Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis.

BACKGROUND: Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults. METHODS: We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes. RESULTS: Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I2 = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes. DISCUSSION: In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications. REGISTRY INFORMATION: PROSPERO - CRD42019132420.

Pharmacist-Led Chronic Disease Management: A Systematic Review of Effectiveness and Harms Compared With Usual Care.

BACKGROUND: Increased involvement of pharmacists in patient care may increase access to health care and improve patient outcomes. PURPOSE: To determine the effectiveness and harms of pharmacist-led chronic disease management for community-dwelling adults. DATA SOURCES: MEDLINE, Cochrane Library, CINAHL, and International Pharmaceutical Abstracts from 1995 through February 2016, and reference lists of systematic reviews and included studies. STUDY SELECTION: 65 patient populations in 63 studies conducted in the United States of any design reported outcomes of pharmacist-led chronic disease management versus a comparator for community-dwelling adults in the United States. Studies set in retail pharmacies were excluded. DATA EXTRACTION: Data extraction done by a single investigator was confirmed by a second investigator; risk of bias was assessed by 2 investigators; and strength of evidence was determined by consensus. DATA SYNTHESIS: Pharmacist-led care was associated with similar numbers of office visits, urgent care or emergency department visits, and hospitalizations (moderate-strength evidence) and medication adherence (low-strength evidence) compared with usual care (typically continuing a prestudy visit schedule). Pharmacist-led care increased the number or dose of medications received and improved study-selected glycemic, blood pressure, and lipid goal attainment (moderate-strength evidence). Mortality and clinical events were similar (low-strength evidence). Evidence on patient satisfaction was mixed and insufficient. The reporting of harms was limited. LIMITATIONS: Interventions were heterogeneous. Studies were typically short-term and designed to assess physiologic intermediate outcomes rather than clinical events. Reporting of many clinical outcomes of interest was limited, and often they were not the study-defined primary end points. CONCLUSION: Pharmacist-led chronic disease management was associated with effects similar to those of usual care for resource utilization and may improve physiologic goal attainment. Further research is needed to determine whether increased medication utilization and goal attainment improve clinical outcomes. PRIMARY FUNDING SOURCE: Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative.

Design and implementation of a targeted approach for pharmacist-mediated medication management at care transitions.

OBJECTIVES: To improve patient care through the development of a clinical risk stratification tool to identify high-risk patients and implementation of pharmacist-mediated medication management after patient care transitions. SETTING: Minneapolis Veterans Affairs (VA) Health Care System from December 1, 2014, to April 1, 2015. PRACTICE DESCRIPTION: A composite care transition score was developed based on risk factors obtained from a literature review and combined with a national stratification tool unique to the Veterans Health Administration (VHA) primary care population, the Care Assessment Need (CAN) score. High-risk individuals were identified to receive a comprehensive medication therapy management (MTM) encounter within 7 days of a recent transition of care. Pharmacists identified and resolved medication-related problems and drug discrepancies using an independent scope of practice. PRACTICE INNOVATION: Pharmacists with an independent scope of practice, using a novel risk-stratification tool, are able have a positive impact on transitions of care for high-risk patients. INTERVENTIONS: High-risk patients engaged in comprehensive medication therapy management appointments performed by primary care clinical pharmacists with an independent scope of practice. EVALUATION: Medication-related problems, drug discrepancies, and pharmacist mediated interventions were analyzed after completion of MTM encounters in 31 high-risk patients. Patient characteristics and time demands per encounter were also assessed. RESULTS: A total of 31 patients were seen for MTM encounters. A total of 127 medication-related problems were identified, resulting in an average of 4.1 ± 2.9 (range, 0-14) problems per patient. In addition, 137 drug discrepancies were found during medication reconciliation, with an average of 4.4 ± 2.8 (range, 0-13) discrepancies per patient. Pharmacist-mediated interventions were performed in 84% (n = 26) of patients, totaling 121 interventions with an average of 3.9 ±3.8 (range, 0-13) interventions per patient. CONCLUSION: Stratification of patients and pharmacist-mediated MTM appointments resulted in the identification and resolution of medication-related problems and drug discrepancies at care transitions.