Medication review, especially in patients who take a large number of drugs, can be very complex, like a Rubik’s cube with many elements. Medication Decision Support Systems can help clinicians solve the 3D puzzle of complex therapies.
The World Health Organisation (WHO) considers medication reconciliation to be one of the best strategies for ensuring good quality patient care. In Italy, reconciliation has been included among the criteria and accreditation requirements that Regions and health structures are required to ensure for their patients. In this context, the Ministry of Health issued Recommendation No. 17 for a proper reconciliation of drug therapy and, more recently, guidelines for the reconciliation of drug therapy on the territory during the care transitions.
The document focuses on the importance of medication reconciliation within nursing-care homes, since patients in these homes have a clinical picture characterized by intrinsic age-related fragility and frequent comorbidities associated with chronic diseases.
Patients in these facilities have a high risk of Adverse Drug Reaction (ADR), with important relapses in terms of hospitalization and mortality. Literature data show that as the number of drugs taken increases, the risk of ADR grows, with an increase of 82% with the intake of 7 drugs.
In this context, in addition to the onset of ADR, polypharmacy is a risk factor for many aspects such as an increased probability of even serious interactions between drugs or between drugs and foods taken, greater complexity in the management of drugs, and exposure to potentially inappropriate drugs.
Studies have shown that two-thirds of long-term residents are exposed to errors and therapeutic discrepancies and that 25% of ADRs are caused by therapy errors. Reconnaissance and medication reconciliation procedures, when correctly applied, have shown a reduction of 15-48% in the number of ADRs and 70% in therapy errors.
Since the transfer of the patient from one healthcare setting to another represents the moment when the patient is most exposed to errors in therapy, the document recommends that the medication reconciliation process be carried out at all so-called “Transition of Care” moments such as hospitalisation or transfer from home to a nursing-care structure and/or from nursing-care home to another.
Medication reconciliation consists of a critical review of the medicinal products in use and must be carried out by the doctor who, before proceeding with a prescription, assesses the appropriateness of continuing the ongoing pharmacological treatment and its compatibility with the therapy indicated in the specific circumstance.
During medication reconciliation, the physician should review the drug therapy, seeking, where possible, to avoid the prescription of drugs of dubious efficacy and unfavourable risk-benefit profile and to simplify it in order to improve patient adherence. He should also compare the list of medicines obtained from the reconnaissance phase with the medicines he considers necessary to administer, in order to avoid inconsistencies, omissions, associations at risk of incompatibility/drug interactions and errors.
In this respect, the document states that the use of specific software for the detection of possible drug interactions and the STOPP or Beers criteria for the detection of potentially inappropriate prescriptions would be desirable.
On this point, in my opinion, the document should be mandatory because it is not possible to make a medication reconciliation by eye or using inadequate software tools.
The complexity inherent in the reconciliation pharmacology that, not by chance in the opening of this article I compared to a 3D puzzle, is due to the following factors:
- the high amount of interactions and ADR that can arise in a therapy; to give a numerical indication, only the first ones, are 21,000 more (interactions between drugs and between drugs and food);
- the need, following the previous point, to discriminate in a qualitative way the interactions and ADRs;
- the need to reconcile different dimensions of risk: interactions, ADRs, contraindications (e.g. elderly people or people with reduced renal function);
- the need to carry out a multidimensional analysis aimed at assessing the possible combinations, the consequent levels of risk, in order to carry out a risk/benefit analysis.
To manage all this, access to one or more pharmacological databases is not sufficient; on the contrary, a Medication Decision Support System (MDSS) is required that is able to operate considering the entire therapy, current and new, all the risks, highlighting the existing correlations and the level of risk or inappropriateness that each drug, considering the clinical picture of the patient, can determine.
In the figure above you can see an example of MDSS of this type that presents a multidimensional pharmacological risk matrix and suggests possible alternatives that the physician might consider.
The quality and capability of the tool that works to achieve medication reconciliation is crucial. Working only on the basis of one’s own knowledge or accessing partial contents, not linked to each other, without being able to count on suggestions and indications on how to manage the criticalities detected, is like pretending to operate a patient having eyes closed or in the dark.