The challenge to define a relevant change in medication appropriateness index score in older adults – An approach

Krisch, Laura; Mahlknecht, Angelika; Bauer, Ulrike; Nestler, Nadja; Hempel, Georg; Osterbrink, Jürgen; Flamm, Maria

doi:10.1111/bcp.14167

Cited by 4 publications

(6 citation statements)

References 9 publications

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“…In their trial, the appropriateness of prescription was evaluated by pharmacists reviewing the documentation previously prepared by clinical assistants, unlike our study, in which the evaluators were family physicians with clinical experience and training in polypharmacy who had the medical history of each patient available to them, which could have influenced the MAI score. The baseline MAI score found in MULTIPAP is similar to that of other studies, which have had baseline MAI scores of approximately 14 points [ 15 , 17 , 38 , 43 , 44 , 45 , 46 , 47 ].…”

Section: Discussionsupporting

confidence: 85%

“…Randomized controlled trials (RCTs) using MAI mostly report the mean change in the MAI scores and compare mean differences between groups as a measure of effect size. The calculated sample size allowed us to detect an effect size (d) of 0.33 (2/6), somewhat larger than that described as a small effect by Cohen (d = 0.2) [ 16 , 38 , 39 ]. Assuming five eligible patients per FP cluster, an intraclass correlation coefficient of 0.03 [ 40 ], and a loss-to-follow-up rate of 20%, we needed to recruit 80 FPs and 400 patients (200 per group).…”

Section: Methodsmentioning

confidence: 76%

“…In 1997, Schamder et al [ 42 ] found that a difference of two points was associated with differences in hospitalization and unscheduled outpatient or emergency visits. Several studies reviewing MAI interpretation from the 1990s [ 30 ] to the present [ 16 , 17 ] proposed to consider a two–three point change as indicative of a clinical difference [ 36 , 38 ].…”

Section: Discussionmentioning

confidence: 99%

“…There are several ways to interpret the MAI results in studies evaluating the effectiveness of interventions to reduce inappropriate medication [ 38 ]. One of them is to compare the summated MAI score post intervention, adjusted by the MAI baseline value [ 43 ].…”

Section: Discussionmentioning

confidence: 99%

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How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

del-Cura-González

López-Rodríguez

Leiva-Fernández

et al. 2022

JPM

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(1) Purpose: To investigate a complex MULTIPAP intervention that implements the Ariadne principles in a primary care population of young-elderly patients with multimorbidity and polypharmacy and to evaluate its effectiveness for improving the appropriateness of prescriptions. (2) Methods: A pragmatic cluster-randomized clinical trial was conducted involving 38 family practices in Spain. Patients aged 65–74 years with multimorbidity and polypharmacy were recruited. Family physicians (FPs) were randomly allocated to continue usual care or to provide the MULTIPAP intervention based on the Ariadne principles with two components: FP training (eMULTIPAP) and FP patient interviews. The primary outcome was the appropriateness of prescribing, measured as the between-group difference in the mean Medication Appropriateness Index (MAI) score change from the baseline to the 6-month follow-up. The secondary outcomes were quality of life (EQ-5D-5 L), patient perceptions of shared decision making (collaboRATE), use of health services, treatment adherence, and incidence of drug adverse events (all at 1 year), using multi-level regression models, with FP as a random effect. (3) Results: We recruited 117 FPs and 593 of their patients. In the intention-to-treat analysis, the between-group difference for the mean MAI score change after a 6-month follow-up was −2.42 (95% CI from −4.27 to −0.59) and, between baseline and a 12-month follow-up was −3.40 (95% CI from −5.45 to −1.34). There were no significant differences in any other secondary outcomes. (4) Conclusions: The MULTIPAP intervention improved medication appropriateness sustainably over the follow-up time. The small magnitude of the effect, however, advises caution in the interpretation of the results given the paucity of evidence for the clinical benefit of the observed change in the MAI. Trial registration: Clinicaltrials.gov NCT02866799.

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Section: Discussionsupporting

confidence: 85%

Section: Methodsmentioning

confidence: 76%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

del-Cura-González

López-Rodríguez

Leiva-Fernández

et al. 2022

JPM

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“…This contrasts with the findings from our original study in which the MAI score at 12 months was 28% lower in the intervention group compared to only 5% in the control group [4]. It is important to note that there remains a challenge in defining a relevant change in MAI scores despite the MAI demonstrating predictive validity with important patient outcomes [24].…”

Section: Responsiveness To Change In Clinical Trialscontrasting

confidence: 66%

The Medication Appropriateness Index: A Clinimetric Measure

Hanlon

Schmader

2022

Psychother Psychosom

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Decision support software-guided medication reviews in elderly patients with polypharmacy: a prospective analysis of routine data from community pharmacies (OPtiMed study protocol)

Maierhöfer

Waltering

Jacobs³

et al. 2022

J of Pharm Policy and Pract

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Background Pharmacist-led medication reviews are considered a valuable measure to address risks of polypharmacy. The software Medinspector® is used in community pharmacies to assist the performance of this complex service by structuring the medication review process and supporting pharmacists in their decision-making with targeted clinical knowledge. Key feature is a computerized risk assessment of both the initial and adjusted medication regimen of a patient in multiple domains, thus aiming to support the identification and solving of drug-related problems. This study will examine the effects of medication reviews performed with the clinical decision support system in daily routine practice on medication-related and patient-reported outcomes in elderly patients with polypharmacy. Methods A prospective, before–after observational study is conducted in German community pharmacies aiming to include 148 patients aged 65 or older, who chronically use five or more active pharmaceutical substances with systemic effects and utilize the software-supported medication review service. The study is based on routine documentation within the software over the course of the medication review, including a patient’s baseline medication, the medication proposed by pharmacists, and the final medication regimen. A software-implemented questionnaire comprising self-developed and literature-derived instruments is used to collect patient-reported outcome data at baseline and follow-up. Primary outcome is the appropriateness of medication measured with an adapted version of the Medication Appropriateness Index (MAI). Secondary medication-related outcomes are medication underuse, exposition towards anticholinergic/sedative drugs, number of drugs in long-term use and the implementation of pharmacist-proposed medication adjustments by the physicians. Secondary patient-reported outcomes are symptom burden, medication-related quality of life, adherence, fulfillment of medication review-related goals, and perception of the service. Discussion With the recently introduced remuneration of community pharmacist-led MR in Germany, the demand for digital tools supporting the MR process is assumed to rise. The OPtiMed-study is expected to create evidence on the effects of a novel tool on patient care in a vulnerable patient population. Trial registration German Clinical Trials Register, DRKS00027410. Registered 22 December 2021, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027410. Also available on the WHO meta-registry: https://trialsearch.who.int/?TrialID=DRKS00027410

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The challenge to define a relevant change in medication appropriateness index score in older adults – An approach

Cited by 4 publications

References 9 publications

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

How to Improve Healthcare for Patients with Multimorbidity and Polypharmacy in Primary Care: A Pragmatic Cluster-Randomized Clinical Trial of the MULTIPAP Intervention

The Medication Appropriateness Index: A Clinimetric Measure

Decision support software-guided medication reviews in elderly patients with polypharmacy: a prospective analysis of routine data from community pharmacies (OPtiMed study protocol)

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