Homecare safety and medication management with older adults: a scoping review of the quantitative and qualitative evidence

Abstract

Background Healthcare safety is a current national and international priority, and within healthcare safety, one of the most prevalent, high-risk issues is medication safety. While medication safety in general demands consideration, there is a critical gap in our understanding of medication safety in the homecare sector. Understanding what factors contribute to, and/or reduce the risk of adverse drug events in the home setting will enable the identification and promotion of safer medication administration practices. Objectives In this review we focused on the pertinent issues specifically related to medication management for individuals living at home and receiving homecare services. Inclusion criteria Types of participants We considered studies that included older individuals, mean age 65 years or older, who were receiving homecare services. Types of intervention(s)/phenomena of interest We considered studies that focused on individuals living at home and receiving homecare services and evaluated the process of medication management involving either providers (licensed and unlicensed) or caregivers (family/friends paid or unpaid). Types of studies We included all quantitative and qualitative research designs. Types of outcomes The purpose of this review was to map existing literature on this topic and to identify what outcomes were being measured by the current research. Research to date has identified outcomes such as: death, re-hospitalization, emergency room use and adverse drug reactions; adherence; deterioration in primary condition; and experience of medication management (individual report and/or provider/caregiver report). Search strategy A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference list of all identified reports and articles were searched for additional studies. Studies published in English and French were considered for inclusion in this review. No date limitation was imposed. Methodological quality This review is a scoping review to provide a broader picture of the existing literature on this topic. Hence, assessment of methodological quality was not performed to exclude studies based on quality scores. Data collection Data was extracted using an expanded extraction tool from the Joanna Briggs Institute Meta- Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). Data synthesis The findings are presented in narrative form including tables and figures to aid in data presentation where appropriate. Results Thirty-six studies published in English were included in this review. No French studies were located. Research designs of the included studies are heavily weighted in descriptive designs (n=28), one randomized controlled trial, three controlled before and after designs, three pre-post designs and one qualitative design. There was a single mixed methods study combining results from a pre-post (not controlled) investigation and qualitative focus groups. There was a single qualitative study using interpretive qualitative methods. Following the three research questions proposed for this review, three main categories were analyzed: issues (including contributing factors and risk factors) (n=21 studies), documented adverse events or errors that occur in the homecare environment (n=13 studies), and strategies or interventions to prevent the occurrence of errors in the homecare environment (n=11 studies). Conclusions In this scoping review, we sought to gather information to shed light on the current evidence related to medication management in the homecare setting. This is an area of emerging evidence on both the issue and risks in this context, as well interventions to ameliorate the problems. There was a common theme that did emerge across the study designs with respect to polypharmacy, which is recognized as a significant issue and predictor of medication errors, and/or potential inappropriate medication use. Benefits were reported by two experimental studies with the inclusion of a pharmacist to assess medications: improvements in medication use and increased coordination of information between healthcare providers and individuals. Further evidence describing and substantiating the issues and problems specific to home care and medication management is needed to develop and test appropriate interventions in this setting.