Drug therapy and the older person: role of the pharmacist

A survey study to measure the practice of patient counselling and other community pharmacy services in Jordan

Objectives

To identify the type of services currently provided by community pharmacists and to explore the barriers for providing high-quality services within the community pharmacy sector in Jordan.

Methods

Using random sampling technique, pharmacies were approached to take part in this questionnaire-based research. All the collected data were analysed using PASW® 18.0. Correlations were studied using Pearson's correlation.

Key findings

From the 714 community pharmacies that were approached, 374 pharmacists were responded to the survey 52.4%. The majority of pharmacies provided patient counselling for long-term conditions and weight management (72.5%, n = 271 and 70.3%, n = 263 respectively). Lack of patient interest was the main barrier for not providing pharmaceutical services according to 50.8% of pharmacists. Three-quarters of the pharmacists preferred to be given incentives for providing pharmaceutical services by government (73.3%, n = 274). There were significant correlations between providing community pharmacy services and subspecialty of the responding pharmacists (r = 0.142, P < 0.01), experience (r = 0.150, P < 0.01). Concerns regarding patient adherence to medications were raised by 88% of pharmacists. There was a significant positive correlation between subspecialty and concerns about adherence (r = −0.160, P < 0.01), on the other hand, significant negative correlation was found between years of experience and concerns about adherence (r = −0.246, P < 0.01).

Conclusions

This study provides baseline data for policymakers on what pharmaceutical services are currently available across community pharmacies in Jordan and what barriers to these services may exist. These data also give an insight into how to improve the delivery of professional services that could result in better health outcomes.

Reforming the quality use of medicines in Australian aged care facilities: a new pharmacy practice model

Objective

Numerous problems exist with accessing prescription medicines in Australian Residential Aged Care Facilities (RACF). This research aimed to identify the issues surrounding a theoretical model for pharmacists' prescribing in these facilities that had been proposed to address these problems. Specific objectives were to conceptually tailor the model to the RACF setting and qualitatively examine its potential applicability.

Setting

Data were collected from June to September 2004 via 34 semi-structured interviews with representatives of 28 stakeholder organisations, and 12 homogeneous focus groups comprising 25 consumers, 28 pharmacists and 18 medical practitioners representing rural and metropolitan locations. Participants were sourced from four states/territories of Australia.

Method

The so-called ‘Medication Maintenance’ model had previously been developed from the international literature and discussion with an expert steering committee. It proposes a system for pharmacists to continue Pharmaceutical Benefits Scheme prescriptions for patients whose therapy had been stabilised by a medical practitioner, by one month, one repeat or one original pack, as appropriate. The potential benefits, harms, barriers and facilitators were discussed with relevant stakeholders. Data were thematically analysed, and recommendations made for trial of the model.

Key findings

Potential benefits of the ‘Medication Maintenance’ model include improved patient focus, efficiency and interprofessional relationships. Potential harms include increased risk, possible wastage and exploitation. Potential barriers include role conflict, lack of controls, legislative issues and conflict of interest for pharmacists. Facilitators for the model were identified as defined roles and protocols, limitations on supply, regular patient review, communication channels and shared patient records.

Conclusion

A range of benefits, harms, barriers and facilitators of this theoretical model were elucidated from stakeholders. This has led to the proposal of a staged implementation trial of the model, which should involve clinical, humanistic and economic outcome monitoring, and attitudinal, practical and legislative issues to be addressed.

Appropriateness of prescribing among elderly patients in a Dutch residential home: observational study of outcomes after a pharmacist-led medication review

BACKGROUND

Clinically significant pharmacokinetic and pharmacodynamic changes occurring with age make older patients more prone to the consequences of inappropriate prescribing. The combination of higher use of medicines resulting from a higher disease burden with suboptimal treatment monitoring results in a higher risk of unwanted drug effects from sometimes inappropriate choice of drugs, doses and durations of treatment. Pharmacy services are increasingly being targeted to minimize the overall number of unnecessary and potential harmful medicines.

OBJECTIVE

To investigate the impact of a pharmacist-led medication review on quality of prescribing by a healthcare professional team consisting of a general practitioner (GP), care home staff and a pharmacist.

METHODS

This observational study compared outcome measurements before and after a pharmacist-led review of medications for patients under the care of a healthcare professional team consisting of a GP, care home staff and pharmacist. The procedure for conducting and recording the medication review consisted of the preparation of a patient medication profile, which combined the patient's medical records with his or her complete prescription record (current and previous [last 3 years] medication history) and pharmaceutical record (electronic journal entries for the patient over the same period). Laboratory values were evaluated in clinical context. Recommendations for the pharmaceutical plan were discussed at a conference involving the clinical pharmacist and other healthcare team members. Patients were recruited for medication review over the 12-month period 1 April 2003 to 1 April 2004. Medication appropriateness was assessed by an independent panel of clinical pharmacists using the Medication Appropriateness Index (MAI).

RESULTS

A total of 54 patients were eligible according to the inclusion criteria, of whom 24 were subsequently excluded for various reasons; thus, 30 patients were eligible for assessment on the MAI. There was a statistically significant difference between overall pre- and post-intervention summed MAI scores (p=0.013). The pharmacist identified 115 drug-related problems, and the total number of accepted recommendations was 78 (67.8%). Use of a medication review as an intervention by a clinical pharmacist was associated with an improvement in appropriateness of prescribing.

CONCLUSION

This study provides evidence supporting the formal integration of a clinical pharmacist into the healthcare team with the aim of improving prescribing appropriateness for institutionalized elderly Dutch patients. Overall MAI scores for all long-term medications used by a group of elderly patients improved significantly after a pharmacist-led medication review. This is an important finding because quality of prescribing is assuming increasing importance as a means of preventing avoidable medication-related harm.

Concordance-based adherence support service delivery: consumer perspectives

OBJECTIVES

To explore consumers' attitudes towards, and expectations of, adherence support services in primary health care, specifically in community pharmacy; and to explore consumers' attitudes towards the concept of concordance.

SETTING

An exploratory qualitative study conducted in Metropolitan Sydney, Australia.

METHOD

Three focus group discussions with consumers on chronic therapy (n = 22) and two focus groups with consumer representatives (n = 15) were conducted in 2002. Consumer representatives were peer educators volunteering in an association which promotes quality use of medicines among elderly patients. All discussions were audio-taped, transcribed verbatim and thematically content analysed.

MAIN OUTCOME MEASURES

Consumers' experiences with adherence support services delivered by general practitioners and pharmacists, their expectations towards general practitioners' and pharmacists' role in adherence support; and attitudes towards concordance in consultations.

RESULTS

Participants expected an increased provision of medicine information and a reduction in the number of medications taken as the main strategies to promote adherence. They believed that once understandable information had been delivered, it was their responsibility to take their medications as prescribed. Yet participants frequently complained about the information received, especially from doctors. Only a subgroup of participants expected pharmacists to be involved in adherence support services. These participants generally relied on pharmacists for medicine information and were satisfied with the communication process when interacting with the pharmacists. All participants were positive about concordance, because they valued two-way communication and increased consideration of their needs and beliefs by healthcare professionals. However, they were hesitant about being involved in a shared treatment decision-making process. Many participants focused on concordance with doctors and identified barriers to the establishment of concordance: time pressures, financial constraints, the gap of competence and power between patients and doctors.

CONCLUSIONS

Pharmacists should consider consumers' needs for information and establishing concordance, as well as their expectations of the pharmacy profession, in delivering concordance based adherence support services. Given participants' high demand for medicine information, an opportunity might exist for pharmacists to influence consumers' expectations by offering information which is tailored towards their needs.

User-related pharmaceutical care problems and factors affecting them: the importance of clinical relevance

BACKGROUND AND OBJECTIVES

Many studies determined the number and nature of user-related Pharmaceutical Care Problems (PCP) and factors affecting them, but none considered the inclusion of clinical relevance. The aims of this study are (i) to investigate the type, number and clinical relevance of user-related PCP self-reported by home dwelling elderly on polypharmacy and (ii) to develop a risk-model for detecting elderly drug-users at risk of user-related PCP.

METHODS

The study was a cross-sectional study conducted among 286 home dwelling elderly on polypharmacy (> or =75 years, > or =4 medicines) in the Netherlands. The user-related PCP found were divided into problem categories and subsequently a pharmacist and a general practitioner classified the problems into those with low and those with (potential) clinical relevance. Factors possibly associated with PCP (both for all and relevant problems) were identified, and subsequently tested in multivariate models using logistic regression.

RESULTS

Three hundred and ninety-eight user-related PCP were observed in 189 patients (66% of all participants). After classification of user-related PCP only 26% appeared to be of clinical relevance (26% of all participants). When including clinical relevance a shift in predominantly present problem categories is observed. Furthermore, the risk model for problems with clinical relevance contains more factors than the model which considered all problems. Factors associated with clinically relevant PCP are emotional or physical problems interfering with social life, communication skills (vision and hearing), using tablets that have to be divided, using inhaled medicines, and the number of medicines used. This risk-model has a specificity of 92% and a sensitivity of 32%.

CONCLUSIONS

Although user-related PCP were seen in about two-thirds of the participants, in only one out of four participants was the PCP considered to be of clinical relevance. With inclusion of clinical relevance, other problem categories become more dominant. A specific risk model is designed to select elderly patients that are most likely to have PCP in need of more urgent intervention. Unfortunately higher specificity is accompanied by low sensitivity in the present model.

Reduction of polypharmacy in the elderly: a systematic review of the role of the pharmacist

Polypharmacy in the elderly complicates therapy, increases cost, and is a challenge for healthcare agencies. In the context of the evolving role of the pharmacist, this systematic review examines the effectiveness of interventions led by pharmacists in reducing polypharmacy. A computerised search was conducted using Medline, Embase geriatrics and gerontology (2001 edition), the Cochrane Library and International Pharmaceutical Abstracts (IPA) databases. A manual search of articles on polypharmacy and the role of pharmacists in the therapy of the elderly and of the reference sections of all retrieved articles was also carried out. Search terms used were 'polypharmacy', 'elderly', 'aged', 'intervention' and 'pharmacist(s)'. Articles that fulfilled the following criteria were included: only elderly people were included in the study, or all ages were included but the study gave separate results for the elderly; the outcome was expressed as a reduction in the number of medications; a pharmacist participated in the study; and the study was a controlled or a randomised controlled study. We initially identified 106 articles, but only 14 studies met our four inclusion criteria. Reduction in the number of medications was not the major purpose of most selected studies but often a secondary outcome. Objectives differed, the general aim being to enhance the quality of prescribing in elderly patients. These controlled studies argued in favour of the effectiveness of pharmacists' interventions, even though the number of medications eliminated was small. Most studies were not designed to demonstrate the impact of reducing the number of drugs on the clinical consequences of polypharmacy (nonadherence, adverse drug reactions, drug-drug interactions, increased risk of hospitalisation, and medication errors). The most frequently reported outcome related to cost savings. It was therefore difficult to assess whether the interventions benefited the patient. The methodological quality of many identified studies was poor. In particular, the study objectives were often very broad and ill-defined. Polypharmacy itself has been defined in different ways and the appropriate definition may differ according to the patient population and the study setting. Further studies are needed to find the most effective way to reduce polypharmacy, especially in the frail elderly population, and to quantify the real advantages of simplifying their drug regimens in terms of improved quality of life.

Examining influences of pharmacists' communication with consumers about antibiotics

A national study was conducted of community pharmacists to examine influences on their communication with consumers about antibiotics and antibiotic resistance. The objective was twofold: to explore the nature of barriers that might be changed to allow pharmacists greater participation in educational campaigns, and to discover which variables would best predict communication using a modification of the Theory of Reasoned Action model. Whereas most pharmacists agreed that their role in educating patients is important, they also noted several barriers prevent them from engaging in campaigns, such as time constraints, lack of educational materials, and fear of harming relations with physicians. Pharmacists' discussion about antibiotics in general was predicted primarily by attitudes about their role and efficacy, by their autonomy, and by enabling measures-such as pamphlets-that would better aid them in participating in a judicious antibiotic use campaign. Discussion about resistance was predicted by attitudes and enabling measures.

Anticoagulants for atrial fibrillation: why is the treatment rate so low?

The incidence of atrial fibrillation (AF) is increasing in many countries along with aging demographics. Atrial fibrillation is clearly associated with an increased rate of stroke. Numerous large clinical trials have shown that dose-adjusted warfarin can reduce the stroke rate in these patients, particularly in the elderly, and clear guidelines for the use of anticoagulants in such patients have been published. However, many studies show that treatment rates remain disappointingly low (< or = 50%). Numerous barriers to the use of dose-adjusted warfarin exist, including practical, patient-, physician-, and healthcare system-related barriers. These include the complex pharmacokinetics of warfarin, the need for continuous prothrombin time monitoring and dose adjustments, bleeding events, noncompliance, drug interactions, and increased costs of monitoring and therapy. Possible solutions to this problem are discussed and include improved patient and physician education, the use of anticoagulation clinics, new approaches to AF, and potential treatment improvements through use of newer anticoagulants.