Piloting the role of a pharmacist in a community palliative care multidisciplinary team: an Australian experience

Background

While the home is the most common setting for the provision of palliative care in Australia, a common problem encountered here is the inability of patient/carers to manage medications, which can lead to misadventure and hospitalisation. This can be averted through detection and resolution of drug related problems (DRPs) by a pharmacist; however, they are rarely included as members of the palliative care team. The aim of this study was to pilot a model of care that supports the role of a pharmacist in a community palliative care team. A component of the study was to develop a cost-effective model for continuing the inclusion of a pharmacist within a community palliative care service.

Methods

The study was undertaken (February March 2009-June 2010) in three phases. Development (Phase 1) involved a literature review; scoping the pharmacist's role; creating tools for recording DRPs and interventions, a communication and education strategy, a care pathway and evidence based patient information. These were then implemented in Phase 2. Evaluation (Phase 3) of the impact of the pharmacist's role from the perspectives of team members was undertaken using an online survey and focus group. Impact on clinical outcomes was determined by the number of patients screened to assess their risk of medication misadventure, as well as the number of medication reviews and interventions performed to resolve DRPs.

Results

The pharmacist screened most patients (88.4%, 373/422) referred to the palliative care service to assess their risk of medication misadventure, and undertook 52 home visits. Medication reviews were commonly conducted at the majority of home visits (88%, 46/52), and a variety of DRPs (113) were detected at this point, the most common being "patient requests drug information" (25%, 28/113) and "condition not adequately treated" (22%, 25/113). The pharmacist made 120 recommendations in relation to her interventions. Fifty percent of online survey respondents (10/20) had interacted 10 or more times with the pharmacist for advice. All felt that the pharmacist's role was helpful, improving their knowledge of the different medications used in palliative care. The six team members who participated in the focus group indicated that there were several benefits of the pharmacist's contributions towards medication screening and review.

Conclusions

The inclusion of a pharmacist in a community palliative care team lead to an increase in the medication-related knowledge and skills of its members, improved patients' medication management, and minimised related errors. The model of care created can potentially be duplicated by other palliative care services, although its cost-effectiveness was unable to be accurately tested within the study.     

Use of chinese and western over-the-counter medications in Hong Kong

Benefits of engaging community pharmacists in providing wider primary care are internationally acknowledged; in Hong Kong, however, strategies for harnessing their potential contributions are yet to be launched. Here, community pharmacist and Chinese medicine retailers are responsible for providing western and Chinese over-the-counter (OTC) medications. Patterns of OTC uses reflect the characteristics of populations who rely on community pharmacists and Chinese medicine retailers as their main point of contact with the healthcare system. Analyzing the data from a Hong Kong survey (n = 33,263) on self medication and medical consultation patterns, we propose, in this article, an extended role for community pharmacists and Chinese medicine retailers, which entails aspects as follows: (1) referring patients to other medical services where appropriate; (2) providing health education and preventative services; (3) safeguarding the use of Chinese herbal medicines.     

Pharmacist-conducted medication reconciliation at hospital admission using information technology in Taiwan

ObjectivesObtaining an accurate medication history upon admission to the hospital can be challenging and time-consuming. This study evaluated the efficacy of a medication reconciliation program, conducted by pharmacists, with the assistance of medication usage data from the Taiwan National Health Insurance (NHI). Characteristics of patients at high risk for drug discrepancies were also determined.MethodsPatients admitted between May 2008 and September 2009 were recruited. The type and class of medication discrepancies reported by pharmacists, the medication discrepancy rate, physician acceptance rate, and time taken for the intervention were studied. The degree of harm that could have resulted from the discrepancies was independently evaluated by four pharmacists. The association between selected variables and the occurrence of drug discrepancies was analyzed.ResultsAmong 3013 patients interviewed, the pharmacists identified 243 patients (8%) with at least one medication discrepancy between the patient's medication history and admission orders. There were 576 discrepancies identified. About 19% of the errors prevented could have potentially caused moderate to severe harm. The average time for one intervention was 18 ± 9.8 min. The number of preadmission medications, age, frequency of outpatient visits within 3 months prior to this hospital admission, and the number of specialist outpatient clinics the patient had visited within 3 months before the admission were determined to be risk factors for drug discrepancies.ConclusionsThis medication reconciliation program, conducted by pharmacists, was made more efficient by medication usage data from the Taiwan NHI. Pharmacists can reconcile medications more effectively by selecting patients at high risk for unintentional drug discrepancies.     

ADHD service use patterns in youth

OBJECTIVE: To review what is currently known about service use by youth with attention-deficit/hyperactivity disorder (ADHD) and discuss research and policy implications. METHODS: Literature review. RESULTS: The primary care, mental health, and educational service system sectors all play an essential role in caring for youth with ADHD. Recent studies also suggest increasing use of stimulants and other psychoactive medication for youth with ADHD, decreasing mental health visits for ADHD unassociated with medication use, increased use of other psychotropic medications, and a number of barriers to care coordination across primary care, mental health, and schools. CONCLUSIONS: Four important services, research, and policy areas that need to be addressed over the next decade include: 1) delving deeper into current service use, 2) paying attention to the context in which service use occurs, 3) operationalizing evidence-based care for real-world settings, and 4) learning what changes clinician and educator behavior.     

Clinical considerations in the treatment of chronic pain with opiates

This article considers assessment and treatment issues for mental health practitioners working with patients using opiate medications to treat chronic pain with a particular emphasis on their potential relationship to substance abuse. We review general opiate medications, including a discussion of medications with increased addiction potential. Practice guidance is offered regarding long-term opiate treatment, including definitions of addiction, initial assessments, ongoing substance misuse monitoring, use of psychological assessment instruments, and managing medication misuse problems. Additionally, we examine the role of the mental health professional within this area and examine the incorporation of psychological interventions for patients using opiates. A case illustration includes several of these complicated issues of managing chronic pain with opiate medications.     

Pharmacist provided education and counseling for managing pediatric asthma

A program to promote and assess the provision of family directed counseling by pharmacists on the understanding of pediatric asthma is discussed. The program consisted of two questionnaires separated by an educational intervention program. The initial questionnaire was developed to evaluate participants' understanding of asthma and its management. The aim of the intervention program was to improve this understanding through counseling, demonstration, and sharing of families' experiences with asthma. The second questionnaire assessed post-intervention knowledge including short-term retention of information. Before the intervention, few participants (14%) indicated that they were counseled by a pharmacist about the safe and effective use of asthma medications. Seventy-nine percent indicated that more information would aid them in better understanding asthma and possibly better controlling their child's illness. After the intervention, participants were able to correctly answer questions about asthma and medications used to manage the disease 78% of the time. This program offers one method for pharmacists to become involved in patient care through the provision of education and counseling. It also provides an avenue to encourage patients and their families to gain a deeper understanding of asthma and its management.     

Medication refusal by involuntary psychiatric patients: Legal and clinical issues

Recent court decisions have recognized a constitutional right for involuntary psychiatric patients to refuse antipsychotic medications. A review of the literature suggests that refusal by involuntary patients is often a product of mental disorder, and that a significant percentage of psychiatric inpatients meet legal criteria for incompetency. The recognition of a right to refuse medication will not in reality enhance the legal status of the institutionalized mentally ill, nor will it address the underlying problem in medication refusal. The sources of this problem are civil commitment laws that fail to address the issue of a patient's competence to consent to treatment and competency statutes that are too vague or broad to be applied effectively. Statutory changes as well as financial support for increased use of guardianship proceedings will be necessary to resolve the problem of medication refusal in a way that will truly protect the rights of the mentally ill.     

Preferences for pharmacist services to enhance medication management among people with diabetes in Indonesia: A discrete choice experiment

ObjectivesTo elicit patients’ preferences for pharmacist services that can enhance medication management among people with diabetes in Indonesia.MethodsA discrete choice experiment (DCE) among 833 respondents with diabetes in 57 community health centers (CHCs) and three hospitals in Surabaya, Indonesia. Consultation was the baseline service. Four attributes of consultation and two attributes of additional services were used in the DCE profiles based on literature and expert opinion. The DCE choice sets generated were partially balanced and partially without overlap. Random effect logistic regression was used in the analysis.ResultsRespondents preferred a shorter duration of consultation and flexible access to the pharmacist offering the consultation. A private consultation room and lower copayment (fee) for services were also preferred. Respondents with experience in getting medication information from pharmacists, preferred to make an appointment for the consultation. Total monthly income and experience with pharmacist services influenced preferences for copayments.ConclusionDifferences in patients’ preferences identified in the study provide information on pharmacist services that meet patients’ expectations and contribute to improve medication management among people with diabetes.Practice implicationThis study provides insight into evaluating and designing pharmacist services in accordance with the preferences of people with diabetes in Indonesia.     

Effectiveness of shared pharmaceutical care for older patients: RESPECT trial findings

Background

The pharmaceutical care approach serves as a model for medication review, involving collaboration between GPs, pharmacists, patients, and carers. Its use is advocated with older patients who are typically prescribed several drugs. However, it has yet to be thoroughly evaluated.

Aim

To estimate the effectiveness of pharmaceutical care for older people, shared between GPs and community pharmacists in the UK, relative to usual care.

Design of study

Multiple interrupted time-series design in five primary care trusts which implemented pharmaceutical care at 2-month intervals in random order. Patients acted as their own controls, and were followed over 3 years including their 12 months'' participation in pharmaceutical care.

Setting

In 2002, 760 patients, aged ≥75 years, were recruited from 24 general practices in East and North Yorkshire. Sixty-two community pharmacies also took part. A total of 551 participants completed the study.

Method

Pharmaceutical care was undertaken by community pharmacists who interviewed patients, developed and implemented pharmaceutical care plans together with patients'' GPs, and thereafter undertook monthly medication reviews. Pharmacists and GPs attended training before the intervention. Outcome measures were the UK Medication Appropriateness Index, the Short Form–36 Health Survey (SF-36), and serious adverse events.

Results

The intervention did not lead to any statistically significant change in the appropriateness of prescribing or health outcomes. Although the mental component of the SF-36 decreased as study participants become older, this trend was not affected by pharmaceutical care.

Conclusion

The RESPECT model of pharmaceutical care (Randomised Evaluation of Shared Prescribing for Elderly people in the Community over Time) shared between community pharmacists and GPs did not significantly change the appropriateness of prescribing or quality of life in older patients.     

Use of antidepressant medications and the possible association with breast cancer risk. A review

BACKGROUND: Antidepressant medication use has dramatically increased over the past decade, particularly for the newer classes such as selective serotonin reuptake inhibitors. While there is no question about the usefulness of these medications, it is important to review animal and epidemiologic studies that have evaluated the association between antidepressant medication use and the risk of breast cancer. METHODS: This paper reviews the scientific literature pertaining to the prevalence of and indications for antidepressant medication use, and the possible association between antidepressant medication use and breast cancer risk. RESULTS: Antidepressant medications are most commonly indicated for depressive disorders, and are also used for other conditions (e.g., anxiety disorders, personality disorders, and pain). In addition, antidepressants may be an effective alternative to estrogen therapy for the alleviation of hot flashes among peri-/postmenopausal women. Several epidemiologic studies have reported that certain antidepressants may be associated with a slightly increased breast cancer risk; however, the literature remains inconsistent. CONCLUSIONS: The possibility of an association between certain antidepressant medications and breast cancer risk has not been excluded, although further studies are needed before the body of scientific evidence can be conclusive. Evidence to date does not support a change in the current use of antidepressant medications.     

Elderly polypharmacy patients’ needs and concerns regarding medication assessed using the structured patient-pharmacist consultation model

ObjectiveTo evaluate elderly polypharmacy patients’ needs and concerns regarding medication through the Structured Patient-Pharmacist Consultation (SPPC).MethodsOlder patients on chronic treatment with ≥5 medications were asked to fill in the SPPC form at home. A consultation with the community pharmacist, structured according to patient’s answers, followed within 2–4 weeks. Logistic regression associated patients’ individual treatment with care issues and consultation outcomes.ResultsOut of 440 patients, 39.5% experienced problems, and 46.1% had concerns about medication use. 122 patients reported reasons for discontinuing treatment. The main outcome of the consultation was a better understanding of medication use (75.5%). Side effects and/or non-adherence were identified in 50% of patients, and 26.6% were referred to the doctor. Atrial fibrillation, COPD, anticoagulants, benzodiazepines, and beta agonists/corticosteroids were associated with problems during medication use. Patients with diabetes improved their understanding of medication use significantly.ConclusionPatients on benzodiazepines, anticoagulants, and beta agonists/corticosteroids, with atrial fibrillation and/or COPD, may have a higher potential for non-adherence. Counseling patients based on the SPPC model may be particularly useful for patients with diabetes.Practice ImplicationsThe SPPC model is a useful tool for counseling based on patient needs.