Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Consultations with elderly patients and their physicians by clinical pharmacists made a modest difference in improving the appropriateness of drug prescribing

ACP J Club. 1993 Jan-Feb;118:29. doi:10.7326/ACPJC-1993-118-1-029


Source Citation

Lipton HL, Bero LA, Bird JA, McPhee SJ. The impact of clinical pharmacists' consultations on physicians' geriatric drug prescribing. A randomized controlled trial. Med Care. 1992 Jul;30:646-58.


Abstract

Objective

To determine whether the appropriateness of drug prescribing for geriatric outpatients would be improved by consultations with clinical pharmacists.

Design

3-month, randomized controlled trial.

Setting

Follow-up of patients discharged from a 450-bed nonteaching community hospital in California.

Patients

Inclusion criteria were age ≥ 65 years; Medicare recipient; ≥ 3 drugs prescribed for a chronic condition; admission to a nonpsychiatric ward; living within 35 miles of the hospital and not in a nursing home; and accessibility by telephone (or availability of a proxy). A random sample of 274 patients was drawn from 706 of 1383 eligible patients. 236 patients (86%) completed the trial.

Intervention

2 clinical pharmacists reviewed the hospital records and drug regimens of the 123 experimental group patients to assess the appropriateness of prescribing. They held consultations with the patients during hospitalization, before discharge, and after discharge (4 telephone calls during 3 mo) to discuss potential drug-related problems, and subsequently to consult the physicians if potential problems were detected. The purpose of the consultations was to inform patients and physicians and to improve prescribing and compliance with an appropriate regimen. The control group (n = 113) had no consultations. All patients were given booklets to record information about their medication use after discharge.

Main outcome measures

Potential drug-therapy problems (determined by 2 reviewers): inappropriate choice of therapy; underdosage or overdosage; schedule; drug-drug interactions; drug duplication; allergy; and omitted but necessary medications. A case abstract was prepared for each patient, with a blinded review done by physicians and pharmacists.

Main results

Medications taken by the patients were most commonly cardiac drugs, nonsteroidal anti-inflammatory drugs, replacement solutions, vasodilators, and diuretics. Frequency of drug therapies did not differ between groups. Overall, 22% had ≥ 1 potentially life-threatening medication problem. Fewer of the experimental patients compared with the control patients had inappropriate medication (51% vs 68%, P = 0.01), underdosage or overdosage (43% vs 56%, P = 0.05), and any potential drug-therapy problems (84% vs 92% P = 0.05), but the groups did not differ on other measures of potential medication-related problems.

Conclusion

Consultations with elderly patients and their physicians by clinical pharmacists made a modest difference in improving the appropriateness of drug prescribing.

Source of funding: John A. Hartford Foundation.

For article reprint: Dr. H.L. Lipton, Institute for Health Policy Studies, 1388 Sutter Street, 11th Floor, San Francisco, CA 94109, USA. FAX 415-476-0705.


Commentary

Evidence suggests that medications are not always prescribed in an optimal manner to older patients. The occurrence of avoidable adverse drug reactions is the most serious consequence of inappropriate prescribing; economic considerations are also of increasing concern. Strategies for reducing inappropriate prescribing have included government regulatory interventions such as the withdrawal of reimbursement for drug therapies considered to be suboptimal and the requirement of triplicate prescriptions for some classes of medications such as benzodiazepines (1, 2). Such interventions have resulted in some undesirable therapeutic substitutions, with increases in the prescribing of less acceptable medications.

Although randomized controlled clinical trials are the basis for rational medication prescribing, health care delivery interventions are rarely subjected to similar evaluation. A randomized trial of an educational program to reduce the use of psychoactive drugs in nursing homes did result in an improvement in the use of these agents (3). Lipton and colleagues have reported a strategy that produced a modest improvement in the quality of prescribing for elderly patients. Many prescribing problems existed, however, even among the experimental group; 84% of these patients had at least 1 prescribing problem. The true effect of the intervention is difficult to ascertain because the authors provided limited comparative data at baseline.

The study does provide a model framework for physicians and clinical pharmacists to work together. Unanswered questions, however, include the costs of running such a program and the effect of the intervention on clinical outcomes such as the occurrence of adverse drug reactions.

Jerry H. Gurwitz, MD
Harvard Medical SchoolBoston, Massachusetts, USA


References

1. Soumerai SB, Ross-Degnan D, Gortmaker S, Avorn J. Withdrawing payment for nonscientific drug therapy. Intended and unexpected effects of a large-scale natural experiment. JAMA. 1990;263:831-9.

2. Weintraub M, Singh S, Byrne L, Maharaj K, Guttmacher L. Consequences of the 1989 New York State triplicate benzodiazepine prescription regulations. JAMA. 1991;266:2392-7.

3. Avorn J, Soumerai SB, Everitt DE, et al. A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes. N Engl J Med. 1992;327:168-73.