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NHG wetenschapsdag / Sanne Verdoorn / 08-06-2018 Effects of a clinical medication review focused on personal goals in older persons with polypharmacy Hier alle auteurs weergeven. NHG wetenschapsdag / Sanne Verdoorn / 08-06-2018

Results of the DREAMeR study Drug use Reconsidered in the Elderly using goal Attainment scales during Medication Review

Background Clinical medication reviews (CMR) are increasingly performed CMR can reduce drug-related problems (DRPs) Little evidence for effects on clinical outcomes Quality of life Hospital admissions Clinical medication reviews (CMR) are increasingly performed by GPs and pharmacists internationally and in the NL.

Objective To investigate the effects of a CMR, focused on personal goals, on quality of life and health-related complaints in older patients with polypharmacy

Methods Randomized Controlled Trial (RCT) 35 Dutch Community pharmacies 113 cooperating general practices

Methods Inclusion criteria: ≥ 70 years ≥ 7 drugs n = 629 patients randomized Intervention (n=315) Clinical medication review Follow-up: after 3 and 6 months Control group waiting list CMR focused on patient wishes complaints and goals

Clinical medication review √ Questionnaire about complaints √ Preferences √ Goals 1. Patient interview by pharmacist 2. Pharmacotherapeutic Analysis 3. Pharmaceutical care plan: GP and pharmacist 4. Discussion with patient 5. Follow-up and monitoring This is the overview of a CMR, where both patient, GP and pharmacist are involved. New in this intervention was the focus on the patient interview. We focused on patient’s related complaints, wishes and goals during the interview and tried to propose one or more health-realted goals at the end of the interview. These goals were evaluated with goal attainment scaling. .

Outcome measures Quality of life EQ-5D  utility scores (0-1) EQ-VAS (0-100) Health-related complaints Number of complaints with impact on patient’s daily life VAS score ≥5 Influence daily life: moderate, severe, extreme Number of drugs

Health-related complaints Pain Itching Dyspnoea Mobility problems Dizziness Sedation Constipation/diarrhea Gastric complaints Cognition Fatigue Dry mouth Incontinence In total we have measured 12 health-related complaints, based on the most common complaints in older people and most common side effects of medicines. And things that we can influence with medication or medical aids.

Statistical analysis Lineair mixed model analysis 3 measurements over time Adjustment for age, sex and pharmacy We had repeated mesurements, so we could adjust for differences between the individuals. There were no differences between baseline outcomes between both groups.

Results – Quality of life (EQ-VAS) First we see the group averages of both intervention and control group at baseline and after 6 months. CG decreased from 70 to 69 and IG increased from 68 to 70. When we put all the results in the LMM, we can see that the effect after 6 months (the beta) is that the IG 3.4 points more on the VAS scale compared to CG, which was stat. Sign. LMM: β = 3,4; p < 0,01

Results – Quality of life (utility) Here we see the group averages of the utility scores for both groups. They were pretty high for this population, but there was no difference in utility scores after 6 months for both groups. LMM: β = -0,0022; p = 0,89

Results – Complaints with impact We see that on baseline CG had an average of 2.6 complaints with impact on daily life and IG 2.8. The IG decreased more than CG. When we put this in the LMM analysis we see an effect of 12%. The IG decreased -0.34 points more compared to CG after 6 months. LMM: β = -0,34 (12%); p = 0,029

Results – number of drugs Finally, have a look to the number of drugs. We had monthly data from the number of drugs, beacuse we used drug dispensing data to calculate this. When we finally look at the number of drugs, we see that in the IG both more drugs are added as ceased compared to CG, but overall there was slight decrease in number of drugs after 6 months in the IG compared to CG. LMM: β = -0,32; p<0,01

Conclusion A CMR focused on personal goals, improved the health-related quality of life (EQ-VAS) and reduced the number of health-related complaints with impact for the patient, while the number of drugs used decreased

Discussion Limitations Strengths Pragmatic trial Innovative Patient centred approach Patient reported outcomes 1st study using GAS and complaints in CMR 1st study effect on EQ-VAS and complaints Limitations No blinding possible Complaints questionnaire “new” Proposing goals can be risky  SMART

Thank you for the attention! Authors: Sanne Verdoorn MSc Dr. Henk-Frans Kwint Dr. Jeanet Blom Prof. dr. Jacobijn Gussekloo Prof. dr. Marcel L. Bouvy Contact: s.verdoorn@sirstevenshof.nl Dit naar begin.

Thank you for the attention! A CMR focused on personal goals, improved the health-related quality of life (EQ-VAS) and reduced the number of health-related complaints with impact for the patient, while the number of drugs used decreased Contact: s.verdoorn@sirstevenshof.nl Are there any further questions?