Asil Sadeq1, Monica Strugaru2, Maryam Almutairi2, Derek Stewart3, Cristin Ryan2, Tamasine Grimes2. 1. The School of Pharmacy and Pharmaceutical Sciences, Panoz Institute, Trinity College Dublin, The University of Dublin, Dublin 2, D02PN40, Ireland. sadeqa@tcd.ie. 2. Trinity College Dublin, Dublin, Ireland. 3. College of Pharmacy, QU Health, Qatar University, Doha, Qatar.
Abstract
BACKGROUND: Nursing home residents are often prescribed multiple medications, which increases their susceptibility to drug-related problems. The medicines management process involves multiple stages, for example, assessing, prescribing, dispensing, delivering and storing, administering, reviewing and monitoring. The medicine management process aims to optimise medicine use and associated patient outcomes. Interprofessional interventions of healthcare professionals from different disciplines in many clinical settings, including the nursing home setting, have shown success in improving patients' clinical outcomes. However, reporting of the pharmacist's role and the impact of these interventions has been unclear. OBJECTIVES: We aimed to systematically identify and describe interprofessional interventions involving pharmacists that target the medicine management process in nursing homes by (a) describing interprofessional interventions and the role of pharmacists within, (b) describing the impact of these interventions, (c) exploring which of the medicine management process stages were targeted and (d) identifying any reported theoretical underpinning. METHODS: EMBASE, MEDLINE, CINAHL, SCOPUS, PsycInfo, Cochrane library, Web of Science and clinical trial registers were searched from the inception date until August 2021. Randomised controlled trials reporting interprofessional interventions involving pharmacists, targeting at least one stage of the medicine management process and provided to nursing home residents with a mean age ≥ 65 years, were included. The search had no restriction on outcomes measured. Included randomised controlled trials were assessed for quality and risk of bias using the Jadad scale and Cochrane Collaboration tool, respectively. The overall certainty of outcomes was assessed using GRADEpro. If present, details about theoretical underpinning were extracted using the theory coding scheme. Fixed and random-effects models were used to calculate the pooled effect estimates to compare outcomes between intervention and control groups, where feasible, or a narrative description was reported. RESULTS: Eighteen manuscripts describing interprofessional interventions involving pharmacists were identified: medication review (n = 14), education (n = 3) and medication simplification (n = 1) based interventions. The pharmacists' most frequent role was the provision of medicine-related recommendations, and they worked mostly with general practitioners and nurses. Residents/family members contributed in 44% of included interventions. A meta-analysis identified that interventions were significantly associated with significant improvements in prescribing appropriateness (standard mean difference - 0.20; 95% confidence interval - 0.33 to - 0.77; I2 = 27%) but not with hospitalisation and mortality. None of the included studies reported a theoretical underpinning to intervention development. CONCLUSIONS: This systematic review provides a detailed description of the impact of interprofessional practice, involving pharmacists, which targets at least one stage of the medicine management process in the nursing home setting. The findings suggest that future research should prioritise improving prescribing inappropriateness rather than the number of long-term medications prescribed. It remains unknown if interventions are designed using theory and, therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. CLINICAL TRIAL REGISTRATION: The protocol was published in the International Prospective Register of Systematic Reviews (PROSPERO) [Ref: CRD42020181744].
BACKGROUND: Nursing home residents are often prescribed multiple medications, which increases their susceptibility to drug-related problems. The medicines management process involves multiple stages, for example, assessing, prescribing, dispensing, delivering and storing, administering, reviewing and monitoring. The medicine management process aims to optimise medicine use and associated patient outcomes. Interprofessional interventions of healthcare professionals from different disciplines in many clinical settings, including the nursing home setting, have shown success in improving patients' clinical outcomes. However, reporting of the pharmacist's role and the impact of these interventions has been unclear. OBJECTIVES: We aimed to systematically identify and describe interprofessional interventions involving pharmacists that target the medicine management process in nursing homes by (a) describing interprofessional interventions and the role of pharmacists within, (b) describing the impact of these interventions, (c) exploring which of the medicine management process stages were targeted and (d) identifying any reported theoretical underpinning. METHODS: EMBASE, MEDLINE, CINAHL, SCOPUS, PsycInfo, Cochrane library, Web of Science and clinical trial registers were searched from the inception date until August 2021. Randomised controlled trials reporting interprofessional interventions involving pharmacists, targeting at least one stage of the medicine management process and provided to nursing home residents with a mean age ≥ 65 years, were included. The search had no restriction on outcomes measured. Included randomised controlled trials were assessed for quality and risk of bias using the Jadad scale and Cochrane Collaboration tool, respectively. The overall certainty of outcomes was assessed using GRADEpro. If present, details about theoretical underpinning were extracted using the theory coding scheme. Fixed and random-effects models were used to calculate the pooled effect estimates to compare outcomes between intervention and control groups, where feasible, or a narrative description was reported. RESULTS: Eighteen manuscripts describing interprofessional interventions involving pharmacists were identified: medication review (n = 14), education (n = 3) and medication simplification (n = 1) based interventions. The pharmacists' most frequent role was the provision of medicine-related recommendations, and they worked mostly with general practitioners and nurses. Residents/family members contributed in 44% of included interventions. A meta-analysis identified that interventions were significantly associated with significant improvements in prescribing appropriateness (standard mean difference - 0.20; 95% confidence interval - 0.33 to - 0.77; I2 = 27%) but not with hospitalisation and mortality. None of the included studies reported a theoretical underpinning to intervention development. CONCLUSIONS: This systematic review provides a detailed description of the impact of interprofessional practice, involving pharmacists, which targets at least one stage of the medicine management process in the nursing home setting. The findings suggest that future research should prioritise improving prescribing inappropriateness rather than the number of long-term medications prescribed. It remains unknown if interventions are designed using theory and, therefore, it is not clear whether theory-derived interventions are more effective than those without a theoretical element. CLINICAL TRIAL REGISTRATION: The protocol was published in the International Prospective Register of Systematic Reviews (PROSPERO) [Ref: CRD42020181744].