Impact of pharmacist-led multidisciplinary medication review on the safety and medication cost of the elderly people living in a nursing home: a before-after study

ABSTRACT

Objectives: Adverse drug events (ADE) are a common cause of morbidity and mortality in elderly patients. In this study, we assessed the impact of multidisciplinary medication review (MMR) for nursing home residents on patient safety and costs incurred by the hospital and the national health service.

Methods: Medical files of residents were retrospectively assessed for medications prescribed in the previous six months. A pharmacist reviewed the prescriptions and suggested modifications to the patient’s medical team. Patients were followed for six months. Trivalle’s ADE geriatric risk score was calculated before and after MMR, as were number of potentially inappropriate medications, and economic impact from the perspective of the health care system and the nursing home.

Results: Forty-nine patients were recruited. ADE score dropped one risk level (median score of 4 before versus 1 after, p < 0.0001). The number of patients taking at least one potentially inappropriate medication decreased from 30.6% before to 6.1% after MMR (p = 0.005). A mean saving of €232 per patient was made from the nursing home perspective following MMR (p = 0.008).

Conclusion: The MMR reduced the iatrogenic drug risk for elderly residents and costs from the nursing home perspective, particularly drug expenditure.

KEYWORDS:

• Clinical pharmacy
• drug safety
• geriatrics
• medication errors
• pharmacoeconomics
• pharmaceutical care
• pharmacist’s medication management
• nursing home

Article highlights

• Chronic conditions of nursing home residents are poorly monitored.

• Drug-related problems are particularly prevalent in nursing homes, specifically the prescription of potentially inappropriate medications.

• Inappropriate prescribing in elderly patients is associated with adverse drug events, hospitalizations and higher total medication costs.

• Medication review is a multidisciplinary activity that can reduce costs and/or iatrogenic risk, although mixed results are found in terms of impact on falls and hospitalizations.

• The multidisciplinary nature of the intervention was key to the success of this activity as well as the involvement of a clinical pharmacist whose pharmacological expertise is essential to optimize drug prescribing.

• The value of medication reviews is now generally accepted despite lack of robust research evidence consistently demonstrating cost or clinical effectiveness compared with traditional care.

• Multidisciplinary medication review (MMR) reduced the adverse drug event geriatric risk score from average to low level and decreased the rate of elderly residents taking at least one potentially inappropriate medication.

• MMR did not change the rate of patients experiencing at least one hospital stay or one fall.

• All the patients living in the nursing home who had benefited from the MMR for the first time had at least one medication error detected and corrected.

• The majority of errors related to non-indicated/class redundant medication or medications non-confirming to standards or with a physiological contra-indication.

• The main intervention proposed by the clinical pharmacist to resolve the errors was medication discontinuation or dosage adjustment with high acceptance by the physician.

• Medication mean cost incurred by the nursing home was hugely reduced with the MMR which was a dominant strategy in the sensibility analysis.

Author contributions

GLB: drafting the protocol, planning the study, drafting the case report form, interpreting the data, drafting of the paper.

CCa: co-drafting and correcting the protocol, writing the methodology of the study, co-performing and revising statistical and economic analysis, co-interpreting the data, co-drafting and revising the paper critically for intellectual content.

JR: co-drafting the case report form, enrolling the patients, performing the medication review in nursing home, collecting and monitoring data, revising the paper critically for intellectual content.

SB: performing statistical analysis, co-drafting and revising the paper critically for intellectual content

SC: performing economic analysis, co-drafting and revising the paper critically for intellectual content

SK: co-drafting and revising the paper critically for intellectual content, English proof-reading the paper

BJ: performing the medication review in nursing home, revising the paper critically for intellectual content

SR: correcting the protocol, co-planning the study, revising the paper critically for intellectual content

CCh: correcting the case report form, collecting and monitoring data, revising the paper critically for intellectual content.

HR: correcting the protocol, co-planning the study, performing the medication review in nursing home, revising the paper critically for intellectual content

JMK: co-drafting and correcting the protocol, co-planning the study, interpreting the data, co-drafting and revising the paper critically for intellectual content

All authors have approved the final version of the manuscript to be published and have agreed to be accountable for all aspects of the work.

Acknowledgments

The authors are grateful to Richard Malkoun for data management and Pierre Rataboul for help in drafting the protocol.

Declaration of interest

The authors have no conflict of interest to declare.

Clinical trial

Clinical trial registration: www.clinicaltrials.gov identifier is NCT02118259.

Additional information

Funding

This work was supported by Nimes University Hospital under grant LOCAL/2013/GL-001.