Date Published: May 8, 2019
Publisher: Public Library of Science
Author(s): Sanne Verdoorn, Henk-Frans Kwint, Jeanet W. Blom, Jacobijn Gussekloo, Marcel L. Bouvy, Aaron S. Kesselheim
Abstract: BackgroundClinical medication reviews (CMRs) are increasingly performed in older persons with multimorbidity and polypharmacy to reduce drug-related problems (DRPs). However, there is limited evidence that a CMR can improve clinical outcomes. Little attention has been paid to patients’ preferences and needs. The aim of this study was to investigate the effect of a patient-centred CMR, focused on personal goals, on health-related quality of life (HR-QoL), and on number of health problems.Methods and findingsThis study was a randomised controlled trial (RCT) performed in 35 community pharmacies and cooperating general practices in the Netherlands. Community-dwelling older persons (≥70 years) with polypharmacy (≥7 long-term medications) were randomly assigned to usual care or to receive a CMR. Randomisation was performed at the patient level per pharmacy using block randomisation. The primary outcomes were HR-QoL (assessed with EuroQol [EQ]-5D-5L and EQ-Visual Analogue Scale [VAS]) and number of health problems (such as pain or dizziness), after 3 and 6 months. Health problems were measured with a self-developed written questionnaire as the total number of health problems and number of health problems with a moderate to severe impact on daily life. Between April 2016 and February 2017, we recruited 629 participants (54% females, median age 79 years) and randomly assigned them to receive the intervention (n = 315) or usual care (n = 314). Over 6 months, in the intervention group, HR-QoL measured with EQ-VAS increased by 3.4 points (95% confidence interval [CI] 0.94 to 5.8; p = 0.006), and the number of health problems with impact on daily life decreased by 12% (difference at 6 months −0.34; 95% CI −0.62 to −0.044; p = 0.024) as compared with the control group. There was no significant difference between the intervention group and control group for HR-QoL measured with EQ-5D-5L (difference at 6 months = −0.0022; 95% CI −0.024 to 0.020; p = 0.85) or total number of health problems (difference at 6 months = −0.30; 95% CI −0.64 to 0.054; p = 0.099). The main study limitations include the risk of bias due to the lack of blinding and difficulties in demonstrating which part of this complex intervention (for example, goal setting, extra attention to patients, reducing health problems, drug changes) contributed to the effects that we observed.ConclusionsIn this study, we observed that a CMR focused on personal goals improved older patients’ lives and wellbeing by increasing quality of life measured with EQ-VAS and decreasing the number of health problems with impact on daily life, although it did not significantly affect quality of life measured with the EQ-5D. Including the patient’s personal goals and preferences in a medication review may help to establish these effects on outcomes that are relevant to older patients’ lives.Trial registrationNetherlands Trial Register; NTR5713
Partial Text: Medication reviews are increasingly performed and recommended by guidelines for older persons with multimorbidity and long-term medication use [1,2]. There are different types of medication reviews, ranging from a prescription review (which is basically an evaluation of the list of prescribed medicines) to a clinical medication review (CMR; with the availability of all clinical data and an extensive patient interview) . It has been established that a CMR can identify and reduce drug-related problems (DRPs) and can have positive effects on other intermediate outcomes, such as low-density lipoprotein (LDL) cholesterol or HbA1c [4–11]. However, evidence for the effect of CMR on clinical outcomes, for example, hospital admissions and health-related quality of life (HR-QoL), is limited [6,7,12,13].
Of the 2,290 invited patients, 707 (31%) consented to participate (Fig 1). Participants were recruited between April 2016 and February 2017; follow-up was performed up to August 2017.
In this study, we found that a CMR focused on personal goals improved quality of life measured by the EQ-VAS in older persons with polypharmacy and reduced the number of health problems with a moderate to severe impact on daily life. Concurrently, CMR decreased the number of long-term medications. However, CMR had no effect on HR-QoL measured by the EQ-5D-5L or total number of health problems.
The DREAMeR study was an RCT aiming to assess the effect of a CMR focused on personal goals on quality of life in older persons with polypharmacy in the Netherlands. We observed improvements in quality of life measured by the EQ-VAS, reductions in the number of health problems that patients felt had a moderate to severe impact on daily life, and reductions in the number of prescribed long-term medications, but the CMR had no effect on HR-QoL measured by the EQ-5D-5L or total number of health problems. Including patient’s goals and preferences during the patient interviews of CMR may be important to establish clinically relevant effects of this intervention.