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Pharmacist participation in hospital ward teams and hospital readmission rates among people with dementia - a randomized controlled trial
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine. Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience, Pharmacology.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Importance: Among old people, up to 30% of hospital admissions are directly associated with drug-related problems. Old people with dementia or cognitive impairment are especially vulnerable to adverse drug reactions.

Objective: To evaluate whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team reduce hospital readmissions rates among old people with dementia or cognitive impairment.

Design: A randomized controlled trial was carried out between January 9, 2012, and December 2, 2014. The total follow-up time was 180 days.

Setting: Patients admitted to acute internal medicine wards at the Skellefteå County Hospital and Umeå University Hospital, and to the orthopedic ward at Umeå University Hospital were included. Both hospitals are located in Northern Sweden.

Participants: Eligible were patients aged 65 years or older with dementia or cognitive impairment. Of the 473 deemed eligible for participation, 230 were randomized to intervention and 230 to control group by block randomization.

Intervention: In addition to standard therapy the intervention group received a standardized medication review performed by experienced clinical pharmacists.

Main Outcomes and Measures: The primary outcome, risk of drug-related hospital readmissions, was assessed at 180 days of follow-up by intention-to-treat analysis.

Results: During the 180 days of follow-up, 19% (40/212) of patients in the intervention group and 23% (50/217) of those in the control group were readmitted for drug-related reasons (hazard ratio [HR], 0.80 [95% CI, 0.53 to 1.21]; P=.28, univariate Cox regression). Heart failure was significantly more common in the intervention group. After adjustment for heart failure as a potential confounder multiple Cox regression analysis indicated that pharmacist participation significantly reduced the risk of drug-related readmissions (HR, 0.49 [95% CI, 0.27 to 0.90]; P=.02).

Conclusions and Relevance: Pharmacist participation in the ward team significantly reduced the rate of drug-related hospital readmissions. However, in a subset of patients with concomitant heart failure only early 30-day readmissions were significantly reduced. Participation of clinical pharmacists in the healthcare team may significantly reduce the risk of drug-related readmissions in patients with dementia or cognitive impairment.

Trial Registration: clinicaltrials.gov Identifier: NCT01504672

National Category
Geriatrics
Identifiers
URN: urn:nbn:se:umu:diva-118307OAI: oai:DiVA.org:umu-118307DiVA: diva2:912075
Available from: 2016-03-15 Created: 2016-03-15 Last updated: 2016-03-15
In thesis
1. Optimizing drug therapy among people with dementia: the role of clinical pharmacists
Open this publication in new window or tab >>Optimizing drug therapy among people with dementia: the role of clinical pharmacists
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Drugs are one of the cornerstones in the management of many diseases. In general, drugs are used for diagnosis, prevention, mitigation of symptoms, and, sometimes, to cure disease. However, drug treatment in elderly people, especially those with dementia and cognitive impairments, may involve significant risk of adverse drug events.  The aim of this thesis was to identify the extent of potentially inappropriate drug treatment among people with dementia and cognitive impairment and to assess the occurrence and character of drug-related problems that lead to acute hospital admissions. Another aim was to assess the potential impact of a comprehensive medication review conducted by clinical pharmacists as part of a health care team on quality of patients’ drug therapy and drug-related hospital readmission rates.

Method: Long-term use of antipsychotic/psychotropic drugs and associated factors were investigated among 344 and 278 people respectively with dementia living in specialized care units. Trends in the prescribing of potentially inappropriate drugs between 2007 and 2013, comprising 2772 and 1902 people, living in nursing homes in the county of Västerbotten, were assessed using six national quality indicators. Data on drug use, function in the activities of daily living, cognitive function and behavioral and psychological symptoms were collected using the Multi-Dimensional Dementia Assessment Scale. Further, an investigation of a separate corresponding population from 2012 was done, where potentially inappropriate drug use was measured before and after a total of 895 medication reviews. Finally, a randomized, controlled trial was carried out among people 65 years or older with dementia or cognitive impairment in internal medicine and orthopedic wards at two hospitals in northern Sweden. The proportion of hospital admissions that were drug-related were estimated, and also whether comprehensive medication reviews conducted by clinical pharmacists as part of a health care team could affect the risk of drug-related hospital readmissions.

Results: Antipsychotic and other psychotropic drugs were frequently prescribed to people with dementia living in specialized care units for prolonged periods. Associations were found between behavioral and psychological symptoms and different psychotropic drugs. The extent of potentially inappropriate drug use declined between 2007 and 2013. In the separate corresponding population from 2012, the frequency of potentially inappropriate drug use was significantly reduced among people who underwent medication reviews. Hospitalizations due to drug-related problems among old people with dementia or cognitive impairment were prevalent. We found that inclusion of a clinical pharmacist in the health care team significantly reduced the risk of drug-related 30-day and 180-day readmissions. However, in a subset of patients with concomitant heart failure no effect was seen.

Conclusion: Among patients with dementia or cognitive impairment long-term treatment with antipsychotic and other psychotropic drugs is common. The results indicate that these drugs are prescribed to treat behavioral and psychological symptoms among cognitively impaired individuals, despite limited evidence of their efficacy and the high risk of adverse effects. Drug-related problems, such as adverse drug reactions, constituted a major cause of hospital admissions. By reducing potentially inappropriate drug use and optimizing overall drug therapy, inclusion of clinical pharmacists in a health care team might improve the quality of patient care and reduce the risk of hospital readmissions among people with dementia.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 104 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1789
Keyword
Psychotropic drugs, potentially inappropriate drugs, drug-related problems, old people, dementia, nursing homes, drug-related hospitalizations, medication reviews, clinical pharmacists
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-118309 (URN)978-91-7601-436-3 (ISBN)
Public defence
2016-04-08, Hörsal B, byggnad 1A, Tandläkarhögskolan våning 9, Umeå universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2016-03-18 Created: 2016-03-15 Last updated: 2016-05-10Bibliographically approved

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