The Relationship between the Extent of Collaboration of General Practitioners and Pharmacists and the Implementation of Recommendations Arising from Medication Review: A Systematic Review

Pharmacist-led medication reviews: A scoping review of systematic reviews

BACKGROUND

Medication reviews aim to support patients who take medicines, and they are often led by pharmacists. There are different types of medication reviews undertaken in various settings. Previous research undertaken in 2015 found mixed evidence that medication reviews in community settings improve clinical outcomes, but further work needs to be undertaken to establish their impact on patient-orientated and economic outcomes.

AIM

This scoping review aims to explore the extent and range of systematic reviews of medication reviews conducted by pharmacists, the nature of the intervention, the evidence for effectiveness, and reported research gaps.

METHOD

Systematic reviews were included irrespective of participants, settings or outcomes and were excluded if pharmacists did not lead the delivery of the included interventions. Data extracted included the design of included studies, population, setting, main results, description of interventions, and future research recommendations.

RESULTS

We identified twenty-four systematic reviews that reported that medication review interventions were diverse, and their nature was often poorly described. Two high-quality reviews reported that there was evidence of no effect on mortality; of these one reported an improvement in medicines-related problems (all studies reported an increase of identified problems), and another a reduction in hospital readmissions (Risk ratio 0.93 [95% CI 0.89, 0.98]). Other lower-quality reviews reported evidence supporting intervention effectiveness for some clinical outcomes (odds ratio: achieving diabetes control = 3.11 95% prediction intervals (PI), 1.48-6.52, achieving blood pressure target = 2.73, 95% PI, 1.05-7.083.50).

CONCLUSION

There is mixed evidence of effectiveness for medication reviews across settings and patient populations. There is limited data about the implementation of medication reviews, therefore is difficult to ascertain which components of the intervention lead to improved outcomes. As medication reviews are widely implemented in practice, further research should explore the nature of the interventions, linking the components of these to outcomes.

Pharmacists' current and potential prescribing roles in primary care in the Netherlands: a case study

In some countries, pharmacists have obtained prescribing rights to improve quality and accessibility of care and reduce physician workload. This case study explored pharmacists' current roles in and potential for prescribing in primary care in the Netherlands, where prescribing rights for pharmacists do not exist. Participatory observations of pharmacists working in either general practice or community pharmacy were conducted, as were semi-structured interviews about current and potential practice. The latter were extended to patients and other healthcare professionals, mainly general practitioners, resulting in 34 interviews in total. Thematic analyses revealed that pharmacists, in all cases, wrote prescriptions that were then authorized by a physician before dispensing. General practice-based pharmacists often prescribed medications during patient consultations. Community pharmacists mainly influenced prescribing through (a) medication reviews where the physician and/or practice nurse often were consulted to make treatment decisions, and (b) collaborative agreements with physicians to start or substitute medications in specific situations. These findings imply that the pharmacists' current roles in prescribing in the Netherlands resemble collaborative prescribing practices in other countries. We also identified several issues that should be addressed before formally introducing pharmacist prescribing, such as definitions of tasks and responsibilities and prescribing-specific training for pharmacists.

Systematic review and meta-analysis on the effectiveness of multidisciplinary interventions to address polypharmacy in community-dwelling older adults

Interventions to address polypharmacy in community-dwelling older adults often focus on medication-related outcomes. The aim was to explore the impact of multidisciplinary interventions to manage polypharmacy on clinical outcomes for community-dwelling older adults. This systematic review and meta-analysis included randomized controlled trials (RCTs) on interventions by at least a pharmacist and a physician, indexed in MEDLINE, EMBASE or CENTRAL up to January 2023. Evidence certainty was assessed using the GRADE approach. Seventeen RCTs were included. Fifteen were rated as 'high' risk of bias. No relevant benefits were found in functional and cognitive status (primary outcomes), falls, mortality, quality of life, patient satisfaction, hospital admissions, emergency department or primary care visits. Interventions reduced medication costs, improved medication appropriateness (odds ratio [OR] 0.39), reduced number of medications (mean difference [MD] -0.57), resolved medication-related problems (MD -0.45), and improved medication adherence (relative risk [RR] 1.14). There was a low or very low certainty of the evidence for most outcomes. Multidisciplinary interventions to address polypharmacy appear effective in improving multiple dimensions of medication use. However, evidence for corresponding improvements in functional or cognitive status is scarce. New efficient models of multidisciplinary interventions to address polypharmacy impacting clinical outcomes should be explored.

Harmonizing the definition of medication reviews for their collaborative implementation and documentation in electronic patient records: A Delphi consensus study

BACKGROUND

Medication review practices have evolved internationally in a direction in which not only physicians but also other healthcare professionals conduct medication reviews according to agreed practices. Collaborative practices have increasingly highlighted the need for electronic joint platforms where information on medication regimens and their implementation can be documented, kept updated, and shared.

OBJECTIVE

The aim of this study was to harmonize the definition of medication reviews and create a unified conceptual basis for their collaborative implementation and documentation in electronic patient records (definition appellation: collaborative medication review).

METHODS

The study was conducted using the Delphi consensus survey with three interprofessional expert panel rounds in September-December 2020. The consensus rate was set at 80%. Experts assessed the proposed definition of collaborative medication review based on an international and national inventory of medication review definitions. The expert panel (n = 41) involved 12 physicians, 13 pharmacists, 10 nurses, and six information management professionals. The range of response rates for the rounds was 63-88%.

RESULTS

The experts commented on which of the pre-selected items (n = 75) characterizing medication reviews should be included in the definition of collaborative medication review. The items were divided into the following five themes and 51 of them reached consensus: 1) Actions included in the collaborative medication review (n = 24/24), 2) Settings where the review should be conducted (n = 5/5), 3) Situations where the review should be considered as needed and carried out (n = 10/11), 4) Prioritization of top five benefits to be achieved by the review and 5) Prioritization of top five patient groups to whom the review should be targeted.

CONCLUSIONS

A strong interprofessional consensus was reached on the definition of collaborative medication review. The most challenging was to identify individual patient groups benefiting from the review.

Detection and management of clinically relevant drug-drug interactions with direct oral anticoagulants: an intervention study in community pharmacies

INTRODUCTION

Direct oral anticoagulants (DOACs) are increasingly used and can be involved in clinically relevant drug-drug interactions (DDIs) that increase the risk of major bleeding or thromboembolism. Skilled drug interaction management is essential to ensure safe and effective use of DOACs. In this study, we aimed to investigate the impact of the detection and management of DDIs with DOACs in a real-life community pharmacy setting on the pharmacotherapy of DOAC users.

METHODS

We conducted an intervention study in 201 community pharmacies in Belgium. On random days, patients purchasing DOACs or drugs known to interact with them were screened. When a DDI with the DOAC was detected, the pharmacist contacted the prescribing physician to discuss the management of the interaction. A previously developed practice-oriented DDI list accompanied by management plans for ambulatory care was used for both screening and management of the DDIs.

RESULTS

In total, 751 patients were included, among whom 875 DDIs were identified, primarily pharmacodynamic DDIs (95.7 %). Predominant interacting drug classes included selective serotonin or serotonin and norepinephrine reuptake inhibitors (32.9 %), antiplatelets (30.9 %), and non-steroidal anti-inflammatory drugs (28.9 %). In 43.0 % of DDIs, an intervention was decided upon. At three-month follow-up, proposed pharmacotherapy changes had been implemented in 79.1 % of these DDIs.

CONCLUSIONS

This study demonstrates that active screening and management of DDIs with DOACs in community pharmacies, in close collaboration with prescribing physicians, resulted in changes in pharmacotherapy in a substantial number of patients. This may contribute significantly to the safer utilisation of DOACs in high-risk populations.

Structured medication reviews in Parkinson's disease: pharmacists' views, experiences and needs - a qualitative study

Background

Executing structured medication reviews (SMRs) in primary care to optimize drug treatment is considered standard care of community pharmacists in the Netherlands. Patients with Parkinson's disease (PD) often face complex drug regimens for their symptomatic treatment and might, therefore, benefit from an SMR. However, previously, no effect of an SMR on quality of life in PD was found. In trying to improve the case management of PD, it is interesting to understand if and to what extent SMRs in PD patients are of added value in the pharmacist's opinion and what are assumed facilitating and hindering factors.

Objectives

To analyse the process of executing SMRs in PD patients from a community pharmacist's point of view.

Design

A cross-sectional, qualitative study was performed, consisting of face-to-face semi-structured in-depth interviews.

Methods

The interviews were conducted with community pharmacists who executed at least one SMR in PD, till data saturation was reached. Interviews were transcribed verbatim, coded and analysed thematically using an iterative approach.

Results

Thirteen pharmacists were interviewed. SMRs in PD were considered of added value, especially regarding patient contact and bonding, individualized care and its possible effect in the future, although PD treatment is found already well monitored in secondary care. Major constraints were time, logistics and collaboration with medical specialists.

Conclusion

Although community pharmacist-led SMRs are time-consuming and sometimes logistically challenging, they are of added value in primary care in general, and also in PD, of which treatment occurs mainly in secondary care. It emphasizes the pharmacist's role in PD treatment and might tackle future drug-related issues. Improvements concern multidisciplinary collaboration for optimized SMR execution and results.

Post Hoc Analyses of a Randomized Controlled Trial for the Effect of Pharmacist Deprescribing Intervention on the Anticholinergic Burden in Frail Community-Dwelling Older Adults

OBJECTIVES

Anticholinergic burden is detrimental to cognitive health. Multiple studies found that a high anticholinergic burden is associated with an increased risk for dementia, changes to the brain structure, function, and cognitive decline. We performed a post hoc analysis of a randomized controlled deprescribing trial. We compared the effect of the intervention on baseline anticholinergic burden across the treatment and control groups and the time of recruitment before and after a lockdown due to the COVID pandemic with subgroup analyses by baseline frailty index.

DESIGN

Randomized controlled trial.

SETTINGS AND PARTICIPANTS

We analyzed data from a de-prescribing trial of older adults (>65 years) previously conducted in New Zealand that was focused on reducing the Drug Burden Index (DBI).

METHODS

We used the anticholinergic cognitive burden (ACB) to quantify the impact of the intervention on reducing the anticholinergic burden. Participants not taking anticholinergics at the start of the trial were excluded. The primary outcome for this subgroup analysis was a change in ACB, measured with the ĝ_Hedges statistic describing the difference in standard deviation units of this change between intervention and control. For this analysis, the trial participants were stratified into low, medium, and high frailty and timing into prior- and post-lockdown (public health measures for COVID-19).

RESULTS

Among the 295 participants in this analysis, the median (IQR) age was 79 (74, 85), and 67% were women. For the primary outcome ĝ_Hedges = -0.04 (95% CI -0.26 to 0.19) with a -0.23 mean reduction in ACB in the intervention arm and -0.19 in the control arm. Before lockdown ĝ_Hedges = -0.38 (95% CI -0.84 to 0.04) and post-lockdown ĝ_Hedges = 0.07 (95% CI -0.19 to 0.33). The mean change in ACB for each of the frailty strata was as follows: low frailty (-0.02; 95% CI -0.65 to 0.18); medium frailty (0.05; 95% CI -0.28 to 0.38); high frailty (0.08; 95% CI -0.40 to 0.56).

CONCLUSIONS AND IMPLICATIONS

The study did not provide evidence for the effect of pharmacist deprescribing intervention on reducing the anticholinergic burden. However, this post hoc analysis examined the impact of COVID on the effectiveness of the intervention, and further research in this area may be warranted.

The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

BACKGROUND

The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient.

OBJECTIVES

To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation.

METHOD

Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis.

RESULTS

In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained.

CONCLUSION

The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics.

Haefeli W, M. Seidling H. Mortality and Hospitalizations Among Patients Enrolled in an Interprofessional Medication Management Program

BACKGROUND

Measures for improving medication safety in outpatient care are often complex and involve medication reviews. Over the period 2016-2022 (with a preceeding one-year pilot phase), an interprofessional medication management program- the Medicines Initiative Saxony-Thuringia (Arzneimittelinitiative Sachsen-Thüringen, ARMIN)-was implemented in two German federal states. More than 5000 patients received a medication review by the end of 2019 by a team composed of physicians and pharmacists and were provided with joint, continuous care thereafter.

METHODS

In the framework of a retrospectively registered cohort study, the mortality and hospitalizations of this population (5033 patients) were studied using routine data from a statutory health insurer (observation period 2015-2019) and compared with those of a control group (10 039 patients) determined from the routine data by propensity score matching. Mortality was compared by survival analysis (Cox regression), and hospitalization rates were compared in terms of event probabilities within two years of enrollment in the medication management program. Robustness was tested in multiple sensitivity analyses.

RESULTS

Over the observation period, 9.3% of the ARMIN participants and 12.9% of persons in the control group died (hazard ratio of the adjusted Cox regression, 0.84; 95% confidence interval [0.76; 0.94], P = 0.001). In the first two years after inclusion, the ARMIN participants were hospitalized just as often as the persons in the control group (52.4% versus 53.4%; odds ratio from the adjusted model, 1.04 [0.96; 1.11], P = 0.347). The effects were consistent in sensitivity analyses.

CONCLUSION

In this retrospective cohort study, participation in the ARMIN program was associated with a lower risk of death. Exploratory analyses provide clues to the potential origin of this association.

Deprescribing for older people living in residential aged care facilities: Pharmacist recommendations, doctor acceptance and implementation

BACKGROUND

Deprescribing is an intervention to address the high prevalence of inappropriate polypharmacy in older people living in residential aged care facilities (RACFs). Many deprescribing interventions are complex and involve several stages including initial pharmacist recommendation, subsequent acceptance of the recommendations by a prescriber and the patient, and then actual implementation.

OBJECTIVES

This study aimed to investigate pharmacist deprescribing recommendations for residents within RACFs, general practitioner (GP) acceptance, and the actual implementation of the accepted recommendations at 12-month.

METHODS

The intervention occurred as part of a randomised controlled trial and comprised a pharmacist-led medication review using an evidence-based algorithm, with the focus on identifying medications to potentially deprescribe. Consent to participate was obtained from residents (or surrogate decision-makers), RACF nursing staff and the resident's GP. Deprescribing recommendations were reviewed by GPs before implementation as part of the intervention and control arms of the trial, although control group participants continued to receive their usual medications in a blinded manner.

RESULTS

There were 303 participants enrolled in the study, and 77% (941/1222) of deprescribing recommendations suggested by the pharmacists were accepted by GPs. Of the recommendations accepted by GPs, 74% (692/ 941) were successfully implemented at the end of the follow-up visit at 12 months. The most common reason for deprescribing was because medications were no longer needed (42%, 513/ 1231).

CONCLUSION

Pharmacist-led deprescribing recommendations arising from an algorithm-based medication review are acceptable to doctors and can have a significant impact on reducing the number of inappropriate medications consumed by older people in RACFs.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613001204730.

Does Collaboration between General Practitioners and Pharmacists Improve Risk Factors for Cardiovascular Disease and Diabetes? A Systematic Review and Meta-Analysis

Objective

To assess whether inter-professional, bidirectional collaboration between general practitioners (GPs) and pharmacists has an impact on improving cardiovascular risk outcomes among patients in the primary care setting. It also aimed to understand the different types of collaborative care models used.

Study design

Systematic review and Hartung-Knapp-Sidik-Jonkman random effects meta-analyses of randomised control trials (RCTs) in inter-professional bidirectional collaboration between GP and pharmacists assessing a change of patient cardiovascular risk in the primary care setting.

Data sources

MEDLINE, EMBASE, Cochrane, CINAHL and International Pharmaceutical Abstracts, scanned reference lists of relevant studies, hand searched key journals and key papers until August 2021.

Data synthesis

Twenty-eight RCTs were identified. Collaboration was associated with significant reductions in systolic and diastolic blood pressure (23 studies, 5,620 participants) of -6.42 mmHg (95% confidence interval (95%CI) -7.99 to -4.84) and -2.33 mmHg (95%CI -3.76 to -0.91), respectively. Changes in other cardiovascular risk factors included total cholesterol (6 studies, 1,917 participants) -0.26 mmol/L (95%CI -0.49 to -0.03); low-density lipoprotein (8 studies, 1,817 participants) -0.16 mmol/L (95%CI -0.63 to 0.32); high-density lipoprotein (7 studies, 1,525 participants) 0.02 mmol/L (95%CI -0.02 to 0.07). Reduction in haemoglobin A1c (HbA1C) (10 studies, 2,025 participants), body mass index (8 studies, 1,708 participants) and smoking cessation (1 study, 132 participants) was observed with GP-pharmacist collaboration. Meta-analysis was not conducted for these changes. Various models of collaborative care included verbal communication (via phone calls or face to face), and written communication (emails, letters). We found that co-location was associated with positive changes in cardiovascular risk factors.

Conclusion

Although it is clear that collaborative care is ideal compared to usual care, greater details in the description of the collaborative model of care in studies is required for a core comprehensive evaluation of the different models of collaboration.

Pharmacist-led clinical medication review service in primary care: the perspective of general practitioners

BACKGROUND

An advanced level medication review service (CMR) is systematically reimbursed and available nationwide in Slovenian primary care since 2016. CMR is performed by clinical pharmacists (CP). Close collaboration with general practitioner (GP) is required as they perform patient selection and make clinical decisions regarding patient's medication.

METHODS

A prospective observational study was conducted in 2018 aiming to evaluate the perspective of GPs on the implementation of pharmacist-led medication review service in Community Health Care Centre Ljubljana, Slovenia. GPs of the patients, who provided written informed consent were invited for the interviews. The semi-structured interview consisted of 5 open ended questions addressing reasons for referral of the patients, implementation of CP recommendations and the GPs' perspective of the service in general. Interviews were audio recorded with GPs written consent, transcribed verbatim and inductive content analysis was performed in NVivo11 Pro.

RESULTS

In total 38 interviews with 24 GPs were performed. The emerged themes were nested under 3 main domains representing Donabedian model of quality healthcare - structure, process, outcomes. The service structure is built on broad pharmacotherapy knowledge as the main CP competency, good accessibility, and complementarity of healthcare professions. Patients are mainly referred to the CMR due to polypharmacotherapy, however in majority there is a more in-depth reason behind (e.g., adverse events, etc.). Lack of time to recognize eligible patients and additional workload to study and implement the recommendations present the major challenges in the service process and therefore low number of referrals. CPs recommendations are mostly accepted, although the implementation time varies. When recommendation addresses medicines prescribed by a clinical specialist, the CMR report is forwarded to them for decision regarding implementation. The empowerment of the patients in medicines use was emphasized as the major benefit of the CMR, which consequently supports and enhances the quality of GP's patient care. Transferability of recommendations to similar cases and high satisfaction with the service of GPs and patients, were mentioned.

CONCLUSION

GPs experiences with CMR are encouraging and supportive and present a base for further growth of the service.

Implementing pharmacists' medication safety recommendations is associated with reduced health care resource utilization and mortality in high-risk older Americans

BACKGROUND

A medication safety review (MSR) is a novel, pharmacist-driven, technology-supported intervention that prioritizes adverse drug event risk mitigation. Previous research has shown that Medicare Part D beneficiaries who received MSRs in an enhanced medication therapy management (EMTM) model realized improvements in total Medicare spending, hospitalizations, emergency department (ED) visits, and mortality compared to control. However, it is unknown whether beneficiaries implemented pharmacists' MSR recommendations.

OBJECTIVE

The objective of the study was to evaluate whether MSR recommendation implementation is associated with improvements in these same outcomes for Part D beneficiaries enrolled in EMTM compared to a control group.

METHODS

This retrospective, pre-post, cohort study evaluated outcomes for beneficiaries who were targeted for MSR services in 2018 and 2019. The "validated implementation MSR (viMSR)" cohort included those who received their first-ever MSR in 2018, received another MSR in 2019, and validated implementation of ≥1 recommendation in their 2018 MSR. The "failed to engage" (FTE) cohort included beneficiaries who were targeted for MSR services in both 2018 and 2019 but did not engage in an MSR at any point through the end of 2019. For both cohorts, we calculated the 2018-to-2019 change for each outcome and then determined whether year-over-year changes differed significantly between cohorts. For mortality, we relaxed the requirement for continuous enrollment in 2019, permitting us to compare the proportion of beneficiaries that died in each group in 2019. Analyses were adjusted for baseline multimorbidity.

RESULTS

Of 4384 beneficiaries who completed MSRs, 602 (13.7%) implemented ≥1 recommendation. The viMSR cohort (N = 602) outperformed the FTE cohort (N = 7052) in total Medicare costs ($2162/y lower; P = 0.020), Part A Medicare costs ($1855/y; P = 0.024), hospitalizations (9.1 fewer admissions/100 beneficiaries/y, P = 0.020), ED visits (10.8 fewer visits/100 beneficiaries/y, P = 0.014), and mortality (3.8% fewer died in 2019; P < 0.001).

CONCLUSION

Implementing pharmacists' recommendations in MSRs was associated with improved health care resource utilization and mortality for MSR-eligible beneficiaries.

Pharmacist-driven interventions to de-escalate urinary antimuscarinics in the Programs of All-Inclusive Care for the Elderly

BACKGROUND

Given associations with serious cognitive and physical adverse effects (e.g., dementia, falls), strong anticholinergics, like urinary antimuscarinics (UAMs), should be avoided in older adults. This feasibility study aimed to (1) evaluate the implementation rate of pharmacists' recommendations intended to de-escalate UAMs, (2) quantify the change in overall anticholinergic dosing exposure from these recommendations, and (3) investigate factors that predict recommendation implementation.

METHODS

This was a retrospective, observational, before-and-after study. Pharmacists (n = 18) devised strategies to de-escalate UAMs in 187 participants (mean age 72.4 ± 9.4; 77.0% female; mean number of medications 12.9 ± 4.6) of 35 Programs of All-Inclusive Care for the Elderly (PACE). PACE prescribers (non-physicians and physicians) determined whether to implement recommendations. Implementation was defined as a change in the prescription records consistent with the pharmacist's recommendation at 2-, 4-, 6-, and 9-months post-recommendation. Anticholinergic dosing exposure was measured at each time point using standardized daily doses (SDD). Multivariable logistic regression was used to identify factors that predicted recommendation implementation.

RESULTS

Across 9 months, recommendations were implemented in 118 out of 187 participants, yielding a 63.1% implementation rate. Of these, 77.1% (n = 91/118) implemented by month 2. Implementers' mean overall anticholinergic SDD decreased 65.4% from baseline (baseline: 2.6 [95% CI: 2.2, 3.0] to month 9: 0.9 [95% CI: 0.6,1.2], p < 0.001) whereas non-implementers demonstrated no significant change (p = 0.52). Taking <10 baseline medications (OR 2.75; 95% CI: 1.09, 7.61); baseline UAM SDD ≥2 (OR 2.20; 95% CI: 1.11, 4.44); uncomplicated recommendations (OR 3.38; 95% CI: 1.67-7.03); and baseline calcium channel blocker use (OR 2.19; 95% CI: 1.09, 4.52) predicted implementation.

CONCLUSION

Our high implementation rate indicates that pharmacists' recommendations to de-escalate UAMs as a way to reduce overall anticholinergic exposure is feasible in medically complex, community-dwelling older adults. Future research should investigate whether these recommendations benefit cognitive (e.g., delirium, dementia) and/or physical functioning (e.g., falls).

Task sharing in an interprofessional medication management program - a survey of general practitioners and community pharmacists

Background

Pharmacist-led medication review and medication management programs (MMP) are well-known strategies to improve medication safety and effectiveness. If performed interprofessionally, outcomes might even improve. However, little is known about task sharing in interprofessional MMP, in which general practitioners (GPs) and community pharmacists (CPs) collaboratively perform medication reviews and continuously follow-up on patients with designated medical and pharmaceutical tasks, respectively. In 2016, ARMIN (Arzneimittelinitiative Sachsen-Thüringen) an interprofessional MMP was launched in two German federal states, Saxony and Thuringia. The aim of this study was to understand how GPs and CPs share tasks in MMP when reviewing the patients’ medication.

Methods

This was a cross-sectional postal survey among GPs and CPs who participated in the MMP. Participants were asked who completed which MMP tasks, e.g., checking drug-drug interactions, dosing, and side effects. In total, 15 MMP tasks were surveyed using a 5-point Likert scale ranging from “I complete this task alone” to “GP/CP completes this task alone”. The study was conducted between 11/2020 and 04/2021. Data was analyzed using descriptive statistics.

Results

In total, 114/165 (69.1%) GPs and 166/243 (68.3%) CPs returned a questionnaire. The majority of GPs and CPs reported (i) checking clinical parameters and medication overuse and underuse to be completed by GPs, (ii) checking storage conditions of drugs and initial compilation of the patient’s medication including brown bag review being mostly performed by CPs, and (iii) checking side-effects, non-adherence, and continuous updating of the medication list were carried out jointly. The responses differed most for problems with self-medication and adding and removing over-the-counter medicines from the medication list. In addition, the responses revealed that some MMP tasks were not sufficiently performed by either GPs or CPs.

Conclusions

Both GPs’ and CPs’ expertise are needed to perform MMP as comprehensively as possible. Future studies should explore how GPs and CPs can complement each other in MMP most efficiently.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08378-4.

The Pharmacist’s Role in the Implementation of FASTHUG-MAIDENS, a Mnemonic to Facilitate the Pharmacotherapy Assessment of Critically Ill Patients: A Cross-Sectional Study

FASTHUG is a mnemonic used by intensive care physicians to ensure the proper management of patients admitted to an Intensive Care Unit (ICU). FASTHUG-MAIDENS is a modified version that incorporates key pharmacotherapeutic elements such as delirium management, drug dosing, and drug interactions for an appropriate medication assessment of critically ill patients. An analytical cross-sectional study of hospitalized patients was carried out to determine aspects related to the pharmacotherapeutic management of critically ill patients that required to be optimized, to design and implement a protocol based on the FASTHUG-MAIDENS mnemonic. A total of 435 evaluations were performed to assess the status of current critical patient management. The main parameters with opportunities to be improved were analgesia, feeding, and sedation. With the implementation of MAIDENS, the parameters of analgesia, sedation, and thromboprophylaxis showed an increase in the percentage of optimal management. Furthermore, 103 drug-related problems were detected, and most of them were associated with feeding (21.3%), glucose control (11.7%), and delirium (9.7%). The FASTHUG MAIDENS protocol implementation allows for the evaluation of more vital aspects in the management of critically ill patients. The daily review of patients admitted to the ICU by a clinical pharmacist (CP) using the FASTHUG-MAIDENS checklist instead of the FASTHUG mnemonic facilitates the identification of DRPs for the performance of possible interventions by the CP to improve the pharmacotherapeutic management.

The Effect of a Structured Medication Review on Quality of Life in Parkinson's Disease

BACKGROUND

Drug therapy is important for controlling symptoms in Parkinson's disease (PD). However, it often results in complex medication regimens and could easily lead to drug related problems (DRP), suboptimal adherence and reduced treatment efficacy. A structured medication review (SMR) could address these issues and optimize therapy, although little is known about clinical effects in PD patients.

OBJECTIVE

To analyze whether an SMR improves quality of life (QoL) in PD.

METHODS

In this multicenter randomized controlled trial, half of the 202 PD patients with polypharmacy received a community pharmacist-led SMR. The control group received usual care. Assessments at baseline, and after three and six months comprised six validated questionnaires. Primary outcome was PD specific QoL [(PDQ-39; range 0 (best QoL) - 100 (worst QoL)]. Secondary outcomes were disability score, non-motor symptoms, general health status, and personal care giver's QoL. Furthermore, DRPs, proposed interventions, and implemented modifications in medication schedules were analyzed.

RESULTS

No improvement in QoL was seen six months after an SMR, with a non-significant treatment effect difference of 2.09 (-0.63;4.80) in favor of the control group. No differences were found in secondary outcomes. In total, 260 potential DRPs were identified (2.6 (±1.8) per patient), of which 62% led to drug therapy optimization.

CONCLUSION

In the current setting, a community pharmacist-led SMR did not improve QoL in PD patients, nor improved other pre-specified outcomes.

Integrating medication risk management interventions into regular automated dose dispensing service of older home care clients - a systems approach

BACKGROUND

Automated dose dispensing (ADD) services have been implemented in many health care systems internationally. However, the ADD service itself is a logistic process that requires integration with medication risk management interventions to ensure safe and appropriate medication use. National policies and regulations guiding ADD in Finland have recommended medication reconciliation, review, and follow-up for suitable risk management interventions. This implementation study aimed to develop a medication management process integrating these recommended risk management interventions into a regular ADD service for older home care clients.

METHODS

This study applied an action research method and was carried out in a home care setting, part of primary care in the City of Lahti, Finland. The systems-approach to risk management was applied as a theoretical framework.

RESULTS

The outcome of the systems-based development process was a comprehensive medication management procedure. The medication risk management interventions of medication reconciliation, review and follow-up were integrated into the medication management process while implementing the ADD service. The tasks and responsibilities of each health care professional involved in the care team became more explicitly defined, and available resources were utilized more effectively. In particular, the hospital pharmacists became members of the care team where collaboration between physicians, pharmacists, and nurses shifted from parallel working towards close collaboration. More efforts are needed to integrate community pharmacists into the care team.

CONCLUSION

The transition to the ADD service allows implementation of the effective medication risk management interventions within regular home care practice. These systemic defenses should be considered when national ADD guidelines are implemented locally. The same applies to situations in which public home care organizations responsible for services e.g., municipalities, purchase ADD services from private service providers.

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation.

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: A systematic review of randomized trials and non-randomized intervention studies

BACKGROUND

Polipharmacy has been identified as a contributing factor to the high hospital readmission rates of heart failure (HF) patients. Nevertheless, there limited evidence on pharmacist-led intervention on the reduction of inappropriate medication use in patients.

OBJECTIVE

To summarize the available evidence resulting from interventions, led by pharmacists (alone or as part of a professional team), aimed at reducing inappropriate medications in patients with heart failure.

METHODS

A systematic review was conducted using MEDLINE through PubMed, Embase, the Cochrane Library and Scopus until June 2020. We reviewed both randomized controlled trials and non-randomized intervention studies.The quality of evidence was assessed in accordance with the modified Cochrane Collaboration tool to assess risk of bias for randomized controlled trials. The search and extraction process followed PRISMA guidelines.

RESULTS

Of the 4367 records screening, 9 studies were included in the analysis. In 4 (44.4%) studies, the intervention was carried out by a pharmacist working together with a physician; in 4 (44.4%) the intervention was carried out by a pharmacist alone, and in 1 study, the pharmacist collaborated with a nurse. Only 5 (55.5%) studies described the utilization of guidelines or recommendations to carry out the deprescription, and 3 of these showed improved clinical outcomes in the interventional group compared to the control group. The other studies (4, 44.4%) did not follow a specific guideline or recommendation to evaluate the appropriateness of medication, and none of them showed statistically significant differences in clinical outcomes between interventional and control groups.

CONCLUSION

Only those studies where pharmacists evaluated the appropriateness of treatment to specific HF guidelines showed significant differences in patients' clinical outcomes. The development and validation of a specific tool to evaluate medication appropriateness in patients with HF, could contribute to the improvement of patient health.

An Overview of Reviews on Interprofessional Collaboration in Primary Care: Effectiveness

Introduction:

Interprofessional collaboration (IPC) is increasingly used but diversely implemented in primary care. We aimed to assess the effectiveness of IPC in primary care settings.

Methods:

An overview (review of systematic reviews) was carried out. We searched nine databases and employed a double selection and data extraction method. Patient-related outcomes were categorized, and results coded as improvement (+), worsening (–), mixed results (?) or no change (0).

Results:

34 reviews were included. Six types of IPC were identified: IPC in primary care (large scope) (n = 8), physician-nurse in primary care (n = 1), primary care physician (PCP)-specialty care provider (n = 5), PCP-pharmacist (n = 3), PCP-mental healthcare provider (n = 15), and intersectoral collaboration (n = 2). In general, IPC in primary care was beneficial for patients with variation between types of IPC. Whereas reviews about IPC in primary care (large scope) showed better processes of care and higher patient satisfaction, other types of IPC reported mixed results for clinical outcomes, healthcare use and patient-reported outcomes. Also, reviews focusing on interventions based on pre-existing and well-defined models, such as collaborative care, overall reported more benefits. However, heterogeneity between the included primary studies hindered comparison and often led to the report of mixed results. Finally, professional- and organizational-related outcomes were under-reported, and cost-related outcomes showed some promising results for IPC based on pre-existing models; results were lacking for other types.

Conclusions:

This overview suggests that interprofessional collaboration can be effective in primary care. Better understanding of the characteristics of IPC processes, their implementation, and the identification of effective elements, merits further attention.

The impact of community pharmacists on older adults in Turkey

OBJECTIVE

This study aimed to evaluate the impact of theory-based, structured, standardized pharmaceutical care services led by community pharmacists (CPs) on patient-related outcomes in older Turkish adults.

PRACTICE DESCRIPTION

This prospective, quasi-experimental pilot study was conducted at the national level at community pharmacies in Turkey. After virtual training of CPs, pharmaceutical care services including medicine bag check-up, medication review, patient medicine card, patient education, and counseling services (including motivational interviewing) were delivered to promote medication adherence in older adults.

PRACTICE INNOVATION

Theory-based, structured, standardized pharmaceutical care services addressing medication adherence problems in older Turkish adults with noncommunicable diseases.

EVALUATION METHODS

Descriptive data (including demographic and clinical data, medication-related problems by using the DOCUMENT classification, potential inappropriate prescribing by using the Ghent Older People's Prescriptions Community Pharmacy Screening- (GheOP³S) tool, and pharmacy service satisfaction) were presented. Pre- and post-evaluation were compared by using the Wilcoxon test (for continuous variables) and McNemar's or McNemar-Bowker chi-square test (for categorical variables).

RESULTS

One hundred and thirty-eight medication-related problems were identified among 52 older adults. The medication adherence rate was significantly increased from 51.9% to 75%, and the mean of total quality of life (QoL) score rose significantly from 51.7 to 53.4 (P < 0.05). There was a statistically significant change in the median of necessity-concern differential (baseline: 7 [2.2-10.0] vs. final: 8.0 [5-11]; P < 0.05). At baseline, all patients had at least 1 potential inappropriate prescribing according to the GheOP³S tool, and the rate was 73.1% at the final assessment.

CONCLUSION

Community pharmacist-led pharmaceutical care services significantly improved patient-related outcomes (such as medication adherence, beliefs about medication, and QoL) in older adults with noncommunicable diseases. No statistically significant change was detected in their lifestyle behaviors (such as physical activity and diet program) or health awareness.

The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge from hospital in patients with polypharmacy

INTRODUCTION

Transitional care programs (i.e. interventions delivered both in hospital and in primary care), could increase continuity and consequently quality of care. However, limited studies on the effect of these programs on Adverse Drug Events (ADEs) post-discharge are available. Therefore, the aim of this study was to investigate the effect of a transitional pharmaceutical care program on the occurrence of ADEs 4 weeks post-discharge.

METHODS

A multicentre prospective before-after study was performed in a general teaching hospital, a university hospital and 49 community pharmacies. The transitional pharmaceutical care program consisted of: teach-back to the patient at discharge, a pharmaceutical discharge letter, a home visit by a community pharmacist and a clinical medication review by both the community and the clinical pharmacist, on top of usual care. Usual care consisted of medication reconciliation at admission and discharge by pharmacy teams. The primary outcome was the proportion of patients who reported at least 1 ADE 4 weeks post-discharge. Multivariable logistic regression was used to adjust for potential confounders.

RESULTS

In total, 369 patients were included (control: n = 195, intervention: n = 174). The proportion of patients with at least 1 ADE did not statistically significant differ between the intervention and control group (general teaching hospital: 59% vs. 67%, OR_adj 0.70 [95% CI 0.38-1.31], university hospital: 63% vs 50%, OR _adj 1.76 [95% CI 0.75-4.13]).

CONCLUSION

The transitional pharmaceutical care program did not decrease the proportion of patients with ADEs after discharge. ADEs after discharge were common and more than 50% of patients reported at least 1 ADE. A process evaluation is needed to gain insight into how a transitional pharmaceutical care program could diminish those ADEs.

Fall prevention interventions in primary care to reduce fractures and falls in people aged 70 years and over: the PreFIT three-arm cluster RCT

BACKGROUND

Falls and fractures are a major problem.

OBJECTIVES

To investigate the clinical effectiveness and cost-effectiveness of alternative falls prevention interventions.

DESIGN

Three-arm, pragmatic, cluster randomised controlled trial with parallel economic analysis. The unit of randomisation was the general practice.

SETTING

Primary care.

PARTICIPANTS

People aged ≥ 70 years.

INTERVENTIONS

All practices posted an advice leaflet to each participant. Practices randomised to active intervention arms (exercise and multifactorial falls prevention) screened participants for falls risk using a postal questionnaire. Active treatments were delivered to participants at higher risk of falling.

MAIN OUTCOME MEASURES

The primary outcome was fracture rate over 18 months, captured from Hospital Episode Statistics, general practice records and self-report. Secondary outcomes were falls rate, health-related quality of life, mortality, frailty and health service resource use. Economic evaluation was expressed in terms of incremental cost per quality-adjusted life-year and incremental net monetary benefit.

RESULTS

Between 2011 and 2014, we randomised 63 general practices (9803 participants): 21 practices (3223 participants) to advice only, 21 practices (3279 participants) to exercise and 21 practices (3301 participants) to multifactorial falls prevention. In the active intervention arms, 5779 out of 6580 (87.8%) participants responded to the postal fall risk screener, of whom 2153 (37.3%) were classed as being at higher risk of falling and invited for treatment. The rate of intervention uptake was 65% (697 out of 1079) in the exercise arm and 71% (762 out of 1074) in the multifactorial falls prevention arm. Overall, 379 out of 9803 (3.9%) participants sustained a fracture. There was no difference in the fracture rate between the advice and exercise arms (rate ratio 1.20, 95% confidence interval 0.91 to 1.59) or between the advice and multifactorial falls prevention arms (rate ratio 1.30, 95% confidence interval 0.99 to 1.71). There was no difference in falls rate over 18 months (exercise arm: rate ratio 0.99, 95% confidence interval 0.86 to 1.14; multifactorial falls prevention arm: rate ratio 1.13, 95% confidence interval 0.98 to 1.30). A lower rate of falls was observed in the exercise arm at 8 months (rate ratio 0.78, 95% confidence interval 0.64 to 0.96), but not at other time points. There were 289 (2.9%) deaths, with no differences by treatment arm. There was no evidence of effects in prespecified subgroup comparisons, nor in nested intention-to-treat analyses that considered only those at higher risk of falling. Exercise provided the highest expected quality-adjusted life-years (1.120), followed by advice and multifactorial falls prevention, with 1.106 and 1.114 quality-adjusted life-years, respectively. NHS costs associated with exercise (£3720) were lower than the costs of advice (£3737) or of multifactorial falls prevention (£3941). Although incremental differences between treatment arms were small, exercise dominated advice, which in turn dominated multifactorial falls prevention. The incremental net monetary benefit of exercise relative to treatment valued at £30,000 per quality-adjusted life-year is modest, at £191, and for multifactorial falls prevention is £613. Exercise is the most cost-effective treatment. No serious adverse events were reported.

LIMITATIONS

The rate of fractures was lower than anticipated.

CONCLUSIONS

Screen-and-treat falls prevention strategies in primary care did not reduce fractures. Exercise resulted in a short-term reduction in falls and was cost-effective.

FUTURE WORK

Exercise is the most promising intervention for primary care. Work is needed to ensure adequate uptake and sustained effects.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN71002650.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 34. See the NIHR Journals Library website for further project information.

General Practitioners and Community Pharmacists' Collaboration in Primary Care: Small Steps for a Major Change

BACKGROUND

Healthcare authorities worldwide search for ways to develop integrated care and interprofessional collaboration. In Belgium, Medical-Pharmaceutical Concertation (MPC) was introduced as a format to promote constructive dialogues between GPs and community pharmacists (CPs) with a focus on pharmacotherapy.

OBJECTIVE

To evaluate the implementation of MPC from the perspective of healthcare authorities and GPs/CPs.

METHODS

Mixed-methods approach, including semi-structured interviews with stakeholders and service users, observations of MPC meetings and surveys in GPs/CPs. Quantitative data were analyzed using descriptive statistics. Qualitative data were analyzed inductively.

RESULTS

The implementation of MPC took a slow start. Parties involved had divergent views on the goals of the MPC: stakeholders focused on measurable results, while service users aimed on improving interprofessional communication. Additionally, service users felt that the lack of local structures hindered consensus building and implementation of agreements in daily practice. Support from professional associations was considered indispensable for the implementation of MPC. In order to organize this efficiently, the establishment of an independent institution, coordinating the MPC initiative, was highly recommended.

CONCLUSION

The study confirms that a thorough context assessment prior to implementation of a complex project is needed and that a step-wise approach should be respected to achieve effective interprofessional relationships.

Impact Analysis of a Pharmacist-Led Home-Medication Review Service Within an interprofessional Outreach Team

OBJECTIVE

To describe the demographic and clinical characteristics of frail and homebound communitydwelling older patients receiving a home medication review (HMR) conducted by a home-visiting pharmacist; the types of drug therapy problems (DTPs) that were identified; the types of clinical interventions being recommended and their implementation rate.

DESIGN

Retrospective, cross-sectional chart-review study using data from patient records.

SETTING

Homes of patients receiving a HMR by a community pharmacy-based consulting home-visiting pharmacist.

PATIENTS

171 patients received a HMR between January 1, 2016, and May 31, 2018.

INTERVENTION

Patients received a comprehensive HMR by a home-visiting pharmacist working as a member of an interprofessional geriatrics team.

MAIN OUTCOME MEASURES

Charlson Comorbidity Index (CCI) score, comorbidities, use of potentially inappropriate medications, DTPs identified, number and type of clinical interventions being recommended and successfully implemented.

RESULTS

Patients had a mean age of 81 years (range: 54-100 years), majority were 65 years of age or older (95%), and female (59%). Fifty-three percent of patients had a CCI score of 1 to 2, and 93.6% were experiencing multi-morbidity and polypharmacy. Patients used an average of 13.0 medications, and 76.1% were found to be using at least 1 potentially inappropriate medication. In total, the home-visiting pharmacist identified 827 DTPs and made 1088 recommendations with a successful implementation rate of 74%.

CONCLUSIONS

Frail and homebound communitydwelling older adults referred for a HMR were observed to be using a high number of medications with a significant number of DTPs identified. Offering HMRs was an effective method for a community-based pharmacist to make acceptable recommendations to optimize medication therapy management for frail older patients.

"Clearly they are in the circle of care, but . . .": A qualitative study exploring perceptions of personal health information sharing with community pharmacists in an integrated care model

Background

Ontario's Health Links approach to care is an integrated care model designed to optimize care for patients with complex needs. Currently, community pharmacists have no formalized role. This study aimed to explore stakeholders' perceptions about privacy and its impact on community pharmacists' involvement with integrated care models.

Methods

A qualitative study using semistructured telephone-based interviews was conducted. Participants worked in Ontario as pharmacists, providers in Health Links or team-based models or decision-makers in Health Links or health regions. Thematic analysis followed the Qualitative Analysis Guide of Leuven.

Results

Twenty-two participants were interviewed, and all but one commented on privacy or information sharing in integrating community pharmacists with integrated care models. The 4 themes identified were as follows: 1) what does the circle of care look like? 2) value of sharing information, 3) uncertainty of what information to share and 4) perceptions on how to share information.

Interpretation

The concerns surrounding privacy of personal health information and who is included in the circle of care represented an important barrier for integration. Enablers to mitigate privacy concerns included relationship building between community pharmacists, patients and other health care professionals and mutual access to information-sharing platforms such as electronic health records.

Conclusion

Providers' and decision-makers' perceptions about community pharmacists and privacy affect information sharing and are incongruent with Ontario's Personal Health Information Protection Act. Education is needed for health care professionals on legislation, especially as health systems move towards integrated care models to improve care. Can Pharm J (Ott) 2020;153:xx-xx.

Application of the GheOP3S-tool in nursing home residents: acceptance and implementation of pharmacist recommendations

Background and objective: The prevalence of potentially inappropriate prescribing (PIP) among nursing home (NH) residents is high. This study aimed to investigate the acceptance and implementation of pharmacist recommendations based on a screening tool for PIP, the Ghent Older People's Prescriptions community Pharmacy Screening (GheOP³S)-tool. Setting and method: Prospective observational study in NH residents (≥ 70 years, using ≥ 5 medications) with a 3-month follow-up period. A pharmacist screened the medication lists using the GheOP³S-tool and formulated recommendations to reduce PIP. The acceptance of recommendations discussed during face-to-face pharmacist-general practitioner (GP) meetings was recorded. Implementation was examined by comparing baseline and follow-up medication lists. A pre-post comparison of the number of chronic medications and GheOP³S-criteria; the anticholinergic and sedative burden quantified by the Drug Burden Index (DBI); and medication costs was performed. Results: Screening with the GheOP³S-tool resulted in 168 pharmacist recommendations for 50 NH residents, mainly to stop (78.0%) and to substitute (14.3%) medications. Ninety-three % (156/168) of recommendations were considered relevant. GPs acceptance rate was 44.9%. Fifty-four % of all accepted recommendations were implemented. At follow-up, the number of chronic medications (p = 0.007), and DBI scores (p = 0.004) significantly differed from baseline. There was no significant decrease in the number of GheOP³S-criteria (p = 0.075) and medication costs (p > 0.05). Conclusion: The acceptance and implementation of pharmacist recommendations were relatively low. Future studies should increase the involvement of patients and all health-care providers. Interdisciplinary collaboration with sufficient education for all disciplines and patients is essential.

A user-centered evaluation of medication therapy management alerts for community pharmacists: Recommendations to improve usability and usefulness

BACKGROUND

Community pharmacists provide comprehensive medication reviews (CMRs) through pharmacy contracts with medication therapy management (MTM) vendors. These CMRs are documented in the vendors' web-based MTM software platforms, which often integrate alerts to assist pharmacists in the detection of medication therapy problems. Understanding pharmacists' experiences with MTM alerts is critical to optimizing alert design for patient care.

OBJECTIVES

The objectives of this study were to 1) assess the usability and usefulness of MTM alerts for MTM vendor-contracted community pharmacists and 2) generate recommendations for improving MTM alerts for use by community pharmacists.

METHODS

This was a convergent, parallel mixed-methods evaluation of data collected from 3 sources, with individual pharmacists contributing data to one or more sources: 1) community pharmacists' submissions of observational data about MTM alerts encountered during routine MTM provision, 2) videos of naturalistic usability testing of MTM alerts, and 3) semi-structured interviews to elicit pharmacists' perspectives on MTM alert usefulness and usability. MTM alert data submitted by pharmacists were summarized with descriptive statistics. Usability testing videos were analyzed to determine pharmacists' time spent on MTM alerts and to identify negative usability incidents. Interview transcripts were analyzed using a hybrid approach of deductive and inductive codes to identify emergent themes. Triangulation of data (i.e., determination of convergence/divergence in findings across all data sources) occurred through investigator discussion and identified overarching findings pertaining to key MTM alert challenges. These resulted in actionable recommendations to improve MTM alerts for use by community pharmacists.

RESULTS

Collectively, two and four overarching key challenges pertaining to MTM alert usability and usefulness, respectively, were identified, resulting in 15 actionable recommendations for improving the design of MTM alerts from a user-centered perspective.

CONCLUSIONS

Recommendations are expected to inform enhanced MTM alert designs that can improve pharmacist efficiency, patient and prescriber satisfaction with MTM, and patient outcomes.

Pharmacist-led medication reviews in aged care residents with dementia: A systematic review

OBJECTIVES

To evaluate outcomes associated with pharmacist-led medication reviews in residential aged care facility (RACF) residents with dementia.

METHODS

Six scientific databases were searched. All study designs investigating pharmacist-led medication reviews in RACF residents with dementia were considered. The protocol was registered with PROSPERO (CRD42019121681).

RESULTS

One randomised controlled trial (RCT) and five observational studies were identified. Two studies reported reductions in medication usage per resident, and one study reported improved appropriateness of psychotropic use following reviews as part of multi-faceted, collaborative interventions. In three studies, reviews undertaken as an isolated intervention or by a visiting pharmacist with minimal collaboration with physicians were associated with low implementation rates of recommendations to alter therapy.

CONCLUSION

Pharmacist-led medication reviews, when conducted collaboratively, may improve the use of medicines in RACF residents with dementia. However, robust conclusions cannot be drawn, largely due to the low quality of evidence available, including only one RCT.

Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study

OBJECTIVE

Limited evidence suggests integration of pharmacists into the general practice team could improve medicines management for patients, particularly those with multimorbidity and polypharmacy. This study aimed to develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland.

DESIGN

Non-randomised pilot study.

SETTING

Primary care in Ireland.

PARTICIPANTS

Four general practices, purposively sampled and recruited to reflect a range of practice sizes and demographic profiles.

INTERVENTION

A pharmacist joined the practice team for 6 months (10 hours/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education.

OUTCOME MEASURES

Anonymised practice-level medication (eg, medication changes) and cost data were collected. Patient-reported outcome measure (PROM) data were collected on a subset of older adults (aged ≥65 years) with polypharmacy using patient questionnaires, before and 6 weeks after medication review by the pharmacist.

RESULTS

Across four practices, 786 patients were identified as having 1521 prescribing issues by the pharmacists. Issues relating to deprescribing medications were addressed most often by the prescriber (59.8%), compared with cost-related issues (5.8%). Medication changes made during the study equated to approximately €57 000 in cost savings assuming they persisted for 12 months. Ninety-six patients aged ≥65 years with polypharmacy were recruited from the four practices for PROM data collection and 64 (66.7%) were followed up. There were no changes in patients' treatment burden or attitudes to deprescribing following medication review, and there were conflicting changes in patients' self-reported quality of life.

CONCLUSIONS

This non-randomised pilot study demonstrated that an intervention involving pharmacists, working within general practices is feasible to implement and has potential to improve prescribing quality. This study provides rationale to conduct a randomised controlled trial to evaluate the clinical and cost-effectiveness of this intervention.

Appropriateness of Medications in Older Adults Living With Frailty: Impact of a Pharmacist-Led Structured Medication Review Process in Primary Care

Background: Older persons with frailty take multiple medications and are vulnerable to inappropriate prescribing. Objective: This study assesses the impact of a team-based, pharmacist-led structured medication review process in primary care on the appropriateness of medications taken by older adults living with frailty. Methods: This was a quasi-experimental pretest-posttest design in 6 primary care practices within an academic clinic in Edmonton, Alberta, Canada. We enrolled community dwelling older adults 65 years and older with frailty who have polypharmacy and/or 2 or more chronic conditions (ie, high-risk group for drug-related issues). The intervention was a structured pharmacist-led medication review using evidence-based explicit criteria (ie, Beers and STOPP/START criteria) and implicit criteria (ie, pharmacist expertise) for potentially inappropriate prescribing, done in the context of a primary care team-based seniors’ program. We measured the changes in the number of medications pre- and postmedication review, number of medications satisfying explicit criteria of START and STOPP/Beers and determined the association with frailty level. Data were analyzed using descriptive and inferential statistics (a priori significance level of P < .05). Results: A total of 54 participants (61.1% females, mean age 81.7 years [SD = 6.74]) enrolled April 2017 to May 2018 and 52 participants completed the medication review process (2 lost to hospitalization). Drug-related problems noted on medication review were untreated conditions (61.1%), inappropriate medications (57.4%), and unnecessary therapy (40.7%). No significant changes in total number of medications taken by patients before and after, but the intervention significantly decreased number of inappropriate medications (1.15 meds pre to 0.9 meds post; P = .006). Conclusion: A pharmacist-led medication review is a strategy that can be implemented in primary care to address inappropriate medications.

Cost avoidance related to a pharmacist-led pharmacogenomics service for the Program of All-inclusive Care for the Elderly

Aim: Estimate cost avoidance of pharmacist recommendations for participants enrolled in the Program of All-inclusive Care for the Elderly. Materials & methods: Convenience sample of 200 pharmacogenomics consultations from the PHARM-GENOME-PACE study. Genetic variants, drug-gene interactions, drug-drug-gene interactions and phenoconversions were interrogated. Cost avoidance was estimated and adjusted for inflation. Results: In total, 165 participants had at least one actionable drug-gene pair totaling 429 drug-gene pairs, of which 158 (36.8%) were clinically actionable. Most (70.5%) pharmacists' recommendations were accepted. Estimated cost avoidance was $233,945 when all recommendations were included but conservatively $162,031 based on acceptance rates. Overall mean cost avoidance per actionable drug-gene pair was $1063 or $1983 per participant. Conclusion: Pharmacist-led pharmacogenomics services added to the traditional medication review can avoid substantial costs for payers. Clinical trial registration number: NCT03257605.

Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials

Background

Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting.

Review methods

To determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data.

Results

Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I² = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I² = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge.

Conclusion

A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.

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

OBJECTIVE

To evaluate pharmacist-encountered medication-related problems (MRPs) among the participants of the Program of All-Inclusive Care for the Elderly (PACE).

DESIGN

This was a retrospective analysis of proprietary pharmacy records detailing pharmacist encounters with PACE clinical staff.

SETTING AND PARTICIPANTS

A 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 MEASURES

MRPs 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.

RESULTS

Overall, 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).

CONCLUSION

Pharmacists 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.

Process evaluation of a complex intervention to optimize quality of prescribing in nursing homes (COME-ON study)

Background

The COME-ON study was a cluster-controlled trial of a complex intervention that consisted of a blended training program, local interdisciplinary meetings, and interdisciplinary case conferences in Belgian nursing homes. The intervention was associated with significant improvements in the appropriateness of prescribing. The aims of this study were to describe the implementation of the intervention and to explore the experiences of participants, for the purpose of identifying factors associated with implementation and perceived impact and to draw lessons for future implementation.

Methods

We performed a mixed-method process evaluation. Questionnaires and reports were used to collect quantitative data on implementation and experiences from the 24 NHs and participating healthcare professionals (coordinating physicians, general practitioners, pharmacists, and nurses) in the intervention group. Multidisciplinary focus groups focusing on factors associated with implementation and perceived impact were conducted in 11 NHs.

Results

Overall, the rate of implementation and the satisfaction of participants were good, despite some variability between NHs and HCPs. Although perceived impact on nursing home residents varied, most participants perceived a positive impact for themselves. Factors associated with implementation and perceived impact were identified at different levels: intervention, healthcare professionals, organization, and external context. The interdisciplinary and face-to-face approaches were recognized as key elements for the success of the intervention, despite organizational constraints. The attitude of general practitioners was identified both as a barrier to and a facilitator for implementation and its success. The professional role and competency of the pharmacist influenced perceived impact. The pre-existing relationships between HCPs and the presence of a leader facilitated implementation and perceived impact. Remuneration was deemed necessary for the study and for future implementation.

Conclusions

Overall, the intervention, and more specifically its interdisciplinary aspect, was well implemented and appreciated by HCPs. This probably contributed to the positive effect on the appropriateness of prescribing. Future implementation must take into account the various factors found to affect implementation and perceived impact, in order to maximize effect and sustainability.

Trial registration

Current Controlled Trials ISRCTN66138978; registered 18 November 2015, retrospectively registered, https://www.isrctn.com/ISRCTN66138978

An inventory of collaborative medication reviews for older adults - evolution of practices

Background

Collaborative medication review (CMR) practices for older adults are evolving in many countries. Development has been under way in Finland for over a decade, but no inventory of evolved practices has been conducted. The aim of this study was to identify and describe CMR practices in Finland after 10 years of developement.

Methods

An inventory of CMR practices was conducted using a snowballing approach and an open call in the Finnish Medicines Agency’s website in 2015. Data were quantitatively analysed using descriptive statistics and qualitatively by inductive thematic content analysis. Clyne et al’s medication review typology was applied for evaluating comprehensiveness of the practices.

Results

In total, 43 practices were identified, of which 22 (51%) were designed for older adults in primary care. The majority (n = 30, 70%) of the practices were clinical CMRs, with 18 (42%) of them being in routine use. A checklist with criteria was used in 19 (44%) of the practices to identify patients with polypharmacy (n = 6), falls (n = 5), and renal dysfunction (n = 5) as the most common criteria for CMR. Patients were involved in 32 (74%) of the practices, mostly as a source of information via interview (n = 27, 63%). A medication care plan was discussed with the patient in 17 practices (40%), and it was established systematically as usual care to all or selected patient groups in 11 (26%) of the practices. All or selected patients’ medication lists were reconciled in 15 practices (35%). Nearly half of the practices (n = 19, 44%) lacked explicit methods for following up effects of medication changes. When reported, the effects were followed up as a routine control (n = 9, 21%) or in a follow-up appointment (n = 6, 14%).

Conclusions

Different MRs in varying settings were available and in routine use, the majority being comprehensive CMRs designed for primary outpatient care and for older adults. Even though practices might benefit from national standardization, flexibility in their customization according to context, medical and patient needs, and available resources is important.

Home medicines reviews: a qualitative study of GPs' experiences

This qualitative study explored GPs' experiences with pharmacist-led home medicines reviews (HMRs) and the barriers and facilitators to GPs using HMRs to optimise medicines for older people. Semi-structured interviews were conducted with 32 GPs Australia-wide. Purposeful sampling was undertaken to obtain a representative group in terms of age, gender and location. Data were analysed using framework analysis. Overall, GPs found HMRs useful for educating patients about their medicines, improving adherence and understanding the patient's home environment. Barriers to effective use of HMRs included patient resistance to having medicines reviewed and limited access to HMRs in regional or rural areas. GPs differed in the extent and way they use HMRs. One group found HMRs very useful, wanted more access to HMRs and reported frequent interactions with pharmacists. A second group was ambivalent, and perceived HMRs could be useful but had limitations in what they can achieve. A third group was sceptical, and reported HMRs rarely provide new insights, and recommendations were not clinically relevant to patients. Understanding GPs' expectations and preferences through interprofessional communication and partnerships are ways to address these barriers. Future improvements to the HMR program may include incentives and resources that promote collaboration between GPs and pharmacists.

Non-dispensing pharmacists' actions and solutions of drug therapy problems among elderly polypharmacy patients in primary care

OBJECTIVE

To evaluate the process of clinical medication review for elderly patients with polypharmacy performed by non-dispensing pharmacists embedded in general practice. The aim was to identify the number and type of drug therapy problems and to assess how and to what extent drug therapy problems were actually solved.

METHOD

An observational cross-sectional study, conducted in nine general practices in the Netherlands between June 2014 and June 2015. On three pre-set dates, the non-dispensing pharmacists completed an online data form about the last 10 patients who completed all stages of clinical medication review. Outcomes were the type and number of drug therapy problems, the extent to which recommendations were implemented and the percentage of drug therapy problems that were eventually solved. Interventions were divided as either preventive (aimed at following prophylactic guidelines) or corrective (aimed at active patient problems).

RESULTS

In total, 1292 drug therapy problems were identified among 270 patients, with a median of 5 (interquartile range 3) drug therapy problems per patient, mainly related to overtreatment (24%) and undertreatment (21%). The non-dispensing pharmacists most frequently recommended to stop medication (32%). Overall, 83% of the proposed recommendations were implemented; 57% were preventive, and 35% were corrective interventions (8% could not be assessed). Almost two-third (64%) of the corrective interventions actually solved the drug therapy problem.

CONCLUSION

Non-dispensing pharmacists integrated in general practice identified a large number of drug therapy problems and successfully implemented a proportionally high number of recommendations that solved the majority of drug therapy problems.

Pharmacists' and older adults' perspectives on the benefits and barriers of Home Medicines Reviews - a qualitative study

Objectives

Conducting a medication review is one way to optimize medications and support older people to reduce the burden of polypharmacy. In Australia, a service called a Home Medicines Review (HMR) is conducted by pharmacists as part of a nationally funded program. HMRs aim to identify and resolve problems associated with polypharmacy and improve collaboration between patient, pharmacist and general practitioner. The aim of this study was to explore the benefits of and barriers to HMRs from the perspective of older patients and pharmacists.

Methods

This qualitative study involved observations of HMRs ( n = 12) and telephone interviews with 32 participants including 11 accredited pharmacists, 17 older adults aged 65 years and above, with 4 of their companions, in Australia. The researcher observing took notes during the HMR and added more detail and reflections afterwards. Transcribed audio-recordings and observational notes were thematically coded using framework analysis.

Results

Older patients and their companions found the HMR useful and they appreciated the opportunity to learn more about their medicines. However, many did not understand the purpose of the HMR, had limited understanding about their medicines and some did not want to know more. Pharmacists found HMRs useful for identifying medication errors and improving adherence. They also reported barriers to effective HMRs relating to patients (resistance to the evaluation of their medicines, misunderstanding about the aim of the HMR) and GPs (limited information upon referral, and limited follow-up afterwards).

Conclusions

Older patients and pharmacists reported a range of benefits for HMRs in terms of optimizing medicines use. Barriers to effective HMR use need to be addressed, including gaps in inter-professional communication and factors related to patient involvement, such as limited medicines understanding and health literacy.