Portal de Periódicos da CAPES

Medication Reconciliation in an Outpatient Geriatrics Clinic: Does Accuracy Improve If Patients “Brown Bag” Their Medications for Appointments?

2014; Wiley; Volume: 62; Issue: 3 Linguagem: Inglês

10.1111/jgs.12706

1532-5415

Erin M. Sarzynski, Clare Luz, Shiwei Zhou, Carlos F. Ríos‐Bedoya,

Patient-Provider Communication in Healthcare

Outpatient medication reconciliation research, including patient and provider education interventions, has shown promise for reducing medication discrepancies in medical records.1-5 However, these studies are limited by varying methods of determining what medications individuals are taking—patient recall, pharmacy records, home visits, "updated" medication lists, "brown bag" review, phone interviews, or any combination thereof. Among studies that included "brown bag" requests, fewer than one-third of subjects brought medications to their appointments,2, 4 and one lacked a control group.6 Still, physicians and pharmacists recommend that patients "brown bag" their medications for office visits.5-7 The current study sought to determine whether physician-documented medication lists are more accurate among individuals who bring medications to outpatient appointments compared with those who do not. This cross-sectional pilot study was conducted in 2011 at a university-affiliated community geriatric clinic in mid-Michigan. The clinic provides routine office visit reminder calls that include a generic request for patients to "brown bag" their medications for appointments. Eligible elderly adults presented for primary care services and were excluded for dementia, inability to communicate via telephone, and receiving assistance with medication management. Subjects self-selected into two groups: those who brought at least one medication ("brown-baggers," BBs) and those who did not bring any medications ("non-brown-baggers," NBBs). Three medication lists were generated for each subject: standard provider-documented list in patient's chart (chart list), in-depth interview at point-of-care (POC list), and post-appointment telephone interview (telephone list, reference standard). Chart lists were assessed for completeness of relevant data (medication name, dose, route, frequency). Chart and POC lists were compared with telephone lists among BBs and NBBs for accuracy3 of drug and dosing information. Discrepancies were defined as inclusion (medications in the chart that patients were no longer taking), omission (absence of medications in the chart that patients reported taking), and inaccuracies in dose or frequency instructions (Table 1). Univariate statistics were performed, including Fisher exact test and t-tests, to compare proportions and mean differences between BBs and NBBs, using a Type I error of .05 to determine statistical significance. Analyses were performed using STATA version 11.2 (StataCorp, College Station, TX). Subjects (mean age 79.8; 67% female) took an average of 9.9 medications (5.7 prescription drugs). There were no differences in demographic or medical comorbidities between BBs and NBBs. Thirty-three (72%) bagged their medications for appointments (BBs); 39% brought all medications. All BBs reported that their physician reviewed their medications, compared with 62% of NBBs (P < .01). All chart lists were incomplete (≥1 medications missing data; 94% lacked "route"). Excluding route, 65% were incomplete, with no difference between BBs and NBBs. Few chart lists were accurate (6.5% overall, 6.1% BBs, 7.7% NBBs); 76% contained discrepancies of inclusion, omission, dosing instructions, or combinations of the three. Within POC lists, there were fewer inclusion and omission discrepancies among BBs (42%) than NBBs (77%; P = .05) (Table 1). Although brown bag requests are common practice among geriatrics clinics and widely endorsed by and nurses, pharmacists, and clinicians,7-9 there are no standardized request instructions which then lead to wide variation in clinical practice. Studies assessing "brown bag" interventions reflect this heterogeneity, with some asking patients to "bring all of your medications" and others prompting specific medications, including non-oral medications, over-the-counter medications, and herbal supplements.6-10 The current study intentionally provided vague instructions because it is common practice in primary care settings. Consistent with other research,4, 5 this pilot study suggests that patients who "brown bag" medications for office visit review may not bring every medication they report taking. Thus, provider-maintained chart lists may be no more accurate in BBs than NBBs. Medication lists generated at POC using semistructured interviews contain fewer inclusion and omission discrepancies among BBs than NBBs. Study limitations include small sample size and single-site location, which reduces generalizability. Furthermore, bagging instructions were intentionally vague, in order to achieve a reasonable sample of NBBs, which led to patient self-selection bias. All BBs perceived that their physicians reviewed their medications, compared with 62% of NBBs—a possible benefit of brown-bagging—although there were no differences in chart-recorded medication accuracy between BBs and NBBs. Furthermore, clinicians should not assume that their patients' "brown bags" are complete. This pilot study challenges the use of the "brown bag" practice alone to reconcile medications during routine care, unless coupled with specific instructions, in-depth questioning, and updating the medication list accordingly. Unfortunately, such comprehensive medication reviews are time-intensive10 and may not be practical during routine office visits. The authors thank Kevin Foley, MD, and Charles Given, PhD, for their critiques. Presented at the American Geriatrics Society Annual Meeting, Grapevine, Texas, May 2013. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Funded by Blue Cross Blue Shield of Michigan Foundation. Author Contributions: Sarzynski E.M.: study design, subject recruitment, interviews, funding, manuscript preparation. Luz C.C.: study design, manuscript revisions. Rios-Bedoya C.F.: study design, data analysis. Zhou S.: recruitment, interviews. Sponsor's Role: Data analysis and conference travel was supported by Blue Cross Blue Shield of Michigan Foundation.