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	The Pharmaceutical Journal Vol 269 No 7225 p737 23 November 2002	This article Reprint Photocopy
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News feature

Ways to develop medication reviews

A summary guide to medication review is being distributed together with this week's Journal to all community pharmacists in England, in advance of the launch of the full document next week. Monika Polak (on the staff of The Journal) looks at what it has to say

Medication review is increasingly recognised as a cornerstone of medicines management. So says "Room for review", a new guide on how to implement medication reviews, published by the Medicines Partnership in conjunction with the national collaborative medicines management services programme which is run by the National Prescribing Centre.

The aim of the guide, which will be launched next week with ministerial backing, is not to dictate. Rather it is to support the development of the medication review process in primary care trusts that are either in the throes of setting up their own strategy, or are yet to begin. Joanne Shaw, director of the Medicines Partnership, believes the guide will meet the needs of many. "It will achieve a lot because the National Service Framework for Older People has set a milestone for medication review, and people know they need to deliver on it," she says.

"[The guide] will encourage people to involve patients as partners in a way they might not have done before. What we hope people will do is develop their own local strategy for which patients need reviews and what kind of review — it might mean implementing more than one type of review."

Proposed definition

Medication review is defined as a structured, critical examination of a patient's medicines with the following objectives:

• Reaching agreement with the patient about treatment

• Optimising the impact of medicines

• Minimising any medication-related problems

• Reducing waste

The guide describes four levels of review of increasing depth and complexity, but the hope is that fully concordant face-to-face clinical medication reviews will eventually be available for all those who could benefit from them, or indeed who want them. It also includes a common set of definitions (see Panel right) and principles, suggests standard ways of recording information from different models of review and offers practical advice on implementation.

The guide also suggests who could be involved in the development of a local medication review strategy and how progress could be monitored. "By encouraging recording, it potentially gives the Department of Health a better idea of what is going on and gives localities the ability to track their own performance," Ms Shaw says.

She adds that one of the spin-off benefits from medication review has been financial savings. "We should not be embarrassed to say that it results in better use of resources, but it is critical that it is not seen as a cost cutting measure. It is, more importantly, about keeping people well — it could mean spending more on medication to keep people out of hospital."

The NSF targets that have driven implementation of medication reviews have been based on work done in the Greater Glasgow Health Board area by Professor Clare Mackie and her colleagues. Results from the first randomised control trial of medication reviews, based on data from the Glasgow project and due for publication in the BMJ soon, will show a clear improvement in quality, cost-effectiveness and acceptance from patients and practitioners alike. Out of 1,673 patients over the age of 20 who were taking four or more medicines, 83 per cent were referred back to their general practitioner for changes to their regimen and only 3 per cent of changes recommended by the community pharmacists were rejected by GPs.

After nine months' follow-up, 83 per cent of drug-related problems were resolved in the group receiving medication review, compared with only 32 per cent of those in the control group (P<0.0001), and most problems related to unnecessary therapy (24 per cent). Furthermore, the majority of patients (84 per cent) wanted a repeat review on a three- to six-monthly basis. Professor Mackie says: "When we withdrew the pharmacists from the clinic, we found the benefits were lost 18 months later and costs went up by about 12 per cent."

Similar results were also found with medication reviews targeted at hypertensive and diabetic patients. Professor Mackie says: "It is consistent across different models and is well accepted by everyone. General adoption is now overdue, so the fact that [the Medicines Partnership] has produced a framework to help everyone is good."

Joanne Shaw says the Medicines Partnership's role is not to set standards and targets, but to help people meet them. "From the Medicines Partnership perspective, there are many ways to do medication review, but the ideal form always involves the patient as a full partner. Medication review is a fantastic way to bring concordance into the health service straight away," she concludes.

"Room for review" will be available on the Medicines Partnership website (www.medicines-partnership.org), after its launch. The Medicines Partnership is keen to get feedback on the new guide as well as comments on medication review.

Examples of best practice illustrate the real savings and benefits made

"Room for review" includes several case studies, including the prescription review and intervention scheme with education, set up by Coventry Primary Care Trust. The PCT estimates it could potentially save Ł150,000 during the first year of the scheme, for an investment of only Ł5,000 on fees and administration. Over 1,000 interventions have been made in the first three months alone and approximately 85 per cent of suggested changes have been acted on immediately. "Most of the time it was purely an advisory scheme, where pharmacists were suggesting to GPs how to make their prescribing more efficient," says Mark Galloway, medicines management project facilitator. "What is most encouraging is that the practices learn and they learn quickly — the number of interventions in the five collaborative practices started to decrease, as they were making amendments themselves. What it does is to build the communication links from the base level."

At the "level three clinical medication review" end of the scale, partnerships and financial savings are also being made. A medicines management support service in East Kent Coastal PCT reviewed 164 patients over two years. An Ł8,000 annual investment to fund provision and monitoring of monitored dosage systems enabled carers to manage medication for 17 particularly at-risk individuals, saving around Ł263,000.

Meanwhile, Sati Ubhi, prescribing adviser and project pharmacist at Huntingdonshire PCT, has been reviewing the medication of patients recently discharged from hospital. Since February, the 100 medication reviews that have taken place have revealed that almost half of patients (49 per cent) did not understand why they were taking one or more of their medicines, while 28 per cent needed help taking it. In 27 per cent of cases, the discharge letter did not match the medicines being taken. As a result, 430 points have been fed back to the patients' GPs. Ms Ubhi says those reviewing medication should avoid working in isolation, as involving both primary and secondary care is vital to ensure continuity of care. "Otherwise the patients will just end up going back into hospital. It is too easy to just go around the beds and be thinking only about what is happening in the hospital. We are hoping that the PCT pharmacists will form links between everyone — the practices and the hospitals — through talking to everyone," she says.