Community pharmacy medication review, death and re-admission after hospital discharge: a propensity score-matched cohort study

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial

OBJECTIVES

To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home.

DESIGN

Randomised, parallel design.

SETTING

Medical wards at six hospital sites in southern Ontario, Canada.

PARTICIPANTS

Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks.

INTERVENTIONS

Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care.

OUTCOMES MEASURES

Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation.

RESULTS

Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)).

CONCLUSION

This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial.

TRIAL REGISTRATION NUMBER

NCT02777047.

The Impact of Pharmacist Medication Reviews on Geriatric Patients: A Scoping Review

Medication review is an intervention with the potential to reduce drug-related problems (DRPs) in the elderly. This study aimed to determine the effect of pharmacists' medication reviews on geriatric patients. This study accessed two online databases, MEDLINE Complete and Scopus, and examined all studies published in English between 2019 and 2023, except for reviews. The studies included (1) participants over 65 years of age and (2) medication reviews conducted by pharmacists. The titles, abstracts, and full texts were reviewed for data extraction to determine whether the studies satisfied the inclusion and exclusion criteria. Forty-four of the initial 709 articles were included in this study. The articles included discussions on the incidence rates of DRPs and potentially inappropriate medications (PIMs) (n=21), hospitalization (n=14), medication adherence (n=9), quality of life (QoL) (n=8), and falls (n=7). Pharmacist medication reviews were associated with a reduced incidence of DRPs and PIMs, and improved adherence to medications. Patients' overall QoL is also increasing. However, pharmacist medication reviews were not strongly associated with decreased hospitalization or falls. A pharmacist's medication review may be a feasible intervention for reducing the incidence rates of DRPs and PIMs, regardless of whether it is performed as a sole intervention or supplemented with other interventions. The intervention was also effective in increasing medication adherence and QoL.

Exploring the implementation of Discharge Medicines Review referrals by hospital pharmacy professionals: A qualitative study using the consolidated framework for implementation research

BACKGROUND

The Discharge Medicines Review (DMR) is a community pharmacy service in Wales that aims to reduce medicines-related harm after care transitions, including hospital discharge. To undertake a DMR, the Community Pharmacist must receive a patient's discharge medicines information, either electronically, by fax or presented by the patient. Although the DMR has evidenced benefits for improving patient safety, its evaluation showed inconsistent uptake, which Community Pharmacists partially attributed to hospitals not providing the necessary information.

OBJECTIVE

Aiming to develop recommendations to improve hospital engagement to DMR referrals, this study explores hospital pharmacy professionals' views of the service.

METHODS

Qualitative focus groups, using hermeneutic phenomenology, were conducted in 16 hospitals across Wales, using a quota sampling method to include 61 Pharmacists and 31 Pharmacy Technicians. To understand the suboptimal engagement to DMR referrals, framework analysis was undertaken using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

The data were mapped onto all five CFIR domains, each containing barriers and facilitators to engagement with DMR referrals and suggestions for improvement. Only one hospital had successfully implemented DMR referrals, with many participants lacking any knowledge of the service or how to refer to it. Specific barriers included a clear absence of processes to implement referrals and engage hospital pharmacy professionals. A considerable barrier was many participants' perceptions that Community Pharmacist roles were less clinically orientated and patient-centred than their own, viewing them almost as a different profession. Participants believed that local champions for DMR referrals could promote engagement and integrate them into the workflow of hospital pharmacy professionals. Further recommendations to improve engagement was staff training for DMRs and regular feedback of its value.

CONCLUSION

Policymakers may use the findings and recommendations from this study to promote hospital pharmacy staff engagement to similar community pharmacy services like the Discharge Medicines Service in England.

Understanding the factors influencing community pharmacist retention - A qualitative study

Background

Shortages in healthcare workers affects the overall delivery and effectiveness of the provision of healthcare. There are currently insufficient pharmacists working in the community sector in Ireland. While several studies have reported on the factors leading to retention in the medical and nursing profession, there is an absence of robust research examining retention within the pharmacist workforce in Ireland.

Objective

To identify and understand the range of factors currently at play in the community pharmacy sector in Ireland which influence the decision-making process for pharmacists deciding whether or not to continue to practice as a community pharmacist.

Method

A cross-sectional qualitative descriptive study was used to investigate the factors influencing community pharmacist retention as elicited from the lived experiences of 23 pharmacists. Study recruitment was undertaken using both convenience and purposive sampling. Qualitative content analysis was used to analyze the interview data to identify and explore themes.

Results

A broad and diverse range of factors were identified as affecting community pharmacist retention including working conditions, career fulfilment and progression, regulatory and administrative burden, the commercial focus within community practice, lack of representation and their overall health and well-being.

Conclusion

The findings show that there are a number of factors which either individually or cumulatively influence a pharmacist's decision to stay in or leave community practice. Various areas for change were identified, which if addressed are considered likely to improve retention in the sector. These include enhanced terms and working conditions, better acknowledgement and resourcing of professional activities, improved opportunities for career progression, reforms to the regulatory model including the personal accountability of a supervising pharmacist for all of the pharmacy's professional activities, a more streamlined model of reimbursement and more effective collective representation.

Characterising hospitalisation risk for chronic obstructive pulmonary disease exacerbations: Bedside and outpatient clinic assessments of easily measured variables

OBJECTIVE

To identify the characteristics of people with chronic obstructive pulmonary disease (COPD) who require hospitalisation for exacerbations.

METHODS

People with COPD were recruited either during hospitalisation or from out-patient respiratory medicine clinics. Hospital admissions were tracked throughout the 5-months recruitment period. For participants who were admitted, hospital readmissions were tracked for at least 30 days following discharge. Participants were grouped as either needing; (i) no hospital admission during the study period (no admission; ø-A), (ii) one or more hospital admissions during the study period but no readmission within 30 days of discharge (no rapid readmission; ø-RR) or (iii) one or more hospital admissions with a readmission within 30 days of discharge (rapid readmission; RR).

RESULTS

Compared with the ø-A group (n=211), factors that independently increased the risk of ø-RR (n=146) and/or RR (n=57) group membership were being aged >60 years, identifying as an Indigenous person (relative risk ratio, 95% confidence interval 7.8 [1.8 to 34.0]) and the use of a support person or community service for activities of daily living (1.5 [1.0 to 2.4]. A body mass index ≥25 kg/m2 was protective.

CONCLUSIONS

Variables recorded at the bedside or in clinic provided information on hospitalisation risk.

Clinical and Cost-Saving Effects of the Drug Utilization Review Modernization Project in Inpatient and Outpatient Settings in Korea

OBJECTIVES

Korea's national health insurance authority introduced a drug utilization review modernization pilot project in which health professionals provided follow-up services to monitor adverse drug events. We aimed to evaluate the effects of the project on clinical and economic outcomes.

METHODS

We conducted difference-in-differences analysis using National Health Insurance claims data from the Health Insurance Review and Assessment Service. We calculated the number of adverse drug events and allergic reactions as a clinical indicator and medical costs incurred to manage these events as an economic indicator. Absolute difference in each outcome measure was defined as the value after the project minus the value before the project. Difference-in-differences was defined as a difference in absolute differences between the intervention group and the control group.

RESULTS

Overall, difference-in-differences were -43 and -826 for the number of drug-related adverse events and allergic reactions and -$198,700 and $53,318 for medical costs in the inpatient and outpatient settings, respectively. For outpatients, the monthly number of adverse drug events and allergic reactions has grown higher for the control group than for the intervention group after implementation of the pilot project.

CONCLUSIONS

Implementation of the pilot project lowered the number of adverse drug events and allergic reactions in the inpatient and outpatient setting. The project also lowered medical costs incurred to manage these events in the inpatient setting only. Based on our findings, we recommend that the pilot project be expanded on a nationwide level at least in the inpatient setting.

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.

External validation of the modified LACE+, LACE+, and LACE scores to predict readmission or death after hospital discharge

BACKGROUND

Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain.

METHODS

We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population-based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination.

RESULTS

Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration-in-the-large and calibration slope no different than ideal) and adequate discrimination (c-statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores.

CONCLUSION

The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission.

Assessment and analysis of outpatient medication errors related to pediatric prescriptions

BACKGROUND

Medication errors are the errors that impact the efficacy and safety of the therapy. The impact of medication errors is higher for certain subjects, such as pediatrics, who require more attention. Hence, the current study aimed to investigate the types and frequency of outpatient medication errors of pediatric subjects related to different prescription types.

METHODS

A cross-sectional study was carried in several community pharmacies to record the medication errors found in outpatient pediatric prescriptions by gathering data from the outpatient prescriptions besides direct counseling with the subjects and their parents. Many medical resources (disease and drug-related) were used for checking the different aspects of medication errors. The data collection process included a preprepared sheet containing several items representing the medication errors in addition to a counseling session. Data were expressed as percentages and compared through the Chi-square test for results of handwritten and computerized prescriptions.

RESULTS

752 outpatient pediatric prescriptions were recruited in the study as they involve medication errors. Among the highest percentage of medication errors was the absence of essential data in the prescription, such as diagnosis, age, and weight. The duration of the therapy and contraindication for some of the prescribed medications were among the highest recorded errors. Among the critical errors were the drug interaction and drug duplication that directly affect the drug's efficacy and safety. There was a significant difference between computerized and handwritten prescriptions regarding the number of medication errors related to each type.

CONCLUSION

Medication errors related to outpatient pediatric prescriptions vary from one to another prescription with predominant errors that influence the therapy's safety or efficacy. The role of patient counseling and prescription checking is critical for improving patient therapy.

Strategies to Prevent Readmissions to Hospital for COPD: A Systematic Review

Patients with chronic obstructive pulmonary disease (COPD) experience high rates of hospital readmissions, placing substantial clinical and economic strain on the healthcare system. Therefore, it is essential to implement evidence-based strategies for preventing these readmissions. The primary objective of our systematic review was to identify and describe the domains of existing primary research on strategies aimed at reducing hospital readmissions among adult patients with COPD. We also aimed to identify existing gaps in the literature to facilitate future research efforts. A total of 843 studies were captured by the initial search and 96 were included in the final review (25 randomized controlled trials, 37 observational studies, and 34 non-randomized interventional studies). Of the included studies, 72% (n = 69) were considered low risk of bias. The majority of included studies (n = 76) evaluated patient-level readmission prevention strategies (medication and other treatments (n = 25), multi-modal (n = 19), follow-up (n = 16), telehealth (n = 8), education and coaching (n = 8)). Fewer assessed broader system- (n = 13) and policy-level (n = 7) strategies. We observed a trend toward reduced all-cause readmissions with the use of medication and other treatments, as well as a trend toward reduced COPD-related readmissions with the use of multi-modal and broader scale system-level interventions. Notably, much of this evidence supported shorter-term (30-day) readmission outcomes, while little evidence was available for longer-term outcomes. These findings should be interpreted with caution, as considerable between-study heterogeneity was also identified. Overall, this review identified several evidence-based interventions for reducing readmissions among patients with COPD that should be targeted for future research.Supplemental data for this article is available online at https://doi.org/10.1080/15412555.2021.1955338 .

Medication reviews in community pharmacy: a scoping review of policy, practice and research in Canada

Objectives

This scoping review aims to systematically map the empirical evidence on publicly funded medication reviews provided by community pharmacists in Canada and identify gaps that could inform future research directions.

Methods

We used a scoping review framework and PRISMA guidelines for Scoping Reviews to conduct the study. Three electronic databases were searched for papers published between January 2000 until August 2020. Data was charted on study characteristics, and a thematic synthesis was performed.

Key findings

Of 41 original studies included, most were conducted in Ontario (n = 21). Majority of the studies employed quantitative designs (70%). Five major themes identified were program uptake, patient health outcomes, stakeholder beliefs and attitudes, processes and collaboration and pharmacy workplace culture, which varied considerably. At the individual, organizational and policy levels, many factors were interrelated and influenced the implementation of reimbursed medication reviews by community pharmacists. Gaps in eligibility policy highlighted some patients who may have complex needs are excluded. Variation in clinical outcomes may relate to different types of medication review and pharmacist practice across Canada. Few researchers evaluated eligibility criteria, the impact of policy changes, strategies to engage patients and healthcare professionals, patient–pharmacist communication or compared practice models of medication reviews. About 12% of the research applied a theoretical framework.

Summary

Publicly funded medication reviews in Canadian community pharmacies reduce medication-related problems and potentially improve patient health outcomes. Future research and policies could consider addressing barriers and exploring models for sustainable delivery of high-quality medication reviews internationally.

Comparing public policies impacting prescribing and medication management in primary care in two Canadian provinces

The challenges of polypharmacy and inappropriate prescribing are recognized internationally. This study synthesizes and compares the policies related to these issues introduced in Canada's two most populous provinces - Ontario and Quebec - over the first two decades of the 21st century. Drawing on policy documents and consultations with experts, we found that while medication management to address polypharmacy and inappropriate prescribing has not been an explicit and consistent policy target in either province, some policy changes sought to directly or indirectly impact medication management. These changes include the introduction of primary care teams that include pharmacists, the introduction of a medication review performed by pharmacists (in Ontario), increased emphasis on quality improvement with some attention to potentially inappropriate medications (specifically opioids in Ontario), and investments in information technology to improve communication across providers and move toward electronic prescribing to improve medication safety and appropriateness. Despite growing evidence of the problem of polypharmacy and inappropriate prescribing, there has been limited policy attention targeting these problems directly, and policy changes with potential to improve prescribing and medication management may not have been fully realized. Further research to evaluate the impact of these changes on provider behaviours, and on patient outcomes, warrants attention.

Patient- and Prescriber-Related Factors Associated with Potentially Inappropriate Medications and Drug-Drug Interactions in Older Adults

We aimed to evaluate the prevalence of potentially inappropriate medication (PIM) use and drug–drug interactions (DDIs) in older adults and their associated factors. This cross-sectional study used National Health Insurance data of older adults in South Korea. The 2015 AGS Beers Criteria were used to classify PIM use and DDIs. The associations of PIM use and DDIs with patient- and prescriber-related factors were evaluated using multiple logistic regression. Of the older adults who received at least one outpatient prescription (N = 1,277,289), 73.0% and 13.3% received one or more prescriptions associated with PIM use or DDIs, respectively. Chlorphenamine was most commonly associated with PIM, followed by diazepam. Co-prescriptions of corticosteroids and NSAIDs accounted for 82.8% of DDIs. Polypharmacy and mainly visiting surgeons or neurologists/psychiatrists were associated with a higher likelihood of prescriptions associated with PIM use or DDIs. Older age, high continuity of care (COC), and mainly visiting a hospital were associated with a lower likelihood of PIM use or DDIs. Prescriptions associated with PIM use and DDIS were more frequent for low COC patients or those who mainly visited clinics; therefore, patients with these characteristics are preferred intervention targets for reducing prescriptions associated with PIM use and DDIs.

Tool development to improve medication information transfer to patients during transitions of care: A participatory action research and design thinking methodology approach

BACKGROUND

Medication changes during transitions of care is a recognized challenge that has been linked to adverse events. The delivery of medication instructions during transition from hospital to home is a priority area for improvement.

OBJECTIVE

The goals of this work were to 1) understand the current experiences of patients and families; and 2) co-design tools to improve medication information transfer during transitions of care together with patients, families, and providers.

METHODS

A participatory action approach, using mixed methods within a design thinking framework was used. Participants were chosen from patient groups at higher risk of adverse events, guided by extreme user design, which posits that needs of extreme users can also fit the majority. Providers, patients and family (users) were interviewed to understand current experiences with medication information transfer during transitions of care and to solicit input on potential elements to inform tool design. Users were engaged in iterative creation of prototypes.

RESULTS

A total of 116 patients, family caregivers, and providers were engaged throughout this project. Findings highlighted challenges currently experienced, strengthening the case for tools that engage the patient and family in medication information transfer. Important information included why medications were prescribed, how to take them, side effects, and an explanation of the role of community pharmacists. Displaying information in a grid format was preferred. Two tools were prototyped: (1) A Medication Whiteboard for engaging patients and families in creating their medication routine, and (2) A Patient Oriented Medication List for providing medication instructions and as a reference once patients are home.

CONCLUSIONS

Through the use of mixed methods within a design thinking framework, the team was able to understand the challenges and design prototypes of tools that both engage patients and families in developing their medication routine and improve medication information transfer during transitions of care.

Development of an informational support questionnaire of transitional care for aged patients with chronic disease

OBJECTIVES

We developed an informational support questionnaire of transitional care (ISQTC) for aged patients with chronic disease and investigated its reliability and validity.

SETTING

This study was conducted in three large general hospitals in Nantong, Jiangsu Province, China.

PARTICIPANTS

A total of 130 aged patients with chronic diseases, admitted into outpatient and inpatient departments from three hospitals in China, participated in the study. The inclusion criteria were: (1) patients must provide consent to participate; (2) being 60 years and above; (3) being diagnosed with at least one chronic disease and hospitalised more than two times within the last 1 year; (4) being able to listen, speak, read and write. The exclusion criteria were: (1) refusing to participate; (2) language expression and communication barriers (and having no caregiver to assist in participation); (3) being in intensive care or long-term hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The developed questionnaire was validated and tested for reliability. The content validity of the questionnaire was determined through experts' interviews and Delphi expert consultation, and the structure validity of the questionnaire was determined by performing exploratory factor analysis. The coefficient of reliability of the questionnaire was measured using Cronbach's alpha.

RESULTS

Through Delphi expert consultation and exploratory factor analysis, the questionnaire was reduced from four dimensions and 12 items to three dimensions and 11 items. A total of 130 patients responded to the questionnaire. The alpha coefficient was 0.747.

CONCLUSION

The ISQTC is a reliable and valid instrument for evaluating aged patients with chronic disease in transitional care.

TRIAL REGISTRATION DETAILS

ChiCTR1900020923. The trial was registered on 22 January 2019.

A realist synthesis of pharmacist-conducted medication reviews in primary care after leaving hospital: what works for whom and why?

BACKGROUND

Medication reviews for people transitioning from one healthcare setting to another potentially improve health outcomes, although evidence for outcome benefits varies. It is unclear when and why medication reviews performed by pharmacists in primary care for people who return from hospital to the community lead to beneficial outcomes.

OBJECTIVE

A realist synthesis was undertaken to develop a theory of what works, for whom, why and under which circumstances when pharmacists conduct medication reviews in primary care for people leaving hospital.

METHODS

The realist synthesis was performed in accordance with Realist And MEta-narrative Evidence Syntheses: Evolving Standards reporting standards. An initial programme theory informed a systematic literature search of databases (PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature, International Pharmaceutical Abstracts, OpenGrey, Trove), augmented by agency and government sources of information. Documents were synthesised by exploring interactions between contexts, intervention, outcomes and causal mechanisms.

RESULTS

The synthesis identified 9 contexts in which 10 mechanisms can be activated to influence outcomes of pharmacist medication reviews conducted in primary care postdischarge. For a medication review to take place these include trust patients have in healthcare professionals, their healthcare priorities postdischarge, capacity to participate, perceptions of benefit and effort, and awareness required by all involved. For the medication review process, mechanisms which issue an invitation to collaborate between healthcare professionals, enable pharmacists employing clinical skills and taking responsibility for medication review outcomes were linked to more positive outcomes for patients.

CONCLUSIONS

Medication reviews after hospital discharge seem to work successfully when conducted according to patient preferences, programmes promote coordination and collaboration between healthcare professionals and establish trust, and pharmacists take responsibility for outcomes. Findings of this realist synthesis can inform postdischarge medication review service models.

For which patient subgroups are there positive outcomes from a medication review? A systematic review

Background:

A medication review is a possibility to assess and optimise a patient’s medicine. A model that includes a medication review and a follow-up seem to provide the best results. However, it is not known whether specific subgroups of patients benefit more from a medication review than others.

Objective:

This literature review summarises the evidence that is available on which patient subgroups exist positive outcomes from a medication review carried out in a primary care setting.

Methods:

We performed a PICO analysis to identify keywords for setting, medication review and effect. We then conducted a search using the PubMed database (2004 to 2019) to identify studies relevant for our investigation. A screening process was carried out based on either title or abstract, and any study that matched the aim and inclusion criteria was included. All matching studies were obtained and read, and were included if they met predefined criteria such as study design, medication review and primary care. The studies were divided into subgroups. First, each subgroup was divided according to the studies’ own definition. Secondly, each subgroup was allocated as either risk patients if the subgroup described a specific patient subgroup or risk medication, if the subgroup was defined as using a specific type of medication. This was done after discussion in the author group.

Results:

28 studies from a total of 935 studies were included. Identified studies were divided into either risk patients; frail, recently discharged or multimorbid patients, or risk medication; heart medication, antithrombotic medication, blood pressure lowering medication, antidiabetic medication, anti-Parkinson medication or medication increasing the risk of falls. The subgroups identified from a medication review in primary care were defined as being frail, recently discharged from hospital or multimorbid (risk patients), or defined as patients using anticoagulant or blood pressure lowering medication (risk medication). Most of the medication reviews in the studies that showed an economic effect included at least one follow-up and were delivered by a pharmacist.

Conclusions:

The literature review demonstrates that medication reviews delivered by pharmacists to specific subgroups of patients are a way of optimising the economic effect of medication reviews in primary care. This is obtained by reducing health-related costs or the number of contacts with primary or secondary health care services.

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.

Understanding perceptions of involving community pharmacy within an integrated care model: a qualitative study

BACKGROUND

Over the past several years, there has been more emphasis on integration within health care. Community pharmacy is often under-represented within integrated care models. This study explored stakeholder perceptions and enablers of including community pharmacy within an integrated care model.

METHODS

A qualitative study was undertaken. Participants were recruited through professional networks and social media, as well as snowball recruitment from other participants. They included community pharmacists, clinicians, and decision-makers working in Ontario, Canada. Data were collected using telephone interviews completed with a semi-structured interview guide based on Consolidated Framework for Implementation Research from June to September 2018. Data were analysed inductively and deductively following the Qualitative Analysis Guide of Leuven. An additional theoretical framework (Rainbow Model of Integrated Care) was used to categorize enablers.

RESULTS

Twenty-two participants were interviewed including nine pharmacists, seven clinicians, and six decision-makers. Three key themes were identified: 1) Positive value of including pharmacy in integrated care models; 2) One model does not fit all; and 3) Conflict of interest. Four key enablers were identified reflecting functional and normative factors: functional - 1) remuneration, 2) technology; normative - 3) engagement, and 4) relationships. While both functional and normative factors were discussed, the latter seemed to be more important to facilitate the inclusion of community pharmacy. Many participants characterized community pharmacists' lack of skills or confidence to provide patient care.

CONCLUSIONS

This study confirms previously known views about concerns with community pharmacy's conflict of interest. However, discordant perceptions of conflict of interest and negative perceptions about capabilities of community pharmacy need to be addressed for successful integration. Normative enablers, such as culture, are likely important for organizational integration and require additional inquiry.