Drugs prescribed for people aged 85 and over living in their own homes in an area of inner London

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Survey research: (1) Design, samples and response

Social survey methodology is the most widely used approach by pharmacy practice researchers, accounting for a higher proportion of published papers than any other. Survey techniques have been used to address a range of research objectives in a variety of populations and settings.

Extensive hand searches of published survey research have enabled a review of the issues and problems that social survey research presents when applied in pharmacy settings, and an exploration of how they have been addressed. This review is in two parts. This first part focuses on the research questions that have been addressed by survey methods, design of the studies, sampling frames and procedures, response rates and management of non-response. A second paper will discuss the development of survey instruments, and the issues of validity, reliability and generalisability.

Oral counselling on dispensed medication: a survey of its extent and associated factors in a random sample of community pharmacies

To establish the current rate of oral counselling on dispensed medications, a random sample of 50 community pharmacists from the greater London area was selected. A non-participant observational method was used to obtain the required information. It was found that most pharmacist characteristics, including age, experience and employment status (proprietor, manager or locum) did not affect the rate of provision of oral counselling. However, the rate varied according to sex, with female pharmacists advising more patients. The rate of counselling was also influenced by the patient's age, the type of prescription (National Health Service or private), whether the prescription was a repeat or for new medication and the therapeutic category of the medicine. During the study, the collection of 1,472 prescription items was observed. Overall, counselling was provided for 39 per cent of patients. Counselling was given for around 70 per cent of new prescription items and for 20 per cent of repeat items.

Delivering domiciliary pharmaceutical care from a health centre pharmacy

Aim

To develop and administer a pharmacist domiciliary visiting programme from a community pharmacy based in a health centre.

Design

Prospective cohort with peer professional intervention assessment and patient feedback questionnaires.

Subjects and setting

Total general practitioner surgery list (4,922 patients) in an urban residential area. Candidates were defined by three inclusion criteria: 65 years or older taking five or more repeat medicines (polypharmacy); any age plus polypharmacy plus significant disablement; 80 years or older taking three or more specified medications on repeat prescription.

Outcome measures

Interventions made during a programme of three visits for each patient; peer assessment of impact on patient care and cost by the three surgery GPs and three clinical pharmacists; patients' perceived worth of the service; cost of the service.

Results

One hundred patients (2 per cent) were visited over a period of six months; 74 completed the three-visit programme that involved a total of 256 visits. There were 160 interventions classified as: medicines management issues (88), health beliefs and concordance (41) or therapeutic problems, including adverse effects (31). Nineteen patients required specific and detailed collaboration with the patient's GP. There was good agreement on the utility of the pharmacist's interventions at this level with only four negative assessments out of a possible 114 (3.5 per cent). The programme was well received by patients. Talking to a pharmacist (as opposed to another health care professional) about their medicines was important to 70 of 74 patients. Sixty-one described their reaction to the visiting programme using one of three positive adjectives, “relieved,” “reassured” or “grateful”. Based on this cohort, the estimated costs to the pharmacy were £5,000 per annum, equivalent to 33 working days. Cost savings based on outcomes were not estimated.

Conclusions

This study demonstrated the feasibility of identifying candidates for domiciliary care from surgery records using carefully selected inclusion criteria. This is likely to encompass between 2 and 3 per cent of a surgery population. The visiting programme, which was well received by patients, had a favourable effect on patient care in the majority of the cohort and a very important impact in a minority (19 per cent). This success required the commitment of all members of the health centre team. It benefited from the proximity of the visiting pharmacist to medical records and prescribers.

Drug-related problems in the elders of the British Virgin Islands

Objective

To explore the extent of drug-related problems in elderly patients in the Caribbean.

Methods

Comprehensive medication reviews were carried out on a 1 in 20 sample of the elderly population of the British Virgin Islands, a UK dependent territory located in the Caribbean. Fifty non-institutionalised patients, 65 years or older and taking at least one prescribed medicine, were interviewed for the study.

Key findings

On average, 4.5 prescribed medications, 4.7 over-the-counter preparations and 3.3 herbal remedies/natural products were used by the sample. A mean of 5.9 potential drug-related problems per patient were identified and a mean of 3.7 complications relating to the sub-optimal use of medicines per patient were observed.

Conclusion

This study has highlighted the need for a multidisciplinary review of the prescribing, dispensing and monitoring of elderly patients receiving prescribed medications. The pharmacist has a role to play in helping prescribers achieve this review, and in educating patients in ways in which they can get the best out of their medicines.

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Survey research: (2) Survey instruments, reliability and validity

Social surveys are an important tool in health services research. They have been used in a high proportion of pharmacy practice research studies and in a wide range of settings. Extensive hand searches of published studies has enabled a review of the issues and problems that survey methods present when applied in pharmacy practice and an exploration of how they have been addressed by researchers. It is hoped that the review will enable pharmacy practice researchers to benefit from the experience of their colleagues when conducting their own research. This is the second part of a two-part review of surveys in pharmacy practice research. The first part (IJPP, 1997;5:152) focused on research questions, study design, sampling frames and procedures, response and non-response. This second part discusses the development of survey instruments and the issues of validity, reliability and generalisability.

The development and validation of a screening tool for the identification of patients experiencing medication-related problems

Objective

Medication-related problems can adversely affect patients' health and treatment outcomes. While many authors have investigated the frequency of different types of medication-related problem, no studies have described the development and validation of a screening tool to identify patients who are experiencing medication-related problems. The aim of this study was to develop and validate a screening tool for the identification of patients experiencing medication-related problems.

Methods

Based on the literature, a screening tool was developed for this purpose. Patients prescribed a cardiovascular medicine, who were aged over 18 years, were recruited from four community pharmacies and five general practice surgeries in South London. Patients were interviewed with the screening tool in the pharmacies and surgeries. Subsequently in-depth interviews in patients' own homes were conducted to validate the findings and assess the effectiveness of the tool.

Key findings

Ninety-nine patients in the pharmacies and 122 in the surgeries were recruited and interviewed using the screening tool; 74 of these were identified with at least one medication-related problem. Seventy-eight participants (43 identified with at least one problem and 35 with no apparent problems) agreed to be interviewed in their own homes. In 83% of cases the screening tool correctly distinguished between patients with at least one medication-related problem and those identified with none. The screening tool was less likely than the home interview to pick up problems which required the patient to comment on the service of the surgery or pharmacy.

Conclusion

The screening tool could have a valuable role in identifying patients experiencing medication-related problems. Its focus on patients' perspectives is important in ensuring that service developments are responsive to the needs of consumers.

Effective chronic disease management: patients' perspectives on medication-related problems

OBJECTIVE

To examine medication-related problems from the perspective of patients with a chronic condition and to identify how they may be supported in managing their medication.

METHODS

Patients prescribed medication for cardiovascular disease were recruited through five general medical surgeries and four community pharmacies in south London. Data were collected in 98 face-to-face interviews in participants' own homes. Interviews were designed to enable a detailed and holistic exploration of medication-related problems from participants' perspectives. Data were audio-recorded and transcribed verbatim to allow qualitative analysis.

RESULTS

Five broad categories of medication-related problem emerged which were examined in the context of patients' perspectives on, and experiences of, the use of medicines and health services. These were concerns about and management of side effects; differing views regarding the use of medicines; cognitive, practical and sensory problems; lack of information or understanding; and problems with access to, and organisation of, services.

CONCLUSION

All categories of problem had potential implications for the success of therapy in that they created barriers to adherence, access to medication or informed decision-making. The study demonstrated how patients actively engage in decision-making about their medicines in the home, if not in the consultation.

PRACTICE IMPLICATIONS

The five categories of problem provide a focus for interventions by health professionals to support patients in achieving optimal theory outcomes. They demonstrate the need for a comprehensive approach, spanning patient education to the systems of delivery of care. Within the NHS in Britain, policy and practice initiatives are being designed to achieve this end. Further research should focus on the evaluation of professional practices and service developments in supporting patients in the self-management of their medicines.