The Pharmaceutical Journal
Vol 278 No 7452 p582
19 May 2007

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Reflections on the latest investigation into medication review by pharmacists

By Nina Barnett and Felicity Smith

Over the past few years there have been a number of national imperatives that have promoted the role of pharmacists in undertaking various forms of medication review. So it is with some interest that we note a trial published online on 20 April 2007 which suggests that pharmacists are neither effective nor desirable as implementers of this form of patient support.

This study, by Salter et al, involved a cohort of 29 patients taken from the HOMER trial population of 758 patients. The authors of the new paper conclude that the advice-giving role of pharmacists in this patient group has the potential to “undermine and threaten patients’ assumed competence, integrity and self-governance”.

Pharmacists could be forgiven for taking a defensive stance in the light of these findings, but there are important lessons from within the study. This work also provides a note of caution to those who might extrapolate from concluding statements and headlines, such as “I haven’t even phoned my doctor yet.”

Research method

The researchers used “discourse analysis”, which enables the detailed study of text: in this case, conversation between pharmacists and patients. Discourse analysis provides insights into characteristics of an interaction and an assessment of the strengths and weaknesses of the communication process. The paper highlights the importance of appropriate communication skills for an effective consultation, as well as how and why many of these interactions might be deemed to have failed — important lessons for all health professionals.

The authors’ starting point seems to be that “pharmacists are still viewed primarily as shopkeepers”’, for which some evidence is presented. This simplistic approach is provided in lieu of an extensive literature search on both the wider roles of pharmacists and research regarding interactions with any health care professionals.

Communication style

The pharmacists undertaking the reviews in the study each had at least 15 years’ experience as community pharmacists. As part of the study, they also participated in a two-day course, which addressed relevant clinical therapeutics and communication issues.

Reviews were conducted in patients’ homes. In the results, the authors comment that the pharmacists’ consultation style was mainly didactic. We must keep an open mind on the skills required for different practice activities and the broad criticism of consultation skills uncovered in this research may be justified.

However, communication is a two-way process and pharmacists would have difficulty developing a constructive discussion using open questions if the patients did not wish to be forthcoming — which is their prerogative, especially in their own homes. A dysfunctional consultation would be unsatisfactory for both pharmacists and patients, and could not be expected to achieve positive therapeutic outcomes. This is an important lesson for commissioners of medication review services.

The study also gives us the opportunity to consider patient selection and targeting with respect to medication reviews. In this trial, the patients were deemed eligible according to mental test scores and if they had had a previous hospital admission. However, the sampling selection and recruitment procedures are unclear. A representative sample would, on the face of it, seem a strong approach, although there is no statement that a random procedure was followed or detail of a purposive sample, or otherwise. It appears the reviews were not initiated following an expressed need by either patients or prescribers.

Patients’ and pharmacists’ perspectives

The theoretical perspective that provides the conceptual framework for the paper raises some questions. For example, we know that patients draw on their own views and experiences in making decisions about their use of medicines. The basis of concordance is a partnership between two autonomous individuals who agree a course of action. In its application to medication review, an agreement to participate in the programme should be based on a clear understanding by patient and pharmacist of its objectives and processes. We note that there is no indication whether patients, pharmacists or GPs felt that a medication review was warranted or desirable.

We suggest that all people (perhaps, especially, older people) might be wary of unfamiliar patterns of care. The only factor known to be predictive of patients desire to be involved in decisions about their medicines is age. Older people are significantly more likely than younger people to prefer medication-related decisions to be taken by their doctor rather than other health care professionals. People who recognise they have medication-related problems are more likely to be ready to discuss them and this study does not acknowledge this.

The pharmacists in the study had no existing relationship with the patients nor were they part of the patient’s existing health care team. In this situation, one might expect that patients would wonder how the review fitted with their ongoing care and existing long-term relationships with health care professionals. The study suggests that patients want involvement by the GP, as their primary health care provider, and this may be an important factor in determining their acceptance of these reviews.

The issue of one-off reviews by pharmacists has also been raised in the recently published HeartMed study (conducted by the researchers of the HOMER trial), in which input from pharmacists is observed not to reduce hospital admissions when providing outpatient heart failure support services. Together these findings may lead us to question the value of one-off visits by pharmacists.

Finally, we need to consider the type of medication review that was undertaken. There is no standard definition of a medication review given in the paper. We are aware of a number of different types, which require different background information and have a variety of uses. Without a description of how the reviews were performed, whether they were patient-led, scripted or conducted using forms or guidelines and, if there were any objectives for the reviews, it is difficult to interpret their effects. The type of review is likely to have affected patients’ ability and desire to ask questions and, therefore, interpretation of the results must be taken in the context of the type of review undertaken.

Summary

We are aware of a number of important questions raised by this study for both individual pharmacists and primary care trusts. Discourse analysis is a powerful tool. In an appropriately designed study, its application to supporting effective interaction in medication reviews could be invaluable. We recognise the need to understand what training and practice is required for pharmacists who undertake these reviews. However the question remains: what are the relative benefits from one-off medication reviews done outside the health care team and not requested by patients compared with those undertaken as part of an ongoing health care process, from within the team and with patient participation?