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The Pharmaceutical Journal Vol 265 No 7114 September 16, 2000
Pharmacy Practice Research
Papers presented at the British Pharmaceutical Conference, Birmingham, September 10 to 13, 2000 pR29

Pharmacist-conducted clinical medication review clinic: consultation generator or saver?

By D. R. Petty, A. G. Zermansky, C. J. Lowe, D. K. Raynor

Introduction Clinical control of repeat prescribing is known to be less than optimal.1,2 This is a concern because long-term prescribing, without review, can lead to waste and suboptimal treatments. Medication review by a general medical practitioner (GP), within the time constraint of an appointment, is not always practical.
Zermansky suggested that a suitably trained clinical pharmacist might be able to conduct a clinical medication review, with patients in need of medical review being referred to the GP.1
This study examines the level of additional referrals generated by such a review process. It forms part of a larger study on clinical medication review by a pharmacist, funded by the National Health Service Research and Development health technology assessment programme.3

Method Four medical practices in the Leeds health authority area were randomly selected. Each provided a list of patients aged 65 years or over who were prescribed repeat medicines. Patients were excluded if terminally ill or living in a nursing or residential home.
The main study design was a controlled trial, where consenting patients were randomised to either a control group (usual care) or intervention group (invited to a medicine review clinic). At the clinic, the pharmacist discussed with the intervention group patients each condition being treated. In those conditions needing clinical or pathological monitoring, the pharmacist determined if these were overdue and, if so, referred the patient to the nurse or doctor. If a new diagnosis was suspected or a condition had significantly worsened, the patient was referred to the doctor. Where a medication intervention was necessary, a protocol defined whether the pharmacist needed prior permission from the GP. Where permission for medication change was required by the protocol, the outcome of the recommendation was recorded.

Focal points

  • Clinical control of repeat prescribing is known to be less than optimal
  • A pharmacist may be able to conduct clinical medication review but, if this results in a high referral rate, there is an argument for the doctor seeing the patient directly
  • This study shows that a large number of interventions can be made with limited involvement of other practice staff
  • Further work is being conducted to investigate the outcome of interventions on practice workload overall

Results The random sample of 240 intervention patients analysed for this work comprised 143 (60 per cent) aged 65 to 74 and 97 (40 per cent) 75 or over. One hundred and thirty two (55 per cent) were female. The sample group did not differ in terms of age and sex from the main group. Home visits were required by 38 (16 per cent) patients.
An intervention was required in 112 (45 per cent) of the consultations. The interventions related to medication change in 69 patients (29 per cent of total consultations), test required (referral to practice nurse) in 18 (8 per cent) and doctor referral due to suspected new diagnosis or deterioration of existing conditions in 12 (5 per cent). Thus 30 patients were referred to another member of the team (27 per cent of patients in whom an intervention was made and 13 per cent of all patients seen).
Interventions were made on 254 of 1,150 medicines (22 per cent). The protocol required that permission was sought from the GP for 75 (30 per cent) of suggested changes. The doctor accepted 67 of these interventions and eight were rejected or not acted upon.

Discussion Previous studies showed that pharmacists can be effective in conducting medication review clinics but did not discuss the workload generated for other members of the team.4,5 If the pharmacist sees patients but this results in the need to refer a high proportion, there is an argument for the doctor seeing them directly.
This study shows that a large number of interventions can be made with limited involvement of other practice staff. Further work is being conducted to investigate the outcome of pharmacist interventions on practice workload overall.

Division of academic pharmacy practice, University of Leeds

References

1. Zermansky AG. Who controls repeats? Br J Gen Pract 1996;46:643-7.
2. McGavock H, Wilson-Davies K, Connolly JP. Repeat prescribing management: a cause for concern? Br J Gen Pract 1999;49:343-7.
3. NHS R&D health technology assessment programme. List of commissioned HTA projects. Available at: URL: www. hta.nhsweb.nhs.uk/projdets/932209.htm
4. Mackie CA, Lawson DH, Campbell A, Maclaren AG, Waigh R. A randomised controlled trial of medication review in patients receiving polypharmacy in general practice. Pharm J 1999;263:R7.
5. Goldstein R, Hulme H, Willits J. Reviewing repeat prescribing: general practitioners and community pharmacists working together. Int J Pharm Prac 1998;6:60-6.