Int J Clin Pharm DOI 10.1007/s11096-014-0063-2
RESEARCH ARTICLE
Drug-related problems in institutionalized, polymedicated elderly patients: opportunities for pharmacist intervention Cristina Silva • Ce´lia Ramalho • Isabel Luz Joaquim Monteiro • Paula Fresco
•
Received: 22 July 2014 / Accepted: 30 December 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Background An aging population and the increasing prevalence of chronic diseases have led to the increased use of medicines. Portugal is one of the European countries where more medicines are consumed and the associated expense is higher. Medicines are associated with enormous health benefits but also with the potential to cause illness and death. A drug related problem (DRP) is an ‘‘an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’. In the U.S., they represent the 4th–6th leading cause of death and have an estimated cost of 130 billion dollars. Moreover, many of these DRP can be avoided. Elderly are at increased risk of DRP due to multiple
C. Silva C. Ramalho I. Luz J. Monteiro P. Fresco SerFarma, Ltd, Coimbra, Portugal C. Silva Faculty of Pharmacy, Center for Pharmaceutical Studies, University of Coimbra, Coimbra, Portugal I. Luz Farma´cia Rainha, Carrazeda de Ansia˜es, Portugal J. Monteiro Department of Pharmaceutical Sciences, Higher Institute of Health Sciences - North (ISCS-N), CESPU, Institute of Research and Advanced Training in Health Sciences and Technologies, Gandra PRD, Portugal J. Monteiro P. Fresco MedInUp - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal P. Fresco (&) Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal e-mail: [email protected]
factors: pluripathology and consequent polypharmacy, complex dosing regimens, pharmacokinetic/pharmacodynamic and functional/cognitive changes. Therefore, this population would be the one who would benefit most from the prevention, detection and control of DRP. The role of the pharmacist as an integral element of health care has been recognized by various international and European organizations. Providing pharmaceutical care as a patientcentered activity, focusing on their needs related to pharmacotherapy, contributes to guarantee that drug expenditure is a good investment, with benefits that outweigh potential risks. Objective To evaluate the need for pharmaceutical care implementation in institutionalized, polymedicated elderly. Methods Descriptive observational cross-sectional study carried out in six Portuguese nursing homes, selected by convenience, in November–December 2013. Each institution selected up to six patients, according to the following inclusion criteria: age C65 years, number of medications C5 and ability to respond to an interview. All participants signed an informed consent form. Pharmacists carried out a structured interview with each patient and consulted patient medical records to gather demographic data and information on health problems and medications used. To identify DRP, official drug information sources were consulted, and the STOPP and START tool was used. The ATC, the ICD-10 and the PCNE Classification V 6.2 classification systems were used for medicines, health problems and DRP classifications, respectively. For each medicine used, the cheapest equivalent available was also identified. Results The sample included 31 elderly (64.52 % female, mean age 81.65 ± 6.86). On average, subjects presented a mean of 7.94 ± 2.76 health problems with diseases of the circulatory system being the most common. The sample used a median of ten medicines per patient. Those medicines
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working in the cardiovascular, nervous and digestive systems were the most frequently used (29.75, 29.43 and 19.30 %, respectively). A total of 484 DRP (median: 15 DRP/patient) was found. The most common DRP were Adverse Drug Event, non-allergic (49.51 %), Drug treatment more costly than necessary (19.11 %), Effect of drug treatment not optimal (14.82 %) and Unnecessary drug treatment (6.16 %). The most cost-effective proposal, would lead to a saving of € 3,950/year in the studied sample. Conclusion These results reinforce the need for the implementation of pharmaceutical care services to institutionalized elderly, necessary to improve medicines efficacy and safety, better clinical outcomes and cost reduction. Keywords Drug-related problems Elderly Pharmacist intervention Polymedication Portugal
Impacts to practice • •
•
•
Institutionalised elderly in Portugal sow a high number of diseases, medications and drug-related problems The pharmacist can have a important role, as a health team member, in nursing homes, to prevent, detect and solve DRP The pharmacist intervention can improve the medication management process and ultimately the economic and clinical outcomes for institutionalized, polymedicated elderly The systematic implementation of pharmaceutical care services in nursing homes, in order to improve the effectiveness and safety of medicines is needed and would contribute to the optimization of clinical results
Introduction World population is aging, due to increased life expectancy and better and more affordable health care. The consequent increase in chronic diseases prevalence has led to a considerable increase in the use of medicines. In Europe, Portugal is one of the countries that consume more medicines (2002: 23 medicine packages per capita) with an extremely high associated expense (2004: 2.3 % of GDP). Nevertheless, better health outcomes relative to other countries with lower consumption and lower costs are not observed [1]. Medicines represent a health-technology that has brought major benefits and a very powerful and costeffective therapeutic tool. However, medicines are also a potential cause of illness and death. Morbidity and mortality associated with medication is widely described in the literature. Over 20 % of visits to emergency departments
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are related to medicines use [2–4]. In the U.S., drug related problems (DRPs) represent the 4th–6th leading cause of death and adverse reactions are responsible for 3–6 % of hospitalizations (700,000 patients/year) [5], representing an estimated cost of 130 billion dollars [6]. Importantly, up to 88 % of these adverse events could be prevented [3, 7, 8]. In Portugal, 43,000 hospitalizations/ year are estimated as unnecessary, corresponding to, approximately, five patients/h [9]. If one compares these numbers to the casualties caused by motor vehicle accidents in 2012, 2,613 (580 deaths and 2,033 serious injuries) [10], a value 169 lower, we can realize the extent of this public health problem, which should alert authorities, professionals and all stakeholders in the health system, which represents waste of resources to health systems and leads to unnecessary damage to patients’ health and quality of life [9]. According to the Pharmaceutical Care Network Europe (PCNE), a DRP is an ‘‘an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’ [11, 12]. In general, DRP may be related to treatment effectiveness, occurrence of adverse reactions and treatment costs. DRP causes include drug selection, pharmaceutical or dosage form, treatment duration, management/use and causes related to logistics and to the patient. Pharmaceutical interventions include actions taken at the prescriber, the patient (or caregiver) and/or medication levels, aiming to prevent/correct DRP contributing to the pharmacotherapy results optimization [12]. Elderly patients are at increased risk of DRP, during the medication use process and the occurrence of adverse clinical outcomes associated therewith, including adverse reactions [3, 7, 13]. This is related to multiple factors including pluripathology and consequent polymedication, complex dosing regimens and pharmacokinetic/pharmacodynamic, cognitive and functional alterations in elderly [14, 15]. A Portuguese study revealed that 46.8 % of homebased polymedicated elderly present DRP [13]. The elderly population can, therefore, get the greater benefits from DRP prevention, detection and control [16]. The pharmacist formation/training is dedicated to the knowledge and understanding of medicines. Their role in society as an integral element of healthcare has been recognized by several international official organizations [6, 17]. It is accepted that the pharmacist main function is to help prevent avoidable iatrogenic risks and its action should be systematically implemented [17]. The pharmacist participation in the healthcare team can help prevent medication errors [18], ensuring that expenditure on medicines is a good investment, with benefits outweighing potential risks [19].
Int J Clin Pharm
Aim of the study To evaluate the need for implementation of pharmaceutical care services to institutionalized, polymedicated elderly concerning both the medication management process and the clinical and economic outcomes.
Medicines and health problems were then classified according to the Anatomical Therapeutic Chemical Classification (ATC/DDD Index 2014) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), respectively. Identification and classification of DRP
Methods
Official drug information sources (i.e. Summary of Product Characteristics) and drug databases (i.e. Drug Interaction Checker from Drugs.com, Epocrates online), were consulted. The STOPP and START toolkit was used to identify potentially inappropriate and appropriate, indicated medicines [20]. Identified DRP were classified according to The PCNE Classification V6.2, in group (all authors) discussions.
Type of study
Cost reduction analysis
Descriptive, observational, cross-sectional study conducted in Portuguese nursing homes (NH), in November– December 2013. Six NH, located in Northern and Central Portugal, were selected by convenience. The study involved two pharmacist visits to each institution: the first to characterize the NH, the second for the therapeutic review of selected patients.
To calculate the total monthly expenditure on medicines, overall and for each patient, prices on the official site of INFARMED, the Portuguese Medicines Agency, were consulted. When it was not possible to identify the prescribed brand or generic, the price of the least expensive equivalent was considered. Then, the least expensive equivalent on the Portuguese market was identified, for each medicine, and the corresponding monthly expenditure calculated.
Ethical approval Patients were informed of the objectives and methodology of the study and, those who agreed to participate, signed an informed consent form. No ethical approval was sought.
NH characterization A questionnaire for collecting information on healthcare and medication management process was developed and administered by the pharmacist to the professional responsible for medicines, at each NH. Therapeutic review Sample recruitment Each NH was asked to identify 5–6 patients, according to the following inclusion criteria: • • •
Age C65 years No of medicines taken C5 Ability to respond to an interview
Information collection Demographic and clinical data (e.g. health problems, medicines used) was gathered from the NH clinical records. Individual interviews were conducted by a pharmacist in order to gather additional data regarding clinical history, health problems and medicines use.
Results Characterization of NH The six selected NH were geographically distributed as follows: three in Porto, one in Braganc¸a, one in Castelo Branco and one in Viseu. An average number of 37 beds and an occupancy rate of 89 %, were found. Health professionals working in the NH: medical doctors, nurses, physiotherapists, nutritionists, psychologists and gerontologists. Only one NH had the daily presence of a medical doctor and three of a nurse. Some NH had physiotherapist, psychologist and gerontologist but none had the collaboration of pharmacists. All NH had an individual clinical file and therapeutic table (with varying type of information and updating frequency). Measurements of physiological and/or biochemical parameters were performed and recorded, albeit with varying intervals, and not always performed by health professionals. In most cases, the responsible for medicines acquisition was the institution itself but medication costs were usually supported by patients. Usually, the community pharmacy merely dispenses medication. In one NH, the pharmacy
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(not necessarily the pharmacist) was also responsible for the weekly preparation of medication. Medication storage was generally done in a specific area, per patient, but a controlled environment was never observed. The medication preparation was not always performed under the supervision of an healthcare professional and, only in two NH, it was made on a daily basis, preserving the original packaging. Double-checking of this process was rarely performed. In five NH, oral dosage forms were splitted and/or crushed, with no previous confirmation of such possibility and no record-keeping of the procedure. Medicines were, usually, administered by care aides and there were no administration records. Therapeutic review
available (C1.7; 18.28 %), (Table 2). Effect of drug treatment not-optimal (P1.2) and Unnecessary drug treatment (P3.2) followed, being the Inappropriate timing of administration and/or dosing intervals (C5.1; 4.52 %) and No indication for drug (C1.2; 6.16 %) the main causes, respectively (Table 2). The STOPP and START toolkit application revealed 69 indications of potentially inappropriate (STOPP) or potentially required medicines (START). From this total, 76.82 % were STOPP criteria, mostly the long term use of Central Nervous System and Psychotropic Drugs (37.73 %) and of proton pump inhibitors (PPI) (30.19 %), and 23.18 % were START criteria, with the need to initiate Angiotensin Converting Enzyme inhibitor as first (25 %) and the need to initiate calcium and vitamin D supplementation as second (18.75 %).
Sample characterization Cost reduction analysis The sample included 31 elderly, mostly female (64.52 %) with a mean age of 81.65 ± 6, 86 (79.13–84.16; IC 95). All elderly had multiple diseases, presenting, on average, 7.94 ± 2.76 health problems (6.93–8.95; IC 95). The most frequent were diseases of the circulatory system (I00– I99, 20 %), followed by endocrine, nutritional and metabolic disorders (E00–E90, 14.23 %) and in third place, with equal frequency (13.07 %), the digestive (G00–G99) and nervous system (K00–K93) disorders (Table 1). Elderly presented a median of ten medicines/patient (5.6–16.4; P5–P95). Medication used was classified across 37 anatomical groups according to the ATC classification (Table 1). Those acting in the Cardiovascular, Nervous and Digestive systems were the most frequently used (29.75, 29.43 and 19.30 %, respectively). Considering the next level of the ATC classification (ATC Therapeutic Subgroups), the most widely used medicines belong to the subgroup of Antipsychotics, anxiolytics, hypnotics and sedatives (12.03 %), followed by Drugs used in disorders related to gastric acidity (7.91 %) and thirdly, ex aequo, by Diuretics and Psychoanaleptics (7.28 %). Drug related problems (DRP) We identified 484 DRP, with a median of 15 DRP per elderly (5.4–35; P5–P95), was found, further classified as potential (63.45 %) or manifested (36.45 %). According to the PCNE classification, the more frequent DRP (manifested or potential) is Adverse Drug Event, nonallergic (P2.1) and the most frequent manifested DRP is Drug treatment more costly than necessary (P3.1) (Table 2). For both DRP, the most commonly identified cause was Inappropriate combination of medicines and/or food (C1.3; 29.16 %) and a More cost-effective drug
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For the entire sample, a monthly expenditure on medicines of 2,272 € was calculated, considering costs for both patients and the reimbursement system. With the more cost-effective alternative, the corresponding expenditure would be of 1,849 €, an overall gain of 423 €. The implementation of this alternative proposal, could lower costs as much as 3,950 €/year, for the elderly in the overall sample, if all were covered by the special reimbursement regimen, applied to elderly with low economic income (Table 3). For an older person with low income, this would represent a mean savings of 127.42 €/year.
Discussion Concerning the medicines management process of the NH in study, various points may be, currently, contributing for the occurrence of DRP and can, therefore, be improved. We emphasize the complete absence of pharmacists cooperating with these institutions. Moreover, supervision and registration of medicines preparation and administration is neither systematic nor continuously done by health professionals. Many of these results are in accordance with the ones reported by studies in Belgian [21] and Portuguese NH (M. Rosa, personal communication). The presence and intervention of the pharmacist would definitely contribute to ensure that administration occurs at the appropriate time, to define rules for medicines handling (e.g. splitting/ crushing of solid oral forms, a common and unsupervised practice) and for optimizing and standardize information items in the therapeutic table. Multiple diseases and polymedication were observed in all patients which, as important risk factors for DRP occurrence, are potentiating the obtention of undesired
Int J Clin Pharm Table 1 Frequencies of health problems and medicines used Health problems (ICD-10)
Frequency (%)
Medicines (ATC group)
Frequency (%)
Diseases of the circulatory system
20.00
Cardiovascular system
29.75
Endocrine, nutritional and metabolic diseases
14.23
Nervous system
29.43
Diseases of the nervous system
13.08
Alimentary tract and metabolism
19.30
Diseases of the digestive system
13.08 Blood and blood forming organs
8.23
Diseases of the musculoskeletal system and connective tissue
8.85
Mental and behavioural disorders
6.15
Diseases of the genitourinary system Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
4.62 4.62
Musculoskeletal system
4.11
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
3.85
Genitourinary system and sex hormones
3.48
Diseases of the respiratory system
3.46
Diseases of the ear and mastoid process
2.31
Respiratory system
2.85
Diseases of the eye and adnexa
1.92 1.92
Systemic hormonal preparations, excluding sex hormones and insulins
1.58
Diseases of the skin and subcutaneous tissue Neoplasms
1.92
Antineoplastic and immunomodulating agents
1.27
health outcomes. These characteristics are common in institutionalized elderly patients, as indicated by other published studies [22]. Nevertheless, the average of ten medicines/elderly found in our study is higher than those previously reported in other Portuguese studies. A study from CEFAR found an average of 7.3 medicines/elderly in a study involving a large number of elderly patients in Portugal [13] and an average of 7.6/elderly in another work [23]. However, these studies were performed in non-institutionalized elderly, a fact that may explain these differences, at least in part. Our results are in agreement with those from an European study assessing polypharmacy in 4023 NH residents from eight countries where 49.7 % elderly used 5–9 medicines and 24.3 % used ten medicines or more [24]. Our results further reinforce the need for pharmacist intervention in institutionalized elderly due to the increased risks presented by this population. Concerning the most commonly used medicines, our results are in line with other reported experiences in institutionalized elderly [25] confirming the need and relevance of pharmaceutical intervention in this setting. For example, the fact that the subgroup Antipsychotics, hypnotics and sedatives is the most frequently used deserves attention as these medicines are consistently associated with falls and, therefore, fractures in the elderly population [26]. Moreover, studies indicate that discontinuation of these medicines in elderly helps to prevent the occurrence of falls [27]. Another potential area of concern relates to the recurrent use of PPI in our sample. PPI use, especially
in elderly patients, is associated with adverse health events, increasing the risk of infections, fractures, nutritional deficits and drug interactions [26]. Nevertheless, these medicines are frequently reported as heavily and inappropriately consumed in the NH setting [28]. The number of DRP found (484 DRP in total) is quite high and significant. The average number of DRP per patient (15 DRP/patient) is greater than the average number of medicines (ten medicines/patient) meaning that some medicines are causing multiple DRP. It should be reinforced that the number of DRP is directly proportional to the number of medicines, evidencing the contribution of polypharmacy to an increased risk of DRP occurrence. The fact that most DRP were classified as potential problems can be justified, in part, by gaps in the clinical data and corresponding clinical assessment. On the other hand, many DRP are, by definition, risk factors for undesired health results. Constant monitoring in order to prevent potential problems from becoming manifested, with damage to the patient’s health, is, therefore, crucial. The most frequently found DRP was Non-allergic Adverse Event (49.51 %), mainly caused by an inadequate drug combination. This is a natural consequence of using multiple medicines and therapeutic classes simultaneously, which, by pharmacokinetic or pharmacodynamics mechanisms, lead to the possibility of adverse events. Most of these interactions require regular monitoring and many can be circumvented by using safer alternatives. As mentioned before, adverse drug events account for about 6 % of hospital admissions [4, 5] with very high costs associated
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Int J Clin Pharm Table 2 Most frequently found drug related problems and their causes Drug related problem (frequency-%)
Causes
Frequency (%) Manifested
P2.1—Adverse drug event (non-allergic) 49.51 %
Potential
Total
C0
5.34
0.82
C1.1—Inappropriate drug (incl. contra-indicated)
2.67
3.08
6.16 5.75
C1.3—Inappropriate combination of drugs, or drugs and food
1.64
27.52
29.16
C1.5—Indication for drug-treatment not noticed
0
0.21
0.21
C1.8—Synergistic/preventive drug required and not given
0
0.41
0.41
C2.1—Inappropriate drug form
0
0.21
0.21
C3.2—Drug dose too high C3.6—Pharmacokinetic problem requiring dose adjustment
0 0
1.85 0.82
1.85 0.82
C3.7—Deterioration/improvement of disease state requiring dose adjustment
0.21
0.82
1.03
C4.2—Duration of treatment too long
0.62
2.46
3.08
C5.1—Inappropriate timing of administration and/or dosing intervals
0
0.62
0.62
C8.1—Other causes
0
0.21
0.21
P3.1—Drug treatment more costly than necessary 19.11 %
C1.2—No indication for drug
0.41
0.21
0.62
0.21 16.43
0 1.85
0.21 18.28
P1.2—Effect of drug treatment not optimal 14.82 %
C1.1—Inappropriate drug (incl. contra-indicated)
0
0.21
0.21
C1.3—Inappropriate combination of drugs, or drugs and food
0.41
3.49
3.90
C2.1—Inappropriate drug form
0.21
0.21
0.42
C3.1—Drug dose too low
1.44
1.23
2.67
C1.3—Inappropriate combination of drugs, or drugs and food C1.7—More cost-effective drug available
C3.3—Dosage regimen not frequent enough
0.41
0
0.41
C3.7—Deterioration/improvement of disease state requiring dose adjustment
0.41
0
0.41
C4.2—Duration of treatment too long
0
0.21
0.21
C5.1—Inappropriate timing of administration and/or dosing intervals
0.21
4.31
4.52
C5.2—Drug underused/under-administered (deliberately)
0
0.21
0.21
C5.5—Wrong drug taken/administered
0
0.41
0.41
C8.1—Other causes
0.21
1.03
1.24
C8.2—No obvious cause
0.21
0
0.21
Table 3 Annual cost reduction of the treatments with the use of the alternative treatment proposals, in our sample Reduction (%)
Annual reduction (€)
Total (costs for the state and the patient)
18.62
2,791
Costs supported by the elderly (general reimbursement regimen) Costs supported by the elderly (special reimbursement regimen)
33.19 42.59
2,627 3,950
[6]. The existence of a more cost-effective equivalent is also a common DRP (19.11 %). Less expensive alternatives were frequently available on the market, either by generic substitution or by switching to a generic of lower cost. Another frequent DRP, Effect of drug treatment not optimal (14.82 %), had Inappropriate timing of
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administration and/or dosing intervals as main cause, reinforcing that inappropriate administration can influence therapeutic effectiveness. These can be easily corrected through pharmacist intervention, through optimization of therapeutic tables and education of health professionals, care aides and/or patients.
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The results from the STOPP and START criteria further support the relevance of pharmacist intervention, as we found, per patient, approximately 2 potentially inappropriate or required, but not used, medicines. Although heavily polymedicated, elderly were using medicines of very low benefit-risk profile and do not use some medicines that would be appropriate. This seems to be a very common problem, especially in older people in NH, both in the U.S. and in Europe, where prescription of potentially inappropriate medications prevalence can reach 40 % [29]. Our results are consistent with those found in another study of pharmaceutical intervention in NH, where the most frequent causes of DRP were drug interactions (32.16 %) and incorrect dose and/or administration frequency (17.39 %) [30]. The current treatment costs are higher than necessary, since changing brand to generic medicines resulted, in all perspectives of costs (patients and health system), in percentages of cost reduction above 18 %. For the elderly covered by the special reimbursement system, cost reduction can reach 43 %. In annual terms, the proposed alternative represented total annual 3,950 € saving for our sample (considering that all elderly are covered by the special reimbursement regimen). Savings could be invested in contracting a differentiated pharmaceutical service that would monitor medicines effectiveness and safety. This service would provide patient care, in a dual validation process, by a qualified health professional in medicines, which can represent an added-value in getting positive results for the patient. The cost analysis carried out did not take into consideration any other pharmaceutical intervention (treatment change/discontinuation). Numbers are clearly underestimated and saved figures can be far superior. An economic study conducted in U.S. NH predicted total expenditure on medicines of institutionalized seniors in about 3 billion dollars and that associated with DRP management/treatment in 4 billion dollars, with the intervention of clinical pharmacists, i.e. for every dollar spent on medication in the elderly, $1.33 are being spent to treat DRP consequences. The estimated value spent on health care allocated to DRP management, without the intervention of the pharmacist, is about 7.6 billion, which means that pharmacists intervention in elderly healthcare represents a reduction of almost 50 % in healthcare expenditure in NH, which would add to gains in health and quality of life of elderly [31]. Moreover, calculations carried out for cost reduction analysis are only approximate, since it was not always possible to identify the brand or generic mark in use. In this case, the price considered was the lowest available making the corresponding cost reduction underestimated. Additionally, cost reduction that would result from the identification of potential or clearly inappropriate, contraindicated or not
necessary medications, was not performed. Note also that, in addition to the estimated economic gains, pharmacist intervention could enable elderly to get several other health, clinical and/or humanistic gains, through the prevention, identification and resolution of DRP. Conclusions This study strongly suggests that systematic implementation of pharmaceutical care services in NH, to improve the effectiveness and safety of medicines, is needed and would contribute to the optimization of clinical results. The service seems to be cost-effective, not only by the possibility of directly reducing drug expenditure but also by potentially reducing other healthcare costs for the management of adverse events associated with medications. Pharmacist intervention could, therefore, result in multiple benefits for patients, healthcare professionals and institutions involved. Acknowledgments The authors are deeply grateful to Dr. Nuno Lages for the trust he has deposited in our work and to Eng. Se´rgio Gonc¸alves for its assistance on facilitating the contact and cooperation with the NH. We also would like to thank the responsibles of the six NH involved, for the kind cooperation and, ultimately, all the patients that agreed to participate in this study. Funding The authors thank Diola—Se´nior Assistance (Portugal) for financial support. Conflicts of interest
None.
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20. Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (screening tool of older person’s prescriptions) and START (screening tool to alert doctors to right treatment). Consensus validation. Int J Clin Pharmacol Ther. 2008;46(2):72–83. 21. Verrue C, Petrovic M, Mehuys E, Boussery K, Somers A, Spinewine A, et al. Organization of the medication management process in Belgian nursing homes. JAMDA. 2011;12(4):308–11. 22. Sergi G, De Rui M, Sarti S, Manzato E. Polypharmacy in the elderly: Can comprehensive geriatric assessment reduce inappropriate medication use? Drugs Aging. 2011;28(7):509–18. 23. Mendes Z, Guedes S, Marques FB, Miranda A. A terapeˆutica e custos no idoso polimedicados. Farma´cia Observato´rio. 2009;23:6–7. 24. Onder G, Liperoti R, Fialova D, Topinkova E, Tosato M, Danese P, et al. Polypharmacy in nursing home in Europe: results from the SHELTER study. J Gerontol A Biol Sci Med Sci. 2012;67(6):698–704. 25. Dwyer LL, Han B, Woodwell DA, Rechtsteiner EA. Polypharmacy in nursing home residents in the United States: results of the 2004 national nursing home survey. Am J Geriatr Pharmacother. 2010;8(1):63–72. 26. Huang AR, Mallet L, Rochefort CM, Eguale T, Buckeridge DL, Tamblyn R. Medication-related falls in the elderly: causative factors and preventive strategies. Drugs Aging. 2012;29(5):359–76. 27. Hill KD, Wee R. Psychotropic drug-induced falls in older people: a review of interventions aimed at reducing the problem. Drugs Aging. 2012;29(1):15–30. 28. de Souto Barreto P, Lapeyre-Mestre M, Mathieu C, Piau C, Bouget C, Cayla F, et al. Prevalence and associations of the use of proton-pump inhibitors in nursing homes: a cross-sectional study. JAMDA. 2013;14(4):265–9. 29. Gallagher P, Barry P, O’Mahony D. Inappropriate prescribing in the elderly. J Clin Pharm Ther. 2007;32(2):113–21. 30. Brulhart MI, Wermeille JP. Multidisciplinary medication review: evaluation of a pharmaceutical care model for nursing homes. Int J Clin Pharm. 2011;33:549–57. 31. Bootman JL, Harrison DL, Cox E. The health care cost of drugrelated morbidity and mortality in nursing facilities. Arch Intern Med. 1997;157(18):2089–96.
RESEARCH ARTICLE
Drug-related problems in institutionalized, polymedicated elderly patients: opportunities for pharmacist intervention Cristina Silva • Ce´lia Ramalho • Isabel Luz Joaquim Monteiro • Paula Fresco
•
Received: 22 July 2014 / Accepted: 30 December 2014 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2015
Abstract Background An aging population and the increasing prevalence of chronic diseases have led to the increased use of medicines. Portugal is one of the European countries where more medicines are consumed and the associated expense is higher. Medicines are associated with enormous health benefits but also with the potential to cause illness and death. A drug related problem (DRP) is an ‘‘an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’. In the U.S., they represent the 4th–6th leading cause of death and have an estimated cost of 130 billion dollars. Moreover, many of these DRP can be avoided. Elderly are at increased risk of DRP due to multiple
C. Silva C. Ramalho I. Luz J. Monteiro P. Fresco SerFarma, Ltd, Coimbra, Portugal C. Silva Faculty of Pharmacy, Center for Pharmaceutical Studies, University of Coimbra, Coimbra, Portugal I. Luz Farma´cia Rainha, Carrazeda de Ansia˜es, Portugal J. Monteiro Department of Pharmaceutical Sciences, Higher Institute of Health Sciences - North (ISCS-N), CESPU, Institute of Research and Advanced Training in Health Sciences and Technologies, Gandra PRD, Portugal J. Monteiro P. Fresco MedInUp - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal P. Fresco (&) Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, Rua Jorge Viterbo Ferreira, 228, 4050-313 Porto, Portugal e-mail: [email protected]
factors: pluripathology and consequent polypharmacy, complex dosing regimens, pharmacokinetic/pharmacodynamic and functional/cognitive changes. Therefore, this population would be the one who would benefit most from the prevention, detection and control of DRP. The role of the pharmacist as an integral element of health care has been recognized by various international and European organizations. Providing pharmaceutical care as a patientcentered activity, focusing on their needs related to pharmacotherapy, contributes to guarantee that drug expenditure is a good investment, with benefits that outweigh potential risks. Objective To evaluate the need for pharmaceutical care implementation in institutionalized, polymedicated elderly. Methods Descriptive observational cross-sectional study carried out in six Portuguese nursing homes, selected by convenience, in November–December 2013. Each institution selected up to six patients, according to the following inclusion criteria: age C65 years, number of medications C5 and ability to respond to an interview. All participants signed an informed consent form. Pharmacists carried out a structured interview with each patient and consulted patient medical records to gather demographic data and information on health problems and medications used. To identify DRP, official drug information sources were consulted, and the STOPP and START tool was used. The ATC, the ICD-10 and the PCNE Classification V 6.2 classification systems were used for medicines, health problems and DRP classifications, respectively. For each medicine used, the cheapest equivalent available was also identified. Results The sample included 31 elderly (64.52 % female, mean age 81.65 ± 6.86). On average, subjects presented a mean of 7.94 ± 2.76 health problems with diseases of the circulatory system being the most common. The sample used a median of ten medicines per patient. Those medicines
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working in the cardiovascular, nervous and digestive systems were the most frequently used (29.75, 29.43 and 19.30 %, respectively). A total of 484 DRP (median: 15 DRP/patient) was found. The most common DRP were Adverse Drug Event, non-allergic (49.51 %), Drug treatment more costly than necessary (19.11 %), Effect of drug treatment not optimal (14.82 %) and Unnecessary drug treatment (6.16 %). The most cost-effective proposal, would lead to a saving of € 3,950/year in the studied sample. Conclusion These results reinforce the need for the implementation of pharmaceutical care services to institutionalized elderly, necessary to improve medicines efficacy and safety, better clinical outcomes and cost reduction. Keywords Drug-related problems Elderly Pharmacist intervention Polymedication Portugal
Impacts to practice • •
•
•
Institutionalised elderly in Portugal sow a high number of diseases, medications and drug-related problems The pharmacist can have a important role, as a health team member, in nursing homes, to prevent, detect and solve DRP The pharmacist intervention can improve the medication management process and ultimately the economic and clinical outcomes for institutionalized, polymedicated elderly The systematic implementation of pharmaceutical care services in nursing homes, in order to improve the effectiveness and safety of medicines is needed and would contribute to the optimization of clinical results
Introduction World population is aging, due to increased life expectancy and better and more affordable health care. The consequent increase in chronic diseases prevalence has led to a considerable increase in the use of medicines. In Europe, Portugal is one of the countries that consume more medicines (2002: 23 medicine packages per capita) with an extremely high associated expense (2004: 2.3 % of GDP). Nevertheless, better health outcomes relative to other countries with lower consumption and lower costs are not observed [1]. Medicines represent a health-technology that has brought major benefits and a very powerful and costeffective therapeutic tool. However, medicines are also a potential cause of illness and death. Morbidity and mortality associated with medication is widely described in the literature. Over 20 % of visits to emergency departments
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are related to medicines use [2–4]. In the U.S., drug related problems (DRPs) represent the 4th–6th leading cause of death and adverse reactions are responsible for 3–6 % of hospitalizations (700,000 patients/year) [5], representing an estimated cost of 130 billion dollars [6]. Importantly, up to 88 % of these adverse events could be prevented [3, 7, 8]. In Portugal, 43,000 hospitalizations/ year are estimated as unnecessary, corresponding to, approximately, five patients/h [9]. If one compares these numbers to the casualties caused by motor vehicle accidents in 2012, 2,613 (580 deaths and 2,033 serious injuries) [10], a value 169 lower, we can realize the extent of this public health problem, which should alert authorities, professionals and all stakeholders in the health system, which represents waste of resources to health systems and leads to unnecessary damage to patients’ health and quality of life [9]. According to the Pharmaceutical Care Network Europe (PCNE), a DRP is an ‘‘an event or circumstance involving drug therapy that actually or potentially interferes with desired health outcomes’’ [11, 12]. In general, DRP may be related to treatment effectiveness, occurrence of adverse reactions and treatment costs. DRP causes include drug selection, pharmaceutical or dosage form, treatment duration, management/use and causes related to logistics and to the patient. Pharmaceutical interventions include actions taken at the prescriber, the patient (or caregiver) and/or medication levels, aiming to prevent/correct DRP contributing to the pharmacotherapy results optimization [12]. Elderly patients are at increased risk of DRP, during the medication use process and the occurrence of adverse clinical outcomes associated therewith, including adverse reactions [3, 7, 13]. This is related to multiple factors including pluripathology and consequent polymedication, complex dosing regimens and pharmacokinetic/pharmacodynamic, cognitive and functional alterations in elderly [14, 15]. A Portuguese study revealed that 46.8 % of homebased polymedicated elderly present DRP [13]. The elderly population can, therefore, get the greater benefits from DRP prevention, detection and control [16]. The pharmacist formation/training is dedicated to the knowledge and understanding of medicines. Their role in society as an integral element of healthcare has been recognized by several international official organizations [6, 17]. It is accepted that the pharmacist main function is to help prevent avoidable iatrogenic risks and its action should be systematically implemented [17]. The pharmacist participation in the healthcare team can help prevent medication errors [18], ensuring that expenditure on medicines is a good investment, with benefits outweighing potential risks [19].
Int J Clin Pharm
Aim of the study To evaluate the need for implementation of pharmaceutical care services to institutionalized, polymedicated elderly concerning both the medication management process and the clinical and economic outcomes.
Medicines and health problems were then classified according to the Anatomical Therapeutic Chemical Classification (ATC/DDD Index 2014) and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), respectively. Identification and classification of DRP
Methods
Official drug information sources (i.e. Summary of Product Characteristics) and drug databases (i.e. Drug Interaction Checker from Drugs.com, Epocrates online), were consulted. The STOPP and START toolkit was used to identify potentially inappropriate and appropriate, indicated medicines [20]. Identified DRP were classified according to The PCNE Classification V6.2, in group (all authors) discussions.
Type of study
Cost reduction analysis
Descriptive, observational, cross-sectional study conducted in Portuguese nursing homes (NH), in November– December 2013. Six NH, located in Northern and Central Portugal, were selected by convenience. The study involved two pharmacist visits to each institution: the first to characterize the NH, the second for the therapeutic review of selected patients.
To calculate the total monthly expenditure on medicines, overall and for each patient, prices on the official site of INFARMED, the Portuguese Medicines Agency, were consulted. When it was not possible to identify the prescribed brand or generic, the price of the least expensive equivalent was considered. Then, the least expensive equivalent on the Portuguese market was identified, for each medicine, and the corresponding monthly expenditure calculated.
Ethical approval Patients were informed of the objectives and methodology of the study and, those who agreed to participate, signed an informed consent form. No ethical approval was sought.
NH characterization A questionnaire for collecting information on healthcare and medication management process was developed and administered by the pharmacist to the professional responsible for medicines, at each NH. Therapeutic review Sample recruitment Each NH was asked to identify 5–6 patients, according to the following inclusion criteria: • • •
Age C65 years No of medicines taken C5 Ability to respond to an interview
Information collection Demographic and clinical data (e.g. health problems, medicines used) was gathered from the NH clinical records. Individual interviews were conducted by a pharmacist in order to gather additional data regarding clinical history, health problems and medicines use.
Results Characterization of NH The six selected NH were geographically distributed as follows: three in Porto, one in Braganc¸a, one in Castelo Branco and one in Viseu. An average number of 37 beds and an occupancy rate of 89 %, were found. Health professionals working in the NH: medical doctors, nurses, physiotherapists, nutritionists, psychologists and gerontologists. Only one NH had the daily presence of a medical doctor and three of a nurse. Some NH had physiotherapist, psychologist and gerontologist but none had the collaboration of pharmacists. All NH had an individual clinical file and therapeutic table (with varying type of information and updating frequency). Measurements of physiological and/or biochemical parameters were performed and recorded, albeit with varying intervals, and not always performed by health professionals. In most cases, the responsible for medicines acquisition was the institution itself but medication costs were usually supported by patients. Usually, the community pharmacy merely dispenses medication. In one NH, the pharmacy
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(not necessarily the pharmacist) was also responsible for the weekly preparation of medication. Medication storage was generally done in a specific area, per patient, but a controlled environment was never observed. The medication preparation was not always performed under the supervision of an healthcare professional and, only in two NH, it was made on a daily basis, preserving the original packaging. Double-checking of this process was rarely performed. In five NH, oral dosage forms were splitted and/or crushed, with no previous confirmation of such possibility and no record-keeping of the procedure. Medicines were, usually, administered by care aides and there were no administration records. Therapeutic review
available (C1.7; 18.28 %), (Table 2). Effect of drug treatment not-optimal (P1.2) and Unnecessary drug treatment (P3.2) followed, being the Inappropriate timing of administration and/or dosing intervals (C5.1; 4.52 %) and No indication for drug (C1.2; 6.16 %) the main causes, respectively (Table 2). The STOPP and START toolkit application revealed 69 indications of potentially inappropriate (STOPP) or potentially required medicines (START). From this total, 76.82 % were STOPP criteria, mostly the long term use of Central Nervous System and Psychotropic Drugs (37.73 %) and of proton pump inhibitors (PPI) (30.19 %), and 23.18 % were START criteria, with the need to initiate Angiotensin Converting Enzyme inhibitor as first (25 %) and the need to initiate calcium and vitamin D supplementation as second (18.75 %).
Sample characterization Cost reduction analysis The sample included 31 elderly, mostly female (64.52 %) with a mean age of 81.65 ± 6, 86 (79.13–84.16; IC 95). All elderly had multiple diseases, presenting, on average, 7.94 ± 2.76 health problems (6.93–8.95; IC 95). The most frequent were diseases of the circulatory system (I00– I99, 20 %), followed by endocrine, nutritional and metabolic disorders (E00–E90, 14.23 %) and in third place, with equal frequency (13.07 %), the digestive (G00–G99) and nervous system (K00–K93) disorders (Table 1). Elderly presented a median of ten medicines/patient (5.6–16.4; P5–P95). Medication used was classified across 37 anatomical groups according to the ATC classification (Table 1). Those acting in the Cardiovascular, Nervous and Digestive systems were the most frequently used (29.75, 29.43 and 19.30 %, respectively). Considering the next level of the ATC classification (ATC Therapeutic Subgroups), the most widely used medicines belong to the subgroup of Antipsychotics, anxiolytics, hypnotics and sedatives (12.03 %), followed by Drugs used in disorders related to gastric acidity (7.91 %) and thirdly, ex aequo, by Diuretics and Psychoanaleptics (7.28 %). Drug related problems (DRP) We identified 484 DRP, with a median of 15 DRP per elderly (5.4–35; P5–P95), was found, further classified as potential (63.45 %) or manifested (36.45 %). According to the PCNE classification, the more frequent DRP (manifested or potential) is Adverse Drug Event, nonallergic (P2.1) and the most frequent manifested DRP is Drug treatment more costly than necessary (P3.1) (Table 2). For both DRP, the most commonly identified cause was Inappropriate combination of medicines and/or food (C1.3; 29.16 %) and a More cost-effective drug
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For the entire sample, a monthly expenditure on medicines of 2,272 € was calculated, considering costs for both patients and the reimbursement system. With the more cost-effective alternative, the corresponding expenditure would be of 1,849 €, an overall gain of 423 €. The implementation of this alternative proposal, could lower costs as much as 3,950 €/year, for the elderly in the overall sample, if all were covered by the special reimbursement regimen, applied to elderly with low economic income (Table 3). For an older person with low income, this would represent a mean savings of 127.42 €/year.
Discussion Concerning the medicines management process of the NH in study, various points may be, currently, contributing for the occurrence of DRP and can, therefore, be improved. We emphasize the complete absence of pharmacists cooperating with these institutions. Moreover, supervision and registration of medicines preparation and administration is neither systematic nor continuously done by health professionals. Many of these results are in accordance with the ones reported by studies in Belgian [21] and Portuguese NH (M. Rosa, personal communication). The presence and intervention of the pharmacist would definitely contribute to ensure that administration occurs at the appropriate time, to define rules for medicines handling (e.g. splitting/ crushing of solid oral forms, a common and unsupervised practice) and for optimizing and standardize information items in the therapeutic table. Multiple diseases and polymedication were observed in all patients which, as important risk factors for DRP occurrence, are potentiating the obtention of undesired
Int J Clin Pharm Table 1 Frequencies of health problems and medicines used Health problems (ICD-10)
Frequency (%)
Medicines (ATC group)
Frequency (%)
Diseases of the circulatory system
20.00
Cardiovascular system
29.75
Endocrine, nutritional and metabolic diseases
14.23
Nervous system
29.43
Diseases of the nervous system
13.08
Alimentary tract and metabolism
19.30
Diseases of the digestive system
13.08 Blood and blood forming organs
8.23
Diseases of the musculoskeletal system and connective tissue
8.85
Mental and behavioural disorders
6.15
Diseases of the genitourinary system Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism
4.62 4.62
Musculoskeletal system
4.11
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
3.85
Genitourinary system and sex hormones
3.48
Diseases of the respiratory system
3.46
Diseases of the ear and mastoid process
2.31
Respiratory system
2.85
Diseases of the eye and adnexa
1.92 1.92
Systemic hormonal preparations, excluding sex hormones and insulins
1.58
Diseases of the skin and subcutaneous tissue Neoplasms
1.92
Antineoplastic and immunomodulating agents
1.27
health outcomes. These characteristics are common in institutionalized elderly patients, as indicated by other published studies [22]. Nevertheless, the average of ten medicines/elderly found in our study is higher than those previously reported in other Portuguese studies. A study from CEFAR found an average of 7.3 medicines/elderly in a study involving a large number of elderly patients in Portugal [13] and an average of 7.6/elderly in another work [23]. However, these studies were performed in non-institutionalized elderly, a fact that may explain these differences, at least in part. Our results are in agreement with those from an European study assessing polypharmacy in 4023 NH residents from eight countries where 49.7 % elderly used 5–9 medicines and 24.3 % used ten medicines or more [24]. Our results further reinforce the need for pharmacist intervention in institutionalized elderly due to the increased risks presented by this population. Concerning the most commonly used medicines, our results are in line with other reported experiences in institutionalized elderly [25] confirming the need and relevance of pharmaceutical intervention in this setting. For example, the fact that the subgroup Antipsychotics, hypnotics and sedatives is the most frequently used deserves attention as these medicines are consistently associated with falls and, therefore, fractures in the elderly population [26]. Moreover, studies indicate that discontinuation of these medicines in elderly helps to prevent the occurrence of falls [27]. Another potential area of concern relates to the recurrent use of PPI in our sample. PPI use, especially
in elderly patients, is associated with adverse health events, increasing the risk of infections, fractures, nutritional deficits and drug interactions [26]. Nevertheless, these medicines are frequently reported as heavily and inappropriately consumed in the NH setting [28]. The number of DRP found (484 DRP in total) is quite high and significant. The average number of DRP per patient (15 DRP/patient) is greater than the average number of medicines (ten medicines/patient) meaning that some medicines are causing multiple DRP. It should be reinforced that the number of DRP is directly proportional to the number of medicines, evidencing the contribution of polypharmacy to an increased risk of DRP occurrence. The fact that most DRP were classified as potential problems can be justified, in part, by gaps in the clinical data and corresponding clinical assessment. On the other hand, many DRP are, by definition, risk factors for undesired health results. Constant monitoring in order to prevent potential problems from becoming manifested, with damage to the patient’s health, is, therefore, crucial. The most frequently found DRP was Non-allergic Adverse Event (49.51 %), mainly caused by an inadequate drug combination. This is a natural consequence of using multiple medicines and therapeutic classes simultaneously, which, by pharmacokinetic or pharmacodynamics mechanisms, lead to the possibility of adverse events. Most of these interactions require regular monitoring and many can be circumvented by using safer alternatives. As mentioned before, adverse drug events account for about 6 % of hospital admissions [4, 5] with very high costs associated
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Int J Clin Pharm Table 2 Most frequently found drug related problems and their causes Drug related problem (frequency-%)
Causes
Frequency (%) Manifested
P2.1—Adverse drug event (non-allergic) 49.51 %
Potential
Total
C0
5.34
0.82
C1.1—Inappropriate drug (incl. contra-indicated)
2.67
3.08
6.16 5.75
C1.3—Inappropriate combination of drugs, or drugs and food
1.64
27.52
29.16
C1.5—Indication for drug-treatment not noticed
0
0.21
0.21
C1.8—Synergistic/preventive drug required and not given
0
0.41
0.41
C2.1—Inappropriate drug form
0
0.21
0.21
C3.2—Drug dose too high C3.6—Pharmacokinetic problem requiring dose adjustment
0 0
1.85 0.82
1.85 0.82
C3.7—Deterioration/improvement of disease state requiring dose adjustment
0.21
0.82
1.03
C4.2—Duration of treatment too long
0.62
2.46
3.08
C5.1—Inappropriate timing of administration and/or dosing intervals
0
0.62
0.62
C8.1—Other causes
0
0.21
0.21
P3.1—Drug treatment more costly than necessary 19.11 %
C1.2—No indication for drug
0.41
0.21
0.62
0.21 16.43
0 1.85
0.21 18.28
P1.2—Effect of drug treatment not optimal 14.82 %
C1.1—Inappropriate drug (incl. contra-indicated)
0
0.21
0.21
C1.3—Inappropriate combination of drugs, or drugs and food
0.41
3.49
3.90
C2.1—Inappropriate drug form
0.21
0.21
0.42
C3.1—Drug dose too low
1.44
1.23
2.67
C1.3—Inappropriate combination of drugs, or drugs and food C1.7—More cost-effective drug available
C3.3—Dosage regimen not frequent enough
0.41
0
0.41
C3.7—Deterioration/improvement of disease state requiring dose adjustment
0.41
0
0.41
C4.2—Duration of treatment too long
0
0.21
0.21
C5.1—Inappropriate timing of administration and/or dosing intervals
0.21
4.31
4.52
C5.2—Drug underused/under-administered (deliberately)
0
0.21
0.21
C5.5—Wrong drug taken/administered
0
0.41
0.41
C8.1—Other causes
0.21
1.03
1.24
C8.2—No obvious cause
0.21
0
0.21
Table 3 Annual cost reduction of the treatments with the use of the alternative treatment proposals, in our sample Reduction (%)
Annual reduction (€)
Total (costs for the state and the patient)
18.62
2,791
Costs supported by the elderly (general reimbursement regimen) Costs supported by the elderly (special reimbursement regimen)
33.19 42.59
2,627 3,950
[6]. The existence of a more cost-effective equivalent is also a common DRP (19.11 %). Less expensive alternatives were frequently available on the market, either by generic substitution or by switching to a generic of lower cost. Another frequent DRP, Effect of drug treatment not optimal (14.82 %), had Inappropriate timing of
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administration and/or dosing intervals as main cause, reinforcing that inappropriate administration can influence therapeutic effectiveness. These can be easily corrected through pharmacist intervention, through optimization of therapeutic tables and education of health professionals, care aides and/or patients.
Int J Clin Pharm
The results from the STOPP and START criteria further support the relevance of pharmacist intervention, as we found, per patient, approximately 2 potentially inappropriate or required, but not used, medicines. Although heavily polymedicated, elderly were using medicines of very low benefit-risk profile and do not use some medicines that would be appropriate. This seems to be a very common problem, especially in older people in NH, both in the U.S. and in Europe, where prescription of potentially inappropriate medications prevalence can reach 40 % [29]. Our results are consistent with those found in another study of pharmaceutical intervention in NH, where the most frequent causes of DRP were drug interactions (32.16 %) and incorrect dose and/or administration frequency (17.39 %) [30]. The current treatment costs are higher than necessary, since changing brand to generic medicines resulted, in all perspectives of costs (patients and health system), in percentages of cost reduction above 18 %. For the elderly covered by the special reimbursement system, cost reduction can reach 43 %. In annual terms, the proposed alternative represented total annual 3,950 € saving for our sample (considering that all elderly are covered by the special reimbursement regimen). Savings could be invested in contracting a differentiated pharmaceutical service that would monitor medicines effectiveness and safety. This service would provide patient care, in a dual validation process, by a qualified health professional in medicines, which can represent an added-value in getting positive results for the patient. The cost analysis carried out did not take into consideration any other pharmaceutical intervention (treatment change/discontinuation). Numbers are clearly underestimated and saved figures can be far superior. An economic study conducted in U.S. NH predicted total expenditure on medicines of institutionalized seniors in about 3 billion dollars and that associated with DRP management/treatment in 4 billion dollars, with the intervention of clinical pharmacists, i.e. for every dollar spent on medication in the elderly, $1.33 are being spent to treat DRP consequences. The estimated value spent on health care allocated to DRP management, without the intervention of the pharmacist, is about 7.6 billion, which means that pharmacists intervention in elderly healthcare represents a reduction of almost 50 % in healthcare expenditure in NH, which would add to gains in health and quality of life of elderly [31]. Moreover, calculations carried out for cost reduction analysis are only approximate, since it was not always possible to identify the brand or generic mark in use. In this case, the price considered was the lowest available making the corresponding cost reduction underestimated. Additionally, cost reduction that would result from the identification of potential or clearly inappropriate, contraindicated or not
necessary medications, was not performed. Note also that, in addition to the estimated economic gains, pharmacist intervention could enable elderly to get several other health, clinical and/or humanistic gains, through the prevention, identification and resolution of DRP. Conclusions This study strongly suggests that systematic implementation of pharmaceutical care services in NH, to improve the effectiveness and safety of medicines, is needed and would contribute to the optimization of clinical results. The service seems to be cost-effective, not only by the possibility of directly reducing drug expenditure but also by potentially reducing other healthcare costs for the management of adverse events associated with medications. Pharmacist intervention could, therefore, result in multiple benefits for patients, healthcare professionals and institutions involved. Acknowledgments The authors are deeply grateful to Dr. Nuno Lages for the trust he has deposited in our work and to Eng. Se´rgio Gonc¸alves for its assistance on facilitating the contact and cooperation with the NH. We also would like to thank the responsibles of the six NH involved, for the kind cooperation and, ultimately, all the patients that agreed to participate in this study. Funding The authors thank Diola—Se´nior Assistance (Portugal) for financial support. Conflicts of interest
None.
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