Prescribing & Medicines Management
page PM1
June 2005

Features

Approaches to medication reviews

Pharmacists, doctors and nurses are different. So it should come as little surprise that each profession has its own approach to medication review. However, identifying these differences and distilling the information to develop best practice can be tricky. Although plenty of research exists on pharmacist-conducted reviews, there is a lack of published evidence on doctor- and nurse-conducted reviews. That is not to say they do not conduct reviews: in fact, the Medicines Partnership’s guide to medication review, “Room for review”, published earlier this year shows that at least as many GPs and nearly as many nurses are involved in medication review as pharmacists. However, the paucity of evidence means that identifying differences comes largely down to the observations of those involved in medication review research.

Observations

Gianpiero Celino, director of Webstar Health (which evaluated “Room for review” for the Medicines Partnership), told P&MM that if you consider medication review to be everything from checking that repeat medicines are synchronised to intensive face-to-face consultations, then lots of different people are involved in the process. Pharmacists and technicians often carry out technical reviews. “Where there are face-to-face reviews, most of them are carried out by [practice] pharmacists,” he said.

The Medicines Partnership is to publish an evaluation of patients’ experiences of medication reviews later this summer. According to Geraldine Mynors, head of projects at the Medicines Partnership, community pharmacists are less likely than GPs, or pharmacists employed by GP practices, to conduct face-to-face reviews. She suggested that this might be explained by a lack of time, coupled with a lack of confidence and competence. Alternatively, it could be that pharmacists take a more technical approach to reviews, and put less emphasis on talking to patients.

Mr Celino said that the new GP contract could help to explain the difference in approach. “Regular review of patients’ medicines is a quality marker in the new GP contract but it does not define what a medication review is. So while some GPs are doing face-to-face reviews, others are taking a paper-based approach without the patient being present. Both seem to suffice for the purpose of getting the quality points,” he said.

Focus

“Pharmacists tend to be able to focus on the medicines rather than the patient, whereas GPs focus on the patient and end up discussing new complaints instead of sticking to the medication review,” according to Janet Krska, practice pharmacist, Kirriemuir Health Centre, Angus, who has researched the differences in outcomes achieved by pharmacists, doctors and nurses in medication review. In one study (IJPP 2002;10[Suppl]:R86 PDF 80K), Dr Krska found that pharmacist- and nurse-conducted reviews resulted in fewer changes to drug therapy and monitoring than reviews conducted by GPs. Why? Dr Krska speculates that this could be a result of GPs having more confidence to make changes. However, she has found that experienced clinical pharmacists are better than GPs at identifying pharmaceutical care issues.

Another difference, pointed out by Ms Mynors, is that GPs tend to be more opportunistic in conducting reviews whereas pharmacists actively look for patients to review. Mr Celino said that in some cases, patients were not aware that the GP had conducted a review. “The review had not provided an opportunity for two-way dialogue,” he explained. The reason behind this is the question of whether or not GPs buy into the concept of patients being partners in medicines-taking. “Pharmacists have adopted this message, they know about ‘Room for review’ but it is a bit more hit and miss with GPs,” he said. Knowledge of this document also seems to influence whether or not a reviewer takes a structured approach.

Dr Krska also believes there are differences in how the professions select patients for reviews. She said that pharmacists generally pick elderly patients and those taking multiple medicines, whereas GPs go for an annual approach and nurses are more likely to review patients who have a specific chronic disease.

Patient perspective

The Medicines Partnership has found a difference in what patients feel comfortable talking about. “Patients expressed a reluctance to bring up what they thought about their medicines with the GP. They were much less inhibited with the pharmacist and felt they could be honest but, on the other hand, thought the pharmacist could not do anything without going back to the GP,” said Ms Mynors. Patients also perceived that pharmacists’ purpose of reviews was to check up on whether they were taking their medicines.

In addition, Dr Krska has found differences between medication reviews provided by GPs and nurses (IJPP 2005:13:77). Before they were trained, GPs tended to conduct reviews using case notes — the patient was not present. They also missed things: an evaluation of 45 reviews identified 79 missed pharmaceutical care issues, most commonly no record of a drug’s indication and inappropriate dose or directions. “The GPs were taking a systematic approach but because the patient was not there, they were missing things,” she said. “Evidence shows that 70 per cent of issues can be picked up from patients’ notes; the remaining 30 per cent will be missed unless the patient is there. How else can you assess compliance and investigate potential side effects,” she asked. After training, the average number of missed pharmaceutical care issues decreased from 1.75 per patient to 0.8 per patient. Nurses achieved the same figure — 0.8 missed issues per patient. However, a difference between the types of issues missed was identified. For GPs, the issues most commonly missed were the need for monitoring to be undertaken, no record of the drug’s indication, dosage problems and cost-effectiveness issues. Nurses were less able than GPs to identify ineffective or poorly tolerated medicines.

Perhaps the best thing is to forget the differences and remember that the Medicines Partnership found that patients valued having a review, no matter who conducted it.