The effectiveness and cost of integrating pharmacists within general practice to optimize prescribing and health outcomes in primary care patients with polypharmacy: a systematic review

Effectiveness at long-term of a multidisciplinary intervention in the reduction of overuse of benzodiazepine prescriptions: A cluster controlled trial

BACKGROUND

The overuse of Benzodiazepines (BZD) has become an area of concern because of its consequences on patients' health and healthcare costs.

OBJECTIVE

to determine whether a multicomponent intervention based on a multidisciplinary education program is effective in withdrawal from BZD long-term use, compared to usual care.

METHODS

Cluster-randomized, parallel-group trial with health centres as units of randomization and patients as units of analysis.

INCLUSION CRITERIA

adults with more than 4 weeks of BZD use, without serious mental disorder, non-terminal, without alcohol dependence or dementia.

INTERVENTION

(i) discussion with the patient describing the advantages, disadvantages and alternatives of BZD use accompanied by tapering protocol with educational material, (ii) the offer of a brief consultation, and (iii) a letter addressed to the patient supported by 6 scientific societies. The primary outcome was dispensing of BZD. Socioeconomic variables and others related with the consumption of BZD (Indication, previously attempted to cease and duration of use).

ANALYSIS

The effect of the intervention on the rate of dispensing of BZD using the multivariable generalized-estimating-equations (GEE) extension of logistic regression.

RESULTS

Complete cessation of dispensing BZD at six months after the intervention was achieved in 108 of 333 participants (32,4 %) compared to 27 of 139 controls (19,4 %). This decrease was maintained over 5 years (41,7 % vs. 33,8 %). Adjusted absolute risk difference was -14.3 (-19.6 to -9.5). An adjusted OR 2.11 (95 % CI, 1.24-3.59). Those with high income were more likely to quit using BZD with the intervention as those with a lower income (OR 1.81, IC 95 % 1.13-2.9, p = 0.012). Similarly, those who had previously tried to withdraw from BZD were more likely to stop using with the intervention (OR 1.8, IC 95 % 1.17-2.8, p = 0.007). Those with high income were more likely to quit using BZD with the intervention as those with a lower income (OR 1.81, IC 95 % 1.13-2.9, p = 0.012). Similarly, those who had previously tried to withdraw from BZD were more likely to stop using with the intervention (OR 1.8, IC 95 % 1.17-2.8, p = 0.007).

CONCLUSIONS

The intervention was effective at 6 months and its effects persist up to 5 years. The factors favouring interruption BZD seem to be having a high income and a previously tried to withdraw from BZD.

Adoption of clinical pharmacist roles in primary care: longitudinal evidence from English general practice

BACKGROUND

Over the past decade, the number of clinical pharmacists working within multidisciplinary teams in English general practices has expanded.

AIM

To examine changes in quality of prescribing after the adoption of clinical pharmacist roles in English general practices.

DESIGN AND SETTING

Longitudinal cohort study in English general practice.

METHOD

Two-way fixed-effects regression was used to compare differences in prescribing indicators in general practices with and without pharmacists between September 2015 and December 2019.

RESULTS

Between September 2015 and December 2019, the proportion of practices employing a clinical pharmacist increased from 236/7623 (3.1%) to 1402/6836 (20.5%). Clinical pharmacist implementation resulted in statistically significant reductions in total costs of medicines per 1000 patients (-0.85%, 95% confidence interval [CI] = -1.50% to -0.21%), the total number of opioid prescriptions per 1000 patients (-1.06%, 95% CI = -1.82% to -0.29%), and the average daily quantity of anxiolytics per 1000 patients (-1.26%, 95% CI = -2.40% to -0.12%). Clinical pharmacist implementation also resulted in reductions in the total number of prescriptions per 1000 patients (-0.58%, 95% CI = -1.30% to 0.13%) and the total number of antibiotic prescriptions per 1000 patients (-0.51%, 95% CI = -1.30% to 0.27%) that trended towards statistical significance. There were no statistically significant differences in the share of broad-spectrum versus narrow-spectrum antibiotics (0.02%, 95% CI = -0.07% to 0.11%) and the oral morphine equivalence of high-dose opioids (>120 mg per 24 h) per 1000 patients (1.19%, 95% CI = -0.46% to 2.85%).

CONCLUSION

This analysis is limited by practice-level data but supports the hypothesis that clinical pharmacist implementation results in improvements in prescribing quality.

Pharmacotherapy and psychological support: Integrating pharmacists into comprehensive cancer care - a literature review

Cancer presents significant physical and mental challenges to patients. Therefore, psychological assessment is important following a cancer diagnosis, as well as during and after chemotherapy. In cancer treatment, the goal of healthcare providers, including pharmacists, should be to deliver holistic care that addresses important aspects of patients' health, with particular emphasis on their psychological readiness to combat their diseases. This article reviews published literature from Google Scholar and PubMed to examine the relevant pharmacotherapy and psychotherapy approaches to managing psychological issues in cancer patients. This article also discusses how pharmacists can be integrated into cancer patients' mental health care, while highlighting the potential benefits and challenges associated with this approach. We conclude that the integration of pharmacists into psychological care and support for cancer patients holds promise due to their knowledge of cancer chemotherapy, their ability to improve their knowledge about psychological care, and their capacity to collaborate with other healthcare professionals in cancer treatment.

Collaborative discussions between GPs and pharmacists to optimise patient medication: a qualitative study within a UK primary care clinical trial

BACKGROUND

There has been significant investment in pharmacists working in UK general practice to improve the effective and safe use of medicines. However, evidence of how to optimise collaboration between GPs and pharmacists in the context of polypharmacy (multiple medication) is lacking.

AIM

To explore GP and pharmacist views and experiences of in-person, interprofessional collaborative discussions (IPCDs) as part of a complex intervention to optimise medication use for patients with polypharmacy in general practice.

DESIGN AND SETTING

A mixed-method process evaluation embedded within the Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP) trial conducted in Bristol and the West Midlands, between February 2021 and September 2023.

METHOD

Audio-recordings of IPCDs between GPs and pharmacists, along with individual semi-structured interviews to explore their reflections on these discussions, were used. All recordings were transcribed verbatim and analysed thematically.

RESULTS

A total of 14 practices took part in the process evaluation from February 2022 to September 2023; 17 IPCD meetings were audio-recorded, discussing 30 patients (range 1-6 patients per meeting). In all, six GPs and 13 pharmacists were interviewed. The IPCD was highly valued by GPs and pharmacists who described benefits, including: strengthening their working relationship; gaining in confidence to manage more complex patients; and learning from each other. It was often challenging, however, to find time for the IPCDs.

CONCLUSION

The model of IPCD used in this study provided protected time for GPs and pharmacists to work together to deliver whole-patient care, with both professions finding this beneficial. Protected time for interprofessional liaison and collaboration, and structured interventions may facilitate improved patient care.

Development, implementation, and evaluation of an advanced primary care pharmacist pilot training program as a strategy to enhance team-based primary care

Canada's 50,000+ pharmacists play a crucial role in the comprehensive delivery of primary care. Recognizing this, a program in alignment with the Team Primary Care national initiative was developed to enhance their skills and knowledge in collaborative care, aiming to cultivate advanced primary care pharmacist leaders. The curriculum development involved aligning activities with pharmacist roles and competencies, emphasizing interprofessional teamwork. A mixed-methods evaluation revealed positive outcomes: 14/15 pharmacists completed the program, reporting improved readiness for team-based care. All non-pharmacist team members expressed a desire for continued pharmacist collaboration. Overall, satisfaction was high among participants and team members, indicating success in training. The program's comprehensive approach, covering primary care landscape, clinical skills, teaching, change management, and advocacy, empowered pharmacists to integrate team-based care and contribute to positive change in primary care settings. Training more pharmacists with this program is one of the many strategies to further establish and optimize team-based primary care.

Pharmacist-led primary care interventions to promote medicines optimisation and reduce overprescribing: a systematic review of UK studies and initiatives

OBJECTIVES

To systematically review and synthesise evidence on the effectiveness and implementation barriers/facilitators of pharmacist-led interventions to promote medicines optimisation and reduce overprescribing in UK primary care.

DESIGN

Systematic review.

SETTING

UK primary care.

METHODS

We searched MEDLINE, Embase, CINAHL PsycINFO and The Cochrane Library for UK-based studies published between January 2013 and February 2023. Targeted searches for grey literature were conducted in May 2023. Quantitative and qualitative studies (including conference abstracts and grey literature) that addressed a relevant intervention and reported a primary outcome related to changes in prescribing were eligible for inclusion. Quality of included studies was assessed using the Multiple Methods Appraisal Tool. We performed a narrative synthesis, grouping studies by publication status, setting and type of data reported (effectiveness or implementation).

RESULTS

We included 14 peer-reviewed journal articles and 11 conference abstracts, together with 4 case study reports. The journal articles reported 10 different interventions, 5 delivered in general practice, 4 in care homes and 1 in community pharmacy. The quality of evidence was higher in general practice than in care home settings. It was consistently reported that the intervention improved outcomes related to prescribing, although the limited number of studies and wide range of outcomes reported made it difficult to estimate the size of any effect. Implementation was strongly influenced by relationships between pharmacists and other health and care professionals, especially general practitioners. Implementation in care homes appeared to be more complex than in general practice because of differences in systems and 'culture' between health and social care.

CONCLUSIONS

Pharmacist-led interventions have been reported to reduce overprescribing in primary care settings in the UK but a shortage of high-quality evidence means that more rigorous studies using high-quality designs are needed. More research is also needed in community pharmacy settings; to assess intervention effects on patient outcomes other than prescribing and to investigate how reducing overprescribing can impact health inequalities.

PROSPERO REGISTRATION NUMBER

CRD42023396366.

Economic cost-benefit analysis of person-centred medicines reviews by general practice pharmacists

BACKGROUND

Medicines reviews by general practice pharmacists improve patient outcomes, but little is known about the associated economic outcomes, particularly in patients at higher risk of medicines-related harm.

AIM

To conduct an economic cost-benefit analysis of pharmacists providing person-centred medicines reviews to patients with hyperpolypharmacy (prescribed ≥ 10 regular medicines) and/or at high risk of medicines-related harm across multiple general practice settings.

METHOD

Service delivery costs were calculated based on the pharmacist's salary, recorded timings, and a general practitioner fee. Direct cost savings were calculated from the cost change of patients' medicines post review, projected over 1 year. Indirect savings were calculated using two models, a population-based model for avoidance of hospital admissions due to adverse drug reactions and an intervention-based model applying a probability of adverse drug reaction avoidance. Sensitivity analyses were performed using varying workday scenarios.

RESULTS

Based on 1471 patients (88.4% with hyperpolypharmacy), the cost of service delivery was €153 per review. Using the population-based model, net cost savings ranging from €198 to €288 per patient review and from €73,317 to €177,696 per annum per pharmacist were calculated. Using the intervention-based model, net cost savings of €651-€741 per review, with corresponding annual savings of €240,870-€457,197 per annum per pharmacist, were calculated. Savings ratios ranged from 181 to 584% across all models and inputs.

CONCLUSION

Person-centred medicines reviews by general practice pharmacists for patients at high risk of medicines-related harm result in substantial cost savings. Wider investment in general practice pharmacists will be beneficial to minimise both patient harm and healthcare system expenditure.

Pharmacist-Led Deprescribing of Opioids and Benzodiazepines in Older Adults: Examining Implementation and Perceptions

Background: This study examines the implementation and perceptions of a pharmacist consultant deprescribing program aimed at reducing the risk of falls in older adults using opioids and benzodiazepines. Methods: This qualitative study conducted interviews with healthcare providers. The interviews were conducted from August to December 2021 and analyzed using inductive coding techniques. Results: Five participants, predominantly female MDs or PA-Cs from rural clinics, were interviewed. The participants adopted a pharmacist-led deprescribing program due to their heightened awareness of the opioid crisis, dedication to patient safety, and a desire for opioid deprescribing education. Initially, concerns included patient resistance and provider-driven barriers. However, over time, patient attitudes shifted toward greater openness to the program. The providers emphasized several critical needs for the success of the program: guaranteed access to pharmacists, tailored patient education, resources specific to providers, and financial support, including telehealth options. These factors were deemed essential to overcoming initial barriers and ensuring effective implementation. Conclusion: Integrating pharmacists into primary care settings shows promise for deprescribing opioids and benzodiazepines in older adults. Future research should explore telehealth options for patient-pharmacist consultations and expand the application of these findings to other healthcare settings. The study highlights the importance of awareness, patient education, access to resources (pharmacists), and provider support in addressing deprescribing among older adults.

Reducing economic burden through split-shared care model for people living with uncontrolled type 2 diabetes and polypharmacy: a multi-center randomized controlled trial

BACKGROUND

Interprofessional collaborative care such as a split-shared care model involving family physicians and community pharmacists can reduce the economic burden of diabetes management. This study aimed to evaluate the economic outcome of a split-shared care model between family physicians and community pharmacists within a pharmacy chain in managing people with uncontrolled type 2 diabetes and polypharmacy.

METHOD

This was a multi-center, parallel arm, open label, randomized controlled trial comparing the direct and indirect economic outcomes of people who received collaborative care involving community pharmacists (intervention) versus those who received usual care without community pharmacist involvement (control). People with uncontrolled type 2 diabetes, defined as HbA1c > 7.0% and taking ≥ 5 chronic medications were included while people with missing baseline economic data (such as consultation costs, medication costs) were excluded. Direct medical costs were extracted from the institution's financial database while indirect costs were calculated from self-reported gross income and productivity loss, using Work Productivity Activity Impairment Global Health questionnaire. Separate generalized linear models with log link function and gamma distribution were used to analyze changes in direct and indirect medical costs.

RESULTS

A total of 175 patients (intervention = 70, control = 105) completed the trial and were included for analysis. The mean age of the participants was 66.9 (9.2) years, with majority being male and Chinese. The direct medical costs were significantly lower in the intervention than the control group over 6 months (intervention: -US$70.51, control: -US$47.66, p < 0.001). Medication cost was the main driver in both groups. There were no significant changes in productivity loss and indirect costs in both groups.

CONCLUSION

Implementation of split-shared visits with frontline community partners may reduce economic burden for patient with uncontrolled type 2 diabetes and polypharmacy.

TRIAL REGISTRATION

Clinicaltrials.gov Reference Number: NCT03531944 (Date of registration: June 6, 2018).

Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study

INTRODUCTION

Problematic polypharmacy is the prescribing of five or more medications potentially inappropriately. Unintentional prescribing cascades represent an under-researched aspect of problematic polypharmacy and occur when an adverse drug reaction (ADR) is misinterpreted as a new symptom resulting in the initiation of a new medication. The aim of this study was to elicit key stakeholders' perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades.

METHODS

qualitative one-to-one semi-structured interviews were conducted with predefined key stakeholder groups. Inductive thematic analysis was employed.

RESULTS

Thirty-one stakeholders were interviewed: six patients, two carers, seven general practitioners, eight pharmacists, four hospital doctors, two professional organisation representatives and two policymakers. Three main themes were identified: (i) ADRs and prescribing cascades-a necessary evil. Healthcare professionals (HCPs) expressed concern that experiencing an ADR would negatively impact patients' confidence in their doctor. However, patients viewed ADRs pragmatically as an unpredictable risk. (ii) Balancing the risk/benefit tipping point. The complexity of prescribing decisions in the context of polypharmacy made balancing this tipping point challenging. Consequently, HCPs avoided medication changes. (iii) The minefield of medication reconciliation. Stakeholders, including patients and carers, viewed medication reconciliation as a perilous activity due to systemic communication deficits.

CONCLUSION

Stakeholders believed that at a certain depth of polypharmacy, the risk that a new symptom is being caused by an existing medication becomes incalculable. Therefore, in the absence of harm, medication changes were avoided. However, medication reconciliation post hospital discharge compelled prescribing decisions and was seen as a high-risk activity by stakeholders.

Defining, identifying and addressing problematic polypharmacy within multimorbidity in primary care: a scoping review

INTRODUCTION

Polypharmacy and multimorbidity pose escalating challenges. Despite numerous attempts, interventions have yet to show consistent improvements in health outcomes. A key factor may be varied approaches to targeting patients for intervention.

OBJECTIVES

To explore how patients are targeted for intervention by examining the literature with respect to: understanding how polypharmacy is defined; identifying problematic polypharmacy in practice; and addressing problematic polypharmacy through interventions.

DESIGN

We performed a scoping review as defined by the Joanna Briggs Institute.

SETTING

The focus was on primary care settings.

DATA SOURCES

Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and Cochrane along with ClinicalTrials.gov, Science.gov and WorldCat.org were searched from January 2004 to February 2024.

ELIGIBILITY CRITERIA

We included all articles that had a focus on problematic polypharmacy in multimorbidity and primary care, incorporating multiple types of evidence, such as reviews, quantitative trials, qualitative studies and policy documents. Articles focussing on a single index disease or not written in English were excluded.

EXTRACTION AND ANALYSIS

We performed a narrative synthesis, comparing themes and findings across the collective evidence to draw contextualised insights and conclusions.

RESULTS

In total, 157 articles were included. Case-finding methods often rely on basic medication counts (often five or more) without considering medical history or whether individual medications are clinically appropriate. Other approaches highlight specific drug indicators and interactions as potentially inappropriate prescribing, failing to capture a proportion of patients not fitting criteria. Different potentially inappropriate prescribing criteria also show significant inconsistencies in determining the appropriateness of medications, often neglecting to consider multimorbidity and underprescribing. This may hinder the identification of the precise population requiring intervention.

CONCLUSIONS

Improved strategies are needed to target patients with polypharmacy, which should consider patient perspectives, individual factors and clinical appropriateness. The development of a cross-cutting measure of problematic polypharmacy that consistently incorporates adjustment for multimorbidity may be a valuable next step to address frequent confounding.

Proton Pump Inhibitors: Rational Use and Use-Reduction - The Windsor Workshop

BACKGROUND

Despite deprescribing initiatives to curb overutilization of proton pump inhibitors (PPIs), achieving meaningful reductions in PPI use is proving a challenge.

SUMMARY

An international group of primary care doctors and gastroenterologists examined the literature surrounding PPI use and use-reduction to clarify: (i) what constitutes rational PPI prescribing; (ii) when and in whom PPI use-reduction should be attempted; and (iii) what strategies to use when attempting PPI use-reduction.

KEY MESSAGES

Before starting a PPI for reflux-like symptoms, patients should be educated on potential causes and alternative approaches including dietary and lifestyle modification, weight loss, and relaxation strategies. When commencing a PPI, patients should understand the reason for treatment, planned duration, and review date. PPI use at hospital discharge should not be continued without a recognized indication for long-term treatment. Long-term PPI therapy should be reviewed at least annually. PPI use-reduction should be based on the lack of a rational indication for long-term PPI use, not concern for PPI-associated adverse events. PPI use-reduction strategies involving switching to on-demand PPI or dose tapering, with rescue therapy for rebound symptoms, are more likely to succeed than abrupt cessation.

A Digital Health Perspective on Medication Use and Polypharmacy Management for Improving Healthcare Outcomes in Geriatric Patients

The high prevalence of multiple comorbidities poses unique medication-related challenges for geriatric patients. Polypharmacy is a particular concern since taking several medications simultaneously increases the likelihood of adverse drug events and the risk of drug interactions while decreasing patient adherence. These factors are associated with suboptimal health outcomes and a heightened burden on the healthcare system (insurance claims) and the patient (out-of-pocket expenses). These challenges can significantly affect the quality of life of geriatric patients. This chapter critically examines the impact of medication use and polypharmacy on the quality of life of older patients. In addition, the authors discuss how artificial intelligence-based digital tools and precision medicine can address these issues by streamlining medical decision-making, improving the patient experience, and allowing remote monitoring. Finally, they interpret the findings from the lens of ethical considerations associated with the adoption and implementation of digital applications and gadgets.

GPs' perceptions of pharmacists working in general practices: A mixed methods survey study

BACKGROUND

Pharmacists are increasingly incorporated into general practice teams globally and have been shown to positively impact patient outcomes. However, little research to date has focused on determining general practitioners' (GPs') perceptions of practice-based pharmacist roles in countries yet to establish such roles.

OBJECTIVES

To explore GPs' perceptions towards integrating pharmacists into practices and determine if any significant associations were present between GPs' perceptions and their demographic characteristics.

METHODS

In June 2022, a survey was disseminated to GPs in Ireland via post (n = 500 in Munster region), Twitter, WhatsApp, and an online GP support and education network. Quantitative data were captured through multiple option and Likert-scale questions and analysed using descriptive and inferential statistics. Qualitative data were captured via free-text boxes, with the open comments analysed using reflexive thematic analysis.

RESULTS

A total of 152 valid responses were received (24.6% response to postal survey). Overall, GPs welcomed the role of practice-based pharmacists and perceived that they would increase patient safety. Most agreed with practice pharmacists providing medicine information (98%) vs. 23% agreeing with practice pharmacists prescribing independently. Most agreed they would partake in a practice pharmacist pilot (78.6%). The free-text comments described current pressures in general practice, existing relationships with pharmacists, funding and governance strategies, potential roles for pharmacists in general practice, and anticipated outcomes of such roles.

CONCLUSION

This study provides a deeper understanding of GPs' perceptions of integrating pharmacists into practices and the demographic characteristics associated with different perceptions, which may help better inform future initiatives to integrate pharmacists into practices.