Health Service Research and Pharmacy Practice
Concerns about MUR service revealed
There is a divide between independent and multiple pharmacies in the
way medicines use reviews (MURs) have been prioritised, according to
Rebecca Elvey, of the University of Manchester, who presented some results
from a national study funded by the Department of Health.
Last summer, 44 interviews were carried out with primary care trust leads,
local pharmaceutical committee representatives and community pharmacists
at various sites around England. Three key issues were identified, said
Ms Elvey.
First, pharmacists working in independents found MURs time-consuming
and difficult to fit into their day-to-day routine. Secondly, there were
concerns that pharmacy multiples are putting pressure on their employees
to achieve the maximum number of MURs. And, thirdly, although MURs were
designed to improve concordance and patients’ understanding of
medicines, pharmacists were making clinical recommendations seen as inappropriate
by primary care trusts and GPs.
Ms Elvey concluded that further training for pharmacists on the appropriate
use of MURs may be necessary to ensure that they are successfully embedded
into community pharmacy service provision and that they fulfil their
potential.
Asam Latif, of the University of Nottingham, presented the results of
a survey that addressed pharmacists’ attitude towards medicines
use reviews and whether certain factors influence the number of MURs
performed.
A questionnaire was sent to 280 accredited pharmacists working within
one community pharmacy chain during April and May 2006.
Mr Latif found that pharmacists perceive MURs to be of value to patients
and see them as an opportunity for an extended role. However, several
barriers remain, including a lack of time, support staff, financial incentives
and issues surrounding the consultation area.
The results indicated that the number of MURs undertaken is influenced
by job role, the presence of a consultation area and whether pharmacists
work full- or part-time. Store-based pharmacists carried out the most
MURs and relief pharmacists carried out the least, he said. Gender, time
since qualification, store size and completion of a clinical diploma
did not affect the number of MURs carried out. “This finding may
indicate that it is the barriers that are preventing pharmacists engaging
in the service rather than a lack of confidence,” he said.
Melandi Van den Berg: leaflets feature inconsistent terminology |
Melandi Van den Berg, of Kingston University, examined how MURs are
symbolised and given meaning via printed patient information. Patient
recruitment
has been identified as a barrier to uptake of MURs and information leaflets
play a key role in promoting the service, explained Ms Van den Berg.
She looked at 10 MUR leaflets, including those from the Department of
Health, the NHS, wholesalers and multiples, and conducted a detailed
analysis of the images and language used. She explained that the leaflets
generally target people with problems or questions. “At the moment,
the service is reactive, relying heavily on patients’ ability to
identify that they have a problem and access the service as a result.” It
is for pharmacists to identify the problems during an MUR. That way the
service becomes proactive, she added.
Ms Van den Berg also pointed out that none of the leaflets explicitly
describes the MUR as new and the images used often depict a traditional
interaction between pharmacist and patient (ie, over the counter). “The
MUR service is new, with a different mode of interaction. The illustrations
do not show an MUR,” she explained.
Ms Van den Berg highlighted that the leaflets feature inconsistent and
interchangeable use of formal and informal terminology, including “review
meeting”, “focus appointment” and “chat”.
Nicola Davey, of Hampshire Primary Care Trust, commented that she has
been “appalled” at the way MURs have been marketed by some
community pharmacists, for example, implying it is a quick process and
offering free videos and books if people participate. “The tenor
of it undermines the professionalism of pharmacists. The marketing needs
to be more sophisticated and evidence-based,” she said.
MURs can threaten relationships with GPs
Although the new contract has the potential to improve integration of
pharmacists within the primary health care team it has not done so yet,
according
to Fay Bradley, of the University of Manchester.
Ms Bradley conducted 44 interviews with pharmaceutical advisers, local
pharmaceutical committee representatives and community pharmacists across
10 PCTs in England during August and September 2006. She found several
examples that suggested MURs could have a negative affect on integration
and threaten relationships with GPs. “There was a perception that
GPs viewed MURs negatively and did not welcome them. Some felt that GPs
had formed this opinion as a result of some poor quality or overly detailed
and clinical MURs being carried out,” she said.
To overcome these
problems, one PCT was using an incentive scheme to ensure that GPs met
with pharmacists to discuss which patients to target and to agree on
a process of feedback. This has resulted in fewer, but better quality,
MURs
being conducted.
Overall, the results suggest that the new contract had not increased
the level of integration, with most examples of successful integration
in existence
before the contract was introduced, said Ms Bradley.
Hospital admissions
Measuring the effectiveness of pharmacist medication review by its impact
on hospital admissions is unlikely to show significant benefits, according
to research presented by Janet Krska and Phil Rowe, of Liverpool John
Moores University. Mr Rowe demonstrated that detecting changes in total
admissions is extremely difficult because only a minority of patients
receiving reviews will be admitted to hospital.
In addition, only a small
proportion of admissions are drug-related and preventable. He calculated
that at least 100,000 people would need to be admitted to detect an effect
on total admissions. To detect a change in preventable drug-related admissions,
a more realistic sample size of 1,000–5,000 would be needed. “Different
endpoints, such as compliance, may be more statistically achievable,” he
said. |
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Pharmaceutical Journal