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

  1. Rebecca Ryan1,*,
  2. Nancy Santesso2,
  3. Dianne Lowe3,
  4. Sophie Hill1,
  5. Jeremy Grimshaw4,
  6. Megan Prictor5,
  7. Caroline Kaufman6,
  8. Genevieve Cowie1,
  9. Michael Taylor7

Editorial Group: Cochrane Consumers and Communication Group

Published Online: 29 APR 2014

Assessed as up-to-date: 31 MAR 2012

DOI: 10.1002/14651858.CD007768.pub3


How to Cite

Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD007768. DOI: 10.1002/14651858.CD007768.pub3.

Author Information

  1. 1

    La Trobe University, Centre for Health Communication and Participation, School of Public Health and Human Biosciences, Bundoora, VIC, Australia

  2. 2

    McMaster University, Department of Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada

  3. 3

    School of Public Health and Human Biosciences, La Trobe University, Centre for Health Communication and Participation, Bundoora, VIC, Australia

  4. 4

    Ottawa Hospital Research Institute, Clinical Epidemiology Program, Ottawa, ON, Canada

  5. 5

    School of Public Health and Human Biosciences, La Trobe University, Cochrane Consumers and Communication Review Group, Bundoora, VIC, Australia

  6. 6

    Austin Regional Clinic, Cedar Park, TX, USA

  7. 7

    Australian Catholic University, Public Health, School of Allied Health, Fitzroy, VIC, Australia

*Rebecca Ryan, Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, 3086, Australia. r.ryan@latrobe.edu.au.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 29 APR 2014

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

Background

Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers’ medicines use.

This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.

Objectives

To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.

Methods

Search 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 databases from their start dates to March 2012.

Selection criteria: We screened and ranked reviews based on relevance to consumers’ medicines use, using criteria developed for this overview.

Data collection and analysis: We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.

Main results

We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.

Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.

Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:

· simplified dosing regimens: with positive effects on adherence;

· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).

Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:

· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;

· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;

· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;

· financial incentives: with positive, but mixed, effects on adherence.

Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.

There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.

Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.

In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.

In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.

Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.

Authors' conclusions

This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.

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 decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

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

Review question: This is an update of an overview first published in 2011. Researchers in the Cochrane Collaboration reviewed the evidence from systematic reviews about the effects of interventions to improve safe and effective medicines use by consumers, irrespective of disease, medicine type, population or setting.

Background: 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 poorly 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.

Study characteristics: This overview summarised the evidence from 75 systematic reviews on consumers' medicine use published to March 2012. Reviews covered acute and chronic diseases in diverse populations and settings; and evaluated a wide range of strategies to improve medicines use, including support for behaviour change, risk minimisation and skills acquisition. Medicines adherence was the most commonly-reported outcome, with others such as knowledge and clinical outcomes also reported. Adverse events were identified less often.

Key results: Collectively, the results suggest that there are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes. However, no single strategy improved all medicines-use outcomes across all diseases, populations or settings.

Strategies that appear to improve medicines use include medicines self-monitoring and self-management programmes, while simplified dosing regimens and directly involving pharmacists in medicines management (eg medicines reviews) appear promising. Other strategies, such as delayed antibiotic prescriptions; practical management tools (eg reminders, packaging); education or information combined with other strategies (eg self-management skills training, counselling); and financial incentives, may also have some positive effects, but their effects are less consistent.

Some strategies, such as directly observed therapy, may be ineffective. Other strategies such as providing information or education alone may have variable effects, being ineffective to change some outcomes (eg medicines adherence) but improving others such as knowledge, which is key for informed medicines choices. Despite a doubling of the number of included reviews in this update, uncertainty remains about the effects of many interventions, and the evidence on what works was particularly sparse for several populations, including children and young people, carers, and people with multimorbidity.

Quality of the evidence: Included reviews often had methodological limitations - at study level, review level, or both - meaning results should be interpreted with caution.

 

Laienverständliche Zusammenfassung

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. Laienverständliche Zusammenfassung

Strategien zur Verbesserung der Verwendung von sicheren und wirksamen Medikamenten bei Konsumenten: ein Überblick von systematischen Reviews

Reviewfrage: Dies ist eine Aktualisierung einer Übersicht, welche erstmals 2011 veröffentlicht wurde. Forscher der Cochrane Collaboration begutachteten die Evidenz aus systematischen Reviews zur Wirkung von Interventionen, welche die Nutzung von sicheren und wirksamen Medikamenten bei Konsumenten verbessern wollen, unabhängig von der Art der Erkrankung, des Medikamententypus, der Population oder des Settings.

Hintergrund: Medikamente stellen einen der Grundpfeiler in der Behandlung von vielen Gesundheitsproblemen dar. Es existieren viele Strategien, um Menschen dabei zu helfen Medikamente sicher und wirksam zu verwenden, jedoch ist die Forschung in diesem Gebiet, welche über verschiedene Krankheiten, Populationen und Settings spannt, nur schlecht organisiert. Dies kann dazu führen, dass es für politische Entscheidungsträger, Gesundheitsfachleute oder andere erschwert wird, Evidenz, über das was effektiv und nicht effektiv ist, zu finden und zu nutzen.

Studienmerkmale: Diese Übersicht fasst die Evidenz aus 75 systematischen Reviews zur Medikamentennutzung bei Konsumenten, welche bis März 2012 veröffentlicht wurden, zusammen. Die Reviews umfassten akute und chronische Krankheiten in diversen Populationen und Settings und sie untersuchten eine breite Palette an Strategien zur Verbesserung der Medikamentennutzung, wozu die Unterstützung zur Verhaltensänderung, die Risikominimierung und die Aneignung von Fähigkeiten zu zählen sind. Einhaltung der Dosierung und Art der Anwendung war der am meisten berichtete Endpunkt, wobei Kenntnisse und klinische Endpunkte ebenso berichtet wurden. Unerwünschte Ereignisse wurden weniger häufiger identifiziert.

Hauptergebnisse: Zusammengenommen weisen die Ergebnisse darauf hin, dass verschiedene potentielle Pfade existieren wie die Medikamentennutzung auf Seiten der Konsumenten beeinflusst werden kann, um Endpunkte zu verbessern. Jedoch gibt es keine Strategie, die alle Endpunkte für Medikamentennutzung über alle Krankheiten, Populationen, oder Settings verbessern konnte.

Zu den Strategien, die die Medikamentennutzung zu verbessern scheinen, gehören Medikamenten-Selbstüberwachung und Eigenmanagement-Programme, wobei Dosisregimes und die direkte Miteinbeziehung von Apothekern im Medikamentenmanagement (z.B. Medikamenten Überprüfung) vielversprechend sind. Andere Strategien, wie die verzögerte Verschreibung von Antibiotika; praktisches Management (z.B. Erinnerungen, Verpackung); Bildung oder Information kombiniert mit anderen Strategien (z.B. Selbstmanagement in der Kompetenzenaneignung, Beratung); und finanzielle Anreize, könnten auch einen positiven Einfluss ausüben, wobei die Wirkungen weniger konsistent sind.

Einige Strategien, wie direkt beobachtete Therapie, sind womöglich ineffektiv. Andere Strategien, wie die Bereitstellung von Informationen oder Bildung alleine, mögen unterschiedliche Wirkungen haben, wobei sie für manche Endpunkte (z.B. Medikamenteneinhaltung) ineffektiv sind, aber einen positiven Einfluss auf andere Endpunkte, wie Kenntnisse, welche wiederum den Schlüssel zu informierten Medikamentenentscheidungen darstellen, ausüben. Obwohl sich die Zahl der eingeschlossenen Reviews in dieser Aktualisierung verdoppelt hat, besteht weiterhin eine Unsicherheit zu den Wirkungen vieler Interventionen wobei die Evidenz zu 'was wirkt' besonders spärlich für Populationen wie z.B. Kinder, junge Menschen, Pfleger und Menschen mit Multimorbidität war.

Qualität der Evidenz: Eingeschlossene Studien hatten oft methodologische Einschränkungen - auf Studienlevel, Reviewlevel, oder beiden. Das bedeutet, dass Ergebnisse mit Vorsicht interpretiert werden sollten.

Anmerkungen zur Übersetzung

Koordination durch Cochrane Schweiz