Impact of pharmacists' interventions on the pharmacotherapy of patients with complex needs monitored in multidisciplinary primary care teams

Incorporation of an Efficient Pharmacist Workflow During the Transition From In-Person to Telemedicine Geriatric Clinics in Response to the COVID-19 Pandemic

The COVID-19 pandemic created care continuity challenges for older adults in the ambulatory care setting. Similarly, maintaining the multidisciplinary team concept of geriatric care among healthcare practitioners working from home presented several logistical difficulties. It became apparent there was a need to address these problems to avoid care gaps in this vulnerable population. Realizing that in-person clinics could put vulnerable older adults at increased risk of contracting COVID-19, a workflow was proactively developed to convert a traditional in-person multidisciplinary geriatric clinic to a telemedicine-based model. A video patient encounter option within our electronic health record along with a secure on-line meeting platform was used to maintain a team-based approach to care. This resulted not only in a high level of efficiency in care delivery, but also ensured the safety of older adult patients served by the clinic. This model provides a template for the continued use of telemedicine as a strategy for the care of vulnerable older adults who experience challenges with attending in-person clinics.

Models of care and the role of clinical pharmacists in UK primary care for older adults: A scoping review protocol

INTRODUCTION

There has been global investment of new ways of working to support workforce pressures, including investment in clinical pharmacists working in primary care by the NHS in the England. Clinical pharmacists are well suited to support older adults who have multiple long-term conditions and are on multiple medications. It is important to establish an evidence base for the role of clinical pharmacists in supporting older adults in primary care, to inform strategic and research priorities. The aim of this scoping review is to identify, map and describe existing research and policy/guidance on the role of clinical pharmacists in primary care supporting older adults, and the models of care they provide.

METHODS AND ANALYSIS

A scoping review guided by the Joanne Briggs Institute methodology for scoping reviews, using a three-step strategy. We will search Medline, CINAHL, Scopus, EMBASE, Web of Science, PSYCHInfo, and Cochrane for English language articles, from 2015 -present day. Grey literature will be searched using Grey Matters guidelines, the Index of Grey Literature and Alternative Sources and Resources, and Google keyword searching. References of all included sources will be hand searched to identify further resources. Using the Population, Concept and Context framework for inclusion and exclusion criteria, articles will be independently screened by two reviewers. The inclusion and exclusion criteria will be refined after we become familiar with the search results, following the iterative nature of a scoping review. Data will be extracted using a data extraction tool using Microsoft Excel and presented using a narrative synthesis approach.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Review findings will be disseminated in academic conferences and used to inform subsequent qualitative research. Findings will be published and shared with relevant local and national organisations.

Multimorbidity Treatment Burden Questionnaire (MTBQ): Translation, Cultural Adaptation, and Validation in French-Canadian

Reliable treatment burden measures are needed given the aging population and the associated increase in multimorbidity and polypharmacy. Treatment burden is defined as the effort to care for one's health and the resulting impact on one's daily life. This study aimed to translate the Multimorbidity Treatment Burden Questionnaire (MTBQ) for French-Canadians and assess its reliability and validity. The MTBQ was translated and tested with cognitive debriefing interviews, and the French version (MTBQ-F) was then administered 2 times among 105 participants. Reliability and validity were examined using the intra-class correlation coefficient (ICC), Cronbach's alpha, and Spearman's correlations. The median global MTBQ-F scores were 32.69 (interquartile range [IQR]: 21.15-48.08) and 30.77 (IQR: 21.15-46.15) for the first and second administrations, respectively. Test-retest (ICC: 0.73; 95% CI: 0.63-0.81) and internal consistency reliability (Cronbach's alpha: 0.80) were good. There was a moderate positive correlation between the MTBQ-F score and the number of self-reported conditions (rho: 0.28). This valid instrument could identify patients experiencing a high treatment burden and assess the impact of interventions among them.

Interprofessional Collaboration and Team Effectiveness of Pharmacists in General Practice: A Cross-National Survey

As team-based care continues to evolve, pharmacists have been included in general practice teams in many countries, to varying extents, to improve medication use and patient safety. However, evidence on interprofessional collaboration and team effectiveness of pharmacists in general practice is sparse. This study aimed to compare the extent of interprofessional collaboration and team effectiveness of general practice pharmacists in Australia with international sites (Canada and the UK), and identify the factors associated with interprofessional collaboration and team effectiveness. General practice pharmacists from Australia, Canada, and the UK were identified through professional organisations and networks, and invited to participate in an online survey, adapted from existing validated tools. The survey explored interprofessional collaboration through four sub-domains (professional interactions, relationship initiation, trust and role clarity, and commitment to collaboration) and team effectiveness of general practice pharmacists. Of the 101 respondents (26 from Australia, 44 from Canada and 31 from the UK), 79% were female and 78% were aged below 50 years. Interprofessional collaboration and team effectiveness appeared to be high and similar between countries. Total scores for collaboration of pharmacists were 86.1 ± 7.4 in Australia, 88.5 ± 7.5 in the UK, and 89.1 ± 7.3 in Canada (mean ± SD, where higher scores represent more advanced collaboration), while the team effectiveness scores of the pharmacists were 88.6 ± 14.6 in Canada, 91.8 ± 14.6 in Australia and 97.5 ± 14.0 in the UK. Pharmacists who had worked in general practice for a longer time showed advanced interprofessional collaboration while those who worked exclusively in general practice had higher scores for team effectiveness. Overall, general practice pharmacists in the three countries were highly collaborative with general practitioners. Long-term employment and longer work hours could enhance interprofessional collaboration and team effectiveness in general practice pharmacists by improving trust and working relationships over time.

Cross-sector pre-registration trainee pharmacist placements in general practice across England: A qualitative study exploring the views of pre-registration trainees and education supervisors

The Pharmacy Integration Fund commissioned 95 cross-sector pre-registration trainee pharmacist placements across England, which incorporated trainees spending 3-6 months in general practice (GP), whilst employed in hospital or community pharmacy. Delivery models varied (blocks or split weeks/days); trainees had pharmacist tutors at the employing/base (hospital/community pharmacy) organisation and in GP. This study aimed to evaluate implementation of cross-sector pre-registration placements, and to identify barriers and enablers of a "successful" placement that achieved its intended outcomes. A qualitative study was undertaken, using semi-structured interviews with triads/dyads of trainee and pharmacist tutors at base and/or GP site. Interviews explored trainees' and tutors' GP placement experiences, and the contribution of GP placements to achieving intended learning outcomes. Data were thematically analysed. Thirty-four interviews (14 trainees, 11 base tutors, 9 GP tutors) were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). GP placements were perceived as valuable and producing well-rounded pre-registration trainees with a good understanding of two settings. Key benefits of GP placements were trainees' ability to work within multidisciplinary teams, and improved clinical and consultation skills. Contingency planning/flexibility was important when setting up cross-sector placements. GP tutor supervision which supported a gradual transition from shadowing to more independent clinical practice with feedback was perceived as valuable. Good collaboration between tutors at the base and GP site ensured joined-up learning across settings. All participants considered 13 weeks in GP an appropriate minimum duration; community trainees preferred longer duration (26 weeks) for more opportunities for clinical and consultation skills learning. Base and GP tutors would welcome clarity on which pre-registration competencies should be achieved in GP placements, which would also aid quality and consistency across providers. Findings from this study identified key attributes of a successful pre-registration cross-sector training experience. These findings can inform policy reforms including changes to initial education and training of pharmacists.

Pharmacist-led medication reviews in primary healthcare for adult community-dwelling patients – a descriptive study charting a new target group

Background

Medication treatment can reduce morbidity but can also cause drug-related problems (DRPs). One method to identify and solve DRPs is medication reviews (MRs) that are aimed at increased patient safety and quality in drug treatment. In Skåne county, Sweden, a well-established multi-professional model for MRs in nursing homes is practiced. However, a demand for MRs regarding community-dwelling patients has emerged. These patients may be extra vulnerable since they have less supervision from healthcare personnel.

AIM: To describe the community-dwelling patients in primary healthcare considered in need of an MR, as well as the outcomes of these pharmacist-led MRs.

Methods

Personnel from 14 primary healthcare centers selected patients for the MRs. Based on electronic medical records, the symptom assessment tool PHASE-20 (PHArmacotherapeutical Symptom Evaluation 20 questions) and medication lists, pharmacists conducted MRs and communicated adjustment suggestions via the medical record to the general practitioners (GPs).

Results

A total of 109 patients were included in the study and 90.8% (n = 99) of the patients were exposed to at least one DRP, with an average of 3.9 DRPs per patient. Patients with impaired renal function (glomerular filtration rate, GFR < 45 ml/min) or ≥ 10 medications were exposed to a significantly higher number of DRPs per patient, 5.1 DRP and 5.3 respectively. The most frequent DRP-categories were Unnecessary drug therapy and Adverse drug reaction, which represented 23.0% respectively 22.9% of the total amount of DRPs.

Conclusions

Our results indicate a prioritized need for MRs for community-dwelling patients, specifically with impaired renal function or polypharmacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01849-x.

A new perspective: Practice-enhancing publications about the ambulatory care medication-use process in 2020

DISCLAIMER

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

This article identifies, prioritizes, and summarizes published literature on the ambulatory care medication-use process (ACMUP) from calendar year 2020 that can impact ambulatory pharmacy practice.

SUMMARY

The medication-use process is the foundational system that provides the framework for safe medication utilization within the healthcare environment and was reimagined to focus on new innovations and advancements in ambulatory pharmacy practice. The ACMUP is defined in this article as having the following components: transitions of care, prescribing and collaborative practice, accessing care, adherence, and monitoring and quality. Articles evaluating at least one step of the ACMUP were assessed for their usefulness toward practice improvement. A PubMed search covering calendar year 2020 was conducted in January 2021 using targeted Medical Subject Headings (MeSH) keywords and the table of contents of selected pharmacy journals, providing a total of 9,433 articles. A thorough review identified 65 potentially practice-enhancing articles: 14 for transitions of care, 19 for prescribing and collaborative practice, 10 for adherence, 6 for accessing care, and 16 for monitoring and quality. Ranking of the articles for importance by peers led to the selection of key articles from each category. The highest-ranked articles are briefly summarized, with a mention of why each article is important. The other articles are listed for further review and evaluation.

CONCLUSION

It is important to routinely review the published literature and to incorporate significant findings into daily practice. This article is the first to define and evaluate the currently published literature pertinent to the ACMUP. As healthcare continues to advance and care shifts to ambulatory settings, the ACMUP will continue to be a crucial process to evaluate.

Deploying and Maintaining Standards of New Pharmacy Services Provision in Poland-Introducing the National Pharmacist Competencies Assessment Tool: Pre-Registration Exam–Results of the Pilot Project

Despite the functioning of the Bologna Declaration, the knowledge and skills of graduates educated in different countries may differ significantly. Therefore, this article aims to present the differences in results of the final exam in pharmacy among Polish pharmacy students. This exam was modeled on the British national exam supervised by the General Pharmaceutical Council. The exam was conducted in three cities in Poland, among a total of 175 final-year students (a full sample of those eligible was 451 with 276 refusals (38.58% response rate)). Taking the exam was voluntary and anonymous. The results indicate that none of the Polish students achieved the 70% mark required to pass the Great Britain exam. Significant differences in test results were noticed between cities. Students achieved the best average exam result in Bydgoszcz (46.35%), then in Warsaw (38.81%) and Łódź (38.35%). The pharmaceutical education system in Poland requires complete changes that will prepare future pharmacists for clinical work.

Development of a decision tree for the pharmacy-led consultation of elderly patients with haematological malignancies

INTRODUCTION

Elderly patients with haematological malignancies are a population at risk of iatrogenic for whom these activities could optimize therapeutic management. However, the limitation of human resources requires optimization of the process in order to improve the efficiency of pharmaceutical activities. The objective was to build a decision tree to optimize the pharmaceutical consultation in these population within a multidisciplinary team in haematology.

METHOD

Pharmaceutical consultations were proposed to elderly subjects with haematological malignancies followed up in a haematology day hospitalization at the University Hospital of Limoges. Risk factors for prescribing risky drugs in this population were determined by logistic regression models. A decision tree was constructed based on these results and by agreement between pharmacist, geriatrician and hematologist.

RESULTS

Female gender (aOR[CI95%] = 1.71 [1.14-2.57]), polypharmacy (aOR[CI95%] = 1.89 [1.14-3.13]), hyper-polypharmacy (aOR[CI95%] = 5.73 [3.03-10.84]) and moderate cholinergic load (aOR[CI95%] = 2.15 [1.04-4.45]) were risk factors for the prescription of inappropriate medicine. Female gender (aOR[CI95%] = 1.55 [1.02-2.35]) and hyper-polypharmacy (aOR[CI95%] = 6.19 [1-1.28]) were risk factors for prescribing anticholinergic drugs or anticoagulants; in contrast, frailty status was a protective factor for prescribing anticholinergics (aOR[CI95%] = 0.51 [0.33-0.81]). Prioritization of pharmaceutical consultations is based on frailty status, prescription of a target drug and polypharmacy.

DISCUSSION

Pharmaceutical consultations during the day hospitalization of elderly subjects with hematological diseases allow to propose therapeutic optimizations. The prioritization proposed in our study would increase the efficiency of pharmaceutical activities in order to improve quality and safety throughout the care pathway of these patients.

Effects of Pharmacist Intervention on Community Control of Hypertension: A Randomized Controlled Trial in Zunyi, China

OBJECTIVE

We aimed to test the effects of pharmacist intervention on the community control of hypertension through a comparative randomized controlled trial.

METHODS

We recruited adult hypertensive patients with comorbidity or confusion with medication (n=636) from 2 community health centers in Zunyi, China. They were randomly and equally divided into 2 groups. Both groups received the usual care and participated in the community systematic management program of hypertension. Participants in the intervention group were given interventions from pharmacists, including a monthly review of medications, patient education, and medication adjustment advice to medical doctors over 6 months. Participants' blood pressure was assessed at baseline, 3 months, and 6 months. Participants' knowledge and medication adherence were measured using a questionnaire before and after the trial.

RESULTS

Compared to the control group (n=298), a significantly higher percentage of participants in the intervention group (n=290) had their blood pressure under control 3 months (46.9% vs. 38.3%, P=.034) and 6 months (60.7% vs. 40.9%, P<.001) after the interventions. Difference-in-differences analyses showed that the pharmacist intervention resulted in an increase in knowledge scores by 12.55 points (P<.001), a decrease in systolic blood pressure by 6.65 mmHg (P=.001), and a decrease in diastolic blood pressure by 7.26 mmHg (P<.001) compared to the controls after adjustment for variations in potential confounding factors. The odds of participants passing the hypertension knowledge tests in the intervention group was 4.45 times those in the control group (P<.001). Similarly, it was found that the intervention group had higher odds of not needing any medication adjustments (adjusted odds ratio [AOR]=2.75, P<.001) and having their blood pressure under control (AOR=2.18, P=.002) compared to the control group.

CONCLUSION

It is evident that pharmacist intervention has significant short-term effects on improving the knowledge and medication adherence of hypertensive patients, as well as timely medication adjustments from medical doctors, resulting in lowered blood pressure and an increased control rate. Further studies should explore the long-term sustainability of the effects of community pharmacist intervention.

Drug-Related Problems of Patients in Primary Health Care Institutions: A Systematic Review

Introduction: Drug-related problems (DRPs) are not only detrimental to patients' physical health and quality of life but also lead to a serious waste of health care resources. The condition of DRPs might be more severe for patients in primary health care institutions.

Objective: This systematic review aims to comprehensively review the characteristics of DRPs for patients in primary health care institutions, which might help find effective strategies to identify, prevent, and intervene with DRPs in the future.

Methods: We searched three English databases (Embase, The Cochrane Library, and PubMed) and four Chinese databases (CNKI, CBM, VIP, and Wanfang). Two of the researchers independently conducted literature screening, quality evaluation, and data extraction. Qualitative and quantitative methods were combined to analyze the data.

Results: From the 3,368 articles screened, 27 met the inclusion criteria and were included in this review. The median (inter-quartile range, IQR) of the incidences of DRPs was 70.04% (59%), and the median (IQR) of the average number of DRPs per patient was 3.4 (2.8). The most common type of DRPs was “treatment safety.” The causes of DRPs were mainly in the prescribing section, including “drug selection” and “dose selection”, while patients' poor adherence in the use section was also an important cause of DRPs. Risk factors such as the number of medicines, age, and disease condition were positively associated with the occurrence of DRPs. In addition, the medians (IQR) of the rate of accepted interventions, implemented interventions, and solved DRPs were 78.8% (22.3%), 64.15% (16.85%), and 76.99% (26.09%), respectively.

Conclusion: This systematic review showed that the condition of DRPs in primary health care institutions was serious. In pharmaceutical practice, the patients with risk factors of DRPs should be monitored more closely. Pharmacists could play important roles in the identification and intervention of DRPs, and more effective intervention strategies need to be established in the future.

Acceptance of Pharmaceutical Services by Home-Dwelling Older Patients: A Case Study in a Portuguese Community Pharmacy

Background: Aging-related comorbidities predispose older adults to polypharmacy and consequently an increased risk of adverse drug reactions and poor compliance. Pharmacists’ interventions can have a beneficial impact on the improvement of clinical outcomes. Thus, this work aimed to assess the acceptance of Portuguese home-dwelling older adults regarding a pharmaceutical service paid by patients for medication management and pharmacotherapy follow-up. We also intended to analyze medication, characterize the medication consumption profile, and identify the main difficulties of our sample during their daily medication management. Methods: A questionnaire on adherence and medication therapy management was applied to polymedicated patients ≥65 years old, in a community pharmacy. Results: Of the 88 participants, 92.2% would be willing to pay for a pharmacotherapy management service, and 75.6% answered that they would be willing to pay for an individual medication preparation service. In addition, 45.7% of the participants were categorized as lower adherents to a medication therapeutic regimen. Our sample reported that during their daily lives, they felt difficulty: to remember to take their pills (17%), to manage so many medicines (15.9%), and to swallow the pills (9.1%). Conclusions: Polymedicated older adults are willing to pay for a service to improve the management of their medicines, suggesting that they recognize the role of pharmacists in medication management. This study provides useful information for the conceptualization of a pharmacotherapy management service that includes medication review and a pharmacotherapy follow-up.

Oral therapy adherence and satisfaction in patients with multiple myeloma

The transition to oral therapies in patients with multiple myeloma (MM) offers potential benefits to patients; however, they must self-manage their medication and adherence plays an important role in patient care. It has been shown that patient satisfaction with their medication has a strong positive correlation with adherence in chronic diseases. The aim of this study was to estimate adherence rate of oral antimyeloma therapies and to identify risk factors for medication non-adherence. This observational, prospective, and multicentre survey based on a self-report questionnaire enrolled MM patients with at least 3 months of oral therapy. The 6-item Girerd scale and the medication possession ratio (MPR) were used for measuring medication adherence and the SATMED-Q® questionnaire was used for measuring satisfaction. An analysis of risk factors for non-adherence to oral therapy was performed using univariate analysis. A total of 101 patients participated in the survey, yielding a response rate of 87%. The prevalence of adherence to oral antimyeloma therapy was estimated at 51.5% using the Girerd questionnaire. According to the MPR, adherence was evaluated at 96% (i.e. MPR ≥ 0.80). Both methods combined, adherence was estimated at 50.5%. One risk factor for medication non-adherence was identified: Eastern Cooperative Oncology Group Performance Status > 2 (p = 0.007). One predictive factor for high medication adherence was identified: high satisfaction with treatment (p = 0.01). Identifying patients at higher risk for non-adherence allows clinical pharmacists to personalise therapeutic information and education and to improve the quality of healthcare overall.

The Evolving Role and Impact of Integrating Pharmacists into Primary Care Teams: Experience from Ontario, Canada

The movement to integrate pharmacists into primary care team-based settings is growing in countries such as Canada, the United States, the United Kingdom, and Australia. In the province of Ontario in Canada, almost 200 pharmacists have positions within interdisciplinary primary care team settings, including Family Health Teams and Community Health Centers. This article provides a narrative review of the evolving roles of pharmacists working in primary care teams, with a focus on evidence from Ontario, as well as drawing from other jurisdictions around the world. Pharmacists within primary care teams are uniquely positioned to facilitate the expansion of the pharmacist’s scope of practice, through a collaborative care model that leverages, integrates, and transforms the medication expertise of pharmacists into a reliable asset and resource for physicians, as well as improves the health outcomes for patients and optimizes healthcare utilization.

Community pharmacists' evolving role in Canadian primary health care: a vision of harmonization in a patchwork system

Canada's universal public health care system provides physician, diagnostic, and hospital services at no cost to all Canadians, accounting for approximately 70% of the 264 billion CAD spent in health expenditure yearly. Pharmacy-related services, including prescription drugs, however, are not universally publicly insured. Although this system underpins the Canadian identity, primary health care reform has long been desired by Canadians wanting better access to high quality, effective, patient-centred, and safe primary care services. A nationally coordinated approach to remodel the primary health care system was incited at the turn of the 21st century yet, twenty years later, evidence of widespread meaningful improvement remains underwhelming. As a provincial/territorial responsibility, the organization and provision of primary care remains discordant across the country. Canadian pharmacists are, now more than ever, poised and primed to provide care integrated with the rest of the primary health care system. However, the self-regulation of the profession of pharmacy is also a provincial/territorial mandate, making progress toward integration of pharmacists into the primary care system incongruent across jurisdictions. Among 11,000 pharmacies, Canada's 28,000 community pharmacists possess varying authority to prescribe, administer, and monitor drug therapies as an extension to their traditional dispensing role. Expanded professional services offered at most community pharmacies include medication reviews, minor/common ailment management, pharmacist prescribing for existing prescriptions, smoking cessation counselling, and administration of injectable drugs and vaccinations. Barriers to widely offering these services include uncertainties around remuneration, perceived skepticism from other providers about pharmacists' skills, and slow digital modernization including limited access by pharmacists to patient health records held by other professionals. Each province/territory enables pharmacists to offer these services under specific legislation, practice standards, and remuneration models unique to their jurisdiction. There is also a small, but growing, number of pharmacists across the country working within interdisciplinary primary care teams. To achieve meaningful, consistent, and seamless integration into the interdisciplinary model of Canadian primary health care reform, pharmacy advocacy groups across the country must coordinate and collaborate on a harmonized vision for innovation in primary care integration, and move toward implementing that vision with ongoing collaboration on primary health care initiatives, strategic plans, and policies. Canadians deserve to receive timely, equitable, and safe interdisciplinary care within a coordinated primary health care system, including from their pharmacy team.

A Descriptive Quantitative Analysis on the Extent of Polypharmacy in Recipients of Ontario Primary Care Team Pharmacist-Led Medication Reviews

Pharmacist-led medication reviews have been shown to improve medication management, reducing the adverse effects of polypharmacy among older adults. This paper quantitatively examines the medications, medication discrepancies and drug therapy problems of recipients in primary care. A convenience sample of 16 primary care team pharmacists in Ontario, Canada contributed data for patients with whom they conducted a medication review over a prior four-week period. Data were uploaded using electronic data capture forms and descriptive analyses were completed. Two hundred and thirty-seven patients (on average, 67.9 years old) were included in the study, taking an average of 9.2 prescription medications ( ± 4.7). Majority of these patients (83.5%) were categorized as polypharmacy patients taking at least five or more prescribed drugs per day. Just over half of the patients were classified as having a low level of medication complexity (52.3%). Pharmacists identified 2.1 medication discrepancies ( ± 3.9) and 3.6 drug therapy problems per patient ( ± 2.8). Half these patients had more than one medication discrepancy and almost every patient had a drug therapy problem identified. Medication reviews conducted by pharmacists in primary care teams minimized medication discrepancies and addressed drug therapy problems to improve medication management and reduce adverse events that may result from polypharmacy.