Can medicines management services reduce hospital admissions?

Reducing avoidable hospital admissions is a priority for the NHS. Medicines account for about 4–6.5 per cent of emergency admissions, 3 and causes related to medicines fall into three broad categories: adverse drug reactions,prescribing errors and poor compliance. In theory it should be possible to reduce the underpinning causes for these three types of problems, but evidence from randomised controlled trials (RCTs) suggests that pharmacist medication reviews do not reduce admissions. However, most studies have not been designed to show a reduction in admissions or even to log this outcome. For instance, they have not focused on the most at-risk group of patients, were not well designed — the pharmacists had no access to clinical records, and admissions occurred, but a medicines cause was not demonstrated. A retrospective review of hospital admissions from one large UK RCT showed that of 77 admissions (from 332 elderly patients recruited to the study) only 17 (22 per cent) were related to pharmaceutical care issues and only 10 (13 per cent) were preventable by pharmacist intervention. In the absence of a specific focus on unplanned admissions as an outcome measure, it could be that the results merely show that emergency hospital admission records are not sufficiently sensitive to show the benefits of pharmacist medication reviews. The belief persists that carefully targeted medication reviews do benefit some patients, despite the lack of supporting evidence in unplanned hospital admission records. Medication reviews reduce harm, improve people’s confidence about their medicines and help to improve long-term outcomes. This review will focus on the factors related to monitoring and taking medicines where medication reviews might improve outcomes. In Panel 1 factors that contribute to poor patient medicines-related outcomes are assigned to five categories. Pharmacist medication reviews can affect all of them. Clinical medication review is the best method for assessing prescribing risk, under prescribing and high-risk drug use since it includes access to the clinical record. A pharmacist conducting a clinical medication review can cover all five categories. Medicines use review (MUR) is likely to be best for assessing compliance and improving medicines-taking through a concordance approach, although careful patient questioning could also identify some aspects of prescribing risk. Together these reviews offer a practical method for practice-based pharmacists to work closely with community pharmacists. Once treatment is optimised from the clinical viewpoint the patient can be referred to the community pharmacist for ongoing support with medicines taking and compliance through MUR. Community pharmacists conducting MURs can refer patients to practice-based pharmacists to help implement solutions such as reducing the number of prescribed medicines and changing dosage formulations.