Development and Application of Comprehensive Medication Review Procedure to Community- Dwelling Elderly
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Division of Social Pharmacy Faculty of Pharmacy University of Helsinki Development and Application of Comprehensive Medication Review Procedure to Community- Dwelling Elderly Saija Leikola ACADEMIC DISSERTATION To be presented with the permission of the Faculty of Pharmacy, University of Helsinki, for public examination in Auditorium 2041, Biocenter 2, Viikinkaari 5, University of Helsinki, on 30th March 2012, at 12 noon. Helsinki 2012 Supervisors: Professor Marja Airaksinen, Vice Dean, PhD Division of Social Pharmacy Faculty of Pharmacy University of Helsinki Finland Pharmacy Owner Eeva Savela, PhD Lohja 1st Pharmacy Finland Co-supervisors: Professor Raimo K. Tuominen, MD, PhD Division of Pharmacology and Toxicology Faculty of Pharmacy University of Helsinki Finland Professor Alan Lyles, ScD, MPH School of Health and Human Services, School of Public and International Affairs University of Baltimore United States Reviewers: Associate Professor Timothy Chen, PhD Faculty of Pharmacy University of Sydney Australia Director Kenneth Shermock, PharmD, PhD Center for Pharmaceutical Outcomes and Policy The Johns Hopkins Hospital United States Opponent: Associate Professor Tommy Westerlund, PhD Unit of Social Medicine Department of Community Medicine and Public Health Institute of Medicine The Sahlgrenska Academy at the University of Gothenburg Sweden ISBN 978-952-10-7697-8 (pbk.) ISBN 978-952-10-7698-5 (PDF) ISSN 1799-7372 Helsinki University Printing House Helsinki, Finland 2012 Abstract Populations in Western countries are ageing. At the same time, use of medications is increasing among older people. Age-related changes in the body make the elderly vulnerable to adverse drug events. Thus, ensuring medication safety among this patient group is a growing health care concern. For this purpose, several criteria to indicate inappropriate prescribing among the aged have been developed. Also, different types of medication review procedures have been created in several countries to identify drug-related problems (DRPs). The aim of this study was to develop a collaborative Comprehensive Medication Review (CMR) procedure applicable to the Finnish health care system and evaluate its usefulness as a means to improve the appropriateness of pharmacotherapy among community-dwelling elderly. The specific aims were 1) to determine the prevalence of potentially inappropriate medication use according to the Beers 2003 criteria among Finnish non-institutionalized population aged ≥65 years; 2) to describe the development and assess participant satisfaction on the CMR accreditation training; 3) to describe the development of the CMR procedure and related documentation, and to assess CMR training participants’ satisfaction on the documentation; and 4) to assess the DRPs pharmacists report to collaborating physicians during CMR and the resulting interventions among outpatients aged ≥65 years. This study applied both quantitative and qualitative methods. The prevalence of potentially inappropriate drug use according to the Beers criteria was studied by using the drug reimbursement register of the Finnish Social Insurance Institution covering the entire non-institutionalized population aged ≥65 years in 2007 (n=841 509, Study I). The development of the CMR procedure and accreditation training involved a review of literature and medication review procedures used in other countries as well as pilot testing by 26 experienced pharmacists undergoing the CMR training in 2005– 2006 (Studies II, III). Participants’ satisfaction on the CMR training (n=38) and documentation (n=27) were assessed by surveys completed by pharmacists attending CMR training in 2006–2007 (Studies II, III). The DRPs identified and reported to the collaborating physicians during CMR were studied by a retrospective review of CMR case reports (n=121) by 26 community pharmacists attending the CMR training in 2006–2007 (Study IV). Approximately 15% of the entire non-institutionalized population aged ≥65 years used potentially inappropriate medications in Finland in 2007. This prevalence is low compared to studies in other countries. The most worrying finding was the common use of benzodiazepines: one third of the potentially inappropriate drug use involved these drugs, particularly high-dose temazepam. The 1.5- year CMR accreditation training for practicing pharmacists combines distance learning and face-to-face learning and consists of 5 modules: 1) Multidisciplinary Collaboration; 2) Clinical Pharmacy and Pharmacotherapy; 3) Rational Pharmacotherapy; 4) CMR Tools; and 5) Optional Studies. The participating pharmacists’ satisfaction with the training was high but several factors prevent them from conducting CMRs after the training. The collaborative CMR procedure involves access to clinical patient information, home visit with patient interview, a case conference with the collaborating physician and extensive documentation to support the process. The procedure covers four main dimensions critical for safe and appropriate pharmacotherapy for the aged: Aging and Safety; Co- Morbidities; Polypharmacy; and Adherence. When using the CMR procedure, pharmacists reported to collaborative physicians an average of 6.5 DRPs per patient. Most common DRPs were inappropriate drug selection, especially involving psychotropic drugs, and undertreatment. Also treatment of pain was often found to need improvement. Approximately half of the pharmacists’ recommendations led to medication changes, i.e., to an average of 3 changes/patient. The most common agreed change was to stop hypnotics or sedatives. The results of this study confirm many well-known problems in elderly pharmacotherapy: prescribing of inappropriate drugs, undertreatment, and issues related to inadequate management of pain. The CMR procedure could be beneficial for improving pharmacotherapy among older outpatients as a large portion of DRPs identified by pharmacists led to medication changes. Actions to facilitate implementation of the model to Finnish health care system are needed. Also, further studies are needed to evaluate the effects of CMR on clinical, humanistic and economic outcomes. Acknowledgements This study was a long process, starting in 2005. It is amazing how many people have been involved and helped me along the way. I want to warmly thank you all! First, I want to express my gratitude to my main supervisor, Professor Marja Airaksinen, Head of the Division of Social Pharmacy, who supported me throughout the process. Her outstanding expertise, valuable advice and endless patience were essential for this thesis to be completed. Second, I want to thank my energetic employer, pharmacy owner Eeva Savela, who pushed me to start this study. I am grateful for her continuous support and encouragement. I also want to thank my supervisors Professor Raimo K. Tuominen, Head of the Division of Pharmacology and Toxicology, and Professor Alan Lyles, University of Baltimore, for sharing their expertise and giving valuable comments. Professor Timothy Chen, University of Sydney, and Dr. Kenneth Shermock, The Johns Hopkins Hospital, are warmly thanked for their pre-examination of this thesis and for giving such encouraging comments. Thomas Fulda, BA, MA, is acknowledged for his enormous work reviewing the language and for giving insightful advice. The material for this study was acquired from multiple sources and the articles were written in collaboration with numerous co-authors. I especially want to thank the members of the TIPPA Coordination group who developed the CMR training and procedure. My warmest thanks go to training coordinator Lea Tuomainen who made the data collection for studies II-IV possible. In addition, I want to thank Lea for her friendship and incredible way of giving feedback and support during the CMR accreditation training. I also want to express my deepest gratitude to all CMR training participants who took the effort to complete the surveys and to provide the CMR case reports for this study. My excellent MSc students Maarit Dimitrow and Johanna Virolainen are warmly thanked for doing a great job with their Master’s theses and helping with related manuscripts. I am grateful for all colleagues and peers who were involved in this process. This concerns foremost Anna Westerling, a recent PhD and a dear friend who was always willing to help and listen. Together we shared the greatest and funniest moments from the first submissions and manuscript acceptances to congresses, but also the surprisingly many moments of despair. Personnel at the Division of Social Pharmacy are all thanked for always being helpful and supportive. PhD student Juha Sinnemäki and PhD Marika Pohjanoksa-Mäntylä are specially acknowledged for their continuous assistance and useful discussions. The Association of Finnish Pharmacies, The Pharma Industry Finland Research Foundation and The Finnish Pharmacists’ Society are acknowledged for their financial support. In addition, the Graduate School in Pharmaceutical Research is acknowledged for providing the 2-year doctoral student position at the University, which enabled full commitment to the PhD studies. My special thanks go to my dear family, relatives and friends who have always listened, encouraged and shared fun moments to make me forget study-related concerns. I especially want to thank my sisters Saila and Silja, friends Minna, Ralf, Tiina and Topi, and my great co-workers from the Lohja 1st Pharmacy for all hilarious get-togethers and travels. I sincerely thank my mom Seija and dad Erkki for emphasizing