A medication list is an important clinical tool, but it may not tell us what is actually happening with a patient’s medicines at home.
In primary care, medication lists are routinely used to guide prescribing, identify interactions and support continuity of care. Yet there can be a significant difference between what is documented, what is prescribed and what a patient actually takes.
For some patients, particularly elderly and people living with multiple chronic conditions, medicines can become complex. Different prescribers, changes following hospitalization, over-the-counter products, supplements and changes made by the patient themselves can all contribute to discrepancies. This is where a Home Medicines Review can provide an additional perspective.
The medication list is only the starting point
A medication list may tell us that a patient has been prescribed five, ten or even fifteen medicines. It may not tell us that the patient:
has stopped taking one because they believe it is no longer necessary
is taking a medicine at a different dose or frequency
is using an over-the-counter medicine that has not been documented
is taking several products containing similar ingredients
is unsure why a medicine was prescribed
has difficulty opening packaging or remembering doses
is experiencing an adverse effect but has not reported it
has developed their own system for managing medicines that differs from the prescribed regimen.
These differences are not necessarily a reflection of poor adherence. They may reveal practical, clinical or communication barriers that need to be addressed.
What happens when we look beyond the prescription?
A medication review provides an opportunity to examine medicines in the context in which they are actually being used. A pharmacist can review the patient's prescription medicines alongside over-the-counter medicines, and complementary medicines. Importantly, the review also considers the patient's understanding of their treatment and how medicines are being used in everyday life.
This can reveal issues that may not be obvious from a medication chart alone. For example, a patient may have a correctly prescribed medicine but be taking it incorrectly because the instructions were misunderstood. Another patient may have stopped a medicine because of an adverse effect but never discussed this with their GP.
In other cases, the problem may be more practical: difficulty managing multiple dosing times, confusion following a recent hospital discharge, or difficulty physically handling medicines.
These are clinically relevant findings because a medicine can only provide its intended benefit if it is used safely and appropriately.
The hidden complexity of polypharmacy
Polypharmacy is increasingly common, particularly among elderly living with multiple chronic conditions. Taking multiple medicines is not automatically inappropriate. In many patients, several medicines are clinically justified and provide substantial benefit.
The challenge is determining whether each medicine remains appropriate as the patient's health, circumstances and treatment goals change. A medication review can provide an opportunity to ask:
- Does every medicine still have a clear indication?
- Is the dose still appropriate?
- Are there potential interactions or adverse effects?
- Is the treatment achieving its intended outcome?
- Is the patient able and willing to use the medicine as intended?
- Could any medicines be safely reduced or discontinued?
This last question is particularly important. Medication review shouldn't simply focus on identifying medicines to add. It can also identify opportunities for optimizing therapy and, where clinically appropriate, deprescribing.
The home environment can provide important clinical information
One of the distinctive features of an HMR is that the medication review occurs in the patient's home. This provides an opportunity to understand the patient's medication management within their normal environment.
A pharmacist may identify medicines stored in several different locations, expired or unused medicines, multiple medication packs, or a mixture of prescribed and non-prescribed products.
More importantly, the home visit allows the pharmacist to have a conversation with the patient about how they actually manage their medicines. Patients may feel more comfortable demonstrating their usual routine than trying to recall every detail during a consultation.
Medication adherence: look beyond the word “non-adherent”
When a patient is not taking a medicine as prescribed, it can be tempting to label this simply as “non-adherence.” However, the reason behind the behavior is often more important than the behavior itself. A patient may not take a medicine because:
they do not understand its purpose
they are concerned about adverse effects
the treatment is too complicated
they cannot afford or access the medicine
they forget doses
they have difficulty swallowing
they believe the medicine is no longer necessary
they have experienced symptoms that they associate with the medicine.
Understanding the reason allows the healthcare team to consider a more appropriate solution. Sometimes the answer may be education. Sometimes it may involve simplifying a regimen, changing a formulation, addressing an adverse effect or discussing alternative treatment options with the prescriber.
Medication reconciliation after transitions of care
Medication discrepancies can become particularly important when patients move between healthcare settings. Hospital admission and discharge may result in medicines being started, stopped or changed. Patients may return home with new instructions while their previous medicines remain in the home. Without careful reconciliation, there is potential for confusion or unintended duplication. Identifying discrepancies between the patient's current medication list, discharge information and medicines actually being used at home is an important component of medication safety.
From medication lists to medication experiences
So, the most useful question may not be: “What medicines is this patient prescribed?”
Instead, we should also ask: “What medicines is this patient actually using, how are they using them, and what is their experience of those medicines?”
That distinction can uncover information that is otherwise difficult to see. A medication list provides a valuable clinical snapshot, but a medication review can help connect that snapshot with the patient's everyday experience. For healthcare professionals, this can provide another opportunity to identify medication-related problems, optimize therapy, support adherence and improve communication around medicines.