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17th February 2023
Older residents in a care home (CH) are at a potentially higher risk of medication error and adverse drug reactions due to both polypharmacy and aged-related alterations in drug pharmacokinetics and pharmacodynamics.
Moreover, data from a 2009 study found that in a home of 259 residents, taking a mean of eight different medicines, 69.5% had one or more errors. Given this high level of errors, various interventions have been developed to optimise prescribing for elderly CH residents.
Nevertheless, despite numerous studies employing a range of different interventions, a 2016 Cochrane review concluded that it was not possible to draw robust conclusions because of the variability in study designs, interventions, results and reported outcomes. However, the authors of the Cochrane review did call for high-quality, cluster-randomised controlled trials that measured well-defined, important, resident-related outcomes.
Consequently, the current trial was designed to estimate the effectiveness of using an independent pharmacist prescriber in care homes. The pharmacists provided pharmaceutical care plans to approximately 20 residents in one to three care homes through weekly visits over a 6-mont period.
For the control arm, residents received their usual general practitioner care and any pharmacist input ranged from medicine supply (i.e. via a community pharmacy) or visits by a primary care pharmacist undertaking medication reviews. The primary outcome of interest was the fall rate per person over the six month period and which was based on findings from a feasibility study of the intervention.
Pharmacist care home intervention and fall rates
A total of 876 residents with a mean age of 85.3 years (30.4% male) and taking a median of 6 medicines, were included and of these, 449 were randomised to the pharmacist intervention.
During the period of study, 697 falls were documented in the intervention group and 538 in the control arm, although this difference in fall rate was not statistically significant (risk ratio, RR = 0.91, 95% CI 0.66 – 1.26) even after adjustment for various factors.
Other secondary outcomes which included quality of life, hospital admissions and mortality were not significantly different between the two groups, with the exception of the drug burden index, which significantly favoured the intervention (RR = 0.83, 95% CI 0.74 – 0.92, p < 0.001).
The authors suggested that the lack of difference in the primary outcome could have arisen due to the short duration of the study and concluded that the significant reduction in the drug burden index was predicted to yield future clinical benefits to patients.
Holland R et al. Evaluation of effectiveness and safety of pharmacist independent prescribers in care homes: cluster randomised controlled trial. BMJ 2023.