Pharmacist intervention in an elderly care facility

Systematic review and narrative synthesis of pharmacist provided medicines optimisation services in care homes for older people to inform the development of a generic training or accreditation process

OBJECTIVES

To develop a training programme to enable pharmacists with prescribing rights to assume responsibility for the provision of pharmaceutical care within care homes, a systematic review and narrative synthesis was undertaken to identify reported approaches to training pharmacists and use this literature to identify potential knowledge requirements.

METHODS

A PROSPERO-registered systematic review was performed using key search terms for care homes, pharmacist, education, training and pharmaceutical care. Papers reporting primary research focussed on care of the older person within the care home setting were included. No restrictions were placed on methodology. Two researchers independently reviewed titles, abstracts and papers. Agreement on inclusion was reached through consensus. Data on titles, training and activities undertaken were extracted and knowledge requirements identified. Findings were synthesised and reported narratively.

KEY FINDINGS

Fifty-nine papers were included, most of which were uncontrolled service evaluations. Four papers reported an accreditation process for the pharmacist. Thirteen papers reported providing tools or specific training on a single topic to pharmacists. The main clinical and therapeutic areas of activity (requiring codified knowledge) were dementia, pain, antipsychotic and cardiovascular medication. Provision of pharmaceutical care, effective multidisciplinary working and care home staff training represented the main areas of practical knowledge.

CONCLUSIONS

Information regarding training and accreditation processes for care home pharmacists is limited. This study provides insight into potential codified and practical knowledge requirements for pharmacists assuming responsibility for the provision of pharmaceutical care within care homes. Further work involving stakeholders is required to identify the cultural knowledge requirements and to develop a training and accreditation process.

Pharmacist services in nursing homes: A systematic review and meta-analysis

AIMS

Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown.

METHODS

Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes.

RESULTS

Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers.

CONCLUSION

Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

A classification system for issues identified in pharmaceutical care practice

Objective

To investigate the usefulness of a system for classifying pharmaceutical care issues (PCIs), defined in Scottish practice guidelines as “an element of a pharmaceutical need which is addressed by the pharmacist,” which were identified during the delivery of pharmaceutical care in a primary care setting.

Method

The classification system had 12 categories, each with a definition and examples reflecting the primary care setting to assist in assigning categories to individual PCIs. There was no category of “other” or “miscellaneous”. The system was used by two clinical pharmacists in a study involving 332 patients aged 65 years or over collecting four or more medicines regularly. The point at which PCIs were identified and resolved, the drugs involved and the actions required to resolve them were analysed for each type of PCI.

Setting

Six randomly selected medical practices in the Grampian region of Scotland.

Key findings

All 2,586 PCIs identified were successfully assigned one category within this classification system. The most commonly occurring types of PCI were “potential adverse drug reaction”, “need for monitoring”, “potentially ineffective therapy” and “need for education.” Most PCIs classed as “potential adverse drug reaction” and “need for monitoring” were identified from the prescription record. A third of “potentially ineffective therapy” PCIs, plus most PCIs classed as “drug use — no indication” and “indication — no treatment” were identified from medical records. Patient interview identified most of the PCIs categorised as “need for education,” “suspected adverse drug reaction” and “actual compliance issue.” Resolving the “need for education,” “suspected/actual compliance issue” and “out of date medicines” PCIs mostly involved the patient, whereas those involving changes to prescribed therapy or monitoring required contact with a health care professional.

Conclusion

The classification system was comprehensive in its coverage of PCIs arising from clinical pharmacists' direct patient care activities in a primary care setting. While the system requires further development and testing, it would appear to be a useful tool for researchers and practitioners to use in describing and comparing PCIs in different studies and using different practices.

HEALTH SERVICES RESEARCH METHODS IN PHARMACY: Evaluation of pharmaceutical services: (2) Methods and measures

Numerous studies have been undertaken to evaluate pharmaceutical services. These include both the evaluation of existing practice and assessments of innovative services in both hospital and community settings. Evaluation requires employment of methods and measures to ensure that relevant data on the effects of a programme are obtained. To evaluate a service from different perspectives (eg, acceptability to health professionals or patients, uptake, clinical outcomes or resource implications), a number of methods may be required. The outcomes may also be wide-ranging. Measures must be selected which provide a true reflection of the extent to which these outcomes are, or are not, achieved. Designs and frameworks used in the evaluation of pharmacy services have been discussed previously,1 this paper reviews the methods and measures that have been employed.

Health Services Research Methods In Pharmacy

The aim of this paper is to review the methodologies employed by health service and pharmacy practice researchers in the evaluation of pharmacy services. The review is in two parts. Part 1 discusses the application of different study designs and frameworks in the evaluation of existing and innovative services and interventions; part 2, to be published in a later issue, will address the methods and measures employed in the evaluation process. The studies included in this review were selected to give examples of different study objectives, designs and frameworks and their application in pharmacy settings. Although many of the issues regarding study design and evaluation frameworks may be relevant to clinical trials comparing the efficacy of alternative drug therapies, the focus of this paper is on pharmacy services.

Impact of medication regimen reviews performed by community pharmacists for ambulatory patients through liaison with general medical practitioners

Objective

To evaluate the cost and clinical benefits of the provision of medication regimen reviews (MRRs) by community pharmacists for patients identified and referred by a general practitioner using a collaborative approach.

Method

There were two cohorts of patients — 105 in stage 1 and 170 in stage 2 — from 34 GPs. The reviews were performed by 45 community pharmacists who had completed a training programme in MRR. The protocol was as follows: (1) a proforma MRR request form, including relevant clinical information and the patient's current regimen, was completed by the GP, (2) the review was conducted by the pharmacist and documented in a proforma report, (3) pharmacists and GPs met to discuss the review findings and recommendations for each patient, and (4) three months later, GPs were surveyed to verify any accepted recommendations and changes to medication regimen. A clinical panel estimated the clinical significance of the regimen changes for a subset of 141 cases.

Key findings

The patients had an average of five diagnoses, with cardiovascular disease (34 per cent) and musculoskeletal disease (15 per cent) the most common conditions. A total of 2,220 medications were prescribed, representing a mean of eight per patient. In all, 869 changes to therapy were observed at the three-month follow up: 47 per cent drug ceased; 17 per cent dose reduced; 11 per cent dose increased; and 12 per cent drug changed. Examining the impact of MRR on the mean number of medications per patient, the null hypothesis of no difference pre- and post-MRR was rejected. There was a mean reduction of one medication per patient (P<0.001). As a consequence of this reduction, the average annual cost of medications was reduced by $A240 per patient. This translated to a projected annual cost saving for medication alone of $A90 per patient after offsetting the $A150 cost (professional remuneration) of the MRR. Considering health outcomes, overall, the reviewers rated at least 40 per cent of the MRR changes as leading to a positive effect on the patient's health.

Conclusion

This study provides a good indication that MRR through GP-pharmacist collaboration in the community can lead to positive clinical benefits and reduction in health care costs.

Pharmacist-led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives

To ascertain general practitioners' views of a pharmacist-led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems.

Method

Semi-structured interviews with a purposive sample of six GPs informed the development of a self-completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free-text responses were sought on benefits, problems and areas for future improvement.

Key findings

The response rate was 84% for GPs (93% of practices were represented). Ninety-five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP-pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP-pharmacist communication and extended pharmacist roles.

Conclusion

The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.

Psychotropic prescribing in long-term care facilities: impact of medication reviews and educational interventions

The objective of this literature review was to evaluate the evidence pertaining to the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. A computerized search was conducted using MEDLINE, Cochrane Central Register of Control Trials, CINAHL, EMBASE, International Pharmaceutical Abstracts and PsycINFO, from January 1980 to April 2007. Controlled studies or randomized controlled studies were included for review. The authors identified 26 studies evaluating the impact of medication reviews and/or educational interventions on psychotropic drug use in long-term care facilities. Eleven studies met the inclusion criteria for this review and the data from six of these studies were included in a meta-analysis. The pooled odds ratio (OR) from five studies on hypnotic prescribing showed a decrease in use postintervention (OR = 0.57, 95% confidence intervals [CI] = 0.41-0.79). The pooled OR from five studies on prevalence of antipsychotic prescribing postintervention was not significant (OR = 0.81, 95% CI = 0.63-1.04). Medication reviews and/or educational interventions are effective at reducing psychotropic drug prescribing. However, research on the benefits of these interventions in reducing psychotropic drug use on total health care costs and resident health outcomes is lacking.

Pharmacotherapeutic interventions by a multi-specialty team: opinions of the general practitioners and nurses

OBJECTIVES

The objective of this study was to assess the opinions of the general practitioners (GPs) and nurses towards a previous pharmacotherapeutic intervention and their opinions towards future alternative or complementary methods to improve nursing-home patients' drug treatments.

METHODS

Sixty-six GPs and forty-five nursing-home nurses, working at nursing homes in southern Sweden, were sent a questionnaire to assess their opinions towards a pharmacotherapeutic intervention conducted by a multi-specialty team and their opinions on alternative or complementary future methods potentially improving patient treatment.

RESULTS

The response rate was 62% for the GPs and 69% for the nurses. Both GPs and nurses were positive towards further co-operation regarding pharmacotherapeutic interventions. All nurses that were positive to further co-operation wished to do it in a multidisciplinary team, whereas some GPs wished to do this in a multi-specialty team.

CONCLUSION

The opinions of GPs and nurses towards the pharmacotherapeutic intervention indicate that this or similar methods may successfully be used in clinical practice for improving drug therapy.

Clinical pharmacy interventions by community pharmacists during the dispensing process

AIMS

To evaluate the professional contact between the community pharmacist and general practitioner during the dispensing process on issues other than the legality or simple clarification of the prescription.

METHODS

Fourteen community pharmacists from five adjacent localities completed details of each clinical pharmacy intervention during 1 week of each month for a period of 1 year. Each week of the month was randomly selected. When a community pharmacist had to contact the prescriber, during the dispensing of a prescription, the following data were recorded: brief patient details, the prescribed drug therapy, the reason for intervention, the outcome and the time taken. The main outcome measures were the type and nature of each intervention, the BNF category of the drug involved and the time taken. A multidisciplinary clinical panel assessed the potential of each intervention to alter the outcome of the patient's clinical management and to prevent a drug related hospital admission. These assessments were ranked between 0 and 10 (100% confident).

RESULTS

During a period covering 1 week per month over 1 year, 1503 clinical pharmacy interventions were made out of 201 000 items dispensed. When normalized for the dispensing volume of each community pharmacy the lower the number of items dispensed then the greater was the percentage of interventions (P=0.013). The clinical panel decided that between 19 (0.01% of the total items dispensed) and 242 (0.12%) interventions may have prevented a drug-related hospital admission, 71 (0.04%) to 483 (0.24%) could have prevented harm whilst 103 (0.05%) to 364 (0.18%) had the potential to improve the efficacy of the intended therapeutic plan. The panel also decided that 748 (0.37%) interventions improved the clinical outcome and could have saved a visit to or by the general practitioner. Conclusion Clinical pharmacy provided by a community pharmacist during the dispensing process has the potential to provide a valuable contribution to health care.

Medication use in nursing homes for elderly people

Residents of nursing and residential homes are often prescribed medication for physical and mental ill-health with resultant polypharmacy and the possibility of iatrogenic disorders. Sometimes drugs are prescribed inappropriately and a number of studies have highlighted the overuse of psychotropic drugs. Legislation in the USA has been effective in controlling their use in that neuroleptic prescriptions for the treatment of behavioural disturbances have been significantly reduced and non-pharmacists have a role to play in the appropriate management of medicines in elderly residents; they can improve patient care and be cost-effective. Identification of methods by which to improve awareness of inappropriate medication prescription and to avoid certain types of drugs is required. This review critically evaluates medication use in this population with specific reference to psychotropics and aims to raise awareness of the issue.