How effective are pharmacists who work with medical practitioners? A study of interventions intended to influence prescribing

Objective — This study was designed to describe the interventions made by pharmacists working within different therapeutic areas in medical practices in primary care and to estimate the effects on prescribing. Method — All medical practices and community pharmacists in one health authority area in England were invited to participate. Pharmacists were allocated to work with specific practices and training was provided in musculoskeletal, respiratory and anxiolytic/hypnotic (sedative) prescribing. Pharmacists negotiated and agreed with their medical practice the type of interventions which would meet the practice's needs. Pharmacists were remunerated to provide a maximum of eight three‐hour sessions in each medical practice on each therapeutic area over a 12‐month period. Details of all interventions were recorded by each pharmacist and countersigned by a practice GP. A summary form was then sent to the health authority. Analysis of prescribing data before and after intervention in all practices was carried out using a predictive model to calculate estimated costs. Key findings — Twenty‐seven pharmacists working with 39 medical practices participated in the study. Pharmacist interventions resulted in 165 dose changes, 368 drug changes, 470 drug discontinuations and 1,042 patient reviews. On average, £3.99 was saved for each musculoskeletal intervention made. This compared with an additional cost of £15.50 and £17.92 for each intervention in sedative and respiratory prescribing, respectively. Analysis of prescribing data showed that the total spend in musculoskeletal and sedative prescribing in participating practices one year after intervention was lower than that predicted. Conclusion — Accurate recording of individual interventions with reasons, outcomes and direct cost consequences allows purchasers to make more informed decisions about the potential benefits of practice pharmacists. This method may, however, underestimate the pharmacist's indirect impact on prescribing since it does not take into account any educational effect on prescribers.     

Extended adherence support by community pharmacists for patients with hypertension: a randomised controlled trial

Objective — To determine the effects of a patient‐centred intervention by community pharmacists on adherence to treatment for hypertension. Study design — Randomised controlled trial. Method — Randomisation was at pharmacy level. Pharmacists in the intervention group used a structured, brief questioning protocol to identify patients' medication‐related problems and their information needs relating to hypertension and its treatment. Advice, information and referral to the general practitioner (GP) were provided by the pharmacist, based on patients' responses. Pharmacists in the control group provided usual care. The intervention was delivered three times at approximately two‐month intervals. Blood pressure measurements were collected retrospectively from GP medical records. Patients completed feedback questionnaires at baseline and post‐study. The questionnaire comprised a self‐reported adherence measure and explored satisfaction with pharmaceutical services. Setting — Twenty community pharmacy sites (11 intervention and nine controls) in one health authority area in England. Outcome measures — Control of blood pressure; patient satisfaction with pharmaceutical services; self‐reported adherence. Results — In total, 180 patients (101 intervention and 79 control) from 43 general medical practices completed the trial. Patients whose blood pressure was uncontrolled prior to the study were more likely to become controlled in the intervention group (P<0.05). Most of the effect on self‐reported adherence was seen after the first intervention. Patient satisfaction was high prior to the study and was increased in the intervention group after the study. The increase was statistically significant for five items relating to communication between pharmacist and patient. Conclusion — A simple intervention delivered by community pharmacists produces positive effects on blood pressure control, self‐reported adherence and on patient satisfaction with pharmaceutical services.     

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.     

Analysis of inpatient and high-risk medicine pharmacist interventions associated with insulin prescribing for hospital inpatients with diabetes

Background Insulin is a high-risk medicine, associated with hospital medication errors. Pharmacists play an important role in the monitoring of patients on insulin.

Objective To analyse interventions made by hospital pharmacists that were associated with insulin prescribing for inpatients with diabetes.

Method Retrospective audit of pharmacist interventions for adult inpatients for an 8-month period, 1 June 2019–31 January 2020. Pharmacist interventions recorded in the electronic medication management system by inpatient unit and dedicated high-risk medicine pharmacists were extracted, screened, and analysed.

Results Of 3975 pharmacist interventions 3356 (84.43%) were recorded by high-risk medicine pharmacists and 619 (15.57%) by inpatient unit pharmacists. July and August 2019 had the highest numbers of interventions with 628 and 643 (15.80 and 16.18%) respectively. Most of the interventions, namely 3410 (85.79%) were classified as medicine optimisation interventions and 565 (14.21%) as prescribing errors. In the medicine optimisation intervention category, 2985 (75.09%) were due to insulin not charted for ongoing administration.

Conclusion This study provides insights into pharmacist interventions for inpatients on insulin, showing that high-risk medicine pharmacists recorded most interventions. The classification of the insulin interventions into medicine optimisation and prescribing errors provides useful information for the training of prescribers in insulin management.

     

Prescribing errors on medical wards and the impact of clinical pharmacists

Objectives To assess the incidence of prescribing errors, predict patient outcome from clinical pharmacists' recommendations made in response to identified prescribing errors, and evaluate the influence of clinical pharmacists on recommendation implementation. Method Clinical pharmacy activities were conducted on two wards, one of which had an existing clinical pharmacy service (intervention ward) while the other did not (control ward). For the control ward, prescribing errors were documented but not followed up unless a potentially life‐threatening problem was identified. Prescribing errors were identified and recommendations made by pharmacists. A consultant physician and pharmacist conducted an independent, blinded assessment of these recommendations to predict the impact on patient outcome if implemented. Recommendations were communicated to medical staff or implemented by the pharmacist on the intervention ward only. The proportion of recommendations implemented for intervention and control group patients were recorded. Setting Two medical wards in a UK district general hospital. The study was carried out over 12 weeks. Key findings There were 740 errors recorded for 235 patients. Fourteen recommendations could not be assessed. For all recommendations, the consultant and pharmacist predicted patient outcomes with life‐saving (one consultant vs three pharmacist), major (186 vs 318), minor (328 vs 324), neutral (211 vs 85) or harmful (five vs five) impact respectively. For the intervention group, 79% of recommendations were implemented, including 81 of 92 (88%) predicted by the consultant to have major impact on patient outcomes. In the control group, only 18% of recommendations were spontaneously implemented, including only 10 of 94 (11%) recommendations predicted by the consultant to have major impact. Conclusion Ward‐based clinical pharmacists identified large numbers of prescribing errors and made clinically significant recommendations. Implementation of recommendations was predicted to improve the outcome of patient care. Further research, specifically assessing the outcome of pharmacists' recommendations on patient care, is warranted.     

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.     

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.     

The General Practitioner-Pharmacist Collaboration (GPPC) study: a randomised controlled trial of clinical medication reviews in community pharmacy

Objectives There are conflicting results in studies of pharmacists undertaking medication reviews for older people. With increasing promotion and funding for ‘medication reviews’ there is a need for them to be standardised, and to determine their effectiveness and the feasibility of providing them from a community pharmacy. The objective was to determine whether involvement of community pharmacists undertaking clinical medication reviews, working with general practitioners, improved medicine‐related therapeutic outcomes for patients. Methods A randomised controlled trial was carried out in people 65 years and older on five or more prescribed medicines. Community pharmacists undertook a clinical medication review (Comprehensive Pharmaceutical Care) and met with the patient's general practitioner to discuss recommendations about possible medicine changes. The patients were followed‐up 3‐monthly. The control group received usual care. The main outcome measures were Quality of Life (SF‐36) and Medication Appropriateness Index. Key findings A total of 498 patients were enrolled in the study. The quality‐of‐life domains of emotional role and social functioning were significantly reduced in the intervention group compared to the control group. The Medication Appropriateness Index was significantly improved in the intervention group. Only 39% of the 44 pharmacists who agreed to participate in the study provided adequate data, which was a limitation of the study and indicated potential barriers to the generalisability of the study. Conclusion Clinical medication reviews in collaboration with general practitioners can have a positive effect on the Medication Appropriateness Index. However, pharmacist withdrawal from the study suggests that community pharmacy may not be an appropriate environment from which to expand clinical medication reviews in primary care.     

Professional perspectives on a feasibility study of GP‐pharmacist collaboration in the management of angina

Objective — To report the views and experiences of a convenience sample of community pharmacists and general practitioners (GPs) who participated in a five‐month feasibility study exploring the ways in which community pharmacists could contribute to the management of patients with stable angina when working in partnership with GPs. Method — Five pharmacists delivered a specified model of care, which represented one component of a district‐wide strategy aimed at improving the management of ischaemic heart disease (IHD), to 208 patients in eight general practices. The care involved six evidence‐based interventions: smoking cessation, dietary advice, exercise, aspirin, beta‐blockers and statins. This paper illuminates professional perspectives concerning involvement in the study. The findings of semi‐structured interviews exploring views and experiences of the pharmacists during the first and the final month of the study and those of the GPs at completion of the study are reported. Setting — St Helens and Knowsley, UK, an area with a high IHD standardised mortality rate (SMR). Key findings — The pharmacists reported high levels of satisfaction and success in relation to the study interventions and more professionally satisfying relationships with patients and GPs. Successes with therapeutic interventions were described, both within and external to the study protocol. The GPs expressed a high level of satisfaction with the conduct and outcome of the pharmacist delivered care and heightened awareness of the need to review their approach to preventive care for IHD patients. Conclusion — The findings confirm that pharmacists and GPs can work in partnership to deliver a specified model of care to patients with stable IHD and also inform the debate on a role for community pharmacists as dependent prescribers.     

Perceptions,current practices,and interventions of community pharmacists regarding antimicrobial stewardship: A qualitative study

BackgroundCommunity health care accounts for the vast majority of antibiotic use in Europe. Given the threat of antimicrobial resistance (AMR), there is an urgent need to develop new antimicrobial stewardship (AMS) interventions in primary care that could involve different health care providers, including community pharmacists.ObjectivesThis study aimed to explore the perceptions, currents practices, and interventions of community pharmacists regarding AMS.MethodsSemistructured qualitative interviews were conducted with community pharmacists in France. Participants were recruited through a professional organization of community pharmacists combined with a snowballing technique. Interviews were audio recorded, transcribed, and analyzed using thematic analysis. The Consolidated Framework for Implementation Research was used while developing the interview guide and carrying out thematic analysis.ResultsSixteen community pharmacists participated. All the respondents had good awareness about antimicrobial resistance and believed that community pharmacists had an important role in tackling AMR. Some barriers to community pharmacists’ participation in AMS were identified such as difficult interactions with prescribers, lack of time, and lack of access to patient medical records and diagnosis. Increased patient education, audits and feedback of antibiotic prescribing, increased point-of-care testing, and delayed prescribing were interventions suggested by the pharmacists to improve antibiotic use in primary care. Strategies cited by participants to facilitate the implementation of such interventions are increased pharmacist–general practitioner collaboration, specialized training, clinical decision support tools, and financial incentives.ConclusionThis study suggests that community pharmacists could play a greater role in infection management and AMS interventions. Further interprofessional collaboration is needed to optimize antibiotic prescribing and utilization in community health care.     

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.