The pharmacist's role in supporting people living with cystic fibrosis

Objectives

To describe the critical need for pharmacists' involvement in outpatient care for people living with cystic fibrosis (CF).

Pharmacist consultations in general practice clinics: The Pharmacists in Practice Study (PIPS)

BackgroundMedication-related problems (MRPs) are a concern in primary care settings. Pharmacists based in the community or community pharmacies are able to identify, resolve and prevent MRPs; however, the lack of a formal partnership with physicians and poor access to patients' medical records are limitations. In Australia, delivery of pharmacist services within general practice clinics is rare.ObjectivesTo evaluate the effectiveness of consultations by pharmacists based within primary care medical practices.MethodsA prospective, before-after intervention study was conducted at two primary health care (general practice) clinics in Melbourne, Australia. Participants were clinic patients who had risk-factors for MRPs (e.g. polypharmacy). Patients received a consultation with the pharmacist in a private consulting room at the clinic or in their home. The pharmacist reviewed the patient's medication regimen and adherence, with full access to their medical record, provided patient education, and produced a report for the general practitioner. The primary outcome was the number of MRPs identified by the pharmacist, and the number that remained unresolved 6 months after the pharmacist consultation. Secondary outcomes included medication adherence, health service use, and patient satisfaction.ResultsEighty-two patients were recruited and 62 (75.6%) completed the study. The median number of MRPs per patient identified by the practice pharmacist was 2 (interquartile range [IQR] 1, 4). Six months after review, this fell to 0 (IQR 0, 1), P < 0.001. The proportion of patients who were adherent to their medications improved significantly, according to both the Morisky (44.1% versus 62.7%, P = 0.023) and the Tool for Adherence Behaviour Screening (TABS) (35.6% versus 57.6%, P = 0.019) scales. There was no significant effect on health service use. Patients were highly satisfied with the pharmacist consultations.ConclusionsConsultations undertaken by pharmacists located within primary health care clinics were effective in identifying and resolving MRPs. The consultations were well received by patients and were associated with improvements in medication adherence.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

Evaluating the role and value of a clinical pharmacist in a concierge primary care clinic

ObjectiveTo understand the perceived role and value of the clinical pharmacist in a southern Arizona concierge primary care practice (CPCP) by employees.MethodsSemistructured face-to-face interviews were conducted with health care team members employed by the CPCP site in December 2019 and January 2020 for this study. The interviews were audio recorded, transcribed, and thematically analyzed using an inductive approach with ATLAS.ti (version 7). A qualitative assessment was performed by 2 independent reviewers to identify the themes, which included clinical, economic, and humanistic outcomes.ResultsEleven CPCP employees were interviewed: physicians (n = 2), a nurse practitioner (n = 1), medical assistants (n = 4), and administrative staff (n = 4). The perceived role and value of the clinical pharmacist in this CPCP varied by employee position; yet, all expressed the pharmacist’s positive impact on patient care. Five themes were identified. The most common pharmacist roles identified included providing medication knowledge to providers, preventing abuse of controlled substances, monitoring clinical response to medications and adverse drug events, aiding in prior authorizations, educating patients, and providing patient-centered care.ConclusionThese results demonstrate that the integration of a clinical pharmacist into a CPCP can be valuable. This study highlights that the pharmacist was positively received by the physicians and staff. This further supports the value of the pharmacist as a key interprofessional health care team member. Further study is warranted to assess the longitudinal impact of pharmacists’ services in a CPCP.     

Evaluation of an educational strategy to improve medication reconciliation in ambulatory care

BackgroundImproper medication reconciliation can result in inaccurate medication lists. When medication lists are inaccurate, it can result in drug-drug interactions, dosing errors, and medication duplication. Interventions targeting medication reconciliation have had varying levels of success.ObjectiveThis study aimed to describe the medication reconciliation educational program, its implementation in a health care system, pharmacist and clinic personnel perception of the program, and its impact on clinic personnel knowledge and practice.MethodsGuided by the Conceptual Model of Implementation Research, a partially mixed sequential dominant status evaluation of a pharmacist-led educational program on evidence-based practices for medication reconciliation implemented into all primary care clinic sites by examining implementation outcomes was conducted. The implementation outcomes measured include penetration, fidelity, acceptability, appropriateness, feasibility, and adoption. Data were collected through program data and direct observations, pre- and postsurveys, and semistructured interviews of pharmacists and clinic personnel.ResultsOf 46 primary care sites, 37 primary care sites (80%) implemented the pharmacist-delivered medication reconciliation education from April to June 2021 with representation from each of Geisinger’s regions. Ten clinic sites (27%) completed the medication reconciliation educational program as originally designed, with the remainder adapting the program. A total of 296 clinic personnel completed the presurvey, and 178 completed the postsurvey. There were no differences in baseline characteristics between clinic personnel who completed the pre- versus postsurvey. All clinic personnel interviewed felt satisfied with the educational program and felt it was appropriate because it directly affected their job. Clinic personnel felt the educational program was acceptable and appropriate; two major concerns were discussed: a lack of patient knowledge about their medications and a lack of time to complete the medication reconciliation. The adherence rate to the elements of the medication reconciliation that were covered in the education program ranged from 0% to 95% in the 55 observations conducted.ConclusionAn educational program for medication reconciliation was found to be acceptable and appropriate but was often adapted to fit site-specific needs. Additional barriers affected adoption of best practices and should be addressed in future studies.     

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation

ObjectivesTo describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.DesignObservational case series study.SettingIndigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.Patients219 adults presenting for follow-up medical visits and self-reporting medication use.InterventionMedication reconciliation as part of patient interview and concurrent chart review.Main outcome measuresFrequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.ResultsOf 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.ConclusionPharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.     

Family physician perceptions of barriers and enablers to integrating a co-located clinical pharmacist in a medical clinic: A qualitative study

ObjectivePharmacists from The University of British Columbia Pharmacists Clinic provide comprehensive medication management services once to twice a month through the co-location model at multiple general practice clinics beginning from 2014 and consistently since 2016. For some of the clinics, this was the first experience with a co-located allied health professional. The objective of this study was to examine the perspectives of physicians who had a relatively long-standing relationship with a co-located pharmacist to identify barriers and facilitators to integrating a clinical pharmacist.MethodsA qualitative research methodology was used to gain the perspectives of physicians. Data were collected through convenience sampling and one-on-one semistructured interviews. In-person or telephone interviews were conducted from August 12, 2019, to September 10, 2019, and audio was recorded with the participants’ consent. The recorded interviews were transcribed, and a thematic analysis with an inductive approach was used to analyze the data.ResultsEight physicians from 4 general practice clinics were interviewed. Analysis of the interviews identified 6 themes that contained barriers or enablers to the integration of a co-located pharmacist: (1) electronic medical record (EMR) use, (2) identifying patients and the referral process, (3) workload and logistics, (4) patients’ willingness, (5) impact of in-person communication, and (6) shifting physicians’ perspectives. The enablers included the use of an EMR to proactively identify patient referrals, a dedicated pharmacist workspace, a physician champion, and intentional scheduling of in-person physician-pharmacist case conferences. The barriers included identifying patients for referral, the lack of EMR interoperability, pharmacist availability, physician colleagues who were less committed to team-based care, and financial implications despite externally funded pharmacists.ConclusionThe physician participants perceived several barriers and enablers to the integration of a pharmacist into their practice. The themes identified can be used to inform physicians and pharmacists on the integration process for team-based primary care.     

Protocol for a pilot and feasibility study of nurse practitioner-pharmacist telehealth collaboration to simplify complex medication regimens

IntroductionNew and flexible multidisciplinary workforce models are needed to address unnecessary medication regimen complexity in residential aged care facilities (RACFs). This study will investigate the feasibility of a nurse practitioner-pharmacist telehealth-based collaborative care model to simplify complex medication regimens.MethodsThis is a pragmatic, non-randomized pilot and feasibility study of up to 30 permanent residents from 4 RACFs in Western Australia. Simplification will be conducted in accordance with a validated 5-step implicit process. Nurse practitioners will identify residents potentially interested in and who may benefit from simplification, including any regulatory or safety imperatives that might preclude simplification. Medication regimens will be assessed by an off-site clinical pharmacist to identify opportunities for simplification in terms of drug–drug, drug–food, or drug–time interactions, and the availability of alternative formulations. The pharmacist will communicate simplification opportunities to nurse practitioners via video case conferencing. Nurse practitioners will then discuss simplification opportunities with the resident, caregiver and the health and care team, including any unintended consequences for the resident or RACF. The primary outcome measure will be feasibility (stakeholder acceptability, protocol adherence, recruitment and retention rates). Secondary outcomes include change in the number of medication administration times per day, medication and behavioral incidents, falls and fractures, hospitalization and mortality at 4 months.Ethics and disseminationEthical approval has been obtained from the Monash University Human Research Ethics Committee. Research findings will be disseminated through industry report, lay summaries, conference presentations and peer-reviewed publications.