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 patient‐held medication record and a patient medication profile to support the continuity of acute cancer care

□ The sharing of care of patients receiving medical oncology care is vulnerable to errors in their documented drug history □ A patient‐held medication record identified over 90 per cent of patients' medications but was ‘forgotten’ by the patient in a third of contacts with a pharmacist □ Discrepancies between the medication records of GPs, community pharmacists and the medical oncology clinic were highly prevalent □ A posted patient medication profile issued by the hospital pharmacist to both the patient's GP and their community pharmacist was associated with a significant convergence in their records (discrepancies reduced from 17 to 6 % P<0.001) □ The patient‐held record had little impact on the accuracy of practitioners' records and its value lies more in facilitating patient education than rectifying errors in documentation     

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”.     

Pharmaceutical care and its relationship to prescribing behaviour of general practitioners

Objective To study the correlation between pharmaceutical care and prescribing routines of general practitioners (GPs).Methods Cross-sectional study; 201 pharmacies, 408 general practices, The Netherlands, 2000/2001. The variation in prescribing behaviour was characterised using 20 validated prescribing indicators based on general practice guidelines. The general construct ‘adherence to guidelines’ served as the dependent variable and was formed by summing the scores of the prescribing indicators. Four possible determinants of the variation were determined on the basis of survey questions: the construct ‘the pharmacist’s attitude towards pharmaceutical care’, and three partial constructs derived from the pharmacist’s care-providing function: the care for the individual patient, the cooperation with general practitioners and the registration of the care provided. A multiple linear regression analysis was then performed.Main outcome measure The weighted score for the prescribing indicators.Results The weighted average score for the prescribing indicators was 65% (SD 3.7). The response rate to the survey was 71%. The pharmacist’s attitude to pharmaceutical care, as well as the degree to which the pharmacist provided care for the individual patient, the degree to which he cooperated with the general practitioner and the degree to which he registered the care provided were not correlated with the ‘adherence to guidelines’ by the general practitioner with whom the pharmacist frequently cooperated.Conclusion Variations between general practitioners in the quality of prescribing, as measured by their adherence to guidelines, were not correlated with pharmaceutical care by the pharmacist with whom they cooperated on a day-to-day basis.     

An evaluation of a collaborative pharmacist prescribing model compared to the usual medical prescribing model in the emergency department

BackgroundWorkforce reform has placed a significant focus on the role of non-medical prescribers in the healthcare system. Pharmacists are trained in pharmacology and therapeutics, and therefore well placed to act as non-medical prescribers.ObjectivesTo assess the safety and accuracy of inpatient medication charts within a pharmacist collaborative prescribing model (intervention), compared to the usual medical model (control) in the emergency department (ED). Another objective compared venous thromboembolism (VTE) risk assessment and prescribing, between intervention and control groups.MethodsAdult patients in ED referred for hospital admission were randomised into control or intervention by a block randomisation method, until the required sample size was reached. Medication charts were audited retrospectively by an independent auditor, using validated audit forms.ResultsIntervention group medication charts contained significantly fewer prescribing errors, omissions and discrepancies compared to the control group, and improved documentation of adverse drug reactions. VTE risk assessment and prescribing had higher guideline concordance in the intervention group compared to the control group.ConclusionsThis collaborative prescribing trial showed excellent results in safety and accuracy of pharmacist prescribing when compared to the usual medical model of prescribing. The admitting medical practitioner and extended scope pharmacist prescriber worked as a collaborative team in emergency, which improved Australian national prescribing safety indicators.     

SIGN guidelines and the management of sore throat in community pharmacy

□ Scottish Intercollegiate Guidelines Network guidance on the management of sore throat recommends analgesia and refer to the role of the community pharmacist in advising symptomatic relief □ Advice given to 749 patients from 65 community pharmacies; 49 patients (6.5 per cent) were referred to their general practitioner □ Paracetamol, drug of choice from SIGN guideline, was recommended to 219 patients (29 per cent); a preparation for symptomatic relief either alone or in combination with an analgesic was advised for 590 patients (79 per cent) and of these, 315 patients (42 per cent) were recommended lozenges with anaesthetic and antibacterial action □ Compliance with SIGN guidelines was observed regarding choice of analgesic □ Evidence is required for choice of symptomatic relief.     

Effect of pharmaceutical pre‐assessment on post‐operative interventions

□ The study determined the extent of post‐operative interventions required for patients admitted for elective hip or knee arthroplasty □ In Phase 1, patients were pre‐assessed by nurses at admission, according to existing practice; in Phase 2, patients received pharmacist‐led pre‐assessment □ There were 131 interventions (2.05 per patient) in Phase 1 compared with 40 (0.68 per patient) in Phase 2, a reduction of approximately 70 per cent □ This study demonstrates that pharmaceutical pre‐assessment substantially reduces the number of interventions made during patients' post‐operative stay.     

Pharmaceutical care for older people: recording and review of medication following admission to hospital

The National Service Framework for Older People calls for regular medication review for all patients over the age of 75 Studies have shown that pharmacists take more accurate admission medication histories than do junior medical staff, but few studies have evaluated pharmacist‐mediated medication review An ethnographic study was used to develop structured protocols for medication review and history taking, which were evaluated by a pharmacist on two acute medical wards The study found that a structured medication review by a pharmacist results in more appropriate prescribing, including discontinuing drugs no longer required or contraindicated, avoiding adverse drug reactions and tailoring therapy to patient's needs     

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.     

Pharmacist‐led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives To ascertain general practitioners' views of a pharmacist‐led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems. Method Semi‐structured interviews with a purposive sample of six GPs informed the development of a self‐completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free‐text responses were sought on benefits, problems and areas for future improvement. Key findings The response rate was 84% for GPs (93% of practices were represented). Ninety‐five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP‐pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP‐pharmacist communication and extended pharmacist roles. Conclusion The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.     

Pharmacist prescribing in primary care: the views of patients across Great Britain who had experienced the service

OBJECTIVE To evaluate the views of patients across primary care settings in Great Britain who had experienced pharmacist prescribing. METHODS All Royal Pharmaceutical Society of Great Britain (RPSGB) prescribers (n = 1622) were invited to participate. Those consenting were asked to invite up to five consecutive patients who had experienced their prescribing to participate. Patients were mailed one questionnaire and a reminder. The questionnaire included five sections: demographics; you and your pharmacist prescriber; you and your general practitioner; your views and experiences based on your most recent pharmacist prescriber consultation; and additional views. KEY FINDINGS Of the 482 (29.7%) pharmacists who responded, 92 (19.1%) were eligible to participate, of whom 49 (53.3%) consented. Of those excluded, 193 (49.5%) were prescribing in secondary care and 171 (43.8%) were not prescribing. Between September 2009 and March 2010, 143 patients were recruited. Patient response rate was 73.4% (n = 105/143). Consultation settings were largely general practice (85.7%) or community pharmacy (11.4%). Attitudes were overwhelmingly positive with the vast majority agreeing/strongly agreeing that they were totally satisfied with their consultation and confident that their pharmacist prescribed as safely as their general practitioner (GP). Pharmacists were considered approachable and thorough, and most would recommend consulting a pharmacist prescriber. A slightly smaller majority would prefer to consult their GP if they thought their condition was getting worse and a small minority felt that there had been insufficient privacy and time for all their queries to be answered. CONCLUSIONS Patients were satisfied with, and confident in the skills of, pharmacist prescribers. However, the sample was small, may be biased and the findings lack generalisability.     

Application of a prescribing indicators tool to assist in identifying drug-related problems in a cohort of older Australians

Objective Drug‐related problems (DRPs) are common in older people, resulting in a disproportionate number of serious medication adverse events. Pharmacist‐led interventions have been shown to be effective in identifying and reducing DRPs such as medication interactions, omission of recommended medications and use of ineffective medications. In 2008 we proposed a prescribing indicators tool to assist in identifying DRPs as part of the Australian medication review process. The objective was to apply the proposed prescribing indicators tool to a cohort of older Australians, to assess its use in detecting potential DRPs. Methods The prescribing indicators tool was applied in a cross‐sectional observational study to 126 older (aged ≥65 years) English‐speaking Australians taking five or more medications, as they were being discharged from a small private hospital into the community. Indicators were unmet when prescribing did not adhere to indicator tool guidelines. Key findings We found a high incidence of under‐treatment, and use of inappropriate medications. There were on average 18 applicable indicators per patient, with each patient having on average seven unmet indicators. Conclusion The use of a prescribing indicators tool for commonly used medications and common medical conditions in older Australians may contribute to the efficient identification of DRPs.     

Pharmaceutical needs assessment in general practice

Objective — To develop a method of prioritising the need for pharmaceutical input into a general practice. Method — An adaptation of health needs assessment methodology was used to study areas of potential pharmacist input into a practice. Prescribing data, information from the practice's computer system and medical records were used to identify the practice's needs for pharmacist input and changes to practice. Interviews with practice staff and direct observation were used to obtain information on current systems and suggestions for change. A summary of the needs identified and suggestions for change were used in a prioritisation process. Setting — One UK general medical practice. Key findings — The study identified the need for improvements to the repeat prescribing system, a greater agreement between practice partners on the use of a practice formulary and treatment protocols, and regular review and improved monitoring of patients taking long‐term medication. Among patients taking repeat medication, those aged 45 or over and those taking four or more medicines were found to be at greatest risk of having potential pharmaceutical care issues which needed to be addressed. The prioritisation process resulted in pharmacist input into maintaining registers of patients taking drugs with narrow therapeutic indexes, reviewing the practice's computer‐based formulary and undertaking medication review being considered of highest priority by medical staff. Conclusion — The method enabled the identification of many areas which could benefit from pharmacist input and the prioritisation of these to plan future work.     

Do increasing levels of income deprivation have an effect on the prescribing of OTC medication?

□ People who are on a low income frequently visit their general practitioner to obtain medication that is also available over the counter, because it will be dispensed at no cost to them □ This activity reduces the amount of time available for the GP to treat more serious illnesses □ This leads to inequity when compared with the service provided in more affluent areas □ Pharmacists should be more involved in the provision of free health care to these patients