International Journal of Clinical Pharmacy (2023) 45:304–319
https://doi.org/10.1007/s11096-022-01494-5
REVIEW ARTICLE
Terms used to describe and define activities undertaken as a result of the medication review process: Do they require standardisation? A systematic review
Mohammed Alharthi1,2 · David Wright · Sion Scott1 · Jeanette Blacklock1
Received: 21 April 2022 / Accepted: 27 September 2022 / Published online: 21 November 2022
© Crown 2022
Abstract
Background Medication review (MR) is the systematic assessment of a patient’s medications by a healthcare practitioner. It is necessary to compare such MR interventions to rationalise differences between them and assess their impact. The development of an international taxonomy for terms used to describe activities undertaken within the MR process would facilitate quality of reporting, and the comparison of different interventions.
Aim To identify overarching and individual MR activity terms and definitions reported within studies where MR was the main intervention.
Method A systematic review of the literature was performed using search terms for ‘Intervention’ and ‘Outcome’. Papers with empirical data reporting and describing MR activities in English were included. The Mixed Method Appraisal Tool was used to assess research quality. Two researchers reviewed all included literature independently. Data extraction was performed using Cochrane Effective Practice and Organisation of Care to report study characteristics, and terms and definitions used to describe MR activities.
Results Twenty-one papers were included: eight quantitative non-randomised trials (38%), eight randomised controlled trials (38%), and five quantitative descriptive studies (24%). Overarching interventions such as ‘Clinical’, ‘Education’ and ‘Technical’ were identified with no standardised definitions. Terms used to describe the medication review activities, such as stop, start and change, varied with significant potential for ambiguity.
Conclusion The literature reports a variety of overlapping, ambiguous and undefined MR terms. As a result, comparing process evaluations from MR interventions may be difficult. A standardised taxonomy to describe, define and report MR activities is required.
Keywords Medication review · Standardisation · Systematic review · Taxonomy

Impact statements
•		Ambiguous terminologies for the process of medication review combined with a lack of agreed definitions limit the ability to compare medication reviews between studies.
* Mohammed Alharthi msma10@leicester.ac.uk
•		The findings of this review will be used to underpin the development of a taxonomy to achieve international agreement on how medication review interventions are described.
Introduction
Medication review (MR) is an integral part of the practice of many different healthcare professionals and is defined as a systematic assessment of a patient’s medicines with the goal of optimising medicine use and improving health outcomes [1]. According to the available information, Pharmaceutical Care Network Europe (PCNE) classifies the medication review into three levels: type 1 includes the 
medication history, type 2a includes medication history and patient interview, and type 2b includes medication history and clinical data [2]. Type 3, the most advanced level of review, includes medication history, patient interview, and clinical data. The goals of MR include minimising drug-related problems (DRPs) and recommending actions [1, 3]. Activities resulting from MR include medication discontinuation, addition, changing, dose increase, dose decrease and monitoring [4, 5]. So, whilst an international definition of the term ‘medication review’ has been developed, combined with the recognition that a number of activities result from it, there are no standardised, agreed terms or definitions to describe these ensuing activities.
For example, whilst one study may describe different MR activities as discontinue a drug, add a drug, change dose, change drug, change dosage form, and change timing [4], another may use cessation of drug, addition of drug, dose increase, dose decrease, replacement of drug, drug formulation change, schedule change and monitoring [5]. The terms treatment stop, treatment start, dose adaptation, therapy switch, and change timing of administration are also used to describe similar MR activities [6]. Researchers are increasingly interested in comprehending processes within interventions to enable them to better understand the mechanism of impact (‘how the provided intervention occurred’) [7]. This is achieved by looking at fidelity (‘whether the intervention delivered as intended’); dose (‘how much of the intervention is delivered to each participant’); and reach (‘the proportion of individuals who should have received the intervention’) [7]. Therefore, a standard definition of MR activities enables the terms fidelity, dose and reach to be compared accurately. However, the existence of locally developed MR activity classifications makes it difficult to compare the different process evaluations from various countries and settings. Furthermore, when different terms are used, it is frequently without an underpinning definition, the assumption being that the reader will automatically understand the activity from the term used. Also, this issue creates difficulties in finding the medication review activities in the evidence search and synthesis.
Whilst the term ‘discontinue’ may seem intuitive, it may be used to describe either active discontinuation of ongoing therapy or removal of a medicine from a medication list because it has not been supplied for an extended duration. This is different from actively stopping a medicine after discussion with a patient and agreeing on this course of action. For process evaluation purposes, it is potentially important that active discontinuation of ongoing therapy is differentiated from discontinuation largely for administrative purposes, namely, to update records. The first activity is far more likely to have an impact on the patient than the latter.
Frequently, authors further classify MR activities with overarching terms such as clinical, technical or education [	8]. Similarly, these overarching terms have no agreed, standard definitions.
The lack of standardised terms and definitions for overarching and individual MR activities creates unnecessary difficulties for researchers wishing to compare their process data with similar interventions and studies. The findings from this study will be used to develop a standardised, consensus taxonomy for overarching and individual MR activities.
Aim
The aim of this systematic review was to identify overarching and individual activity terms and definitions reported within studies, where MR was the main intervention, to inform the development of an international taxonomy.
Method
This systematic review was reported according to Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) [9]. The systematic review protocol was developed and registered on the international database of Prospectively Registered Systematic Reviews (PROSPERO), with the registration number CRD 42,020,215,992. This systematic review was guided by Cochrane Effective Practice and Organisation of Care (EPOC). A scoping review had been performed before conducting this systematic review to identify search terms and data extraction tools, select the quality assessment tool, and review 10% of preliminary searches in order to establish inclusion and exclusion criteria; the full scoping review is attached in supplementary file 1. The search strategy is provided in supplementary file 2.
Search keywords were determined, with synonyms for medication review and for stop, start, monitor, decrease and increase identified.
Regarding participants in the included studies, no restrictions were given to age, gender, or medical condition of the patients or to healthcare professionals (HCPs). All healthcare settings were considered.
Inclusion criteria
Papers meeting all of the following criteria were included:
•		Studies that focused primarily on describing the nature of medication review interventions.
•		Studies that describe medication review interventions: clinical, technical and education interventions.
•		Medication reviews based on patients with multi-morbidity.
•		Medication reviews conducted by any healthcare professional.
•		Studies written in English.
Exclusion criteria
Any paper having any of the following exclusion criteria was not included:
•		Studies that focused on medication reviews within a single disease state such as those focusing on medication review of cardiovascular medications
•		Conference proceedings
•		Systematic reviews
•		Abstracts
•		Audits
•		Posters
•		Papers without empirical data such as protocols and editorials
•		Pilot studies
•		Grey literature studies
Databases searched were Embase (Excerpta Medica Database) (Ovid); Medline (Ovid); AMED (Alternative Medicine database) (EBSCO); PsycInfo (Psychological Information Database) (EBSCO); and CINAHL Complete (Cumulative Index to Nursing and Allied Health Literature) (EBSCO). Bibliographies of included studies were also searched. The search terms were carried out using Medical Subject Heading (MeSH) and other appropriate text words.
Search results for databases were exported into the reference manager Endnote × 9.3.3, where any duplication was identified and removed. Then, the remaining titles were exported to Microsoft Excel for titles, abstract and full-text screening. Search results were limited by two filters: publication type (journal) and the English language. An updated search was conducted in October 2021 to ensure that recent data had been included in this review.
All titles and abstracts were screened independently by two reviewers to check their eligibility against inclusion and exclusion criteria. Screening decisions were then compared between the two reviewers, and any discrepancy resolved by a discussion. A third independent reviewer was not required.
The number of screened titles, abstracts and full paper texts identified at each stage was recorded in a PRISMA diagram [9]. Inter-rater agreement was measured through Cohen’s Kappa coefficient for every stage of screening [10].
Quality assessment
An independent, duplicate quality assessment of each study was undertaken (by MA and DW). All the included studies were assessed using the Mixed Method Appraisal Tool (MMAT) which enables appraisal of different types of study designs [11].
Data extraction
In line with Cochrane Effective Practice and Organisation of Care (EPOC) [12], the following data were extracted from papers and abstracts by two independent researchers. General characteristics of the included studies:
•		Title, author(s)
•		Year of study publication
•		Study objective
•		Study design
•		Study setting
•		Country of the study
Characteristics of the participants:
•		Target population (e.g., HCPs or patients)
•		Participants’ sample size
Description of the main findings:
•		All terms used to describe medication review interventions conducted by HCPs in different settings
•		Description of medication review interventions
Data from eligible studies were then checked by two independent reviewers (MA and DW) to verify the accuracy and completeness of the included data. Any disagreement was resolved by a consensus between the reviewers.
Data analysis
Medication review activities’ data were themed by the research team and collated to inform the development of a medication review activities’ taxonomy. All the medication review activities were extracted. The results were then analysed by narrative synthesis.
Results
Paper selection and description
The systematic search identified 17,117 citations, of which 21 met the inclusion criteria. The process of literature identification is summarised in a PRISMA flow diagram provided in Fig. 1. The level of agreement between independent
Identification of studies included in the systematic review via databases
Screening	Identification	Records identified through database searching (Total = 17,117)
•		AMED (n = 21)
•		PsycInfo (EBSCO) (n = 946)
•		CINAHL (n= 3107)
•		Embase (Ovid) (n = 6324)
•		Medline (Ovid) (n = 6719)				
			Records removed before screening:
Duplicate records removed (n = 7371)		

						
	Records screened (n = 9746)		Records excluded by title screening (n = 9365)		

	Records screened by abstract (n = 381)			
			Records excluded by abstract screening
(n = 280)
•		161 Not reporting medication review (MR) activities classification and description
•		46 Focus on single disease
•		3 Audits
•		36 No empirical data
•		15 Pilot studies
•		3 Posters
•		4 Protocols
•		12 Systematic reviews	

	Records assessed by full text screening
(n = 101)		Records excluded by full text reading (n = 81)
•		29 Conference abstracts
•		46 No medication review (MR) activities recorded
•		6 Single disease state			

	Records meeting inclusion criteria after full text assessment (n = 20)					
							
	Additional papers
Checking bibliographies of eligible papers
(n = 1)					

	Records included in the systematic review
(n = 21)		
Fig. 1 PRISMA flow diagram for literature review process [13]
Its*	Table 1 Summary of general characteristics of included studies	
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S 00 2	Title	Author, year, and country	Objective	Design	Setting	Target population	Sample size	Who delivered the intervention	
	Clinical medication review by a pharmacist of elderly people living in care homes: pharmacist interventions	Alldred et al. (2007) UK
[29]	To describe the frequency and nature of pharmacist interventions following clinical medication reviews in elderly people living in nursing homes	Quantitative non— randomised	Care home	Residents aged + 65 years	331	Pharmacist	
	Clinical medication reviews in elderly patients with polypharmacy: a cross sectional study on drug- related problems in the Netherlands	Chau et al. (2015) Nether- land [14]	To measure the presence of drug-related problems (DRPs) recognised through a clinical medication review and the level of implementation of proposed interventions in a large group of elderly patients with polypharmacy in community pharmacies	Quantitative non— randomised	Community pharmacies	Older patients aged + 65 years	3807	Community pharmacist	
	Drug-related problems (DRPs) and changes in drug utilisation after medication reviews in homes in Oslo, Norway	Fog et al. (2017) Norway
[26]	Defining DRPs discovered throughout medication reviews (MRs) in nursing homes in Oslo, Norway	Quantitative descriptive	Nursing homes	Long term care patients	2465	Physician, nurse, clinical pharmacist	
	An evaluation of medication review reports across different settings	Christopher et al. (2012)
Australia [4]	To contrast medication review reports completed by pharmacists working outside of a medical centre to those completed by an integrated practice pharmacist	Quantitative descriptive	A primary care medical centre	Medical centre patients	415	Pharmacist	
	Medication review by a clinical pharmacist at the transfer point from ICU to ward: a randomised controlled trial	Heselmans et al. (2015)
Belgium [5]	To assess the impact of assigning a clinical pharmacist to the transfer process from intensive care unit to wards on the number and severity of drug- related problems	Randomised controlled trial (RCT)	Hospital	Intensive care unit patients (ICU)	1363	Pharmacist	
co

Title	Author, year, and country	Objective	Design	Setting	Target population	Sample size	Who delivered the intervention	
Pharmacist-supported medication review training for general practitioners: feasibility and acceptability	Krska et al. (2006) UK
[30]	To investigate the feasibility and acceptability of training in medication reviews provided by practice pharmacists for general practitioners (GPs)	Quantitative non— randomised	Primary care	General Practitioners	51	Pharmacist	
Pharmacist-based medication review reduces potential drug-related problems in the elderly: the SMOG controlled trial	Vinks et al. (2009) Netherlands [18]	To see if a community pharmacist-led intervention reduces the number of potential DRPs in patients aged 65 and higher who are taking six or more medications concurrently	Randomised controlled trial (RCT)	Community pharmacies	Older patients aged + 65 years	100	Pharmacist	
Effects of medication review on drug related problems in patients using automated drug dispensing system	Kwint et al. (2011) Netherlands [19]	To investigate the impact of a pharmacist-led medication review on drug-related problems (DRPs) in older patients receiving their medications through automated dispensing systems	Randomised controlled trial (RCT)	Primary care	Older patients	125	Pharmacist	
The contribution of patient interviews to the identification of drug-related problems in home medication review	Kwint et al. (2012) Netherlands [20]	To ascertain the extent to which patient interviews aid in the identification of DRPs in terms of number, type, and clinical relevance	Quantitative non— randomised	Community pharmacies	Older patients aged + 65 years	155	Pharmacist	
Completeness of medication review provided by community pharmacists	Kwint et al. (2013) Netherlands [5]	To investigate the completeness of DRPs in terms of quantity, category, and clinical significance as recognised by community pharmacists during home medication reviews (HMRs)	Quantitative non— randomised	Community pharmacies	Older patients aged + 65 years	155	Pharmacist	

Its*	Table 1 (continued)	
ω 5' CD	Title	Author, year, and country	Objective	Design	Setting	Target population	Sample size	Who delivered the intervention	
	Performance of community pharmacists in providing clinical medication reviews	Laaksonen et al. (2010)
UK [8]	To review the efficiency of trained community pharmacists in writing care plans and referrals for older patients as part of a patient outcome- focused medications management program	Quantitative non— randomised	Community pharmacies	Older patients aged + 65 years	461	Clinical pharmacist	
	Medication reviews in primary care in Sweden: importance of clinical pharmacists’ recommendations on drug-related problems	Modig et al. (2015) Sweden [24]	To assess the quality of clinical pharmacy service to primary care through structured medication review, with a focus on the therapeutic effect of clinical pharmacist suggestions	Quantitative descriptive	Primary care	Older patients	150	General practitioner, nurse, clinical pharmacist, and assistant nurse	
	Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice: pharmacist interventions and review outcomes	Petty et al. (2002) UK [15]	To explore the nature of interventions carried out by a pharmacist during a clinical medication review in general practice	Quantitative non— randomised	General practice	Older patients aged + 65 years	1188	Pharmacist	
	General practitioner acceptance of medication review in Sydney nursing homes	Smith et al. (2002) Australia [21]	To perform a one-time medication review in nursing homes to identify medication issues and identify why suggestions made by the pharmacist conducting the review were not actioned by physicians	Quantitative descriptive	Nursing homes	Nursing home residents	202	Pharmacist	
	Clinical medication review by a pharmacist of elderly people living in care homes: randomised controlled trial	Zermansky et al. (2006)
UK [16]	To assess the impact of a pharmacist-conducted clinical medication review versus standard care	Randomised controlled trial (RCT)	Care homes	Older patients aged + 65 years	331	Pharmacist	
CO

Title	Author, year, and country	Objective	Design	Setting	Target population	Sample size	Who delivered the intervention	
Pharmacists in humanitarian crisis settings: assessing the impact of pharmacist-delivered home medication management review service to Syrian refugees in Jordan	Al Alawaneh et al. (2019)
Jordan [28]	To see how the home medication management review (HMMR) service affected the frequency of treatment-related problems (TRPs) between Syrian refugees living in Jordan	Randomised controlled trial (RCT)	Syrian refugees living in Jordan	Syrian refugees	106	Clinical pharmacist	
Evaluation of collaborative medication reviews for high-risk older patients	Chan et al. (2018) Canada [27]	To quantify and identify the drug therapy issues identified and interventions implemented by pharmacists prior to and following the implementation of collaborative medication review for high-risk older adult patients	Quantitative descriptive	Hospital	Older patients	137	PharmacistFamily physician	
Pharmacist-led medication review to identify medication-related problems in older people referred to an aged care assessment team	Elliott et al. (2012) Australia [22]	To compare three approaches to facilitating a pharmacist-led comprehensive medication review for people referred to an aged care assessment team (ACAT)	Randomised controlled trial (RCT)	Residential home	Older people	80	Clinical pharmacist	
Effects of medication reviews on use of potentially inappropriate medications in elderly patients: a cross sectional study in Swedish primary care	Lenander (2018) Sweden
[25]	To assess the impact of medication reviews on overall drug use and potentially inappropriate use in older patients, as well as to describe the frequency and categories of drug-related problems	Quantitative non— randomised	Nursing home	Older people	1720	Clinical pharmacist	
Medication reviews in the community: results of randomised controlled trial	Sorensen (2004) Australia
[23]	To assess the efficacy of a multidisciplinary service model that provides medication review to patients in the community who are at risk of medication misadventure	Randomised controlled trial (RCT)	Patients’ home	Polypharmacy patients	400	PhysicianPharmacist	

itS>
Who delivered the intervention Pharmacist	reviewers at title, abstract and full text screening was 56.7%, 89.7% and 78%, respectively, with Kappa 0.18, 0.70 and 0.55, respectively.
Table 1 summarises the characteristics of the 21 papers that were included. Most of the studies were located in the UK, representing 28.5% of the total studies included (n = 6)	
Sample size 1188	[9, 14–18]; 23.8% from the Netherlands (n = 5) [5, 14, 18–20]; 19% from Australia (n = 4) [4, 21–23]; and smaller numbers (9.5%) from Sweden (n = 2) [24, 25]; 4.8% from	
Target population Older patients aged + 65 years	Norway (n = 1) [26]; 4.8% from Belgium (n = 1) [5]; 4.8% from Canada (n = 1) [27]; and 4.8% from Jordan (n = 1) [28]. No specific study design was designated as this review was looking for papers for which MR activities and overarching activities had been described and defined. Accordingly, 38% of the papers were quantitative, non-randomised trials	
Setting
General practice	(n = 8) [5, 8, 14, 15, 20, 25, 29, 30]; 38% were randomised controlled trials (RCTs) (n = 8) [5, 16–19, 22, 23, 28]; and 24% were quantitative descriptions of medication review services (n = 5) [4, 21, 24, 26, 27]. The objectives of the studies included in this review varied and none of them described the nature of healthcare professionals’ activities,	
Design Randomised controlled trial (RCT)	with the exception of two studies. Alldred et al. described them as stop medicine/stop drug, start medicine, dose increase/alter dose, dose reduction/alter dose, switch medi- cine/switch drug, alter formulation, alter timing, and test to monitor condition/test to monitor medicine [28] Petty et al. described them as stop drug, start drug, alter formulation dose, timing, switch drug, test request [15]. Papers ranged	
Objective
To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice	in publication date from 2002 to 2019.
Quality assessment
The quality assessment used the Mixed Method Appraisal Tool (MMAT) [11] for quantitative randomised controlled trials, quantitative non-randomised controlled trials, and quantitative descriptive studies. These are shown in supplementary file 3. Thirteen papers were allocated a score of 6	
Title	Author, year, and country
Randomised controlled trial Zermansky et al. (2001) of clinical medication	UK [17]
review by a pharmacist of elderly patients receiving repeat prescriptions in general practice	(62%) [5, 5, 8, 14, 16, 18–20, 22, 23, 25, 28, 29]; five papers a score of 7 (23.8%) [4, 21, 24, 26, 27]; and three papers a score of 5 (14.20%) [15, 23, 30].
Descriptions and definitions of medication review interventions for clinical, technical and education interventions
Table 2 summarises terms used to describe the overarching activities which are ‘clinical’, ‘technical’, and ‘education’ interventions in the included studies.
Eleven papers (53.3%) used term ‘clinical’ [5, 8, 14–16, 20, 21, 24, 27–29] and only one of them provided a definition for this term [15].	
Table 1 (continued)

Table 2 Summary of description of medication review activities for clinical, technical and education interventions
Author, year, and country Overarching intervention categories
	Clinical	Definitions for ‘clinical’ category	Technical	Definitions for ‘technical’ category	Education	Definition for education category	
Alldred et al. (2007) [29]	Clinical	NA	Technical	NA	NA	NA	
Chau et al. (2015) [14]	Clinical	NA	NA	NA	Provide education	NA	
Christopher et al. (2012)
[4]	NA	NA	NA	NA	Advice, suggest medication aid/advice/ monitor, advise administration techniques	NA	
Heselmans et al. (2015)	Clinical	NA	NA	NA	NA	NA	
[5]		
Krska et al. (2006) [30]	NA	NA	NA	NA	Lifestyle advice given to patient; advice given to patient about drug therapy	NA	
Kwint et al. (2012) [20]	Clinical	NA	NA	NA	Education, counselling session	NA	
Kwint et al. (2013) [5]	NA	NA	NA	NA	Education, counselling session	NA	
Laaksonen et al. (2010)	Clinical	NA	Clerical	NA	Provide counselling	NA	
[8]		
Modig et al. (2015) [24]	Clinical	NA	NA	NA	NA	NA	
Petty et al. (2002) [15]	Clinical	The process where
the HCP reviews the patient, the illness, and the drug treatment during the consultation	Technical	Altering quantities on prescription, deleting unused medicines, generic switch, adding dosage instructions	Compliance counselling	NA	
Smith et al. (2002) [21]	Clinical	NA	NA	NA	NA	NA	
Zermansky et al. (2006)	Clinical	NA	Technical	NA	NA	NA	
[16]		
Al Alawaneh et al. (2018) [28]	Clinical	NA	NA	NA	Patient education, counselling on adherence	NA	
Chan et al. (2018) [27]	Clinical	NA	NA	NA	NA	NA	
Elliott et al. (2012) [22]	NA	NA	NA	NA	NA	NA	
Sorensen et al. (2004)
[23]	NA	NA	NA	NA	Provision of patient (or carer) education or information	NA	

Four papers (19%) used the term ‘technical’ or ‘clerical’ [8, 15, 16, 29]and one of them provided a definition for this term [15].
Ten papers (47.6%) used the term ‘education’ or synonyms [4, 5, 8, 14, 15, 20, 22, 23, 28, 30] and none provided a definition for this term.
Table 2 shows that the authors agreed in their use of the ‘clinical’ term, whereas they described the technical intervention using two different terms, namely, ‘technical’ and ‘clerical.’ Furthermore, the education intervention was described in four different ways, namely, ‘educate,’ ‘advise,’ ‘aid,’ and ‘counsel.’
The authors used various terms to describe MR activities, as shown in Table 3. The term ‘stop’ has been described using four different words: ‘stop,’ ‘discontinue,’ ‘cease,’ and ‘withdraw.’ Three different words were used to describe the ‘start’ term: ‘start,’ ‘add,’ and ‘initiate.’ The term ‘increase’has been described by seven different words, namely, ‘increase’, ‘alter’, ‘adjust’, ‘change’, ‘adapt’, ‘rise’, and ‘titrate’. Dose decrease was described using seven different words: ‘reduce,’ ‘alter,’ ‘adjust,’ ‘change,’ ‘adapt,’ ‘decrease,’ and ‘titrate.’
Table 3 demonstrates that medication changes, formulation changes, and timing changes are described in different ways. Words used to describe medication changes included ‘switch,’ ‘change’, ‘replace,’ and ‘alter’. The words ‘switch’, ‘change,’ and ‘alter’ were used to describe formulation changes. The words ‘change’, ‘synchronise,’ ‘alter,’ and ‘adjust’ were used to describe timing changes.
Author, year, and country	Terms used to describe medication review activities	
	Terms used to describe ‘stop’ term	Terms used to describe ‘start’ term	Terms used to describe ‘dose increase’ term	Terms used to describe ‘dose decrease’ term	Terms used to describe ‘change’ term (for medication)	Terms used to describe ‘change’ term (for formulation)	Terms used to describe ‘change’ term (for timing)	Terms used to describe ‘monitor’ term	
Alldred et al.
(2007) UK [29]	Stop medicine/Stop drug	Start medicine	Dose increase/alter dose	Dose reduction/ alter dose	Switch medicine/ switch drug	Alter formulation	Alter timing	Conduct a test to monitor condition. Test to monitor medicine	
Chau et al. (2015).
Netherland [14]	Stop drug	Add drug	Adjust dose	Adjust dose	Switch drug	Switch dose form	Synchronise medication	Provide monitoring	
Fog et al. (2017).
Norway [26]	Stop the drug	Start new drug	Adjust the drug dose	Adjust the drug dose	Drug switch	NA	NA	Monitor the drug use	
Christopher et al.
(2012). Australia
[4]	Discontinue drug	Add drug	Change dose	Change dose	Change drug	Change dosage form	Change timing, change schedule	Additional monitoring	
Heselmans et al.
(2015). Belgium
[6]	Treatment stop	Treatment start	Dose adaptation	Dose adaptation	Therapy switch because interaction	NA	Change of moment of administration	NA	
Krska et al. (2006).
UK [30]	Drug stopped completely	New drug added	Dose changed	Dose changed	Drug changed to alternative	Formulation changed	NA	Monitoring done or ordered	
Vinks et al. (2009).
UK [18]	Cease a drug	Add drug	Change dose, dosage interval or frequency	Change dose, dosage interval or frequency	NA	Change dose form	NA	Laboratory tests	
Kwint et al. (2011).
Netherland [19]	Cessation of drug	Addition of drug	Dose change	Dose change	Replacement of drug	Drug formulation changed	Dose frequency/ schedule change	NA	
Kwint et al. (2012).
Netherland [20]	Cessation of drug	Addition of drug	Dose increase	Dose decrease	Replacement of drug	Drug formulation changed	Dose frequency/ schedule change	Monitoring	
Kwint et al. (2013).
Netherland [5]	Cessation of drug	Addition of drug	Dose increase	Dose decrease	Replacement of drug	Drug formulation changed	Dose frequency/ schedule change	Monitoring	
Laaksonen (2010).
UK [8]	Stop drug	Initiate therapy	Change dose or directions	Change dose or directions	Change drug or formulation within the same BNF subsection	Change drug or formulation within the same BNF subsection	NA	Start monitoring	
Modig et al.	Consider withdraw	Consider addi-	Consider rise/	Consider reduce	Consider change	Consider change	Consider change	Consider evaluation	
(2015). Sweden
[24]	of drug therapy	tional therapy/ Initiation of therapy	increase dose	dosage	drug therapy	drug formulation	dosage regimen/ dosage interval	of therapy	
Petty et al. (2002).
UK [15]	Stop drug	Start drug (new indication)	Alter formulation, dose, timing	Alter formulation, dose, timing	Switch drug (same indication)	Alter formulation, dose, timing	Alter formulation, dose, timing	Test required	
Smith et al. (2002).
Australia [21]	Cease therapy	Initiate therapy	Increase dosage regimen	Reduce dosage regimen	NA	NA	NA	NA	

Author, year, and country	Terms used to describe medication review activities	
	Terms used to describe ‘stop’ term	Terms used to describe ‘start’ term	Terms used to describe ‘dose increase’ term	Terms used to describe ‘dose decrease’ term	Terms used to describe ‘change’ term (for medication)	Terms used to describe ‘change’ term (for formulation)	Terms used to describe ‘change’ term (for timing)	Terms used to describe ‘monitor’ term	
Zermansky et al.
(2006). UK [16]	Stop medicine	Start medicine	Alter dose	Alter dose	Switch	Alter formulation	Alter timing	Test required	
Al Alaweneh et al.
(2018) Jordan	Ceasing drug	Adding drug	Changing therapeutic regimen	Changing therapeutic regimen	Changing drug	NA	NA	Monitoring (lab test or home-based	
[28]			(changing dose and/or frequency)	(changing dose and/or frequency)				monitoring)	
Chan et al. (2018).
Canada [27]	Discontinue a medication	Add or restart drug	Dose titration	Dose titration	Change medication or regimen	NA	Change medication or regimen	Monitor therapy	
Elliott et al. (2012).
Australia [22]	Stop drug	Add drug	Adjust dose	Adjust dose	Switch drug	Switch dose form	Adjust dose timing	Additional monitoring e.g., blood pressure, blood test	
Lenander et al.
(2018). Sweden
[25]	Withdrawal of drug therapy	Initiation of drug therapy	Increased dose	Decreased dose	Change of drug therapy	Change drug formulation	Dose regimen adjustment	Evaluation of drug therapy	
Sorensen et al.
(2004). Australia	Cease drug or trial withdrawal to	Add a drug	Change dose, dosage interval or	Change dose, dosage interval or	Change drug—substitute one for	Change administration time, route,	Change administration time, route,	Monitoring, laboratory, monitoring	
[23]	confirm need for treatment		frequency	frequency	another	or dose form	or dose form	observation and non-lab monitoring	
Zermansky et al.
(2001). UK [17]	Drug stopped	New drug started	Dose changed	Dose changed	Switched drug	Formulation changed	Frequency changed	NA	

Author, year, and country	‘Stop’ term	Definition used to describe ‘stop’ term	‘Start’ term	Definitions used to describe ‘start’ term	‘Monitor’ term	Definitions used to describe ‘monitor’ term	
Chau et al. (2015) [14]	Stop drug	NA	Add drug	NA	Provide monitoring	Patient was monitored to decide whether the intervention was indicated	
Fog et al. (2017)
[26]	Stop the drug	NA	Start new drug	NA	Monitor the drug use	Monitoring of drug use	
Christopher et al.
(2012) [4]	Discontinue drug	NA	Add drug	Additional therapy required	Additional monitoring	NA	
Vinks et al. (2009)
[18]	Cease a drug	NA	Add drug	When another drug was started	Laboratory tests	NA	
Petty et al. (2002)
[15]	Stop drug	NA	Start drug (new indication)	Addition of drug for untreated indication	Test required	NA	
Chan et al. (2018) [27]	Discontinue a medication	When drugs stopped during patient hospitalisation	Add or restart drug	When the patient needs additional drugs for an indication	Monitor therapy	NA	
Sorensen (2004)
[23]	Cease drug or trial withdrawal to confirm need for treatment	NA	Add a drug	NA	Monitor therapy	When drug therapy needs monitoring	

Definitions of medication review terms
In seven of the included studies (33.3%) [4, 14, 15, 18, 23, 26, 27], the authors provided a description of some of the terms used for medication review as summarised in Table 4. The ‘Stop’ term was defined once (4.7%) [27], the ‘start’ term was defined four times (19%) [4, 15, 18, 27], and the ‘monitor’ term was defined three times (14.2%) [14, 23, 26].
Table 4 shows that some authors provided definitions for some of the terms such as ‘discontinue’, ‘add’ and ‘monitor’. However, the defined terms vary and were described by the authors without consensus.
Discussion
Main findings
This is the first systematic review to examine and propose standardisation of the way MR interventions are described. It highlights an absence of consistent terms used to define and describe such interventions. Terms used to describe instructions such as ‘alter’, ‘adapt’, ‘monitor’ lack sufficient detail to enable learning from and comparison of studies. There was limited uniformity with respect to overarching terms such as ‘clinical’ and ‘technical’, with the same activity being frequently classified differently between studies. There is a need for a consistent approach when describing medication review activities in studies.
Strength and limitations
The search strategy employed was restricted to articles written in English. This risked rejecting potentially useful studies written in another language, reporting different HCPs’ activities.
The inclusion criteria used in this systematic review, together with the wide range of databases searched, have ensured that all the related studies from the largest possible number of articles initially identified were selected. However, having a greater number of initial studies to screen can result in less agreement. The large initial pool used in this systematic review may explain the lack of agreement between reviewers in the first stage of screening.
An extensive search was undertaken to gather all possible evidence regarding medication review activities, definitions and descriptions over time because there was no publication year restriction. The study designs ranged from randomised controlled trials to service evaluations in terms of quality. The Mixed Method Appraisal Tool (MMAT) showed that most studies reviewed were of high quality.
Main discussion
The Mixed Method Appraisal Tool (MMAT) was chosen to review the included studies because no specific type of study was required, and it was expected that a variety of study types would be discovered when conducting the systematic review protocol.
It is worth noting at this point that, although they are not terms used to describe and define activities undertaken as a result of the medication review process, inconsistency was apparent to the authors in the use of the words ‘drug’, ‘medicine’, ‘medication’ and ‘treatment’. A ‘drug’ is defined as any chemical substance that affects the body's physiological process [31]. The term ‘treatment’ may refer to the use of an agent, procedure or regimen, such as surgery, drug, or exercise, in an attempt to cure or alleviate a medical issue. ‘Medicine' is defined as a formulated drug with a specific dose and dosage form used to prevent, diagnose, control, and treat disease [31]. It would seem that the latter is more appropriate. Consensus is required but it is outside the scope of this study.
The term ‘deprescribing’ first emerged in 2003 and there is a growing body of literature using it [32]. However, this systematic review showed that, despite being consistent with deprescribing, all papers researched used alternative terms under the overarching term ‘deprescribing’. This may be due to it being a relatively new term but also because it better describes the purpose rather than the activity—it is not a specific instruction. It can mean discontinuation, dose reduction or, potentially, dose increase if another medicine is up titrated to enable a second medicine to be stopped altogether. As such, it can be considered to be a generic term. However, there is growing literature on ‘deprescribing’ as an activity itself [33]. The medication review is a holistic process; the process of deprescribing includes reviewing all medications; identifying those that should be discontinued, substituted, or reduced; co-planning a deprescribing regimen with the patient; and regularly monitoring and supporting the patient [34].
The actions of stopping medication, changing dose, changing medication, formulation and monitoring are classed as clinical interventions. A clinical intervention is described as an activity performed to improve, maintain or assess the health of a person in a clinical situation. Altering the dose timing and changing from a branded to a generic version of a medication was defined as a technical intervention by some authors and as a clinical intervention by others. The classification disparity between authors of these two activities presents difficulties for researchers when comparing process evaluation studies. For example, Hes- elmans et al. [6] classified the medication timing change as a technical intervention [5], whilst the same activity was classified as a clinical intervention by Modig et al. [24]. Likewise, the medication formulation change is classified as a clinical intervention by Alldred et al. [29] and as a technical intervention by Chau et al. [14]. This inconsistency between authors in the use of overarching intervention categories indicates that there is a need to create a taxonomy to classify each of the conducted activities under the appropriate category which will enable meaningful comparison between process evaluations and help identify the mechanism of impact.
Various terms were used by different authors to indicate the same activity. For example, the terms ‘increase dose’ and ‘alter dose’ were used to describe one activity [29]. Another author applied the term ‘change dose’ to denote the dosage interval or frequency [18].
The act of stopping medication was described with different words in the included studies. The words ‘discontinue’, ‘cease’ and ‘stop’ suggest a permanent change whereas ‘suspend’ suggests a temporary change to medication.
The act of starting medication was described as ‘start’ and ‘restart’. It is crucial to separate the term ‘restart’ from ‘start’ because the former describes a medication deprescribing attempt that needs to be reversed.
The act of increasing the medication dose was described as ‘change dose’, ‘alter dose’, or ‘adjust dose’. Such terms do not specify whether the healthcare professional needs to increase the dose to improve medication effectiveness or decrease the medication dose to reduce side effects. Such terms give no indication of the precise instruction to be carried out or the reason for it. These vague descriptions and instructions give no indication as to the problem regarding the medication or the exact activity to be carried out by the practitioner. Despite some authors providing definitions for medication review terms used in their papers, these terms varied between authors. Such ambiguities would be eliminated by the development of a specific and inclusive consensus taxonomy of standardised medication review terms.
Conclusion
This systematic review identified gaps in previous literature regarding the terms used by healthcare professionals with respect to the medication review process. Most of the studies included had wide and varied term definitions which demonstrated that there is no consensus terminology used by all researchers. The findings from this review support the need to develop a consensus between all healthcare professionals and researchers to use unique and specific terminology that facilitates process evaluation comparison, consequently providing a better understanding of the mechanism of impact.
As an outcome of this systematic review, the next step should aim to develop a consensus among a group of experts in the field of medication review to explore their decisions and agree the specific terms through a convenient and transparent consensus methodology. This proposal will be implemented in a future study by the authors.
Supplementary Information The online version contains supplementary material available at https://doi. org/ 10. 1007/s11096- 022- 01494-5.
Funding The authors have not disclosed any funding.
Conflicts of interest The authors have declared no conflict of interest.
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2 College of Pharmacy, Taif University, Taif, Kingdom of Saudi Arabia