Morrison Clare, MacRae Yvonne
National Health Service Highland, Larachan House, 9 Dochcarty Road, Dingwall, IV15 9UG, UK.
National Health Service Highland, Naver Teleservice Centre, Bettyhill, Sutherland, KW14 7SS, UK.
Drugs Real World Outcomes. 2015 Sep;2(3):261-271. doi: 10.1007/s40801-015-0031-8.
Adverse drug reactions are a recognised cause of hospital admissions. A small group of medicines carry a higher risk of adverse outcomes and are more frequently involved in hospital admissions than other medicines. These 'high-risk medicines' have been identified in previous research. However, it is less clear how to reduce the risks associated with these known high-risk medicines, or which high-risk medicines should be prioritised when implementing risk reduction interventions. Previous research has questioned the efficacy of pharmacist-led medication reviews in reducing hospital admissions and drug-related morbidity and mortality.
In this study, we aimed to identify high-risk medicines through medication review to reduce iatrogenic disease; to determine a short list of high-risk medicines to target in medication reviews to achieve the greatest impact on reducing iatrogenic disease and patient harm; and to determine whether pharmacist-conducted medication reviews of high-risk medicines are safe and effective.
A prospective cohort study was undertaken in 16 general practices in one Scottish health board. All patients prescribed a high-risk medicine were identified and received a medication review from a pharmacist (3643 patients from a total population of 38,399). The pharmacist decided whether it was appropriate to continue the high-risk medicine, or if the medicine should be stopped or amended. The pharmacist made recommendations to the patient's general practitioner (GP) for medicines to be stopped or amended, which the GP could choose to accept or not. Patient outcomes for all of the pharmacist's recommendations were identified 1 year later to determine the effectiveness of the recommendations.
High-risk medicines were prescribed to 3643 patients from a total population of 38,399 patients. The pharmacist made 440 recommendations for GPs to stop or amend high-risk medicines. GPs accepted 214 recommendations and rejected 226, giving an acceptance rate of 49 %. The 440 recommendations were then followed up 1 year later. The risk of having an adverse outcome was significantly reduced when the pharmacist's recommendation to stop or amend a high-risk medicine was followed compared with rejecting the pharmacist's recommendation and continuing the high-risk medicine unchanged (p < 0.001). A total of 22 adverse outcomes occurred when the pharmacist's advice was rejected. Of these, 21 would have been prevented if the pharmacist's recommendation had been followed and three resulted in hospital admission.
This study demonstrated that medication reviews for high-risk medicines are safe and effective, with results achieved within 1 year of the initial review. It identified six high-risk medicines that could form the basis of targeted medication reviews in order to reduce iatrogenic disease. It also demonstrated that pharmacists are safe and effective at delivering medication reviews.
药物不良反应是导致住院的一个公认原因。一小部分药物产生不良后果的风险更高，且与其他药物相比，它们更频繁地导致患者住院。这些“高风险药物”已在先前的研究中得到确认。然而，目前尚不清楚如何降低与这些已知高风险药物相关的风险，或者在实施风险降低干预措施时，哪些高风险药物应被优先考虑。先前的研究对药剂师主导的药物评估在减少住院、药物相关发病率和死亡率方面的效果提出了质疑。
在本研究中，我们旨在通过药物评估来识别高风险药物，以减少医源性疾病；确定一份高风险药物清单，以便在药物评估中针对这些药物进行干预，从而对减少医源性疾病和患者伤害产生最大影响；并确定药剂师对高风险药物进行的药物评估是否安全有效。
在苏格兰一个卫生委员会的16家普通诊所进行了一项前瞻性队列研究。所有开具了高风险药物的患者均被识别出来，并接受了药剂师的药物评估（来自38399名总人口中的3643名患者）。药剂师决定继续使用高风险药物是否合适，或者是否应停用或修改该药物。药剂师向患者的全科医生（GP）提出关于停用或修改药物的建议，全科医生可以选择接受或不接受。1年后确定了所有药剂师建议的患者结局，以确定这些建议的有效性。
在38399名患者中，有3643名患者被开具了高风险药物。药剂师向全科医生提出了440条关于停用或修改高风险药物的建议。全科医生接受了214条建议，拒绝了226条，接受率为49%。然后在1年后对这440条建议进行了跟进。与拒绝药剂师的建议并继续使用未改变的高风险药物相比，遵循药剂师停用或修改高风险药物的建议后，出现不良后果的风险显著降低（p<0.001）。当药剂师的建议被拒绝时，共发生了22起不良后果。其中，如果遵循药剂师的建议，21起不良后果本可避免，3起导致了住院。
本研究表明，对高风险药物进行药物评估是安全有效的，在初次评估后的1年内即可取得成效。它确定了六种高风险药物，这些药物可作为有针对性的药物评估的基础，以减少医源性疾病。它还表明，药剂师在进行药物评估方面是安全有效的。
