Effectiveness of medication review on the number of drug-related problems in patients visiting the outpatient cardiology clinic: A randomized controlled trial

Synchronous telepharmacy models of care for adult outpatients: A systematic review

BACKGROUND

Telephone and video consultations have been used as telepharmacy modalities for a number of years, particularly during the COVID-19 pandemic where in-person services were limited. However, a widespread global literature review has yet to be completed on studies since June 2016 regarding the effectiveness of telephone and video consultations as telepharmacy models.

OBJECTIVES

The aim of this review was to summarise the synchronous telepharmacy models of care for adult outpatients since June 2016. The secondary aim was to report on the effect of these models on clinical, service, and user-perspectives and non-clinical outcomes compared to the standard model of care, as well as facilitators and barriers of the telepharmacy models.

METHODS

A PROSPERO registered systematic review was conducted using PubMed, CINAHL, and Embase in March 2023. Key search terms included pharmacy, telepharmacy, and outpatient; data extraction and narrative analysis were then performed and NHMRC level of evidence determined.

RESULTS

From 2129 unique articles reviewed, 103 were eligible for inclusion. Synchronous telepharmacy services in an outpatient setting were delivered by telephone consultations and video consultations, with the majority being delivered by the telephone modality (87 %) and the remainder by video (13 %). Services primarily involved a pharmacist providing a single consultation with a patient. The purpose of this was either to provide counselling, obtain a best possible medication history, or to provide ongoing support as part of a clinical program, such as diabetes and blood pressure monitoring. Patients reported the quality of care received through telepharmacy consultations provided the same level of care or was superior to in-person services. Key facilitators for the success of telepharmacy services were access to training, technical assistance, digital literacy and availability of technology.

CONCLUSIONS

Telephone and video telepharmacy services are being delivered across a range of outpatient clinical areas. More evidence is needed for video consultation services and how this modality may potentially provide further benefit for certain clinical tasks such as counselling and use of medication delivery devices. Overall, telepharmacy services enhance patient accessibility to healthcare and offer a convenient method of delivering high quality services.

Components of pharmacist-led medication reviews and their relationship to outcomes: a systematic review and narrative synthesis

INTRODUCTION

Pharmacist-led medication reviews are an established intervention to support patients prescribed multiple medicines or with complex medication regimes. For this systematic review, a medication review was defined as 'a consultation between a pharmacist and a patient to review the patient's total medicines use with a view to improve patient health outcomes and minimise medicines-related problems'. It is not known how varying approaches to medication reviews lead to different outcomes.

AIM

To explore the common themes associated with positive outcomes from pharmacist-led medication reviews.

METHOD

Randomised controlled trials of pharmacist-led medication reviews in adults aged 18 years and over were included. The search terms used in MEDLINE, EMBASE and Web of Science databases were "medication review", "pharmacist", "randomised controlled trial" and their synonyms, time filter 2015 to September 2023. Studies published before 2015 were identified from a previous systematic review. Risk of bias was assessed using the Cochrane risk of bias 2 tool. Descriptions of medication reviews' components, implementation and outcomes were narratively synthesised to draw out common themes. Results are presented in tables.

RESULTS

Sixty-eight papers describing 50 studies met the inclusion criteria. Common themes that emerged from synthesis include collaborative working which may help reduce medicines-related problems and the number of medicines prescribed; patient involvement in goal setting and action planning which may improve patients' ability to take medicines as prescribed and help them achieve their treatment goals; additional support and follow-up, which may lead to improved blood pressure, diabetes control, quality of life and a reduction of medicines-related problems.

CONCLUSION

This systematic review identified common themes and components, for example, goal setting, action planning, additional support and follow-up, that may influence outcomes of pharmacist-led medication reviews. Researchers, health professionals and commissioners could use these for a comprehensive evaluation of medication review implementation.

PROSPERO REGISTRATION NUMBER

CRD42020173907.

Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai

BACKGROUND

Pharmacist clinics offer professional pharmaceutical services that can improve public health outcomes. However, primary healthcare staff in China face various barriers and challenges in implementing such clinics. To identify existing problems and provide recommendations for the implementation of pharmacist clinics, this study aims to assess the knowledge, attitudes, and practices of pharmacist clinics among primary healthcare providers.

METHODS

A cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model, was conducted in community health centers (CHCs) and private hospitals in Shanghai, China in May, 2023. Descriptive analytics and the Pareto principle were used to multiple-answer questions. Chi-square test, Fisher's exact test, and binary logistic regression models were employed to identify factors associated with the knowledge, attitudes, and practices of pharmacist clinics.

RESULTS

A total of 223 primary practitioners participated in the survey. Our study revealed that most of them had limited knowledge (60.1%, n = 134) but a positive attitude (82.9%, n = 185) towards pharmacist clinics, with only 17.0% (n = 38) having implemented them. The primary goal of pharmacist clinics was to provide comprehensive medication guidance (31.5%, n = 200), with medication education (26.3%, n = 202) being the primary service, and special populations (24.5%, n = 153) identified as key recipients. Logistic regression analysis revealed that education, age, occupation, position, work seniority, and institution significantly influenced their perceptions. Practitioners with bachelor's degrees, for instance, were more likely than those with less education to recognize the importance of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809-28.099, p-value = 0.005) and prescription reviews (aOR: 4.675, 95% CI: 1.548-14.112, p-value = 0.006). Additionally, practitioners expressed positive attitudes but low confidence, with only 33.3% (n = 74) feeling confident in implementation. The confidence levels of male practitioners surpassed those of female practitioners (p-value = 0.037), and practitioners from community health centers (CHCs) exhibited higher confidence compared to their counterparts in private hospitals (p-value = 0.008). Joint physician-pharmacist clinics (36.8%, n = 82) through collaboration with medical institutions (52.0%, n = 116) emerged as the favored modality. Daily sessions were preferred (38.5%, n = 86), and both registration and pharmacy service fees were considered appropriate for payment (42.2%, n = 94). The primary challenge identified was high outpatient workload (30.9%, n = 69).

CONCLUSIONS

Although primary healthcare practitioners held positive attitudes towards pharmacist clinics, limited knowledge, low confidence, and high workload contributed to the scarcity of their implementation. Practitioners with diverse sociodemographic characteristics, such as education, age, and institution, showed varying perceptions and practices regarding pharmacist clinics.

Medication-Related Problems and Their Intervention in the Geriatric Population: A Review of the Literature

In order to implement the principles of providing clinically and economically effective care, the current state of healthcare must be evaluated, and challenges must be addressed. As part of a physician's role in such a context, one tool consists of identifying medication-related problems (MRPs) and accordingly implementing best practices and innovative strategies to improve patient healthcare outcomes. The geriatric population is expected to have passed through the natural ageing process and experienced several physiological and biological changes that impact their bodies and lives. In the presence of geriatric syndromes and the increased number of medications consumed, the risk of MRPs such as polypharmacy, potentially inappropriate medication (PIM), adverse events, drug-drug interactions, and risk of non-adherence increases. Different interventions that focus on practical and perceptual barriers have been studied, and different tools to define clinically important prescribing problems relating to PIM have been established. The Beers Criteria and STOPP (Screening Tool of Older Persons' Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria are the most widely used sets of explicit PIM criteria; however, they are still limited in Saudi Arabia. These tools should be considered in clinical settings to improve healthcare outcomes in the geriatric population, and the clinical relevance of enhancing medication should also be explored from the point of view of both the patient and healthcare practitioners.

Reducing inappropriate polypharmacy for older patients at specialist outpatient clinics: a systematic review

OBJECTIVE

Polypharmacy is associated with negative clinical consequences. The efficacy of deprescribing interventions within medical specialist outpatient clinics remains unclear. Here, we reviewed the research on the effectiveness of deprescribing interventions implemented within specialist outpatient clinics for patients ≥ 60 years.

METHODS

Systematic searches of key databases were undertaken for studies published between January 1990 and October 2021. The diverse nature of the study designs made it unsuitable for pooling for meta-analysis, thus, a narrative review was conducted and presented in both text and tabular formats. The primary outcome for review was that intervention resulted in a change in medication load (either total number of medications or appropriateness of medication). Secondary outcomes were the maintenance of deprescription and clinical benefits. Methodological quality of the publications was assessed using the revised Cochrane risk-of-bias tools.

RESULTS

Nineteen studies with a total of 10,914 participants were included for review. These included geriatric outpatient clinics, oncology/hematology clinics, hemodialysis clinics, and designated polypharmacy/multimorbidity clinics. Four randomized controlled trials (RCTs) reported statistically significant reductions in medication load with intervention; however, all studies had a high risk of bias. The inclusion of a pharmacist in outpatient clinics aims to increase deprescribing, however, the current evidence is mainly restricted to prospective and pilot studies. The data on secondary outcomes were very limited and highly variable.

CONCLUSIONS

Specialist outpatient clinics may provide valuable settings for implementing deprescribing interventions. The addition of a multidisciplinary team including a pharmacist and the use of validated medication assessment tools appear to be enablers. Further research is warranted.

Community pharmacists’ routine provision of drug-related problem-reduction services

Objectives

The present study aimed to assess the degree of the provision of services for drug-related problems (DRPs) and the factors affecting provision within the community pharmacy setting in Irbid, a large city in Northern Jordan.

Methods

A cross-sectional survey was developed and administered to community pharmacists in Irbid, Jordan during the period from January to May 2017. The survey is composed of background and practice characteristics, services provided routinely by the community pharmacists to address DRPs, and barriers and facilitators for DRP-reduction services. A summated score quantifying the degree of DRP-reduction service provision was calculated, which included overall scores and scores for the different scales and domains. Statistical analysis included descriptive statistics and a multivariate linear regression model for factors associated with the high provision of DRP-reduction service.

Results

Two hundred community pharmacists out of 210 pharmacists approached completed the surveys yielding a response rate of 95.2%. The most frequent DRPs encountered within the routine practice in the community pharmacy were economic aspects (76.0%). The mean total score relating to different DRP-reduction services was 32.9 (58.8%) out of 56 as the maximum possible score. It was estimated that 28.2% of the responding pharmacists provided the service overall (scored more than 50% of the scale). For the assessment, intervention, and referral dimensions, similar percentages of providers of the services were achieved: 59.7%, 61.9%, and 49.0%, respectively. Lower rates of providers were achieved on the documentation scale (12.9%). The lack of recognition of the pharmacist role by physicians was the most commonly reported barrier to effective DRP-reduction services among community pharmacists (78.9%). The ability to receive external guidance was indicated by the majority of surveyed pharmacists (94.5%) as a potential facilitator to DRP-reduction services in this study. Predictors associated with high total scores were the presence of medical records for the patients in the pharmacy, patients contact the pharmacy using email, a high satisfaction in professional relationships with physicians, and pharmacists’ age.

Conclusion

Even though community pharmacists in this study have been shown to deliver certain activities to address DRPs to a high degree, the overall rate of DRPs services was suboptimal. Community pharmacists reported several barriers that should be taken into consideration to facilitate the role of community pharmacists in providing adequate DRP reduction services to patients.

Digital Health Interventions by Clinical Pharmacists: A Systematic Review

Integrating digital interventions in healthcare has gained increasing popularity among clinical pharmacists (CPs) due to advances in technology. The purpose of this study was to systematically review CP-led digital interventions to improve patients' health-related clinical outcomes. PubMed and the Cochrane Database were searched to select studies that had conducted a randomized controlled trial to evaluate clinical outcomes in adults following a CP-led digital intervention for the period from January 2005 to August 2021. A total of 19 studies were included in our analysis. In these 19 studies, the most commonly used digital intervention by CPs was telephone use (n = 15), followed by a web-based tool (n = 2) and a mobile app (n = 2). These interventions were provided to serve a wide range of purposes in patients' outcomes: change in lab values (e.g., blood pressure, HbA1c) (n = 23), reduction in health service use (n = 8), enhancing adherence (n = 6), improvement in drug-related outcomes (n = 6), increase in survival (n = 3), and reduction in health-related risk (e.g., CVD risk) (n = 2). Although the impacts of telephone-based interventions on patients' outcomes were decidedly mixed, web-based interventions and mobile apps exerted generally positive influences. To date, little research has investigated the cost-effectiveness of digital interventions. Future studies are warranted.

A Collaborative Deprescribing Intervention in a Subacute Medical Outpatient Clinic: A Pilot Randomized Controlled Trial

Medication deprescribing is essential to prevent inappropriate medication use in multimorbid patients. However, experience of deprescribing in Danish Subacute Medical Outpatient Clinics (SMOCs) is limited. The objective of our pilot study was to evaluate the feasibility and sustainability of a collaborative deprescribing intervention by a pharmacist and a physician to multimorbid patients in a SMOC. A randomized controlled pilot study was conducted, with phone follow-up at 30 and 365+ days. A senior pharmacist performed a systematic deprescribing intervention using the Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) criteria, the Danish deprescribing list, and patient interviews. A senior physician received the proposed recommendations and decided which should be implemented. The main outcome was the number of patients having ≥1 medication where deprescribing status was sustained 30 days after inclusion. Out of 76 eligible patients, 72 (95%) were included and 67 (93%) completed the study (57% male; mean age 73 years; mean number of 10 prescribed medications). Nineteen patients (56%) in the intervention group and four (12%) in the control group had ≥1 medication where deprescribing status was sustained 30 days after inclusion (p = 0.015). In total, 37 medications were deprescribed in the intervention group and five in the control group. At 365+ days after inclusion, 97% and 100% of the deprescribed medications were sustained in the intervention and control groups, respectively. The three most frequently deprescribed medication groups were analgesics, cardiovascular, and gastrointestinal medications. In conclusion, a collaborative deprescribing intervention for multimorbid patients was feasible and resulted in sustainable deprescribing of medication in a SMOC.

Development and Evaluation of a Clinic for Elderly Patients with Rheumatoid Arthritis and Multimorbidity: A Pilot Study

Objective

Integrating patient’s and physician’s goals, especially in elderly patients with multimorbidity, might ultimately improve care. Efforts to develop such care innovations in patients with rheumatoid arthritis (RA) are lacking. The objective of our study was to develop and to pilot test a clinic for elderly patients with RA and multimorbidity.

Methods

First, a referral strategy for and the content of an Elderly Multimorbidity Clinic (EMC) was developed. Next, the EMC was implemented, and it primarily focused on the personal goals of patients and medication review. The EMC was evaluated in a quantitative–qualitative approach.

Results

Referral considered useful by the rheumatologist was chosen as the referral criterion. A rheumatologist and internist–geriatrician provided care to referred patients (≥ 55 years) at the EMC during three visits over 1 year. Twenty patients with RA participated in the pilot study (mean age 76.8±7.7 years; 30% male). Only 12 (60%) patients attended the first follow‐up consultation, and three (15%) attended the second follow‐up consultation. During any follow‐up visit, 9/12 (75%) patients achieved one or more goals. Examples of accomplished goals were reduction of medication and improvement of mobility. In 19/20 (95%) patients, medication was remediated (stop medication for 13 patients; start medication for five patients) during the first visit. After 1 year, medication was changed back in 10 patients. Rheumatologists revealed uncertainty about meaningful referral, and patients and rheumatologists mentioned high (caregiver) burden because of extra visits as reasons for not attending follow‐up. Patients were satisfied with the care provided.

Conclusion

This goal‐directed EMC led to the accomplishment of at least one goal in 75% of patients. Sustained benefits could not be demonstrated because of low follow‐up.

Effectiveness of medication review on the number of drug-related problems in patients visiting the outpatient cardiology clinic: A randomized controlled trial

AIMS

To assess the effectiveness of medication review on the number of drug-related problems (DRPs) in outpatient cardiology patients.

METHODS

In this randomized controlled trial, a computer-assisted and pharmacist-led medication review with patient involvement (questionnaire and telephone call with pharmacist) was conducted in intervention patients prior to their visit to the cardiologist. The control group received usual care. Adult outpatient cardiology patients without support concerning the administration of medication, without a medication review in the past 6 months and who gave permission to access their electronic medication record were included. The primary outcome measure was the number of DRPs 1 month after the visit. Secondary outcome measures concerned the type of DRP and the type of medication involved in the DRPs.

RESULTS

In total, 75 patients (mean [standard deviation, SD] age 66.0 [12.5] years, 41% female) were included. Intervention (n = 90) and control group (n = 85) were comparable at baseline. The mean (SD) number of drugs used per patient was 7.9 (3.9). After 1 month, the mean (SD) number of DRPs was 0.3 (0.7) and 0.8 (1.0) and the median (range) number of DRPs was 0 (0-4) and 0 (0-4) in the intervention group and control group, respectively (P < .001). In the intervention group, 74% of the DRPs identified at T0 were solved at T1 vs 14% in the control group.

CONCLUSION

This randomized controlled trial suggests that a pharmacist-led medication review in patients with a scheduled visit to the outpatient cardiology clinic decreases the number of DRPs.