

Three trials with low risk of bias, including 499 intervention patients, showed no effect of medication review on physical functioning using the Barthel index (Additional file 2 : Table S12). This was confirmed in one study, using three different outcome measures for physical functioning [ 40 ].

Medication review neither improved clinical status [ 41 ], health status [ 40 ] and patient’s perception of severity of illness [ 41 ]. In one study, however, a smaller decrease in self-rated health due to medication review was found [ 35 ].

Two trials, with overall low risk of bias, including 449 intervention patients, found no effect of medication review on cognitive functioning, using the Standard Mini Mental State Examination (Additional file 2 : Table S13). Medication review also did not affect cognitive functioning, expressed with other outcome measures [ 40 , 42 , 43 ], except for the Chrichton-Royal Behaviour Rating Scale [ 42 ].

• Quality of life

The effect of medication review on quality of life is outlined in Fig.  4 . There is evidence with overall low risk of bias that medication review has no effect on quality of life, as measured with the EQ-5D score (based on six trials, including 1583 intervention patients) or the SF-36 score (based on two trials, including 547 intervention patients), whereas evidence with overall high risk of bias was inconclusive about the effect of medication review on the EQ5D-VAS (used in five trials, including 798 intervention patients) (Additional file 2 : Table S14). Pit et al also found no effect of medication review on quality of life measured with the SF-12 score [ 44 ].

Effect of medication review on quality of life, drug-related outcome measures and economical outcome measures as assessed in more than one trial. The percentage of intervention patients is shown on the y-axis. The black part of the bar represents the percentage of intervention patients included in a trial with a positive effect on a specific outcome measure. The outcome measures, the number of trials using the specific outcome measure, the overall risk of bias of the set of evidence per outcome measure and the conclusion of the best evidence synthesis are shown on the x-axis. T = trials; LRB = low risk of bias; HRB = High risk of bias; inconcl. = inconclusive

Drug-related outcome measures

The effect of medication review on drug-related outcome measures is represented in Fig.  4 . An effect of medication review was found on most drug-related outcome measures (the number of drugs, the number of drug changes, the number of drug-related problems and the number of drugs with a dosage decrease), but not on the number of drugs with dosage increase.

Drug-related problems

In four trials with overall high risk of bias, including 599 intervention patients, medication review decreases the number of drug-related problems (Additional file 2 : Table S15). The results of two trials assessing the effect of medication review on the number of patients with drug-related problems (with different pre-defined drug-related problems per trial) were conflicting [ 45 , 46 ].

Number of drug changes and number of drugs with a dosage decrease or increase

Data of three trials with low risk of bias, including 965 intervention patients, showed an increase of the number of drug changes as a result of medication review (Additional file 2 : Table S16). Two other trials with overall high risk of bias, including 486 intervention patients, found an increase of the number of drugs with a dosage decrease, whereas no difference was found with regard to the number of drugs with dosage increase (Additional file 2 : Tables S17 to S18).

Number of drugs and doses

Twelve studies with overall low risk of bias, including 1972 intervention patients, found that medication review leads to a greater decrease or smaller increase of the number of drugs used (Additional file 2 : Table S19). Sellors et al, however, found no difference in the absolute number of drugs used after 5 months due to medication review [ 37 ]. Furthermore, no effect of medication review was found on the number of individual doses per day [ 47 ] and the dosing frequency per day [ 48 ].

Other drug-related outcome measures

Various outcome measures, only used in one trial, but covering the same outcome domains, could not be incorporated in a best evidence synthesis. Two studies assessing the effect of medication review on adherence and knowledge found conflicting results [ 41 , 47 ]. Results with regard to appropriate prescribing and medication use were also conflicting. In two trials, medication review did not improve a set of predefined indicators of prescription quality [ 44 , 46 ], whereas other trials showed improvement of (part of) the indicators [ 38 , 39 , 49 ]. Trials reporting the effect of medication review on scores for appropriateness of prescribing and medication use also found conflicting results. Although medication review improved prescribing appropriateness as measured with the Medication Appropriateness Index (MAI) and the Assessment of Underutilization of Medication Index (AOU) [ 49 ], no effect was found on a composite score reflecting appropriate prescribing of benzodiazepines, NSAIDs and thiazide diuretics [ 44 ]. Finally, the effect of medication review on adverse effects was inconclusive, as one trial demonstrated that medication review decreases adverse effects [ 50 ] and a second trial did not show a significant effect [ 47 ].

• Economical outcomes

Figure  4 shows the effect of medication review on drug costs. Based on the data of nine trials with overall low risk of bias, including 2511 intervention patients, no conclusion could be drawn about the effect of medication review on drug costs (Additional file 2 : Table S20). Trials using various other outcome measures for drug and supply costs did generally not observe effect of medication review on costs [ 37 , 51 , 52 ], except for one study demonstrating that medication review might decrease drug and supply costs due to discontinuation [ 51 ]. Inconclusive results were also observed with respect to total healthcare costs, as two studies found a positive effect of medication review on total healthcare costs [ 32 , 53 ], one study found a temporary positive effect [ 38 ] and two studies did not find any effect [ 37 , 43 ]. Besides this, Burns et al found no decrease or increase of costs related to non-drug GP visits, in patient days, outpatient visits, domiciliary visits and primary care visits due to medication review [ 32 ].

Sensitivity analyses

The sensitivity analysis with a more stringent threshold for risk of bias (≥8; 2/3 of the attainable 12) yielded similar results except for the number of falls per patient, which changed from effective to inconclusive, see Additional file 3 . Based on the sensitivity analysis excluding large trials with high risk of bias from the best evidence synthesis, twice the conclusion changed from effective to inconclusive (number of drug-related problems (DRPs) and number of drugs), twice from inconclusive to not effective (number of patients falling and drug costs), once from not effective to inconclusive (number of emergency admissions) and once from inconclusive to a decreased quality of life (EQ-5D VAS), see Additional file 4 .

This is the first systematic review exploring the effect of medication review as an isolated intervention without co-interventions during a short term (≤3 months) intervention period (as advocated in most medication review guidelines [ 4 – 10 ] and operationalized in practice). Furthermore this systematic review provides an overview of all outcome measures and selection criteria without exclusion criteria based on patient characteristics. In this study, a beneficial effect of medication review was found on most drug-related outcome measures. However, minimal effect was observed on clinical outcomes, no effect was found on quality of life and evidence was inconclusive concerning the effect on economical outcome measures. Only seventeen trials (55%) were designated low risk of bias.

The findings of this systematic review are in line with the findings of other systematic reviews assessing the effect of medication review, although these systematic reviews used other inclusion criteria. Previously published systematic reviews often focused on specific patients (e.g. elderly or hospitalized patients etc.) and/or included trials with multifaceted interventions and/or limited the scope to specific outcome measures.

First of all, the lack of effect of medication review on clinical outcomes (e.g. mortality, number of hospital admissions) observed in this systematic review is in line with the findings of other systematic reviews [ 16 – 22 ], although Patterson found conflicting results concerning hospital admissions [ 14 ]. In other systematic reviews a positive effect of medication review on some clinical outcomes was suggested only when non RCTs [ 21 ], unpublished data [ 18 ], co-interventions [ 15 , 18 ] and/or lengthier interventions (> 3 months) [ 21 ] were included. Secondly, no effect of medication review on quality of life was found by this systematic review, which is also confirmed by other systematic reviews [ 14 , 16 , 17 , 21 , 23 ]. Thirdly, the effect of medication review on drug-related outcomes (e.g. a decrease in the number of drug-related problems and the number of drugs) found in this systematic review was confirmed by other systematic reviews [ 17 , 19 ], although Patterson found no consistent intervention effect on medication-related problems across studies [ 14 ]. In addition, in these systematic reviews an effect of medication review on some other drug-related outcome measures (e.g. adherence, adverse drug events, medication appropriateness) was reported [ 14 – 17 , 19 , 21 , 23 ]. Finally, based on this systematic review, no conclusion could be drawn about the effect of medication review on economical outcome measures , including drug costs . These results were confirmed by the majority of other systematic reviews, since only one out of six other systematic reviews [ 23 ] reported effect of medication review on certain subdomains of economical outcome measures [ 15 – 17 , 19 , 21 , 23 ].

Thus, when the effect of medication review is assessed in terms of how it is operationalized in practice (with medication review as isolated intervention) and even when this effect is assessed irrespective of the patient population and on all available outcome measures, the impact found on clinical outcomes and quality of life is minimal, the observed effect on drug-related outcomes is limited and the evidence about the effect on economical outcome measures is inconclusive. This requires further elaboration of the possible explanations of these findings. Several aspects seem to contribute to these findings, including the 1) selection of patients , the 2) interventions (how medication reviews are being operationalized in practice) and the 3) outcome measures and follow-up time used in trials assessing the effect of medication review. Besides these explanations it might also be the case that the hypothesis that medication review significantly improves clinical outcomes, economical outcomes and quality of life should be rejected.

A possible explanation for the lack of evidence about the effect of medication review is that the 1) selection of patients does not fit the aim of the intervention. If the aim of medication review is, for example, decreasing mortality or preventing patients from being admitted to the hospital, one should select a population with high risk for any of these events. Inclusion criteria often mentioned in medication review trials are age 65-plus and a minimum number of drugs used. Although age and polypharmacy are predominantly positively associated with the risk of having drug-related problems [ 54 – 59 ], several other risk factors (e.g. co-morbidity, renal impairment, high risk medication) contributing to the occurrence of DRPs and/or hospital admissions are found in literature [ 54 , 60 – 69 ]. This suggests that a more sensitive selection of patients for medication review in order to reduce the risk of hospital admission and or death may increase the chance of demonstrating an effect of medication review on these outcomes. Consequently, another aim of the intervention (e.g. increasing adherence) will require a different selection of patients (e.g. lack of therapeutic effect, adherence scores). A second explanation for the lack of evidence about the effect of medication review might be the heterogeneity of 2) the interventions . No golden standard exists for how medication review should be operationalized in practice. Several implicit as well as explicit medication review methods are used [ 70 ]. Furthermore, different levels of medication review are applied in daily practice [ 10 ]. This limits the ability to compare the results of trials assessing the effect of medication review. In addition, the multidisciplinary character of medication reviews is possibly a complicating factor. Often problems are difficult to solve 1) as many care-practitioners are involved and 2) as it is not always clear which healthcare practitioner should be addressed and/or 3) as the responsible physician may not agree with implementation of a recommendation made by another healthcare practitioner. Once the aims of medication review are known, one or more consistent (international) definitions and accompanying operationalizations of medication review should be put into practice. Uniform medication reviews are easier to compare in systematic reviews, this will contribute to the ability to demonstrate effect of these interventions. Finally, the lack of evidence about the effect of medication review might be explained by 3) the outcome measures and follow-up time used in trials assessing the effect of medication review. The outcome measures used in published RCTs examining the effect of medication review are often broad outcome measures, as for instance hospital admissions and all-cause mortality, which are affected by multiple (also not drug related) factors. Although in RCTs these outcome measures may be the ideal outcome measures, since these reflect the overall benefit/risk ratio of drug treatment, no effect of medication review on these outcome measures is found, possibly because the intervention medication review is not powerful enough to have impact on hospitalizations and mortality. Therefore (clinical) outcome measures should be chosen which fit 1) the aim of the medication review (improve safety and (cost-)effectiveness of a patient’s medication use) and 2) are more disease/medication specific (e.g. blood pressure, HbA1c) [ 12 , 71 ]. However, these more disease/medication specific outcome measures should not only reflect the negative effects, but also the positive effects of drug treatment. Although it is often seen in medication review trials, only reporting drug-related outcome measures (e.g. DRPs, number of drugs, adverse events) is suboptimal, as these outcome measures only focus on the disadvantages of drug treatment. Furthermore the outcome measures used are often heterogeneous, as for each outcome a different set of outcome measures is used per trial. This limits the ability to draw robust conclusions. Standardization of outcome measures and time of follow-up should be applied in order to increase the ability to compare the results of trials assessing the effect of medication review. For instance, as one of the aims of the intervention is to improve the quality of life of patients, a standard set of quality of life scores (e.g. EQ-5D and SF-36) should be defined and subsequently used in future research to measure the effect of medication review on quality of life.

In the meantime, it is also conceivable that even when medication review is operationalized and/or investigated as described above, it is not effective on clinical outcomes, economical outcomes and quality of life. A possible explanation is that medication review is a cross-sectional intervention at an arbitrary moment during patient’s drug therapy. However, it might be assumed that at specific moments of drug therapy (e.g. when drugs are started, adapted or stopped) the risk for preventable drug-related problems causing negative clinical outcomes is higher. These specific high-risk moments seem to be the best occasion to apply medication optimization in order to prevent clinically relevant drug-related problems. It can therefore be suggested to redesign the cross-sectional medication review to longitudinal medication therapy management, directly from the start of a drug, targeting at specific risk moments [ 72 ]. Furthermore a more integral approach of pharmaceutical care will give room for medication improvement strategies to shift from a system repairing overdue maintenance to a more individualized approach. Problems related to prescribing according to general guidelines should be solved by means of population based interventions like for instance clinical rules. Other interventions should be developed to address issues related to a patient’s use of medication in the context of his medical condition. For instance individualized medication coaching consults with non-adherent patients or patients experiencing drug-related problems or adverse events.

A couple of limitations are associated with this systematic review. In order to provide a broad overview on the literature about the effect of medication review, no inclusion criteria were applied with regard to outcome measures. Consequently, in the best evidence syntheses, both trials using a specific outcome measure as primary outcome measure and trials using the outcome measure as secondary outcome measure were included. This possibly leads to underpowered trials being part of the best evidence synthesis (BES). However, large trials (with more power) have more impact in the BES. Furthermore, in the best evidence synthesis, it is theoretically possible that a large trial with a high risk of bias has decisive impact on both the overall risk of bias of a set studies and the conclusion about the effect of medication review on a specific outcome measure. However, only in 1/22 best evidence syntheses would the conclusion change to effect (EQ-5D VAS), when studies with a high risk of bias with a number of intervention patients greater than the median number of intervention patients of the trials would be excluded from the best evidence synthesis. Finally a limitation might be the fact that only RCTs were included in this systematic review, although it was a deliberate choice not to include observational studies, as a randomized controlled trial is the most appropriate study design to demonstrate effect of an intervention.

Besides these limitations, some remarks can be made with regard to the robustness of the conclusions. Firstly, only 55% of the included studies were designated a low risk of bias, which results in a smaller body of evidence. In a sensitivity analysis, increasing the threshold for the risk of bias assessment to an arbitrary 2/3 of the attainable maximum score, the percentage of trials with low risk of bias decreased to 39%. For medication review trials, however, on the one hand it is reasonable to relax the threshold to some extent when it comes to blindness of the patient, care provider and outcome assessor. On the other hand this may lead to an overestimation of positive findings of assessor dependent outcome measures, for instance when a non-blinded assessor has to assess whether an outcome is drug-dependent or not. Secondly, the variety of the included patients and settings in this systematic review should be considered. Although no exclusion criteria based on patient characteristics may have resulted in more power, this also may have led to false negative results in subgroups. In other systematic reviews, however, often no effect was found in these subgroups.

Although an isolated medication review during a short term intervention period (how it is mostly operationalized in practice) has an effect on most drug-related outcomes, medication review has minimal effect on clinical outcomes, no effect on quality of life and no conclusion could be drawn about the effect on economical outcome measures. Therefore, it should be considered to stop performing cross-sectional medication reviews as standard care. It may also be considered to shift the focus of research from cross-sectional medication review to other strategies to improve the safety and (cost-)effectiveness of drug treatment. If, despite this, research on the effect of cross sectional medication review is still continued, high quality studies including high-risk patients and using relevant outcome measures should be conducted to assess if/when medication reviews can contribute to better medication use and subsequent better clinical outcomes. However, more effort should be put in the development and evaluation of other medication improvement strategies, like more individualized and longitudinal medication therapy management, targeting at specific risk moments of drug treatment and targeting at problems that patients experience themselves.

Abbreviations

Assessment of underutilization of medication index

Confidence interval

Drug related problem

General practitioner

High risk of bias

Low risk of bias

Medication appropriateness index

Pharmaceutical care network Europe

Randomized controlled trial

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Acknowledgments

We would like to thank N.S. (Naomi) Wartenberg for checking data entry of the included studies.

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The datasets supporting the conclusions of this article are included within the article and its additional files.

Authors’ contributions

VH and BvdB had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: VH, DB and BvdB. Acquisition, analysis, or interpretation of data: VH, CvdE and BvdB. Drafting of the manuscript: VH and BvdB. Critical revision of the manuscript for important intellectual content: VH, DB, CvdE and BvdB. Statistical analysis: VH, CvdE and BvdB. Study supervision: BvdB. All authors have read and approved the final version of this manuscript.

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David Marinus Burger & Bartholomeus Johannes Fredericus van den Bemt

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Cornelia Helena Maria van den Ende

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Additional files

Additional file 1:.

Development of the search strategy and full electronic search. Full electronic search (MEDLINE). (DOCX 17 kb)

Additional file 2:

Data not shown in the results section of the main text of the manuscript. Table S1. Effect of medication review on mortality. Figure S1. Meta-analysis of the studies assessing the effect of medication review on mortality. Table S3. Effect of medication review on the number of patients with hospital admissions. Figure S2. Meta-analysis of the studies assessing the effect of medication review on the number of patients with hospital admissions. Table S4. Effect of medication review on time to first hospital (re)admission. Table S6. Effect of medication review on the number of emergency admissions/visits. Table S7. Effect of medication review on the number of GP visits. Table S8. Effect of medication review on the number of outpatient visits. Table S9. Effect of medication review on the number of patients admitted to residential homes. Figure S3. Meta-analysis of the studies assessing the effect of medication review on the number of patients admitted to residential homes. Table S10. Effect of medication review on the number of falls per patient. Table S11. Effect of medication review on the number of patients falling. Figure S4. Meta-analysis of the studies assessing the effect of medication review on the number of patients falling. Table S12. Effect of medication review on the Barthel index. Table S13. Effect of medication review on the Standard Mini Mental State Examination. Table S14. Effect of medication review on the quality of life. Table S15. Effect of medication review on the number of drug-related problems. Table S16. Effect of medication review on the number of drug changes. Table S17. Effect of medication review on the number of drugs with a dosage decrease. Table S18. Effect of medication review on the number of drugs with a dosage increase. Table S19. Effect of medication review on the number of drugs. Table S20. Effect of medication review on drug costs. (DOCX 124 kb)

Additional file 3:

Risk of bias assessment: sensitivity analysis. Sensitivity analysis regarding a more stringent cut-off point for risk of bias. (DOCX 19 kb)

Additional file 4:

Best evidence synthesis: sensitivity analysis. Sensitivity analysis with regard to the impact of large trials with high risk of bias on every individual outcome measure in the best evidence synthesis. (DOCX 20 kb)

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Huiskes, V.J.B., Burger, D.M., van den Ende, C.H.M. et al. Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials. BMC Fam Pract 18 , 5 (2017). https://doi.org/10.1186/s12875-016-0577-x

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Article Contents

Introduction, concept and incidence of medication errors, classification of medication errors, other classifications and types of medication errors, causes of medication errors, medication errors and nursing, results of medication errors, reporting medication errors of nurses, strategies for preventing medication errors, conclusion and recommendations, author contributions, conflict of interest.

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Medication errors: a focus on nursing practice

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Nasr Alrabadi, Shaima Shawagfeh, Razan Haddad, Tareq Mukattash, Sawsan Abuhammad, Daher Al-rabadi, Rana Abu Farha, Suzan AlRabadi, Ibrahim Al-Faouri, Medication errors: a focus on nursing practice, Journal of Pharmaceutical Health Services Research , Volume 12, Issue 1, March 2021, Pages 78–86, https://doi.org/10.1093/jphsr/rmaa025

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Health departments endeavor to give care to individuals to remain in healthy conditions. Medications errors (MEs), one of the most types of medical errors, could be venomous in clinical settings. Patients will be harmed physically and psychologically, in addition to adverse economic consequences. Reviewing and understanding the topic of medication error especially by nurses can help in advancing the medical services to patients.

A search using search engines such as PubMed and Google scholar were used in finding articles related to the review topic.

This review highlighted the classifications of MEs, their types, outcomes, reporting process, and the strategies of error avoidance. This summary can bridge and open gates of awareness on how to deal with and prevent error occurrences. It highlights the importance of reporting strategies as mainstay prevention methods for medication errors.

Medication errors are classified based on multifaceted criteria and there is a need to standardize the recommendations and make them a central goal all over the globe for the best practice. Nurses are the frontlines of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Health administrations, all over the world, endeavor to give proper care to individuals when they are ill or to remain healthy. Primary care services are increasingly concentrated at the heart of integrated people-centered health care systems in many countries. [ 1 ] They provide a passage point with a useful framework focused on progressing health planning to ensure safety for individuals and their families. Availability and safe application are basics to accomplish all-inclusive wellbeing criteria and to support the United Nations sustainable development goals, that organize solid lives and advance prosperity for all. [ 2 ]

The therapeutic services’ framework is very unpredictable. It includes basic circumstances of hazard, a collaboration between different experts and institutions, and relies upon huge help from innovations. The attributes of the therapeutic framework may increase the danger of slip-ups and compound the results of these mix-ups. [ 1 , 3 ] In this sense, it is vital to evaluate hazards and harm to patients in the scan for extreme patient wellbeing. The World Health Organization’s meaning of patient wellbeing builds up of which pointless damage or potential harm related to therapeutic services ought to be decreased to a worthy least. [ 4 ]

Healthcare providers consider patient safety one of the paramount priorities in clinical settings. One of the major threats to the well being of patients is medical errors. [ 5 ] One of the main branches of medical errors is medication errors which were demonstrated to be the source of morbidity and mortality in addition to the resulted adverse economic consequences. [ 6–8 ] Patient safety is esteemed as a critical issue for our social insurance framework and human services providers, [ 9 ] and in such manner, medication errors are utilized as a list to survey quiet wellbeing in clinics. In the next sections, we will go through the concept, classification, types, causes, consequences, reporting, and those strategic plans to prevent the occurrence of medication errors.

A medication error is characterized by ignoring the condition of shaping harm, hazard, or any evadable frequency to happen amid the procedure from medicine ordering to patient consumption. [ 10 , 11 ] It might be characterized by National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) as any preventable occasion that may cause, or prompt improper medicine use or patient harm while the medicine is in the control of the healthcare worker, patient, or buyer. [ 12 , 13 ] The measurement of medication errors may vary widely in clinical settings due to the different ways of recognizing and defining the status of medication errors, how to calculate error rates, variation in numerator/dominator, and the process, documentation, and culture of settings technologies. [ 14–16 ]

Medication errors are a global issue where 5.0% is deadly, and almost 50.0% of those are preventable. [ 17 ] The in-hospital incidence for adverse drug events was reported to be high which ranged from 2 to 6 events per 100 admissions. [ 18 , 19 ] Moreover, around 7000–9000 patients’ deaths in the USA each year can be attributed to medication errors. [ 11 , 20 ] However, the rate of patient serious injuries as a result of medication errors among different studies varies, 1–2%, [ 21 ] 9–13%, [ 22 ] 29.0% [ 23 ] and 51.8% [ 24 ] and almost 30.5% death rate per year in the United States because of medication errors. [ 25 ] As indicated by the Institute of Medicine (IOM) of the National Academies in 2006, 400 000 instances of avoidable patient damage because of medication errors happen every year in emergency clinics in the USA. It is noticed that 19% of medication errors in the Intensive Care Units (ICUs) are life-threatening and 42% are considered to be paramount for further maintaining treatment. [ 26 , 27 ] Somewhere in the range of 44 000 and 98 000 emergency clinic patients have been evaluated to kick the bucket every year because of drug errors. [ 28 ] For instance, in the USA hospitals in 1995, the annual spending on medication errors for each hospital was around 2.9 million dollars and a 17% reduction in the error incidence led to 480 000 dollars saving per hospital as in the case of transcription errors. [ 29 ] For example; a patient in an Iranian hospital had given 80 units of insulin instead of eight units which led to the patient’s death, therefore, the government gave 140 million dollars to the patient’s family. [ 14 , 30 ] Add up, the overall cost of adverse outcomes that are associated with medication errors could surpass 40$ billion each year. [ 11 ] Bates et al . stated that medication errors increase the costs for each patient by 2000–2500$ and extend their hospitalization period by at least two days. [ 18 ] The total cost of these errors, including expenses of error, disability, and lost income and productivity, is expected to be between $17 billion and $29 billion per year. [ 31 , 32 ]

Grouping of medication errors occurrence into contextual, modular, or mental (psychological) is considered an ideal protocol to assess how errors happen. Contextual order assesses the specific time, place, medications, and individuals who are included. Modular characterization analyses the manners in how errors occur (i.e, by omission, repetition, or substitution). Mental order is preferred, as it clarifies occasions as opposed to just prescribing them. Its burden is that it focuses on humans as opposed to frameworks wellsprings of errors. The accompanying mental grouping depends on crafted by Reason on errors and there are four distinct types of medication errors. [ 33 , 34 ]

The first type is ‘Knowledge-based errors’ (Learning absence). As it may seem, administering penicillin to the patient without any concise information whether the patient is unfavorably susceptible. Knowledge-based errors that are connected to any kind of knowledge which could be related to expert, specific, or general. As a general knowledge, health care providers should understand that allergic reactions, for instance, could be associated with penicillins, however, realizing that the patient is allergic to penicillin can be considered specific knowledge. On the other hand, experts are those who may know that co-fluampicil has penicillin. As a result, Knowledge-based errors might be provoked when ignoring any of that information. In an Australian examination, correspondence issues with trouble in getting to suitable medication dosing data added to knowledge-based errors. [ 35–39 ] When being educated about medication is being given dispensed to patients could reduce the incidence of medication errors. [ 40 ] Errors can be blocked from occurrence through computerized prescribing entry orders, bar-coded medicine frameworks, and cross-checking by others (for instance, medicine specialists and nurses). [ 41 , 42 ] A study showed that before implantation of electronic Bar-Coded Medication Administration (BCMA-e MAR), wrong time (33.9%), omission (27.7%), wrong technique (18.0%), wrong dose (13.3%), and unauthorized drug (2.9%) were happening frequently. However, after the implementation of BCMA- e MAR, errors have been declined. [ 43 ] In another study, error rates were reduced more than a half after applying BCMA- e MAR. [ 44 ]

The second type is ‘Rule-based errors’ (utilizing a terrible standard or twisting a decent principle). For instance, infusing diclofenac into the sidelong (lateral) thigh instead of being injected into the butt cheek. Appropriate standards and instruction help to keep away from these kinds of errors, as do computerized prescribing frameworks. [ 38 , 39 , 45–47 ]

The third type is ‘Activity-based errors’ (known as slips). For example, when confusion happens between two drugs like diazepam and diltiazem from a medicine store rack. [ 38 , 46 , 47 ] In the Australian examination, most errors were because of slips in consideration that happened amid routine prescribing, dispensing, and administering organization. Slips errors could be minimized through keeping away from distraction, by cross-checking, by naming prescriptions plainly, and by utilizing identifiers, for example, standardized identifications or barcoded); alleged ‘Tall Man’ lettering (when blending lower- and upper-case letters in the same word) which showed to be a good protocol in the prevention of misreading of names, yet tall-man lettering has not been assessed in genuine conditions. [ 48 ] A branch of specialized technical errors of activity-based errors, for instance, as seen in measuring the incorrect amount of potassium chloride into an infusion bottle. Using agendas, safeguard frameworks, and computerized updates could prevent this type of error from occurring. [ 49 , 50 ]

The fourth type is ‘Memory-based errors’ (so-called lapses). For instance, giving penicillin to a patient, with a known history of allergy, but forgetting that the patient is allergic. These are difficult to keep away from; however, computerized prescribing frameworks and cross-checking can reduce the error incidence. [ 50 , 51 ]

Errors might provoke in any stage. [ 52–54 ] Prescribing errors (during drug prescription), transcription errors (wrong/incomplete transfer information from a prescription), dispensing errors (disagreement between medicine dispensed and prescription), administration errors (during drug administration), discharge summaries errors (due to discrepancy between discharged summaries and medical records), and monitoring errors (while taking the medicine of renal and liver). [ 30 ] Karthikeyan et al . reviewed the occurrence of errors among healthcare providers. [ 55 ] (a) Prescribing errors; were presented as follow; drug-drug interaction (68.2%), incomplete prescription (25.0%), monitoring (12.6%), incorrect drug (13.0%), underdose (12.6%), incorrect interval (12.0%), and overdose (7.0%). (b) Nursing errors; as in wrong rate (34.0%), wrong time administration (28.6%), wrong dose (25.3%), medication omitted (24.0%), wrong fluid (22.4%), wrong drug (21.1%), wrong route (19.9%), and wrong patient (19.7%). (c) Pharmacist errors; as in wrong medication (25.0%), excessive dose (23.0%), poor labeling (23%), wrong dosage errors (21.8%), wrong strength (10.8%), wrong quantity (6.9%), and wrong direction dispensing (2.3%). [ 55 ] Prescription and administration types of medication errors are considered common and can contribute up to 65.0%–87.0% of medication errors. [ 56 ] According to the National Patient Safety Agency (2009) in the United Kingdom, it was observed the most prominent kinds of medication errors were 16.0% in prescribing, 18.0% in dispensing, and 50.0% in the drug administration. [ 57 ] Furthermore, medication errors accounted to be 37.6% of administration errors, 21.1% of prescription errors, and 10.0% of transcription errors in Iran. [ 58 ] On the other hand, previous studies showed that in prescription errors mainly occurred at outpatient ward accounted as (39.0–44.0%) and in emergency wards were (60.0–73.5%), however, transcription errors were accounted 16.9% and 13.8% for inpatient and discharged patients, respectively, while discharge summaries errors accounted 16.0–36.0% of (omission, drug name, administration route, drug dose, and drug regimen). [ 59 , 60 ] There were 192 477 medication errors reported by staff from 482 hospitals through voluntary reporting that could occur at any stage. Errors during administration were accounted to be (33.0%), documentation (23.0%), dispensing (22.0%), prescribing (21.0%), and monitoring (1.0%). Also, errors were related to omission (25.0%), dosage (30.0%), unauthorized drugs, and the wrong time, patient, and administration technique. [ 61 ]

Moreover, 0.078 errors per patient, and 0.029 errors per medication mainly because of dosing errors, drug omission, and wrong frequency errors. [ 62 ] A previous study showed that (94.0%) out of 430 errors were omissions and only 6.0% of errors caused a major impact on patients’ life but was not considered as a life–alarming errors. [ 63 ] Medication errors are also related to the problem of wrong phenomena. These incorporate errors of course of medication, doses, timing, patient, and inability to follow up the patient. [ 53 , 64 ]

Prescription errors are a standout amongst the most widely recognized therapeutic errors and their occurrence rate in adult ward accounted to be 5.6 cases per 1000 patients and 14.8 cases per 1000 patients in the pediatrics ward. [ 65 ] As seen, a sample of 57 nurses in pediatric settings, medication errors were 67.0% compared to 56.0% of a sample of 227 nurses working with adults. [ 64 , 65 ] The occurrence of prescription errors in pediatrics is three-times higher than adults. An examination in Canada showed that the number of children who admitted to the emergency clinic accounted to be 5000 because of medication errors and of these, 2500 experienced moderate to serious side effects. [ 66 ] Prescription errors can happen because of human errors just as from fundamental errors and thus is needed for a cautiously monitoring through medication organization. [ 10 ] It is suggested that at whatever point when medication error has occurred it should be reported to the significant manager, and such notice is essential for understanding the reasons for the errors and to enable strides to be taken to lessen such errors later on. [ 67 ] The most frequent types of prescribing errors might be related to the inability to manage the medication and mistaken medication writing. [ 68 ] On the other hand, certain variables add to the high rates of prescription errors in pediatric patients. These incorporate inability to peruse the remedy, distraction, high patient/nurture proportion, and hard to get the accessibility of the right medications as endorsed. [ 65 ] Few investigations have tended to show the rates and reasons for medication errors in grown-up patients, and these examinations have regularly been founded on reports from nursing staff. [ 69 , 70 ] Moreover, few investigations have inspected medication errors from the viewpoint of pediatric nurses. [ 65 ]

The error might be identified with expert practice, which is related to human services items, to systems, or to correspondence issues including prescribing, ordering, item naming, labeling/packaging, preparation, compounding, dispensing, administration, education, and the best possible utilization of medicines. [ 2 , 11 , 71 ]

Patients are sometimes being harmed by incidents despite the safe and effective health services that are provided to them. Medication errors have been considered a global issue and it is essential to focus on the causes, results, and solutions. [ 11 , 72 ] The proportion of medication errors among nurses varies in different studies, it was 57.4% in Ethiopia, [ 16 ] 42.1% in Jordan, [ 15 ] 41.9% in Australia, [ 73 ] and 28.9% in the USA. [ 38 ] Thus, differences in rate are due to differences in organizational reporting systems, and the time frame of studies that have been conducted. Medication errors incorporate not just undesirable impacts from prescriptions, yet additionally incorporate ordering, transcription, dispensing, administration and organization mistakes. [ 11 , 74 ] Medication errors are more barely characterized than unfavorable medication occasions and incorporate mistakes of commission and omission. Errors of commission happen while abusing one of the five privileges of organization: right medication, patient, portion, course, time, and documentation. An error of omission is a mistake that consists of not doing something you should have done, or not including something such as an amount of fact that should be included, or when the patient does not get a drug that was arranged. [ 75 ] In a survey conducted on 1384 nurses in 24 ICUs in the United States hospitals regarding nurses’ perception of medication errors, [ 76 ] the main causes contributing to medication errors are illegible handwriting, mental and physical health, interruption and distraction from patient and co-workers, lack of pharmacological knowledge with problems in calculations, performance deficit, sometimes lab tests are not considered, overtime of working hours, absence of self-awareness, organizational factors (training) and failure to follow protocols. [ 15 , 46 , 53 , 77–88 ] Furthermore, it could be related to execution deficit (36.7%) and impairment of strategies realization, but knowledge, communication, drug distribution, and entry system were accounted for lesser percentages. [ 78 , 89 ] However, interruptions play a big impact on causing medication errors especially during administration. [ 46 ] As it may seem, 1354 errors occurred in 136 hours, which means 10 interruptions per hour. [ 90 ] Besides, registered nurses were interrupted (36.0–57.0%), which accounted from the patients (28.0%), other nurses (25.0%), assistive personnel (10.0%), and physician (9.0%), that led to 7.0% of medication errors from interruptions. [ 65 , 79 ] Moreover, around 20% of hospital registered nurses experienced frequent medication errors because of factors as overload, extra hours, unsatisfactory staffing with low support, and shift length. [ 91 ]

Lack of knowledge and miscalculation of doses are the factors contributing to medication errors. [ 36 , 37 , 39 ] It is noticed that competence skills in drug calculation are prerequisites to nursing registration and examining their learning abilities rather than follow strict protocol which imped nurses thinking skills. [ 11 , 92 ] Moreover, focusing on continuing education with clinical and theoretical support will help in the prevention of medication error occurrence. [ 15 , 93–95 ]

Medication errors are normally characterized as deviations from a doctor’s structure. Sources of errors could be from ordering, prescribing, transcription, dispensing, and administration errors (i.e. when the patient is administered a wrong medicine). Healthcare providers as doctors, medical specialists, pharmacists, unit assistants, and nurses could be related to the incidence of medication errors. [ 96 ] A patient can get up to 18 portions of prescription for each day, and a healthcare provider can regulate upwards of 50 medications for each move. [ 50 , 97 ] This places the healthcare provider at the forefront of administration accountability. [ 98 ]

Nurses are considered critical agents among the medical staff of clinics. One of the real undertakings of nurses is administering medicines to patients. They should be mindful of recognition significance of organized prescription to dodge potential dangers and conceivable complexities coming about because of medicine errors. [ 99 ]

Medication errors in clinics, for the most part, include 3.0–6.9% of hospitalized patients. [ 100 ] Customarily, to maintain a strategic distance from medicine errors, nurses utilized five privileges of the prescription organization; the correct patient, the correct medicine, the correct portion, the correct course, and the ideal time. Following this rule before giving any prescription, can help nurses keep away from the vast majority of medication errors. [ 30 , 52 ]

Most medicine executives are nurses and, in this manner, when errors happen, nurses are frequently considered responsible. [ 101 ] Medicine supervisors can give defend against errors made at any of the past stages, notwithstanding, and are thought to block around 86.0% of errors made by prescribers or medicine specialists. [ 102 , 103 ] Along these lines, nurses give a security guard against medication errors at the same time, can put patients in danger. [ 104 ]

Nurses have a central role in their activities to advance safety and anticipate damage to patients. [ 103 , 105 ] While this of great practice, nurses ought to assess how they work in groups to guarantee that the aggregate frameworks and procedures of training are sheltered and to help and instruct unpracticed partners. [ 46 ]

Even though that the way toward conveying medication to patients requires a joint effort between medical experts, registered nurses, and pharmacists, it is the essential obligation of healthcare providers to protect prescription administration. As indicated by Anderson and Webster administering prescription is the most noteworthy hazard undertaking a nurse can perform and can prompt destroying ramifications for the patient and the nurses’ vocation. [ 106 ] Besides, the mental injury brought about by submitting a medication error can be overpowering to the nurses, they may feel agitated, blameworthy, and panicked. [ 46 ] Therefore, medication errors might not only intend harm to patients, they additionally deface the notoriety of all medical experts in whom patients place their trust. [ 107 , 108 ]

On the off chance that nurses don’t have the fundamental capability on providing important data and capacity for the protection of human wellbeing and life, thus therapeutic errors wind up unavoidable. Notwithstanding these, reasons, for example, numerical deficiency of nurses in the workplace, persistent conditions, restlessness, tiredness, absence of consideration, unsure employment definition, insecure working hours, improper physical conditions, having an extraordinary number of patients, could trigger medication errors. [ 38 , 46 , 53 ]

Execution of medical requests is a critical piece of recovery procedure and patient consideration. Nursing execution is considered a prominent role that impacts patients’ safety. [ 109 ] Certain consequences as an impact on patient safety and treatment expenses will have resulted from medication errorss. [ 110 ] Administration of drugs is likely a standout amongst the most basic missions of nurses since the subsequent errors may have unintended, genuine complication for the patient. [ 111 ] Medication errors can prompt unfriendly results, for example, increased mortality, increased length of hospital stay, and expanded restorative expenses. [ 112 ] Although medication errors can be brought about by all individuals from healthcare providers. Most medical and therapeutic executions are done with the nurses, therefore, nursing medication errors are the most common. Besides, nurses execute most of the therapeutic requests and invest about 40.0% of their energy in the emergency clinic to manage medicines. [ 113 ] In developing and developed countries, the nursing medication error rate is observed to be high. [ 114 ]

Medical nurses are a fundamental piece of the human services group and are in charge of the wellbeing of patients yet sadly, the expansion in complaining from medical nurses and doctors in the previous years is proof of expanded frequency of errors. [ 53 ] On the other hand, no examinations have exhibited solid connections between nurse’s qualities (i.e. age, long stretches of training, and education) and the number of medication errors. [ 115 ] This would appear to show that nurses are conceivably in danger of making a medication error.

It is critical to identify medication error, regardless of whether vital or not, because of identification the error will uncover a disappointment in the treatment procedure which causes another event of hurt. There is additional proof that the demise rate from medication errors is expanding. These increments are not amazing as of late emergency clinics have seen an expanded rate of patients, new medications have developed that are progressively hard to utilize securely and viably, factors that will in general lead to increment the danger of medicine error. [ 116 , 117 ]

At the point when errors are distinguished, they can cause many disappointments because of the inability of how to deal with the resulting error, and they might cause potential harm to patients with disabilities. The backhanded results incorporate harm to the medical nurses as far as an expert and individual circumstances, decreased self-assurance, expanded pressure and clashes at work, lack of quality of the patient’s family to nurse. [ 118 , 119 ] Hence, the need to bring issues to interpret and manipulate the nature and reasons of errors is fundamental and can help nursing chiefs to recognize plans for improving the nature of medication administration, expanding the patient wellbeing, and lessening the extra cost. [ 120 ]

Handling medication is a high-recurrence movement in nursing; the potential for error increments when the normal number of prescriptions builds. Besides, prescription administration is an intricate procedure that is frequently performed under not exactly perfect conditions. Thus, the continuous flow of multifaceted prescriptions could prompt the occurrence of the hazard. [ 11 , 74 ] There is likewise a propensity to accuse people instead of the faulty system. Be that as it may, most medication errors emerge from the requests of doctors, trailed by medical organizations. [ 11 , 121 ]

A previous study about the report referring to the United Kingdom (UK) restorative safeguard associations, showed that 25.0% of all cases were because of prescription errors that included the following accompanying errors: [ 122 ] prescribing and administration errors (miscalculation, contraindicated or unlicensed medication, a wrong dose, or wrong patient), repeat dispensing without legitimate checks, failure to monitor the case, and failure to caution about antagonistic impacts (which may be that as it may, not be viewed as a medicine error).

Reporting the medication errors is critical in improving the medication management process, therefore, it is considered a legal and ethical commitment in each health care settings. Reporting medication errors could provide an effective resource of important information, therefore underreporting errors is observed as a crucial threat. [ 81 , 123 , 124 ] Regardless of whether the nurse is the wellspring of a mistake, a benefactor, or a spectator, associations depend on medical nurses as bleeding-edge staff to perceive and report medication errors. [ 15 ] A previous examination has exhibited underreporting among nurses. Adding to the weight of announcing, over 90.0% are oneself reports. [ 125 ] Moreover, in Israel, 26.0% of medication errors were reported, and 46% were self-reported. [ 126 ] In Taiwan, almost 6000 to 20000 deaths from medication errors, and 10.0% of medical lawsuits were mainly of underreporting. [ 127 ] In Turkey, 66.7% of involved nurses who caused medication errors did not report it. [ 128 ]

Medication administration is a high-risk area of nursing practice. Thus, reporting a medication error is an important step based on awareness and willingness to report it. [ 127 , 129 ] This barrier might be provoked, yet focus on the person rather than a system with fear from adverse outcomes lead to underreporting data. [ 11 , 38 , 52 , 61 , 65 , 77 , 130 ]

Precise detailing of medication errors could result in the avoidance of medication errors. Revealing prescription mistakes is reliant on the nurse’s decision making. Underreporting or not announcing medicine mistakes covers defective frameworks. [ 124 ] Besides, developing structured protocols on drug administration with an un-punitive approach could encourage reporting and improve patient safety. [ 131 ]

At present, self-revealed medication errors give negligible data to associations since disparities, as far as answered to-actual rates, are across the board. Medication errors are normally reported through institutional reporting frameworks, for example, incident reports to give information about the medication errors. [ 132 ]

Reports are created by the medical nurse who distinguishes the error and afterward is sent to the executives, quality divisions, or board offices of hazard. Detailing and reporting the issue is subject to the medical nurse in many ways: [ 117 ] capacity to perceive a mistake has happened, the conviction that the mistake warrants reporting, the conviction that she/he has submitted the error, and eagerness to beat the humiliation and dread of striking back for having submitted a medication error.

Nurses specifically are imperative in evaluating such errors since they are, for the most part, in a situation to see medication errors directly and find a way to lessen the danger of medication errors. [ 133 ] Their uncommon position is regularly fortified by their continuous learning concerning the medications in addition to their strategies regarding planning and controlling the medicines and for checking the impacts of the treatment. [ 11 ] All nurses must get comfortable with different methodologies to forestall or diminish the probability of medication errors. Here are certain techniques to follow:

1. Guarantee the five privileges of the prescription organization

Nurses must guarantee that institutional approaches identified with prescription interpretation are pursued. It isn’t adequate to translate the medicine as prescribed, however, to guarantee the right medicine is recommended for the right patient, right time, the right measurements, through the right course, and planned effectively (otherwise called the five rights). [ 88 , 134 ]

2. Pursue legitimate medication reconciliation techniques

Foundations must have instruments set up for medicine reconciliation while exchanging a patient starting with one establishment then onto the next or starting with one unit then onto the next in a similar organization. Audit and check every prescription for the right patient, right medicine, right measurements, right course, and right time against the exchange (transfer) requests, or medications recorded on the exchange archives. Nurses must contrast this with the Medication Administration Record (MAR). Frequently not all components of a medicine record are accessible for simple confirmation, yet it is of central significance to check with each conceivable source including the releasing or exchanging establishment/unit, the patient or patient’s family, and doctor, to forestall potential mistakes identified with inappropriate reconciliation. [ 135 ]

3. Have the doctor (or other nurses) read it back

This is a procedure whereby a nurse peruses back a request to the recommending doctor to guarantee the arranged medicine is deciphered accurately. This procedure can likewise be completed starting with one medical nurse then onto the next whereby a medical nurse peruses back a request deciphered to the doctor’s structure to another medical nurse as the MAR is checked on to guarantee precision. [ 136 ]

4. Document everything

This incorporates legitimate medicine naming, clear documentation, or appropriate recording of administered medicine. An absence of appropriate documentation for any prescription can result in an error. For instance, a nurse neglecting to report an as required prescription can result in another administration being directed by another healthcare provider since no documentation signifying past administration exists. Perusing the medicine name/label and expiration date of the medicine is additionally another best practice. A right prescription can have a wrong mark or the other way around, and this can likewise prompt a medicine error. [ 11 , 137 ]

5. Guarantee appropriate storage of medications for legitimate adequacy

Health care providers should avoid the medication storage with close or identical names or package on them at the same medication stock rack. Alphabetized drug storage could lead to unintentional confusion. Besides, it is essential to separate ‘high alert’ medications from other medications to avoid ambiguity. Medications that ought to be refrigerated must be kept refrigerated to look after adequacy, and medications that ought to be kept at room temperature ought to be put away in like manner. Most biologicals items require refrigeration, and if a multi-dose vial is utilized, it must be named to guarantee it isn’t utilized past its lapse/expiration date from the date it was opened. Thus, it is recommended to keep it organized and control access to it. [ 138 , 139 ]

6. Consider having a drug guide accessible consistently

Regardless of whether it’s print or electronic is a matter of personal (or institutional) inclination, however, both are similarly significant in giving imperative data on most classifications of prescription, including trade/generic names, therapeutic class, dosing, nursing consideration, side effect, drug-drug interaction and medication cautionary, for example, ‘don’t crush, or give with the meal’. [ 140 ]

7. Know institution policies, regulations, and guidelines

Nurses should be familiar with the policies and guidelines and how to apply them. Since these regulations and policies could provide necessary information regarding drug ordering, transcription, administration, and documentation. Besides, it could provide information for the nurses about black box warnings, look alike, sound alike, and warning labels. [ 138 , 141 ]

As penultimate, medication errors are multifaceted criteria. It is motivated to standardize the recommendation and make it a central goal all over the globe for the best practice. Thus, it is suggested to; (a) get a deeper meaning of the medication errors concept, (b) focus on broader causes outside of the taken picture, (c) converge on clinical settings variations and patient illness severity, (d) include questions related to nurse’s psychology, (c) create a group of expert to publish new guidelines internationally adapted to any changes according to hospital needs. Nurses are the heart of clinical settings, encouraged to be one integrated body to prevent the occurrence of medication errors. Thus, systemizing the guidelines are required such as education and training, independent double checks, standardized procedures, follow the five rights, documentation, keep lines of communication open, inform patients of drug they receive, follow strict guidelines, improve labeling and package format, focus on the work environment, reduce workload, ways to avoid distraction, fix the faulty system, enhancing job security for nurses, create a cultural blame-free workspace, as well as hospital administration, should support and revise processes of error reporting, and spread the awareness of the importance of reporting.

Initiating the idea of the manuscript: Nasr Alrabadi and Razan Haddad. Writing the first draft: Shaima Shawagfah, Nasr Alrabadi, Suzan AlRabadi, Razan Haddad, Daher Al-rabadi, and Tareq Mukattash. Reviewing and approving the final draft: Nasr Alrabadi, Sawsan Abuhammad, Rana Abu Farha, and Ibrahim Al-Faouri.

Not applicable.

The authors declared no conflict of interest.

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Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity

• Review Article
• Published: 11 May 2024

Cite this article

• Phuong Thi Lan Nguyen 1   na1 ,
• Thu Anh Thi Phan 1   na1 ,
• Van Bich Ngoc Vo 1 ,
• Nhi T. N. Ngo 2 ,
• Ha Thi Nguyen 1   na1 ,
• Toi Lam Phung 3 ,
• Mai Thi Tuyet Kieu 4 ,
• Thao Huong Nguyen 5 &
• Khanh N. C. Duong   ORCID: orcid.org/0000-0002-7152-9476 1 , 6  

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Medication errors significantly compromise patient safety in emergency departments. Although previous studies have investigated the prevalence of these errors in this setting, results have varied widely.

The aim was to report pooled data on the prevalence and severity of medication errors in emergency departments, as well as the proportion of patients affected by these errors.

Systematic searches were conducted in Embase, PubMed, and the Cochrane Library from database inception until June 2023. Studies provided numerical data on medication errors within emergency departments were eligible for inclusion. Random-effects meta-analysis was employed to pool the prevalence of medication errors, the proportion of patients experiencing these errors, and the error severity levels. Heterogeneity among studies was assessed using the I 2 statistic and Cochran’s Q test.

Twenty-four studies met the inclusion criteria. The meta-analysis gave a pooled prevalence of medication errors in emergency departments of 22.6% (95% Confidence Interval [CI] 19.2–25.9%, I 2  = 99.9%, p  < 0.001). The estimated proportion of patients experiencing medication errors was 36.3% (95% CI 28.3–44.3%, I 2  = 99.8%, p  < 0.001). Of these errors, 42.6% (95% CI 5.0–80.1%) were potentially harmful but not life-threatening, while no-harm errors accounted for 57.3% (95% CI 14.1–100.0%).

The prevalence of medication errors, particularly those potentially harmful, underscores potential safety issues in emergency departments. It is imperative to develop and implement effective interventions aimed at reducing medication errors and enhancing patient safety in this setting.

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Acknowledgements

We extend our sincere gratitude to Dr. Chia Jie Tan, Department of Pharmacotherapy, College of Pharmacy, University of Utah, U.S., for his invaluable review and insightful contributions to this work.

No sources of funding were used to assist in the preparation of this article.

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Phuong Thi Lan Nguyen and Thu Anh Thi Phan have contributed equally as first authors.

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School of Medicine, Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam

Phuong Thi Lan Nguyen, Thu Anh Thi Phan, Van Bich Ngoc Vo, Ha Thi Nguyen & Khanh N. C. Duong

Health Technology Assessment Program, Mahidol University, Bangkok, Thailand

Nhi T. N. Ngo

Health Strategy and Policy Institute, Ministry of Health, Hanoi, Vietnam

Toi Lam Phung

Faculty of Pharmaceutical Management and Economics, Hanoi University of Pharmacy, Hanoi, Vietnam

Mai Thi Tuyet Kieu

Faculty of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam

Thao Huong Nguyen

Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA

Khanh N. C. Duong

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Nguyen, P.T.L., Phan, T.A.T., Vo, V.B.N. et al. Medication errors in emergency departments: a systematic review and meta-analysis of prevalence and severity. Int J Clin Pharm (2024). https://doi.org/10.1007/s11096-024-01742-w

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Almost all pregnant people face decisions about taking medicines during pregnancy. Many people need to take medicines during pregnancy to treat health conditions. In some cases, avoiding or stopping a medicine during pregnancy may be more harmful than taking it.

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Medicine use during pregnancy is common. About 9 in 10 women report taking some type of medicine during pregnancy. About 7 in 10 report taking at least one prescription medicine. From 1997-2018, use of at least one prescription medication in the first trimester increased 35%. 1 2

Safety information is lacking. Fewer than 10% of medicines approved since 1980 have enough information to determine their safety during pregnancy. This is because pregnant people are often not included in studies that determine the safety of new medicines. 3

As a result, pregnant people and healthcare professionals have limited information to make informed treatment decisions during pregnancy.

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Can I take medicine once I'm no longer pregnant? Can I take medicines if I'm breastfeeding?

Although many medications do pass into breast milk, most have little or no effect on milk supply or on infant well-being. For more detailed information, LactRx is an online database that provides information about managing your health conditions while breastfeeding.

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• Mitchell AA, Gilboa SM, Werler MM, Kelley KE, Louik C, Hernandez-Diaz S, and the National Birth Defects Prevention Study. Medication use during pregnancy, with particular focus on prescription drugs: 1976-2008. Am J Obstet Gynecol. 2011;205(1):51.e1-8.
• Werler MM, Kerr SM, Ailes EC, Reefhuis J, Gilboa SM, Browne ML, Kelley KE, Hernandez-Diaz S, Smith-Webb RS, Garcia MH, Mitchell AA and The National Birth Defects Prevention Study and Birth Defects Study To Evaluate Pregnancy exposureS. Patterns of Prescription Medication Use during the First Trimester of Pregnancy in the United States, 1997–2018. Clin Pharmacol Ther. 2023. https://doi.org/10.1002/cpt.2981
• Adam MP, Polifka JE, Friedman JM. Evolving knowledge of the teratogenicity of medications in human pregnancy. Am J Med Genet Part C. 2011;157:175-82.

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‘Filmlovers!' Review: Arnaud Desplechin's Hybrid Essay Film Explores His Abiding Love of Cinema

D irectors have been filming "love letters to cinema" ever since they first exhibited nostalgia for the medium (or their own burgeoning cinephilia). Arnaud Desplechin's new hybrid essay film "Filmlovers!" waxes poetic about cinema's capacity to entrance, but he doesn't coast on cozy remembrance. Instead, he balances nostalgia with scholarly analysis and a tactile focus. The post-New Wave French filmmaker acutely understands that cinephilia is both an intellectual and sensorial experience; the feeling of the a theater seat and the flicker of a projector hold as much weight as deploying different frameworks to unpack symbolism or allusions. "Filmlovers!" melds fiction and non-fiction, the personal and the political, popular and art cinema, into a lyrical tribute to spectatorship, embracing all the theories and emotions that come with it. 

Via narration by long-time collaborator Mathieu Amalric, Desplechin begins with a meditation on cinema's artistic forebearers (painting, photography, puppetry, etc.) and its intrinsic properties, mainly time and movement. Throughout "Filmlovers!," he repeatedly circles back to cinema's historical development, from the early days of projection in the late 19th century through its industry expansion, the rise of television, and eventually its contemporary moment.

Before invoking theory or personal emotions, "Filmlovers!" grounds the medium in its material realities, conveying to an audience - albeit one who probably already knows this stuff - that film is intrinsically tied to technology, economics, and a country's sociopolitical fabric.

Structured in chapters, "Filmlovers!" deploys multiple film excerpts across cinema history to supplement analyses of spectatorship, specifically the ways movies comment upon the gaze of the viewer. Most of the time, Desplechin uses clips as quotations, using a torrent of imagery to emphasize a particular point, but sometimes Desplechin-via-Amalric will comment at length about a particular film or engage with granular scene analysis.

Desplechin embodies a true cinephile's expansive love of film. Scenes from "Terminator 2: Judgement Day" and "Persona" are given equal weight. Desplechin will dive deep into D.W. Griffith while also incorporating a lengthy examination of a scene from "Notting Hill" as a metaphor for cinema itself, expound upon ideas  he's publicly expressed before .

Desplechin also revives his loose fictional avatar Paul Dedalus for "Filmlovers!" to lend the film a personal edge. A Nathan Zuckerman-like figure, Paul Dedalus sports a flexible persona that allows the filmmaker to explore various pet ideas unbound by continuity. In Desplechin's 1996 international breakthrough "My Sex Life… or How I Got into an Argument," the existentially adrift Paul (Amalric) was a philosophy PhD student struggling to complete his dissertation amidst a complicated love life. The 2015 sorta-prequel "My Golden Days" features Paul, played by Amalric as an adult (also played by Amalric) living in Paris and Quentin Dolmaire as a young man in Roubaix, as an anthropologist who routinely does field work in Asia. But in "Filmlovers!," Desplechin presents Paul as an avowed cinephile from a young age, featuring him in three phases: a curious child, a film-obsessed teen, and a suave twenty-something scholar.

The Dedalus scenes bring out a tenderness in Desplechin, if only because it provides him the chance to remix and fictionally explore memories from his own life. Paul's love of cinema, like Desplechin's, emerges from the time his grandmother, played in "Filmlovers!" by the legendary Françoise Lebrun, took him and his sister to see "Fantômas" in the cinema. He recreates this story on screen by emphasizing the utter mundanity of the setting and experience - Paul goes to the bathroom alone at one point, they leave early because Paul's sister becomes frightened by Jean Marais' performance - but within that normalcy, a lifelong fascination begins to blossom. "Filmlovers!" pays tribute to the ways that elders can shepherd and influence their charges' love of art just by allowing them to experience it on their own.

As Paul grows up, his obsession becomes more of an active pursuit. He sneaks into a repertory screening of "Cries and Whispers" and it changes his life. He programs "Daisies" for his own high school film club where he impresses a girl with his earnest introduction and careful monitoring of the projection. For Paul (and, presumably, Desplechin), cinephilia and amorous desire are forever intertwined.

The best sequence in "Filmlovers!" involves Paul in his twenties engaging with two women - his crush who's involved with someone else and her more outgoing friend - at a screening of Francis Ford Coppola's "Peggy Sue Got Married." While Desplechin definitely filters the scene through a romantic's trapped-in-amber glow, he also neatly captures how cinema-going and romance can become wrapped up in a shared gaze, and how sharing a passion can become a flirtatious game on its own.

Though Paul Dedalus recurs throughout "Filmlovers!," his scenes aren't so much part of a narrative throughline as an example of one spectator amongst many. Desplechin includes other fictional scenes to illustrate different ideas of spectatorship, like a meeting between philosopher Sandra Laugier and a graduate student about the nature of film realism through different theoretical lenses. (How often do the movies depict an extended discussion of the ontology of film by way of Stanley Cavell and Andre Bazin?)

He also features a sequence of documentary-style testimonials from anonymous individuals who discuss their cinematic routines (where they sit in the theater, what they eat) as well as their most cherished film memories. One man talks about how seeing Maurice Pialat's "A Nos Amours" changed his life; a little girl explains how she was emotionally affected by Steven Spielberg's "West Side Story" adaptation.

"Filmlovers!" freely digresses through multiple different cinematic modes, consciously mirroring Desplechin's aggressive cinematic style in his narrative work. Its episodic nature inevitably means certain sequences will endear themselves to different viewers, but Desplechin still offers multiple points of entry. Though the Dedalus sections will likely be cherished more by those who have followed the character for years, they certainly compel on their own merits and require no prior context. Similarly, the more academic scenes might intrigue viewers who have dipped their toes in film theory or cinema studies, but they're never so dry to alienate anyone unfamiliar with the material. Anytime ideas drift towards abstraction, "Filmlovers!" returns to the physical and emotional sensations that film inspires.

For better or worse, Desplechin's palpable passion for cinema is the main selling point of "Filmlovers!" So much of it feels like an opportunity for the director to filmically expunge ideas and memories he's held onto for a while, like a lengthy tribute to Claude Lanzmann's "Shoah" or a shot-by-shot analysis of the opening to "The 400 Blows" filtered through the perspective of a fictional aspiring director.

Desplechin freely risks boring or annoying anyone well-versed in his talking points - which, if we're being honest, might be a sizable portion of the film's actual audience - and he seems predictably, refreshingly indifferent to any charges of pretension. While "Filmlovers!" might not say anything new about the theatrical experience or the history of cinema, it might linger, however briefly, in your mind as a warm memory, and that's certainly Desplechin's chief intention.

"Filmlovers!" premiered at the 2024 Cannes Film Festival. It is currently seeking U.S. distribution.

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Pharmacist medication review: An integrated team approach to serve home-based primary care patients

Michele monzón-kenneke.

1 Northwestern Medicine, Evanston, IL, United States of America

Paul Chiang

2 Home Centered Care Institute, Schaumburg, IL, United States of America

Nengliang (Aaron) Yao

3 Center For Health Management and Policy, School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China

4 Section of Geriatrics, University of Virginia, Charlottesville, VA, United States of America

Associated Data

All relevant data are within the paper. Patient-level data cannot be shared publicly because of the HIPAA requirements.

Comprehensive medication review is a patient-centered approach to optimize medication use and improve patient outcomes. This study outlines a pilot model of care in which a remote corporate-based clinical pharmacist implemented comprehensive medication reviews for a cohort of medically complex home-based primary care (HBPC) patients.

Ninety-six medically complex patients were assessed for medication-related problems. Data collected on these patients were: number of chronic conditions, number of medications, appropriate indication for each medication, dose appropriateness, drug interactions, recommendations for medication optimization and deprescribing. The number of accepted recommendations by the HBPC practice was analyzed.

On average, the patients were 82 years old and had 13 chronic conditions. They were taking a median of 17 medications. Over a four-month pilot period, 175 medication recommendations were made, and 53 (30.3%) of them were accepted, with most common being medication discontinuation, deprescribing, and dose adjustments. Sixty-four (66.7%) patients were on a medication listed as potentially inappropriate for use in older adults. The most common potentially inappropriate medication was a proton-pump inhibitor (38.5%), followed by aspirin (24%), tramadol (15.6%), a benzodiazepine (13.5%) or an opioid (8.3%). Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33.3%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (45.8%). Thirty-four medications were suggested as an addition to the current patient regimen, 2 medications were added (5.9%).

Pharmacist comprehensive medication review is a necessary component of the HBPC healthcare continuum. Additional research is needed to examine whether aligning pharmacists to deliver support to HBPC improves clinical outcomes, reduces healthcare expenditures and improves the patient’s experience.

Introduction

Clinical pharmacists play an essential role within interdisciplinary teams in optimizing medication use, alerting providers to gaps in care, decreasing inappropriate prescribing practices and improving medication safety [ 1 , 2 ]. Comprehensive medication review is a patient-centered approach to optimize medication use and improve patient outcomes by ensuring each patient’s medication is assessed for indication, effectiveness and safety given patient status and comorbidities [ 3 ]. Physicians in ambulatory settings often have limited access to a dedicated pharmacist resource [ 1 – 3 ]. This study sought to implement a remote corporate-based pharmacist into a home-based primary care practice to facilitate comprehensive medication reviews.

About 2 to 4 million Americans have difficulty obtaining office-based primary care because they are frail, functionally limited, chronically-ill and/or homebound [ 4 , 5 ]. These “invisible” people are the most expensive patients [ 6 ], and they fall through the cracks of our current healthcare delivery system. When in need, they often turn to emergency services for medical help but have no continuous, follow-up care [ 7 ]. This continues a cycle of poor health management and high expenses. This population is expected to grow dramatically as our society continues to age. The home-based primary care (HBPC) model offers an opportunity to meet their demand and save healthcare costs [ 5 ]. HBPC brings the expertise of primary care providers and the technology of a health care clinic directly to medically complex patients, providing comprehensive, coordinated care in the comfort of their home.

Limited knowledge exists on the integration of pharmacist support in private sector HBPC practice [ 8 ]. Clinical pharmacist’s role is widely known within outpatient retail settings and hospital inpatient interdisciplinary teams. However, clinical pharmacy support of ambulatory based medical practices is limited [ 9 ], including in HBPC [ 10 ]. As the population ages and the option of many medical services being made available from home, it is important to include all of the services available to patients who standardly seek care in traditional settings. A remote-pharmacist functions as a liaison transcending novel healthcare landscapes providing oversight essential for safe medication use. Comprehensive medication management is a critical function that assists in improving medication use, especially in those utilizing many medications to manage their multiple coexisting disease states. Older adults using multiple medications may be at risk of medication-related problems leading to adverse health outcomes [ 11 ]. Comprehensive medication management in the HBPC population is crucial as these patients have multiple comorbidities and most fit the criteria for polypharmacy. Polypharmacy’s definition can be variable but is commonly considered to be the use of five or more medications [ 12 ]. Polypharmacy has been associated with increased risks of adverse events and poor health outcomes [ 12 ]. Polypharmacy can also lead to countless medication-related problems (MRP).

Literature searches for remote-pharmacist medication management in home-based primary care did not yield any studies. The demographic of the HBPC patient in this pilot is characterized as having multiple comorbidities, elderly and overwhelmed by polypharmacy. Globally, medication safety in older adults impacts health outcomes and is an enduring health issue. Medication-related problems can be the cause of hospital admissions and cause significant morbidity and mortality. Thirty percent of hospital admissions may be a result of an adverse drug reaction, of which 53.4% are considered preventable [ 13 ]. Adverse drug reactions cause significant morbidity and mortality especially as patients age, with a patient aged 75 years or older at the greatest risk [ 14 ].

This pilot population of HCBP was compromised of persons of advanced aged and medically vulnerable. Utilizing a remote-pharmacist service can support a HBCP practice by assisting in illuminating medication-related problems. In a study by Vink et al. pharmacists were able to identify medication-related problems in home care patients that were not identified from other providers [ 15 ]. In that study the most common problems identified were suboptimal therapy and using of unnecessary medications [ 15 ]. A review article describing medication-related problems in home care, commonly noted MRPs were due to potentially inappropriate medications, medication errors and adverse drug reactions [ 16 ]. In that same study, it was relayed that teams lacking an interdisciplinary model had patients who were at risk for experiencing MRPs [ 16 ].

The Northwestern Medicine Physician Network (NMPN) Accountable Care Organization (ACO) includes over 3,100 providers and approximately 400,000 covered lives. Many of these providers, including HBPC physicians and nurse practitioners, have expressed the need for pharmacist resources to assist with general drug information and patient specific medication consult support. This pilot study was a collaboration with Northwestern Medicine (NM) Regional Medical Group (RMG) Home Care Physicians who provide primary care to medically complex patients in their homes. The majority of these patients are older adults who live alone and have functional disabilities making it difficult to travel or leave their homes to obtain medical care. As strong proponents of team-based healthcare, Home Care Physicians requested assistance from the NMPN Pharmacy Team to review and offer feedback on their patient’s medication regimens. The aim of this study was to describe this pilot program and examine the degree of medication recommendation acceptance by the HBPC practice.

Pilot innovation

This program was created to assist our pilot providers with medication management. Our ACO members expressed the need for pharmacist intervention in assisting with their patient care. Many of our members have no dedicated pharmacy resource and have stated that inpatient and outpatient pharmacists do not have the time or access to the patient medical records to provide comprehensive medication reviews. This program is innovative because this is the first program to incorporate a remote-pharmacist into a HBPC practice. There are no studies that have examined this type of team structure.

No clinical pharmacist service existed at the practice prior to the intervention. The pharmacist performing the medication reviews was employed by the ACO. The pharmacist performing the reviews has two board certifications: A Board-Certified Pharmacotherapy Specialist and a Board-Certified Geriatric Pharmacist with extensive experience in the ambulatory care setting managing patient with complex conditions.

The NM RMG Home Care Physician Team includes 2 physicians and 3 advanced practice nurses that serve approximately 750 patients.

Medication review

Over a four-month pilot period, a total of 96 patient charts were reviewed by one clinical pharmacist. The average time spent on each patient’s chart review and medication history was approximately 45 minutes. The total time allotted to the project was about 100 hours or 1 hour per patient. This time included chart review, literature review and guideline research in support of recommendations, messaging providers, and recording interventions in a Microsoft Excel spreadsheet.

The program workflow emanated from a weekly email received by the pharmacist containing a list of new Home Care patients on 5 or more medications to review for that week. Patient name, medical record number, and date of birth were forwarded to the pharmacist. The pharmacist would research the patient in the electronic medical record (EMR). Review consisted of reading patient notes, history and physical, laboratory (lab) results, and the medication list. Initially, the pharmacist would review all the patient’s medications and medical history and ensure that each medication prescribed for that patient was appropriate. Medication reviews were performed in a systematic manner by a single pharmacist. As part of a pharmacist’s training, they perform prospective reviews and determine indications for medication use, correct dosage and directions, duplication of therapy, medication effective for condition (based on current patient status and lab results), symptom management recommendations, and patient-centered considerations (affordability, alternative formulations).

A Microsoft Excel spreadsheet was created and consensus regarding outcomes of interest was agreed upon by the pilot team. The spreadsheet contained several headings allowing for methodical review of each patient capturing demographics; provider name; number of chronic conditions; number of medications; renal/hepatic dosing appropriate; patient currently on a American Geriatric Society Beers List medication; name of American Geriatric Society Beers List medication; drug-drug interaction; number of medications recommended for deprescribing; name of medication recommended for deprescribing; additional medication recommended; name of medication recommended; number of total recommendations; number of recommendations taken and intervention taken by provider.

Determination of the number of chronic diseases a patient had was achieved by reviewing the Problem List in the EMR. Chronic medical conditions were defined mirroring the definition as described by the Centers for Disease Control and Prevention (CDC), a condition lasting one or more years that requires ongoing medical attention and/or limits the activities of daily living.

All medications that were current on the patient medication list in the EMR were totaled and considered the patient’s total medication count. This included regularly scheduled medications, as needed medications and medications taken during a specific time period such as an antibiotic.

The completed Excel spreadsheet was sent back to the providers each week. In addition to the spreadsheet, individual messages were sent to providers alerting them of patients in which the pharmacist recommended adjustments for hepatic/renal dosing, significant drug-interactions, and changes in medications based on laboratory results. Additionally, patients were also brought to the provider’s attention if they had a chronic condition that could benefit from dose titration or augmentation of therapy. PubMed and disease specific guidelines were used in assisting with recommendations. Information for recommendations to augment current treatment was gleaned from the pharmacist’s knowledge and experience in ambulatory care. Knowledge was supported by practice guidelines for major chronic illnesses. For example, for diabetes (American Diabetes Association–ADA Standards of Medical Care in Diabetes), chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease—GOLD Guidelines), hyperlipidemia (American College of Cardiology/American Heart Association Cholesterol Practice Guidelines), chronic kidney disease (Kidney Disease Improving Global Outcomes–KIDIGO), depression (American Psychiatric Association).

Drug interactions were reviewed using Micromedex. Dose adjustments were based on estimated glomerular filtration rate (eGFR) or Cockcroft-Gault Equation for creatinine clearance (CrCl) as suggested by the medication prescribing information.

Patients were assessed for number of chronic conditions, number of active medications prescribed, appropriate indication for each medication, dose appropriate for renal, hepatic, age or other specific monitoring parameters, medication listed on the American Geriatric Society Beers Criteria, drug-drug interactions, medications to consider for deprescribing, medications to add to current therapy to optimize disease state treatment.

At the end of the pilot program, the charts of those patients were re-reviewed to determine how many of the recommendations provided were accepted.

Analysis and approach

We first performed a frequency analysis of the baseline characteristics of the HBPC patients that received pharmacist medication review. At the end of the pilot period, a cross-table was created to show the number of recommendations per patient and accepted recommendations. A frequency table of the potentially inappropriate medications was included in the analysis. We then selected three patients to describe a detailed report of their medication deprescribing and optimization.

Summary of the pilot results was shared with the providers at NM RMG Home Care. The senior medical advisor (physician champion) reviewed findings with his staff to better understand the reasons why many of the recommendations from the pharmacist were not accepted. The senior advisor interviewed the providers to understand the common barriers in implementing the recommendations. They also discussed the role a pharmacist has to assist with medication optimization and deprescribing. We have summarized their discussions in the results section.

The average age of the pilot population was 82 years. Table 1 shows that over a third of the patients were 85 years or older. About 61% are female. About 71% of them were enrolled in the traditional Medicare program. On average, the patients had 13 chronic conditions and were taking a median of 17 medications. About 70% of these patients were taking 15 or more medications ( Table 1 ).

The clinical pharmacist made 175 recommendations, and 53 (30%) were accepted by the HBPC providers. While about 19% of patients did not receive any recommendations, about 28% and 29% of patients have received one and two recommendations, respectively ( Table 2 ). Among 78 patients receiving recommendations, HBPC providers accepted at least one recommendation for 40% of these patients.

The most commonly heeded intervention was medication discontinuance or deprescribing and dose adjustments. Eighty-one medications were recommended for deprescribing and 27 medications were discontinued (33%). There were 24 recommended dose adjustments and 11 medications were dose adjusted (46%). Eleven medications were suggested as an addition to the current patient regimen.

Sixty-four (67%) of the 96 patients were on medication listed as potentially inappropriate on the American Geriatric Society Beers Criteria, 11 patients were not on a Beers List medication and in 21 patients the criteria were not applicable given current age. Fig 1 shows the most common potentially inappropriate medication was a proton-pump inhibitor (41%), followed by aspirin (24%), tramadol (16%), a benzodiazepine (14%) and an opioid (8%).

Pharmacist intervention in HBPC improved patient safety and had financial implications. Table 3 describes three examples of pharmacist recommendations that were accepted. In the first example, a 79-year-old patient on eltrombopag required medication dose adjustment based on their lab results to prevent potential thromboembolism; the second accepted recommendation was for medication consolidation and tapers in a 49-year-old patient taking several central nervous system (CNS) depressants who was at high risk for adverse drug reactions due to concomitant cannabis use and multiple comorbidities. In the third example, a 93-year-old patient on concomitant warfarin and torsemide was switched to apixaban to avert a drug interaction which prior to the modification was the cause of months of not achieving the international normalized ratio (INR) goal. Financial implications are added to each recommendation to emphasize how these interventions could have resulted in health care cost avoidance.

The provider interview shows that the barriers to implementation of recommended changes include (1) provider decision to continue medications based on clinical judgement and patient need; (2) patient/family/provider reluctance to institute changes (“don’t rock the boat”); (3) medical mindset of prescribing medication to address clinical complaints; (4) determining who is responsible for deprescribing when multiple specialists are involved; (5) lack of clinical time; and (6) lack of clear guidelines for deprescribing.

The NM RMG Home Care group identified the need for a pharmacist to assist with medication optimization and deprescribing by offering step by step guidance through the process. The group also believe a pharmacist would be an asset to the team if they would reach out and discuss changes directly with patients, family and caregivers. This would provide patients and caregivers with a dedicated pharmacist treatment team member allowing for immediate access to address uncertainty, understanding and apprehension.

The forefront goal of the program was to implement and integrate a clinical pharmacist presence in a HBPC practice. Establishing this clinical pharmacy pilot demonstrated that pharmacist integration in HBPC identified opportunities to optimize patient care and potentially reduce or avoid additional healthcare spending. Another important aspect of this study was to describe a demographic that is serviced by home-care providers. As outlined, these patients are medically vulnerable, aged and have an increased utilization of medications. As the number of medications, a patient takes increases, so does the potential risk of adverse reactions or complications. It may be the perception that pharmacists review patient’s medications each time a new medication is added to their regimen. While this is true, many outpatient pharmacists lack access to patient’s EMR. Complicating this scenario, is patients who, due to cost, need to obtain medications from multiple different pharmacies. Fragmenting and the siloing of care follows. This adds complexity when attempting to perform a medication review from the outpatient pharmacy perspective. Having a pharmacist as a sentinel of where prescribing originates allows for the most comprehensive review to occur. In this pilot, about 81% of the patients received at least one medication recommendation. Of the 175 recommendations provided, 53 (30.3%) were accepted.

Comprehensive medication review has the unique ability to help identify medication problems. In an article from Castelli et al., it was noted that pharmacist inclusion in patient-centered medical homes (PCMH) is not widespread due to a lack of knowledge of the skill set and benefits [ 22 ]. In that study, in using comprehensive medication management, pharmacists were able to identify and work with the provider to resolve various medication therapy problems. There was a 98% acceptance rate of pharmacist interventions [ 22 ].

HBPC teams within the Veteran’s Health Administration have clinical pharmacy specialists [ 10 ]. They provide comprehensive medication management services to HBPC veterans [ 10 ]. A study of 79 HBPC veterans examined medication appropriateness and the degree of recommendation acceptance [ 23 ]. The acceptance rates for primary care providers were 69% [ 23 ], in contrast with 30% in our study. A recent study in the private sector had pharmacy resident-provider pairs making home visits to 25 homebound patients [ 24 ]. However, their study focused on developing a screening tool that identifies identify HBPC patients likely to benefit from in-home pharmacist review.

In our pilot study, the HBPC provider group agreed to the pharmacist recommendation 33.3% of the time for deprescribing recommendations and 45.8% of the time on dosing recommendations. When reviewing the results, the provider group felt that additional deprescribing would have occurred if the pharmacist was readily available to provide step by step instructions how to de-escalate therapy for the treatment team. Providers also agreed that recommendations would be followed if the pharmacist would act as a liaison discussing changes with the family directly. An integrated pharmacist would be an asset allowing for patient and caregiver buy-in when there is resistance or hesitancy to make changes.

Improving recommendation acceptance can occur by the pharmacist and the providers entering into a collaborative practice agreement (CPA). Initially focusing on a select few disease states, the CPA would outline a defined protocol under which the pharmacist would function to perform medication monitoring, initiating and adjusting medication regimens. Additionally, educating HBPC patients on the services provided by a pharmacist would encourage the patient to reach out to the pharmacist directly when they have any medication related problems. Patient care services provided by pharmacists and facilitated by CPA usage can assist in improving patient outcomes and reduction in the fragmentation of care [ 25 ].

Recommendation acceptance could also be increased by implementing a weekly virtual team huddle to discuss the patients sent to the pharmacist for review. Under this practice, team dialog may help to alleviate any unanswered questions that may hinder recommendation acceptance. Healthcare huddles are known for promoting patient safety, enhancing communication and fostering trust and relationship building amongst the team [ 26 ].

Home care providers are generally the sole clinician visiting the home with no additional care team members present in the home for support. The setting in which visits occur can become overwhelming depending on the environment in the home and the number of caregivers and family members present during the visit. Having immediate access to a pharmacist to assist with speaking with the family/caregiver about changes in medication therapy can be extremely valuable. This approach could become a standard of care which home care patients will grow to expect from their providers.

Our pilot program was predicated on volunteered pharmacist time, which limited the number of patients that could be reviewed on a weekly basis. Patient chart review is extremely labor-intensive as evidenced by the total and average time required to review each case. Given the population that NM RMG Home Care currently has, there exists a divide between pharmacist clinical support and the ambulatory providers/patients who may benefit from pharmacist intervention. Without access and the integration of pharmacists into the treatment team providing this type of service, providers in the field lack expert point of care access and decision-making abilities to optimize patient’s complex medication regimens and conditions.

As evidenced from comments from our own providers, seeking input from various inpatient hospital or retail pharmacists has not been a consistent or ideal state. There needs to be provision and advocacy for pharmacists embedded in the health system that can act as liaisons and consultants to provide this type of support to the multitude of patients seeking care. As the future of reimbursement shifts away from fee for service and to pay-for-performance, a pharmacist is uniquely qualified to assist providers in providing optimal care. A remote-pharmacist model permits a larger landscape than just focusing on a single disease state or discipline. It also allows for support of multiple provider practices. Many times, embedded pharmacists are fraught with assisting with insurance coverage dilemmas, prior authorizations and other administrative tasks resulting in a decrease in the time available to provide pharmacist-specific clinical interventions. The remote-pharmacist model can serve as global resource for patient referrals or questions for complex patients and oversight for essential medication management.

While many HBPC providers state they would value the addition of a pharmacist to their team, the limiting factor frequently stated are the financial resources needed to support a pharmacist. A commonly mentioned barrier is the ability to quantify and assign a dollar value to the myriad of clinical services the pharmacist provides. Using conservative estimates, pharmacist intervention in this pilot program may have resulted in health care cost avoidance in the three patient cases described estimated to be $53,000 in direct medical costs. The estimated annual cost of drug-related morbidity and mortality resulting from non-optimized medication therapy was $528.4 billion, equivalent to 16% of total United States health care expenditures in 2016 [ 27 ]. As the population ages, there will be a growing population of patients who will require multiple medications. Older adults taking multiple medications are at increased risk of adverse events as the number of their prescribed medication increases [ 28 ].

The pharmacy profession has historically been challenged to demonstrate their value with improving patient care. How is that accomplished? For the patient who has a better outcome due to pharmacist intervention, how can one quantify how the patient’s quality of life is impacted by avoiding an emergency room visit or hospitalization, better tolerating their medications or avoiding an adverse drug reaction, improved adherence and reducing overall medical cost? To paraphrase an excerpt from the book, The Little Prince by Antoine de Saint-Exupéry, many of the most impactful things in the world cannot be measured, seen or touched, they are just felt [ 29 ].

This study has several limitations. A small sample size was largely due to the limited staff and time available to direct toward this pilot. One pharmacist performed all the chart reviews which limited the number of patients that could be reviewed on a weekly basis. Additionally, since only one pharmacist performed each medication review, there may be biases in the types of interventions that were recommended. Patients selected represent a single HBPC practice. This cohort resides in a geographic area where there is expanded access to healthcare, this population could have better overall health status than other HBPC patients living in a different area. A noted contributor to disparities in health is differential access to care [ 30 ]. Patients selected for pharmacist review were taking several medications and considered extremely complex. Selection bias may have pushed these patients to the pharmacist for review and may not represent the majority HBPC population. Standardization criteria may help in determining which patients are candidates for review. A home-care provider screening tool could aid to streamline the process of patient referral. We relied on estimated or potential cost-avoidance from the pharmacist medication review. While additional research is needed to investigate what that actual dollar value may truly be, there are added benefits of an integrated pharmacist team member in the management of medically complex patients.

Conclusions

Comprehensive medication review is a critical component of the healthcare continuum. The dynamic of a home-bound patient who is being serviced at home interlaces well with a remote-pharmacist model. Many HBPC patients are medically vulnerable, due to multiple comorbidities necessitating many medications. Pharmacists have a unique skill set allowing them to provide medication support to ensure HBPC patients have optimal medication regimens. However, pharmacist integration into HBPC is lacking.

Pharmacist intervention in this pilot program may have resulted in health care cost avoidance. Aligning pharmacist services to deliver support to HBPC providers can ensure the patient is treated holistically. About 81% of patients selected by HBPC providers received medication recommendations, and 30% of these recommendations were accepted by the HBPC providers. Additional research is needed to discover ways to improve recommendation acceptance and determine if aligning pharmacists to deliver support to home-based primary care providers improve the patient experience, improve clinical outcomes and reduce healthcare expenditure.

Acknowledgments

Thank you to all the providers at Northwestern Medicine RMG Home Care Providers who requested pharmacy partnership to improve their patient experience.

Funding Statement

The authors received no specific funding for this work.

Data Availability

Professor Jeffrey Gonzalez publishes review essay in “Public Books”

Posted in: English Department , Homepage News and Events

English professor Jeffrey Gonzalez recently published a review essay discussing Sonic Youth member Thurston Moore’s memoir, Sonic Life , in the online magazine Public Books . Professor Gonzalez’s review, which appeared on May 16, was included in Lithub’s “ LitHub Daily, ” whose editors describe their selections as “the best of the literary internet,” on May 20.

The State of Development Journals 2024: Quality, Acceptance Rates, Review Times, and What’s New

David mckenzie.

This is the eighth in my annual series of efforts to put together data on development economics journals that is not otherwise publicly available or easy to access (see  2017 ,  2018 ,  2019 ,  2020 , 2021 , 2022 , 2023 for the previous editions). I once again thank all the journal editors and editorial staff who graciously shared their statistics with me.

Journal Quality

The most well-known metric of journal quality is its impact factor . The standard impact factor is the mean number of citations in the last year of papers published in the journal in the past 2 years, while the 5-year is the mean number of cites in the last year of papers published in the last 5. As noted in previous years, the distribution of citations are highly skewed, and while the mean number of citations differs across journals, there is substantial overlap in the distributions – most of the variation in citations is within, rather than across journals. We continue to see growth in these impact factors at many journals. The big news this year is that they have decided that you really don’t need three decimal places any more in the impact factors.  I compliment these stats with RePec’s journal rankings which take into account article downloads and abstract views in addition to citations. 

Table 3 then shows two additional metrics, taken from Scimago , which uses information from the Scopus database. The first is the SJR (SCImago Journal Rank), which is a prestige-weighted citation metric – which works like Google PageRank, giving more weight to citations in sources with a relatively high SJR. I’ve included some of the top general journals in economics for comparison. Scimago also provides an H-index which is the number of papers published by a journal  in any year that were cited at least h times in the reference year – so this captures how many papers continue to be influential but as a result, favors more established journals, and ones that publish more articles, that have a larger body of articles to draw upon. 

How many submissions are received, and what are the chances of getting accepted?

Table 4 shows the number of submissions received each year. See previous years posts for statistics before 2019. The total submissions in the 11 journals tracked is almost 10,000 papers (note I received no data from the Review of Development Economics this year so have excluded it).  Total submissions in these journals are up 7.7% over last year, although not quite at the 2020 peak.

At most journals the number of submissions has either leveled off or fallen since a peak in 2020-21. World Development had the largest 2020 peak when they had a special call for a variety of short papers on COVID-19, but perhaps the combination of people sending off lots of papers during the pandemic and then being a little slower to start new projects has halted the rapid growth somewhat.

·       The newish World Development Perspectives already received 532 submissions last year, more than many long established development journals.

·       The Review of Development Economics has seen very rapid growth in submissions. I only started collecting stats for it last year, but the editors note that in 2015 they received about 450 submissions, and this has now grown to more than 1,500 last year.

Table 5 shows the total number of papers published in each journal. 782 papers were published in 2023, so that’s a lot of development research (even though less than 1 in 10 of the submitted papers and down slightly on the 811 papers published in 2022). I’ve noted in previous years that some of the journals have been able to flexibly increase the number of articles published as their submission numbers have risen, reducing publication lags as well. 

The ratio of the number of papers published to those submitted is approximately the acceptance rate. Of course papers are often published in a different year from when they are submitted, and so journals calculate acceptance rates by trying to match up the timing. Each journal does this in somewhat different ways. Hence Economia-Lacea reports a 0% acceptance rate for 2023 since none of the papers submitted in 2023 have yet been accepted, although some are still under review.  Table 6 shows the acceptance rates at different journals as reported by these journals. Of course the number and quality of submissions varies across journals, and so comparing acceptance rates across journals does not tell you what the chances are of your particular paper getting accepted is at these different journals.  

How long does it take papers to get refereed?

In addition to wanting to publish in a high quality outlet, and having a decent chance of publication, authors also care a lot about how efficient the process is. Table 7 provides data on the review process (see the previous years’ posts for historic data). The first column shows the desk rejection rate, which averages 73%. Column 2 uses the desk rejection rates and acceptance rates to estimate the acceptance rate conditional on you making it past the desk rejection stage. On average, about one in three papers that gets sent to referees gets accepted, with this varying from 12% to 63% across journals.

The remaining columns give some numbers on how long it takes to get a first-round decision. The statistics “Unconditional on going to referees” includes all the desk rejections, which typically don’t take that many days. The average conditional on going to referees is in the 3-5 month range. The last two columns then show that at most journals, almost all papers have a decision within 6 months – so in my opinion, you should feel free to send an enquiry if your paper takes longer than that. 

Do revisions typically get sent back to the referees or handled by the editor?

Another factor that can make a big difference in how long it takes to publish a paper is whether editors send revised papers back to referees, or instead reads the response letter and revision themselves and just makes a decision on this basis. This is something that the AER and AEJ Applied have been trying to do more and more, with only 25% of revisions at the AEJ Applied going back to referees. In my own editing at WBE, I send fewer than 5% of revisions back to referees. This year I asked the different journals what their approaches were. Many do not systematically track this, but offered some approximations:

·       Journal of Development Economics: approximately 60% of revisions go back to referees, although 0% for the short papers (see below)

·       Development Policy Review: only 10% of revisions go back to referees.

·       Journal of Development Effectiveness: 7.7% were sent back to referees

·       Journal of Development Studies: not tracked, but less than 20% go back to referees

·       Journal of African Economies: 52% are sent back to referees

·       Economia: 70% go back to referees.

·       EDCC: does not track this, but first revisions are usually sent back to referees.

·       World Development, World Development Perspectives, WBRO, and WBER do not track this, and results may vary a lot by editor.

Updates on the JDE Short Paper and Registered Report Tracks

The Journal of Development Economics has two other categories of papers that differ from other development journals:

·       The short paper format has proved popular. There were 148 submissions in 2023 (about 8% of total submissions), and 21 short papers were accepted. These papers follow the model of AER Insights, ReStat, etc in which papers are either conditionally accepted or rejected, and so any revisions are minor and are not sent back to referees.

·       The JDE registered reports had 19 stage 1 acceptances in 2023, and 1 stage 2 acceptance, reflecting a lag from COVID when there were not many new submissions. They have a website jdepreresults.org which tracks the stage 1 and stage 2 registered reports, but some of the data was lost when transitioning the website, so if you have a registered report accepted that is not listed there, please let the journal know.

Other Development Journal News

Finally, I asked the journals if they had any other major news or changes to report. Here are what they wanted to share:

·       At EDCC, Prashant Bharadwaj has replaced Marcel Fafchamps as editor. Thanks to Marcel for 10 years at the helm. The journal is one of the few development journals with a submission fee ($50), but offers a fee waiver to referees who have submitted a timely report in the year prior to submission.

·       Other editorial changes are Ganeshan Wignaraja replacing Colin Kirkpatrick as co-editor at Development Policy Review, and Marie Gardner and Ashu Handa taking over from Manny Jimenez at the Journal of Development Effectiveness.

·       The Journal of Development Effectiveness notes they are implementing a set of actions to raise awareness about transparency, ethics and equity in research, and to address power imbalances among HIC-L&MIC research teams. The editors note they are particularly concerned with research involving primary data collection in an L&MIC where there is no author from an institution in that country. For articles submitted to JDEff that fall into this category, they will require the authors to complete a short author reflexivity statement that will be published along with the article. The statement will explain the contribution of each author per Taylor & Francis authorship criteria, which are consistent with the criteria established by the International Committee of Medical Journal Editors. Authors will be asked to explain why there is no contributing author from the study location, specifically, whether any team member based in the study location made a ’significant contribution to conception, study design, execution or acquisition of data,’ and if so, why they were not subsequently invited to review the manuscript and take responsibility for its contents. And for work involving randomized controlled trials or interviews with vulnerable groups, authors will also be asked to answer a set of questions about research ethics. Final manuscript acceptance and publication in JDEff will be based on the scientific quality of the work as well as an assessment of whether the work was conducted in an equitable, inclusive and ethical manner.

Finally, thanks again to all the editors for all the time and effort they devote to improving the quality and visibility of development research. As you can see, they have a lot to deal with!

Lead Economist, Development Research Group, World Bank

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Supreme Court will decide access to key abortion drug mifepristone

The Supreme Court will decide this term whether to limit access to a key abortion drug, returning the polarizing issue of reproductive rights to the high court for the first time since the conservative majority overturned Roe v. Wade last year.

The Biden administration and the manufacturer of mifepristone have asked the justices to overturn a lower-court ruling that would make it more difficult to obtain the medication, which is part of a two-drug regimen used in more than half of all abortions in the United States. Oral arguments will likely be scheduled for the spring, with a decision by the end of June, further elevating the issue of abortion, which has proven galvanizing for Democrats, during the 2024 campaign season.

The justices announced Wednesday that they will review a decision from the conservative U.S. Court of Appeals for the 5th Circuit that said the Food and Drug Administration did not follow proper procedures when it began loosening regulations for obtaining mifepristone, which was first approved more than 20 years ago.

The changes made over the last few years included allowing the drug to be taken later in pregnancy, mailed directly to patients and prescribed by a medical professional other than a doctor.

Medications to terminate pregnancy, which can be taken at home, have increased in importance over the last 18 months, as more than a dozen states severely limited or banned abortions following the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization.

The justices agreed to review the mifepristone case as the broader issue of abortion access remains divisive politically and legally. A pregnant woman in Texas this week lost her legal battle for permission to end her pregnancy, after she had left the state to obtain an abortion. Last week, a Kentucky woman went to court asserting the state’s abortion restrictions violate her constitutional right to privacy.

Where is abortion legal and illegal?

Democrats have tried to capitalize on the backlash to stringent limits, and abortion rights initiatives have played a role in Republican defeats in recent elections in Ohio, Kentucky and Virginia.

The Supreme Court’s much-anticipated decision to overturn Roe after nearly 50 years was a long-sought win for conservatives that cleared the way for states to quickly restrict or ban abortion. The court majority included three nominees of President Donald Trump . The former president, now the leading GOP candidate for the 2024 election, has touted his role in overturning Roe , but more recently has tried to appear more moderate , attracting criticism from some conservatives.

The court’s decision to review the mifepristone case is not surprising. In April, after a district-court ruling to suspend FDA approval of the drug, the justices said existing rules for prescribing and distributing mifepristone would remain in place nationwide while the litigation continues.

In that order , only Justices Clarence Thomas and Samuel A. Alito Jr. said they would not have granted the Biden administration’s request for a stay of the district-court decision. Critics say the lower court’s ruling undermines the role of federal regulatory agencies.

The justices said Wednesday they would not consider a separate challenge to FDA’s initial approval of mifepristone in 2000. That means that whatever the Supreme Court decides will not remove the medication from the market but could make it more difficult to obtain.

If access to mifepristone was restricted, abortion providers and advocates say, pregnancies could still be terminated using only the second drug in the regimen, misoprostol. But using that drug alone causes more cramping and bleeding, and abortion opponents could move to restrict its use as well if they win limits on the use of mifepristone from the high court.

How mifepristone is used

White House press secretary Karine Jean Pierre said in a statement that the Supreme Court must ensure full access to mifepristone. The lower-court ruling, she said, “threatens to undermine the FDA’s scientific, independent judgment and would reimpose outdated restrictions on access to safe and effective medication abortion.”

“States have imposed extreme and dangerous abortion bans that put the health of women in jeopardy and that threaten to criminalize doctors for providing the health care that their patients need and that they are trained to provide,” Pierre said.

In urging the court to take the case, Solicitor General Elizabeth B. Prelogar emphasized in court filings that mifepristone has been safely used by millions of people over more than two decades and warned that allowing the lower court’s decision to stand would have “damaging consequences for women seeking lawful abortions and a healthcare system that relies on the availability of the drug under the current conditions of use.”

The challenge to mifepristone was initiated by the Alliance for Hippocratic Medicine, an association of antiabortion doctors and others. The group asserted that the FDA did not sufficiently consider safety concerns when it approved the drug in 2000 or when it removed some restrictions years later — allowing the use of mifepristone through 10 weeks of pregnancy, for instance, instead of seven.

The group filed its lawsuit in Amarillo, Tex., where U.S. District Judge Matthew J. Kacsmaryk — a Trump nominee with long-held antiabortion views — is the sole sitting judge. He sided with the challengers and suspended FDA approval of the medication.

The 5th Circuit reversed that part of Kacsmaryk’s order, but agreed with him in blocking the changes starting in 2016 for how the drug was prescribed and distributed, and at what point in a pregnancy it could be used.

Erin Hawley, an Alliance Defending Freedom attorney who represents the challengers, urged the Supreme Court to reinstate restrictions on the medication.

“Like any federal agency, the FDA must rationally explain its decisions. Yet its removal of common-sense safeguards — like a doctor’s visit before women are prescribed chemical abortion drugs — does not reflect scientific judgment but rather a politically driven decision to push a dangerous drug regimen,” Hawley said in a statement.

The case is FDA v. Alliance for Hippocratic Medicine.

U.S. abortion access, reproductive rights

Tracking abortion access in the United States: Since the Supreme Court struck down Roe v. Wade , the legality of abortion has been left to individual states. The Washington Post is tracking states where abortion is legal, banned or under threat.

Abortion and the election: Voters in about a dozen states could decide the fate of abortion rights with constitutional amendments on the ballot in a pivotal election year. Biden supports legal access to abortion , and he has encouraged Congress to pass a law that would codify abortion rights nationwide. After months of mixed signals about his position, Trump said the issue should be left to states . Here’s how Biden and Trump’s abortion stances have shifted over the years.

New study: The number of women using abortion pills to end their pregnancies on their own without the direct involvement of a U.S.-based medical provider rose sharply in the months after the Supreme Court eliminated a constitutional right to abortion , according to new research.

Abortion pills: The Supreme Court seemed unlikely to limit access to the abortion pill mifepristone . Here’s what’s at stake in the case and some key moments from oral arguments . For now, full access to mifepristone will remain in place . Here’s how mifepristone is used and where you can legally access the abortion pill .