Association of Focused Medication Review With Optimization of Psychotropic Drug Prescribing

Importance Medication review has been proposed to achieve improved use of psychotropic drugs, but benefits have not been confirmed. Objective To synthesize evidence for focused psychotropic medication review in medication optimization. Data Sources Medline, PsycINFO, EMBASE, and CINAHL Plus were searched from inception to February 2018 using the index terms “drug utilization review” and “psychotropic drugs” and synonyms. Additional articles were retrieved using citation tracking and reference checking. Study Selection Full-length, peer-reviewed articles that reported focused psychotropic medication review were included. Inclusion was determined against prespecified criteria and assessed independently. Data Extraction and Synthesis Study quality was assessed using National Institutes for Health appraisal tools and informed a structured synthesis of results. Meta-analysis using a random effects model was conducted. Main Outcomes and Measures Change in the number or dosage of psychotropic medications, change in clinical parameters, change in patient-reported outcomes, and economic data were collected. Results A total of 26 studies met the inclusion criteria. Four studies were randomized clinical trials (n = 712 participants), while the remainder were before-after studies (n = 7844 participants). Most studies were conducted in elderly individuals, people with dementia, and adults with intellectual disability. Focused psychotropic medication review is a complex intervention; the professional(s) involved, target drug, degree of integration with usual care, and participant involvement varied greatly among the studies. Meta-analysis included 3 studies (n = 652 participants). Psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs compared with control (pooled odds ratio, 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment living in nursing homes. Before-after studies consistently reported a change in psychotropic drug prescribing after medication review, regardless of the population. Studies that reported the effects of psychotropic medication review on clinical outcomes failed to demonstrate benefit. Economic implications of focused psychotropic medication review were not adequately assessed. The quality of evidence is poor and studies are at risk of bias. Conclusions and Relevance Focused psychotropic medication review was associated with a reduction in prescribing of psychotropic drugs, but has not been shown to improve clinical outcomes or to provide economic benefit. More robust evidence is needed before programs of focused psychotropic medication review can be recommended as part of routine care for any patient group.


Proportion of participants prescribed antipsychotic drugs
Significantly lower proportion prescribed antipsychotic drugs in the medication review group compared with the non-review group at follow-up (adjusted OR b 0.17, 95% CI 0.05 to 0.60, p=0.006).

Neuropsychiatric symptoms (measured with NPI c )
Those receiving medication review had a 7.37 point (95% CI 1.53 to 13.22, p=0.02) disadvantage in NPI at follow-up compared with those not receiving review Agitation (Cohen-Mansfield Agitation Inventory) No difference between intervention and control groups (adjusted score difference 4.60, 95% CI -1.43 to 10.63, p=0.13)

Mortality
Antipsychotic review conferred a non-significant reduction in mortality compared with the group not receiving review (OR 0.67, 95% CI 0.39 to 1.14, p=0. 15

Proportion of nursing home residents prescribed ≥1 inappropriate psychotropic drug at follow-up
Significantly lower proportion prescribed inappropriate psychotropic drugs in intervention group compared with the control group at followup (intervention group proportion: 20%, control group proportion: 50%, p<0.001; adjusted OR a for receiving inappropriate psychotropic medication 0.26 (0.14 to 0.49))

Rate of falls
No significant difference in rate of falls between intervention and control groups (intervention group rate: 16.3 falls per 100 personmonths, control group rate: 11.4 falls per 100 person-months, p=0.09) Author's conclusions A pharmacist-delivered program of medication review targeting specific drugs can result in marked reduction in inappropriate psychotropic drug prescribing but had no effect on falls Source of funding A multi-disciplinary team who met each month to review presentation and antipsychotic medication. Review included discussion of benefits and side-effects of antipsychotics. Guidelines for antipsychotic medication reduction were applied Duration of follow-up Up to 18 months Optimisation outcome measures and results

Number (proportion) of participants discontinuing antipsychotic medication
Reduced from 97 before intervention to 29 after intervention (70%) Author's conclusions A medication review program can play an important role in the monitoring and regulation of drug use in an institution Source of funding

Number (proportion) with change to antipsychotic drug before (without) and after (with) intervention
Greater number of participants underwent change in antipsychotic drugs occurred with the intervention (17/28) than without the intervention (11/28)

Total dose of antipsychotic drugs prescribed before (without) and after (with) intervention
Decrease in total dose of antipsychotic dose used with intervention

Aggressive challenging behavior
No difference in number of incidents of aggressive challenging behavior in the group undergoing intervention compared with groups not undergoing intervention Author's conclusions Multi-disciplinary medication reviews can result in reductions in the prescription of antipsychotic drugs used for challenging behavior and is not associated with worsening of aggression Source of funding Multi-disciplinary team conduct medication review according to a standard structure and provided recommendations to responsible physician. Rolling processaverage of 12 reviews per participant. Duration of follow-up 2 years Optimisation outcome measures and results

Number (proportion) of participants receiving psychotropic polypharmacy
Psychotropic polypharmacy: 13 (52%) before intervention, 6 (24%) at follow-up Change in challenging behavior (frequency counts) Average daily frequency of challenging behavior lower at the end of the program than at baseline for 20/25 participants (full data not reported) Author's conclusions Multi-disciplinary medication review is effective in reducing use of psychotropic medication in people with intellectual disabilities in a residential setting Source of funding