Humanistic and economic outcomes of pharmacist-provided medication review in the community-dwelling elderly: A systematic review and meta-analysis.

WHAT IS KNOWN AND OBJECTIVE: Recent reviews have shown that pharmacist-provided medication review in the elderly can improve clinical outcomes and reduce medication discrepancies compared with usual care. However, none determined whether these translate to improved humanistic and economic outcomes. This review sought to evaluate the effects of medication review on health-related quality of life (HRQoL) and healthcare costs in the elderly. METHODS: A systematic search of MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane library for studies published in English from inception to 31 August 2015 was conducted. The review included studies lasting at least 3 months that randomly assigned community-dwelling participants aged at least 65 years to receive either pharmacist-provided medication review or usual care. Studies set in nursing homes were excluded. RESULTS AND DISCUSSION: The review identified 25 studies that included 15 341 participants and lasted between 3 and 36 months. Twenty and 13 studies reported HRQoL and economic outcomes, respectively. Overall, there was no significant difference in HRQoL and healthcare costs between pharmacist-provided medication review and usual care. Meta-analysis of studies that reported the 36-item Short-Form Health Survey found significant differences in favour of usual care in the body pain (mean difference: 2·94, 95% CI: 0·54-5·34, P = 0·02) and general health perception (mean difference: 1·83, 95% CI: 0·16-3·50, P = 0·03) domains, whereas there were no significant differences in other domains. Meta-analysis of the EuroQol-5D utility (mean difference: -0·01, 95% CI: -0·02-0·01, P = 0·57) and visual analogue scale (mean difference: 0·01, 95% CI: -3·24-3·26, P = 1·00) found no significant differences. Costs of hospitalization, medication and other healthcare resources consumed were similar between groups. WHAT IS NEW AND CONCLUSION: Humanistic and economic outcomes of pharmacist-provided medication review were largely similar to those of usual care. Further research using more robust methodology is needed to determine whether improved medication management can improve HRQoL and reduce healthcare costs. Careful thought should be given to capturing relevant outcomes that reflect the potential benefits of this intervention.

Secondary prevention of osteoporotic fractures--an "OPTIMAL" model of care from Singapore.

UNLABELLED: A significant care gap exists in the management of osteoporotic fractures. Osteoporosis Patient Targeted and Integrated Management for Active Living (OPTIMAL) is a secondary fracture prevention program instituted in the public hospitals of Singapore. We aim to describe the operational characteristics of OPTIMAL and initial audit data of patients who were recruited into the program at Singapore General Hospital. INTRODUCTION: Fractures often represent the first opportunity for care of osteoporosis. However, a significant care gap still exists in the management of these sentinel events and underdiagnosis and undertreatment of osteoporotic fractures are prevalent worldwide. Fracture liaison services run by care coordinators have been shown to reduce the fracture care gap. OPTIMAL is a clinician champion-driven, case manager-run secondary fracture prevention program set up in the public hospitals of Singapore in 2008. METHODS: We present the operational characteristics and initial audit data of OPTIMAL from the largest tertiary teaching hospital in Singapore. RESULTS: One thousand and fourteen patients have been recruited into OPTIMAL at our hospital since 2008, and 476 patients are currently in active follow-up. Two hundred and eighty-seven patients had completed a 2-year follow-up at the hospital as of August 2012 and were evaluated; 97.5% of these patients had DXA evaluation upon enrollment into the program, and 62% of the patients reported compliance with an exercise program over the 2-year follow-up. Compliance to osteoporosis medications as estimated by the medication possession ratio (MPR) was 72.8 ± 34.5% at 2 years with patients maintaining good compliance (MPR ≥ 80%) for an average of 20.2 months (95% CI 19.3-21.1). CONCLUSION: Our report provides the first compelling evidence of the potential success of a secondary fracture prevention program from an Asian country. The ultimate success of the program will be determined by fracture outcomes and cost effectiveness, but in the interim, clear evidence of enhanced assessment and treatment rates has been demonstrated.

Adherence to osteoporosis medications amongst Singaporean patients.

UNLABELLED: Compliance and persistence to bisphosphonates amongst Singaporean patients with osteoporosis were estimated. Mean medication possession ratio (MPR) ± standard deviation (SD) was 78.9 ± 27.5%, and 69.0% was persistent at 1 year. In contrast to US and Europe where poor adherence is noted, our study suggests higher adherence rates to bisphosphonate therapy amongst patients. INTRODUCTION: Adherence to bisphosphonate therapy during treatment of osteoporosis has been reported to be poor. We aimed to estimate the compliance and persistence to prescribed bisphosphonate therapy amongst patients at the largest public restructured hospital in Singapore. METHODS: This is a retrospective analysis of records of patients who were prescribed the two most commonly used oral bisphosphonates-alendronate and risedronate. The study was conducted between January 2007 and December 2008. Prescription and pharmacy refill records of all patients were extracted and matched. Compliance was calculated using the MPR, while persistence, a dichotomous variable, was defined as continuous refill of bisphosphonates for at least 12 months with a permissible gap of 30 days. RESULTS: Seven hundred ninety-eight patients were included in the study. Mean MPR ± SD was 78.9 ± 27.5%, and 69.0% of the patients were persistent with bisphosphonate therapy at 1 year. The proportion of patients with MPR ≥ 80% at 6, 12 and 18 months was 90%, 72% and 62%, respectively. Age <69 years was associated with better compliance (OR, 1.34; 95% CI, 0.99-1.82; P = 0.043), and history of fractures was associated with better compliance (OR, 1.38; 95% CI, 1.02-1.87; P = 0.038) and persistence (OR, 1.33; 95% CI, 0.97-1.82; P = 0.046). CONCLUSION: In contrast to studies conducted in the US and Europe that show poor adherence, our study suggests higher adherence rates to bisphosphonate therapy amongst Singaporean patients.

The effects of fasting in Muslim patients taking warfarin.

BACKGROUND: Anticoagulation with warfarin is influenced by dietary changes but the effect of fasting on warfarin therapy is unknown. OBJECTIVES: To study changes in international normalized ratio (INR) and the percentage of time within therapeutic range (%TTR) before, during and after the Muslim fasting month (Ramadan) in stable warfarinised Muslim patients. METHODS/PATIENTS: In this prospective study, weekly INR readings were taken at home visits from participating patients during three study periods: before, during and after Ramadan. Readings were blinded to patients and their primary physicians except for when pre-set study endpoints were reached. RESULTS: Among 32 participating patients, mean INR increased by 0.23 (P = 0.006) during Ramadan from the pre-Ramadan month and decreased by 0.28 (P < 0.001) after Ramadan. There was no significant difference (P = 1.000) in mean INR between the non-Ramadan months. %TTR declined from 80.99% before Ramadan to 69.56% during Ramadan (P = 0.453). The first out-of-range INR was seen around 12.1 days (95% CI, 9.0-15.1) after the start of fasting and returned to range at about 10.8 days (95% CI, 7.9-13.7) after Ramadan. Time above range increased from 10.80% pre-Ramadan to 29.87% during Ramadan (P = 0.027), while time below range increased from 0.57% during Ramadan to 15.49% post-Ramadan (P = 0.006). No bleeding or thrombotic events were recorded. CONCLUSIONS: Fasting significantly increases the mean INR of medically stable patients taking warfarin and the likelihood of having an INR above therapeutic targets. For patients maintained at the higher end of INR target ranges or at increased risk of bleeding, closer monitoring or dosage adjustment may be necessary during fasting.