Medication reviews in long-term care and supportive living: a physician’s perspective

Issue

What does the evidence say about the risks posed to patient safety in residential care homes as a result of medication errors and adverse drug events?

Bottom Line

The single greatest risk to patient safety in residential care homes is medication use: specifically medication errors and adverse drug events.¹

Evidence

A recent prospective study identified two thirds of LTC residents as having been exposed to one or more medication errors.² Gurwitz and colleagues found the rate of adverse drug events was 9.8 per 100 resident-months in two academic LTC facilities and 42% of events were deemed preventable, having most often occurred at the stages of medication ordering and monitoring.³ The risks of medication use for those living in long-term care (LTC) where the median life expectancy is less than two years and the average daily number of medications is over eight have been well documented. Ineffective medications at the end of life, and under-treated conditions, are also patient safety concerns. Mitigating these risks and planning the most appropriate drug therapy medication reviews have long been practice priorities for physicians, pharmacists and nursing.

In Alberta, medication reviews are part of the Continuing Care Health Service standards.⁴ Reviews are conducted every three months, or more frequently, based on the patient’s health needs. Physicians are reimbursed for the “formal scheduled review of patient medication in Continuing Care facilities.” While there is little to define these reviews, they typically involve clinical pharmacy consulting with nursing colleagues, reviewing the patient and making recommendations for change on a medication review form. The physician will then decide to continue or make changes based on their assessment of the patient, review of pharmacy notes and discussion with nursing or relevant members of the interdisciplinary team.

The scheduled medication review presents the ideal opportunity for the care team to critically examine all therapies, addressing medication safety concerns including polypharmacy and potential side effects in a predictable and purposeful manner. Each team member brings specialized skills and information that provide the most complete picture of therapeutic and adverse effect. It is somewhat surprising, therefore, that the effectiveness of such reviews is weak and not well studied. Graabæk and colleagues conducted a systematic review of medication reviews by in-hospital clinical pharmacists that demonstrated a positive effect on medication use and costs, and no significant effect on health service use or mortality.⁵ In 2014, a systematic review and meta-analysis of twelve studies showed no benefit to LTC residents from formal medication reviews compared to usual care, in terms of mortality or hospitalization outcomes. ^6-7

As the medication review is so well established with the care team, and the medical challenges of care (and presumed risk) are only expected to intensify in the future, now may be the time to revisit the utility of the review. Perhaps an enhanced medication review that would more actively involve all three disciplines – clinical pharmacy, the attending physician and nursing – could potentially more effectively identify and address concerns of medication appropriateness and safety? A goal-oriented approach to prescribing that took into account key clinical outcomes such as pain management, prognosis, change in condition or the wishes of the patient might provide a necessary focus for the medication review.⁸ If decision-making actively involved all three disciplines it would be reasonable to expect an improved flow of critical patient information, including opportunities to change medications and monitor outcomes.

A suggested process for enhanced medication review in LTC and Supportive Living (SL)

1. Nursing , pharmacy and physician to meet in person on a scheduled basis
2. Clinical pharmacy to continue to prepare key information for the review
3. Participation of the patient or decision-maker during or after the review
4. A clear understanding of the patient’s goals of care and prognosis
5. Use of a medication appropriateness tool such as the modified Beers list or the STOPP START criteria 9-11
6. Use of a formal checklist for each medication: scheduled and as-required

Checklist

(see acronym, below)

1) Indication

• Is there a clear indication and is it still valid?

2) Benefit

• Will the patient benefit from the treatment, e.g. therapies at the end-of-life and treatments with long lead time to take effect?

3) Dose and frequency

• Is the dose and frequency correct?

4) Side effects

• Are there known or potential side-effects?
• Are there potential drug-drug or drug-disease interactions?

5) Drug Monitoring

• Is therapeutic drug monitoring required and up-to-date?

6) Risk medications

• Has special attention been given to high-risk medications?

1. All psycho-active medications especially anti-psychotics, benzodiazepines and antidepressants
2. Anti-hypertensives and diuretics
3. Insulin
4. Warfarin

7) Expectations

Are the treatments aligned with the patient’s goals of care?

Helpful enhanced review checklist mnemonic: DEBRIDE

Dose and frequency
Effects
Benefit
Risk
Indication
Drug monitoring>br/> Expectations

The goals of such an enhanced review would be three-fold:

1. Reduction in inappropriate use
2. An increase in appropriate use
3. All therapies concordant with patient’s wishes

Medication reviews are the ideal platform to bring together the care team in a truly interdisciplinary way to critically appraise therapies and make the best and safest decisions regarding drug treatments.

References

1. Handler S Epidemiology of medication-related adverse events in nursing homes The American Journal of Geriatric Pharmacotherapy Volume 4, Issue 3, September 2006, Pages 264–272
2. Barber ND Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care 2009 Oct;18(5) 341-6
3. Gurwitz, the incidence of adverse drug events in two large academic long-term care facilities The American Journal of Medicine (2005) 118, 251–258
4. Alberta Health Seniors Services and Continuing Care Division Continuing Care Health Service Standards Amended March 2013
5. Graabæk T Medication Reviews by Clinical Pharmacists at Hospitals Led to Improved Patient Outcomes: A Systematic Review Basic & Clinical Pharmacology & Toxicology 2013,112, 359-373
6. Wallerstedt S Medication reviews for nursing home residents to reduce mortality and hospitalization: systematic review and meta-analysis Br J Pharmacol 78.3 488-497
7. CADTH Rapid Response Report: Summary with critical appraisal Multidisciplinary Medication Review in Long Term Care: A Review of the Clinical Evidence and Guidelines July 18^th 2011
8. Alldred DP Interventions to optimise prescribing for older people in care homes. Cochrane Database Sys Rev 2013 Feb 28;2 CD009095
9. Beers MH Explicit criteria for determining inappropriate medication in the elderly a systematic review Arch Int Med Vol 151 Sept 1991
10. Gallagher P STOPP ( Screening Tool of Older Persons’ Prescriptions) and START (Screening Tools to Alert Doctors to Right Treatment) consensus validation Int J Clin Pharm Ther 2008;46:72-83
11. Gokula M Tools to Reduce Polypharmacy Clin Geriatr Med 28 (2012) 323-341