Medication therapy problem documentation and reporting: A review of the literature and recommendations

Medication therapy problems detected at community pharmacy INR checks

Background

Despite the shift towards direct-acting anticoagulants, warfarin remains widely used in Canada and is traditionally managed by family physicians through laboratory-based international normalized ratio (INR) testing. The Community Pharmacy Anticoagulation Management Service (CPAMS) in Nova Scotia represents an innovative approach, enabling community pharmacists to conduct point-of-care (POC) INR testing and manage warfarin therapy. A potential benefit of this approach is the opportunity to identify non-warfarin medication therapy problems (nwMTPs) during routine visits.

Method

We conducted a prospective, multicentre, observational study across 40 community pharmacies in Nova Scotia, part of CPAMS's second phase. Pharmacists documented nwMTPs identified in patients with atrial fibrillation during routine POC INR visits using the Qualtrics Insight Platform, categorizing them by indication, effectiveness, safety, or adherence, alongside corresponding interventions.

Results

Over 6 months, 43 nwMTPs were submitted from 13 unique pharmacies. There were 3404 POC INR tests in patients with atrial fibrillation, yielding an estimated nwMTP detection rate of 1.26 (95% CI, 0.69 to 2.32) per 100 INR tests. The most common nwMTP category was "Indication," primarily requiring additional therapy. Pharmacists frequently intervened by recommending medication adjustments or providing patient education.

Discussion

The findings highlight a modest, yet potentially significant role of pharmacists in detecting and managing diverse MTPs during focused warfarin management assessments. The predominance of indication-related problems underscores unmet therapeutic needs in patients on warfarin.

Conclusion

This study illustrates the potential of pharmacist-led POC INR testing in community settings to identify and address nwMTPs, contributing to comprehensive patient care.

Optimal follow-up schedule for patients taking PCSK9 monoclonal antibodies in a health system: Analysis of specialty pharmacy clinical interventions

PURPOSE

The objective of this study was to determine if and when it is clinically appropriate to consider a reduction in the frequency of health-system specialty pharmacy (HSSP) clinical pharmacist assessments for patients taking a proprotein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibody (mAb) after they are deemed clinically stable on therapy.

METHODS

A single-center, retrospective, observational study of adult patients on PCSK9 mAb therapy enrolled in the University of Rochester Specialty Pharmacy Cardiology Patient Management Program was performed between October 24, 2016, and April 30, 2022. The primary outcome was the number of clinical pharmacist interventions per interval within the baseline 12 months compared to 12-month intervals for up to 72 months after initiation of PCSK9 mAb therapy.

RESULTS

A total of 368 patients on PCSK9 mAb therapy were included in the study. A significantly lower percentage of patients had more than 2 interventions during the 12- to 24-month interval (24.3%) as compared to the baseline 12-month interval (80.2%) (P < 0.001); this represented a 70% reduction in the chance of a patient requiring more than 2 interventions (relative risk, 0.30; 95% CI, 0.24-0.38). A similar trend was demonstrated in the 24- to 36-month and 36- to 48-month intervals when compared to the first year of therapy. The most commonly documented clinical pharmacist interventions were in the categories of safety (29.2%), effectiveness (28.4%), and adherence (19.9%).

CONCLUSION

Patients beyond 1 year of PCSK9 mAb therapy required less clinical pharmacist interventions. Therefore, stable patients receiving a PCSK9 mAb may be considered for less frequent clinical assessments to allow for HSSP growth to nontraditional clinical areas.

Pharmaceutical care- urgency: Proposing a practical clinical framework for pharmacy students

BACKGROUND AND PURPOSE

Prioritizing a drug therapy problem (DTP) during an experiential placement is challenging for some pharmacy students, suggesting a gap in pre-placement preparedness and the need to modify existing resources. A modified DTP prioritizing framework is proposed to enhance clinical reasoning and increase students' confidence in performing this important step in the pharmaceutical care process.

EDUCATIONAL ACTIVITY AND SETTING

Students' baseline DTP prioritizing capability was assessed in an informal focus group consisting of pharmacy students and experienced hospital pharmacy preceptors. Participants ranked the urgency for addressing 47 common medical conditions and selected a time frame to resolve the DTP. Participants also provided feedback on a proposed DTP prioritizing framework. A modified, student-focused DTP prioritizing framework, incorporating elements of curricular knowledge, principal elements of urgency, and time frame for taking action to resolve the identified DTP is described.

FINDINGS

Students' DTP urgency rankings were heterogeneous and showed greater deviation from the anticipated ranking (R = 0.61) compared to the pharmacist cohort (R = 0.807), reinforcing our view of the need for a modified DTP prioritizing framework for students. In qualitative terms, students felt the framework's focus on curricular knowledge would contribute to the development of expertise. Preceptors felt the framework reflected their usual practice and would help guide discussions with students.

SUMMARY

The modified DTP prioritizing framework, described in this article, may be utilized both to enhance student success and preceptor development in the experiential setting.

Medication-Related Problems and Interventions Identified and Addressed by Pharmacists Conducting Enhanced Medication Therapy Management Services

Pharmacists identify, resolve, and document medication-related problems (MRPs) in community pharmacies. Enhanced medication therapy management (eMTM) targets specific situations, such as high-risk medications, while continuous medication monitoring (CoMM) occurs for every patient and is integrated into the dispensing process. This study describes types and frequencies of MRPs and interventions for health plan-directed eMTM and pharmacist-identified CoMM for a cohort of Medicare Part D patients. Pharmacy dispensing and clinical records from one independent community pharmacy in the Midwest were reviewed for patients eligible for eMTM in 2019. Data were coded for medication-related problems and interventions; descriptive statistics were calculated. Forty-seven patients were included in the study, resulting in 439 health plan-directed and 775 pharmacist-identified MRPs and corresponding interventions for a total of 1214 over 12 months. The average age of the patients was 77; they received an average of about 14 medications dispensed over 25 dates. Nonadherence was the most common MRP overall, as well as for the two categories separately. Patient Counseling and Lab Values Needed MRPs were found more often by pharmacists. Continue to Monitor was the most common intervention flagged overall. Medication Discontinued was found more often in health plan-directed interventions; Patient Counseling occurred more frequently in pharmacist-identified interventions. Using pharmacists to identify MRPs can complement health plan-driven eMTM, which can provide more complete medication management. Future work is needed to determine if this approach is reproducible in other pharmacies.