Supporting prescribing in Irish primary care: protocol for a non-randomised pilot study of a general practice pharmacist (GPP) intervention to optimise prescribing in primary care

Non-dispensing pharmacists integrated into general practices as a new interprofessional model: a qualitative evaluation of general practitioners' experiences and views

BACKGROUND

A new interprofessional model incorporating non-dispensing pharmacists in general practice teams can improve the quality of pharmaceutical care. However, results of the model are dependent on the context. Understanding when, why and how the model works may increase chances of successful broader implementation in other general practices. Earlier theories suggested that the results of the model are achieved by bringing pharmacotherapeutic knowledge into general practices. This mechanism may not be enough for successful implementation of the model. We wanted to understand better how establishing new interprofessional models in existing healthcare organisations takes place.

METHODS

An interview study, with a realist informed evaluation was conducted. This qualitative study was part of the Pharmacotherapy Optimisation through Integration of a Non-dispensing pharmacist in primary care Teams (POINT) project. We invited the general practitioners of the 9 general practices who (had) worked closely with a non-dispensing pharmacist for an interview. Interview data were analysed through discussions about the coding with the research team where themes were developed over time.

RESULTS

We interviewed 2 general practitioners in each general practice (18 interviews in total). In a context where general practitioners acknowledge the need for improvement and are willing to work with a non-dispensing pharmacist as a new team member, the following mechanisms are triggered. Non-dispensing pharmacists add new knowledge to current general practice. Through everyday talk (discursive actions) both general practitioners and non-dispensing pharmacists evolve in what they consider appropriate, legitimate and imaginable in their work situations. They align their professional identities.

CONCLUSIONS

Not only the addition of new knowledge of non-dispensing pharmacist to the general practice team is crucial for the success of this interprofessional healthcare model, but also alignment of the general practitioners' and non-dispensing pharmacists' professional identities. This is essentially different from traditional pharmaceutical care models, in which pharmacists and GPs work in separate organisations. To induce the process of identity alignment, general practitioners need to acknowledge the need to improve the quality of pharmaceutical care interprofessionally. By acknowledging the aspect of interprofessionality, both general practitioners and non-dispensing pharmacists will explore and reflect on what they consider appropriate, legitimate and imaginable in carrying out their professional roles.

TRIAL REGISTRATION

The POINT project was pre-registered in The Netherlands National Trial Register, with Trial registration number NTR-4389.

General practice pharmacists in Australia: A systematic review

Background

The inclusion of pharmacists into general practices in Australia has expanded in recent years. This systematic review aimed to synthesise the literature of qualitative and quantitative studies, and identify the knowledge gaps, related to pharmacists working in general practice in Australia.

Methods

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, EBSCOhost, EMBASE, and the Cochrane Library were searched from the inception of databases to January 2021. The search was focused on studies investigating general practice pharmacists in Australia. The quality of each study was appraised using the Mixed Method Appraisal Tool criteria. The narrative synthesis approach was utilised to describe data due to the heterogeneity among study designs and measures.

Results

Twenty-five studies were included in this review. General practice pharmacists engaged in various non-dispensing patient care services, with medication management reviews being the primary activity reported. General practice pharmacists’ characteristics and an environment with a willingness of collaboration were the notable influencing factors for successfully including pharmacists in general practices. Factors that posed a challenge to the adoption of general practice pharmacists were lack of funding and other resources, poorly defined roles, and absence of mentoring/training.

Conclusion

This review has summarised the characteristics, activities, benefits, barriers, and facilitators of including pharmacists in general practices in Australia. General practice pharmacists are well accepted by stakeholders, and they can engage in a range of patient-centred activities to benefit patients. There is a need for more robust research to explore the patient and economic outcomes related to clinical activities that a pharmacist can perform in general practice, as a foundation to developing an appropriate and sustainable funding model. The findings of this review will be beneficial for pharmacists, researchers, policymakers, and readers who wish to implement the role of general practice pharmacists in the future.

Intervention elements and behavior change techniques to improve prescribing for older adults with multimorbidity in Singapore: a modified Delphi study

PURPOSE

Potentially inappropriate prescribing among older adults is a rising concern, attributed mainly by polypharmacy and multimorbidity. We aimed to identify key components and strategies for construction of a context-relevant intervention to facilitate appropriate prescribing in outpatient clinics in Singapore.

METHODS

The modified Delphi study was conducted in two rounds with 20 geriatricians from seven public hospitals in Singapore. Round one survey presented 69 statements formulated from a scoping review, while round two presented 23 statements with some modifications based on round one comments. The statements were rated against a 7-point Likert scale on their importance and impact on prescribing for older adults with multimorbidty.

RESULTS

Consensus were achieved for 90% of the statements. Seven intervention elements were identified as being important: medication review, training, medication therapy management, shared decision making, patient interview, medication reconciliation, comprehensive geriatric assessment. In addition, some commonly identified behavior change techniques included goal setting (behavior), goal setting (outcome) and problem solving.

CONCLUSIONS

This study identified important intervention elements and their potential strategies that could be adopted in an intervention to optimize appropriate prescribing for older adults with multimorbidity.

Integrating clinical pharmacists within general practice: protocol for a pilot cluster randomised controlled trial

INTRODUCTION

Managing patients with multiple conditions (multimorbidity) is a major challenge for healthcare systems internationally, particularly in older patients. Multimorbidity and subsequent polypharmacy increase treatment burden and the risk of potentially inappropriate prescribing, and both are complex to manage in primary care. Limited evidence suggests integration of pharmacists into general practice teams could improve medication management for patients with multimorbidity and polypharmacy. Building on findings from a non-randomised, uncontrolled General Practice Pharmacist (GPP) feasibility study conducted in Irish primary care, the aim of this study is to conduct a pilot cluster randomised controlled trial (cRCT) of the GPP study, to assess feasibility, intervention impact, costs and appropriateness of continuing to a definitive cRCT.

METHODS AND ANALYSIS

This pilot cRCT will involve 8 general practitioner (GP) practices and 120 patients. Practices will identify and recruit patients aged ≥65 years, who are taking ≥10 regular medications. Practices will be allocated to intervention or control after baseline data collection. Intervention practices will have a pharmacist integrated within their service, working with GPs, patients and practice staff to optimise prescribing and other medication-related activities. Control practices will provide standard GP care. The primary feasibility outcomes will include recruitment rate, uptake of medication reviews and study retention. For the primary clinical outcome, the number of potentially inappropriate prescribing incidences per patient will be collected. Secondary outcomes will include medication-related outcomes, patient-reported outcome measures, and data pertaining to the role and impact of the pharmacist on prescribing. In addition, economic and process evaluations will be conducted.

ETHICS AND DISSEMINATION

This trial has been approved by the Irish College of General Practitioners Research Ethics Committee and will be performed in accordance with the Declaration of Helsinki. The results will be reported in peer-reviewed journals and be presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN Registry (https://doi.org/10.1186/ISRCTN18752158).

Evaluation of General Practice Pharmacists: Study Protocol to Assess Interprofessional Collaboration and Team Effectiveness

The inclusion of pharmacists into general practices has expanded in Australia. However, there is a paucity of research examining interprofessional collaboration and team effectiveness after including a pharmacist into the general practice team in primary or community care. This is a protocol for a cross-national comparative mixed-methods study to (i) investigate interprofessional collaboration and team effectiveness within the general practice team after employing pharmacists in general practices in the Australian Capital Territory (ACT) and (ii) to compare interprofessional collaboration and team effectiveness of pharmacists in general practice across Australia with international sites. The first objective will be addressed through a multiphase sequential explanatory mixed-method design, using surveys and semi-structured interviews. The study will recruit general practice pharmacists, general practitioners, and other health professionals from eight general practices in the ACT. Quantitative and qualitative results will be merged during interpretation to provide complementary perspectives of interprofessional collaboration. Secondly, a quantitative descriptive design will compare findings on interprofessional collaboration (professional interactions, relationship initiation, exchange characteristics, and commitment to collaboration) and team effectiveness of general practice pharmacists in Australia with international sites from Canada and the United Kingdom. The results of the study will be used to provide recommendations on how to best implement the role of general practice pharmacists across Australia.

Acceptability of a Novel Telemedication Review for Older Adults in Nursing Homes in France: A Qualitative Study

Purpose

In France, polypharmacy among older people living in nursing homes (NH) is a major public health concern. In this context, the randomized controlled trial TEM-EHPAD was recently launched in various NH in southern France to evaluate the impact of implementing a novel telemedication review (TMR) on hospital admission rates of NH residents at high risk of iatrogenic disease. A qualitative study was integrated into the main trial study to assess general practitioners' (GP) and other NH healthcare professionals' (HP) acceptability of the proposed TMR before its implementation.

Material and Methods

A qualitative study using face-to-face semi-structured interviews was conducted with 16 HP before the beginning of the intervention. A manual thematic analysis was performed on the transcribed interviews.

Results

Four main themes emerged from the thematic analysis: HP perceptions of the TMR, difficulties related to medication management for NH residents, HP perceptions of the roles of different professionals, and facilitators of good practices. Most participants were favorable to the TMR, but some GP expressed fears about loss of control over their prescription writing.

Conclusion

This study fulfilled its objective to assess pre-intervention acceptability by GP and other HP. Results provided important information about how to adapt the TMR intervention to make it more acceptable to HP who will be involved in TEM-EHPAD. One of the main recommendations is the importance of providing participating GP with the opportunity to take part in the process of reviewing prescriptions.

Pharmacists in general practice: a qualitative process evaluation of the General Practice Pharmacist (GPP) study

BACKGROUND

There is some evidence to suggest that pharmacists integrated into primary care improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack of detail about the context of the role.

OBJECTIVE

To explore the implementation of The General Practice Pharmacist (GPP) intervention (pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the experiences of study participants and lessons for future implementation.

DESIGN AND SETTING

Process evaluation with a descriptive qualitative approach conducted in four purposively selected GP practices.

METHODS

A process evaluation with a descriptive qualitative approach was conducted in four purposively selected GP practices. Semi-structured interviews were conducted, transcribed verbatim and analysed using a thematic analysis.

RESULTS

Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses, four practice managers and four practice administrators) were interviewed. Themes reported include day-to-day practicalities (incorporating location and space, systems and procedures and pharmacists' tasks), relationships and communication (incorporating GP/pharmacist mode of communication, mutual trust and respect, relationship with other practice staff and with patients) and role perception (incorporating shared goals, professional rewards, scope of practice and logistics).

CONCLUSIONS

Pharmacists working within the general practice team have potential to improve prescribing quality. This process evaluation found that a pharmacist joining the general practice team was well accepted by the GP and practice staff and effective interprofessional relationships were described. Patients were less clear of the overall benefits. Important barriers (such as funding, infrastructure and workload) and facilitators (such as teamwork and integration) to the intervention were identified which will be incorporated into a pilot cluster randomized controlled trial.

The challenges of COVID-19 for community pharmacists and opportunities for the future

Pharmacists, like psychiatrists, have modified their practices amidst COVID-19 in order to guarantee care and support to their patients. Designated an essential frontline service, community pharmacists are facing a spectrum of challenges to surmount to ensure patient care continues. These include assisting in the prevention of infection, managing supply chains, preventing stockpiling and provision of evidence-based medical information. However, disasters like COVID-19 disproportionately affect poor and vulnerable populations, and patients with mental health conditions may be among the hardest hit. Pharmacist-level, system-level and regulatory responses have sought to minimise this impact, although there is likely to be a lasting impression on the profession, both good and bad. This article reviews the pandemic-related challenges and responses by pharmacists, as well as forming recommendation for areas of professional support and role expansion, particularly in the case of mental health.

Non-dispensing pharmacist integrated in the primary care team: effect on the quality of physician's prescribing, a non-randomised comparative study

Background Especially in elderly with polypharmacy, medication can do harm. Clinical pharmacists integrated in primary care teams might improve quality of pharmaceutical care. Objective To assess the effect of non-dispensing clinical pharmacists integrated in primary care teams on general practitioners’ prescribing quality. Setting This study was conducted in 25 primary care practices in the Netherlands. Methods Non-randomised, controlled, multi-centre, complex intervention study with pre-post comparison. First, we identified potential prescribing quality indicators from the literature and assessed their feasibility, validity, acceptability, reliability and sensitivity to change. Also, an expert panel assessed the indicators’ health impact. Next, using the final set of indicators, we measured the quality of prescribing in practices where non-dispensing pharmacists were integrated in the team (intervention group) compared to usual care (two control groups). Data were extracted anonymously from the healthcare records. Comparisons were made using mixed models correcting for potential confounders. Main outcome measure Quality of prescribing, measured with prescribing quality indicators. Results Of 388 eligible indicators reported in the literature we selected 8. In addition, two more indicators relevant for Dutch general practice were formulated by an expert panel. Scores on all 10 indicators improved in the intervention group after introduction of the non-dispensing pharmacist. However, when compared to control groups, prescribing quality improved solely on the indicator measuring monitoring of the renal function in patients using antihypertensive medication: relative risk of a monitored renal function in the intervention group compared to usual care: 1.03 (95% CI 1.01–1.05, p-value 0.010) and compared to usual care plus: 1.04 (1.01–1.06, p-value 0.004). Conclusion This study did not demonstrate a consistent effect of the introduction of non-dispensing clinical pharmacists in the primary care team on the quality of physician’s prescribing.

This study is part of the POINT-study, which was registered at The Netherlands National Trial Register with trial registration number NTR‐4389.

Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study

OBJECTIVE

Limited evidence suggests integration of pharmacists into the general practice team could improve medicines management for patients, particularly those with multimorbidity and polypharmacy. This study aimed to develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland.

DESIGN

Non-randomised pilot study.

SETTING

Primary care in Ireland.

PARTICIPANTS

Four general practices, purposively sampled and recruited to reflect a range of practice sizes and demographic profiles.

INTERVENTION

A pharmacist joined the practice team for 6 months (10 hours/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education.

OUTCOME MEASURES

Anonymised practice-level medication (eg, medication changes) and cost data were collected. Patient-reported outcome measure (PROM) data were collected on a subset of older adults (aged ≥65 years) with polypharmacy using patient questionnaires, before and 6 weeks after medication review by the pharmacist.

RESULTS

Across four practices, 786 patients were identified as having 1521 prescribing issues by the pharmacists. Issues relating to deprescribing medications were addressed most often by the prescriber (59.8%), compared with cost-related issues (5.8%). Medication changes made during the study equated to approximately €57 000 in cost savings assuming they persisted for 12 months. Ninety-six patients aged ≥65 years with polypharmacy were recruited from the four practices for PROM data collection and 64 (66.7%) were followed up. There were no changes in patients' treatment burden or attitudes to deprescribing following medication review, and there were conflicting changes in patients' self-reported quality of life.

CONCLUSIONS

This non-randomised pilot study demonstrated that an intervention involving pharmacists, working within general practices is feasible to implement and has potential to improve prescribing quality. This study provides rationale to conduct a randomised controlled trial to evaluate the clinical and cost-effectiveness of this intervention.

More than coffee - a World Café to explore enablers of pharmacy practice research

BACKGROUND

Pharmacists are in demand now more than ever to provide high-quality expertise about the effectiveness, safety and use of medications. Amidst an increasingly complex and costly healthcare system, policy makers need robust evidence to justify public spending on pharmacy services. Research on the impact of existing and emerging pharmacy practices is required.

OBJECTIVE

To explore barriers and opportunities to enhance research among pharmacists in Ireland utilising a World Café methodology.

METHODS

A pharmacy research discussion day was held in November 2018, open to all pharmacists in Ireland. A World Café methodology was utilised as a mechanism to facilitate group discussions about pharmacy practice research.

RESULTS

Discussions with 63 attendees identified four themes and seventeen subthemes. The four themes were challenges undertaking research, research motivations, leadership and training. Subthemes included robust evidence, clinical, economic and societal outcomes, alignment with national and international health system priorities, need for incentives from professional training bodies, competitive business model and embed within schools of pharmacy.

CONCLUSIONS

The most commonly discussed barriers inhibiting research were workload, technology limitations and financial considerations. Organisational leadership to prioritise and coordinate research efforts, training to build research capacity, building on existing examples of excellence and initiation of bottom-up community-based research projects were identified in our study as opportunities to enhance pharmacist involvement in research and ultimately patient health outcomes.

Impact of medication review via tele-expertise on unplanned hospitalizations at 3 months of nursing homes patients (TEM-EHPAD): study protocol for a randomized controlled trial

Background

Inappropriate drug prescribing causes preventable drug-related adverse events that result in increased morbidity and mortality, additional costs and diminished quality of life. Numerous initiatives have been launched to improve the quality of drug prescribing and safeguard the security of drug administration processes in nursing homes. Against the backdrop of implementation of telemedicine services, the focus of the present work is to evaluate the impact of a telemedication review carried out by a hospital physician and pharmacist as part of the telemedicine offer.

Methods

The present study is a randomized controlled clinical trial. A total of 364 patients will be randomized into two groups: (1) an experimental group (182 patients) benefiting from a telemedication review using tele-expertise and (2) a control group (182 patients) receiving standard care. The primary endpoint will be rate of all-cause unplanned hospital admissions occurring within 3 months of randomization. The secondary endpoints will be rate of unplanned admissions at 6 months, patient quality of life, incidence of behavioral disturbances, number of falls, number of residents prescribed at least one inappropriate medication, nursing staff satisfaction, proposed medication reviews and their acceptability rate, characteristics of patients whose general practitioners have taken account of tele-expertise, efficacy of tele-expertise as compared to standard prescription and acceptability and satisfaction surveys of participating caregivers.

Discussion

In the literature, various studies have investigated the utility of structured medication review processes, but outcome measures are heterogeneous, and results vary widely. Medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Incremental cost-effectiveness ratios will be used to compare the cost and effectiveness of the experimental strategy and that of standard care. Our approach, involving the combination of an acceptability survey and a mixed-method (qualitative and quantitative) satisfaction survey, is particularly innovative. The results of this randomized trial are expected to confirm that medication review using tele-expertise has potential as a worthwhile care management strategy for nursing home residents.

Trial registration

Clinicaltrials.gov NCT03640845; registered August 21, 2018 (Clinicaltrials.gov NCT03640845).

Comparing Potentially Inappropriate Prescribing Tools and Their Association With Patient Outcomes

OBJECTIVE

To assess the agreement of several different measures of potentially inappropriate prescribing (PIP) in older people and compare their relationship with patient-reported outcomes.

DESIGN

Prospective cohort study including participants in The Irish Longitudinal Study on Ageing (TILDA).

SETTING

Waves 1 and 2 of TILDA, a nationally representative aging cohort study.

PARTICIPANTS

A total of 1753 community-dwelling TILDA participants with linked administrative pharmacy claims data on medications.

MEASUREMENTS

Potentially inappropriate medications were assessed using the Screening Tool of Older Persons' Potentially Inappropriate Prescriptions (STOPP) v1, American Geriatrics Society (AGS) Beers Criteria® 2012, and relevant Assessing Care of Vulnerable Elders (ACOVE) v3 indicators. Potential prescribing omissions were assessed using the Screening Tool to Alert Doctors to the Right Treatment (START) v1 and ACOVE v3 indicators. Their agreement was assessed via κ statistics, and multivariate regression was used to assess relationships with emergency department visits, general practitioner (GP) visits, quality of life, and functional decline (increased assistance needed for activities of daily living).

RESULTS

There was slight agreement between STOPP and AGS Beers Criteria® (κ = 0.20) and ACOVE indicators (κ = 0.15), while agreement between AGS Beers Criteria® and ACOVE indicators was fair (κ = 0.31). Agreement was fair between START and ACOVE indicators (κ = 0.34). All measures of inappropriate medications were significantly associated with increased GP visits. Only exposure to two or more START indicators was associated with reduced quality of life (adjusted mean difference = -1.12; 95% confidence interval [CI] = -1.92 to -0.33), and only two or more AGS Beers Criteria® were associated with functional decline (adjusted odds ratio = 2.11; 95% CI = 1.37-3.28). For omissions, both measures were associated with functional decline, but only ACOVE indicators were associated with increased GP visits.

CONCLUSION

Prevalence of PIP and relationships with outcomes can differ substantially between tools with little agreement. Choice of PIP measure for research or practice should be considered in light of the circumstances and requirements in each case. J Am Geriatr Soc 68:526-534, 2020.