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First published online September 8, 2009

Interventions to Improve Medication Reconciliation in Primary Care

Abstract

Abstract

Objective:

To systematically review all primary care intervention studies designed to implement medication reconciliation for effects on medication discrepancies, clinical outcomes, and patient knowledge of their medications.

Data Sources:

We searched MEDLINE (1988–March 2008); Healthstar (1966–March 2008): CINAHL (1982–March 2008); EMBASE (1980–March 2008); Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, and Health Technology Assessments; and unpublished material. No language restrictions were applied. Search terms included medication reconciliation, medication errors, prescribing error, medication systems, adverse drug events, drug utilization review, medication list, medication record, and medications management.

Study Selection And Data Abstraction:

Randomized controlled trials or before-and-after studies that examined the effect of various interventions on medication discrepancies either in ambulatory settings or at hospital discharge among community-dwelling adults were included. Two reviewers independently assessed studies to determine inclusion. Level of agreement between the reviewers was good, with unweighted Cohen's κ of 0.71. Two of 3 independent reviewers abstracted data and evaluated validity from included studies. Disagreements between reviewers were resolved by consensus.

Data Synthesis:

Four trials met the inclusion criteria. Two before-and-after studies (n = 275) in ambulatory care examining systematic medication reconciliation at each visit produced conflicting results. One study showed a reduction in the proportion of medication discrepancies from 88.5% to 49.1% (OR 0.13; 95% CI 0.07 to 0.21); the other showed no benefit. One randomized controlled trial and one before-and-after study (n = 202) evaluated pharmacist medication review at hospital discharge. Neither showed a benefit. Heterogeneity precluded pooling of studies. All included studies had significant design flaws.

Conclusions:

There is no good quality evidence demonstrating the effectiveness of medication reconciliation in the primary care setting. Further research is needed.

Resumen

Objetivo:

Revisar sistemáticamente todos los estudios de intervención en cuidado primario diseñados para evaluar la implementación de reconciliación de medicamentos y su efecto en discrepancias de medicamentos, resultados clínicos, y conocimiento del paciente sobre sus medicamentos.

Fuentes De Información:

Se buscó en MEDLINE (1988-marzo 2008), Healthstar (1966–marzo 2008), CINAHL (1982–marzo 2008), EMBASE (1980–marzo 2008), Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Cochrane Methodology Register, Health Technology Assessments, en adición a otro material no publicado. No se aplicó restricción de lenguaje. Los términos de la búsqueda incluyeron reconciliación de medicamentos, errores de medicación, errores de prescripción, sistemas de medicación, eventos adversos a fármacos, revisión de utilización de fármacos, lista de medicamentos, récord de medicamentos, y manejo de medicamentos.

Selección De Fuentes De Información Y Extracción De Información:

Se incluyeron estudios aleatorios, controlados o estudios de antes-y-después donde se examinó el efecto de varias intervenciones en discrepancias de medicamentos ya sea en escenarios ambulatorios o al salir de la institución entre adultos que residen en la comunidad. Dos revisores independientes evaluaron los estudios para determinar su inclusión. El nivel de concordancia entre los revisores fue buena (Cohen's K = 0.71). Dos de 3 revisores independientes resumieron la información y evaluaron la validez de los estudios incluidos. Las discrepancias entre los revisores se resolvieron por consenso.

Resultados:

Cuatro estudios cumplieron con los criterios de inclusión. Dos estudios de antes-y-después (n = 275) en cuidado ambulatorio donde se examinaba sistemáticamente la reconciliación de medicamentos en cada visita produjeron resultados conflictivos. Un estudio demostró una reducción en la proporción de discrepancias de medicamentos de un 88.5% a un 49.1% (OR 0.13; 95% CI 0.07 a 021); el otro no demostró beneficios. Un estudio aleatorio, controlado y un estudio de antes-y-después (n = 202) evaluaron la revisión de medicamentos por el farmacéutico al salir del hospital. Ninguno demostró beneficio. La heterogeneidad evitó que se unieran los estudios. Todos los estudios incluidos tenían fallas de diseño significativas.

Conclusiones:

No existe evidencia de buena calidad que demuestre la efectividad de la reconciliación de medicamentos en el escenario de cuidado primario. Se requiere más investigación en esta área.

Résumé

Objectifs:

Revoir systématiquement toutes les études portant sur des interventions en première ligne visant à implanter un bilan des médicaments afin de mesurer les effets sur les inexactitudes dans les médicaments, les résultats de santé et la connaissance des patients à propos de leurs médicaments.

Source De Données:

MEDLINE (1988–mars 2008), Healthstar (1966–mars 2008), CINAHL (1982–mars 2008), CENTRAL ainsi que des données non publiées. Aucune restriction linguistique n'a été appliquée.

Sélection Des études Et Extraction Des Données:

Les essais randomisés et contrôlés de même que les essais pré-post interventions examinant les effets de diverses interventions sur les inexactitudes dans le bilan des médicaments en milieu communautaire ou au congé de l'hospitalisation chez une population de patients adultes ont été inclus dans l'analyse. Deux réviseurs indépendants ont évalué les études afin de déterminer leur inclusion. Le niveau d'accord entre les deux réviseurs a été jugé bon avec un coefficient Cohen κ non-ajusté de 0.71. Deux des 3 réviseurs indépendants ont extrait des essais sélectionnés les données et évalué leur validité. Les désaccords ont été résolus par consensus.

Synthèse Des Données:

Quatre essais ont rencontré les critères d'inclusion. Deux études pré-post intervention (n = 275) dans un milieu ambulatoire ont examiné l'impact d'un bilan médicamenteux systématique à chaque visite et ont obtenu des résultats contradictoires. Un essai a démontré une réduction de la proportion d'inexactitudes de 88.5% à 49.1% (RC 0.13; IC 95% 0.07-0.21); le second essai n'a prouvé aucune différence. Un essai randomisé et contrôlé et un essai pré-post intervention (n = 202) ont évalué la revue des médicaments au congé de l'hôpital. Aucune de ces 2 études n'a démontré une différence. L'hétérogénéité des études ne permettait pas de mélanger les études ensemble. Toutes les études avaient des faiblesses marquées au niveau du devis de recherche.

Conclusions:

Il n'existe pas d'évidence de qualité justifiant l'efficacité du bilan de médicaments dans un milieu de soins primaires. Des études supplémentaires sont requises.

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Information

Published In

Article first published online: September 8, 2009
Issue published: October 2009

Keywords

  1. medical history taking
  2. medication errors
  3. primary health care
  4. prospective studies

Rights and permissions

Copyright © 2009 Harvey Whitney Books Company.
Request permissions for this article.

History

Published online: September 8, 2009
Issue published: October 2009
PubMed: 19737997

Authors

Affiliations

Imaan Bayoumi, MD CCFP
Department of Family Medicine, McMaster University, Hamilton, ON, Canada
Michelle Howard, MSc PhD
Department of Family Medicine, McMaster University
Anne M Holbrook, MD PharmD MSc FRCPC
Division of Clinical Pharmacology and Therapeutics, Department of Medicine, McMaster University
Inge Schabort, MB ChB CCFP
Department of Family Medicine, McMaster University

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