Health Services Research & Development

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2006 HSR&D National Meeting Abstract


1026 — The VA Enhanced Pharmacy Outpatient Clinic (EPOC) Trial: A Randomized-Controlled Intervention

Author List:
Kaboli PJ (Iowa City VAMC)
Hoth AB (Iowa City VAMC)
Carter BL (Iowa City VAMC)
Chrischilles EA (University of Iowa College of Public Health)
Schorr RI (University of Tennessee, Memphis)
Ness J (University of Iowa College of Medicine)
Bhattacharyya A (Iowa City VAMC)
Barnett MJ (Iowa City VAMC)
Rosenthal GE (Iowa City VAMC)

Objectives:
Older patients on multiple medications are at risk for adverse drug events (ADEs) and other medication-related complications. This study evaluated the efficacy of a pharmacist-physician team to improve medication prescribing and patient outcomes.

Methods:
The sample included 493 primary care patients >= 65 years receiving prescriptions for >= 5 medications. Patients were randomized to usual care or to an intervention, which included a structured medication history and records review by a pharmacist and development of therapeutic recommendations that were presented to primary care providers by the intervention physician. The primary outcome measurement was the Medication Appropriateness Index (MAI), a validated instrument that measures 10 domains of prescribing quality. Baseline and 3-month data were obtained and change assessed by analysis of covariance.

Results:
Patients had a mean age of 74, were 98% male, and were taking a mean of 13.7±4.9 medications at baseline. The mean number of therapeutic recommendations per intervention patient was 7.1±3.5; of these, 63% were adopted by the primary care provider immediately and 72% within one year. Provider surveys indicated the intervention was well accepted by 80%; 77% indicated that they would refer patients to the service. Improvements in mean MAI scores, between baseline and 3 months, were greater (p=.04) for intervention (15.7 to 10.8) than usual care (15.5 to 12.3) patients. Decreases in the mean number of medications patients were prescribed were also somewhat greater in intervention patients (1.0 vs. 0.1; p=.08). However, no differences were observed in the occurrence of ADEs (21% of patients in both groups reported >= 1 ADEs; p=.97) or changes in health-related quality of life (SF-8), symptom scores, overall patient satisfaction, medication knowledge, monthly drug costs, or VA and non-VA healthcare utilization.

Implications:
This well-accepted collaborative pharmacist-physician intervention resulted in improvements in prescribing appropriateness in older patients on multiple medications. However, no significant changes were observed in ADEs, healthcare utilization, drug costs, and other endpoints.

Impacts:
Improving prescribing quality through one-time pharmacist-physician interventions may have limited potency with regard to improving clinically relevant outcomes. Future research should determine if the benefit of such interventions is limited to particular subgroups of patients.