|
Duncan Petty, PhD, MRPharmS, is
a research pharmacist
DK Theo Rayner, PhD, MRPharmS, is professor
and head of pharmacy practice
Arnold Zermansky, MB ChB, MRCGP,
is a senior research
fellow
David Alldred, MSc, MRPharmS, is a research clinical
pharmacist at the School of Healthcare, University of Leeds.
Correspondence to:
Duncan Petty
Research Pharmacist,
Medicines Management and Pharmacy Practice, School of Healthcare,
University
of Leeds, LS2 9UT
e-mail D.Petty@leeds.ac.uk |
Medication review by pharmacists — an advanced service in
the new pharmacy contract, but is it doing more harm than good? |
In 2002 The Pharmaceutical Journal published our appraisal of medication
review.1 In it, we concluded that medication review would be a key part
of pharmacists’ extended role, because it employs both clinical
skills (eg, knowledge of therapeutics and patient counselling) and technical
skills (eg, supply, and product knowledge), the combination of these
attributes being unique to pharmacists.
Since then, medication review has been recognised as being a process
that should be conducted in an explicit and systematic way for all patients
prescribed long-term medicines.2 As a consequence, medication review
has become a component of the new general medical services contract3 and medication use review (MUR) has become an advanced service in the
new pharmacy contract.4 The Medicines Partnership Task Force has been
instrumental in ensuring patients are involved in decisions about their
treatments. The task force sees medication review as an important mechanism
to involve patients in decisions about their medicines.5 Taking forward
medication review by practitioners has been facilitated by the production
of materials as part of the “Room for review” initiative.2
Questions remain
Clinical medication review has been shown to be effective in optimising
therapy, improving health outcomes, reducing the likelihood of medicines-related
problems and reducing waste.6–8 Questions remain, however, over
who should do clinical medication reviews and the exact way in which
they should be conducted. Most of the literature relates to pharmacist-conducted
reviews.1 (To the best of our knowledge there are no published studies
of GP or nurse conducted reviews.) It is widely acknowledged that a
medication review can be done at a number of levels. “Room for
review” describes four levels of review:
· Level 0 — Ad hoc (an unstructured, opportunistic review)
· Level 1 — Prescription review (a technical review of a list of
patients’ medicines)
· Level 2 — Treatment review (a review of medicines with patient’s
full notes)
· Level 3 — Clinical medication review2
In a clinical medication review (level 3) access is required to the
patient’s notes and prescription history, and it is important to
have the patient present. We defined a clinical medication review as “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.”9
The Medicines Partnership also emphasises the need to reach an agreement
with patients about their treatment.2
In February, a randomised controlled trial of pharmacist-conducted medication
review was published in the BMJ (the HOMER study), which suggested that
reviews might in fact make matters worse by increasing hospital admissions
and decreasing patients’ quality of life.10 A feature on this paper
in The Pharmaceutical Journal was entitled “Medication reviews
hang in the balance”.11 So, is this alarmist title deserved on
the basis of one study?
The study participants (n=872) were all recruited on the basis of previous
unplanned hospital admissions. Their mean age was 85 years. They were
not typical of the UK elderly population. This group was chosen because
on discharge they were most likely to have drug changes and, therefore,
be vulnerable to medication errors (duplication, unclear changes to medication,
etc) and be potential beneficiaries of an intervention. The aim of the
study was to see if a home-visit by a pharmacist, with a follow up visit
six to eight weeks later, reduced hospital admissions compared with a
control group who received usual care from the GP. The primary outcome
measure was the number of unplanned hospital admissions in the following
six months. Readmissions in the intervention group were 30 per cent higher
and home visits by GPs 43 per cent higher in the intervention group.
Not a holistic review
It should be emphasised that in the HOMER study the intervention was
described as: “Two home visits by a pharmacist … to educate
patients and carers about their drugs, remove out of date drugs, inform
general practitioners of drug reactions or interactions, and inform
the local pharmacist if a compliance aid is needed.” We would
argue, however, that this is not a holistic medication review, which
has been defined as “a structured critical examination of a patient’s
medicines with the objective of reaching an agreement with the patient
about treatment, optimising the impact of medicines, minimising the
number of medicine-related problems and reducing waste”.2
Thus a large component of what is commonly understood as a medication
review is to optimise the treatment regimen. This does not appear to
be a component of the intervention in this study but was an important
part of other studies.6–8
The authors speculated that the “counter-intuitive” findings
might have been due to:
· An increase in health care seeking behaviour by intervention patients
who had been educated by the pharmacists to recognise problems earlier
and to seek help
· An improvement in compliance leading to greater iatrogenic disease
· An increase in intervention patient confusion and anxiety about their
treatment
A number of comments relating to this study have subsequently been made
in correspondence addressed to the BMJ (bmj.bmjjournals.com).
In this study, pharmacists were doing a level 1 review, since they only
had access to the patient and his or her medicine supplies, although
they also had a copy of the discharge advice note which may or may not
include some clinical information. A review without access to the full
clinical record is limited and could be dangerous. A number of studies
have shown that discharge advice notes frequently contain incorrect information
with, for example, medicines omitted or incorrect doses.11,12 Encouraging
compliance with the discharge medicines regimen, without being able to
check GP records for accuracy, could have compounded iatrogenic disease.
It is interesting to note that there have been other studies in which
reviewers have been able to access the entire clinical record. These
studies recorded fewer hospital admissions than normal, although these
studies were not home-based medication reviews.12,13
Another comment that has been made about the HOMER study is that the
reasons for hospital admissions were not given. The hypothesis put forward
in the study was that hospital admissions could be reduced by identifying
and avoiding potential drug interactions and adverse drugs effects, and
by improving compliance. We do not know if interventions by the pharmacist
increased admission rates, and where there were fewer admissions, whether
this was due to a pharmacy intervention. This would be a difficult question
for the authors now to answer, because 21 different reasons for admission
were found and sub-group analysis of each one would lack statistical
power.
The HOMER study has implications for community pharmacists and MUR. In
the MUR model, pharmacists are likely to be doing a review of the medicines
with the patient but without full access to the clinical record and the
primary health care team. The HOMER study tests a model which is similar
to that advocated in the new pharmacy contract and from the results this
is not a comfortable proposition. So what do pharmacists need to do to
ensure good quality reviews? Our experience and that from other studies
suggests several criteria for effective pharmacist medication review
(see Panel).
Criteria for effective
pharmacist medication
review
· Ensure adequate training, accreditation and ongoing CPD
· Identify an experienced mentor to discuss ongoing problems
and options
· Establish appropriate links to ensure pharmacist is working
as part of the primary health care team
· Maintain effective working relationships with GPs and other
primary health care staff to allow identification of most suitable
patients
for review, access to the medical record and two-way communication
of problems and solutions
· Use a systematic approach to medication review
· Always involve the patient or carer
· Decide on the most important and realistic interventions for
the individual patient. Do not try to do too much at the first
review
· Before making a recommendation to the patient or GP check in
the medical notes to see if it is sensible to do so
· Ensure follow up to check that recommendations are acted upon
or reasons for not doing so are given |
We do not think that pharmacists and commissioners of new pharmacy
services should be unduly swayed by the HOMER study. The majority of
evidence
for pharmacist-conducted medication review, by trained and supported
pharmacists, who have access to patients and their clinical record,
shows a benefit to patients and the NHS.
References
1. Evidence shows medication reviews by pharmacists point way forward.
The Pharmaceutical Journal 2001;267:863–4.
2. Task Force on Medicines Partnership and The National Collaborative
Medicines Management Services Programme. Room for review. A guide to
medication review: the agenda for patients, practitioners and managers.
London; Medicines Partnership; 2002.
3. The New GMS Contract. The NHS confederation. Available at: www.nhsconfed.org/gms
(accessed 13 April 2005).
4. The Service Framework of the New Contract. The Pharmaceutical Services
Negotiating Committee. Available at: www.psnc.org.uk (accessed 13 April
2005).
5. Medication
review. Medicines Partnership.
(accessed 6 May 2005).
6. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A, Lowe CJ.
Randomised controlled trial of clinical medication review by a pharmacist
of elderly patients receiving repeat prescriptions in general practice.
BMJ 2001;323:1340–3.
7. Mackie CA, Lawson DH, Campbell A, Maclaren AG, Waigh R. A randomised
controlled trial of medication review in patients receiving polypharmacy
in general practice. The Pharmaceutical Journal 1999;263(Suppl):R7.
8. Krska J, Cromerty JA, Arris F, Jamieson D, Hansford D, Duffus PRS
et al. Pharmacist-led medication review in patients over 65: a randomized,
controlled trial in primary care. Age and Ageing 2001;30:205–11.
9. Lowe CJ, Petty DR, Zermansky AG, Raynor DK. Development of a method
for clinical medication review by a pharmacist in general practice. Pharmacy
World and Science 2000;22:121–6.
10. Holland R, Lenaghan E, Harvey I, Smith R, Shepstone L, Lipp A et
al. Does home based medication review keep older people out of hospital?
The HOMER randomised controlled trial. BMJ 2005;330:293.
11. Duggan C, Bates I, Hough J. Discrepancies in prescribing — where
do they occur? The Pharmaceutical Journal 1996;256:65–7.
12. Beagon P, Scott MG, McElnay JC. Quantifying the impact of an intensive
clinical pharmacy service on re-admission rates to hospital. Pharmacy
World and Science 2004;26(Suppl):A9.
13. Stewart S, Pearson S, Luke CG, Horowitz JD. Effects of home-based
intervention on unplanned readmissions and out-of-hospital deaths. Journal
of the Anerica Geriatric Society 1998;46:174–80. |
The
Pharmaceutical Journal