Mapping and reconfiguration of hyperacute stroke services in Wales

South West PeninsulaStroke
Start Date: 1 Oct 2015

Background

For many older adults, the ability to remain independent in one’s home depends on the ability to manage medication. Non-adherence to medication regimens is a major cause of nursing home placement of frail older adults. Approximately 30 percent of hospital admissions of older adults are drug related, with more than 11 percent attributed to medication non-adherence and 10–17 percent related to adverse drug reactions. Many elderly patients are unable to attend pharmacies and may not be able to rely on others to collect prescriptions. Similarly, those with complex health needs and restricted mobility may also be less able to access appropriate medications advice. Although there are no estimates of the proportion of UK residents who are housebound, the UK 2011 census found that 11% of those less than 65 years and 52% of those over 65 years, had health conditions sufficient to limit their daily activity. A home visit service by community pharmacists for those unable to visit local pharmacies may have both health and resource benefits.

A few randomised controlled studies in elderly populations on this topic, primarily from the UK, Australia and the United States have been published. Trials have either assessed the effectiveness of community pharmacist home visits with medication review in reducing readmission to hospital for the elderly recently discharged, or have assessed the effects of a home visit service to vulnerable elderly populations already within the community. The results have been mixed. Some have shown  reductions in visits to health practitioners, improved identification and resolution of medicine related problems, and improved compliance. For example,  a prospective, randomized, comparative study involving 80 community dwelling patients in Melbourne, Australia reported that a home visit service by pharmacists resulted in 45% of patients having their drugs either reduced or stopped, and 38% surplus medication removed, aiding safe disposal of drugs and potentially reducing toxicity and environmental damage. 

In contrast, other trials have shown no effect on hospital or care home admissions, or on medicine costs and health related quality of life. For example, a UK study of more than 800 patients over 80 years old receiving an intervention involving two home visits by a pharmacist within two weeks and eight weeks of discharge to educate patients and carers about their drugs, remove out-of-date drugs, and inform general practitioners of drug reactions or interactions, resulted in more deaths and no improvement in quality of life, compared to usual care. Findings related to cost effectiveness have also been mixed. Most of the studies have involved reasonable follow-up lengths of six to twelve months. Without further investigation into the individual trial details and synthesis of the findings, it is not possible to tease out whether there were any commonalities between the interventions that showed benefit, or alternatively those that showed no change or benefit. In terms of feasibility, most studies which assessed satisfaction, found the option of a home service to be valued by general practitioners, community pharmacists and the elderly living in the community.

Research questions

  1. Do home visits by community pharmacists for those who are elderly and/or vulnerable result in greater patient safety, improved medication adherence, lower readmission rates and improved quality of life?
  2. Are home visits by community pharmacists to elderly and/or vulnerable populations cost effective?
  3. What are the barriers and facilitators to a home visit service by community pharmacists for elderly and /or vulnerable populations?
Contact 
Dr Mike Allen
m.allen@exeter.ac.uk