Focused Medication Review Not Linked to Psychotropic Drug Optimization
Focused psychotropic medication review was associated with a reduction in the prescribing of psychotropic drugs.
According to the results of a meta-analysis published in JAMA Network Open, focused psychotropic medication review was associated with a reduction in the prescribing of psychotropic drugs; however, this result did not appear to improve clinical outcomes or provide economic benefit.
Investigators performed a literature search of Medline, PsycINFO, Embase, and CINAHL Plus from inception to February 2018 to identify peer-reviewed research articles that reported the effect of focused psychotropic medication review on medication optimization outcomes. Specifically, researchers sought to capture changes in the number or dosage of psychotropic medications and any resultant changes in clinical parameters, patient-report outcomes, or economic data. Two investigators independently used the quality checklist published by the National Institutes of Health Study to assess the quality. Studies received an overall quality grading according to the proportion of checklist items met (poor, <30% of items; fair, 30%-60%; and good, >60%). Results were summarized narratively, with higher-quality study results given precedence.
The literature search yielded 9485 articles, among which 27 met inclusion criteria. Of these 27 articles, 4 discussed cluster randomized controlled trials (n=712 participants) and 22 were about before-after study designs (n=7844). A total of 19 studies were conducted in institutional settings and performed psychotropic medication review with patients with intellectual disability (9 studies; 1054 participants) or with dementia (6 studies; 3664 participants). As such, the narrative meta-analysis included 3 studies (n=652 participants). Study conditions varied greatly across published articles, although 3 primary categories were identified: one-off medication review concerning a single class of psychotropic drug, typically conducted by a single professional; longitudinal medication review, typically conducted by a multidisciplinary team who reviewed the patient's drug regimen over a series of meetings; and a 2-stage review, in which patients at high risk for suboptimal drug therapy were directed to clinician medication review.
Change in psychotropic drug prescribing after focused psychotropic medication review was the most consistently reported medication outcome of these studies. One-off psychotropic medication review was associated with a mean 34% (95% CI, 32.9%-35.2%) of participants experiencing a subsequent change in medication prescription.
In addition, according to the meta-analysis of 3 randomized controlled trials, psychotropic medication review was associated with a reduction in the prescribing of psychotropic drugs compared with control (pooled odds ratio 0.24; 95% CI, 0.14-0.39) in elderly participants with cognitive impairment who lived in nursing homes. However, disparate clinical outcomes were observed across studies, as some demonstrated clinical improvements and some indicated worsened psychopathology or quality of life. Just 5 studies reported descriptive cost data after focused psychotropic medication review, although these data were not sufficient to assess economic implications. Study quality was poor to fair, and many were at risk for bias.
These data indicate that although psychotropic medication review may reduce the number of prescriptions dispensed, clinical and economic benefits have yet to be identified. Additional research is necessary to assess the patient- and cost-related outcomes of medication review before it can be recommended as part of routine care.
Sheehan R, Strydom A, Brown E, Marston L, Hassiotis A. Association of focused medication review with optimization of psychotropic drug prescribing: a systematic review and meta-analysis. JAMA Netw Open. 2018;1(6):e183750.