Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews

  • Review
  • Overview

Authors


Abstract

Background

Numerous systematic reviews exist on interventions to improve consumers’ medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers’ medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use.

Objectives

To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services.

Methods

We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers’ medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews.

Main results

We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.

Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.

Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.

No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes.

Authors' conclusions

Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers’ medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.

Decision makers faced with implementing interventions to improve consumers’ medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.

Resumen

Antecedentes

Intervenciones orientadas a los consumidores para el uso de medicamentos y prescripciones basado en la evidencia: un resumen de revisiones sistemáticas

Existen numerosas revisiones sistemáticas sobre intervenciones para mejorar el uso de medicamentos por parte de los consumidores, pero esta investigación está distribuida entre enfermedades, poblaciones y contextos. El alcance y el propósito de las revisiones sobre el uso de medicamentos por parte de los consumidores también varían ampliamente. Dichas diferencias crean retos para los responsables de tomar decisiones que buscan pruebas a nivel de revisiones para informar las decisiones acerca del uso de medicamentos.

Objetivos

Resumir las pruebas de las revisiones sistemáticas sobre los efectos de las intervenciones que apuntan a los consumidores de asistencia sanitaria para promover el uso de medicamentos y prescripciones basado en la evidencia por parte de los consumidores. Se buscaron pruebas sobre los efectos en la salud y otros resultados para los consumidores, los profesionales y los servicios de asistencia sanitaria.

Estrategia de búsqueda

 

Criterios de selección

 

Obtención y análisis de los datos

 

Resultados principales

Se incluyeron 37 revisiones (18 Cochrane, 19 no Cochrane), de calidad metodológica variada.

Las revisiones evaluaron intervenciones con objetivos diversos incluido el apoyo al cambio en el comportamiento, la minimización del riesgo, la adquisición de habilidades y la provisión de información. Ninguna revisión procuró promover la participación de los consumidores a nivel de los sistemas en las actividades relacionadas con los medicamentos. El cumplimiento con los medicamentos fue el resultado informado más comúnmente, aunque también se informaron otros resultados como los clínicos (salud y bienestar), del uso del servicio y del conocimiento. Las revisiones rara vez informaron los eventos adversos o efectos perjudiciales, y las pruebas fueron escasas para varias poblaciones, incluidos los niños y los jóvenes, los cuidadores y las personas con multimorbilidad.

Las intervenciones prometedoras en cuanto a la mejoría del cumplimiento y otros resultados importantes del uso de medicamentos (p.ej. eventos adversos, conocimiento) incluyeron automonitorización y autocuidado, dosificación simplificada e intervenciones que incluían directamente a los farmacéuticos. Otras estrategias parecieron prometedoras con relación al cumplimiento, aunque sus efectos fueron menos consistentes. Las mismas incluyeron recordatorios; educación combinada con adiestramiento de las habilidades de autocuidado, asesoramiento o apoyo; incentivos económicos; e intervenciones con trabajadores sanitarios no profesionales.

Ninguna intervención fue efectiva para mejorar todos los resultados del uso de medicamentos en todas las enfermedades, las poblaciones o los contextos. Para algunas intervenciones, como la información o la educación proporcionadas solas, las pruebas indican ineficacia; para muchas otras no hay pruebas suficientes para determinar los efectos sobre los resultados del uso de medicamentos.

Conclusiones de los autores

Al reunir sistemáticamente las pruebas de las revisiones es posible identificar las intervenciones efectivas o prometedoras para mejorar el uso de medicamentos por parte de los consumidores, así como aquellas cuyas pruebas indican ineficacia o incertidumbre.

Los responsables de tomar decisiones, enfrentados con la ejecución de intervenciones para mejorar el uso de medicamentos por parte de los consumidores, pueden usar este resumen para informar estas decisiones y también para considerar el rango de intervenciones disponibles; mientras que los investigadores y los patrocinadores pueden usar este resumen para determinar dónde se necesita investigación. Sin embargo, también deben considerarse las limitaciones de la bibliografía en relación con la ausencia de pruebas sobre los resultados importantes y las poblaciones específicas, como las personas con multimorbilidad.

Traducción

Traducción realizada por el Centro Cochrane Iberoamericano

Plain language summary

Strategies to improve safe and effective medicines use by consumers: an overview of systematic reviews

Medicines are a cornerstone of treatment for many health problems. Many strategies exist to help people to use medicines safely and effectively, but research in the area is not well organised across diseases, populations and settings. This can make it difficult for policy makers, health professionals and others to find and use the evidence about what works and what does not.

This overview summarised the evidence contained in 37 systematic reviews on consumers' medicine use. A wide range of strategies to improve medicines use, including information provision, support for behaviour change, risk minimisation and skills acquisition, was included. No one type of strategy improved medicines use outcomes across all diseases, populations or settings, or for all outcomes.

Strategies that appear promising to improve medicines use included medicines self-monitoring and self-management, simplified dosing and direct involvement of pharmacists in medicines management. Other strategies such as reminders; education combined with self-management skills training, counselling or support; financial incentives; and strategies involving lay health workers may also show promise, although effects were less consistent. Some strategies, such as providing information or education as single interventions, may be ineffective; while for many strategies there is not enough evidence to decide how effective or ineffective they are.

Reviews included in this overview often had methodological limitations, meaning results should be interpreted with caution. Despite the large number of included reviews there are many gaps in the assembled evidence on medicines use strategies, such as those focussing on children, young people or carers, or those for people with more than one coexisting health problem.

Ancillary