Pharmacists’ perspectives on medication reviews for long-term care residents with advanced dementia: a qualitative study

Background Medication reviews by pharmacists have been shown to identify and reduce drug-related problems in long-term care residents. Objective To explore pharmacist perspectives of the Australian Government funded pharmacist-conducted residential medication management review and its role improving the quality and safety of prescribing in long-term care, in particular for those living with advanced dementia. Setting Australian Long-term care pharmacists. Method A qualitative research methodology approach using semi-structured interviews was used, with participants pharmacists with Residential Medication Management Review experience. Interviews were recorded, transcribed and coded utilising a meta-model of Physician-Community Pharmacy Collaboration in medication review. Main outcome measure Pharmacists’ perspectives on the Residential Medication Management Review and how to improve the quality of reviews for residents with advanced dementia. Results Fifteen accredited pharmacists participated. The majority believed that the Residential Medication Management Review had the potential to improve the quality and safety of medicines but highlighted systemic issues that worked against collaborative practice. Participants emphasised the importance of three-way collaboration between general practitioners, pharmacists and nursing staff and highlighted key strategies for its optimisation. Conclusion Incorporating avenues for greater communication between team members can improve collaboration between health professionals and ultimately the quality of medication reviews.

     

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.     

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.     

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.     

Interventions in seamless care

Objective: The aim of this study was to investigate whether good collaboration between community pharmacists and hospital pharmacists prevents medication errors. These errors might occur when a patient is discharged from hospital. Both disciplines can complement each other in medication management for the patient.Method: The documented interventions of eight teams consisting of a community pharmacist and a hospital pharmacist, were collected and interpreted with a focus on structural problems and also on positive and negative items, that could influence the intensive collaboration between both disciplines.Results: The registered interventions can be grouped into five categories. Most interventions were registered in the category where the major problem is a lack of communication with the patient. Due to collaboration between the hospital and community pharmacist, all identified problems were resolved properly.Conclusion: When communication between community and hospital pharmacists is optimised, patients will face fewer problems with their medication when they are discharged from hospital.     

Stakeholder perspectives on pharmacist involvement in a memory clinic to review patients’ medication management and assist with deprescribing

BackgroundMemory clinics usually involve a team of health professionals who assess and review people with memory impairment. Memory clinic patients are typically older, have multiple comorbidities and potentially inappropriate polypharmacy. Pharmacists are not typically part of memory clinic teams.ObjectiveTo explore stakeholder perspectives on pharmacist involvement in a memory clinic to conduct medication reviews and assist with deprescribing potentially inappropriate/unnecessary medications.MethodsQuantitative and qualitative evaluation of stakeholder perspectives within a deprescribing feasibility study. Patient/carer questionnaires were administered at 6-month follow-up. Fax-back surveys were sent to general practitioners (GPs) shortly after the pharmacist review. A focus group was conducted with memory clinic staff and semi-structured interviews with pharmacists at conclusion of the study. Focus group/interviews were transcribed and thematically analysed.ResultsMost patients/carers found the pharmacist medication review helpful (84%, 31/37) and believed it was important to have pharmacists in the memory clinic (92%, 36/39). Twenty-one (48%) GPs responded to the survey; most found the pharmacist reports useful for identifying inappropriate medication and providing deprescribing recommendations (86% and 81%, respectively), and 90% thought a pharmacist review should be part of the memory clinic service. Feedback from memory clinic staff and pharmacists was largely positive. Questions were raised by some staff about whether deprescribing fell within the clinic's scope of practice. Challenges associated with memory clinic-GP communication were highlighted.ConclusionPatients, GPs and memory clinic staff were receptive to increased pharmacist involvement in the memory clinic. Stakeholder feedback will inform the development and delivery of pharmacist medication reviews and deprescribing in memory clinics.     

Patients' views of the value of “brown bag” medication reviews

Objective — To explore and describe patients' views of the value of brown bag medication reviews. Method — Semi‐structured, tape‐recorded interviews were conducted with 20 patients who had participated in a brown bag medication review scheme. Setting — A health authority area in south‐east inner London. Key findings — Patients perceived the following benefits from brown bag reviews: clinical problems resolved; better understanding of their medications, leading to increased confidence; and appreciation that an interest was being taken in their health care. Reviews had given patients a sense of empowerment, and had made them realise that they had a right to information about their medical treatment and medication. As a result they were likely to be more proactive in seeking information in future. Reviews had made patients realise that pharmacists were knowledgeable about medicines, where previously many had thought that only doctors had sufficient knowledge. Reviews had enhanced relationships between patients and pharmacists. However, some patients still perceived their doctor as the authoritative source of information about medicines. Patients' accounts indicated that much of the information provided by the pharmacist was new, raising the issue of what information was routinely being provided by pharmacists. Conclusions — Brown bag reviews were regarded by patients as beneficial and they wanted them to be available in the future. Patients' perceptions of pharmacists as health professionals and providers of information on medicines were enhanced by brown bag reviews.     

Medication-related problems encountered in the Program of All-Inclusive Care for the Elderly: An observational study

ObjectiveTo evaluate pharmacist-encountered medication-related problems (MRPs) among the participants of the Program of All-Inclusive Care for the Elderly (PACE).DesignThis was a retrospective analysis of proprietary pharmacy records detailing pharmacist encounters with PACE clinical staff.Setting and participantsA national provider of pharmacy services to more than 75 PACE organizations. In total, 1057 PACE participants at 69 PACE sites across the United States with documented pharmacist encounters between March and May 2018.Outcome measuresMRPs were classified using the Hepler-Strand taxonomy, and pharmacists’ recommendations made to prescribers to resolve these MRPs were classified using a modified Hoth taxonomy. In addition, pharmacists’ communication methods and prescribers’ responses were analyzed.ResultsOverall, 2004 MRPs were encountered. The most frequent MRPs identified were related to medication safety concerns, including drug interactions (720, 35.9%), adverse drug reactions (ADRs, 356, 17.8%), high doses (270, 13.5%), and unindicated drugs (252, 12.6%). Drug interactions frequently involved competitive inhibition, 3 or more drugs, opioids, anticoagulants, antiplatelets, and antidepressants. Deprescribe medication (561, 24.8%), start alternative therapy (553, 24.4%), change doses (457, 20.2%), and monitor (243, 10.7%) were the top 4 types of recommendations made by pharmacists. Among 1730 responses obtained from PACE prescribers, 78.1% (n = 1351) of pharmacists’ recommendations were accepted. Compared with electronic communication, telephonic communication was associated with more acceptance and less prescriber nonresponse (χ² = 78.5, P < 0.001).ConclusionPharmacists identified a substantial number of MRPs in PACE, especially those related to medication safety such as drug interactions and ADRs. In this practice setting, significant collaboration occured between pharmacists and PACE prescribers, as evidenced by the rate of prescribers’ acceptance of pharmacists’ recommendations. Further research is needed to fully evaluate the economic, clinical, and humanistic outcomes associated with pharmacists’ encounters in PACE.     

Training Australian pharmacists for participation in a collaborative, home-based post-discharge warfarin management service

Objective To describe the development, implementation and outcomes of an anticoagulation education program for pharmacists participating in a community-based post-discharge warfarin management service. Setting Australian community pharmacy practice. Method Three education modules were developed in collaboration with medical experts and delivered electronically and via hands-on training sessions to pharmacists in three Australian states. Educational outcomes were assessed via a short answer assignment and evaluation of their warfarin dosing recommendations for five hypothetical scenarios. Consumer and pharmacist perceptions of the adequacy of the training were surveyed using a structured postal questionnaire. Main outcome measure Pharmacists’ score in the short answer assignment and evaluation of their responses to the hypothetical warfarin dosing scenarios. Results Sixty-two pharmacists successfully completed the training program with a mean score for the short answer assignment of 14.3 out of 15 (95.3%; 95% CI 13.8–14.7). The pharmacists’ warfarin management recommendations were very similar to those of two experienced medical specialists. Pharmacists and consumers expressed confidence in the adequacy of the training program. Conclusion This education program successfully up-skilled a cohort of pharmacists for involvement in a post-discharge warfarin management service. These findings support formalisation and further development of the program to facilitate widespread implementation of home-based post-discharge warfarin care.     

General practice pharmacists in England: Integration,mediation and professional dynamics

BackgroundA number of key publications in recent years have advocated a more integrated vision of UK primary care involving increased multi-professional communication and understanding. This has resulted in a marked change in the roles being undertaken by pharmacists. Community pharmacists have traditionally provided a medicine supply function and treated minor ailments in addition to delivering a suite of locally commissioned services; however these functions have not necessarily been part of a programme of care involving the other clinicians associated with the patient. An integrated model of care would see much closer working between pharmacy and general practice but also with pharmacists not only working with, but in the practice, in an enhanced patient-facing role, trained as independent prescribers. This has implications for the dynamics amongst professionals in this environment.ObjectivesThis exploratory multiple case study attempts to explore these changing dynamics across ten GP surgeries throughout the South-East of England.MethodsSemi-structured, in-depth interviews were conducted with one nurse, one pharmacist and one physician from each clinic, and survey data was collected from 38 patients who had appointments with a pharmacist.ResultsThe data suggested that the pharmacists who had enhanced roles perceived some uncertainty about their professional role and identity, which resulted in instability and insecurity and that this uncertainty led to both professional and interprofessional tension with their primary care colleagues. The survey data revealed that n = 35 (92%) patients stated they were ‘very satisfied’ or ‘satisfied’ with their appointment. And n = 37 (97%) were ‘very comfortable’ or ‘comfortable’ discussing their medications with the pharmacist. In addition, 36 patients (95%) reported that they strongly agreed or agreed with the clinical recommendations made by the pharmacist.ConclusionsThese findings are discussed in relation to role expansion and professional/interprofessional relations before key practical suggestions are offered.     

Delivering a home‐based medication review,process measures from the HOMER randomised controlled trial

Objectives The HOme‐based MEdication Review (HOMER) trial investigated whether home‐based medication review by pharmacists could decrease hospital re‐admission in older people. This trial demonstrated that the intervention increased admissions by 30% (P=0.009). This unexpected finding provoked significant interest. This paper describes the intervention in detail and the process measures recorded by review pharmacists, and investigates whether results differed according to pharmacist characteristics. Method 437 patients were randomised to the intervention, which involved two pharmacist home visits within two and eight weeks of discharge, and 435 were randomised to usual care. An analysis was undertaken of the process measures and to determine whether admission rates differed within the intervention group according to the type of pharmacist performing the review. Setting Norfolk or Suffolk patients aged over 80 years discharged to their own home after an emergency admission (any cause), and taking two or more medications daily. Key findings Twenty‐two pharmacists participated. The majority (68%) were experienced community pharmacists (mean age = 42 years), 71% had a postgraduate qualification. Pharmacists identified adverse drug reactions in 33% of patients and made a mean of 1.6 recommendations/comments per visit undertaken. At least 35% of these were enacted. Pharmacists reduced inappropriate drug storage from 7% to 2% of visited patients by their second visit (P = 0.04), and reduced hoarding of unnecessary drugs from 40% of visited patients to 19% (P < 0.001). Finally, the rate of admission within the intervention group did not vary significantly according to experience or type of pharmacist delivering the intervention. Conclusion The HOMER intervention was conducted in a similar way to interventions in many other medication review studies. Given the HOMER trial's counter‐intuitive findings it is clear that there is an urgent need to refine this intervention, identify the most suitable location for its delivery, and develop training that can ensure it is delivered to best effect.     

Evaluation of medication reviews conducted by community pharmacists: a quantitative analysis of documented issues and recommendations

Aims

To describe issues noted and recommendations made by community pharmacists during reviews of medicines and lifestyle relating to coronary heart disease (CHD), and to identify and quantify missed opportunities for making further recommendations and assess any relationships with demographic characteristics of the pharmacists providing the reviews.

Methods

All issues and recommendations noted by 60 community pharmacists during patient consultations were classified and quantified. Two independent reviewers studied a subsample of cases from every participating pharmacist and identified and classified potential issues from the available data. The findings of the pharmacists and the reviewers were compared. Relevant pharmacist characteristics were obtained from questionnaire data to determine relationships to the proportion of potential issues noted.

Results

A total of 2228 issues and 2337 recommendations were noted by the pharmacists in the 738 patients seen, a median of three per patient (interquartile range 2–4). The majority of the recommendations made (1719; 74%) related to CHD. In the subsample of 169 patients (23% of the total), the reviewers identified 1539 potential issues, of which pharmacists identified an average of 33.8% (95% confidence interval 30.1, 36.4). No relationship was found between the proportion of issues noted and potentially relevant factors such as pharmacists'' characteristics and their experience of doing reviews.

Conclusions

The majority of issues and recommendations noted by pharmacists related to CHD, although pharmacists recorded only a minority of the issues identified by reviewers. Variation between pharmacists in the completeness of reviews was not explained by review or other relevant experience.

What is already known about this subject?

• There is conflicting evidence concerning the potential benefits of pharmacist-led medication review.
• Little work has been published on the completeness of medication reviews provided by community pharmacists.

What this study adds

• The 60 community pharmacists taking part in a large randomized controlled trial showed considerable variation in the completeness of the reviews they recorded for intervention patients.
• Overall, pharmacists recorded only a minority of the potential issues present in these patients.
• The frequency with which pharmacists recorded issues was not related to key characteristics or to the number of reviews completed.

     

Evaluation of a Danish pharmacist student–physician medication review collaboration model

Background Interprofessional collaboration between pharmacists and physicians to conduct joint home medication reviews (HMR) is important for optimizing the medical treatment of patients suffering from chronic illnesses. However, collaboration has proved difficult to achieve. The HMR programme “Medisam” was launched in 2009 at the University of Copenhagen with the aim of “developing, implementing and evaluating a collaboration model for HMRs and medicine reconciliations in Denmark”. The Medisam programme involves patients, pharmacy internship students, the (pharmacist) supervisor of the pharmacy students and physicians. Objective To explore if it was possible through the Medisam programme to obtain a fruitful HMR collaboration between pharmacy internship students and physicians as a means to develop HMR collaboration between trained pharmacists and physicians further. Setting Ten matching pairs of student–physician collaboration were studied across Denmark. Method Semi-structured interviews about existing collaboration were conducted with pharmacy internship students in the HMR programme, their supervisors and physicians partners. The theoretical framework forming the analyses was derived especially from works of Bradley et al. (Res Soc Adm Pharm 8:36–46, 2012), and Snyder et al. (Res Soc Adm Pharm 6:307–23, 2010) on pharmacists/physician collaboration. Main outcome measure The development of inter-professional collaboration between students and physicians according to the three collaboration drivers: trustworthiness, role specification and professional interaction. Results Full collaboration was not achieved. Physicians found collaboration satisfactory, students however expressed the need of more interaction with physicians. The written collaboration contracts did not ensure a possible need of students to re-negotiate roles and tasks, and did therefore not entirely ensure role specification. Developing mutual professional interdependence through students being recognized by physicians to contribute to improved patient outcomes was also limited. Conclusion Some challenges to fruitful collaboration were identified. Solutions to these challenges include students and their pharmacist supervisors to find ways to present their collaborative needs to physicians and for students to illustrate more explicitly the benefits patient achieve if physicians implement the recommendations of students.