Clinical medication review: one step beyond: Computer rules of personal goals?

In this ageing society, older persons are using more and more medications for chronic diseases. During a clinical medication review, the community pharmacist evaluate all the medication use together with the patient in a personal conversation. They discuss whether all the medication is necessary, if there are drugs missing, or if there are side effects or usage problems. Then the pharmacist proposes a pharmaceutical care plan together with the general practitioner to solve these drug-related problems. These clinical medication reviews are increasingly performed in the Netherlands over the past years. In this thesis, we investigated how we could further optimise the efficiency and effectiveness of these clinical medication reviews. Therefore we designed the 'Drug use Reconsidered in the Elderly using goal Attainment scales' (DREAMeR) study: a randomised controlled trial performed in 35 community pharmacies in the Netherlands. 629 older persons aged 70 years and over using seven or more chronic drugs were included. Patients in the intervention group (n=315) received a clinical medication review focused on personal goals and patients in the control group (n=314) received usual care. In the DREAMeR study, we chose a patient-centred approach, because clinical-decision support systems were not specific enough to identify the most important drug-related problems for older persons. An innovative aspect of this study was the measurement of personal goals and health-related complaints. Primary outcomes were health-related quality of life, measured with EQ-5D and EQ-VAS and the number of health-related complaints with an impact on daily life (twelve different complaints, such as pain and dizziness were measured). The attainment of goals, such as reduction or pain or number of pills, was evaluated with a special measurement scale: goal attainment scaling. 90% of older persons was able to set at least one goal together with the pharmacist and more than 50% of persons improved on their personal goals. In the group of older persons who received a clinical medication review, quality of life measured wih EQ-VAS improved and the number of health-related complaints with impact on patients’ daily lives decreased, although quality of life measured with the EQ-5D did not change. Simultaneously, the number of drugs used decreased. Finally, an economic evaluation showed that there was a high probability that a clinical medication review can lead to cost savings in healthcare expenditure