BMJ  2005;330:E347 (16 April), doi:10.1136/bmj.330.7496.E347

BMJ USA: Letter

RAPID RESPONSE FROM BMJ.COM

Following is an edited excerpt from one of the Rapid Responses generated by this article, all of which can be read in their entirety at http://bmj.bmjjournals.com/cgi/eletters/330/7486/293#94490.

—Editor

The Holland et al findings that pharmacist medication reviews for home-dwelling patients are associated with a 30% increase in emergency hospitalizations and a greater reduction in global health score (as measured on a visual analog scale) is paradoxical, counterintuitive, and inconsistent with the US literature on pharmacist management of medication therapy.^1–3 The authors attribute these results to either 1) an increase in health care–seeking behavior by intervention patients who become better-sensitized to their health conditions, 2) an increase in hospitalizations among frail intervention patients who otherwise would have died, 3) an increase in iatrogenic medication adherence among intervention patients, and/or 4) an increase in intervention patient confusion and anxiety about health care services.

While all of these explanations imply strong pharmacist intervention effects (good or bad), it would be valuable to have more details about the patient sample and their reasons for hospital readmission....

This sample is atypical in that all patients were quite elderly (mean age 85.5), averaged 5.9 drugs daily, and were recruited from an initial inpatient admission. Patients admitted to the hospital initially because of iatrogenic medication prescribing, or other issues of relatively poor health care quality (eg, inappropriate medical diagnosis or treatment) would be more likely to be recruited into this study than patients recruited from the community or from ambulatory settings. It is not clear that the pharmacist interventions utilized in this study were specifically designed to address and correct such health care quality issues.

The study certainly raises a very valuable cautionary note that medication management interventions, particularly in the frail elderly, and particularly in patients averaging more than five daily medications, need to be designed and planned very carefully to ensure that the intervention benefits outweigh the risks. But because of these study design concerns it is not clear how relevant these findings are to the broader issue of assessing the value of medication therapy management services.

Department of Pharmaceutical Economics and Policy University of Southern California, School of Pharmacy, Los Angeles, CA

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Competing interests: None declared.

References

1. Etemad L, Hay J. Cost effectiveness analysis of pharmaceutical care in a medicare drug benefit program. Value in Health. 2003;6(4): 425-435.
2. Yuan Y, Hay JW, McCombs JS. Mortality and hospitalization impacts of pharmacist consultation in ambulatory care. Am J Manag Care 2003;9: 101–12.
3. McCombs JS, Cody M, Parker JP, Johnson KA, Besinque K, Borok G, et al. The Kaiser Permanente/USC Patient Consultation Study: change in use and cost of health services. Am J Health-Syst Pharm 1998;55(2): 2485-99.[Abstract/Free Full Text]

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