Is a Home Medicine Review (HMR) warranted for a patient with recent hospital discharge, polypharmacy, and potential adverse drug interactions?

Home Medicine Review is Strongly Warranted for This Patient

A Home Medicine Review (HMR) is definitively indicated for this patient given the combination of recent hospital discharge and polypharmacy, as these factors substantially increase the risk of adverse drug events, hospital readmission, and mortality. 1

Evidence Supporting HMR Referral

Critical Risk Factors Present

The patient presents with multiple high-risk indicators that mandate medication review:

• Recent hospital discharge: Patients discharged from hospital with polypharmacy concerns should be referred for medication review as a standard practice 1
• Polypharmacy (>5 medications): This creates a 50-60% probability of drug-drug interactions, escalating to 90% when taking 10 or more medications 1
• Potential drug interactions: These represent a major cause of emergency department visits, hospital admissions, increased morbidity and mortality, and prolonged hospital stays 1

Proven Benefits of Medication Reviews

The most recent high-quality evidence demonstrates that medication reviews with multiple patient contacts reduce hospital readmissions by 15% and all-cause mortality by 19%. 1 This 2025 systematic review and meta-analysis specifically found that:

• Medication reviews with 2 or more patient contacts showed approximately twice the benefit compared to single-contact reviews 1
• Comprehensive mortality assessment via registries demonstrated significant mortality reduction (19% decrease) 1
• The intervention is most effective when involving pharmacists in a multidisciplinary approach 1

Guideline-Directed Management

Geriatric emergency department guidelines explicitly recommend that patients discharged with polypharmacy concerns be referred to their primary physician for medication review. 1 The multidisciplinary approach should focus on:

• Minimizing drug-drug interactions 1
• Reducing polypharmacy burden 1
• Identifying and eliminating high-risk medications 1
• Establishing pharmacist-assisted management plans for interactions 1

Australian HMR Program Effectiveness

Research specific to the Australian HMR program demonstrates substantial clinical benefit:

• 99% of older patients had at least one inappropriate medication rating at baseline 2
• HMR intervention resulted in statistically significant improvement in medication appropriateness (mean MAI score decreased from 18.6 to 9.3, p<0.001) 2
• The collaborative GP-pharmacist model effectively prevents, detects, and resolves medication-related problems 3, 2

Key Implementation Considerations

Optimal HMR Structure

To maximize benefit, ensure the HMR includes multiple patient contacts rather than a single visit. 1 The evidence strongly supports:

• At least 2 patient contacts for optimal readmission reduction 1
• Pharmacist involvement throughout the process 1
• Follow-up to ensure recommendation implementation 1, 2

Critical Assessment Areas

The medication review should systematically evaluate:

• Drug-drug interactions: Particularly important given the exponential increase in interaction risk with polypharmacy 1, 4
• Drug-disease interactions: Common in patients with multiple comorbidities 1
• Potentially inappropriate medications (PIMs): Using validated criteria such as Beers or STOPP/START 1
• Medication-related adverse events: Any new symptoms should be considered potential adverse drug reactions until proven otherwise 1
• Adherence barriers: Including complexity of regimen, administration difficulties, and treatment burden 1

Common Pitfalls to Avoid

Do not delay the HMR referral. The post-discharge period represents a critical window where medication-related problems are most likely to cause readmission 1. Additional cautions include:

• Ensure complete medication reconciliation including over-the-counter medications, supplements, and herbal products 1
• Monitor for prescribing cascade (where adverse drug reactions are misinterpreted as new conditions requiring additional medications) 1
• Address anticholinergic burden, particularly in elderly patients where it correlates with cognitive impairment 1, 4
• Consider renal function adjustments for renally-cleared medications 1

Expected Outcomes

Based on the evidence, proceeding with this HMR should:

• Reduce risk of hospital readmission by approximately 15% 1
• Potentially reduce all-cause mortality by 19% with comprehensive follow-up 1
• Improve medication appropriateness scores significantly 2
• Decrease adverse drug events and drug-drug interactions 1, 4
• Enhance patient understanding and adherence 3, 5

Forward the referral with relevant clinical information and patient summary to facilitate the HMR process. 1 The multidisciplinary collaboration between the GP, community pharmacist, and accredited pharmacist represents best practice for managing polypharmacy in recently discharged patients. 3, 2