Post discharge medicines use review (dMUR) service for older patients: Cost-savings from community pharmacist interventions

Abstract Background Based on several existing patient-oriented activities, Medicines Use Review (MUR) service was standardized and officially adopted in Slovenia in 2015. Service aims to provide adherence support and ensure safe and effective medicines use. Therefore, the aim of the study was to evaluate the benefits of MUR in Slovenia, primarily the impact on medication adherence. Methods A randomised controlled trial was performed in community pharmacies to compare MUR with standard care. Patients were randomised into either the test (patients received MUR by a certified MUR provider at visit 1), or control group. The study primary outcome was self-reported adherence to multiple medications, assessed by electronic ©Morisky Widget MMAS-8 Software at the first visit (V1) and after 12 weeks (V2). A sub-analysis of intentional and unintentional non-adherence was performed. MUR impact was defined as the relative difference in ©MMAS-8 score after 12 weeks between the test and control group. A multiple linear regression model was used to predict MUR impact based on baseline adherence (low versus medium and high). Several secondary outcomes (e.g. evaluation of drug-related problems (DRPs)) were also assessed. Results Data from 153 (V1) and 140 (V2) patients were analysed. Baseline adherence was low, moderate and high in 17.6, 48.4 and 34.0% patients, respectively. In the low adherence subpopulation, test group patients showed a 1.20 point (95% CI = 0.16–2.25) increase in total ©MMAS-8 score (p = 0.025) compared to control group patients. A 0.84 point (95% CI = 0.05–1.63) increase was due to intentional non-adherence (p = 0.038), and a 0.36 point (95% CI = − 0.23-0.95) was due to unintentional non-adherence (p = 0.226). Additionally, statistically significant decrease in the proportion of patients with manifested DRPs (p < 0.001) and concerns regarding chronic medicines use (p = 0.029) were revealed. Conclusion MUR service in Slovenia improves low medication adherence and is effective in addressing DRPs and concerns regarding chronic medicines use. Trial registration ClinicalTrials.gov - NCT04417400; 4th June 2020; retrospectively registered.

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Structure and processes of emergency observation units with a geriatric focus: a scoping review

BMC Geriatrics ◽

10.1186/s12877-021-02029-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Pieter Heeren ◽

Annabelle Hendrikx ◽

Janne Ceyssens ◽

Els Devriendt ◽

Mieke Deschodt ◽

...

Keyword(s):

Scoping Review ◽

Emergency Care ◽

Older Patients ◽

Clinical Care ◽

Care Needs ◽

Post Discharge ◽

Care Services ◽

Observation Units ◽

Primary Care Services ◽

Healthcare Professions

Abstract Background Combining observation principles and geriatric care concepts is considered a promising strategy for risk-stratification of older patients with emergency care needs. We aimed to map the structure and processes of emergency observation units (EOUs) with a geriatric focus and explore to what extent the comprehensive geriatric assessment (CGA) approach was implemented in EOUs. Methods The revised scoping methodology framework of Arksey and O’Malley was applied. Manuscripts reporting on dedicated areas within hospitals for observation of older patients with emergency care needs were eligible for inclusion. Electronic database searches were performed in MEDLINE, EMBASE and CINAHL in combination with backward snowballing. Two researchers conducted data charting independently. Data-charting forms were developed and iteratively refined. Data inconsistencies were judged by a third researcher or discussed in the research team. Quality assessment was conducted with the Methodological Index for Non-Randomized Studies. Results Sixteen quantitative studies were included reporting on fifteen EOUs in seven countries across three continents. These units were located in the ED, immediately next to the ED or remote from the ED (i.e. hospital-based). All studies reported that staffing consisted of at least three healthcare professions. Observation duration varied between 4 and 72 h. Most studies focused on medical and functional assessment. Four studies reported to assess a patients’ medical, functional, cognitive and social capabilities. If deemed necessary, post-discharge follow-up (e.g. community/primary care services and/or outpatient clinics) was provided in eleven studies. Conclusion This scoping review documented that the structure and processes of EOUs with a geriatric focus are very heterogeneous and rarely cover all elements of CGA. Further research is necessary to determine how complex care principles of ‘observation medicine’ and ‘CGA’ can ideally be merged and successfully implemented in clinical care.

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Impact of community pharmacist–performed post-discharge medication reviews in transitions of care

Journal of the American Pharmacists Association ◽

10.1016/j.japh.2018.06.017 ◽

2018 ◽

Vol 58 (6) ◽

pp. 659-666 ◽

Cited By ~ 5

Author(s):

Christa E. Tetuan ◽

Kendall D. Guthrie ◽

Steven C. Stoner ◽

Justin R. May ◽

D. Matthew Hartwig ◽

...

Keyword(s):

Community Pharmacist ◽

Transitions Of Care ◽

Post Discharge ◽

Discharge Medication ◽

Medication Reviews

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Proposed guidance on cost-avoidance studies in pharmacy practice

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxab211 ◽

2021 ◽

Author(s):

Asad E Patanwala ◽

Sujita W Narayan ◽

Curtis E Haas ◽

Ivo Abraham ◽

Arthur Sanders ◽

...

Keyword(s):

Clinical Pharmacy ◽

Best Practice ◽

Pharmacoeconomic Analysis ◽

Pharmacy Practice ◽

Cost Savings ◽

Sensitivity Analyses ◽

Cost Assessment ◽

Potential Consequence ◽

Cost Avoidance ◽

Pharmacist Interventions

Abstract Disclaimer In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose Cost-avoidance studies of pharmacist interventions are common and often the first type of study conducted by investigators to quantify the economic impact of clinical pharmacy services. The purpose of this primer is to provide guidance for conducting cost-avoidance studies pertaining to clinical pharmacy practice. Summary Cost-avoidance studies represent a paradigm conceptually different from traditional pharmacoeconomic analysis. A cost-avoidance study reports on cost savings from a given intervention, where the savings is estimated based on a counterfactual scenario. Investigators need to determine what specifically would have happened to the patient if the intervention did not occur. This assessment can be fundamentally flawed, depending on underlying assumptions regarding the pharmacists’ action and the patient trajectory. It requires careful identification of the potential consequence of nonaction, as well as probability and cost assessment. Given the uncertainty of assumptions, sensitivity analyses should be performed. A step-by-step methodology, formula for calculations, and best practice guidance is provided. Conclusions Cost-avoidance studies focused on pharmacist interventions should be considered low-level evidence. These studies are acceptable to provide pilot data for the planning of future clinical trials. The guidance provided in this article should be followed to improve the quality and validity of such investigations.

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Lower Skeletal Muscle Mass at Admission Independently Predicts Falls and Mortality 3 Months Post-discharge in Hospitalized Older Patients

The Journals of Gerontology Series A ◽

10.1093/gerona/gly281 ◽

2018 ◽

Vol 74 (10) ◽

pp. 1650-1656 ◽

Cited By ~ 4

Author(s):

Esmee M Reijnierse ◽

Sjors Verlaan ◽

Vivien K Pham ◽

Wen Kwang Lim ◽

Carel G M Meskers ◽

...

Keyword(s):

Older Adults ◽

Cognitive Impairment ◽

Muscle Mass ◽

Older Patients ◽

Test Score ◽

Handgrip Strength ◽

Bed Rest ◽

Post Discharge ◽

Male Sex ◽

Prospective Longitudinal

Abstract Background Approximately 10% of older adults are annually admitted to a hospital. Hospitalization is associated with a higher risk of falls and mortality after discharge. This study aimed to identify predictors at admission for falls and mortality 3 months post-discharge in hospitalized older patients. Methods The Evaluation of Muscle parameters in a Prospective cohort of Older patients at clinical Wards Exploring Relations with bed rest and malnutrition (EMPOWER) study is an observational, prospective longitudinal inception cohort of 378 patients aged 70 years and older who were subsequently admitted to a tertiary hospital (the Netherlands). Potential predictors for falls and mortality 3 months post-discharge were tested using univariate and multivariate logistic regression analyses and included the following domains: demographic (age, sex, living independently), lifestyle (alcohol, smoking), nutrition (SNAQ score), muscle mass (absolute, relative), physical function (handgrip strength, Katz ADL score), cognition (six-item cognitive impairment test score), and disease (medications, diseases). Results The mean age was 79.6 years (standard deviation 6.23) and 50% were male. Within 3 months post-discharge, 19% reported a fall and 13% deceased. Univariate predictors for falls were higher age, lower absolute muscle mass and higher six-item cognitive impairment test score. Lower absolute muscle mass independently predicted falls post-discharge (multivariate). Univariate predictors for mortality were higher age, male sex, no current alcohol use, higher SNAQ score, lower absolute and higher relative muscle mass, higher Katz ADL score and higher number of diseases. Male sex, higher SNAQ score, and lower absolute muscle mass independently predicted mortality post-discharge (multivariate). Conclusions In hospitalized older adults, muscle mass should be measured to predict future outcome. Future intervention studies should investigate if increasing muscle mass prevent short-term falls and mortality.

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The Conflict of Interest Inherent to Community Pharmacy in England: A Game-Theoretic Analysis of the Failure of the Medicines Use Review (MUR) Service

SSRN Electronic Journal ◽

10.2139/ssrn.3941775 ◽

2021 ◽

Author(s):

Richard J. Fairchild ◽

Jon Lischetzki

Keyword(s):

Community Pharmacy ◽

Conflict Of Interest ◽

Theoretic Analysis ◽

Game Theoretic Analysis ◽

Medicines Use ◽

Game Theoretic ◽

Medicines Use Review

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Can in-hospital or post discharge caregiver involvement increase functional performance of older patients? A systematic review

BMC Geriatrics ◽

10.1186/s12877-020-01769-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Margaretha van Dijk ◽

Jasmien Vreven ◽

Mieke Deschodt ◽

Geert Verheyden ◽

Jos Tournoy ◽

...

Keyword(s):

Systematic Review ◽

Older Adults ◽

Older Patients ◽

Functional Performance ◽

Care Pathway ◽

Intervention Group ◽

Post Discharge ◽

Home Setting ◽

Randomized Controlled ◽

Caregiver Involvement

Abstract Background Regaining pre-hospitalization activity levels is only achieved in 30–50% of older patients. Extra physiotherapy time has been proven to improve functional outcome and shorten length of stay, but is costly. Considering their key role in caring for older people, involving informal caregivers in rehabilitation might further improve functional performance. Aim To determine if in-hospital or post discharge caregiver involvement can increase functional performance in older adults. The secondary aim was to determine if caregiver involvement can influence, quality of life of patient and caregiver, medical costs, readmission rate, discharge location, and mortality. Design Systematic review with narrative synthesis. Methods The electronic bibliographic databases MEDLINE, Embase, CINAHL, Cochrane and Web of Science were searched for (quasi) experimental and observational studies, with the following inclusion criteria; caregiver involvement regarding functional performance, mean age over 65 years, admitted to a hospital unit and subsequently discharged to their home setting. Risk of bias was assessed with the Rob 2 (randomized trials) and the ROBINS-1 tool (non-randomized studies). Results Eight studies of an initial 4683 were included: four randomized controlled trials, one prospective cohort study, one non-randomized controlled trial, one subgroup analysis of an RCT and one prospective pre-post study. All but one study included patients with stroke. Three types of caregiver interventions could be distinguished: a care pathway (inclusion of caregivers in the process of care), education on stroke and teaching of bed-side handling-skills, and caregiver-mediated exercises. The one study evaluating the care pathway reported 24.9% more returns home in the intervention group. Studies evaluating the effect of education and bed-side handling-skills reported higher effect sizes for several outcomes with increasing session frequency. All studies with caregiver-mediated exercises showed beneficial effects on functional performance, immediately after the intervention and within 3 months follow-up. Conclusion The findings of this review suggest that involvement of caregivers in the rehabilitation of older adults leads to better functional performance up to 3 months after initiation. However, evidence is low and mainly focusing on stroke.

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