Referrals made by different health care professionals to community pharmacists for domiciliary visits

Objective — To examine the suitability of referrals made by health professionals to a pharmacist for a domiciliary visiting service. Method — General practitioners (GPs), district nurses and social services carers were contacted to request that they refer patients who they thought might benefit from a home visit by a pharmacist, using a referral form agreed by an expert panel. Information gathered by the visiting pharmacist during the patient interview was compared with the reason for referral by the health care worker. Setting — All GPs, district nurses and social services carers who cared for housebound patients in the Kenton and Stanmore areas of the London Borough of Harrow. Key findings — Ninety patients were visited. Of these, 47 had been referred by GPs, 29 by nurses and 14 by social services. The highest level of incorrectly stated referrals (22 per cent of their referrals) came from nurses. Nurses tended to refer patients for an explanation of the purpose of their medicines, and GPs because patients were taking more than three medications. Six patients, five of whom were referred by GPs, appeared not to have any problems that could be helped by a visit. Conclusion — There may be a need to raise awareness among social services carers about potential medication problems and the role that could be played by community pharmacists in helping these patients. When GPs make referrals, the criterion of patients taking more than three medications may not be sufficiently sensitive; this should be expanded to ensure that the GP has additional clinically related suspicions that there are adherence issues. Generally, little difference was found between the appropriateness of referrals from the three agencies.     

A randomised controlled trial of a pharmaceutical care programme in high‐risk diabetic patients in an outpatient clinic

Objective — To determine the impact of a pharmaceutical care programme (PCP) in diabetic patients. Design — Randomised controlled study of high‐risk diabetic patients. Setting — Outpatient clinic at Fremantle hospital (FH), Western Australia. Method — Patients over 18 years of age who could communicate freely in English and fulfilled pre‐determined criteria for being high‐risk for the development of diabetic complications, were randomly assigned to the PCP or control groups in a ratio of 2:1. In the PCP arm, a clinical pharmacist reviewed and monitored all aspects of the patients' drug therapy in collaboration with other health care professionals at six‐weekly intervals for six months. The control patients received usual outpatient care. Main outcome measures — Glycosylated haemoglobin (HbA_1c), quality of life (QOL), patient satisfaction with health care providers and changes in drug therapy during the PCP. Results — Seventy‐three patients were recruited into the study, of whom 48 (66 per cent) were randomised to the PCP. There were no significant differences between the PCP (cases) and the control groups for demographic variables. The mean (±SD) HbA_1c for the cases was 8.4±1.4 per cent at the beginning and 8.2±1.5 per cent at the end of the study period (P>0.05). There was similarly no change in the control group (8.5±1.6 per cent to 8.1±1.6 % P>0.05). There were no significant changes in QOL for cases or controls over the period of the study. During the PCP, there was a significant increase in patient satisfaction with the care provided by the clinical pharmacist (P=0.007) and the provision of drug information (P=0.036). The clinical pharmacist facilitated 39 drug interventions in the 48 cases. A high level of complementary medicine usage was found in the PCP group (16.7 per cent). Conclusions — PCPs provide patients with important medication information and result in changes to drug therapy. However, in diabetic patients under specialist care, a six‐month PCP did not lead to an improvement in glycaemic control. The role for pharmacist intervention in primary care now needs to be evaluated.     

The development and evaluation of an extended adherence support programme by community pharmacists for elderly patients at home

Objective —To devise, implement and evaluate a medication adherence support service by community pharmacists for elderly patients living at home and at risk of non‐adherence. Method — Six community pharmacists identified patients who were 65 years of age and older, prescribed four or more regular medicines and living alone. A random sample of patients was visited at home and assessed for adherence‐related problems using a structured interview. The pharmacist then drew up an action plan in conjunction with the patient and general practitioner (GP), and returned for a second home visit, where the revised regime was delivered and explained. A self‐reported adherence questionnaire was also administered. After two months an independent researcher visited the patients at home to assess progress. Setting — Six community pharmacies in the city of Leeds, UK, and patients' homes. Key findings — A total of 143 patients were recruited and 441 medicine‐related problems were identified. Of these, 241 (55 per cent) required the provision of information and advice, 106 (24 per cent) required consultation with the GP and 86 (20 per cent) required changes in the presentation of the medicines. The median number of regular prescribed medicines fell from six to five (P<0.001). Overall, there was a reduction in the number of patients with one or more problems from 94 per cent to 58 per cent (P<0.001). The proportion of patients who reported non‐adherence fell from 38 per cent to 14 per cent (P<0.001). Conclusion — This study shows that community pharmacists can target patients at risk of medication non‐adherence and, using a structured approach, identify problems and implement solutions. The pharmacy patient medication record is an underutilised tool for identifying patients with adherence problems. The software needs enhancing to enable pharmacists to maximise their use of these records in adherence support. An adherence support programme needs to take more account of intentional non‐adherence and should be closely linked with the rest of the primary health care team.     

Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners

Objective — To evaluate the cost and clinical benefits of the provision of medication regimen reviews (MRRs) by community pharmacists for patients identified and referred by a general practitioner using a collaborative approach. Method — There were two cohorts of patients — 105 in stage 1 and 170 in stage 2 — from 34 GPs. The reviews were performed by 45 community pharmacists who had completed a training programme in MRR. The protocol was as follows: (1) a proforma MRR request form, including relevant clinical information and the patient's current regimen, was completed by the GP, (2) the review was conducted by the pharmacist and documented in a proforma report, (3) pharmacists and GPs met to discuss the review findings and recommendations for each patient, and (4) three months later, GPs were surveyed to verify any accepted recommendations and changes to medication regimen. A clinical panel estimated the clinical significance of the regimen changes for a subset of 141 cases. Key findings — The patients had an average of five diagnoses, with cardiovascular disease (34 per cent) and musculoskeletal disease (15 per cent) the most common conditions. A total of 2,220 medications were prescribed, representing a mean of eight per patient. In all, 869 changes to therapy were observed at the three‐month follow up: 47 per cent drug ceased; 17 per cent dose reduced; 11 per cent dose increased; and 12 per cent drug changed. Examining the impact of MRR on the mean number of medications per patient, the null hypothesis of no difference pre‐ and post‐MRR was rejected. There was a mean reduction of one medication per patient (P<0.001). As a consequence of this reduction, the average annual cost of medications was reduced by $A240 per patient. This translated to a projected annual cost saving for medication alone of $A90 per patient after offsetting the $A150 cost (professional remuneration) of the MRR. Considering health outcomes, overall, the reviewers rated at least 40 per cent of the MRR changes as leading to a positive effect on the patient's health. Conclusion — This study provides a good indication that MRR through GP‐pharmacist collaboration in the community can lead to positive clinical benefits and reduction in health care costs.     

Surveillance of adverse drug reactions at two multidisciplinary hospitals and an outpatient specialty clinic in India

Context — Adverse drug reaction (ADR) reporting is under‐developed in India, with only two of six national reporting centres currently functioning. Objective — To introduce an ADR monitoring programme at two hospitals and an outpatient skin specialty clinic in South India and to evaluate the programme. Design — An ADR monitoring programme was introduced in three participating centres and ADRs were documented and analysed over a period of six months. All unplanned admissions, all inpatients of the two participating hospitals and all outpatients of the skin specialty clinic were included in the study. A clinical pharmacist (the investigator) interviewed all patients on admission to identify suspected ADRs. For inpatients and clinic outpatients, suspected ADRs were documented by the treating doctor. A panel of four judges, including the investigator and the physician treating the patient with the suspected ADR, assessed the cases. Confirmed ADRs were then classified and categorised. Key findings — In total, 152 ADRs were documented. The percentage of patients with a reported ADR at each of the three centres was 3.5, 3.7 and 2.3. The gender of patients with reported ADRs was 53.9 per cent male and 46.1 per cent female. Most of the patients had a type “A” reaction (110, 72.4 per cent). Using Naranjo's probability scale, 25.7 per cent of ADRs were categorised as “probable” and 74.3 per cent as “possible.” Of the ADRs reported in the two hospitals, 31.1 per cent related to unplanned medication‐related hospital admissions and 68.9 per cent occurred during the hospital stay. Antibiotics (32.2 per cent), psychotropic drugs, steroids and non‐steroidal anti‐inflammatory drugs (11.8 per cent each) were the most common drugs that caused ADRs. General medicine (37.5 per cent) and dermatology (35.5 per cent) departments accounted for the highest number of ADRs. Pruritic rash (36.7 per cent) was the most common ADR reported at the skin clinic while pruritic rash, gastritis and diarrhoea (10.7 per cent each) and akathisia and hypoglycaemia (7.8 per cent) were the most common ADRs reported in the hospitals. Conclusion — This is the first study to evaluate an ADR reporting programme in India. Introduction of the ADR monitoring programme improved health care practitioners' awareness of the importance of pharmacovigilance. Occurrence of ADRs seemed to be similar to those reported in the developed world, with the exception of the proportion of severe ADRs (25 per cent), which was higher than reported elsewhere in published studies.     

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.     

Development of a pharmacist‐led cholesterol screening and lipid‐lowering medication review service in coronary artery bypass graft patients

Objective — To assess the effects of pharmacist intervention on lipid management in coronary artery bypass graft (CABG) patients. Method — Open study in which total cholesterol (TC) levels were measured in 43 elective CABG patients at visit 1 (pre‐surgery) and visit 2 (six weeks post‐discharge following surgery). Statin therapy was initiated (using atorvastatin) or statin doses were adjusted according to an agreed protocol. Key findings — Prior to CABG surgery, 19 patients (44 per cent) did not have target TC values. Fourteen (74 per cent) of these patients were already receiving a statin while five patients (26 per cent) were not receiving statin therapy. At visit 2, 33 patients (77 per cent) had achieved target TC. Mean (SD) TC was 5.7 (0.72) mmol/L at visit 1 and 4.8 (0.68) mmol/L at visit 2 in the intervention patients (P<0.01). There was no significant difference between mean TC at visits 1 and 2 in the non‐intervention patients (patients who had target TC values at visit 1). From a previous meta‐analysis, the decrease in TC of 0.9 mmol/L (16 per cent) in the intervention patients equates to a 24 per cent risk reduction in coronary heart disease (CHD) mortality and an 18 per cent risk reduction in total mortality. The recent National Service Framework for CHD has set standards for improving the care of CHD patients. From this study, it appears that the management of raised TC in this high‐risk population is sub‐optimal. Conclusion — This study has shown that the role of the pharmacist can be extended to encompass the management of raised total cholesterol in CABG patients, thereby contributing towards health care benefit.     

Contribution of a ward‐based technician service to delivering effective patient health care and reducing dispensary workload

Objective — To determine whether introduction of a ward‐based technician service reduces medication administration errors and decreases pharmacy workload. Method — Information on the incidence of unavailable medication administration errors (U‐MAEs), number of calls to pharmacy, volume of weekend medicine supply and workload of the non‐stock supply (NSS) pharmacist was compared during a two‐week period prior to the implementation of a ward‐based technician service (control period) and a two‐week period after the introduction of the service (study period). Setting — Five wards (two acute admission wards and three care of the elderly medical wards) at Bristol Royal Infirmary with a perceived high workload. Key findings — When a ward‐based technician service was implemented the number of U‐MAEs was almost halved (46 per cent reduction), and there was a 60 per cent reduction in the number of telephone calls from the five pilot wards to the dispensary. Overall, there was a decrease in the number of item requests during the weekend; however, the number of items requested from the non stock supply pharmacist increased from 51 to 58 (14 per cent). Conclusion — Following the introduction of the ward‐based technician service, patient care has improved as medicines are available more reliably, and the work life of the pharmacy team has benefited.     

Clinical medication review by a pharmacist of elderly patients on repeat medications in general practice — pharmacist interventions and review outcomes

Objectives — To describe the nature and rate of interventions made by a pharmacist conducting clinical medication reviews in general practice. Method — Patients, randomly allocated to the intervention group, in a randomised controlled trial of 1,188 patients, were invited to a pharmacist‐conducted medication review clinic at their general practice. Patients were seen over one year from June 1, 1999, to May 31, 2000. In the consultation an assessment was made of the patient, their clinical conditions and medication. Consultation outcomes for each patient and intervention outcomes for each medicine were evaluated. Setting — Patients were recruited from four randomly selected general practices in Leeds, UK. Patients were eligible if aged 65 years or over and on at least one repeat medicine. Key findings — Consultations were held with 590 patients in the intervention group (97 per cent). A recommendation for change was made in 44 per cent (258/591) of consultations. The most common outcome was a change in medication: 29 per cent of consultations (170/591). Doctor referral occurred for 28 patients (5 per cent) and nurse referral for 25 (4 per cent). Study patients were recorded as taking 2,927 repeat medications (mode of two per patient). Interventions were made for 21 per cent of medications (603). Clinically related interventions accounted for 71 per cent (430/603). Recommendations were spread evenly across therapy groups. At the study end, 90 per cent (433/484) of recommendations remained implemented. Conclusion — A pharmacist who clinically reviewed elderly patients, their conditions and their medications, intervened in nearly half the patients. The pharmacist was able to implement most interventions without referring the patient to a doctor or nurse.     

Over‐the‐counter ibuprofen: how and why is it used?

Objectives — To pilot an over‐the‐counter (OTC) medicine pharmacovigilance project, using ibuprofen as a model. Method — All users of any tablet or capsule form of ibuprofen (excluding compound products) purchased from 61 participating community pharmacies, aged ≥18 years and able to give informed consent, were eligible to join the study. A postal questionnaire one week after the index purchase monitored the follow‐up rate, drug usage, past medical history, concurrent medication, symptoms and health service utilisation. Setting — Primary care: community pharmacies in Grampian, Scotland. Key findings — A total of 443/544 (81 per cent) questionnaires were completed. The recommended daily dose of OTC ibuprofen (1,200mg) was exceeded by 35 customers (8 per cent) on at least one day and the recommended maximum daily dose that can be prescribed by a physician (2,400mg) was exceeded on five occasions. During the seven days after the index purchase, ibuprofen was used by 15 customers (4 per cent) with an active or past history of peptic ulcer, and 30 (7 per cent) with an active or past history of asthma. Thirty‐eight per cent had purchased ibuprofen for a chronic condition and 32 per cent were still taking it at the end of the initial seven‐day period. Twenty‐eight of 412 customers (7 per cent) sought advice during the seven‐day period about at least one symptom: 13 consulted their general practitioner, 12 consulted a pharmacist, two consulted both their GP and a pharmacist, and one consulted a hospital doctor. Some of these consultations (23/28, 82 per cent) might have related to an adverse reaction to ibuprofen: 11 customers (3 per cent) consulted about lower abdominal symptoms, nine about gastric symptoms and three about wheeziness. Conclusions — This pilot study identifies instances of contraindicated and excessive use of OTC ibuprofen, indicating a need for pharmacovigilance studies of OTC medicines; it also demonstrates the feasibility of a major study.     

Doctors' and pharmacists' attitudes to the use of sugar‐free and sugar‐containing medicines in the elderly

Background — Much progress has been made towards the prescribing and dispensing of sugar‐free alternatives for medicines used long‐term in children. However, older people may also take sugar‐containing medicines and those with natural teeth are at risk of dental caries. Objective — To assess the knowledge and attitudes of health professionals with regard to the use of sugar‐free medicines with prolonged oral clearance in elderly people. Method — Postal questionnaire survey of three groups of health professionals (general practitioners, community pharmacists, consultant geriatricians). Statistical analysis using factor analysis, Mann Whitney U test and Kruskal Wallis test. Setting — Five districts of north‐east England. Key findings — The overall response rate was 66 per cent (349 responses). Support for the use of sugar‐free medicines was greater among GPs than pharmacists (P=0.014). There was general agreement that, wherever possible, pharmacists should dispense sugar‐free medicines for elderly people, although more GPs (P<0.0001) and consultant geriatricians (P=0.024) agreed than pharmacists. More pharmacists than GPs believed sugar‐free medicines to be more expensive although there was general uncertainty about whether this deters doctors and pharmacists from using them. There was a good understanding of the role of sugars in medicines in the aetiology of dental disease, although respondents felt that elderly people were unaware of this link. Only 51 per cent of respondents agreed that government should subsidise sugar‐free medicines production. Ninety‐four per cent felt that the pharmaceutical industry should produce more sugar‐free products. Conclusion — Although there is support for the sugar‐free option, there is a need to raise the awareness of health professionals to barriers which currently discourage utilisation, and to encourage a more multi‐professional approach in the education of health professionals, health care providers, manufacturers and regulators with regard to sugar control in medicines use and related regulatory issues.     

Public perceptions of community pharmacists in Benin City,Nigeria

Objective — To determine public perceptions of community pharmacists and pharmacies in Benin City, Nigeria. Method — A self‐completion questionnaire was distributed to a stratified random sample of 1,500 households. Data were collected using a 22‐item, Likert‐type scale which was shown to have 0.77 reliability. The neutral point was assumed to be 66 on the scale of 22 to 110. Scores above 66 were interpreted as positive perception. Results — The response rate was 68.3 per cent (1,025/1500). Almost two‐thirds (64 per cent) of respondents perceived the community pharmacist as a health care provider, and 70 per cent agreed that community pharmacists are needed, especially in the area of medicinal product selection (76 per cent). However, 52 per cent believed pharmacists are profit motivated and only 43 per cent said they would be willing to pay for pharmacist consultation. Respondents reported difficulty in differentiating between pharmacists and pharmacy attendants, with only 58 per cent reporting that they could tell the difference. The pharmacists scored 76.37 ± 27.63, with 60 per cent of respondents scoring them above 66. Conclusion — This study found that community pharmacists received a moderately positive rating from the public. There is a need for community pharmacists to carve out a more distinct professional identity for themselves.     

Evaluation of a new health centre pharmacy: a case study

Background — This case study describes the evaluation of a primary care intervention in the Isle of Wight, United Kingdom, arising from the decision to move a medical practice from its town location into a new health centre in a nearby village. The new centre incorporated a new community pharmacy within the practice. Aim — To determine stakeholders' views on whether there was any perceived benefit resulting from the location of a pharmacy within the new health centre, over and above that of supply. Method — The evaluation explored both process and outcome features by means of self‐completion questionnaires with patients and semi‐structured interviews with health centre staff. The first phase of the study was undertaken prior to the medical practice move into the new health centre in July, 1996, and the second phase 12 months after the move. An interim report was used to influence change by making recommendations to the health authority to provide support and resources for the new pharmacist. Key findings — Prior to the move: three‐quarters of medical practice patients surveyed expected to use the new pharmacy, and 55 per cent expected to receive a better service. The health centre staff and pharmacist were enthusiastic about the potential for service development in the pharmacy. The general practitioners (GPs) had the clearest ideas about possible additional services but there was no implementation strategy. Based on these findings, the evaluators made specific recommendations on action to be taken by the health authority. After the move: 88 per cent of patients surveyed had used the pharmacy and considered that the service was better. The perception was based on matters of convenience. Health centre staff and GPs considered that the pharmacy was providing services beyond supply and had raised awareness of prescribing issues. Conclusion — A pharmacy located within a health centre can, given appropriate support, enhance the pharmacist's contribution to primary health care over and above supply, and provide a mechanism for developing pharmaceutical support for the prescribing function. Evaluation can help to provide insight into ways of ensuring a more satisfactory outcome following organisational change.     

Developing and evaluating a model for pharmaceutical care in Australian community pharmacies

Objective — To develop and evaluate a medication management service. The service was based on the principles of pharmaceutical care and targeted patients at risk of medication misadventure, primarily elderly patients, in five community pharmacies. Methods — In phase one, pharmacists defined the service in consultation with consumers, medical practitioners and professional pharmacy organisations. Agreed characteristics of the service were: patient selection criteria, a structured patient care process, systematic documentation, a quality assurance process and a complementary relationship with services of other health professionals. Implementation and evaluation of the service occurred in the second phase. The service was provided over an 11-month period to 205 patients. Key findings — Of the patients who received the service, 179 (87 per cent) had one or more medication or health-related problems. Pharmacists identified a total of 526 problems. Follow-up was available for 432 problems and 75 per cent of these problems were well managed by the end of the study. Of the 115 consumers surveyed, 74 responded. Eighty-five per cent of respondents believed the service had made a “significant” or “great” contribution to their health and 64 per cent thought that their knowledge of their medication had improved. Health economic evaluation indicated that net cost benefits were delivered to the health system. The net annual cost savings per patient ranged from $A40 to $A311. Conclusion — Pharmacists were able to apply the principles of pharmaceutical care to meet the needs of at-risk consumers in the community. Further development of this service delivery model is under way and would appear to offer substantial advantages to consumers and the health system.     

Domiciliary medication reviews by fourth year pharmacy students in Western Australia

Objective The principal aim of this study was to assess the potential value of final‐year undergraduate pharmacy students in domiciliary medication review (DMR). Method Students attended workshops on communication skills, complementary medicines and medication review. Each student contacted 5–10 patients by telephone and asked them to identify from memory all current medications. The student later conducted a DMR in the patient's home and prepared a report for the pharmacist preceptor and the patient's medical practitioner (GP) to review. Results The students recruited 189 patients, 80% of whom were over 60 years of age. The mean number of medications recalled by patients (5.8±2.9) was significantly lower than the number of medications that patients were actually taking (8.5 ± 3.5; P <0.001). Overall, 39% of patients gave incorrect/unknown indications for at least one medication and 17% had expired medicines. Students identified an average of 2.1 ± 1.7 actual or potential medication problems per patient. The mean number of problems endorsed by the pharmacist and GP were 1.1 and 0.9, and an additional 0.4 and 0.2 problems were identified, respectively. Nineteen patients (10%) required changes in therapy. Pharmacists and GPs thought it was appropriate for students to conduct DMRs under supervision and to include DMR as part of the students' training. Conclusion Final‐year pharmacy students were capable of collecting and collating medication information for DMRs in the community setting. The programme was acceptable to patients, GPs and pharmacist preceptors. Experience in DMRs should be included in the education of pharmacy students and pre‐registration trainees.