Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials

Abstract

Background: Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting. Review methods: To determine the effectiveness of pharmacist home visits for individuals at risk of medicationrelated problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data. Results: Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I 2 = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I 2 = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge. Conclusion: A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

Association between recorded medication reviews in primary care and adequate drug treatment management – a cross-sectional study

“…In summary, previous evidence, combined with our blinded medical assessments at the individual level, supports that pay for performance based on the recording of codes does not have the intended effect to improve the quality of drug treatment. In a similar vein, repeated systematic reviews have failed to demonstrate beneficial effects of medication reviews on patient-relevant outcomes reflecting the net benefitrisk balance of drug treatment, that is, overall mortality and hospitalizations [2,[21][22][23][24][25][26].…”

The value of domiciliary medication reviews: a thematic analysis of patient views

“…Published evidence around domiciliary medication reviews tends to focus on clinical outcomes, such as validated measures for medication appropriateness [8], suggesting this is where the value of these services lies. However, assessment of whether these services definitively have a positive effect on these outcomes varies [9][10][11][12]. There is a gap in the literature around where the value of these DMR services lies.…”

Nobody ever questions—Polypharmacy in care homes: A mixed methods evaluation of a multidisciplinary medicines optimisation initiative

“…We did not use quality-of-life measures, as we found that these fail to capture important symptoms, such as pain and emesis, are difficult to administer with people with cognitive impairment [ 6 ], and reviewers indicate that they are infrequently used in this area [ 28 ].…”

“…There is little evidence that existing interventions to improve the appropriateness of polypharmacy in older people improve outcomes [27]. Pharmacist-led innovations in pharmaceutical care and computerised decision support improve prescribing but not outcomes [27][28][29][30][31][32], and single-problem initiatives may be ineffective [33]. However, nurses' and carers' contributions to medicines optimisation remain unexplored.…”