Clinical Results of Comprehensive Medication Management Services in Primary Care in Belo Horizonte

The Impact of a Medication Therapy Management Service on the Outcomes of Hypertension Treatment Follow-Up Care in an Ethiopian Tertiary Hospital: A Pre-Post Interventional Study

Background

According to a report from the WHO, an estimated 1.13 billion people worldwide have hypertension. Medication therapy management (MTM) service is a clinical service based on the theoretical and methodological framework of pharmaceutical care practice, which aims to ensure the best therapeutic outcomes for the patient by identifying, preventing, and resolving drug therapy problems (DTPs).

Purpose

The goal of this study was to determine the impact of MTM on hypertension management in Ethiopia.

Methods

A pre-post interventional study design was used. Descriptive statistics, linear regression, and logistic regressions were employed to present and analyze data.

Results

The final analysis included 279 patients out of 304, with a 7.8% attrition rate. The prevalence of drug therapy problems (DTPs) reduced from 63.4% at baseline to 31.5% during the post-intervention phase. Polypharmacy (AOR = 2.46; 95% CI: 1.27-4.77) and complications (AOR = 0.52; 95% CI: 0.27-0.99) were substantially associated with DTPs at the start of the study. The MTM resulted in a significant reduction in mean systolic blood pressure (SBP) (AOR = 5.31, 95% CI (3.50-7.11), P < .001), as well as a significant increase (P < .001) in the number of study patients who reached a target BP. At the end of the MTM intervention, non-adherence was linked with DTP (AOR = 2.40; 95% CI: 1.33-4.334) and living outside Addis Ababa (AOR = 1.73; 95% CI: 1.38-1.88). On average, treatment satisfaction was 86.55% (+SD) 10.34.

Conclusion

To resolve DTPs and improve clinical outcomes, the MTM service was critical. The majority of patients were found to be compliant with a high treatment satisfaction score.

Prescribers' approval rate of pharmacist-initiated interventions to optimise patients' clinical status of hypertension in the ambulatory care setting

This perspective, pre- and post-intervention study with a one-year follow-up primarily aimed to ascertain prescribers' approval rate of pharmacists' interventions and clinical status of hypertension following comprehensive medication management (CMM) intervention in the ambulatory care clinic. Between January 2018 and January 2022 overall 100 patients with hypertension and other comorbidities were referred to the CMM services at the Health Centre Zagreb - Centar (HCZC). Out of 275 interventions directed to prescribers, 73.1 % of interventions were approved, 12.4 % were rejected and 14.5 % were not reviewed. The percentage of patients with a blood pressure goal increased from 45 % at the initial consultation to 82.5 % at the patients' latest encounter (p < 0.001). The average number of drug therapy problems (DTPs) per patient totaled 3.53 ± 1.80, where 98 % of patients had one or more DTPs, 48 % had 4 or more DTPs, whereas 26 % had 5 or more DTPs. Sub-therapeutic dosage (32.6 %) and the need for additional drug therapy (30.9 %) were the two most commonly identified DTPs. These results reinforce the need to integrate pharmacy-led services in the primary care setting with the aim of improving patients' health outcomes.

Optimizing Hypertension Treatment in Older Patients Through Home Blood Pressure Monitoring by Pharmacists in Primary Care: The MINOR Clinical Trial

PURPOSE

Incorporating technology such as home blood pressure monitoring (HBPM) into the clinical routine generates opportunities to improve BP monitoring and control in primary health care. It is also important to prevent overtreatment. However, the combination of HBPM with collaborative drug therapy management (CDTM) has not yet been studied. This study aimed to assess the efficacy of combining HBPM with CDTM to optimize hypertension treatment for older patients.

METHODS

This open-label, parallel-group, randomized clinical trial was conducted between June 2021 and August 2022 in a Brazilian community pharmacy and included older patients (aged ≥60 years) with hypertension. Those who were classified as poorly adherent or nonadherent to the prescribed drug treatment or who were unable to perform HBPM were excluded. In the control group, participants received a BP monitor and instructions on how to perform HBPM. A general practitioner, who was provided a report with the obtained BP values, determined any changes to the treatment protocol. In the intervention group, a pharmacist enrolled participants in a drug therapy management protocol and provided the general practitioner with suggestions to optimize the antihypertensive drug therapy, in addition to the report with the BP values. The following outcomes were considered: the proportion of participants receiving deprescriptions of antihypertensive drugs, other treatment adjustments, and the difference in mean BP between the groups 45 days after performing HBPM. The study used a t test combined with Levene's test to calculate mean intergroup differences in BP, the paired t test to calculate mean intragroup differences in BP, and Pearson's χ2 test to determine intergroup differences in changes in drug therapy.

FINDINGS

In each group, 161 participants completed the trial. Antihypertensive agents were deprescribed for 31 (19.3%) participants in the intervention group versus 11 (6.8%) in the control group (P = 0.01). In addition, 14 (8.7%) participants were prescribed antihypertensive drugs in the intervention group versus 11 (6.8%) in the control group (P = 0.52). The mean office systolic BP and HBPM values were lower in the intervention group (P = 0.22 and P = 0.29, respectively).

IMPLICATIONS

Combining HBPM with a CDTM protocol effectively optimized antihypertensive treatment for older patients in a primary health care setting.

CLINICALTRIALS

gov identifier: NCT04861727.

The association between drug therapy problems and blood pressure control of patients with hypertension in public health center setting

Background: Patients with hypertension are at risk of experiencing Drug Therapy Problems (DTPs). However, few have studied the pattern of DTPs in Indonesian public health center (PHC) and how it affected the blood pressure control. Objective: This study aims to identify DTPs and its association to blood pressure control among patients with hypertension in Indonesian PHCs. Methods: A descriptive, observational and cross-sectional study involving 150 selected persistent hypertensive patients was conducted from August to December 2019 in 63 PHCs in Surabaya. A questionnaire asking patients’ experiences during treatment of hypertension was used. Chi-square test was used to analyze the association between DTPs and blood pressure control. Results: The majority of respondents were aged 50-65 (54.7%), female (76%), only half has controlled blood pressure (52.7%) and most of them used three to four medicines at the same time (57.3%). A total 563 DTPs was identified with 15.6% was unnecessary drug use, 11.4% indicated need for additional drug therapy, one-fifth experienced dosage too low (21.5%) and non-adherence (19.2%) and 26% suffered from adverse drug reactions. There was a significant association between number of DTPs and blood pressure control (P<0.05). Conclusion: Most patients experienced more than two DTPs and undertook more than three medicines at the same time. There is a significant association between the number of DTPs in hypertensive patient and the blood pressure control.

Comprehensive Medication Management Services with a Holistic Point of View, a Scoping Review

Implementing Comprehensive Medication Management (CMM) services uncovered the importance of the totality of the patient's perspective in this process. The holistic approach takes into account the physical, mental and emotional well-being of individuals, as well as their socioeconomic circumstances. The aim of this study was to characterize the scientific evidence associated with CMM services that included this holistic approach. A scoping review was conducted based on Arksey and O'Malley's method. Searches were performed in Google Scholar for papers published between 2010 and 2020 in English, Spanish and Portuguese. Study design, health contexts, sample of patients, results obtained, barriers and facilitators, and the integration of a holistic approach were determined. Two hundred and eighteen papers were evaluated, most of which focused on the implementation of this service through prospective observational studies. A minority of studies reported on a holistic approach, a smaller number examined the effect of social determinants of health, the patient's medication experiences and the pharmacotherapy outcomes from the patient's perspective. Despite the progress achieved, most of the referents do not yet reflect a broader view of the patient's life situation and its relationship to pharmacotherapy and the ways in which the pharmacist implements holistic elements to solve or prevent drug-related problems.

Improving the Experience of Providing Care in Community-Based Pharmacies

This study applied a human factors and ergonomics approach to describe community-based pharmacy personnel perspectives regarding how work environment characteristics affect the ability to perform the duties necessary for optimal patient care and how contributors to stress affect the ability to ensure patient safety. Data were obtained from the 2021 APhA/NASPA National State-Based Pharmacy Workplace Survey, launched in the United States in April 2021. Promotion of the online survey to pharmacists and pharmacy technicians was accomplished through social media, email, and online periodicals. Responses continued to be received through the end of 2021. A data file containing 6973 responses was downloaded on 7 January 2022 for analysis. Qualitative thematic analysis was applied for developing operational definitions and coding guidelines for content analysis of the data. The patterns of responses for the dependent variables were compared among community-based practice setting types (chain, supermarket/mass merchandiser, and independent) and work positions (manager, staff pharmacist, technician/clerk, and owner). Chi-square analysis was used for determining statistically significant differences. The findings showed that personnel working in community-based pharmacies reported undesirable work environments and work stress that affected their ability to perform assigned duties for optimal patient care and ensure patient safety. Four work system elements were identified that were both facilitators and barriers to the ability to perform duties and ensure patient safety: (1) people, (2) tasks, (3) technology/tools, and (4) organizational context. Acknowledging local contexts of workplaces, giving adequate control, applying adaptive thinking, enhancing connectivity, building on existing mechanisms, and dynamic continuous learning are key elements for applying the HFE (human factors ergonomics) approach to improving the experience of providing care in community-based pharmacies.

Initiation of the pharmacist-delivered antidiabetic medication therapy management services in a tertiary care hospital in Nepal

The medication therapy management (MTM) pharmacists follow the philosophy of pharmaceutical care to address individualistic medication therapy requirements in their practice settings.The present study aimed to introduce the pharmacist-delivered MTM services among type 2 diabetes mellitus patients at a tertiary care hospital in Nepal.Cross-sectional study was conducted at Patan Hospital, Lalitpur, Nepal, among 200 patients with type 2 diabetes mellitus from July to December 2019. The intervention included maintenance of medication profile for individual patients, and then MTM service was proposed based on 5 core elements of MTM services proposed by the American Pharmacists Association. Both antidiabetic and non-antidiabetic medicines were coded as per the anatomic, therapeutic, and chemical classification and defined daily dose assignment 2020 for documentation. The Charlson Comorbidity Index was used to index comorbidities. The drug interaction profile was checked with the Medscape Drug Interaction Checker.Both fasting and postprandial blood sugar levels were significantly associated with age (P-values <.000 for both), baseline symptom (P-values .012 and .003 respectively), and diet plan proposed (P-values .049 and .011 respectively). Maximum cases of drug interactions requiring close monitoring were between metformin and insulin regular (i.e., 11, 5.5%).This was a novel initiative of the MTM services in a resource constraint country like Nepal and can show a clue for the pharmacists targeting such services in other similar settings.

Budget Impact Analysis of Pharmacist-Led Medication Management in Cardiovascular and Type 2 Diabetic Patients

The paper aims to identify and measure the costs and savings associated with the delivery of Comprehensive Medication Management (CMM) services in Croatia in patients diagnosed with hypertension accompanied by at least one additional established cardiovascular disease (CVD) and/or type 2 diabetes mellitus (DMT2) who use five or more medicines daily. The budget impact analysis (BIA) employed in this study compares the total costs of CMM to the cost reductions expected from CMM. The cost reductions (or savings) are based on the reduced incidence of unwanted clinical events and healthcare service utilisation rates due to CMM. The BIA model is populated by data on medication therapy costs, labour, and training from the pilot CMM intervention introduced in Zagreb’s main Health Centre, while relevant international published sources were used to estimate the utilisation, incidence, and unwanted clinical events rates. Total direct costs, including pharmacists’ labour and training (EUR 2,667,098) and the increase in the cost of prescribed medication (EUR 5,182,864) amounted to EUR 7,849,962 for 3 years, rendering the cost per treated patient per year EUR 57. CMM is expected to reduce the utilisation rates of healthcare services and the incidence of unwanted clinical events, leading to a total 3-year reduction in healthcare costs of EUR 7,787,765. Given the total CMM costs of EUR 7,849,962, CMM’s 3-year budget impact equals EUR 92,869, rendering per treated patient an incremental cost of CMM EUR 0.67. Hence, CMM appears to be an affordable intervention for addressing medication mismanagement and irrational drug use.

Healthcare Utilisation and Clinical Outcomes in Older Cardiovascular Patients Receiving Comprehensive Medication Management Services: A Nonrandomised Clinical Study

The objective of this study was to evaluate the impact of comprehensive medication management (CMM) services on healthcare utilisation and cardiovascular risk factors among older patients with established cardiovascular diseases (CVDs). This quasi-experimental study that was performed at the Croatian primary care ambulatory clinic included patients aged 65 to 80 years. Patients were divided into intervention (65 patients) and control groups (68 patients) and were followed-up for one year. Pharmacists provided face-to-face consultations to patients from the intervention group. Groups were compared with regards to the clinical parameters (blood pressure, HbA1c, LDL, TC) and healthcare utilisation (hospital admission, emergency visits, unplanned GP visits). The CMM intervention significantly improved systolic blood pressure (p = 0.038), diastolic blood pressure (p = 0.001), total cholesterol (p = 0.014), low-density lipoprotein cholesterol (p = 0.005), and glycosylated haemoglobin (p = 0.045) in comparison with the control group. Patients included in CMM services had statistically and clinically lower systolic (−9.02 mmHg, p < 0.001) and diastolic blood pressure (−4.99 mmHg, p < 0.001) at the end of the study. The number of hospital admissions and unplanned GPs visits were 3.35 (95% CI 1.16−10.00) and 2.34 (95% CI 1.52−3.57) times higher in the control group compared to the intervention group, respectively. This study demonstrated that pharmacists providing CMM services can significantly contribute to better clinical outcomes and lower healthcare utilisation, thus potentially contributing to total healthcare savings.

Use and access to medications for type 2 diabetes mellitus in elderly: a population-based household survey

The objective of this study was to analyze the use and access to medications for type 2 diabetes among older people registered in the family health strategy in Ribeirão Preto, São Paulo. A population-based household survey was undertaken with 338 older adults selected using two-stage cluster sampling. Pharmacotherapy of diabetes and access to medications was investigated using a structured questionnaire administered by means of face-to-face interviews. The number of medicines used to treat diabetes ranged between 1 and 4. Respondents predominantly used only oral antidiabetic agents. The use of metformin and sulfonylureas on their own was reported by 37.9% and 9.8% of respondents, respectively. Frequency of insulin use was greatest in the 80 years and overage group (38.9%). The large majority of respondents (96.4%) had full access to medicines. Means of payment was "free of charge" in 78.1% of the respondents and public pharmacies were the main source of medication (74.8%). The most commonly used oral antidiabetic was metformin, which is consistent with current treatment guidelines. However, the findings show inappropriate medication use among older people, more specifically the use of sulfonylureas on their own. The findings of this study highlight the important role played by the public health service in providing medications for type 2 diabetes.

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

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

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

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

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

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

Assessing the Impact of Comprehensive Medication Management on Achievement of the Quadruple Aim

Nonoptimized medication regimens cost patients and payors in the United States more than $528 billion in additional health care expenses each year. Comprehensive medication management is a patient-centered approach to medication optimization delivered by a clinical pharmacist working with the patient, physicians, and other members of the health care team. Comprehensive medication management ensures medications are assessed for appropriateness, effectiveness, and safety given the patient's clinical status, comorbidities, and other medications, as well as the patient's ability to take the medications as intended and adhere to the regimen. This article reviews the growing body of literature demonstrating the value of comprehensive medication management in achieving the quadruple aim of health care: better care, reduced health care costs, an improved patient experience, and provider well-being.

The Subjective Experience of Using Medications: What We Know and the Paths Forward

Medications can cause bodily changes, where the associated benefits and risks are carefully assessed based on the changes experienced in the phenomenal body. For this reason, the phenomenology of Merleau-Ponty is an important theoretical framework for the study of experience related to the daily use of medications. The aim of this study was to discuss the contribution of a recently developed framework of the general ways people can experience the daily use of medications—resolution, adversity, ambiguity, and irrelevance—and present reflections about the little-understood aspects of this experience. However, some issues raised throughout this article remain open and invite us to further exploration, such as (1) the coexistence of multiple ways of experiencing the use of medications, by the same individual, in a given historical time; (2) the cyclical structure of this experience; (3) the impact of habit and routine on the ways of experiencing the daily use of medications; and (4) the contribution of the concept of existential feelings to this experience and its impact on patients’ decision-making. Therefore, the experience with the daily use of medications is a complex and multifaceted phenomenon that directs the decision-making process of patients, impacting health outcomes.

Decision-Making Process in Comprehensive Medication Management Services: From the Understanding to the Development of a Theoretical Model

In Comprehensive medication management (CMM), the practitioner applies a decision-making method to assess patients' pharmacotherapy in order to identify and solve drug therapy problems. Grounded theory was used to understand how pharmacists make clinical decisions when providing CMM service. Data collection included individual semi structured interviews with 11 pharmacists, observation of clinical case discussions and CMM consultations provided by the participating pharmacists. Two main categories emerged: 1. Understanding the rational method of decision-making: the foundation of the patient care process. 2. Balancing the care equation: the objective and the subjective, which includes a theoretical proposal explaining the pharmacists' decision-making process and the factors that can modify this process. The pharmacotherapy knowledge should guide the anamnesis. Thus, the professional can evaluate the indication, effectiveness, safety and convenience of medications used by the patient. After exploring patients' medication experiences, pharmacists can follow two courses of action: helping the patient overcome barriers to medication use; or matching the pharmacotherapy to the patient's routine. Professional autonomy and absence of the patient at the time of the decision were some factors that influenced the pharmacist's decision. Findings provide a broad understanding of pharmacists' decision-making process during the care of patients using medications. It can be applied as a basis for educational interventions to train professionals on decision-making.

Pharmacist Segments Identified from 2009, 2014, and 2019 National Pharmacist Workforce Surveys: Implications for Pharmacy Organizations and Personnel

Background/Objective: Findings from the 2009 and 2014 National Pharmacist Workforce Surveys showed that approximately 40% of U.S. pharmacists devoted their time primarily to medication providing, 40% contributed a significant portion of their time to patient care service provision, and the remaining 20% contributed most of their time to other health-system improvement activities. The objective of this study was to characterize the U.S. pharmacist workforce into segments based on the proportion of time they spend in medication providing and patient care services and compare changes in these segments between 2009, 2014, and 2019. Methods: Data from 2009, 2014, and 2019 National Pharmacist Workforce Surveys were analyzed. Responses from 1200 pharmacists in 2009, 1382 in 2014, and 4766 in 2019 were used for analysis. Respondents working in the pharmacy or pharmacy-related fields reported both their percent time devoted to medication providing and to patient care services. Medication providing included preparing, distributing, and administering medication products, including associated professional services. Patient care services were professional services designed for assessing and evaluating medication-related needs, monitoring and adjusting patient's treatments, and other services designed for patient care. For each year of data, pharmacist segments were identified using a two-step cluster analysis. Descriptive statistics were used for describing the characteristics of the segments. Results: For each year, five segments of pharmacists were identified. The proportions of pharmacists in each segment for the three surveys (2009, 2014, 2019) were: (1) medication providers (41%, 40%, 34%), (2) medication providers who also provide patient care (25%, 22%, 25%), (3) other activity pharmacists (16%, 18%, 14%), (4) patient care providers who also provide medication (12%, 13%, 15%), and (5) patient care providers (6%, 7%, 12%). In 2019, other activity pharmacists worked over 45 hours per week, on average, with 12 of these hours worked remotely. Patient care providers worked 41 hours per week, on average, with six of these hours worked remotely. Medication providers worked less than 40 hours per week, on average, with just one of these hours worked remotely. Regarding the number of patients with whom a respondent interacted on a typical day, medication providers reported 18 per day, patient care providers reported 11 per day, and other activity pharmacists reported 6 per day. In 2009, 8% of patient care providers worked in a setting that was not licensed as a pharmacy. In 2019, this grew to 17%. Implications/Conclusions: The 2019 findings showed that 34% of U.S. pharmacists devoted their time primarily to medication providing (compared to 40% in 2009 and 2014), 52% contributed a significant portion of their time to patient care service provision (compared to 40% in 2009 and 2014), and the remaining 14% contributed most of their time to other health-system improvement activities. Distinguishing characteristics of the segments suggested that recent growth in the pharmacist workforce has been in the patient care services, with more being provided through remote means in organizations that are not licensed as pharmacies. The findings have implications for pharmacist training, continuing education, labor monitoring, regulations, work systems, and process designs. These changes will create new roles and tasks for pharmacy organizations and personnel that will be needed to support emerging patient care services provided by pharmacists.