Pharmacist-led medication reviews to improve medication use by older women: uptake, impact and enabling technology

Background: The proportion of frail older people is growing in Australia and Malaysia with implications in all sectors of society. The prevalence of polypharmacy and use of potentially inappropriate medications (PIMs) is highest among the oldest old (≥80 years), especially women. Medication reviews can optimise medications although the outreach of medication reviews in Malaysia is limited. In Australia, Residential Medication Management Reviews (RMMRs) and Home Medicines Reviews (HMRs) are remunerated by the Government. There is little evidence about the association between frailty, polypharmacy and PIMs, and the impact of RMMRs and HMRs and associated medication costs. Therefore, this thesis determined common combinations of medications to underpin prevalence and associations between polypharmacy, PIMs and frailty, and the uptake and impact of RMMRs and HMRs. In Malaysia, the algorithm that underpinned an app to facilitate medication reviews, MedReview, was designed by the candidate and evaluated. Methods: Data were obtained from participants enrolled in the Australian Longitudinal Study on Women’s Health from 2003 (aged 77 to 82 years) to 2017 (aged 91 to 96 years). Latent class analysis was used to determine medication combinations, and generalised estimating equations were used in regression analyses to determine associations over time. Data from a validated questionnaire distributed among Malaysian community pharmacists were rigorously evaluated using factor analysis. Results: Frail women aged ≥77 years had an 8% increased risk of having continuous polypharmacy and a 2% increased risk of using PIMs, both when adjusted for other characteristics. There was a high tendency to use medications of multiple anatomical groups, including regular use of antiinfectives. In 2017, only 26% of eligible women residing in aged care and 3% of eligible women residing in the community received RMMRs and HMRs, respectively. RMMRs did not reduce the use of PIMs and polypharmacy, whereas HMRs increased polypharmacy and PIMs, in the following year. Women experienced increased out-of-pocket (OOP) medication and PIM costs over time, with women who received medication reviews having higher OOP costs. In Malaysia, community pharmacists had a positive attitude about the MedReview app and intended to use it, finding it trustworthy. Conclusions: The thesis provides evidence that medications for older people can still be optimised, especially for the frail oldest old, and that the RMMRs and HMRs in Australia may not be appropriately targeting this segment of the population. The evidence can be used by policy-makers in Australia and provides a reference point for other countries. This study also provided a platform to encourage the uptake of medication reviews in Malaysia, Australia and elsewhere, by designing and evaluating the MedReview app.