Development of a model of medication review for use in clinical practice: Bristol Medication Review Model
Medication review is a core aspect of medicines optimisation, although robust evidence is lacking that this translates to improvements in important clinical outcomes. Existing models of medication review vary substantially, both in content and structure, and are not necessarily easy to implement in real-world clinical practice. This study aimed to use evidence from the existing literature to identify the ‘active ingredients’ of a medication review, and use this to inform development of a model of medication review for use in clinical practice.
A systematic review was conducted (PROSPERO: CRD42018109788) to identify randomised control trials of medication review in adults, with no specific therapeutic or prescribing objective, that did not form part of more complex medication optimisation interventions. Searches were conducted up to 2018, using MEDLINE and Embase, building on the previous review by Huiskes (BMC Fam Pract 2017). A working group, comprising primary and secondary care clinicians as well as patients, was convened to develop the model through an iterative consensus process. The group was presented with the systematic review findings, brief evidence summaries for core review components, and examples of previous models. Working group members agreed the main purpose of the review model, overarching model structure, review components, and supporting material.
We identified 1498 potential records, of which 16 were suitable for full-text assessment, and 12 articles included in the analysis. From the original 33 articles identified by Huiskes, 20 were considered suitable for inclusion. The resulting 32 articles represented 28 unique studies, with moderate bias overall. Consistent medication review components included reconciliation (26/28 studies), safety assessment (22), suboptimal treatment (19), patient knowledge/preferences (18), adherence (14), over-the-counter therapy (13) and drug monitoring (10). There was limited evidence from studies for improvement in key clinical outcomes; studies were too heterogenous to allow meta-regression of review components with outcomes.The review structure was underpinned by patient values and preferences, with parallel information gathering and evaluation stages, feeding into the final decision making and implementation. The working group included most of the key components identified in the literature within the proposed model, although cost reduction and use of potentially inappropriate prescribing tools were excluded. The working group considered the final model to benefit from a patient-centred, holistic approach, which captured both patient-orientated and medication-focused problems, and aligned with traditional consultation methods thus facilitating implementation in practice. Additional materials were developed to support implementation.
The Bristol Medication Review Model is suitable for use by all health care professionals with relevant clinical experience, providing flexibility of implementation not limited to a particular healthcare setting. The model provides a clear framework for standardised delivery of structured medication reviews which will be appropriate for use in both a clinical and research environment.