The Pharmaceutical
Journal Vol 267 No 7178 p863-864
15 December 2001
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The Pharmaceutical
Journal Vol 267 No 7178 p863-864 |
Evidence shows medication reviews by pharmacists point way forward |
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By D. R. Petty, DipClinPharm, MRPharmS, A. G. Zermansky, MB ChB, MRCGP, and D. K. Raynor, PhD, MRPharmS |
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The Pharmacy Practice and Medicines Management Group at the University of Leeds has recently completed a randomised controlled trial of medication review by a pharmacist that was published in the British Medical Journal. This article puts that work into the wider context and suggests the way forward for pharmacists in the area of medication review |
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Pharmacists have been seeking an extended role that makes better use of their skills and training for many years.1 Medication review could be a key part of that role because it employs both clinical skills (eg, knowledge of therapeutics and patient counselling) and technical skills (eg, supply, product knowledge and optimising quantities). This combination of attributes is unique to pharmacists. Medication review is popular with patients because it provides an opportunity for them to ask questions about their treatments and have answers, and popular with the National Health Service because it can reduce waste, improve compliance and enhance quality of care.2 It could also be popular with general practitioners who recognise the need to review their patients' treatment, but lack the time to do it. Medication review is now emerging as an important component of medicines management. The NHS Plan envisages pharmacists providing extended services to improve the way medicines are used.2 In England the Medicines Management Services Collaborative3 is focusing on repeat prescribing systems and medication review as areas for improvement. The National Service Framework for Older People proposes that patients aged 75 years and over should have their repeat medicines reviewed annually and those on four or more medicines twice yearly.4 The workload for GPs in reviewing these patients is considerable. GPs do not consistently review patients on repeat medicines5,6 and it has been proposed that pharmacists might fill this gap. The clinical medication review project We recently reported a randomised controlled trial (RCT) that tests the hypothesis that a suitably trained clinical pharmacist can conduct effective clinical medication review of elderly patients on repeat medication in general practice. The study was funded by the NHS R&D programme through its Health Technology Assessment Programme.7 Ninety-seven per cent of the patients randomised to pharmacist review received a medication check compared with 44 per cent of those who continued to receive normal GP care. Patients seen by the pharmacist were more likely to have changes made to their medicines and had a smaller rise in the number of repeat medicines. The rise in medication costs was less in the intervention group (mean difference £61 per patient per year). Furthermore, the pharmacist was able to conduct the reviews without increasing the GPs' workload. A number of other RCTs have also demonstrated that pharmacist medication review produces beneficial outcomes for patients.8–10 These studies and our own concentrated on examining whether pharmacists can provide a beneficial clinical role and had cost saving as a secondary measure. Although the savings made by the pharmacist would not necessarily be wholly repeatable year on year, we believe that the intervention would easily be self-funding. Extrapolating from our findings, we think a full-time clinical pharmacist (who would probably work in several practices) could save as much as £170,000 net per year. Others have also shown cost savings. A Scottish study of medication review has suggested savings of £37 per patient per annum.11 A Department of Health study conducted in Leicestershire showed savings of £36 per patient per annum.12 The average time taken with each patient was 52 minutes. Another study conducted in the Isle of Wight had costs of £29,627 for pharmacist time and resulted in savings of £49,757.13 Costs per patient were not described. Why clinical medication review? The model we tested was clinical medication review — the process where a health professional reviews the patient, the illnesses and the drug treatment during a consultation. It involves evaluating the therapeutic efficacy of each drug, unmet therapeutic need and the progress of the conditions being treated. Other issues, such as compliance, actual and potential adverse effects, interactions and the patient's understanding of the condition and its treatment are considered, where appropriate. The outcome of a clinical review is a decision about the continuation (or otherwise) of the treatment. We have described this process in more detail elsewhere.14 This method of medication review is the ideal because the pharmacist has access to the patient, their medicines (they were asked to bring them in), the clinical record and the rest of the health care team (when conducted in the GP surgery). It is possible to conduct medication reviews without all these elements but this can limit the information gained and therefore the completeness of the review. For example Krska8 and McGuire15 both found that pharmacists were able to identify around 50 per cent of the care issues from the prescription alone but the medical record and a patient interview was required to identify the other half. The concept of medication review being clinical is important. "Prescription review" involves making recommendations about therapy after reviewing the prescribed medicines and the patient's notes. It does not, however, involve the patient being seen and therefore important information may be missed. Clinical medication review involves asking the patient questions about their illness and the medicines taken (both prescribed and non prescribed). It is important to know what the patient actually takes and how they respond to it, whether the patient adheres to their medicine regimen, whether their condition is worsening or improving and if there are any unrecognised medical needs. Community pharmacy-based review Many community pharmacists will not be willing or able to conduct medication reviews in the general practice setting. Significant barriers remain to this being a model for all pharmacists and practices, including the legal requirement for a pharmacist to be present in the community pharmacy to supervise sales of pharmacy medicines. However this does not mean that a community pharmacy-based review is not worthwhile. Most importantly, a community pharmacy-based review allows an opportunity to educate patients about their treatments and to monitor for efficacy and potential side effects by asking the patient questions. In addition it allows recommendations for reducing waste to be made through identifying unused treatments that the patient continues to order and by standardising quantities of repeats. One approach is the "brown-bag" review. "Brown bag" reviews were developed in the United States. The system was devised for a health care professional to review long-term medication by asking patients to bring their medicines in a specially provided "brown bag".16 Two UK studies on community pharmacist-run "brown bag" clinics have been published. A DoH-funded project conducted by Devon Family Health Services Authority17 recruited four GP practices with associated pharmacies. Four hundred patients aged 60 years or over and taking five or more items were invited for review. In total 335 were interviewed and 38 per cent had medicines that were no longer required. The pharmacist made 507 referrals to GPs for a variety of reasons over the study period. The GPs actioned 42 per cent of suggestions. Nathan18 conducted a study of 205 volunteer patients in 23 pharmacies in south-east London. Interventions were made in 87 per cent of reviews. "Brown bag" reviews appear to be a simple means of getting patients to talk about their repeat medicines and to identify problems and wastage. Although a "brown bag" review can be run in a community pharmacy without an appointment system, a review can take 20 minutes. Also a private area is required for the interview. Repeat dispensing and medication review The proposed system for repeat dispensing2 will provide an ideal opportunity for review, as it allows questions to be asked at each dispensing. An RCT conducted in Northern Ireland19 showed that patients randomised to repeat dispensing had better compliance with medicine taking and reduced medicine costs compared with the current system for supplying repeat medicines. Intervention patients were twice as likely to be compliant at six months compared with control patients. The total cost savings from non-dispensed medicines in the intervention group was approximately £10 per patient per month. Reviewing medication in housebound patients Home visits may be required for elderly housebound patients. In our study we found that 15 per cent of elderly patients required a home visit.7 Studies of pharmacist-conducted domiciliary medication review suggest benefits. Two UK randomised controlled studies have been conducted.20,21 The first20 involved 190 elderly patients randomised to either an intervention group or control group. Patients were visited soon after hospital discharge. The effects of visits on compliance and medication management were measured. Patients in the intervention group demonstrated better compliance, better drug storage practice, a reduced tendency to hoard drugs and fewer GP consultations. The second21 involved 161 patients from one practice. In the intervention group the pharmacist simplified the medication, assessed the patients' needs regarding the presentation of the medicines and educated them about their medicine regimen. Intervention patients were visited three times. Patients' knowledge and compliance were found to increase in the intervention group compared with the control group. Sidel22 found that educational home visits had no effect on patients' knowledge about their treatments. Implementing interventions Many potential interventions can result from a medication review. Many of these require communication with the patient and the GP for implementation. This will mean community pharmacists developing their working relationships and communication with local GPs. Interventions are most likely to be implemented if done by the pharmacist.23 It is also important that records are kept of recommendations and actions implemented and that somebody follows up the patient to check the outcome of the intervention. Often this will fall to the GP, as part of a follow up review, but it could be done by the pharmacist. Funding As with most extended roles, a key issue for medication review is funding. Local pharmaceutical services (LPS) will be piloted in 2002. The funding proposed in LPS (ie, a contract with the primary care trust for providing an extended pharmacy service that must include an element of dispensing) may provide a solution since it will, for example, allow pharmacy businesses to employ a second pharmacist to provide the service. Pharmacists may also be able to make a case to PCTs for local funding of a medication review service outside LPS arrangements. Training Medication review requires a good knowledge of applied therapeutics and pharmacists need to remain up to date with evidence. This can be time consuming but professionally rewarding. In addition communication skills, change management and implementation skills are important for getting messages over to both other health care professionals and patients. Good interview techniques can improve information gathering in consultations. This combination of therapeutic knowledge and change management skills forms the basis for the Prescribing Management in Primary Care training programme development in Leeds alongside the clinical medication review research.24 National training organisations such as the College of Pharmacy Practice, the Centre for Pharmacy Postgraduate Education and the Scottish Centre for Post Qualification Pharmaceutical Education also provide such training. An understanding of local health care systems, including those provided by the primary care organisation and the general practice, are also important. A medication review service has to be linked to local practices so that information can be shared and appropriate referrals made. Conclusion Medication review allows pharmacists an opportunity to extend their clinical skills and improve patient care. There is good evidence from randomised controlled trials to support medication review services, which probably save more money than they cost to run. Community pharmacists need to consider how they can provide such services as part of repeat dispensing and whether they can build this type of service into their bids for LPS. References 1. Parkin B. Pharmacy in a new age: the road to the future. Tomorrow's Pharmacist 1999; (October):58–60. 2. Pharmacy in the future — Implementing the NHS Plan. A programme for pharmacy in the National Health Service. London: Department of Health; 2000. 3. Medicine Management Services Collaborative. Available at: http://www.npc.co.uk/mms/Web_Dev/Collaborative_Area/Home.htm (accessed 7 December 2001). 4. Medicines and older people: Implementing medicine related aspects of the NSF for Older People. London: Department of Health; 2001. 5. Zermansky AG. Who controls repeats? Br J Gen Pract 1996;46:643–7. 6. McGavock H, Wilson-Davis K, Connolly JP. Repeat prescribing management — a cause for concern? Br J Gen Pract 1999;49:343–7. 7. Zermansky A, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe C. Clinical medication review by a pharmacist of elderly patients on repeat prescriptions in general practice: a randomised controlled trial BMJ 2001;323:1340–1343. 8. Krska J, Cromarty JA, Arris F, Jamieson D, Hansford D, Duffus PRS. Pharmacist-led medication review in patients over 65: a randomised, controlled trial in primary care. Age Ageing 2001;30:205–11. 9. Mackie CA, Lawson DH, Campbell A, MacLaren A, Waigh R. A randomised controlled trial of medication review in patients receiving polypharmacy in general practice. Pharm J 1999;263(Suppl):R7. 10. Granas AG, Bates I. The effect of pharmaceutical review of repeat prescriptions in general practice. Int J Pharm Pract 1999;7:264–75. 11. Forrest F. Evaluation of pharmacist-led medication review and repeat dispensing within primary care. Perth and Kinross NHS Trust: North East Fife Community Healthcare; 1999. 12. Repeat prescribing. Leicestershire Health Authority; 1996. 13. Pharmacy drug interaction and cost saving intervention study. Isle of Wight Health Authority; 1997. 14. Lowe CJ, Petty DR, Zermansky AG, Raynor DK. Development of a method for clinical medication review by a pharmacist in general practice. Pharm World Sci 2000;22:121–6. 15. McGuire AJ, Radley AS, Silburn JN, et al. Pharmaceutical care planning in a community setting Pharm J 1996;257(Suppl):R12. 16. Multiple medicines misuse in the bag. Lancet 1992;339:1475. 17. Repeat prescribing review — "brown bag" clinics. Devon FHSA; 1996. 18. Nathan A, Goodyer L, Lovejoy A, Rashid A. "Brown bag" medication reviews as a means of optimising patients' use of medication and of identifying potential clinical problems. Family Practice 1999;16:278–82. 19. Hughes CM, Varma S, McElnay, Mawhinney DC, MacAuley DC. Repeat dispensing: the potential for improved drug utilisation and reduced costs. PharmJ 2000;265(Suppl):R34. 20. Begley S, Livingstone C, Hodges N, Williamson V. Impact of domiciliary pharmacy visits on medication management in an elderly population. Int J Pharm Pract 1997;5:111–21. 21. Lowe CJ, Raynor DK, Purvis J, Farrin
A, Hudson J. Effects of a medication review and education programme for
older people in general practice. Br J Clin Pharmacol 2000;50: 22. Sidel VW, Beizer JL, Lisi-Fazio D, Kleinmann K, Wenston J, Thomas C. Controlled study of the impact of educational home visits by pharmacists to high-risk older patients. J Community Health 1990;15:163–74. 23. Krska J, Cromarty JA, Arris F, Jamieson D, Hansford D. Providing pharmaceutical care using a systematic approach. Pharm J 2000;265:656–60. 24. Lowe CJ. Management of change in prescribing. Primary Care Pharmacy 2001;2:1–2. |
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