Enhanced medication management services in the community: A win-win proposal from an economic, clinical and humanistic perspective

Impact of a clinical decision support system on identifying drug-related problems and making recommendations to providers during community pharmacist-led medication reviews in Ontario, Canada: A pilot study

OBJECTIVE

To evaluate the impact of a clinical decision support system (CDSS) to identify drug-related problems (DRPs) during community pharmacist medication reviews.

DESIGN

Pilot 3-phase (group), open-label study.

SETTING AND PARTICIPANTS

Two community pharmacies in Sarnia, Ontario, with pharmacists providing medication reviews to patients.

STUDY PROCEDURES

Five pharmacists participated in three phases (groups). During Phase 1, pharmacists conducted medication reviews in 25 adult patients using the usual approaches. In Phase 2, pharmacists were trained to use a CDSS to identify DRPs, and then conducted medication reviews using the tool in a different group of 25 adult patients. In Phase 3, pharmacists conducted medication reviews without the aid of the CDSS in 25 additional adult patients.

MAIN OUTCOME MEASURES

The primary outcome was recommendation to the primary care physician to alter pharmacotherapy based on medication review, assessed using mean number and frequency (yes/no) of recommendations by patient. Secondary outcomes included number of potential DRPs, actual DRPs, medication review duration time, pharmacist's perceptions of the CDSS and patient satisfaction with medication review.

RESULTS

The mean number of recommendations to primary care physicians to alter pharmacotherapy per patient in Phases 1, 2 and 3 did not differ: 1.0 (SD = I.2) versus 1.5 (1.0) versus 1.5 (1.0), respectively; p = 0.223. The percentage of patients with a pharmacy recommendation sent to physicians across the phases, however, differed: 52% versus 80% versus 88%, respectively; p = 0.010, with more in Phases 2 and 3 compared to 1. There were more potential DRPs in group 2 compared to other groups. There were no differences in actual DRPs and medication review time. Pharmacists had positive attitudes about the CDSS. Patients were generally satisfied with their medication review.

CONCLUSIONS

This small pilot study provides some preliminary evidence for performance and feasibility of a CDSS to identify DRPs that pharmacists will act on. Future research is recommended to validate these findings in a larger sample.

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.

Level of medication self-management capacity among patients on ambulatory care exiting hospital pharmacy at Muhimbili National Hospital, Tanzania: a descriptive cross-sectional study

Objectives

Medication management capacity of a patient on ambulatory care is direct related to adherence. To our knowledge data on medication management capacity for ambulatory care patients exiting outpatient pharmacy outlets in Tanzania are scarce. This study aimed to determine the level of medication management capacity among patients on ambulatory care exiting Muhimbili National Hospital outpatient pharmacy outlet.

Results

A total of 424 patients on ambulatory care participated in the study. Three hundred eighty-seven (91.3%) out of 424 interview questionnaires had complete data and qualified for data analysis. Majority (62.3%) out of 387 study participants had poor medication management capacity; 65.3% out of 387 patients were unable to correctly read the prescription and match the drugs they are carrying. More than half (57.4%) out of 387 participants were unable to correctly take the dose, 73.9% out of 387 were unable to correctly tell the dosing frequency and duration. Only 10.6% out 155 patients with prescription containing drugs with warning or precaution or contraindication or potential side effects were aware.

Community pharmacists' experiences with the Saskatchewan Medication Assessment Program

Background

The Saskatchewan Medication Assessment Program (SMAP) is a publicly funded community pharmacy-based medication assessment service with limited previous evaluation. The purpose of this study was to explore community pharmacists' experiences with the SMAP.

Methods

Online, self-administered questionnaire that consisted of a combination of 53 Likert scale and free-text questions. All licensed pharmacists who were practising in a community pharmacy setting in Saskatchewan were eligible to participate.

Results

Response rate was 20.3% (n = 228/1124). Most respondents agreed that the SMAP is achieving all of its intended purposes. For example, 89.7% agreed that the SMAP improved medication safety for patients who receive the service. Most pharmacists enjoyed performing the assessments (84.6%) and were confident in their ability to identify drug-related problems (88.3%). Pharmacists reported lack of time, patients having difficulty coming to the pharmacy and restrictive eligibility criteria as the top barriers to the SMAP. Good teamwork, employer support and personal professional commitment were the top recognized facilitators. Respondents made several suggestions to improve the SMAP in the free-text areas of the questionnaire.

Conclusions

Community pharmacists in Saskatchewan were positive and confident about performing medication assessments, and most agreed that the SMAP is achieving all of the intended purposes. Respondents also identified several barriers to providing SMAP services, which have resulted in specific recommendations that should be addressed to improve the program.

A model for the financial assessment of professional services in community pharmacy: A systematic review

OBJECTIVES

Limited studies have assessed the financial benefit of professional pharmacy services (PPSs) to the community pharmacy as a business. These studies are crucial in developing an insight into the long-term sustainability and broader implementation of services. We reviewed the literature to identify measures and indicators used to assess the financial performance of professional services in community pharmacy.

DATA SOURCES

The literature search was undertaken in Pubmed and Scopus, and a gray literature search was performed in Google.com. References of the included papers were reviewed for other relevant studies.

STUDY SELECTION

Articles were reviewed against the following exclusion criteria: 1) literature reviews, 2) studies not reporting quantitative financial data from community pharmacy, 3) studies not assessing a PPS, 4) studies lacking a methodology for the measurement and assessment of financial outcomes, and 5) cost-effectiveness analysis, cost-utility analysis, or cost-benefit analysis studies.

DATA EXTRACTION

A piloted data extraction form was used. A selection of key data collected is as follows: 1) method of data collection and calculation, 2) currency, limitations for cost and revenue and method of data collection and method of calculation, 3) standardized currency value for the results reported, 4) professional services: number assessed, type of service, name of services, nature of services, implementation stage reported, financial result, the frequency of service, costs, sources of revenue, net total cost, net total revenue, break-even point, break-even price, net profit and loss.

RESULTS

The 21 studies included used different methodologies and indicators to financially assess PPSs. This has led to the development of a model for assessing PPSs composed of the key financial elements identified in this systematic review.

CONCLUSION

From this review, we propose a model that provides a structured approach for pharmacists to manage the financial performance of services.

Pharmacists in humanitarian crisis settings: Assessing the impact of pharmacist-delivered home medication management review service to Syrian refugees in Jordan

BACKGROUND

Refugees all over the world are facing several health-related problems. Chronic diseases among Syrian refugees in Jordan are high. The Home Medication Management Review (HMMR) service could be ideal to optimize refugees' health management.

OBJECTIVES

To assess the impact of the HMMR service on the type and frequency of Treatment Related Problems (TRPs) among Syrian refugees living in Jordan.

METHODS

This prospective randomized single blinded intervention-control study was conducted in three main cities in Jordan, between May and October 2016. Syrian refugees with chronic conditions were recruited and randomized into intervention and control groups. The HMMR service was conducted for all patients to identify TRPs at baseline. Data were collected via two home visits for all study participants. Clinical pharmacist's recommendations were written in a letter format to the physicians managing the patients in the intervention group only. Physicians' approved recommendations were conveyed to the patients via the pharmacist. Interventions at the patient level were delivered by the pharmacist directly. Patients were reassessed for their TRPs and satisfaction 3 months after baseline.

RESULTS

Syrian refugees (n = 106) were recruited with no significant differences between the intervention (n = 53) and control groups (n = 53). A total of 1141 TRPs were identified for both groups at baseline, with a mean number of 10.8 ± 4.2 TRPs per patient. At follow-up, there was a significant decrease in the number of TRPs among the intervention group (P < 0.001, paired sample t-test) but not among the control group (P = 0.116). Physicians' approval rate of the pharmacist's recommendations was high (82.9%), and more than 70.0% of refugees in the intervention group reported high satisfaction with the HMMR service.

CONCLUSION

Identified TRPs are high amongst Syrian refugees living in Jordan. The HMMR service significantly reduced the number of TRPs, and was highly accepted by the physicians. Refugees reported high satisfaction with this service.

Home Care Pharmacy Practice in Canada: A Cross-Sectional Survey of Services Provided, Remuneration, Barriers, and Facilitators

BACKGROUND

As the population ages, and individuals desire to remain in their homes as long as possible, the need for in-home care is expected to increase. However, pharmacists have rarely been included in studies of in-home care, and little is known about the prevalence or effectiveness of pharmacists' home-based services in Canada.

OBJECTIVE

To identify pharmacy practices in Canada that regularly provide in-home patient care and to identify specific services provided, remuneration obtained, and barriers and facilitators influencing the provision of home-based care.

METHODS

A link to a web-based survey was posted in e-newsletters of provincial, territorial, and national pharmacy associations in Canada. In addition, pharmacists known to the researchers as providing in-home clinical services were contacted directly. The survey was open from October to December 2015. Practices or organizations that performed at least one home visit per week for clinical purposes, with documentation of the services provided, were eligible to participate. One response per practice or organization was allowed.

RESULTS

Seventeen practices meeting the inclusion criteria were identified, representing community, hospital, and clinic settings. Home visits were most commonly performed for individuals with complex medication regimens or nonadherence to medication therapy. The most common services were conducting medication reconciliation and reviews and counselling patients about medication adherence. No practices or organizations billed patients for these services, yet lack of remuneration was an important barrier identified by many respondents. Although 12 (71%) of the respondents collected data for evaluative purposes, collection of clinical or health system outcome data was rare.

CONCLUSIONS

Few Canadian pharmacy practices that provide in-home patient care at least once a week could be identified. Data collection suitable to establish an evidence base for this service was infrequently performed by practices and organizations providing home-based care. Such evidence is needed to justify the expansion of this service nationally, including consistent and adequate remuneration from governments or other payers.

BC Medication Management Project: Perspectives of pharmacists, patients and physicians

BACKGROUND

The BC Medication Management Project (BCMMP) was developed by the BC Ministry of Health and the BC Pharmacy Association. This pilot project ran from September 2010 to January 2012. Pharmacists reviewed patients' medication histories, discussed best use of medications, provided education and monitored for adverse effects, developed a plan to deal with medication issues and created a best possible medication history.

METHODS

To evaluate the experience of participating in the BCMMP, challenges and strengths of the project and the alignment of these experiences with the overarching goals, focus groups and interviews were conducted with 6 stakeholder groups. Themes were compared within and across stakeholder type and descriptively analyzed.

RESULTS

A total of 88 people participated in the focus groups/interviews. Pharmacists stated that providing BCMMP services was professionally satisfying and concurred with patients that the service did benefit them. However, participating in the BCMMP was not seen as financially sustainable by pharmacy owners, and there were concerns about patient selection. Physicians expressed concerns about increased workload associated with the BCMMP, for which they were not compensated. The computer system and burden of documentation were identified as the greatest problems.

CONCLUSIONS

The BCMMP pilot project was enthusiastically received by pharmacists and patients who felt that it benefited patients and moved the pharmacy profession in a positive direction. It was widely felt that the BCMMP could be successful and sustainable if the identified challenges are addressed.

Elder and caregiver solutions to improve medication adherence

Medication mismanagement is a growing public health concern, especially among elders. Annually, it is a major contributor to emergency hospitalization and nursing home placement. Elders and their caregivers, as healthcare consumers and stakeholders in this issue, are uniquely qualified to inform strategies to improve medication adherence. We conducted a qualitative study to ascertain caregiver and elder perceptions of barriers to medication management and to identify community-derived solutions to improve medication management. Nine focus groups (N = 65, mean age = 71) were conducted with caregivers or elders from five communities. Participants were recruited by key informants utilizing snowball sampling methodology. The following themes were identified in the participant-recommended proposed solutions improving medication adherence: (i) use of personal systems to overcome barriers to medication adherence, (ii) various solutions to address cost concerns, (iii) the need for regular review of medications by doctors or pharmacists to eliminate unnecessary medications, (iv) desire for community-driven support systems, and (v) using medical advocates. Elders and caregivers recognized medication non-adherence as a community-wide issue and were eager to offer solutions they thought would work in their communities. These solutions can lend credibility to strategies currently being developed/utilized and offer innovative recommendations for future interventions.