Implementation of medication reviews and use of dose administration aids for patients at risk of medication misadventure

Sorensen, Lene (2003). Implementation of medication reviews and use of dose administration aids for patients at risk of medication misadventure PhD Thesis, School of Medicine, The University of Queensland.

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Author Sorensen, Lene
Thesis Title Implementation of medication reviews and use of dose administration aids for patients at risk of medication misadventure
School, Centre or Institute School of Medicine
Institution The University of Queensland
Publication date 2003
Thesis type PhD Thesis
Supervisor Michael Roberts
Total pages 379
Collection year 2003
Language eng
Subjects L
321099 Clinical Sciences not elsewhere classified
730399 Health and support services not elsewhere classified
Formatted abstract

Patients at risk of medication misadventure can be identified by various characteristics including taking multiple medication doses or using multiple medications (polypharmacy), taking medications with a narrow therapeutic index and medication non-adherence. These risk factors are associated with potential medication misadventure such as inappropriate prescribing, adverse drug events (ADEs), hospital admissions, increased health care use and costs, mortality as well as decreased functioning and health related quality of life (HRQOL). Some populations are particularly vulnerable to medication misadventure, and these populations include elderly patients and war veterans.

According to experts, substantial morbidity and health care costs can be avoided by improving prescribing practices. To improve prescribing practices as well as other quality use of medicines (QUM) issues, two types of interventions were studied in the current thesis based on four studies. Trials of medication reviews conducted by clinical pharmacists in the community and in a hospital setting, as well as the use of dose administration aids (DAA) in a community setting were evaluated.  

The first study evaluated a Commonwealth Department of Veterans' Affairs (DVA) initiated medication review service and included 102 veterans. The analysis suggested that the service led to an increased activity in medication changes relative to a comparison group. There was, however, no statistically significant evidence, from the available data, of changes in medication or health care cost. Validation of a hypothesis that the increase in medication use as a result of the medication review may facilitate a decrease in health services such as hospitalisation requires a larger, randomised, controlled study with follow-up over a suitable time period. 

Addressing these issues, the second study was designed as a randomised controlled trial and included 400 patients. The medication review model was trialled for patients at risk of medication misadventure including veterans. The model was successfully implemented with participants reporting high levels of satisfaction. Even in the relative short period of follow up, there was evidence of medication misadventure risk reduction and positive patient outcomes. Once the evaluation burden is omitted, the model would be achievable in practice. Indeed a domiciliary medication review program similar to this model has now been implemented into national practice, where GPs and pharmacists are reimbursed by the Australian government for the provision of these services

The third study investigated clinical pharmacists medication reviews of 359 veterans in private hospitals. This intervention showed a significant improvement in appropriateness of medication use as a result of the medication reviews. Medication information provided on discharge was greatly appreciated by the patients, their community doctors and their community pharmacists.

A tool to assess appropriateness of medication regimens; the quality use of medicine coding system, was developed and assessed on 216 medication regimen profiles. It was possible to use the quality use of medicine coding system to rate the quality and potential health impact of pharmacists' medication reviews. Scoring based on the original coding system proved to be suboptimal, but the aggregated scoring system was found to have a fair interrater reliability. A larger sample of medication regimen is needed to detect all codes possible in the coding system.

The study also found that patients using DAAs were taking more medication. It was, however, not clear whether patients originally had DAAs initiated because they were taking more medication, or whether DAA users have more medication initiated. DAA users visited their general practitioners more frequently after hospital discharge, and reported more adverse events after discharge. The higher frequencies of GP visits and adverse events reported by DAA users disappeared when correcting for number of medications. The use of DAAs does not automatically solve the problems of forgetting to take medication, but it may lead to a lower number of GP visits for patients with memory trouble and therefore costs.

The fourth and final study sought to further investigate the use of DAAs in veterans. The model was trialled using a randomised, controlled design and included 1128 patients. The results showed that the following patient characteristics could be used as a part of patient assessment to determine the need of a DAA: A 3MS score between 90 and 91.9, high severity of illness, male gender, lower number of medications and older age. The results are, however, not exhaustive but rather a starting point for assessment use. 

The results presented in the current thesis revealed that there is evidence of significant suboptimal medication treatment in Australian patients in the two surveyed settings; the community and private hospitals. The trialled health care service models showed various benefits for the surveyed patients suggesting that patients at risk of medication misadventure are in need of interventions to optimise their medication treatment and subsequently achieve improved health outcomes. The overall hypothesis that the quality use of medicines interventions will be of benefit with regard to medication use and health care outcomes for a selection or all participating intervention patients was therefore confirmed.

Keyword Drugs -- Dosage

Document type: Thesis
Collection: UQ Theses (RHD) - UQ staff and students only
Citation counts: Google Scholar Search Google Scholar
Created: Fri, 24 Aug 2007, 18:09:04 EST