Withington Hospital, Manchester
Correspondence: Alistair Burns, Professor of Old Age Psychiatry, Department of Psychiatry, University of Manchester, Withington Hospital, Manchester M20 8LR. Tel: 0161 291 4831; Fax: 0161 445 5305; e-mail:A_Burns{at}fsl.with.man.ac.uk
Declaration of interest The study was funded by the North West NHS Executive
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ABSTRACT |
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Aims To investigate the effect of a review of medication by a pharmacist.
Method An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.
Results The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).
Conclusion This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality.
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INTRODUCTION |
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METHOD |
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Homes and residents
Fourteen homes took part in the study, matched into seven pairs equivalent
in number of beds, registration status and resident mix. Each home in the pair
came from different areas in South Manchester, to avoid a situation in which a
general practitioner (GP) was looking after residents in both a control home
and an intervention home. Using computer-generated pseudorandom numbers, one
home in each pair was randomly allocated to receive a regular medication
review by a pharmacist (intervention group) and the other to receive no
pharmacist review (normal control group). Homes were randomised
at the start of the observation phase. Written consent was obtained from each
resident (from the next of kin if necessary) and the investigation was
approved by the local ethics committee.
Intervention
The intervention consisted of a medication review by the study pharmacist
for all consenting residents in homes in the intervention group. The review
took place at the beginning of the intervention phase, in the GP's surgery, at
the nursing home or (in exceptional circumstances) over the telephone. The
pharmacist (L.F.) collected details of current medication for each resident
from the Medicines Administration Record (MAR) chart in the home, together
with a brief medical history and any current problems identified by the home
staff. Three weeks after the medication review, the homes were revisited, to
ascertain whether there had been any immediate problems with the changes in
medication and to see if the suggested changes had been implemented.
Assessments
The following standardised tests were carried out on each resident in both
groups at the beginning of the study (Time 0), after 4 months (Time 1, i.e.
the beginning of the intervention) and 8 months (Time 2, i.e. the end of the
intervention): Mini-Mental State Examination (MMSE;
Folstein et al, 1975);
Geriatric Depression Scale (GDS; Yesavage,
1988); Brief Assessment Schedule Depression Cards (BASDEC;
Adshead et al, 1992);
and Crichton-Royal Behaviour Rating Scale (CRBRS;
Robinson, 1965;
Wilkin et al,
1978).
Data were also collected on the types and numbers of drugs each resident was taking, and the reason for the use of any neuroleptic drugs was obtained from the nursing staff. The study pharmacist assessed whether the use of neuroleptics complied with the US Ombudsman Reconciliation Act (OBRA) guidelines (i.e., that the use of a neuroleptic is appropriate for psychotic disorders and organic mental syndromes associated with types of behaviour that present a danger to others or interfere with the abilities of staff to provide care for the resident) (McGrath & Jackson, 1996). Information was collected on the use of primary and secondary care resources, and the number of accidents and deaths.
The initial assessments were made by the study pharmacist and the psychiatrist. The second and third assessments were carried out by six Registered Mental Nurses trained in the administration of the instruments, to ensure consistency and reliability.
Statistical analysis
The size of the study sample was determined from changes observed in
behavioural characteristics (CRBRS) in a previous study
(Wilkin et al, 1978).
Assuming a within-homes variance of 50 and an intra-class correlation between
0.01 and 0.05, six to eight homes, each containing at least 20 residents, were
required to detect differences of four points on the CRBRS scale as being
statistically significant at the conventional 5% level with 90% power. To
allow for drop-outs and refusals, homes with more than 20 residents were
sought; the average number of residents per home who agreed to take part in
the study was 23.6.
Changes over the study period were compared between the two study groups, using multivariate regression methods. To account properly for the cluster randomisation design used, nursing home was forced into all regression models as a cluster variable (thus the unit of analysis was nursing home, not individual resident). In order to make full use of the study subjects remaining alive at each assessment time, separate analyses were carried out using the Time 1 and Time 2 observations; for both analyses, Time 0 observations were used as covariates to adjust appropriately for baseline differences between the study groups. All computations were done using the SPSS and STATA statistical computer packages.
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RESULTS |
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Mental and physical state (Table
2)
Table 2 shows the mean
differences in the rating scores between the two study groups; those reported
for Times 1 and 2 are covariate, adjusted for the differences observed between
the groups at Time 0. In addition, the numbers of residents scoring above or
below the accepted cut-off points are summarised for each scale.
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The MMSE scores and the numbers of residents with scores below 23 did not change significantly over the study period, although there was a decline in the total MMSE scores for the intervention group. No statistically significant changes were observed in the depression scores during the study. Mean CRBRS scores tended to increase in the intervention group relative to the control group, and the difference between the groups became significant at Time 2. However, these changes could not be attributed to the intervention, as the increase in impairment occurred before this.
The number of accidents and falls (recorded in the nursing home reports) in each group did not differ significantly throughout the study. Over the intervention phase, there were 14 deaths in the control homes (one death in each of three homes; two in each of two homes; three in one home; four in one home) compared with just four deaths in the intervention group homes (two deaths in each of two homes). This difference was statistically significant (Mann-Whitney U-test: P=0.028).
Drug use and pharmacist recommendations
The mean number of drugs prescribed for all residents at admission to the
study was 4.91, with a range of 0-17 (see
Table 3). In 54% of cases,
prescribing of neuroleptics was inappropriate according to the US OBRA
guidelines. Residents in both groups of homes experienced a decrease in the
mean number of drugs prescribed during the intervention phase
(Table 4). After adjustment for
baseline differences, the reduction in the homes where medication was reviewed
was greater than that in control homes, but this difference was not
statistically significant (P=0.070).
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A total of 261 recommendations were made by the pharmacist, of which 239 (91.6%) were accepted by the GP and resulted in 144 actual treatment changes. Thirty residents received no modification to their drug treatment and the mean number of recommendations per resident for the other residents was 2.46, with a range of 0-7. Recommendations were classified according to the reasons given in Table 5.
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Economic data
Numbers and associated costs of all contacts with primary and secondary
care services were calculated for each resident alive at the end of each phase
of the study, using contemporaneous local figures for comparative costing. It
is likely that costs per resident do overlap between the intervention and
control homes: the degree of overlap might not be great, but sufficient to
prevent statistical significance being established. Costs vary very
considerably between residents, making average costs per home very variable
also. Costs relating to the use of primary and secondary care resources could
not always be determined for individual home residents. For example, a GP or
physiotherapist might attend more than one resident on a single visit to a
home. Costs were thus computed for each home overall for each study period and
divided by the number of individual residents in that period, to provide
average costs per resident. These are summarised in
Table 6. Because only 14
nursing homes in total could be included in the study, no formal statistical
comparison of these average costs between the control and the intervention
groups was possible. However, there was a clear trend for reduction in costs
in the intervention group.
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DISCUSSION |
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Previous reports that nursing home residents are prescribed medication which can be changed (Beers et al, 1991; Lunn et al, 1997) is substantiated by this study, in which one-third of all the recommendations made by the pharmacist was that medications no longer indicated should be reviewed. The prescription of neuroleptics was higher than in previous studies (24% in the Glasgow study by McGrath & Jackson, 1996) but their inappropriate prescription, as judged against the US OBRA guidelines, was far less than the comparative figure of 88% in the Glasgow study. Not all the changes suggested by the pharmacist were implemented; the reasons for this were not specifically recorded. The study showed positive benefits nonetheless.
It appears that medication review by a pharmacist with GPs can reduce the number of inappropriate drugs prescribed for residents. Such a review may be cost-effective for the National Health Service, and could potentially have positive benefits for residents. The number of older people entering nursing and residential homes in the future is likely to increase (Melzer et al, 1997). This study is the first controlled trial in the UK of the effects of a medication review by a pharmacist, and should be of interest to purchasers of health and social care.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Received for publication July 2, 1999. Revision received October 25, 1999. Accepted for publication October 26, 1999.