Is medication regimen complexity often overlooked, and what can we do about it?

Patients are often identified for referral for medication reviews based on the complexity of their treatment regimen. Regimen complexity can arise due to the number of mediations, formulations, administration timings, and special instructions for medication use. Regimen complexity has been associated with non-adherence, hospitalisations, and medication errors. Patients with three or more medical conditions, who experience difficultly self-administering specific formulations (e.g. inhalers, eye drops, transdermal patches) or who have other difficulty self-managing their medication regimen are thought to benefit from medication review.

In this issue of JPPR, Seth et al. describe an analysis of 196 Home Medicines Reviews (HMRs) in New South Wales, Australia. Seth et al. report that patients had similar median Medication Regimen Complexity Index (MRCI) scores before (28.5) and after (29.0) HMR, even when assuming that all pharmacists' recommendations were implemented. These findings were consistent with an earlier study of 285 recipients of Residential Medication Management Reviews (RMMRs) by Pouranayatihosseinabad et al. There are some considerations when interpreting the results of these two studies. First, the HMRs and RMMRs were performed by just two pharmacists and one RMMR service provider, respectively meaning that generalisability may be limited. Second, it is unclear whether the general practitioners who initiated these HMRs and RMMRs specified regimen complexity as a reason for referral. The stated purposes of the HMR and RMMR programs are broad and regimen simplification is not explicitly stated. Nevertheless, the lack of apparent impact on MRCI scores (the most widely used method for quantifying regimen complexity) will cause readers to question whether opportunities to simplify complex medication regimens are overlooked when conducting medication reviews.

Seth et al. correctly argue that not all clinically important HMR recommendations reduce regimen complexity. Medication review often includes a range of activities, including taking a best possible medication history and conducting an individualised assessment of the benefits and risks of each medication. The HMRs analysed by Seth et al. also involved recommending additional medications, patient education, lifestyle advice and referral to other health care professional, which may increase the complexity of treatment regimens even as patients better understand their medications. Previous research suggests HMR recipients have a mean of 3.6 medication-related problems each, and so it is unrealistic to expect all aspects of medication management be addressed in a standard HMR or RMMR of 45–60 min duration and the corresponding follow ups.

In contrast to Seth et al.4 and Pouranayatihosseinabad et al, a cluster randomised controlled trial in eight South Australian residential care homes found that a one-off, structured, 5-step simplification process resulted in modest but sustained reductions in residents' number of daily administration times. This was a ‘simplification review’ rather than a ‘clinical review’ and involved strategies that did not change the therapeutic intent such as consolidating dose administration times, recommending long-acting rather than multiple shorter-acting formulations, and using combination products when available. A pharmacist-led simplification service has also been successfully trialled for recipients of community-based home care services. Nearly two-thirds and over half of the participants in these two studies respectively could take their medications in a simpler way. This was despite many participants in the former study having received RMMRs.

Australia and Japan both have ageing populations, high rates of multimorbidity, and similarities in their models of aged care. The Japanese Society of Geriatric Pharmacy recently described the burden to residents and nurses associated with needing to administer complex medication regimens, including in residents who have received effective medication reviews. The Japanese Society highlight that reducing the number of daily medication administration times following a medication review may free up time for nurses working in residential care to focus on other direct care activities.

The new Australian Aged Care On-site Pharmacist (ACOP) program provides an opportunity to expand the ‘pharmacist tool-kit’ in residential care to include a range of resident- and system-level services. These services could be delivered as a standalone service or following a medication review. A simplification review could be delivered alongside a clinical review to assist people in a range of care settings to better manage complex medication regimens. This would be particularly relevant for people with frailty, cognitive impairment, low health literacy, language barriers and other factors that may increase the risk of medication-related harm.