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Studies to reduce unnecessary medication use in frail older adults: a systematic review |
Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA |
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CRD summary This review found that there was very little rigorous research on reducing unnecessary medication for frail older adults. The studies were generally of low quality and had a diverse range of interventions, so this conclusion is reasonable, but it may be over cautious, given the favourable results in most studies. Authors' objectives To investigate interventions to reduce unnecessary medication for frail older adults. Searching MEDLINE, EMBASE, and IPA were searched, without language restrictions, for published articles from January 1966 to September 2012. A search strategy was presented. Reference lists of identified studies were searched. Study selection Eligible studies were those that considered an intervention designed to discontinue unnecessary medication for people aged 65 years or older, who were frail, disabled, in a hospice, or receiving palliative care. Studies of patients in intensive care units were excluded. Many designs were eligible, as long as the study included at least five participants. Studies of acute medications, or government policy, were excluded. Medication reduction had to be measured by direct drug reduction, recommendations to discontinue drugs, or reductions in composite measures, such as the Medication Appropriateness Index. In the included studies, a variety of interventions were used, including pharmacist or physician reviews of medication, multidisciplinary approaches, education programmes, and audit and feedback. Most studies were conducted in a nursing home or assisted living, almost as many were of hospital in-patients, and the others were in hospices or palliative care, in-home care, or the community. The average age of participants, where reported, ranged from 69 to 87 years. Four studies targeted patients at the end of their life. Three reviewers assessed articles for inclusion, with disagreements resolved by consensus. Assessment of study quality Two reviewers independently performed a risk of bias assessment, based on the presence of a control group, blinding and objective measurement of the outcome, and adjustment for potential confounding variables. If all three were present, there was a low risk; if two were present, there was a medium risk; and if only one was present, there was a high risk of bias. Data extraction The general results were extracted from each study, including whether the intervention achieved a statistically significant reduction in medication use. One reviewer extracted the data, which were checked by a second reviewer. Methods of synthesis The studies were deemed too diverse for a formal meta-analysis. Their results were presented in a table, and a summary was presented by type of intervention, with the numbers of studies that had statistically significant results. Results of the review There were 36 studies included in the review, with 13,906 participants (range 23 to 3,230). Nineteen studies were controlled trials, six were before-and-after intervention studies, and 11 were case series. Of the controlled trials, three had low risk of bias, six were at a moderate risk, and 10 were at a high risk. All the other studies seem to have been at a moderate or high risk of bias. Of 26 studies that reporting statistical results, 22 reported statistically significant reductions in medication use; 20 of the 26 studies had a control group. There were 12 studies of pharmacist review, and six reported statistical results. Four of these had statistically significant reductions in medication, with the review. There were 13 studies of pharmacists working with interdisciplinary teams, and 10 reported statistical results. Eight of these showed significant benefits. All four academic detailing studies, both of two audit and feedback studies, and four of the five physician review studies (one did not report statistical results), reported statistically significant reductions in medication use. Authors' conclusions There was very little rigorous research on reducing unnecessary medication for frail older adults. CRD commentary This generally well-conducted review addressed a relevant research question, and used appropriate inclusion criteria. A suitable search was performed, but unpublished information was not sought, so some relevant evidence may have been missed. Appropriate action was taken to reduce reviewer error and bias. Study quality was assessed and most studies were at a moderate or high risk of bias. The diverse nature of the interventions and outcomes means that the decision not to perform a meta-analysis seems to have been appropriate. Reporting the numbers of studies with statistically significant results may be misleading, as this does not take account of the size of the intervention effect. Some studies presented no statistical results, and this may have introduced bias. The authors' cautious conclusions were reasonable, given the diversity and low quality of the studies, but they may have been over cautious, as most studies produced favourable results. Implications of the review for practice and research Practice: The authors made no recommendations for medical practice. Research: The authors recommended research on reducing medication use, particularly with an intervention using prescribing criteria that incorporate goals of care, and patient and caregiver preferences. Funding Support received from the American Federation for Aging Research; Queens University Belfast; and the National Institute of Aging, USA. Bibliographic details Tjia J, Velten SJ, Parsons C, Valluri S, Briesacher BA. Studies to reduce unnecessary medication use in frail older adults: a systematic review. Drugs and Aging 2013; 30(5): 285-307 Indexing Status Subject indexing assigned by NLM MeSH Aged; Clinical Trials as Topic; Drug Therapy /utilization; Frail Elderly; Homes for the Aged; Hospices; Humans; Inappropriate Prescribing /statistics & Nursing Homes; Outcome Assessment (Health Care); Palliative Care /methods; Pharmacists; Practice Patterns, Physicians'; Terminal Care /methods; Treatment Outcome; numerical data AccessionNumber 12013027501 Date bibliographic record published 06/06/2013 Date abstract record published 23/10/2013 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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