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Natalie Lane is production editor for
journals at the Pharmaceutical Press, London
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One of the two review articles published in the March issue of The
International Journal of Pharmacy Practice aims to identify methods for evaluating
specialist heart failure patients. Tracey-Lea Hargraves et al discuss
how efforts are being made to increase the optimisation of disease management
programmes for heart failure patients. Since such patients may be taking
more than four medicines daily and have other illnesses, there is an
increased risk of adverse events. It is suggested that pharmacists may
have the most relevant training with regards to educating patients about
the safe use of medicines, improving adherence by simplifying regimens
and monitoring for adverse drug events.
The authors’ objective was to “identify appropriate methods
to evaluate a specialist pharmacy service for heart failure patients”.
A literature search of several databases was limited to studies between
1996 and April 2003. Seventeen studies were identified but only six evaluated
outpatient pharmacy services for heart failure. All six addressed patient
education regarding the importance of prescribed medicines and compliance,
and four also emphasised non-pharmacological management and self-monitoring.
From two studies, patient knowledge of prescribed medication had improved
after pharmacist-led education but compliance varied. A valid method
for measuring non-compliance is needed in compliance research and remains
a barrier to results otherwise.
The authors discuss identifying whether different settings for means
of delivery would be associated with defined study endpoints and look
at the optimum number of pharmacy services and length of follow-up which
produced “sustainable benefit”. Primarily, they recommended
identifying the specific components that had “the most impact on
outcome measures” in order to deliver a time- and cost-efficient
outpatient pharmacy service for heart failure. Issues and recommendations
highlighted from this review may also be applied to outpatient services
as for diabetes and hypertension.
Repeat dispensing
The second review article focuses on the impact of repeat dispensing
in community pharmacies. In light of the new community pharmacy contract,
which includes repeat dispensing as an essential service in England
and Wales, Morecroft et al assess the quality of published evidence,
since there are few published randomised controlled trials in the pharmacy
practice research and service development field. Several electronic
databases were searched from 1992 to May 2005, as well as electronic
catalogues from three libraries, online editions of The Pharmaceutical
Journal and the IJPP and abstracts.
Four RCTs and a before-and-after study were identified. All four RCTs
lacked details about how sample size was determined and other “quality
criteria” were absent from the published data. Thus, each RCT “failed
to meet the Health Development Agency standards of transparency and systematicity
[sic]”. The authors note that only two RCTs reported outcome measures
relating to the impact of repeat dispensing on quality of care and discuss
the different perceptions of repeat dispensing from various stakeholders,
including community pharmacists and patients.
Three RCTs were poorly reported, which had implications for the conclusions
that the review was able to draw. Key findings from the review indicated
patient satisfaction with repeat dispensing as a service, due to increased
convenience and the reduction of time required to obtain prescribed medicines.
Health care professionals’ satisfaction was influenced by the workload
involved and several studies indicated cost savings for the NHS drug
budget. It was noted that comparisons between the intervention and control
groups were not stated in most RCTs and different intervention strategies
could impact on the study outcomes. Smaller studies that did not meet
the inclusion criteria for the review were excluded as a limitation and “publication
bias may have influenced the findings of this review”. Certainly,
the key outcome is a lack of robust evidence and “future research
should address this by more transparent reporting of outcomes”.
In summary, Morecroft et al highlight the need to explore the quality
of patient care now that one system of repeat dispensing is being introduced.
HOMER RCT measures
The Home-based Medication Review trial (the HOMER trial, first published
in the BMJ) reviewed whether home-based medication review by pharmacists
could lower hospital readmission rates in older people. The trial recruited
872 participants (control and intervention) aged over 80 years and the
primary outcome was the “total number of emergency hospital admissions” occurring
in a six-month period. The results saw an increase in hospital readmission
rates.
The recruited review pharmacists were provided with further training
in medication review before being allocated patients. Pharmacists were
expected to “review the discharge medication, considering the dose,
frequency, length of time it would be prescribed for [and] likely side
effects” and consider the patient’s regimen as a whole (following
a basic assessment of the patient). Pharmacists asked patients which
over-the-counter medicines they took and for each drug used pharmacists
were to ascertain if patients knew why they were taking it. First and
second visits were detailed on a medication review form. The follow-up
visits were used to establish if recommendations had been implemented,
whether those recommendations had helped the patient, and if new problems
now existed for the patient. The results of
issues such as ADRs noted during visits, medicanes storage and hoarding,
and recommendations to GPs and local pharmacists are all discussed.
Limitations included pharmacists’ availability in terms of time,
the information available to the review pharmacists provided limited
clinical information, and the lack of direct access to GPs to discuss
recommendations and the difficulty of ensuring whether GPs had implemented
the recommendations.
Comparison with other medication review studies saw the authors conclude
that the HOMER intervention was conducted similarly. Yet a comparison
of recommendations made saw similarities to studies involving multiple
pharmacists but “fewer recommendations were enacted than in those
studies involving single pharmacists in close liaison with prescribers”.
The authors voice concern that the NHS is about to implement an approach
whereby community pharmacists review patients “at a distance from
the GPs who make the patient’s treatment decisions” and feel
that there is an “urgent” need to refine this intervention,
investigate the patients’ perspective, identify a location for
the intervention’s delivery and develop training to ensure the
best delivery. |
The
Pharmaceutical Journal