Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice

Focal points

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

INTRODUCTION

Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes.

METHODS

A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement.

RESULTS

The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff's high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.

CONCLUSIONS

That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial

OBJECTIVE

to measure the impact of pharmacist-conducted clinical medication review with elderly care home residents.

DESIGN

randomised controlled trial of clinical medication review by a pharmacist against usual care.

SETTING

sixty-five care homes for the elderly in Leeds, UK.

PARTICIPANTS

a total of 661 residents aged 65+ years on one or more medicines.

INTERVENTION

clinical medication review by a pharmacist with patient and clinical records. Recommendations to general practitioner for approval and implementation. Control patients received usual general practitioner care.

MAIN OUTCOME MEASURES

primary: number of changes in medication per participant. Secondary: number and cost of repeat medicines per participant; medication review rate; mortality, falls, hospital admissions, general practitioner consultations, Barthel index, Standardised Mini-Mental State Examination (SMMSE).

RESULTS

the pharmacist reviewed 315/331 (95.2%) patients in 6 months. A total of 62/330 (18.8%) control patients were reviewed by their general practitioner. The mean number of drug changes per patient were 3.1 for intervention and 2.4 for control group (P < 0.0001). There were respectively 0.8 and 1.3 falls per patient (P < 0.0001). There was no significant difference for GP consultations per patient (means 2.9 and 2.8 in 6 months, P = 0.5), hospitalisations (means 0.2 and 0.3, P = 0.11), deaths (51/331 and 48/330, P = 0.81), Barthel score (9.8 and 9.3, P = 0.06), SMMSE score (13.9 and 13.8, P = 0.62), number and cost of drugs per patient (6.7 and 6.9, P = 0.5) (pounds sterling 42.24 and pounds sterling 42.94 per 28 days). A total of 75.6% (565/747) of pharmacist recommendations were accepted by the general practitioner; and 76.6% (433/565) of accepted recommendations were implemented.

CONCLUSIONS

general practitioners do not review most care home patients' medication. A clinical pharmacist can review them and make recommendations that are usually accepted. This leads to substantial change in patients' medication regimens without change in drug costs. There is a reduction in the number of falls. There is no significant change in consultations, hospitalisation, mortality, SMMSE or Barthel scores.

Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice

OBJECTIVE

To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.

DESIGN

Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.

SETTING

Four general practices.

PARTICIPANTS

1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.

INTERVENTION

Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.

MAIN OUTCOME MEASURES

Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.

RESULTS

590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference 4.72 pound sterling per 28 days, - 7.04 pound sterling to - 2.41 pound sterling); equivalent to 61 pound sterling per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference -0.2, -0.4 to -0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.

CONCLUSIONS

A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.

"No thank you": why elderly patients declined to participate in a research study

OBJECTIVES

To compare the population consenting for a study of the effectiveness of a pharmacist-run medication review clinic with the population not consenting for patients aged over 65 years old with respect to age, sex and number of repeat medicines. To explore the reasons why some patients declined to consent to the study.

METHODS

Letters were sent to 2,403 patients aged 65 and over and taking at least one repeat medicine from 4 general practices. If no reply was received to a second letter they were followed up by telephone. If they declined to consent they were asked for their reasons. Data for consenting and non-consenting patients was collected on the stratification factors: age, sex and number of repeat medicines. Multiple logistic regression was used to assess the association of each factor with consent rates.

RESULTS

Consenting patients were dissimilar to non-consenting patients. Patients were less likely to consent if they were older, OR (95% CI) = 0.54 (0.46, 0.64), or female, OR (95% CI) = 0.74 (0.63, 0.88). Patients were more likely to consent if on 5 or more repeat medicines: OR (95% CI) = 1.3 (1.1, 1.5). Ten broad categories of reasons why patients did not wish to participate were identified from the patient interviews.

CONCLUSIONS

Patients were less likely to give their consent if they were elderly, female and on fewer repeat medicines. A number of administrative and behavioural factors were identified which reduced the chances of informed consent being given. These factors need to be addressed to maximise numbers of consenting patients in medication review studies.

Development of a method for clinical medication review by a pharmacist in general practice

Medication review of patients on long-term treatment in general practice in the UK has been reported to be inadequate. Proposals followed suggesting that pharmacists could use their expertise to lead such a medication review in conjunction with the general practitioner. This paper describes the concept of clinical medication review by a pharmacist based in general practice. We describe the development of a method for a structured and systematic process for undertaking such a review in clinics conducted by a pharmacist. The method was developed for a nationally funded study in the UK. We provide a definition of clinical medication review and suggests a structure for the process through data gathering, evaluation and implementation.

Who controls repeats?

BACKGROUND

The need for patients on long-term medication to be periodically reviewed is well documented, but until now there have been no large-scale systematic studies of the process of repeat prescribing.

AIM

To propose a model for the process and control of repeat prescribing in general practice, and to use this model to evaluate the management control and clinical control of repeat prescribing in 50 practices.

METHOD

Interviews were conducted with practice staff and the process of repeat prescribing was observed in consenting practices from 57 randomly selected practices in Leeds. A batch of repeat prescriptions was identified in each practice, and the patients' records were examined for evidence of clinical authorization and review. The records of 427 patients taking 556 drugs within three drug groups were studied. A subjective scoring system was used to assess quality of management control. Clinical control was assessed by noting the presence or absence of evidence in general practitioner records of doctor authorization of repeat status, and of clinical review of therapy for each drug.

RESULTS

Management control-Many practices had inadequate controls of repeat prescribing, leading to unauthorized repeat prescriptions, poor compliance checks (or none at all), and inadequate systems, if any, for identifying patients in need of medication review, and for bringing them to prescribers' attention. Clinical control-66% of repeat drugs showed no evidence of authorization by a doctor; 72% showed no evidence of having been reviewed by a doctor in the previous 15 months.

CONCLUSION

Inadequate control of repeat prescribing is wasteful and potentially dangerous. Major improvement is required in the management and clinical aspects of the control of repeat prescribing in many practices. This will need changes in procedures and training, and may require more resources and the imaginative use of nurses and pharmacists.

Health library for patients in general practice

We describe the establishment of a health lending library for patients in a suburban general practice. The library is housed in the surgery waiting room and comprises 413 books and 35 audio tapes on topics related to health. Analysis of the first year's use showed 703 borrowings (677 books and 26 audio cassettes). Borrowers ranged the spectrum of social class and educational status but women predominated, and borrowers included many who admitted that they seldom read books. Most borrowings were opportunistic, though some were planned by the patient and a few recommended by a health care professional. Most readers claimed to have learned from their reading and to have found their reading useful. We think that a health library is a useful tool of primary care, particularly for prevention.