Drug-related problems identified in medication reviews by Australian pharmacists

Objective In Australia, accredited pharmacists perform medication reviews for patients to identify and resolve drug-related problems. We analysed the drug-related problems identified in reviews for both home-dwelling and residential care-facility patients. The objective of this study was to examine the number and nature of the drug-related problems identified and investigate differences between each type of review. Setting Australian patients living at home or in residential care-facilities. Method We collected a nation-wide sample of medication reviews conducted between 1998 and 2005. These reviews had been self-selected by pharmacists and submitted as part of the reaccreditation process to the primary body responsible for accrediting Australian pharmacists to perform medication reviews. The drug-related problems identified in each review were classified by type and drugs involved. Main outcome measure The number and nature of drug-related problems identified in pharmacist-conducted medication reviews. Results There were 1,038 drug-related problems identified in 234 medication reviews (mean 4.6 (±2.2) problems per review). The number of problems was higher (4.9 ± 2.0 vs. 3.9 ± 2.2; P < 0.001) in reviews for home-dwelling patients compared with care-facility residents. The number of clinically-significant problems was higher (2.1 ± 1.1 vs. 1.5 ± 0.7; P < 0.001) for home-dwelling patients. Oral hypoglycaemics and analgesics/antipyretics were significantly more likely to be associated with problems in home-dwelling patients than in residential care-facility patients. Conclusion These data illustrate the prevalence of drug-related problems and the ability of pharmacists to identify these problems in the Australian models of medication review. The nature and frequency of problems varied between reviews for home-dwelling and care-facility patients. Such information may be used to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug-related problems in the two settings.     

The majority of hospitalised patients have drug-related problems: results from a prospective study in general hospitals

Objective : To describe the frequency and types of drug-related problems (DRPs) in hospitalised patients, and to identify risk factors for DRPs and the drugs most frequently causing them.Methods From May to December 2002, 827 patients from six internal medicine and two rheumatology departments in five hospitals in Norway were included in this study. We recorded demographic data, drugs used, relevant medical history, laboratory data and clinical/pharmacological risk factors, i.e. reduced renal function, reduced liver function, heart failure, diabetes, compliance problems, drugs with a narrow therapeutic index and drug allergy. DRPs were documented after reviewing medical records and participation in multidisciplinary team discussions. An independent quality assessment team retrospectively assessed the DRPs in a randomly selected number of the study population.Results Of the patients, 81% had DRPs, and an average of 2.1 clinically relevant DRPs was recorded per patient. The DRPs most frequently recorded were dose-related problems (35.1% of the patients) followed by need for laboratory tests (21.6%), non-optimal drugs (21.4%), need for additional drugs (19.7%), unnecessary drugs (16.7%) and medical chart errors (16.3%). The patients used an average of 4.6 drugs at admission. A multivariate analysis showed that the number of drugs at admission and the number of clinical/pharmacological risk factors were both independent risk factors for the occurrence of DRPs, whereas age and gender were not. The drugs most frequently causing a DRP were warfarin, digitoxin and prednisolone, with calculated risk ratios 0.48, 0.42 and 0.26, respectively. The drug groups causing most DRPs were B01A-antithrombotic agents, M01A-non-steroidal anti-inflammatory agents, N02A-opioids and C09A-angiotensin converting enzyme inhibitors, with risk ratios of 0.22, 0.49, 0.21 and 0.35, respectively.Conclusions The majority of hospitalised patients in our study had DRPs. The number of drugs used and the number of clinical/pharmacological risk factors significantly and independently influenced the risk for DRPs. Procedures for identification of, and intervention on, actual and potential DRPs, along with awareness of drugs carrying a high risk for DRPs, are important elements of drug therapy and may contribute to diminishing drug-related morbidity and mortality.     

Development of a method for clinical medication review by a pharmacist in general practice

Medication review of patients on long-term treatment in general practice in the UK has been reported to be inadequate. Proposals followed suggesting that pharmacists could use their expertise to lead such a medication review in conjunction with the general practitioner. This paper describes the concept of clinical medication review by a pharmacist based in general practice. We describe the development of a method for a structured and systematic process for undertaking such a review in clinics conducted by a pharmacist. The method was developed for a nationally funded study in the UK. We provide a definition of clinical medication review and suggests a structure for the process through data gathering, evaluation and implementation.     

Drug-related problems and pharmacotherapeutic advisory intervention at a medicine clinic

Objective To describe the scenario and frequency of drug-related problems (DRPs) in in-patients and to determine whether a pharmacotherapeutic advisory intervention aiming at reducing DRPs could affect rates of re-hospitalisation and/or death within 6 months.Methods This prospective, randomised, controlled advisory intervention study was carried out at the Clinic of Internal Medicine at Stockholm S?der Hospital. Three hundred patients from four wards took part in the study. Patients taking two drugs or more were included. In the intervention arm, potential drug interactions were found using a computer system. Medical symptoms were estimated by a nurse together with the patient. Creatinine clearance was calculated. Thereafter a clinical pharmacologist scrutinised the patient′s medical record for DRPs together with the nurse. DRPs judged to be clinically relevant resulted in written advice to the physician in charge of the patient. The control group received usual care.Results In the intervention group, a total of 299 DRPs were found among 71% of the patients (106/150). The number of written letters of advice to the physicians in charge was 106. Of these, 63% were accepted. After 6 months, the proportion of re-hospitalisations or death in the intervention group was 49% (73/150) compared to 46% (69/150) in the control group. The difference was not significant.Conclusions DRPs were common. Potential drug interactions and adverse drug reactions dominated. Hospital-based medication review by a clinical pharmacologist was not associated with reduced rates of re-hospitalisation and/or death. The clinical relevancy of DRPs might be overestimated as a risk for re-hospitalisation or death. It is of great importance to clarify if and how drug-related problems can be prevented. In designing such studies, one should consider choosing inclusion criteria that accumulate risk.     

Drug-related problems in patients with angina pectoris, type 2 diabetes and asthma – interviewing patients at home

Objective of the study The objective of the overall study was to create a foundation for improving the quality of counselling practice in pharmacies. The research question addressed in this sub-study was to describe drug-related problems (DRPs) in terms of frequency as well as type in people with angina pectoris, type 2 diabetes and asthma, as the problems were identified through medication reviews and home interviews.Setting and method During their pharmacy internships, fourth-year pharmacy students collected data for the study in 1999, 2000 and 2001 by carrying out medication reviews, conducting home interviews and registering DRPs for 414 patients. Data were collected from the following patient groups in the years indicated: in 1999, 123 angina pectoris patients; in 2000, 192 type 2 diabetes patients, and in 2001, 99 asthma patients. The interviews dealt with the patient’s drug-related experiences, knowledge, perceptions, problems and actions. The DRPs were registered according to the so-called PI-Doc system.Results A medication review was supplemented by qualitative interviews with the three patient groups, which revealed a relatively high number of DRPs compared to other studies. An average of 2.8 DRPs were identified per angina pectoris patient; 4.1 DRPs per type 2 diabetes patient and 4.0 DRPs per asthma patient. “Inappropriate use of medicines by the patient” and “Other problems” (such as limited knowledge of the illness, inappropriate lifestyle, fear of medication, lack of information, etc.) were the two most common DRP sub-categories identified in all three patient groups.Conclusion The study provided a profile of a pharmacy-based population of 414 patients visiting the pharmacy, all of whom are at high risk of experiencing drug-related problems. Pharmacy staff needs to take this high rate of DRPs in people with angina pectoris, asthma and type 2 diabetes into account when dispensing medicines to and advising patients from the three groups, especially when explaining how to use medicines appropriately.     

Project Octo-Pills - A practice model engaging community pharmacists in the care of patients from a tertiary hospital

Even while pharmacy practice evolves to a more patient-centric mode of practice, local hospitals, due to high patient load as well as space and resource constraints, find it challenging to conduct thorough medication review and physical medication reconciliation for all patients. In light of this, optimizing the local current healthcare system to involve community pharmacists in the care of patients from public hospitals could potentially better cater to the healthcare needs of the older population. Due to easy accessibility, community pharmacies are often the first point of contact in the healthcare system. Project Octo-Pills aims to engage community pharmacists in the collaborative care of patients from a tertiary hospital, providing patients with quality medication reconciliation and review services from a more convenient location within their neighborhood. This paper describes the model for this pilot initiative.     

Studying the impact of a medication use evaluation by the community pharmacist (Simenon): Drug-related problems and associated variables

BackgroundA medication use review (MUR) aims to optimize medication use, patient knowledge and can improve health outcomes. This pharmaceutical care service is not yet available in Belgium.ObjectivesTo describe drug-related problems (DRPs) detected during a MUR, subsequent interventions proposed by pharmacists and evolution of DRPs until follow-up and to identify patient-related variables associated with the number of reported DRPs.MethodsBelgian community pharmacists provided a MUR to older polymedicated ambulatory patients and registered DRPs, interventions and resolution at follow-up using the PharmDISC classification. The relationship between 14 patient-related variables and the number of reported DRPs was investigated with univariate analysis. A prediction model was developed with significant variables using negative binomial regression analysis.ResultsAcross 56 pharmacies, 453 patients received a MUR and 1196 DRPs were registered (median 3DRPs/patient, range 0–10). Only for 11.7% of patients no problems were identified. The top-3 causes were interaction (15.2%), inappropriate timing or frequency (13.5%) and adverse effect (11.9%). The top-3 recommended interventions by pharmacists were transmission of information (25.1%), in-depth patient counselling (15.0%) and therapy stop (8.2%). After six weeks, 42.6% of DRPs were resolved; data was missing for 33.3%. A higher number of chronic drugs, female gender and living alone were associated with more DRPs. The prediction model found that per additional chronic drug, the number of problems increases by 4.3% (95% CI: 2.0–6.6%). Male gender decreases DRPs by 22.1% (95% CI: 10.4–32.0%). Living alone provided no additional predictive value in the prediction model. Confounding process- and pharmacist-related variables also influenced the number of reported DRPs.ConclusionA MUR appears an effective strategy to detect and resolve DRPs. The number of chronic medications and female gender predict a higher number of DRPs. These findings are a starting point for evidence-based eligibility criteria for a MUR service in Belgium.     

The role of clinical pharmacists in general practice in England: Impact,perspectives, barriers and facilitators

BackgroundBy 2020/1 NHS England plans to invest over 100 m to ensure that there is one clinical pharmacist post in primary care for every 30,000 patients. A recent realist review identified key questions in the literature related to the implementation of a clinical pharmacist (CP) in a general practice role. These relate to the impact of the role, perspectives on the role (patients, GPs and pharmacists), and barriers and facilitators to the implementation process. The data collected in the national evaluation of the pilot scheme provides data to answer the realist questions identified.ObjectivesThis paper examines the experience of implementing the clinical pharmacist in general practice role, in relation to the areas identified above.MethodsThe research took a mixed methods approach to understanding the scheme implementation and this research draws on both survey and qualitative interview data from a wide range of stakeholders.ResultsPharmacists in the pilot phase are motivated to develop clinical skills and make a positive impact on patients. Data suggests that clinical pharmacists have a positive impact, in particular on health outcomes related to polypharmacy and long-term conditions. GPs have a broadly positive response to the CPs, in particular when they save time and money for the practice. However, GPs have to invest time in mentoring and building relationships to realise the benefits of the role. Patients appreciate the CP role for increasing access to a practitioner and providing expertise in medications. There are some barriers to successful implementation of the role, including policy and funding, lack of clarity around the role and lack of quantitative and economic validation of the role. Facilitators of success include supportive working relationships, integration and mentoring.ConclusionThe pilot implementation of this new role was successful but there are lessons which can be learned for the success of future iterations and more work is required to economically validate the role which is likely to in turn generate positive relationships with GPs.     

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.     

Drug therapy problems found in ambulatory patient populations in Minnesota and South Australia

OBJECTIVE: To compare drug therapy problems identified by pharmacists in two patient samples, the Minnesota Sample and the South Australian Sample. METHODS: Two patient samples were selected for this comparison. Both sets of patients received pharmaceutical care services from pharmaceutical care practitioners between March 1999 and February 2000. The two databases were then compared for common drug therapy problems. MAIN OUTCOME MEASURE: Comparison of drug therapy problems in the two samples. RESULTS: Both patient samples included patients who were 40 years of age or older. The Minnesota Sample included 1,598 individual patients, of whom 70% experienced one or more drug therapy problems at some time during their care. The South Australian Sample included a total of 982 patients of whom 90% experienced one or more drug therapy problems at some time during their care. Conditions common to both patient samples include hypertension, diabetes, arthritis, ischemic heart disease, and osteoporosis. Frequently occurring drug therapy problems in the Minnesota Sample included the need for additional drug therapy, dosage too low and non-compliance and in the South Australian Sample included non-compliance, additional drug therapy and ineffective drug therapy. Frequent drug therapy problems associated with medical conditions in the Minnesota Sample included addition of new therapies for conditions such as arthritis, hypertension, hyperlipidemia and allergic rhinitis, while for the South Australian Sample included compliance issues with conditions such as asthma, diabetes mellitus, angina and digestive disorders. Frequent drug therapy problems with associated drug classes in the Minnesota Sample included additional therapy for classes such as salicylates and calcium supplements, while in the South Australian Sample included the need for therapy for pneumococcal vaccines, salicylates, calcium supplements and tetanus vaccines. CONCLUSION: These data demonstrate that this age group has significant drug therapy problems and therefore emphasize the need for pharmaceutical care services in this population. The provision of pharmaceutical care by experienced practitioners can result in improved recognition of the full range of drug therapy problems confronting patients. Analyses such as those presented here provide information to better focus the training of practitioners based on the most frequently encountered health problems and the nature of common drug therapy problems in the community setting.     

A pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting

BackgroundThere is a paucity of research describing the pharmacist's role in the multidisciplinary care of older adults in the intermediate care setting.ObjectiveTo determine the types of drug-related problems (DRPs) in older patients in this setting, to evaluate the implementation rate of pharmacist recommendations and the factors affecting implementation, and to assess the clinical significance of these recommendations.MethodsData were collected over a 12-week period on one pharmacist's recommendations to reduce clinically relevant DRPs identified during medication reconciliation and review for all patients ≥65 years admitted to an intermediate care unit. The clinical significance of the recommendations was judged by four independent assessors using a validated tool. Statistical significance was predetermined as p < 0.05.ResultsOf 494 clinically relevant DRPs identified in 91 patients (mean age: 82 years), 406 recommendations were communicated to the medical team, and 89.2% were implemented. Overall, 48.5% were communicated verbally, but no difference was found between the implementation rates of verbal and written recommendations (87.8% versus 90.4%; p = 0.4). Medication reconciliation recommendations were implemented more commonly than those regarding medication review (96.5% versus 79.5%; p < 0.0001). Recommendations judged to be of ‘moderate significance’ (66.8% of total) were implemented more often than those of ‘minor significance’ (93.2% versus 81.6%; p < 0.001). The consultant was provided with a significantly higher proportion of recommendations of ‘moderate significance’ when compared to the junior doctor (79.6% versus 63.3%; p = 0.02), but implemented significantly fewer recommendations (69.4% versus 91.9%; p < 0.0001).ConclusionThe high implementation rate in this study shows the importance of pharmacist involvement to reduce DRPs in the multidisciplinary care of older adults in an intermediate care unit. Future research should focus on investigating the impact of pharmacist interventions on older patient outcomes and the associated cost-effectiveness in this setting.     

Using network analysis to explore factors moderating the implementation of a medication review service in community pharmacy

BackgroundImplementation factors are hypothesised to moderate the implementation of innovations. Although individual barriers and facilitators have been identified for the implementation of different evidence-based services in pharmacy, relationships between implementation factors are usually not considered.ObjectivesTo examine how a network of implementation factors and the position of each factor within this network structure influences the implementation of a medication review service in community pharmacy.MethodsA mixed methods approach was used. Medication review with follow-up service was the innovation to be implemented over 12 months in community pharmacies. A network analysis to model relationships between implementation factors was undertaken. Two networks were created.ResultsImplementation factors hindering the service implementation with the highest centrality measures were time, motivation, recruitment, individual identification with the organization and personal characteristics of the pharmacists. Three hundred and sixty-nine different interrelationships between implementation factors were identified. Important causal relationships between implementation factors included: workflow-time; characteristics of the pharmacy-time; personal characteristics of the pharmacists-motivation.Implementation factors facilitating the implementation of the service with highest centrality scores were motivation, individual identification with the organization, beliefs, adaptability, recruitment, external support and leadership. Four hundred and fifty-six different interrelationships were identified. The important causal relationships included: motivation-external support; structure-characteristics of the pharmacy; demographics-location of the pharmacy.ConclusionNetwork analysis has proven to be a useful technique to explore networks of factors moderating the implementation of a pharmacy service. Relationships were complex with most implementation factors being interrelated. Motivation and individual identification with the organisation seemed critical factors in both hindering and facilitating the service implementation. The results can inform the design of implementation programs and tailored strategies to promote faster implementation of innovations in pharmacy.     

Pharmacist services provided in general practice clinics: A systematic review and meta-analysis

BackgroundIntegration of pharmacists into primary care general practice clinics has the potential to improve interdisciplinary teamwork and patient care; however this practice is not widespread.ObjectiveThe aim of this study was to review the effectiveness of clinical pharmacist services delivered in primary care general practice clinics.MethodsA systematic review of English language randomized controlled trials cited in the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and International Pharmaceutical Abstracts was conducted. Studies were included if pharmacists had a regular and ongoing relationship with the clinic; delivered an intervention aimed at optimizing prescribing for, and/or medication use by, clinic patients; and were physically present within the clinic for all or part of the intervention, or for communication with staff. The search generated 1484 articles. After removal of duplicates and screening of titles and abstracts against inclusion criteria, 131 articles remained. A total of 38 studies were included in the review and assessed for quality. Seventeen studies had common endpoints (blood pressure, glycosylated hemoglobin, cholesterol and/or Framingham risk score) and were included in meta-analyses.ResultsTwenty-nine of the 38 studies recruited patients with specific medical conditions, most commonly cardiovascular disease (15 studies) and/or diabetes (9 studies). The remaining 9 studies recruited patients at general risk of medication misadventure. Pharmacist interventions usually involved medication review (86.8%), with or without other activities delivered collaboratively with the general practitioner (family physician). Positive effects on primary outcomes related to medication use or clinical outcomes were reported in 19 studies, mixed effects in six studies, and no effect in 13 studies. The results of meta-analyses favored the pharmacist intervention, with significant improvements in blood pressure, glycosylated hemoglobin, cholesterol and Framingham risk score in intervention patients compared to control patients.ConclusionsPharmacists co-located in general practice clinics delivered a range of interventions, with favorable results in various areas of chronic disease management and quality use of medicines.