Effect of medicines management versus standard care on readmissions in multimorbid patients: a randomised controlled trial

Abstract

ObjectiveTo investigate the effect of pharmacist-led medicines management in multimorbid, hospitalised patients on long-term hospital readmissions and survival.DesignParallel-group, randomised controlled trial.SettingRecruitment from an internal medicine hospital ward in Oslo, Norway. Patients were enrolled consecutively from August 2014 to the predetermined target number of 400 patients. The last participant was enrolled March 2016. Follow-up until 31 December 2017, that is, 21–40 months.ParticipantsAcutely admitted multimorbid patients ≥18 years, using minimum four regular drugs from minimum two therapeutic classes. 399 patients were randomly assigned, 1:1, to the intervention or control group. After excluding 11 patients dying in-hospital and 2 erroneously included, the primary analysis comprised 386 patients (193 in each group) with median age 79 years (range 23–96) and number of diseases 7 (range 2–17).InterventionIntervention patients received pharmacist-led medicines management comprising medicines reconciliation at admission, repeated medicines reviews throughout the stay and medicines reconciliation and tailored information at discharge, according to the integrated medicines management model. Control patients received standard care.Primary and secondary outcome measuresThe primary endpoint was difference in time to readmission or death within 12 months. Overall survival was a priori the clinically most important secondary endpoint.ResultsPharmacist-led medicines management had no significant effect on the primary endpoint time to readmission or death within 12 months (median 116 vs 184 days, HR 0.82, 95% CI 0.64 to 1.04, p=0.106). A statistically significantly increased overall survival was observed during 21–40 months follow-up (HR 0.66, 95% CI 0.48 to 0.90, p=0.008).ConclusionsPharmacist-led medicines management had no statistically significant effect on time until readmission or death. A statistically significant increased overall survival was seen. Further studies should be conducted to investigate the effect of such an intervention on a larger scale.Trial registration numberNCT02336113.

Intervention fidelity and process outcomes of the IMMENSE study, a pharmacist‐led interdisciplinary intervention to improve medication safety in older hospitalized patients

“…The number and frequency of MRPs are also in line with previous Norwegian and Scandinavian studies, where MRPs have been identified in 80–100% of hospitalized internal medicines patients, 2,21,23,30 in the range of 2–9 MRPs per patient 2,22,24,30‐32 . The number and type of MRPs per patient vary across studies with similar interventions, 21,22,32,33 likely because of the lack of consensus concerning the classification of MRPs 34 . One outlier is the number of MRPs identified in a recently published study by Lea et al 21 They tested IMM working procedures in an intervention similar to IMMENSE and identified 3826 MRPs in 193 intervention patients giving a mean of 19.7 MRPs per patient 21 .…”

“…For the single steps, all were delivered to over 80% of patients. An overall fidelity of 54.8% is in line with other studies showing fidelity of 53–67% of similar complex interventions, 20,21 while many studies do not report overall fidelity 9,10,22,23 …”

“…The interdisciplinary team appreciated the pharmacist recommendations, as almost 70% were agreed upon. The high agreement rate is in line with other hospital pharmacist intervention studies in Scandinavia, showing agreement rates of 57–75% 9,20‐23,31 . A reason for the high agreement in the IMMENSE study may be that the pharmacists discussed MRPs and solutions face‐to‐face in the interdisciplinary team, in addition to documenting in patients’ records.…”

“…The study pharmacists performed MedRec and MedRev (step1&2) more frequently than the other steps, which has also been reported by others 21,24 . This may be because the pharmacist can perform both MedRec and MedRev independently of the team if electronic medical records and patients are available.…”

“…The number and type of MRPs per patient vary across studies with similar interventions, 21,22,32,33 likely because of the lack of consensus concerning the classification of MRPs 34 . One outlier is the number of MRPs identified in a recently published study by Lea et al 21 They tested IMM working procedures in an intervention similar to IMMENSE and identified 3826 MRPs in 193 intervention patients giving a mean of 19.7 MRPs per patient 21 . However, only 43% of the identified MRPs were discussed in the multidisciplinary team.…”