Impact of Psychotropic Medication Reviews on Prescribing Patterns

Methods

Patients were included in this study if they had a PMR note entered in the EMR between September 2014 and January 2015. Baseline demographic information collected included patient age and gender. One study author manually reviewed all PMR notes and collected the type of pharmacy intervention (characterized as recommendation for medication adjustment, patient education, both medication adjustment and patient education, or no recommendation), provider discipline, provider response to intervention, and any changes to medication therapy that occurred as a result of pharmacist intervention.

When patients were not cognitively able to receive education, family members or caretakers were educated. The primary outcome of this study was prescriber response to pharmacist recommendations, which was characterized as acknowledged, ignored, accepted, or declined with justification. In instances where both medication adjustment and patient education was recommended, the recommendation was considered to be accepted only if both components of the recommendation were addressed. The secondary outcome sought to identify any difference in provider response based on discipline.

Results

Eighty-nine patients were included in the study. Due to the nature of LVAMC, the patient population was fairly homogeneous, with an average patient age of 80 years (range 52-95 years); > 97% of patients were male. Fifty patients were noted to have prescriptions for benzodiazepines and were aged > 75 years, 11 patients had prescriptions for benzodiazepines and a diagnosis of dementia, and 38 patients had prescriptions for antipsychotics and a diagnosis of dementia. Several patients fell into more than one of the categories (Table 1).

Specific written recommendations were made for 69 (78%) patients, with 20 patients having appropriate documentation in the chart for therapy continuation. The most common documented reasons for continuation of therapy were (a) patient/caregiver educated and consent to continue therapy already documented; (b) recent dose reduction or discontinuation attempt failed; (c) recent successful dose reduction; or (d) documented risk to patient or others if medication were to be discontinued.

Most recommendations were for medication adjustments (n = 54; 78.3%). Six (8.7%) recommendations were for patient education only, and 9 (13%) recommendations were for both medication adjustment and patient education. Overall, 33 (48%) of recommendations were accepted, 21 (30%) were not acknowledged, and 15 (22%) were declined. The most common outcome of accepted recommendations was a dose reduction with full taper planned by provider. The most common reasons for declined recommendations were (a) caregivers were educated and consented to continued treatment; (b) clinical presentation warranted continued treatment; (c) patient refused recommended changes; and (d) prescriber preferred to wait until next appointment to discuss with patient (Table 2).

Forty-nine recommendations were made to prescribers in the Psychiatry Department, 17 to prescribers in the Home-Based Primary Care (HBPC) Department, 15 to prescribers in the Primary Care Department, and 8 to prescribers in the Neurology Department. Prescribers in the Primary Care Department accepted recommendations at the highest rate (n = 13; 69%), while Neurology Department prescribers (n = 2; 33%) accepted recommendations at the lowest rate.