Does home based medication review keep older people out of hospital? T
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《英国医生杂志》
1 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, 2 Great Yarmouth Teaching Primary Care Trust, Astley Cooper House, Estcourt Road, Great Yarmouth, Norfolk NR14 8AB, 3 Academic Pharmacy Practice Unit, University of East Anglia, Norwich NR4 7TJ, 4 Suffolk Public Health Network, Suffolk House, St Clement's, Foxhall Road, Ipswich IP3 8LS
Correspondence to: R Holland r.holland@uea.ac.uk
Abstract
Twenty eight per cent of all prescribed drugs in the United Kingdom are consumed by the 7% of the population aged over 751 2; 6.5% of hospital admissions have recently been shown to be related to adverse drug reactions, and these are significantly more likely to occur in older patients.3 This may be due to a combination of factors, including polypharmacy and age related physiological changes. Older patients can also have considerable problems with adhering to their drug regimens—up to 50% of prescribed drugs are estimated to be not taken as prescribed.4 5
The national service framework for older people and the NHS plan recommend regular medication reviews for older patients to maximise therapeutic benefit and minimise potential harm.6 7 Historically, UK studies of medication review have focused on prescribing outcomes rather than effects on hospital admissions.8-10 An Australian study of a home based medication review-type intervention showed a 25% reduction in admissions and a reduction in deaths outside hospital.11 We sought to investigate the effectiveness of home based medication review in terms of its impact on hospital admissions in the United Kingdom. We chose home visits to ensure that the intervention could reach all very elderly participants. We also considered that home visits would allow pharmacists to gain greater insight into patients' methods of managing their drugs. The trial involved a large number of pharmacists delivering the intervention to ensure its generalisability.
Methods
Participant flow and follow up
We invited 1399 patients to participate after screening them for eligibility between October 2000 and December 2002; 872 (62%) patients agreed and were randomised (fig 1). We excluded 17 recruited patients after randomisation. Reasons for exclusion were elective baseline admission (n = 5), discharge to nursing or residential home (5), death before discharge (4), previously recruited (2), and taking fewer than two drugs (1). Table 1 shows that the two groups were very similar at baseline. Twenty patients withdrew from the trial, and six moved from the study area. Primary outcome data were thus available for 829 (97%) patients.
Fig 1 Flowchart showing progress of patients through the HOMER trial
Table 1 Baseline comparison of intervention and control group patients. Values are numbers (percentages) unless stated otherwise
Review pharmacists and intervention visits
We recruited 22 review pharmacists. Of 429 patients in the intervention group, 362 received first visits. Reasons for not visiting were visit not wanted (46 patients), pharmacist unavailable (11 patients), and patient unavailable due to death or early readmission (10 patients). Review pharmacists carried out a mean of 17 (range 1-37) first visits. More than 90% of first visits occurred within two weeks of recruitment (mean 7.2 days), and visits lasted a mean (SD) of 61 (23) minutes. Second visits were conducted for 297 patients and took a mean (SD) of 42 (19) minutes. Visits generated a total of 933 recommendations or comments to general practitioners (2.58/visited patient); 120 of these referred to possible drug reactions or interactions in 81 patients (22% of visited patients).
Compliance aids and pharmacists' view of intervention
Review pharmacists recommended compliance aids in 39 patients (11% of those receiving first visits). Pharmacists were asked after their second visit to record whether they believed the visits had been useful. For 216 (73%) patients, pharmacists felt the visits were definitely or probably useful; for 81 (27%) patients, pharmacists felt the visits were unlikely to be useful or not at all useful, generally when patients were found to be coping very well.
Number of hospital readmissions
A total of 178 emergency readmissions occurred in the control group and 234 in the intervention group (table 2). The Poisson model indicated a 30% greater rate of readmission in the intervention group (rate ratio = 1.30, 95% confidence interval 1.07 to 1.58; P = 0.009).
Table 2 Number of emergency hospital readmissions by group during six month trial follow up
Secondary outcomes
Mortality data were available for 829 (97%) patients. Fewer deaths occurred in the intervention group (49 v 63). Figure 2 shows the Kaplan-Meier survival graph. The hazard ratio for the intervention group compared with the control group was 0.75 (0.52 to 1.10; P = 0.14). Data on residential or nursing home admissions were available on fewer patients, as these were collected by telephone (585, 68%). Table 3 shows that fewer control patients than intervention patients were admitted to residential or nursing homes, but again these differences were not statistically significant.
Fig 2 Survival analysis over six month follow up period for patients in the HOMER trial
Table 3 Number of admissions to residential or nursing homes by group during six month trial follow up
Quality of life data
Change in utility scores could be calculated for 308/380 (81%) surviving intervention patients and 284/362 (78%) surviving control patients. Both groups' scores decreased over the six month follow up period, but the changes were not significantly different between the groups (table 4). Scores on the visual analogue health scale also fell; the difference of 4.1 (95% confidence interval 0.15 to 8.09) units in favour of the control group was statistically significant (P = 0.042).
Table 4 Mean EQ-5D scores and visual analogue health scale scores for groups at baseline, three months, and six months follow up
Primary care data
We included 165 patients from 12 practices in this analysis (84 intervention, 81 control). General practitioners carried out 204 home visits in the intervention group and 125 in the control group, a difference of 43% (rate ratio = 1.43, 1.14 to 1.80; P = 0.002). No statistically significant differences occurred between the groups in attendance at general practices or prescription items received.
Discussion
ASTRO-PUs and chapter STAR-PUs: 2001 revision. Leeds: Prescribing Support Unit, 2001.
Office for National Statistics. UK Census 2001. www.statistics.gov.uk/census2001/pop2001/united_kingdom.asp (accessed 9 July 2004).
Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004;329: 15-9.
Wright EC. Non-compliance—or how many aunts has Matilda? Lancet 1993;342: 909-13.
Law R, Chalmers C. Medicines and elderly people: a general practice survey. BMJ 1976;i: 565-8.
Pharmacy in the future: implementing the NHS plan—a programme for pharmacy in the National Health Service. London: Department of Health, 2000.
National service framework for older people: implementing medicines related aspects of the NSF for older people. London: Department of Health, 2001.
Raynor DK, Booth TG, Blenkinsopp A. Effects of computer generated reminder charts on patients' compliance with drug regimens. BMJ 1993;306: 1158-61.
Begley S, Livingstone C, Hodges N, Williamson V. Impact of domiciliary pharmacy visits on medication management in an elderly population. Int J Pharm Pract 1997;5: 111-21.
Goodyer LI, Miskelly F, Milligan P. Does encouraging good compliance improve patients' clinical condition in heart failure? Br J Clin Pract 1995;49: 173-6.
Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc 1998;46: 174-80.
Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity. Age Ageing 1991;20: 332-6.
Tidermark J, Bergstrom G, Svensson O, Tornkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12: 1069-79.
Holland R, Smith RD, Harvey I, Swift L, Lenaghan E. Assessing quality of life in the elderly: a direct comparison of the EQ-5D and AQoL. Health Econ 2004;13: 793-805.
Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001;33: 337-43.
Lowe CJ, Raynor DK, Purvis J, Farrin A, Hudson J. Effects of a medicine review and education programme for older people in general practice. Br J Clin Pharmacol 2000;50: 172-5.
Varma S, McElnay JC, Hughes CM, Passmore AP, Varma M. Pharmaceutical care of patients with congestive heart failure: interventions and outcomes. Pharmacotherapy 1999;19: 860-9.
Al-Eidan FA, McElnay JC, Scott MG, McConnell JB. Management of Helicobacter pylori eradication: the influence of structured counselling and follow-up. Br J Clin Pharmacol 2002;53: 163-71.
Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol 2002;54: 657-64.
Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients—a randomized controlled trial. Age Ageing 2001;30: 33-40.
Krska J, Cromarty JA, Arris F, Jamieson D, Hansford D, Duffus PR, et al. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Age Ageing 2001;30: 205-11.
Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe CJ. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ 2001;323: 1340-3.(Richard Holland, senior lecturer in publ)
Correspondence to: R Holland r.holland@uea.ac.uk
Abstract
Twenty eight per cent of all prescribed drugs in the United Kingdom are consumed by the 7% of the population aged over 751 2; 6.5% of hospital admissions have recently been shown to be related to adverse drug reactions, and these are significantly more likely to occur in older patients.3 This may be due to a combination of factors, including polypharmacy and age related physiological changes. Older patients can also have considerable problems with adhering to their drug regimens—up to 50% of prescribed drugs are estimated to be not taken as prescribed.4 5
The national service framework for older people and the NHS plan recommend regular medication reviews for older patients to maximise therapeutic benefit and minimise potential harm.6 7 Historically, UK studies of medication review have focused on prescribing outcomes rather than effects on hospital admissions.8-10 An Australian study of a home based medication review-type intervention showed a 25% reduction in admissions and a reduction in deaths outside hospital.11 We sought to investigate the effectiveness of home based medication review in terms of its impact on hospital admissions in the United Kingdom. We chose home visits to ensure that the intervention could reach all very elderly participants. We also considered that home visits would allow pharmacists to gain greater insight into patients' methods of managing their drugs. The trial involved a large number of pharmacists delivering the intervention to ensure its generalisability.
Methods
Participant flow and follow up
We invited 1399 patients to participate after screening them for eligibility between October 2000 and December 2002; 872 (62%) patients agreed and were randomised (fig 1). We excluded 17 recruited patients after randomisation. Reasons for exclusion were elective baseline admission (n = 5), discharge to nursing or residential home (5), death before discharge (4), previously recruited (2), and taking fewer than two drugs (1). Table 1 shows that the two groups were very similar at baseline. Twenty patients withdrew from the trial, and six moved from the study area. Primary outcome data were thus available for 829 (97%) patients.
Fig 1 Flowchart showing progress of patients through the HOMER trial
Table 1 Baseline comparison of intervention and control group patients. Values are numbers (percentages) unless stated otherwise
Review pharmacists and intervention visits
We recruited 22 review pharmacists. Of 429 patients in the intervention group, 362 received first visits. Reasons for not visiting were visit not wanted (46 patients), pharmacist unavailable (11 patients), and patient unavailable due to death or early readmission (10 patients). Review pharmacists carried out a mean of 17 (range 1-37) first visits. More than 90% of first visits occurred within two weeks of recruitment (mean 7.2 days), and visits lasted a mean (SD) of 61 (23) minutes. Second visits were conducted for 297 patients and took a mean (SD) of 42 (19) minutes. Visits generated a total of 933 recommendations or comments to general practitioners (2.58/visited patient); 120 of these referred to possible drug reactions or interactions in 81 patients (22% of visited patients).
Compliance aids and pharmacists' view of intervention
Review pharmacists recommended compliance aids in 39 patients (11% of those receiving first visits). Pharmacists were asked after their second visit to record whether they believed the visits had been useful. For 216 (73%) patients, pharmacists felt the visits were definitely or probably useful; for 81 (27%) patients, pharmacists felt the visits were unlikely to be useful or not at all useful, generally when patients were found to be coping very well.
Number of hospital readmissions
A total of 178 emergency readmissions occurred in the control group and 234 in the intervention group (table 2). The Poisson model indicated a 30% greater rate of readmission in the intervention group (rate ratio = 1.30, 95% confidence interval 1.07 to 1.58; P = 0.009).
Table 2 Number of emergency hospital readmissions by group during six month trial follow up
Secondary outcomes
Mortality data were available for 829 (97%) patients. Fewer deaths occurred in the intervention group (49 v 63). Figure 2 shows the Kaplan-Meier survival graph. The hazard ratio for the intervention group compared with the control group was 0.75 (0.52 to 1.10; P = 0.14). Data on residential or nursing home admissions were available on fewer patients, as these were collected by telephone (585, 68%). Table 3 shows that fewer control patients than intervention patients were admitted to residential or nursing homes, but again these differences were not statistically significant.
Fig 2 Survival analysis over six month follow up period for patients in the HOMER trial
Table 3 Number of admissions to residential or nursing homes by group during six month trial follow up
Quality of life data
Change in utility scores could be calculated for 308/380 (81%) surviving intervention patients and 284/362 (78%) surviving control patients. Both groups' scores decreased over the six month follow up period, but the changes were not significantly different between the groups (table 4). Scores on the visual analogue health scale also fell; the difference of 4.1 (95% confidence interval 0.15 to 8.09) units in favour of the control group was statistically significant (P = 0.042).
Table 4 Mean EQ-5D scores and visual analogue health scale scores for groups at baseline, three months, and six months follow up
Primary care data
We included 165 patients from 12 practices in this analysis (84 intervention, 81 control). General practitioners carried out 204 home visits in the intervention group and 125 in the control group, a difference of 43% (rate ratio = 1.43, 1.14 to 1.80; P = 0.002). No statistically significant differences occurred between the groups in attendance at general practices or prescription items received.
Discussion
ASTRO-PUs and chapter STAR-PUs: 2001 revision. Leeds: Prescribing Support Unit, 2001.
Office for National Statistics. UK Census 2001. www.statistics.gov.uk/census2001/pop2001/united_kingdom.asp (accessed 9 July 2004).
Pirmohamed M, James S, Meakin S, Green C, Scott AK, Walley TJ, et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004;329: 15-9.
Wright EC. Non-compliance—or how many aunts has Matilda? Lancet 1993;342: 909-13.
Law R, Chalmers C. Medicines and elderly people: a general practice survey. BMJ 1976;i: 565-8.
Pharmacy in the future: implementing the NHS plan—a programme for pharmacy in the National Health Service. London: Department of Health, 2000.
National service framework for older people: implementing medicines related aspects of the NSF for older people. London: Department of Health, 2001.
Raynor DK, Booth TG, Blenkinsopp A. Effects of computer generated reminder charts on patients' compliance with drug regimens. BMJ 1993;306: 1158-61.
Begley S, Livingstone C, Hodges N, Williamson V. Impact of domiciliary pharmacy visits on medication management in an elderly population. Int J Pharm Pract 1997;5: 111-21.
Goodyer LI, Miskelly F, Milligan P. Does encouraging good compliance improve patients' clinical condition in heart failure? Br J Clin Pract 1995;49: 173-6.
Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based intervention on unplanned readmissions and out-of-hospital deaths. J Am Geriatr Soc 1998;46: 174-80.
Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity. Age Ageing 1991;20: 332-6.
Tidermark J, Bergstrom G, Svensson O, Tornkvist H, Ponzer S. Responsiveness of the EuroQol (EQ 5-D) and the SF-36 in elderly patients with displaced femoral neck fractures. Qual Life Res 2003;12: 1069-79.
Holland R, Smith RD, Harvey I, Swift L, Lenaghan E. Assessing quality of life in the elderly: a direct comparison of the EQ-5D and AQoL. Health Econ 2004;13: 793-805.
Rabin R, de Charro F. EQ-5D: a measure of health status from the EuroQol Group. Ann Med 2001;33: 337-43.
Lowe CJ, Raynor DK, Purvis J, Farrin A, Hudson J. Effects of a medicine review and education programme for older people in general practice. Br J Clin Pharmacol 2000;50: 172-5.
Varma S, McElnay JC, Hughes CM, Passmore AP, Varma M. Pharmaceutical care of patients with congestive heart failure: interventions and outcomes. Pharmacotherapy 1999;19: 860-9.
Al-Eidan FA, McElnay JC, Scott MG, McConnell JB. Management of Helicobacter pylori eradication: the influence of structured counselling and follow-up. Br J Clin Pharmacol 2002;53: 163-71.
Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol 2002;54: 657-64.
Nazareth I, Burton A, Shulman S, Smith P, Haines A, Timberal H. A pharmacy discharge plan for hospitalized elderly patients—a randomized controlled trial. Age Ageing 2001;30: 33-40.
Krska J, Cromarty JA, Arris F, Jamieson D, Hansford D, Duffus PR, et al. Pharmacist-led medication review in patients over 65: a randomized, controlled trial in primary care. Age Ageing 2001;30: 205-11.
Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe CJ. Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice. BMJ 2001;323: 1340-3.(Richard Holland, senior lecturer in publ)