What does a medication review mean?

19.11.2019

What does a medication review mean?

Over the years, there has been a well-established term in Finnish health care, and more specifically in the pharmaceutical field, referring to the overall review of medication, more commonly known as "LHKA". The English equivalent is Medication Review(MR). A comprehensive review of medication by a pharmaceutical professional is a relatively new thing especially in Finland. It would be natural to ask the following question:

"Doesn't a pharmaceutical professional always review  the medications carefully? After all, medicines come from the pharmacy."

Well, for the most part, this isn't the case. As many other activities, medication review is a specified procedure, that requires its  own processes, correct personnel, and appropriate channels of communication. Medication review can't automatically be a part of the basic service in a pharmacy, as carrying it out requires a specific combination of different resources. .Of course, with a relatively small effort, we can perform a concise medication review, but its effectiveness can't be guaranteed. Generally, a lot more information is needed to carry out a more extensive review than is possible to find in the pharmacy database systems.

Sufficient data collection is a big challenge  by itself, and the costs of review rises due to lengthy labour intensive process. In addition, it isn't meaningful to perform a review without a proper relationship with the doctor, especially if the results obtained and changes suggested by the review won’t be utilised after the evaluation. In other words, in order to perform meaningful and efficient reviews, a functioning collaboration has to be established and the effectiveness of the review has to be fully monitored.

Medication review can't automatically be apart of the basic service in a pharmacy, as carrying it out requires a specific combination of different factors.

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Model and definitions come from abroad

During my study trip to England in the fall of 2006, we visited three treatment units providing different levels of care:nursing home/hospice and city hospital in Somerset, and a St. Thomas' Hospital in London. The theme of the trip was "multi-professional collaboration - English model for Finland". In every unit, in addition to the nurse and doctor, a pharmaceutical professional participated in working with the patient. It is difficult to assess if medication reviews and division of labour were specifically defined in these units, or whether the situation had just evolved over the years, as they had been working like this since the 70s and 80s. However, the underlying idea became clear: in addition to the nurse and doctor, a pharmaceutical professional participates in working with the patient.

However, the underlying idea became clear: in addition to the nurse and doctor, a pharmaceutical professional participates in working with the patient.

In England (in the places I visited), a medication review is performed once a year if the patient is having three medications, and twice a year if the patient is having four medications. If the medication list was about to reach five medications, experts were called in for a crisis meeting. In the Netherlands, the medication review is mandated by law, and when purchasing services, the sales argument is not a lower cost but improved quality of the service. However, it has been proven that medication review services increase both savings and quality of life. Pharmaceutical Care Network Europe, PCNE, which was established in 1994, defines medication review in the following way:

"Medication review is a structured evaluation of a patient's medicines with the aim of optimizing medicines use and improving health outcomes.This entails detecting drug-related problems and recommending interventions."

"Medication review is a structured evaluation of a patient's medicines with the aim of optimizing medicines use and improving health outcomes.This entails detecting drug-related problems and recommending interventions."

PCNE classifies medication reviews into three main categories; Simple MR (Medication Review), Intermediate MR and AdvancedMR. Corresponding measures adopted in Finland include the verification of medication, medication review, and overall review of medication. From now on, I will use the term "medication review" for all these procedures. Each measure has its own specific content. This brings us to the original question: Why doesn't the pharmacy automatically provide medication reviews? Sure, the medicines will be reviewed in the pharmacy at some level, but I don't think this is conducted at a level matching the severity of the situation.

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Is it a necessary evil and a waste  of resources or something useful?

Reasonably thinking, MR should've been a standard procedure for some time. The statement released by STM in 2007 "Safe medical treatment of elderly people: municipal obligations", the guide for safe medical treatment, and laws and regulations related to patient safety and patient rights leave no room for interpretations: medication review should be everyone's right. However, municipalities are suffering from alack of resources, health care costs are increasing year after year and there is no light at the end of the tunnel. It doesn't help that the population is aging and the dependency ratio is changing.

For some reason, most medicines are consumed by the eldest people, who will most likely get side-effects from them. Granted, that many a long-term illness requires treatment even in old age, but at what cost? The annual cost to treat perfectly preventable harm from medicines is  estimated to be 1-2 billion euros in Finland. It might be even more than that. To be clear: These figures reflect the adverse effects of medication, which could've been completely avoided with relatively little consideration, and an investment in appropriate intervention. Undoubtedly, the biggest cause of these numbers are the medication-related issues experienced by the elderly, and the additional treatment that those issues cause at different levels of care, in hospitals, health centers, etc.

Have you ever heard of a case where a grandmother or grandfather has been receiving terminal care, medications have been discontinued, and then the senior has risen from the bed and lived happily even for years after the incident?

Stories like this are familiar to anyone who has had any contact with the field of elderly care. It is difficult to understand that even in the2010s, our system can lead to a situation where inappropriately combined medications have caused the patient to be in terminal care. It is difficult to imagine any other service package costing thousands of euros per month in which the same situation could be even remotely possible. And once the terminal care of the grandmother has begun, and delivery of medications has been stopped, but she is having the time of her life soon afterwards, there are hardly any apologies offered for the person concerned.

You probably wouldn't want to be that person? Unfortunately, this situation means that unless things change you are likely to enjoy the benefits and disadvantages of our elderly care. There are many good things too, but the downsides are far too blatant at the moment. To emphasize: things will never change unless you are involved in changing them yourself.

The real benefits of medicines are achieved by eliminating their disadvantages. It is not in anyone's interest that people suffer from any harm caused by medicines, even to a small extent. Sure, there are situations, where some harm is worth tolerating so that the benefits of a particular medication are not lost. I would argue that in most cases with the elderly, the disadvantages of medications outweigh their benefits multiple times, both for an individual as well as at  the municipal level.

The real benefits of medicines are achieved by eliminating their disadvantages.

So, what is medication review? There are certain definitions for medication reviews, and the process could be explained and defined from a clinical point of view, but we will leave that topic for another blog post. Instead, it should be noted that medication review is a process which addresses the fragmentation and complexity of our system and determines whether there is anything in the medication that could jeopardize the delivery of quality health care.

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Pauli Puirava

Pharmacist, trained in Advanced Medication Review

CEO, Causalus

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