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Section 1: Background

Importance of medication review
 
Medication is by far the most common form of medical intervention in the UK. Many people are prescribed multiple and long term medication, so ensuring that patients get the maximum benefit from all their medicines is a major challenge.
 
There is considerable published evidence on issues associated with medicines and an increasing body of evidence for the effectiveness of medication review as a route to optimising therapy, improving health outcomes, reducing the likelihood of medicine-related problems and cutting waste. Evidence is also emerging that targeted medication review can enable people to maintain their independence and avoid admission to residential care or hospital.
 
Three recent documents have summarised current evidence of problems associated with medicine taking: (1,2,3)
  • Adverse reactions to medicines are implicated in 5-17% of hospital admissions, and once in hospital, 6-17% of older patients suffer an adverse drug reaction during their stay
  • Polypharmacy increases the risk of adverse drug reactions and of hospital readmission in older people
  • In the case of patients with long term conditions, some 50% of prescribed medicines are not taken as prescribed
  • Following hospital discharge, changes to medication are frequently made by patients and GPs, some intentional but many unintentional.
 
Common medicines-related problems include adverse drug reactions and treatment failures. Many are attributed to lack of monitoring and follow-up of the effects of medicines, over or under-prescribing, and patients not understanding their medicines and not taking them as prescribed (4).
 
Some commonly prescribed medicines including non-steroidal antiinflammatory drugs (NSAIDs), tricyclic anti-depressants, digoxin and lithium frequently cause problems (5). In an average PCT with 100,000 patients, NSAIDs account for some 18 hospital admissions with gastro-intestinal bleeding, and 22 admissions with congestive heart failure each year (6). Drugs such as benzodiazepines and antipsychotic medicines are often prescribed inappropriately for the elderly; they can also contribute to falls. Medication review has been shown to play an important part in falls prevention (7).
 
There has been recent emphasis on the need for regular review of treatment and a growing awareness that many medication related problems can be avoided with increased vigilance and intervention by the health care team (4,7,8). A number of clinical trials in the UK and North America have shown the benefits of pharmacists reviewing long term prescriptions in community practice (9-12). Many problems with medicines could be prevented by monitoring the effects of long-term drug therapy, by identifying those at risk, and by modifying their medication where necessary (12,13).
 
Non-compliance with prescribed medicines can result in avoidable ill health, premature death, unnecessary hospital admissions and additional costs to the NHS. Although there is considerable evidence of its scale and consequences and much is known about its causes, we understand far less about how to overcome it.
Medicines concordance is a novel approach to prescribing and medicine taking which involves an agreement between patients and health care professionals about the treatment to be followed (3).
Medication review provides an important opportunity to discuss medicine taking and to work towards partnership between patients and health professionals in relation to medicines.
 
Against this background, the process of medication review is increasingly recognised as a cornerstone of broader medicines management. The targets for medication review included in the National Service Framework (NSF) for Older People testify to the significance of medication review within the bigger picture of health and well being for older people.
 
Partly as a result of the NSF target and work taking place in National Collaborative Medicines Management Services pilot sites, there is ongoing activity around the country aimed at implementing processes for medication review. These efforts are hampered by the lack of a common understanding of what a medication review should consist of, and how to provide it. Consequently, the quality and effectiveness of medication review can vary widely and there is a need for practical guidance to support the provision of reviews that meet the needs of patients as well as fulfilling the obligations of primary care organisations under the NSF.
 
In very many places, good work is already being done. But it is clear that scope remains for greater involvement of patients and carers, which can lead to genuine partnership and better outcomes for both patients and the NHS. In its attempt to set the scene for medication review and provide some pointers towards more consistent and inclusive practice, this guide has drawn heavily on the experiences and views of patients and carers. Thus, we hope that the guide will contribute towards increasingly effective and patient-focussed practice in medication review.
 
This guide seeks to take account of the needs of patients and health professionals for more information and support around the medication review process. They are written primarily for practitioners and managers working within the NHS including GPs, pharmacists, nurses and practice staff, as well as PCTs being performance managed by the new Strategic Health Authorities, and their partners in local authorities who are responsible for ensuring safe, high quality, cost effective services for their communities. They should also be helpful to patient groups and to any individual older people, patients or carers who are interested in how to get the most out of medication review. Finally, they should be of interest to decision-makers at a national level who are concerned with how the NHS can deliver effective and efficient services, to improve the health of particular groups of patients and the population as a whole.