Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice

□ The government proposes an extension to pharmacists' role to medicine management, including services such as medication review □ We found that pharmacist‐conducted clinical medication review identified medication related problems in nearly half of the patients seen and a quarter of medicines reviewed □ Pharmacist‐conducted clinical medication review is effective in identifying clinical issues related to patients' repeat medication and recommendations are accepted by general practitioners □ There are education and training issues for pharmacy if this model is to be accepted more widely. The pharmacist will need to be part of the primary health care team with access to medical records     

A randomised,controlled study to quantify the benefits of community pharmacist interventions on the prescribing of cardiovascular drugs in general practice

□ The impact of a one‐off medication review by a specially trained community pharmacist, with recommendations to the patient's general practitioner was studied □ No differences were observed in any of the physiological or biochemical monitoring indicators □ There was greater improvement post‐intervention in some key quality prescribing indicators (eg, prescribing of antiplatelet and beta blocker or ACE inhibitor post‐MI); others showed equal improvement in both groups (diabetic patients on ACE inhibitor) □ A single review of medication records by a practice‐based pharmacist, with a dependence on the general practitioner to implement change may have limited benefit.     

Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge

Background Medication discrepancies may occur at transitions in care and negatively impact patient outcomes. Objective To determine if involving clinical pharmacists in hospital care, medication reconciliation and discharge medication plan communication can reduce medication discrepancies with a prospective, randomized, blinded, controlled trial. Setting A large, tertiary care, academic medical center. Method The intervention consisted of clinical pharmacist medication reconciliation, patient education and improved communication of the discharge medication plan, as devised by the hospital physician and care team, to primary care physicians and community pharmacists. Medication discrepancies were identified by blinded research pharmacists who reviewed primary care physician and pharmacy records at discharge through 90 days post-discharge to create 30- and 90-day medication lists. Main outcome measure Rate of medication discrepancies compared across groups. Results A total of 592 subjects from internal medicine, family medicine, cardiology and orthopedic services were evaluated for this study. Clinically important medication discrepancies in the primary care physician record were different between groups 30 days after hospital discharge following a clinical pharmacist’s intervention. The mean number of medication discrepancies per patient for the enhanced group being nearly half the number in the control group. However, this effect did not persist to 90 days post-discharge and did not extend to community pharmacy records. Conclusion The present study demonstrates the involvement of pharmacists in hospital care, medication reconciliation and discharge medication plan communication may affect the quality of the outpatient medical record.     

Patients' perspectives on medicines and pharmacy: views of patients with Type 2 diabetes

□ The study was conducted to inform the design of pharmaceutical care support to patients with Type 2 diabetes – a recognised health care priority and a target for new pharmacy initiatives □ Interviews in an outpatient clinic revealed an apparent lack of patient‐pharmacist communication and low patient expectations □ Some patients felt a lack of feedback about the results of clinic checks and what they meant for disease control □ Patient information leaflets were not consistently seen as meeting patients' needs for information and advice □ Patients' experiences can be used to develop the role of community pharmacy services within the health care team effort     

Provision of a domiciliary service by community pharmacists

The potential benefits of home visits by community pharmacists to housebound people with medication difficulties were examined. Sixteen community pharmacist volunteers made initial home visits to 39 patients referred by 14 general practitioners. The medication in their possession was noted, and information about the medication recorded from the medication container label, a patient medication record provided by the referring sugery and the patients' own knowledge. In 35 cases there were discrepancies between the medicines in the patient's possession, those they were currently taking and those listed on the patient medication record. Non-adherence, medication hoarding and adverse drug reactions were found. After each visit a summary was sent to the patient's GP and dispensing pharmacist. GP intervention was requested for 25 patients and dispensing pharmacist intervention for 17. Follow-up visits to 18 patients one month later showed that 37 per cent of suggested GP interventions and 50 per cent of suggested dispensing pharmacist interventions had been acted on. Feedback was received from the visiting pharmacists during a meeting and from the GPs and dispensing pharmacists by interview. The service was valued by the patients and endorsed by the GPs and all the community pharmacists involved, indicating that community pharmacists have a potential role to play in enhancing the care of specific housebound patients through domiciliary visits.     

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.     

General medical practitioners' attitudes towards the use of patient medication records

A survey was conducted to ascertain general medical practitioners' (GPs') attitudes to community pharmacists' use of patient medication records (PMRs) and to assess whether GPs envisage a role for family health service authorities (FHSAs) in maintaining records of patients' data. The survey questionnaire was sent by post to all 1,257 GPs in contract with Avon and Devon FHSAs. A total of 811 questionnaires was returned, an overall response rate of 64.5 per cent. A majority (59 per cent) of GPs considered that community pharmacists should keep patient medication records and there was strong support for pharmacists holding PMRs for the elderly and confused, and also for patients with diabetes, asthma, epilepsy, and those patients who had experienced major adverse drug reactions or allergies. Some GPs, however, remained unconvinced of the usefulness of a pharmacy PMR. Seventy four per cent of respondents considered that patients should keep their own medication records. In contrast, only 4 per cent were in agreement with patient medication data being stored by FHSAs. The community pharmacist's role in maintaining PMRs received less support from doctors in dispensing practices than from their non-dispensing counterparts. Some 80 per cent of respondents were in favour of pharmacists providing PMR system-generated patient information leaflets with dispensed medicines. Most GPs considered that such leaflets had a positive effect on patient compliance. Recently registered GPs were found to be more supportive than their older colleagues of community pharmacists recording patients' clinical conditions and providing information leaflets.     

Perceptions of patients on Medicare Part D medication therapy management services

ObjectivesTo determine patients’ perceptions and expectations about medication therapy management (MTM) services pertaining to the core elements of an MTM service in the community pharmacy setting, and to develop educational strategies and outreach programs aimed at increasing patients’ knowledge of MTM services and the expanded role of pharmacists in the community pharmacy setting.DesignMulticenter, cross-sectional, anonymous study.SettingFour regional community chain pharmacies in Maryland and Delaware in January and February 2006.Patients81 patients who were 18 years of age or older and able to complete the survey.InterventionSurvey containing 14 questions administered within pharmacies, two of which had patient care centers that were providing clinical services.Main outcome measurePatients’ perceptions and expectations regarding MTM services.Results49 of 81 patients (60%) had never heard of MTM services. A total of 65 patients (80%) had never had or received a medication therapy review, 63 (78%) never had or received a personal medication record, and 70 (86%) never had or received a medication action plan. Some 56% of participants (n = 45) thought that pharmacist provision of medication therapy reviews, personal medication records, medication action plans, recommendations about medications, and referral to other health care providers was very important. At least 70% of participants (n = 57) thought that having one-on-one consultation sessions with pharmacists to improve communication and relationships with their pharmacists and to improve their medication use and overall health was very important. More than 50% of participants indicated that they would like to receive brochures or talk to their pharmacist to learn more about MTM services.ConclusionPatients have very limited knowledge of the core elements of an MTM service in the community pharmacy setting. Patients reported that pharmacist provision of MTM services was important, but they were concerned about privacy and pharmacists’ time. Patients are also supportive of and believe that MTM services can improve communication and relationship with their pharmacist and improve medication use. Patients appear to prefer receiving brochures and talking to pharmacists to learn more about MTM services. This survey identified a key opportunity for pharmacists to inform patients about MTM services.     

An evaluation of medication review reports across different settings

Background There is a growing body of evidence which supports that a pharmacist conducted medication review increases the health outcomes for patients. A pharmacist integrated into a primary care medical centre may offer many potential advantages in conducting medication reviews in this setting however research describing this is presently limited. Objective To compare medication review reports conducted by pharmacists practicing externally to a medical centre to those medication review reports conducted by an integrated practice pharmacist. The secondary objective was to compare medication review reports conducted by pharmacists in the patient’s home to those conducted in the medical centre. Setting A primary care medical centre, Brisbane, Australia Method A retrospective analysis of pharmacist conducted medication reviews prior to and after the integration of a pharmacist into a medical centre. Main outcome measures Types of drug related problems identified by the Pharma cists, recommended intervention for drug related problems made by the pharmacist, and the extent of implementation of pharmacist recommendations by the general practitioner. Results The primary drug related problem reported in the practice pharmacist phase was Additional therapy required as compared to Precautions in the external pharmacist phase. The practice pharmacist most frequently recommended to add drug with Additional monitoring recommended most often in the external pharmacists. During the practice pharmacist phase 71 % of recommendations were implemented and was significantly higher than the external pharmacist phase with 53 % of recommendations implemented (p < 0.0001). Two of the 23 drug related problem domains differed significantly when comparing medication reviews conducted in the patient’s home to those conducted in the medical centre.     

Evaluation of medication reconciliation in an ambulatory setting before and after pharmacist intervention

ObjectivesTo determine the accuracy of medication reconciliation in an internal medicine clinic and to evaluate pharmacist interventions targeted at improving the accuracy of medication reconciliation.DesignProspective case series.SettingMemphis, TN, from October 2007 to March 2008.Patients180 adults attending an internal medicine appointment.InterventionOn patient arrival, a nurse completed the medication reconciliation form. In Phase 1 of the study, a pharmacist randomly selected and reviewed a patient's medication reconciliation form, interviewed the patient, and verified information if indicated. A total of 90 forms were reviewed and compared to determine baseline medication reconciliation accuracy. Education interventions were held with the medical and nursing staff, targeting areas for improvement. In Phase 2 of the study, 90 additional medication reconciliation forms were reviewed in the same manner. Phase 1 and Phase 2 results were compared to evaluate differences in accuracy after the pharmacist's education interventions.Main outcome measuresAccuracy of medication reconciliation forms and number of potentially significant errors at baseline and after pharmacist interventions.ResultsIn Phase 1, 14.4% of medication reconciliation forms were correct. The remaining forms contained 190 potentially significant errors. After the education interventions, 18.9% of medication reconciliation forms were correct and the others contained 139 potentially significant errors.ConclusionMedication reconciliation accuracy is poor. Although education interventions showed a trend toward improvement, continued education training for staff and patients is needed in addition to other interventions to optimize this process and prevent medication errors.     

Professional development of pharmaceutical care in type 2 diabetes mellitus: a multidisciplinary conceptual model

Objective To generate a validated model of care providing a framework for continued professional development of the community pharmacist for patients with type 2 diabetes mellitus. Setting A purposive sample of medical, nursing and community pharmacist interviewees in 10 health boards in Scotland. Method Investigation, using a semi‐structured questionnaire approach, of the views held by 19 healthcare practitioners. Key findings A model of multidisciplinary diabetes care was generated to aid definition of pharmaceutical care provision. Processes emphasised in the model were: compliance monitoring, agreed multidisciplinary protocols and the continuity of patient education. Potential areas for community pharmacist contributions included the running of diabetes clinics, provision of patient education, near‐patient testing, repeat dispensing and identification of clinic defaulters. Conclusions Development of the community pharmacists' role for patients with type 2 diabetes mellitus requires extensions to current independently delivered patient‐centred services through working in partnership with other professionals. Methods of improved communication and attention to methods of referral, where appropriate, are important focal points. The targeting of this care and the care model that is best suited to particular settings will be subject to local variation. The generation of a diabetes care model offers pharmacists a means of matching learning opportunities to their needs. It is also a step towards the development of appropriate continued professional development tools and systems to equip community pharmacists for the future.     

Identification of psychosocial factors which influence patient adherence with antihypertensive medication

□ It is estimated that only 50 per cent of hypertensive patients adhere to medication regimens □ In this study evaluation of self‐efficacy and the theory of planned behaviour was used to identify psychosocial factors which impact on patient adherence to antihypertensives □ High self‐efficacy, intentions to comply with the medication regimen, possessing a positive attitude towards taking medication, perceiving pressure from significant others to take medication as prescribed, and perceiving control over taking medication were determinants of good adherence □ The successful identification of factors which influence adherence will allow health‐care providers to implement interventions, aimed at enhancing adherence with antihypertensive medication.     

基于临床药师工作实践构建电子药历管理平台

目的：构建高效实用的电子药历管理平台,协助临床药师开展药学服务,保障医疗质量和医疗安全。方法：电子药历管理平台采用C++语言编写,尝试与电子病历系统实现无缝对接;根据患者在院流程设置七大药学服务模块,实现患者的全程化药学管理,并制定了患者药学监护的分级管理制度。结果：药历和病历系统的融合真正实现了医药护数据的无缝对接和共享,能让医护及时了解相关药学建议,促进合理用药;药学监护的全流程化则确保了患者药学监护的连续性和完整性;而药学监护分级管理制度则让临床药师的工作有的放矢,在提高效率的同时突出了重点。结论：该电子药历管理平台的构建不仅促进了我院临床药学工作的发展,而且为我国临床药学电子药历的规范化建设和管理提供参考,对医疗质量和医疗安全的保障起到了积极作用。     

Working alongside nursing staff to review medication in nursing homes

□ Pharmacists performed medication reviews in nursing homes using the nursing staff as a source of information □ Lack of access to medical records did hamper the review but was not the main reason for non‐implementation □ The recommendations were more likely to be implemented if further clinical information was supplied to the general practitioner □ All of the pharmacists, all of the nursing staff responding and a majority of the GPs who responded wished to see the project continue □ Future training of community pharmacists should focus on “how to review”.     

A study contrasting different modalities of medication discharge counseling

The effects of different modalities of medication discharge counseling on patients' medication knowledge were studied. Patients discharged from medical/surgical units in a community hospital were counseled utilizing one of three methods or received no counseling, according to their randomized study group assignment. The three types of discharge counseling studied were: (1) distributing written information and answering all patient questions, (2) verbal counseling performed by a pharmacist, or (3) verbal counseling performed by a pharmacist with distribution of written information. The control group received no counseling or written information. Patient information was collected, and the time and costs of the counseling were recorded. A questionnaire was sent to each patient 1 week after discharge from the hospital to determine a patient's knowledge of his/her medications. The questionnaires were scored by a pharmacist unaware of the type of counseling the patient had received. Upon completion of the scoring, the study data was collated and statistically analyzed. The results showed that medication discharge counseling conducted by a pharmacist does improve a patient's knowledge of his medications and that pharmacist intervention in medication teaching does improve the counseling results. Also, the study demonstrated that verbal counseling in combination with written information increased the patient's awareness of his medications the most, and was a financially feasible method. This study supports the development and continuation of pharmacist-conducted medication discharge counseling in rural community hospitals.